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Introduction From 2001 to 2012, kindergarten curriculum entered the local stage of curriculum reform. Kindergartens in various regions began to carry out early childhood education curriculum reforms. It gradually resulted in the emergence of the curriculum concepts and types. In September 2001, the Ministry of Education issued the "Guidelines for Kindergarten Education " , which set relevant requirements for kindergarten curriculum. It was proposed that the development of kindergarten curriculum should consider its own actual situation and strive to develop curriculum suitable for young children by combining local regions, local kindergartens and classes. Under the lead of Guidelines, there is an increasing number of distinctive kindergarten based courses which have achieved remarkable results and characteristics in promoting the construction of kindergarten based courses. China is a multi-ethnic and multicultural country with rich Chinese culture. Many folk stories, fables, fairy tales, nursery rhymes, and nursery rhymes have been included in the curriculum development. As multicultural educator Banks pointed out, the curriculum content should reflect the history, experiences, and values of other ethnic groups, giving minority students the opportunity to understand their own country and national culture. At present, cultural elements are increasingly prominent in the research of kindergarten curriculum. Just as Fei Xiaotong proposed the concept of "the diversity and unity of the Chinese nation", it emphasizes the diversity of national culture and focuses on inheriting traditional Chinese culture as its main function and role. --- The Background of Integrating Traditional Chinese Culture into the Development of Kindergarten Curriculum in Ethnic Regions In the mid-1980s, many early childhood education curriculums from abroad began to be introduced into China, such as Montessori courses, Reggio courses and High Vision courses etc. Some kindergartens imitated the curriculum concepts and models that resulting in the development of kindergarten based curriculum like a fleeting observation. However, many kindergartens based curriculum imitates its appearance without substance. For example, some kindergartens in China are named after Montessori and purchase lots of expensive Montessori teaching aids, but it have little actual knowledge of Montessori's true philosophy. Moreover, this phenomenon lead kindergarten based curriculum to move towards a misconception and become a "testing ground" for various curriculum models. Therefore, developing the characteristics of kindergarten based curriculum has become the direction of teaching and research in recent years, and the integration of traditional Chinese culture has injected new vitality into kindergarten curriculum. The researchers have collected some relevant studies that are more distinctive in the development of kindergarten based curriculum. On the one hand, it mainly focuses on the construction of kindergarten based curriculum under the background of kindergarten's characteristic culture. For example, Xi --- The Problems of Integrating Traditional Chinese Culture into the Development of Kindergarten Curriculum in Ethnic Regions --- The Relatively High Understanding of Traditional Chinese Cultural Resources and Lack of Better Application Punit's research found that the higher a teacher's awareness of multiculturalism, the more responsible and conscious they are, and consciously incorporate the concept of cultural diversity into curriculum design and teaching activities. The acception and identification from kindergarten teachers will directly affect the traditional Chinese culture as an important curriculum resource to integrate into early childhood education. By interviews methods, researchers learned that 19 teachers hold a positive attitude towards integrating ethnic culture into kindergarten curriculum. They believe that integrating traditional Chinese culture as an important resource into kindergarten curriculum can not only allow children to have access to more diverse cultural forms and feel the charm of multiculturalism, but also have a positive effect on enhancing the ethnic identity of minority children. In addition, kindergarten teachers have a positive and supportive attitude towards the development of cultural curriculum resources in their own environment and their professional development, and can clearly recognize the unique value of traditional Chinese culture in curriculum resource development. --- Insufficient Understanding of Local Ethnic Cultural Elements and Less Mastery and Depth of --- Resources Due to the in-depth understanding of local ethnic cultural curriculum resources, preschool teachers are unable to engage in curriculum development activities. During the survey, researchers learned that some kindergarten principals and teachers currently have an average level of understanding of local --- Journal of Education and Culture Studies Vol. 7, No. 3, 2023 78 Published by SCHOLINK INC. ethnic cultural curriculum resources. They not only lack sufficient understanding and attention to local ethnic architecture, clothing, transportation, folk literature, games, sports and competitive activities, but also do not know how to apply ethnic arts such as singing and dancing and weaving, which have more local ethnic cultural characteristics. In addition, there is a utilitarian tendency among teachers to utilize ethnic culture, and a part of teachers believe that the purpose of utilizing ethnic culture is to highlight the characteristics of kindergarten education and create brand effects. --- The Passive Awareness of Integrating Traditional Chinese Culture into Kindergarten Based Curriculum Development Researchers find that the proportion of teachers who independently organize educational activities do not archive the further expectations. On the one hand, there may be a lack of motivation in action due to inadequate understanding. On the other hand, they face significant difficulties in their own professional qualities. Some local preschool teachers often stay at a superficial level and only use many preserved well and relatively mature resources of traditional Chinese culture. In the interview, about the topic of traditional festival culture, teachers have organized relevant activities for some common and popular festivals, such as the National Day, the Spring Festival and the Mid-Autumn Festival. In terms of traditional architectural culture, teachers mostly use pictures and videos to show the Chinese characteristic buildings, such as the Forbidden City, Tiananmen Square and the Great Wall. However, many young children have not seen these buildings with their own eyes and their cognitions can only rely on the teacher's explanation. --- Analysis of the Reasons for Integrating Traditional Chinese Culture into the Development of --- Kindergarten Curriculum in Ethnic Regions --- The Relatively Few Mature Curriculum Resources about Traditional Chinese Cultural Elements of Kindergarten Based Curriculum Teachers can be used some folk literature resources as kindergarten courses, such as mature fables, stories, and poems, which are relatively mature in content. According to the interview results, 18 teachers have told children the fable story of "Grandma Bear", 10 teachers have told children nursery rhymes such as "Gods and Heroes", "Three Brothers", and "Wandering Orphan Snake Mother", which are more commonly used in teaching activities to regulate the atmosphere and guide teaching activities. But this kind of way is mostly a superficial introduction to literary texts, without delving into the essence of traditional Chinese culture. In addition, due to the widespread implementation of Chinese language education in local kindergartens, some folk cultures based on Yi and Tibetan languages are difficult to be absorbed and utilized by kindergartens. Kindergartens are mostly limited to utilizing and introducing the art of painting reflected in their masks, which were included in the first batch of national intangible cultural heritage lists. Few teachers actively explore and develop the typical ethnic singing and dancing art forms in the local area. --- The Unreasonable Allocation of Teachers' Energy and Time Because of Kindergarten Administrative Management Content Many teachers are busy with a large amount of formal work, such as the writing of various plans and summaries, which take up a lot of time and energy of teachers. Teachers have less time to pay more attention to young children and design meaningful teaching activities based on their interests, needs and activity outlines. If kindergartens can liberate teachers from the mundane and dogmatic work of daily management, teachers can not only be proficient in the education process, but also make better reflection on their own work. Teachers can observe and understand their interests and development needs through contacting with them. Thus, it is important for kindergarten teachers to consciously integrate traditional culture into kindergarten based curriculum by their normal teaching work and activities. --- The Weak Subjective Consciousness Due to the Great Influence of Objective Environment There are mainly two aspects about the weak subjective awareness for kindergarten teachers. This means that teachers undertake necessary educational work and take on a large number of childcare tasks for their daily lives. It is difficult for teachers to have the energy and time to think about the construction of kindergarten curriculum culture, and even they also lack the awareness of being the main body of kindergarten curriculum culture construction. --- Effective Strategies for Integrating Traditional Chinese Culture into the Development of Kindergarten Curriculum in Ethnic Regions --- Regarding Teachers: Building a Research and Development Team for Traditional Chinese Culture Courses in Kindergartens by Integrating Teacher Resources The traditional cultural courses in kindergartens are mainly independently developed by teachers in the kindergarten. At present, preschool teachers generally lack relevant knowledges of local traditional regional culture. And also their understanding of traditional culture is not profound. In the basic teaching and research modules in all kindergartens, it is extremely important to add a lot of contents on traditional Chinese culture. It not only helps preschool teachers to familiarize themselves with the history, content, and value of traditional Chinese culture, but also comprehensively improves their traditional cultural literacy. In addition, it is more difficult for teachers to identify and select traditional cultural content and design related activities during the development of kindergarten based curriculum. Teachers need to start from the excellent traditional Chinese cultural characteristic curriculum and --- In Terms of Kindergartens: Building a Traditional Chinese Cultural Base and Strengthening the --- Development of Book Culture in Kindergartens There are the fundamental conditions for educational activities based on the rich book and cultural resources. We often say that "a skillful woman cannot cook without rice", which is also applicable to teachers engaged in educational work. Leo Strauss pointed out in his article "What is Free Education" that "education is within or towards culture." The famous modern educator John Dewey pointed out in his article "My Educational Creed": All education is carried out through individual participation in human social consciousness. Through this way, individuals gradually share the wisdom and moral wealth accumulated by humanity. He becomes an inheritor of inherent cultural capital. Whether in the concepts of famous thinkers and educators, or in the cognition of ordinary people, education is related to the "possession" and "sharing" of cultural resources. Education cannot be separated from the fundamental condition of "possessing" and "sharing" cultural resources at any stage. If there is a sole criterion for judging the richness of kindergarten curriculum culture and the quality and effectiveness of kindergarten curriculum activities, then this criterion must be the level of book culture construction in the kindergarten. Before teachers become experts in the development of cultural resources in kindergarten curriculum, they must possess cultural resources and achieve spiritual "sharing" under the premise of formal "possession". This requires teachers to be able to purposefully acquire rich book cultural resources based on their own educational practice activities, and at the same time be able to use book cultural resources to organize educational and teaching activities. In this two-way process, teachers have achieved their own professional growth and gradually become expert teachers and course developers. From this, it can be seen that strengthening the construction of book culture in kindergartens in ethnic regions is not only beneficial for enriching the curriculum and cultural resources of kindergartens in ethnic regions, but also for enhancing the professional development level of teachers and improving their curriculum innovation ability. --- Community and Family Aspects: Kindergarten and Family Work Together to Lay an Environmental Foundation for Integrating Traditional Chinese Cultural Elements into Kindergarten Based Curriculum For children in ethnic areas, as their social life gradually expands, different cultures in the community gradually enter their world. These different cultures gradually being perceived, accepted and recognized by them. As American scholar F. Walter once said, students who do not receive education in their own culture may feel distant and rootless, but students who lack mainstream cultural education

have begun to pay attention to the development of kindergarten curriculum. Most of teachers search for the characteristics of kindergarten curriculum that is suitable for young children's age groups. The excellent Chinese traditional culture, as an important element with Chinese cultural symbols, is gradually being used by kindergarten teachers. When carrying out activities, kindergartens in ethnic regions integrate traditional Chinese culture into the development of kindergarten curriculum. This study starts with the background of integrating traditional Chinese culture into the development of kindergarten curriculum. Through interviews with preschool teachers, it identifies the current problems and reasons, and proposes some suggestions for better integrating traditional Chinese culture into the kindergarten curriculum.

introduction from 2001 to 2012 kindergarten curriculum entered the local stage of curriculum reform kindergartens in various regions began to carry out early childhood education curriculum reforms it gradually resulted in the emergence of the curriculum concepts and types in september 2001 the ministry of education issued the guidelines for kindergarten education which set relevant requirements for kindergarten curriculum it was proposed that the development of kindergarten curriculum should consider its own actual situation and strive to develop curriculum suitable for young children by combining local regions local kindergartens and classes under the lead of guidelines there is an increasing number of distinctive kindergarten based courses which have achieved remarkable results and characteristics in promoting the construction of kindergarten based courses china is a multiethnic and multicultural country with rich chinese culture many folk stories fables fairy tales nursery rhymes and nursery rhymes have been included in the curriculum development as multicultural educator banks pointed out the curriculum content should reflect the history experiences and values of other ethnic groups giving minority students the opportunity to understand their own country and national culture at present cultural elements are increasingly prominent in the research of kindergarten curriculum just as fei xiaotong proposed the concept of the diversity and unity of the chinese nation it emphasizes the diversity of national culture and focuses on inheriting traditional chinese culture as its main function and role the background of integrating traditional chinese culture into the development of kindergarten curriculum in ethnic regions in the mid1980s many early childhood education curriculums from abroad began to be introduced into china such as montessori courses reggio courses and high vision courses etc some kindergartens imitated the curriculum concepts and models that resulting in the development of kindergarten based curriculum like a fleeting observation however many kindergartens based curriculum imitates its appearance without substance for example some kindergartens in china are named after montessori and purchase lots of expensive montessori teaching aids but it have little actual knowledge of montessoris true philosophy moreover this phenomenon lead kindergarten based curriculum to move towards a misconception and become a testing ground for various curriculum models therefore developing the characteristics of kindergarten based curriculum has become the direction of teaching and research in recent years and the integration of traditional chinese culture has injected new vitality into kindergarten curriculum the researchers have collected some relevant studies that are more distinctive in the development of kindergarten based curriculum on the one hand it mainly focuses on the construction of kindergarten based curriculum under the background of kindergartens characteristic culture for example xi the problems of integrating traditional chinese culture into the development of kindergarten curriculum in ethnic regions the relatively high understanding of traditional chinese cultural resources and lack of better application punits research found that the higher a teachers awareness of multiculturalism the more responsible and conscious they are and consciously incorporate the concept of cultural diversity into curriculum design and teaching activities the acception and identification from kindergarten teachers will directly affect the traditional chinese culture as an important curriculum resource to integrate into early childhood education by interviews methods researchers learned that 19 teachers hold a positive attitude towards integrating ethnic culture into kindergarten curriculum they believe that integrating traditional chinese culture as an important resource into kindergarten curriculum can not only allow children to have access to more diverse cultural forms and feel the charm of multiculturalism but also have a positive effect on enhancing the ethnic identity of minority children in addition kindergarten teachers have a positive and supportive attitude towards the development of cultural curriculum resources in their own environment and their professional development and can clearly recognize the unique value of traditional chinese culture in curriculum resource development insufficient understanding of local ethnic cultural elements and less mastery and depth of resources due to the indepth understanding of local ethnic cultural curriculum resources preschool teachers are unable to engage in curriculum development activities during the survey researchers learned that some kindergarten principals and teachers currently have an average level of understanding of local journal of education and culture studies vol 7 no 3 2023 78 published by scholink inc ethnic cultural curriculum resources they not only lack sufficient understanding and attention to local ethnic architecture clothing transportation folk literature games sports and competitive activities but also do not know how to apply ethnic arts such as singing and dancing and weaving which have more local ethnic cultural characteristics in addition there is a utilitarian tendency among teachers to utilize ethnic culture and a part of teachers believe that the purpose of utilizing ethnic culture is to highlight the characteristics of kindergarten education and create brand effects the passive awareness of integrating traditional chinese culture into kindergarten based curriculum development researchers find that the proportion of teachers who independently organize educational activities do not archive the further expectations on the one hand there may be a lack of motivation in action due to inadequate understanding on the other hand they face significant difficulties in their own professional qualities some local preschool teachers often stay at a superficial level and only use many preserved well and relatively mature resources of traditional chinese culture in the interview about the topic of traditional festival culture teachers have organized relevant activities for some common and popular festivals such as the national day the spring festival and the midautumn festival in terms of traditional architectural culture teachers mostly use pictures and videos to show the chinese characteristic buildings such as the forbidden city tiananmen square and the great wall however many young children have not seen these buildings with their own eyes and their cognitions can only rely on the teachers explanation analysis of the reasons for integrating traditional chinese culture into the development of kindergarten curriculum in ethnic regions the relatively few mature curriculum resources about traditional chinese cultural elements of kindergarten based curriculum teachers can be used some folk literature resources as kindergarten courses such as mature fables stories and poems which are relatively mature in content according to the interview results 18 teachers have told children the fable story of grandma bear 10 teachers have told children nursery rhymes such as gods and heroes three brothers and wandering orphan snake mother which are more commonly used in teaching activities to regulate the atmosphere and guide teaching activities but this kind of way is mostly a superficial introduction to literary texts without delving into the essence of traditional chinese culture in addition due to the widespread implementation of chinese language education in local kindergartens some folk cultures based on yi and tibetan languages are difficult to be absorbed and utilized by kindergartens kindergartens are mostly limited to utilizing and introducing the art of painting reflected in their masks which were included in the first batch of national intangible cultural heritage lists few teachers actively explore and develop the typical ethnic singing and dancing art forms in the local area the unreasonable allocation of teachers energy and time because of kindergarten administrative management content many teachers are busy with a large amount of formal work such as the writing of various plans and summaries which take up a lot of time and energy of teachers teachers have less time to pay more attention to young children and design meaningful teaching activities based on their interests needs and activity outlines if kindergartens can liberate teachers from the mundane and dogmatic work of daily management teachers can not only be proficient in the education process but also make better reflection on their own work teachers can observe and understand their interests and development needs through contacting with them thus it is important for kindergarten teachers to consciously integrate traditional culture into kindergarten based curriculum by their normal teaching work and activities the weak subjective consciousness due to the great influence of objective environment there are mainly two aspects about the weak subjective awareness for kindergarten teachers this means that teachers undertake necessary educational work and take on a large number of childcare tasks for their daily lives it is difficult for teachers to have the energy and time to think about the construction of kindergarten curriculum culture and even they also lack the awareness of being the main body of kindergarten curriculum culture construction effective strategies for integrating traditional chinese culture into the development of kindergarten curriculum in ethnic regions regarding teachers building a research and development team for traditional chinese culture courses in kindergartens by integrating teacher resources the traditional cultural courses in kindergartens are mainly independently developed by teachers in the kindergarten at present preschool teachers generally lack relevant knowledges of local traditional regional culture and also their understanding of traditional culture is not profound in the basic teaching and research modules in all kindergartens it is extremely important to add a lot of contents on traditional chinese culture it not only helps preschool teachers to familiarize themselves with the history content and value of traditional chinese culture but also comprehensively improves their traditional cultural literacy in addition it is more difficult for teachers to identify and select traditional cultural content and design related activities during the development of kindergarten based curriculum teachers need to start from the excellent traditional chinese cultural characteristic curriculum and in terms of kindergartens building a traditional chinese cultural base and strengthening the development of book culture in kindergartens there are the fundamental conditions for educational activities based on the rich book and cultural resources we often say that a skillful woman cannot cook without rice which is also applicable to teachers engaged in educational work leo strauss pointed out in his article what is free education that education is within or towards culture the famous modern educator john dewey pointed out in his article my educational creed all education is carried out through individual participation in human social consciousness through this way individuals gradually share the wisdom and moral wealth accumulated by humanity he becomes an inheritor of inherent cultural capital whether in the concepts of famous thinkers and educators or in the cognition of ordinary people education is related to the possession and sharing of cultural resources education cannot be separated from the fundamental condition of possessing and sharing cultural resources at any stage if there is a sole criterion for judging the richness of kindergarten curriculum culture and the quality and effectiveness of kindergarten curriculum activities then this criterion must be the level of book culture construction in the kindergarten before teachers become experts in the development of cultural resources in kindergarten curriculum they must possess cultural resources and achieve spiritual sharing under the premise of formal possession this requires teachers to be able to purposefully acquire rich book cultural resources based on their own educational practice activities and at the same time be able to use book cultural resources to organize educational and teaching activities in this twoway process teachers have achieved their own professional growth and gradually become expert teachers and course developers from this it can be seen that strengthening the construction of book culture in kindergartens in ethnic regions is not only beneficial for enriching the curriculum and cultural resources of kindergartens in ethnic regions but also for enhancing the professional development level of teachers and improving their curriculum innovation ability community and family aspects kindergarten and family work together to lay an environmental foundation for integrating traditional chinese cultural elements into kindergarten based curriculum for children in ethnic areas as their social life gradually expands different cultures in the community gradually enter their world these different cultures gradually being perceived accepted and recognized by them as american scholar f walter once said students who do not receive education in their own culture may feel distant and rootless but students who lack mainstream cultural education

have begun to pay attention to the development of kindergarten curriculum most of teachers search for the characteristics of kindergarten curriculum that is suitable for young childrens age groups the excellent chinese traditional culture as an important element with chinese cultural symbols is gradually being used by kindergarten teachers when carrying out activities kindergartens in ethnic regions integrate traditional chinese culture into the development of kindergarten curriculum this study starts with the background of integrating traditional chinese culture into the development of kindergarten curriculum through interviews with preschool teachers it identifies the current problems and reasons and proposes some suggestions for better integrating traditional chinese culture into the kindergarten curriculum

Introduction Black youth in the United States have had to grow up with the unique challenge of navigating the textured terrain of American society's history with racism. Not only has the impact of individual and institutional level racism been detrimental to Black youth and their families, early academic and policy discourse also furthered racism's destruction by promoting a deficit perspective that wrongfully held Black families and communities responsible for experiences of adversity . Since then, research and policy have shifted to highlighting the inherent cultural strengths of Black families which allows Black youth to persist even in the face of racism-related stressors and adversity . Processes of resiliencenow, an asset-centered, multidimensional construct for promoting psychosocial well-being in Black youthrepresents a habituation to adversity, in which factors such as self-regulation, cultural strengths, social support, and efforts to cope undergird positive outcomes such as academic success and social mobility . Although resilience research is making a broader shift to integrate multisystemic efforts to combat adverse circumstances and events , there is still a gap concerning how racism-related stressors can "come at a cost" to Black youth . Thus, we posit an expansion to the contemporary models of resilience to combat the psychosocial impacts of racism, a unique stressor that influences the psychosocial well-being of Black youth at individual, familial, cultural, and communal levels . As such, we integrate perspectives from psychology, social work, ecology, and public health to reimagine and consider what it would take to move away from examining contextual factors of resilience for Black youth and push toward a collective effort from systems and institutions to address the deleterious effects of racism with the power and structural influence they possess. --- Answering resilience research's big three inquiries in the context of racism and Black youth We began our attempt to interrogate a resilience-based approach to racism by situating Black youth and their experiences with racism within the broader resilience research literature. In recent masterful reviews outlining the evolution of resilience science, Masten and colleagues remind the field that from the onset, the research on resilience attempted to understand and operationalize three major components: 1) what is the challenge, risk, or adversity? 2) how is successful adaptation defined ? and 3) what are the factors or processes that account for this successful adaptation? In the subsequent sections, we seek to briefly answer questions number one and three before returning our attention to two towards the end. --- Racism as a critical challenge, risk, and adversity for Black youth Research on resilience, as well as developmental models such as Bronfenbrener's socio-ecological framework, highlight adverse environments and circumstances that may emerge generally for all youth. However, in considering the treatment of resilience for Black youth in particular, it is critical to highlight the deleterious role of racism. To understand racism's impact as a challenge, risk factor, and source of adversity for Black youth, we must first define and operationalize racism. Racism, as defined by Jones , is "a system in which individuals or institutions intentionally or unintentionally exercise power against a racial group defined as inferior" and is fueled by an "ideology of superiority and the practice of inequity" . Racism, by this definition, is a social construct that evolves, is perpetuated, and pervasively affects every aspect of our society, as well as individuals within that society. Unlike most stressors examined by resilience theories, including natural disasterswhich are finite crisesor personally traumatic experiences, there are continuous and multiple levels upon which racism occurs, ranging from individual bias to inequitable policy enacted on the institutional and systemic levels . For the individual, racism exacts a unique impact on many parts of their development, including identity formation, character development, interpersonal development, and physical health . The deep rooted history and the social construction of racism provides a nuanced backdrop for how individuals are impacted by this multisystemic determinant, often leading to physical, psychological, and emotional trauma that transcends through generations . Jones et al. categorized racism into three main categories: instrumental , interpersonal , and institutional . Through an instrumental lens, racism impacts Black children and adolescents by them being perceived as older and more dangerous , receiving less culturally affirming early education and childcare experiences , and experiencing harsher treatment, grading, and punishment due to their race from their teachers . Interpersonally, Black youth experience direct encounters of racism as well as bearing witness to vicarious racism involving caregivers and peers , with these experiences occurring both in person and online. Black youth, and teens in particular, encounter substantial institutional experiences with racism, such as policies that result in higher interactions with and trauma by police and school administrators. Racism also differentially impacts Black youth across gender. Perpetuated stereotypes around race and gender and their intersections often lead to more negative reactions to racial discrimination . Black males are often stereotypically deemed as aggressive or intellectually lacking athletes . These stereotypes often lead to Black male youth receiving more negative treatment in schools including harsher discipline, more criticism and more social exclusion compared to their peers . Similarly, parental racial socialization messages often include more messages around racial barriers and alertness to racial discrimination for Black boys compared to Black girls in reaction to the societal stereotypes of Black males . While Black girls also report experiencing discriminatory or negative treatment from valued others due to their race, scholars speculate that Black girls have more negative reactions to discriminatory treatment due to more frequent socialization messages focused on relationships, connectedness to community, and approval of others as opposed to messages preparing them for such racial discrimination . This may also lead Black girls to develop negative approaches to their academics to avoid having such negative interactions and treatment from their teachers and peers . These differential impacts of racism on girls and boys in adolescence can have implications throughout their lifetime. The literature has expanded theories and models to account for the influence of racism on resilience across youth development. Both Garcia Coll et al.'s integrative model and Spencer et al.'s phenomenal variant of ecological systems theory extend Bronfenbrener's socio-ecological model in ways that consider the unique realities youth of color must navigate. By incorporating aspects of intersectionality and developmental identity theory, these theories put the vulnerability of youth into the context of their social position and experiences that are most often linked to systems of oppression and power structures . Moreover, in addition to viewing racism as a detrimental factor to positive outcomes for Black youth, these models center how others within the ecosystem can mitigate the stress and vulnerability that racism portends. --- Racial-ethnic protective factors for Black youth experiencing racism Of note, scholars committed to the healthy psychosocial development of Black youth have spent decades elucidating the factors that protect Black youth against the noxious nature of racism in its multiple forms. Even from the earliest conceptualizations of Black youth development , racial-ethnic protective factors were named as critical for understanding Black youth resilience and successful adaptation. Three racial-ethnic protective factors have been distinguished as particularly salient for Black youth: racial identity development, the endorsement of a cultural/Africentric worldview, and racial socialization . --- Racial identity Research on racial identity development among Black youth often contend with Sellers et al.'s multidimensional model of racial identity, which encompasses markers of racial centrality , private/public racial regard , and ideology . When developed in a manner that favors a strong, positive racial identity, these three dimensions coagulate to form the protective barrier against racism. For instance, a strong racial identity has been shown to interrupt the association between racial discrimination and poor mental health . Conceptual models of successful adaptation to adversity note that an awareness around others' and one's own perceptions about their racial group brings along with it high self-esteem , use of effective coping strategies , and a lower likelihood of attributing instances of discrimination to the self all circumventing the deleterious impact of racism on Black youth well-being. --- Africentric worldview In addition to racial identity, the literature also points to the endorsement of an Africentric worldview as a significant protective factor against racism. Africentric worldview refers to a broad system of beliefs, values, expectation, and behaviors of those part of the African Diaspora to make meaning of their immediate contexts . Africentric worldview includes several different dimensions, all of which originate from key cultural aspects of African heritage: spirituality ; collectivism ; time orientation ; orality ; sensitivity to affect and emotional cues ; verve and rhythm ; and balance and harmony . A popular endorsement of Africentric worldview is also apparent in the Nguzo Saba, or the cultural celebration of Kwanzaa, in which principles such as unity, self-determination, collective work and responsibility, cooperative economics, purpose, and faith are emphasized. In Jones and Neblett's systematic review, Africentric worldview through Nguzo Saba was an essential component of psychosocial prevention and intervention programs that promoted principles spanning from conflict resolution to finding a path to one's purpose . Not only has Africentric worldview been linked to a host of promotive factors for Black youth such as self-esteem , academic adjustment , and positive racial identity , it has also been deemed protective against negative psychological and physiological outcomes associated with racism-related stress. Unfortunately, traditional school practices, media portrayals, and societal views do not have a history of promoting racial identity or Africentric worldview for Black youth; rather, these factors are typically tended to by a process called racial socialization. --- Racial socialization Racial socialization is a process through which family members and/or caregivers transmit implicit and explicit messages regarding the meaning of their race and ethnicity and help youth cope with racial discrimination and other racism-related stressors . Researchers have identified different dimensions of RS: messages of cultural socialization/racial pride , preparation for bias , egalitarianism , self-worth , promotion of mistrust , negative messages , and silence about race . Many of these RS dimensions have been linked to a number of promotive effects for Black youth such as better academic performance , psychological well-being and socioemotional adjustment , and racial identity . RS is also a multifaceted protective factor against racial discrimination; for instance, when coalesced, messages of cultural socialization and preparation for bias have been shown to buffer the relationship between racial discrimination and Black youth's perceived stress and problem behaviors . While the bevy of research on RS has centered around the content of caregiver RS, scholars have contributed more recent research spanning from theoretical frameworks such as the racial encounter coping appraisal and socialization theory to multilevel and bidirectional transmission of RS messages . RECAST calls on competency in delivering RS messages as a means for caregivers to know and understand the most effective delivery of RS messages to youth by taking into account their attitudes, behaviors, and reactions during discriminatory racial encounters . Thus, RECAST asserts that caregivers being skilled and confident in RS delivery promotes greater racial coping skills in youth -a speculative, but supported factor in explaining successful adaptation to adversity for Black youth . While studies using the RECAST model have focused on caregiver competency in assessing the quality of RS communication to youth , others have explored the impact of RS from various contextual levels such as peers, media platforms and school transmission . Recent studies demonstrate the bidirectional nature of RS communication among these levels, in that peers reported using media as a catalyst and prompt for RS -supporting a steady flow of communication from one peer to another . Likewise, Saleem and Byrd proposed a conceptual framework that positions teachers and staff, peers, and school policies and practices as key transmitters of RS in the school context. Taken together, it is evident that research on RS processes has shown itself to be "good soil" for growing the racial factors of resilience and successful adaptation, and, importantly, through the incorporation of other individuals or systems to promote such processes for Black youth. Defining Black youth's "successful" adaptation from racism: resilience science's evolution and limitations As Masten and others have noted, a critical question in resilience research is illuminating and defining what successful adaptation from a challenge or stressor looks like in the lives of youth. As we consider this question with the adversity of racism in mind, we find it instructive to pair our answer with a discussion on the progression and evolution of resilience science. --- Historical focus on individual traits In framing our argument for an alternative approach to supporting the mental health and well-being of Black youth in the context of racism, it is necessary to begin by outlining the ways in which resilience has historically been applied to these young people. Resilience was considered as a way of phenomenologically understanding how youth achieved positive psychosocial outcomes despite developing in adverse environments and being exposed to potentially deleterious circumstances . This "dynamic process encompassing positive adaptation within the context of significant adversity" , has led researchers over the past several decades to identify and isolate person-centered factors that seem most likely to protect against negative outcomes. As such, the lion's share of resilience literature to date has congregated at the individual level. Masten et al. describes four major waves of resilience research with the first three focused on identifying individual attributes that separate those who did well versus those that did poorly in the context of risk , explaining why certain individual attributes lead to better adaptation , and targeting the development of these attributes to promote adjustment during adversity . Here, it is evident that much of the research on resilience at the individual level has persisted despite arguments for a multisystem approach, but why? Who does it serve for resilience to be studied as an individual trait? The persistence of research emphasizing grit, hardiness, and self-regulation all maps onto Western ideals of individualism, which consistently places the onus of hardship and or success on the individual rather than considering the multiple societal and historical levels that are primarily at fault. However, as the field evolved and the literature on resilience expanded , researchers have come to recognize the more prominent role of external factors on a child's resilience through development . There has also been a shift to focus on the processes that protect the development of youth from risk exposure instead of the traditional approach of focusing on individual protective factors . One key model in supporting this shift from individual to ecological can be traced to Bronfenbrenner's socio-ecological framework, which describes a child's development as a set of complex relationships within a concentric system that includes various levels of environmental influence from and between immediate family, school, cultural values and laws. The various levels of influence not only interact with the child but also interact with each other at different levels, which might explain the extent to which the child, depicted in the center of the model, is protected from nefarious threats to optimal psychosocial well-being. --- Multisystemic approaches: a welcome addition to the discourse The work of Masten , Masten et al. , and Ungar and Theron has marked an important departure from the individual focus of resilience to a multisystemic one. An important component of understanding resilience from a multisystemic approach is giving attention to the reciprocal interactions across multiple system levels evident in Bronfenbrenner's socioecological model. An individual child, depicted as the focal point of the socio-ecological model, engages with a number of systems, but primarily with family systems that include their caregivers, siblings, and other immediate members of the home. As that child develops, engagement with other families, friends, school, and community becomes more evident. Furthermore, that same child is also impacted, albeit indirectly, by other systems such as a caregiver's workplace and state government. One may speculate that if these dynamic multisystem processes are evident throughout a child's development, then the same can be applied to advanced resilience science. To this end, Masten et al. offers a new definition of resilience: "the capacity of a dynamic system to adapt successfully through multisystem processes to challenges that threaten the function, survival, or development of the system" . Similarly, Ungar and Theron assert that resilience is not an isolated individual quality; rather, it is a quality that leverages access to cultural resources and support at multiple levels to manage adversity. --- Why Black youth deserve more than successful adaption to racism Centering the processes of resilience available to an individual in the face of systemic-level problems like racism is insufficient; systemic adversities and trauma need to be prevented and reduced, thereby lessening the load that processes of resilience are often employed to mitigate . For example, public health evidence that supports focusing on individual-level behaviors, such as eating balanced and healthy meals, is ineffective to address nutrient deficiencies in youth without addressing accessibility of fresh healthy food options . Black youth, on the whole, are more likely to live in poverty and less likely to have access to quality education compared to White youth , yet are expected to pull themselves up by their "proverbial bootstraps" to both achieve individually and compete collectively. This colloquial expressionto elevate one's social positioning without assistanceinsinuates that there are no systemic barriers in place that prevent success for Black youth such as a lack of sufficient investments in public schools , safe and affordable neighborhoods and housing reinforced by historic laws of segregation , and the criminalization of Black boys in school . With systemic racism and structured inequities present in our society, resilience among Black youth will never overcome these oppressive forces due to individual behaviors alone. In addition to varying levels of racialized experiences, Black youth are also currently being exposed to a multitude of societal issues such as exaggerated effects from the COVID-19 global pandemic , economic uncertainty, and videos and commentary of unjust experiences of racism through media exposure . The experience of being subjected to racial discrimination through social media interactions or witnessing others' experiences with racism and violence is unique for Black youth of today and is a growing population-level public health concern . In addition to experiencing vicarious exposure to racism online, some Black youth are on the frontlines fighting against racism through protests, education, and activism , taking on a considerable amount of the resistance against racism and oppression, infringing on their ability to devote time and energy to other developmentally relevant activities. A number of positive or protective processes have been documented by engaging in activism , yet a growing body of evidence is unearthing the toll that this activism takes on the psychological and physical wellness of young people . This double-edged sword demonstrates how prior conceptualizations of resilience miss the damage that may be exacted when Black youth take up the charge to fight back against systems that are disproportionately fashioned against them. As such, the new generation of resilience research must eliminate the undue responsibility for Black youth to fight for the right to be young and grow old; rather, they deserve specific solutions that are necessary for their optimal development. Where we are and where we need to go: moving from coping and adaptation to agency and transformation Viewing racism as a multifaceted system that impacts youth development in multiple domains and across development, Jones et al. place this unique stressor directly in conversation with two of the most prevalent debates in the literature concerning the construct of resilience: whether resilience is defined as a positive developmental response to a singular negative life event or compounded negative events or demonstrated through excelling in one domain or excelling in multiple domains . For Black youth navigating the adversity and trauma of interpersonal and systemic racism on a consistent basis , one could speculate that resilience is no longer a characteristic or choice, but rather a forced act to live with, push through, and excel to survive. The ways researchers have studied and discussed resilience, particularly within the context of Black communities, may therefore sensationalize the survival and endurance of these communities, oftentimes not leading to actual or sustained efforts to eradicate the enduring effects of racism. It calls the humanity of the individuals experiencing the race-based trauma into question by essentially viewing them as rubber bands being pulled to their limits and remaining intact despite severe weathering, all while receiving little to no reinforcement or, better yet, coverage, from the systems and institutions that hold the power to prevent the erosion in the first place . Our perspective here mirrors discourse by prior scholars. Bottrell notes that so-called mainstream approaches to resilience, particularly through an individualistic lens, "may shift the emphasis from positive adaptation despite adversity to positive adaptation to adversity" . We contend that such an approach, adaptation to racism, has been rampant for far too long. We assert, as we outlined in the foregoing section, that Black youth should not have to adapt to racism. In fact, we contend that in some ways, our willingness to allow Black youth to adapt to racism is more deleterious than desirable. Again, as Masten rightly notes, resilience is "the dynamic capacity of a complex adaptive system to respond successfully to challenges that threaten the function, survival, or development of the system" . This begs the question, however, of what happens when we consider that racism is also a complex, adaptive system? What does it mean to imagine that racism, as such a system, responds "successfully" to our current and historical attempts to thwart its survival? As we have outlined in previous discourse , the system of racism is savvy and virulent. Thus, responding to racism in the same wayby asking Black youth to be resilientrepresents a form of systematic insanity, or doing the same thing and expecting a different outcome. An illustrative and contemporaneous example includes the machine learning algorithms found within powerful tools such as ChatGPT. This predictive text relies on script from large bodies of knowing, being, and doing and generates a response that is aligned with such prior input. It can therefore "learn" the ways to both embody and respond to discourse. While youth response to racial stressors has changed over time and proved beneficial in many regards, racism has also been able to study and learn from these efforts and waged new strategies and tactics in response, therefore dictating the input and the output of processes with which to contend. Laws enacted in 2022 and 2023 which point to fears around discussion of racism within classrooms or in libraries benefitted from understanding the fears of voters in the 2016 election, that is, the evolution of racial policy learned from the hope of the 2008 and 2012 elections . If we rely solely on individuals to fight against these larger machines, we will be woefully unprepared when that machine is stronger and bigger than even the programmers intended it to be. Though we acknowledge that a multisystem approach provides a welcomed improvement from the individual perspective, we express concern that this merely shifts from Black boys needing to have joy and Black girls needing to be magic, to Black families, Black teachers, and Black communities needing to be exceptional, all with only the mere promise of adapting to the nefariousness of racism. Holding these perspectives then, what is our recommendation for where we must ascend in consideration of supporting the optimal well-being of Black youth beset by racial prejudice, discrimination, and oppression? What follows is our attempt to begin answering this question, knowing that our response will be incomplete, and hoping that it will encourage those reading to also consider a world where adaptation is not the end goal. Of note, we organize our charge by re-centering the goals of resilience research from a psychological perspective, while also integrating the recommendations and considerations made by scholars in adjoining fields of social work, ecology, and public health. Masten reminds us that an ultimate goal of resilience research through a psychological perspective was to better understand positive adaptation in the context of adversity as a means of informing practices and policy. This begs the question of which are the practices and policies that need to emerge from our understanding of Black youth resilience in the face of racism? Although it is tempting to argue for deepening our understanding of practices such as racial socialization and racial identity , or even elevating policies that affirm racial pride in educational spaces , we maintain that such practices and policies are insufficient on their own. Rather, we offer a question from the field of social work, akin to what Bottrell posed in their critique of individual approaches to resilience: How much adversity should resilient individuals endure before social arrangements rather than individuals are targeted for intervention ? We find this question particularly important to consider in the context of Black youth's navigation of racism. For instance, we can conceptualize the cascading impacts of racism, such that individual experiences of racism intersect with institutional experiences of racism . We also know through the conceptual work of Elder et al. and the empirical work of Jones et al. that Black youth experience racism in dynamic, "linked lives'' ways, such that both experiences with and sequelae associated with racism travels in families, communities, and across generations. From this perspective then, even adopting a multisystemic resilience framework may omit the reality that Black parents, siblings, neighbors, educators, and clergy are similarly attempting to adapt despite the adversities of racism. Masten invokes several stakeholders in the research on resilience, including clinicians, educators, research institutes, and philanthropic foundations. Of note, each of these constituents, it can be argued, wields significant relative power in the fight against racism compared to the Black youth experiencing it. Thus, we would submit that the social arrangements that upheld racism as a nefarious threat to Black youth be targeted for intervention, and invite the various stakeholders in positions of power offering the first lines of intervening rather than Black youth or their families. It is important to note that our call is not unique. Rather, it joins and aligns with a recent call for paradigmatic shifts in the approach to resilience as utilized in health services research and public health . Similar to these authors, we agree with the limitations of a "resilience as treatment" framework, and elevate the consideration that resilience represents an "adverse event" and "scar tissue" as a result of structural harm, often to the most marginalized, such as Black youth . In imagining alternative approaches to resilience in the face of racism, notions of agency and transformation loom large. Of note, agency is seen through a collective and relational, rather than individualistic lens . Moreover, Lister , in their discussion of poverty, an apt social system when considering racism, offers multiple forms of agency, viewed through two axes. The first axis concerns a continuum between everyday and strategic forms of action. The second axis concerns a continuum between personal and more political or collective forms of action. As such, Lister argues that actions in response to adversity can be personalXeveryday, collectiveXeveryday, personalXstrategic, and collectiveXstrategic. Indeed, Brown and Westaway in their discussion of environmental and climate change offer a useful taxonomy, which employs this axial approach. As seen in Figure 1, Brown and Westaway utilized the aforementioned axes to draw distinctions among coping , self-help , adaptation , and transformation . Although both coping and adaptation are familiar in the psychological discourse on resilience, we wish to briefly define transformation as offered by Hackman and St Clair . According to these scholars, transformation is a process of altering the fundamental attributes of a system, which can include structures and institutions, finances, attitudes and practices, policies, and power dynamics. In the consideration of Black youth's navigation of racism as adversity, we focus on the distinctions among coping, adaptation, and transformation. We conceptualize Black youth's ability to read, recast, and resolve racially stressful encounters in their everyday lives ; to employ both emotion-and problem-focused approaches to experiences with racism ; and to adopt culturally relevant practices as key indicators that these youth demonstrate a remarkable ability to cope with racism. We also concede that the impressive, nearly four-decade research on racial socialization as a process and a practice, centering content and competency , as well as the companion legacy of positive racial identity development serve as preeminent examples that Black youth and the families from whence they come are able to adapt to racism. And yet, we contend that coping and adaptation are insufficient, and that, ultimately, transformationfundamental changes to navigating racismis not only what is needed, but is what is due Black babies, children, and adolescents. --- Conclusion We conclude by reflecting on Masten's question concerning resilience: "What makes a difference?" . Indeed, concerning Black youth navigating racism, how would a model of resisting racism in a multisystemic and collective manner look differently than the individual and multisystemic resilience approaches for Black youth? How might that interdisciplinary model or models differentially respond to the complex and involving system that is racism, not allowing it to run roughshod over Black youth, but rather, offer avenues for thwarting racism's attempts at continued resilience and existence? And ultimately, how would such a model make the difference? As scholars and practitioners concerned with social and behavioral health, we posit this needed framework and practice would optimally support the psychosocial well-being and thriving of Black youth, in turn supporting the wellbeing and thriving of our society more broadly. Importantly, however, the solution would not rest in any individual system. It requires the understanding, interlocking, and retooling of each system to ensure that the psychosocial outcomes of youth are optimal. As humans, organizations, and societies come together to actively eradicate racism from its systems, it is critical to move lockstep in the provision of resources and resistance across systems. As a practical example, when "busing" opportunities are offered to Black youth to provide them with exposure to a new educational experience, are we simultaneously reassessing: a) asbestos-free buildings and residences; b) tax-based educational policies; c) outdated pedagogy, and d) beliefs that by virtue of Black youth being around youth who do not look like them, they will have optimal outcomes? Are we providing identity-based support for their out-of-school time to ensure they get all of the benefits of being around people who share their identity? In total, are we thinking, behaving, and planning collectively or focusing solely within our silo or for individual youth? In our acknowledgment that even our own sub-discipline of racial socialization is insufficient in tackling this gargantuan task, we must also shine a light on the challenges to move forward conjointly if scholars across disciplines are not citing and or reading each other's work. In preparation for this paper, we were astonished by the wealth of thought on resilience outside of the social and behavioral sciences, yet also amazed at the lack of crossdisciplinary acknowledgment of this work. Future research will require these multidisciplinary teams of scholars across "levels and lanes" such that eminent scholars from psychology to ecology should all join forces for this wicked problem. Moving collectively and en masse is required as we advance multisystemic resilience theory and practice for Black youth in the next generation until there is no racialized stressor for which Black youth need to be resilient.

The narrative surrounding the impact racism has had on the well-being of Black youth has shifted across sociocultural and historical context. Early discourse around these topics were problem-saturated, focusing on deficits "within" Black youth. Over time, an important narrative shift occurred: greater attention was paid to the inherent assets of Black youth, their families, and communities, including how racial-ethnic protective factors such as racial socialization afforded them resilience. What resulted was decades of research seeking to understand the mechanisms that allow Black youth to bounce back in spite of racism-related adversity. Notwithstanding the viable practice and policy implications that have emerged from such inquiry, at what point does our focus on the resilience of Black youthwhether individual or multisystemicfall short? It is with this question in mind that this paper challenges those committed to the optimal development of Black youth to consider yet another narrative shift: one that stands upon the legacy of cultural ecological frameworks and the seminal models underlying resilience research, and calls us toward not supporting Black youth's adaptation to racism, but toward collective efforts to transform our approach, pushing back against the perniciousness of racism.

introduction black youth in the united states have had to grow up with the unique challenge of navigating the textured terrain of american societys history with racism not only has the impact of individual and institutional level racism been detrimental to black youth and their families early academic and policy discourse also furthered racisms destruction by promoting a deficit perspective that wrongfully held black families and communities responsible for experiences of adversity since then research and policy have shifted to highlighting the inherent cultural strengths of black families which allows black youth to persist even in the face of racismrelated stressors and adversity processes of resiliencenow an assetcentered multidimensional construct for promoting psychosocial wellbeing in black youthrepresents a habituation to adversity in which factors such as selfregulation cultural strengths social support and efforts to cope undergird positive outcomes such as academic success and social mobility although resilience research is making a broader shift to integrate multisystemic efforts to combat adverse circumstances and events there is still a gap concerning how racismrelated stressors can come at a cost to black youth thus we posit an expansion to the contemporary models of resilience to combat the psychosocial impacts of racism a unique stressor that influences the psychosocial wellbeing of black youth at individual familial cultural and communal levels as such we integrate perspectives from psychology social work ecology and public health to reimagine and consider what it would take to move away from examining contextual factors of resilience for black youth and push toward a collective effort from systems and institutions to address the deleterious effects of racism with the power and structural influence they possess answering resilience researchs big three inquiries in the context of racism and black youth we began our attempt to interrogate a resiliencebased approach to racism by situating black youth and their experiences with racism within the broader resilience research literature in recent masterful reviews outlining the evolution of resilience science masten and colleagues remind the field that from the onset the research on resilience attempted to understand and operationalize three major components 1 what is the challenge risk or adversity 2 how is successful adaptation defined and 3 what are the factors or processes that account for this successful adaptation in the subsequent sections we seek to briefly answer questions number one and three before returning our attention to two towards the end racism as a critical challenge risk and adversity for black youth research on resilience as well as developmental models such as bronfenbreners socioecological framework highlight adverse environments and circumstances that may emerge generally for all youth however in considering the treatment of resilience for black youth in particular it is critical to highlight the deleterious role of racism to understand racisms impact as a challenge risk factor and source of adversity for black youth we must first define and operationalize racism racism as defined by jones is a system in which individuals or institutions intentionally or unintentionally exercise power against a racial group defined as inferior and is fueled by an ideology of superiority and the practice of inequity racism by this definition is a social construct that evolves is perpetuated and pervasively affects every aspect of our society as well as individuals within that society unlike most stressors examined by resilience theories including natural disasterswhich are finite crisesor personally traumatic experiences there are continuous and multiple levels upon which racism occurs ranging from individual bias to inequitable policy enacted on the institutional and systemic levels for the individual racism exacts a unique impact on many parts of their development including identity formation character development interpersonal development and physical health the deep rooted history and the social construction of racism provides a nuanced backdrop for how individuals are impacted by this multisystemic determinant often leading to physical psychological and emotional trauma that transcends through generations jones et al categorized racism into three main categories instrumental interpersonal and institutional through an instrumental lens racism impacts black children and adolescents by them being perceived as older and more dangerous receiving less culturally affirming early education and childcare experiences and experiencing harsher treatment grading and punishment due to their race from their teachers interpersonally black youth experience direct encounters of racism as well as bearing witness to vicarious racism involving caregivers and peers with these experiences occurring both in person and online black youth and teens in particular encounter substantial institutional experiences with racism such as policies that result in higher interactions with and trauma by police and school administrators racism also differentially impacts black youth across gender perpetuated stereotypes around race and gender and their intersections often lead to more negative reactions to racial discrimination black males are often stereotypically deemed as aggressive or intellectually lacking athletes these stereotypes often lead to black male youth receiving more negative treatment in schools including harsher discipline more criticism and more social exclusion compared to their peers similarly parental racial socialization messages often include more messages around racial barriers and alertness to racial discrimination for black boys compared to black girls in reaction to the societal stereotypes of black males while black girls also report experiencing discriminatory or negative treatment from valued others due to their race scholars speculate that black girls have more negative reactions to discriminatory treatment due to more frequent socialization messages focused on relationships connectedness to community and approval of others as opposed to messages preparing them for such racial discrimination this may also lead black girls to develop negative approaches to their academics to avoid having such negative interactions and treatment from their teachers and peers these differential impacts of racism on girls and boys in adolescence can have implications throughout their lifetime the literature has expanded theories and models to account for the influence of racism on resilience across youth development both garcia coll et als integrative model and spencer et als phenomenal variant of ecological systems theory extend bronfenbreners socioecological model in ways that consider the unique realities youth of color must navigate by incorporating aspects of intersectionality and developmental identity theory these theories put the vulnerability of youth into the context of their social position and experiences that are most often linked to systems of oppression and power structures moreover in addition to viewing racism as a detrimental factor to positive outcomes for black youth these models center how others within the ecosystem can mitigate the stress and vulnerability that racism portends racialethnic protective factors for black youth experiencing racism of note scholars committed to the healthy psychosocial development of black youth have spent decades elucidating the factors that protect black youth against the noxious nature of racism in its multiple forms even from the earliest conceptualizations of black youth development racialethnic protective factors were named as critical for understanding black youth resilience and successful adaptation three racialethnic protective factors have been distinguished as particularly salient for black youth racial identity development the endorsement of a culturalafricentric worldview and racial socialization racial identity research on racial identity development among black youth often contend with sellers et als multidimensional model of racial identity which encompasses markers of racial centrality privatepublic racial regard and ideology when developed in a manner that favors a strong positive racial identity these three dimensions coagulate to form the protective barrier against racism for instance a strong racial identity has been shown to interrupt the association between racial discrimination and poor mental health conceptual models of successful adaptation to adversity note that an awareness around others and ones own perceptions about their racial group brings along with it high selfesteem use of effective coping strategies and a lower likelihood of attributing instances of discrimination to the self all circumventing the deleterious impact of racism on black youth wellbeing africentric worldview in addition to racial identity the literature also points to the endorsement of an africentric worldview as a significant protective factor against racism africentric worldview refers to a broad system of beliefs values expectation and behaviors of those part of the african diaspora to make meaning of their immediate contexts africentric worldview includes several different dimensions all of which originate from key cultural aspects of african heritage spirituality collectivism time orientation orality sensitivity to affect and emotional cues verve and rhythm and balance and harmony a popular endorsement of africentric worldview is also apparent in the nguzo saba or the cultural celebration of kwanzaa in which principles such as unity selfdetermination collective work and responsibility cooperative economics purpose and faith are emphasized in jones and nebletts systematic review africentric worldview through nguzo saba was an essential component of psychosocial prevention and intervention programs that promoted principles spanning from conflict resolution to finding a path to ones purpose not only has africentric worldview been linked to a host of promotive factors for black youth such as selfesteem academic adjustment and positive racial identity it has also been deemed protective against negative psychological and physiological outcomes associated with racismrelated stress unfortunately traditional school practices media portrayals and societal views do not have a history of promoting racial identity or africentric worldview for black youth rather these factors are typically tended to by a process called racial socialization racial socialization racial socialization is a process through which family members andor caregivers transmit implicit and explicit messages regarding the meaning of their race and ethnicity and help youth cope with racial discrimination and other racismrelated stressors researchers have identified different dimensions of rs messages of cultural socializationracial pride preparation for bias egalitarianism selfworth promotion of mistrust negative messages and silence about race many of these rs dimensions have been linked to a number of promotive effects for black youth such as better academic performance psychological wellbeing and socioemotional adjustment and racial identity rs is also a multifaceted protective factor against racial discrimination for instance when coalesced messages of cultural socialization and preparation for bias have been shown to buffer the relationship between racial discrimination and black youths perceived stress and problem behaviors while the bevy of research on rs has centered around the content of caregiver rs scholars have contributed more recent research spanning from theoretical frameworks such as the racial encounter coping appraisal and socialization theory to multilevel and bidirectional transmission of rs messages recast calls on competency in delivering rs messages as a means for caregivers to know and understand the most effective delivery of rs messages to youth by taking into account their attitudes behaviors and reactions during discriminatory racial encounters thus recast asserts that caregivers being skilled and confident in rs delivery promotes greater racial coping skills in youth a speculative but supported factor in explaining successful adaptation to adversity for black youth while studies using the recast model have focused on caregiver competency in assessing the quality of rs communication to youth others have explored the impact of rs from various contextual levels such as peers media platforms and school transmission recent studies demonstrate the bidirectional nature of rs communication among these levels in that peers reported using media as a catalyst and prompt for rs supporting a steady flow of communication from one peer to another likewise saleem and byrd proposed a conceptual framework that positions teachers and staff peers and school policies and practices as key transmitters of rs in the school context taken together it is evident that research on rs processes has shown itself to be good soil for growing the racial factors of resilience and successful adaptation and importantly through the incorporation of other individuals or systems to promote such processes for black youth defining black youths successful adaptation from racism resilience sciences evolution and limitations as masten and others have noted a critical question in resilience research is illuminating and defining what successful adaptation from a challenge or stressor looks like in the lives of youth as we consider this question with the adversity of racism in mind we find it instructive to pair our answer with a discussion on the progression and evolution of resilience science historical focus on individual traits in framing our argument for an alternative approach to supporting the mental health and wellbeing of black youth in the context of racism it is necessary to begin by outlining the ways in which resilience has historically been applied to these young people resilience was considered as a way of phenomenologically understanding how youth achieved positive psychosocial outcomes despite developing in adverse environments and being exposed to potentially deleterious circumstances this dynamic process encompassing positive adaptation within the context of significant adversity has led researchers over the past several decades to identify and isolate personcentered factors that seem most likely to protect against negative outcomes as such the lions share of resilience literature to date has congregated at the individual level masten et al describes four major waves of resilience research with the first three focused on identifying individual attributes that separate those who did well versus those that did poorly in the context of risk explaining why certain individual attributes lead to better adaptation and targeting the development of these attributes to promote adjustment during adversity here it is evident that much of the research on resilience at the individual level has persisted despite arguments for a multisystem approach but why who does it serve for resilience to be studied as an individual trait the persistence of research emphasizing grit hardiness and selfregulation all maps onto western ideals of individualism which consistently places the onus of hardship and or success on the individual rather than considering the multiple societal and historical levels that are primarily at fault however as the field evolved and the literature on resilience expanded researchers have come to recognize the more prominent role of external factors on a childs resilience through development there has also been a shift to focus on the processes that protect the development of youth from risk exposure instead of the traditional approach of focusing on individual protective factors one key model in supporting this shift from individual to ecological can be traced to bronfenbrenners socioecological framework which describes a childs development as a set of complex relationships within a concentric system that includes various levels of environmental influence from and between immediate family school cultural values and laws the various levels of influence not only interact with the child but also interact with each other at different levels which might explain the extent to which the child depicted in the center of the model is protected from nefarious threats to optimal psychosocial wellbeing multisystemic approaches a welcome addition to the discourse the work of masten masten et al and ungar and theron has marked an important departure from the individual focus of resilience to a multisystemic one an important component of understanding resilience from a multisystemic approach is giving attention to the reciprocal interactions across multiple system levels evident in bronfenbrenners socioecological model an individual child depicted as the focal point of the socioecological model engages with a number of systems but primarily with family systems that include their caregivers siblings and other immediate members of the home as that child develops engagement with other families friends school and community becomes more evident furthermore that same child is also impacted albeit indirectly by other systems such as a caregivers workplace and state government one may speculate that if these dynamic multisystem processes are evident throughout a childs development then the same can be applied to advanced resilience science to this end masten et al offers a new definition of resilience the capacity of a dynamic system to adapt successfully through multisystem processes to challenges that threaten the function survival or development of the system similarly ungar and theron assert that resilience is not an isolated individual quality rather it is a quality that leverages access to cultural resources and support at multiple levels to manage adversity why black youth deserve more than successful adaption to racism centering the processes of resilience available to an individual in the face of systemiclevel problems like racism is insufficient systemic adversities and trauma need to be prevented and reduced thereby lessening the load that processes of resilience are often employed to mitigate for example public health evidence that supports focusing on individuallevel behaviors such as eating balanced and healthy meals is ineffective to address nutrient deficiencies in youth without addressing accessibility of fresh healthy food options black youth on the whole are more likely to live in poverty and less likely to have access to quality education compared to white youth yet are expected to pull themselves up by their proverbial bootstraps to both achieve individually and compete collectively this colloquial expressionto elevate ones social positioning without assistanceinsinuates that there are no systemic barriers in place that prevent success for black youth such as a lack of sufficient investments in public schools safe and affordable neighborhoods and housing reinforced by historic laws of segregation and the criminalization of black boys in school with systemic racism and structured inequities present in our society resilience among black youth will never overcome these oppressive forces due to individual behaviors alone in addition to varying levels of racialized experiences black youth are also currently being exposed to a multitude of societal issues such as exaggerated effects from the covid19 global pandemic economic uncertainty and videos and commentary of unjust experiences of racism through media exposure the experience of being subjected to racial discrimination through social media interactions or witnessing others experiences with racism and violence is unique for black youth of today and is a growing populationlevel public health concern in addition to experiencing vicarious exposure to racism online some black youth are on the frontlines fighting against racism through protests education and activism taking on a considerable amount of the resistance against racism and oppression infringing on their ability to devote time and energy to other developmentally relevant activities a number of positive or protective processes have been documented by engaging in activism yet a growing body of evidence is unearthing the toll that this activism takes on the psychological and physical wellness of young people this doubleedged sword demonstrates how prior conceptualizations of resilience miss the damage that may be exacted when black youth take up the charge to fight back against systems that are disproportionately fashioned against them as such the new generation of resilience research must eliminate the undue responsibility for black youth to fight for the right to be young and grow old rather they deserve specific solutions that are necessary for their optimal development where we are and where we need to go moving from coping and adaptation to agency and transformation viewing racism as a multifaceted system that impacts youth development in multiple domains and across development jones et al place this unique stressor directly in conversation with two of the most prevalent debates in the literature concerning the construct of resilience whether resilience is defined as a positive developmental response to a singular negative life event or compounded negative events or demonstrated through excelling in one domain or excelling in multiple domains for black youth navigating the adversity and trauma of interpersonal and systemic racism on a consistent basis one could speculate that resilience is no longer a characteristic or choice but rather a forced act to live with push through and excel to survive the ways researchers have studied and discussed resilience particularly within the context of black communities may therefore sensationalize the survival and endurance of these communities oftentimes not leading to actual or sustained efforts to eradicate the enduring effects of racism it calls the humanity of the individuals experiencing the racebased trauma into question by essentially viewing them as rubber bands being pulled to their limits and remaining intact despite severe weathering all while receiving little to no reinforcement or better yet coverage from the systems and institutions that hold the power to prevent the erosion in the first place our perspective here mirrors discourse by prior scholars bottrell notes that socalled mainstream approaches to resilience particularly through an individualistic lens may shift the emphasis from positive adaptation despite adversity to positive adaptation to adversity we contend that such an approach adaptation to racism has been rampant for far too long we assert as we outlined in the foregoing section that black youth should not have to adapt to racism in fact we contend that in some ways our willingness to allow black youth to adapt to racism is more deleterious than desirable again as masten rightly notes resilience is the dynamic capacity of a complex adaptive system to respond successfully to challenges that threaten the function survival or development of the system this begs the question however of what happens when we consider that racism is also a complex adaptive system what does it mean to imagine that racism as such a system responds successfully to our current and historical attempts to thwart its survival as we have outlined in previous discourse the system of racism is savvy and virulent thus responding to racism in the same wayby asking black youth to be resilientrepresents a form of systematic insanity or doing the same thing and expecting a different outcome an illustrative and contemporaneous example includes the machine learning algorithms found within powerful tools such as chatgpt this predictive text relies on script from large bodies of knowing being and doing and generates a response that is aligned with such prior input it can therefore learn the ways to both embody and respond to discourse while youth response to racial stressors has changed over time and proved beneficial in many regards racism has also been able to study and learn from these efforts and waged new strategies and tactics in response therefore dictating the input and the output of processes with which to contend laws enacted in 2022 and 2023 which point to fears around discussion of racism within classrooms or in libraries benefitted from understanding the fears of voters in the 2016 election that is the evolution of racial policy learned from the hope of the 2008 and 2012 elections if we rely solely on individuals to fight against these larger machines we will be woefully unprepared when that machine is stronger and bigger than even the programmers intended it to be though we acknowledge that a multisystem approach provides a welcomed improvement from the individual perspective we express concern that this merely shifts from black boys needing to have joy and black girls needing to be magic to black families black teachers and black communities needing to be exceptional all with only the mere promise of adapting to the nefariousness of racism holding these perspectives then what is our recommendation for where we must ascend in consideration of supporting the optimal wellbeing of black youth beset by racial prejudice discrimination and oppression what follows is our attempt to begin answering this question knowing that our response will be incomplete and hoping that it will encourage those reading to also consider a world where adaptation is not the end goal of note we organize our charge by recentering the goals of resilience research from a psychological perspective while also integrating the recommendations and considerations made by scholars in adjoining fields of social work ecology and public health masten reminds us that an ultimate goal of resilience research through a psychological perspective was to better understand positive adaptation in the context of adversity as a means of informing practices and policy this begs the question of which are the practices and policies that need to emerge from our understanding of black youth resilience in the face of racism although it is tempting to argue for deepening our understanding of practices such as racial socialization and racial identity or even elevating policies that affirm racial pride in educational spaces we maintain that such practices and policies are insufficient on their own rather we offer a question from the field of social work akin to what bottrell posed in their critique of individual approaches to resilience how much adversity should resilient individuals endure before social arrangements rather than individuals are targeted for intervention we find this question particularly important to consider in the context of black youths navigation of racism for instance we can conceptualize the cascading impacts of racism such that individual experiences of racism intersect with institutional experiences of racism we also know through the conceptual work of elder et al and the empirical work of jones et al that black youth experience racism in dynamic linked lives ways such that both experiences with and sequelae associated with racism travels in families communities and across generations from this perspective then even adopting a multisystemic resilience framework may omit the reality that black parents siblings neighbors educators and clergy are similarly attempting to adapt despite the adversities of racism masten invokes several stakeholders in the research on resilience including clinicians educators research institutes and philanthropic foundations of note each of these constituents it can be argued wields significant relative power in the fight against racism compared to the black youth experiencing it thus we would submit that the social arrangements that upheld racism as a nefarious threat to black youth be targeted for intervention and invite the various stakeholders in positions of power offering the first lines of intervening rather than black youth or their families it is important to note that our call is not unique rather it joins and aligns with a recent call for paradigmatic shifts in the approach to resilience as utilized in health services research and public health similar to these authors we agree with the limitations of a resilience as treatment framework and elevate the consideration that resilience represents an adverse event and scar tissue as a result of structural harm often to the most marginalized such as black youth in imagining alternative approaches to resilience in the face of racism notions of agency and transformation loom large of note agency is seen through a collective and relational rather than individualistic lens moreover lister in their discussion of poverty an apt social system when considering racism offers multiple forms of agency viewed through two axes the first axis concerns a continuum between everyday and strategic forms of action the second axis concerns a continuum between personal and more political or collective forms of action as such lister argues that actions in response to adversity can be personalxeveryday collectivexeveryday personalxstrategic and collectivexstrategic indeed brown and westaway in their discussion of environmental and climate change offer a useful taxonomy which employs this axial approach as seen in figure 1 brown and westaway utilized the aforementioned axes to draw distinctions among coping selfhelp adaptation and transformation although both coping and adaptation are familiar in the psychological discourse on resilience we wish to briefly define transformation as offered by hackman and st clair according to these scholars transformation is a process of altering the fundamental attributes of a system which can include structures and institutions finances attitudes and practices policies and power dynamics in the consideration of black youths navigation of racism as adversity we focus on the distinctions among coping adaptation and transformation we conceptualize black youths ability to read recast and resolve racially stressful encounters in their everyday lives to employ both emotionand problemfocused approaches to experiences with racism and to adopt culturally relevant practices as key indicators that these youth demonstrate a remarkable ability to cope with racism we also concede that the impressive nearly fourdecade research on racial socialization as a process and a practice centering content and competency as well as the companion legacy of positive racial identity development serve as preeminent examples that black youth and the families from whence they come are able to adapt to racism and yet we contend that coping and adaptation are insufficient and that ultimately transformationfundamental changes to navigating racismis not only what is needed but is what is due black babies children and adolescents conclusion we conclude by reflecting on mastens question concerning resilience what makes a difference indeed concerning black youth navigating racism how would a model of resisting racism in a multisystemic and collective manner look differently than the individual and multisystemic resilience approaches for black youth how might that interdisciplinary model or models differentially respond to the complex and involving system that is racism not allowing it to run roughshod over black youth but rather offer avenues for thwarting racisms attempts at continued resilience and existence and ultimately how would such a model make the difference as scholars and practitioners concerned with social and behavioral health we posit this needed framework and practice would optimally support the psychosocial wellbeing and thriving of black youth in turn supporting the wellbeing and thriving of our society more broadly importantly however the solution would not rest in any individual system it requires the understanding interlocking and retooling of each system to ensure that the psychosocial outcomes of youth are optimal as humans organizations and societies come together to actively eradicate racism from its systems it is critical to move lockstep in the provision of resources and resistance across systems as a practical example when busing opportunities are offered to black youth to provide them with exposure to a new educational experience are we simultaneously reassessing a asbestosfree buildings and residences b taxbased educational policies c outdated pedagogy and d beliefs that by virtue of black youth being around youth who do not look like them they will have optimal outcomes are we providing identitybased support for their outofschool time to ensure they get all of the benefits of being around people who share their identity in total are we thinking behaving and planning collectively or focusing solely within our silo or for individual youth in our acknowledgment that even our own subdiscipline of racial socialization is insufficient in tackling this gargantuan task we must also shine a light on the challenges to move forward conjointly if scholars across disciplines are not citing and or reading each others work in preparation for this paper we were astonished by the wealth of thought on resilience outside of the social and behavioral sciences yet also amazed at the lack of crossdisciplinary acknowledgment of this work future research will require these multidisciplinary teams of scholars across levels and lanes such that eminent scholars from psychology to ecology should all join forces for this wicked problem moving collectively and en masse is required as we advance multisystemic resilience theory and practice for black youth in the next generation until there is no racialized stressor for which black youth need to be resilient

the narrative surrounding the impact racism has had on the wellbeing of black youth has shifted across sociocultural and historical context early discourse around these topics were problemsaturated focusing on deficits within black youth over time an important narrative shift occurred greater attention was paid to the inherent assets of black youth their families and communities including how racialethnic protective factors such as racial socialization afforded them resilience what resulted was decades of research seeking to understand the mechanisms that allow black youth to bounce back in spite of racismrelated adversity notwithstanding the viable practice and policy implications that have emerged from such inquiry at what point does our focus on the resilience of black youthwhether individual or multisystemicfall short it is with this question in mind that this paper challenges those committed to the optimal development of black youth to consider yet another narrative shift one that stands upon the legacy of cultural ecological frameworks and the seminal models underlying resilience research and calls us toward not supporting black youths adaptation to racism but toward collective efforts to transform our approach pushing back against the perniciousness of racism

Introduction Socioeconomic position is a fundamental cause of health disparities [1]. Those occupying higher rungs on the socioeconomic ladder tend to experience lower rates of morbidity and mortality compared to those placed lower in the social hierarchy [2,3]. In addition to socioeconomic position attained in adulthood, socioeconomic origins exert significant and independent effects on later life health [4,5], reflecting the "long arm" of childhood circumstances [6][7][8]. The enduring effects of childhood circumstances are thought to represent the downstream consequences of cumulative advantage and disadvantage, whereby stresses and strains accrue over the life course to a greater extent among those in socially disadvantaged positions, setting in motion more rapid aging or weathering of biological systems under conditions of chronic adversity [9,10]. An unresolved question in social stratification and social epidemiological research is whether the movement between origin and destination socioeconomic positions, per se, influences health net of origin and destination effects. Because social mobility is linearly dependent on both social origin and destination, traditional regression frameworks are not able to separately estimate the effects of socioeconomic origin, destination, and social mobility simultaneously [11][12][13], calling into question much of the existing evidence [14]. While Sobel's diagonal reference models overcome this methodological limitation [15], few studies have utilized this statistical approach when investigating the health effects of social mobility, particularly in the North American context. This represents an important gap in the literature given renewed scholarly interest in intergenerational transmission of advantages and declining social mobility in the United States [16][17][18]. --- Key theories on health consequences of social mobility Two main theoretical perspectives predict, respectively, negative and positive health consequences of upward social mobility. Sorokin's dissociative thesis views upward social mobility as a deviation from expected continuity associated with individuals' social origins [19]. Adjusting to an unfamiliar socioeconomic environment, while also socially distancing from the familiar and more natural past environment, can be a major stress-inducing process compromising upwardly mobile individuals' psychological and, consequently, physical health. In turn, an alternative perspective, so-called "rags to riches" thesis [20], suggests that upward social mobility could lead to better health outcomes by generating a sense of personal control, boosting psychological well-being from overcoming life course constraints, fostering healthy behaviours and lifestyles, and developing a health conducive sense of gratitude among the upwardly mobile individuals [21][22][23][24][25]. In recent years scholarly interest in health consequences of downward rather than upward social mobility has become particularly salient. This is in line with the post-liberal theory of social stratification which views social mobility primarily in terms of offspring attaining worse off living conditions than their parents did [26]. The so-called "falling from grace" thesis implies that downward social mobility leads to an undesirable loss of an ascribed socioeconomic position at birth and associated changes in practices, behaviours, and norms [27,28]. The perception of downward mobility as undeserved and unjust, together with the overall psychological maladjustment to a new environment, can precipitate chronic stress and thus compromise the health of downwardly mobile individuals [29,30]. Downward mobility may also increase the stress associated with financial hardship, a well-known correlate of physical and mental health [31]. Given these multiple perspectives, one of the goals of our study is to derive new evidence on the merits of the main health-related theories of social mobility. --- Independent social mobility and health selection effects An overview of the existing studies does not provide conclusive answers about social mobility effects on health, as many studies report null findings [14,32]. When significant associations of upward social mobility and health are identified, these links are not usually detrimental for health [20], while downward mobility in a number of studies was found to be damaging to health [33]. Inferring from these findings, however, is problematic because researchers use different indicators of mobility in socioeconomic position such as occupational class, status, education, and income. Moreover, social mobility research is characterised by at least two significant methodological constraints: first, relatively few studies use a statistical approach which is able to separately identify the relative importance of origin and destination socioeconomic position, while also isolating the effect of social mobility on health outcomes; and second, most studies rely on cross-sectional datasets, and are thus unable to differentiate between health selection and social causation effects when studying health implications of social mobility. Referring to the first problem, many studies on the health consequences of social mobility continue to apply conventional regression approaches which usually differentiate social mobility trajectories by combining individuals' origin and destination positions and subsequently comparing health outcomes between these mobility groups; alternatively, some scholars simply omit from models either origin or destination socioeconomic positions to produce an estimate for health effect of upward or downward social mobility [14,34]. These analytical strategies are useful if researchers primarily intend to identify the role of origin and/or destination socioeconomic position for individuals' health, but they are unable to differentiate if health outcomes are independently affected by position and mobility effects. To mitigate this concern, researchers have proposed a special form of regression model that was developed to estimate the relative effects of two hierarchically ranked socioeconomic positions and the net effect of a movement between these two positions on the outcome variable of interest [11]. The second methodological concern implies addressing a likely bias stemming from health selection by which individuals' initial poor and good health not only, respectively, limits upward and facilitates downward mobility, but also is causally related to later life health. If health before social mobility is not accounted for, any possible health effects of social mobility can be erroneously attributed to social causation rather than to the health selection effects [35]. The role of health selection has been shown to be stronger for a transition process from adolescence to adulthood than for later life course transitions [36]. Considering the importance of initial health for educational attainment and resultant success on labour market, an intriguing and underexplored question is what are the health implications for those individuals who, regardless of initial health constraints, still manage to experience upward social mobility? Both positive and negative consequences can be predicted as mobility for disadvantaged individuals might imply greater costs, yet they might also derive greater psychological benefits from overcoming barriers on their social mobility journeys [37]. --- Social mobility and health measures Adding to complexity, social mobility's effects might differ not only if initial health is accounted for, but also depending on the type of health measures used in studies. The most prevalent outcome variable employed by scholars, due to its wide availability in social surveys, is self-rated health [34,38,39]. Yet, self-rated health is not a perfect predictor of objective indicators of health and people might think of different aspects of wellbeing while assessing their health status [40,41]. Some studies also use depressive symptoms to identify possible effects of social mobility on health, but they are not able to capture any effects of social mobility on physical health [20,42]. Timing of death, on the other hand, can be considered as a reliable indicator of health outcome, but data on mortality is mainly useful for studying later life health based on panel/cohort surveys or register-based datasets [43,44]. In this study, we use allostatic load, an index of multi-system physiological dysregulation among individuals [32], to identify the health implications of social mobility. This measure takes into account various aspects of health and provides information on valid variation in health already at a relatively young age [45,46]. --- Heterogeneous position and mobility effects Existing studies on health inequalities suggest that different sociodemographic and socioeconomic groups have vastly different levels of allostatic load. Individuals' age, for instance, is strongly associated with allostatic load, which might imply that across individuals' life course mobility effects on AL also vary. The recent evidence also suggests that mobility effects across European societies are more pronounced among young people than among the elderly [39]. One of the explanations for this could be that psychological and stress-related costs and benefits of social mobility experience have primarily short-term effects that dissipate later in the life course [36]. Existing research on the health consequences of social mobility also indicates that the origin socioeconomic position might matter more for women than for men, while, in turn, mobility effects are more salient for men than women [20]. Social origin, attained socioeconomic position, and mobility between origin and destination positions might have varying implications for various sociodemographic groups which are known to have vastly different health and wellbeing outcomes due to historical, institutional, and structural differences. Race is of central importance in these respects. In the United States, racial and ethnic inequalities in health and illness are well documented [47], and a growing body of research demonstrates the myriad ways that structural racism contributes to these disparities [48]. In addition to contemporaneous inequities, Gaydosh and colleagues argue that the health effects of social mobility may hinge on the disproportionate stressors experienced by racialized groups [49]. The John Henryism hypothesis, for example, posits that African American individuals are exposed to myriad psychosocial adversities throughout the life course, and that the active coping strategies employed to cope with such exigencies result in biological wear and tear [50,51]. Recent studies also suggest African Americans from disadvantaged backgrounds form a "skin-deep resilience," wherein a higher sense of control may lead to favourable psychological outcomes but greater physiological dysregulation [52][53][54][55]. --- The United States as a case study The United States is an interesting case to study the health consequences of social mobility as it is characterized by widening socioeconomic inequalities [56] and declining levels of intergenerational social mobility [17,57]. The United States also has one of the most comprehensive panel datasets, described in detail below, which allows us to investigate socioeconomic origin and destination, social mobility, and selection effects on individuals' health. The same dataset used in the present study has been previously employed to investigate different health aspects of social mobility, including adolescent stressful experiences [58], early adversity on later life health through psychosocial resources [59], and the effects of life course socioeconomic position on cardiovascular health [60]. In turn, our contribution to the relevant scholarship is that we study consequences of social mobility on health by constructing a robust indicator of socioeconomic position for both individuals and their parents; identifying the relative importance of origin and destination socioeconomic positions on health; detecting any residual effects of social mobility; testing if position and mobility effects differ by sociodemographic characteristics such as gender and race; and examining the role of health selection in the observed associations. --- Methods --- Dataset The National Longitudinal Study of Adolescent Health is a representative longitudinal study of individuals in the United States who were adolescents in the beginning of the 1990s. The study started in 1994-95 with Wave I of the panel which included data on 20,745 adolescents aged 12 to 19. By the time of writing, in the latest publicly available Wave IV, conducted in 2007-2008, the number of interviewed participants declined to 15,701 with their average age of 29. Attrition did not occur completely at random, but rather the main identified predictors of response in Wave IV were individuals' gender, race, and parental education [61]. For this analysis, we use data from Waves I and IV. Due to cost-related considerations, in this study, we used the public-use version of Add Health with about 40% of respondents chosen randomly from the restricted-full sample. The main differences between the public and the restricted versions of Add Health arise due to confidentiality concerns. The full version of the dataset contains more sensitive information on respondents including their romantic relationships and DNA-related data. The later information is not of primary interest for our study, while the random mode of selection of participants for the public-use version of Add Health ensures that it is a representative survey data of the United States population of the relevant age. After list-wise deletion of observations with missing information, 4,713 individuals were available for our analysis. --- Measures --- Health outcome. Numerous past studies used the Add Health to investigate the impact of socioeconomic position on physical [62][63][64] and mental [49,55,65] health outcomes. Our goal was to construct a measure that would reliably detect health status determined by individuals' long-term socioeconomic conditions as well as their experienced stress levels from Add Health's Wave I to Wave IV. In this regard, one of the most appropriate indicators is individuals' allostatic load . AL identifies multidimensional physiological dysregulations that contribute to an onset of disease progression [66]. AL index may incorporate neuroendocrine, immune, metabolic, and cardiovascular system functioning and is a validated predictor of morbidity and mortality outcomes, especially at the earlier stages of life [67]. There are alternative approaches to construct AL and no consensus exists concerning which is the most appropriate method [68]. In this study, building on the previous research [32,69,70], we constructed AL index using biomarkers data from a blood test and medical examinations collected at Wave IV. Our AL index is based on seven biomarkers divided into five categories: Lipid-Total to High-Density Lipoprotein Cholesterol; Glucose-Glucose MG/DL; Inflammation-C-reactive protein ; Body Mass Index ; and Cardiovascular- systolic and diastolic blood pressure and resting heart rate. Our approach to constructing this measure is closely matched with the previous research in which AL is based on lipid and glucose metabolism, inflammation , body fat deposition and cardiovascular measures [32]. We first separately z-transformed the described biomarkers and then estimated the mean score of these transformed biomarkers. Finally, we z-transformed the derived mean AL score. Another approach would be to flag the biomarkers if they are above a relevant medical threshold [71]. Our preferred measure, however, is more sensitive as it captures the full variation in individuals' AL and therefore may help to identify individuals that will develop more serious health problems in the future. We consider this measure to be particularly appropriate for our study as it is able to capture even relatively small changes in young adults' health. This is especially important in the context of social mobility where the sensitivity of health outcome measures has yielded in mixed results [32,72]. For more detailed descriptive information about each employed component of AL index, refer to supporting information, S1 Table . 2.2.2. Social origin, destination, and mobility variables. For individuals' social origin variables, we utilised information on parental characteristics collected directly from parents at Wave I, while individuals' social destination variables are constructed from their attained socioeconomic position at Wave IV. A difference between origin and destination variables was classified as upward or downward social mobility. Out of available measures of socioeconomic position in Add Health, we focused on individuals' and their parents' educational and occupational attainment which aligns with prior social stratification research in the United States [73]. Education is a known predictor of individuals' health [74] and since the average age of respondents at Wave IV is 29, most participants have completed their educational attainment [75]. Formal educational credentials, however, measured in the survey did not fully capture individuals' socioeconomic position due to unobserved heterogeneity in, among other areas, specific skills, productivity, and the quality and type of education, especially considering the fragmented and stratified educational system of the United States [76]. Therefore, we also utilised information on individuals' occupational attainment which is a validated proxy for their earnings, work autonomy, and job security [77]. Combining educational and occupational information allowed us to generate a robust measure of socioeconomic position with known links to health outcomes [78]. For parental education, we used the highest level of education obtained by parents [79]. For example, we rely on mothers' education if father completed high school and mother completed college. To construct our measures, we collapsed 10 educational categories for parents and 13 educational categories for respondents into 5 categories. The difference in the number of categories arose due to additional postgraduate degrees for respondents. We coded education variables as follows: some high school and lower , completed high school , some college , completed college 4-year degree , and completed some postgraduate qualifications . Next, based on the previous research [80,81], we created occupational attainment variables for parents and respondents. In the case of parents, occupational data consisted of 10 occupational groups. We used the highest level of occupation obtained by the parents to construct five occupational categories. This was done by taking the average Nam-Power-Boyd scale score [82] for each of the 10 occupational groups and collapsing them into 5 categories from having no occupation to Nam-Power-Boyd scale score from 70 to 100 . Individuals' occupational status was based on the Standard Occupational Classification codes converted into status scores based on the Nam-Power-Boyd scale. We created quintiles from the converted occupational status scores . Finally, to derive the index of socioeconomic position for parents and individuals, we combined educational and occupational attainment variables. This resulted in scores ranging from 2 to 10 points for the highest achieving individuals. To ensure that each mobility group had adequate representation, we collapsed the combined socioeconomic position scores into quintiles, where quintile 5 represents the top 20% . From these combined measures we calculated intergenerational social mobility variables. We subtracted parental from individuals scores. This resulted in a mobility measure ranging from -4 to 4, where 0 represents the immobile group. For example, if the respondent achieved a score equal 5, highest attainment and parental attainment was equal to 4, the difference between the two scores produces one-step upward mobility. To ensure sufficient variation we collapse two, three and four steps into a long-range mobility indicator, separately for upward and downward mobility, while one-step mobility represents short-range mobility. Fig 1 shows the distribution of social mobility patterns with the immobile group being the largest single category of individuals, yet approximately 39% of respondents experienced downward mobility compared with 32% for upward mobility. In the empirical analysis, we differentiate between short-range mobility and long-range mobility . --- Confounders and initial health status. In all multivariable models, we accounted for respondents' gender and age. Additionally, based on the previous research on predictors of health in the United States [83], in the main analyses we controlled for respondents' race/ethnicity , the type of residential area , and marital status [84]. To address possible health selection effects due to initial health status which could affect both social mobility experience and Wave IV health, we first utilised information on respondents' self-rated health at Wave I. More specifically, the respondents were asked the following question: "In general, how is your health?" which they could rate on from 1 to 5 health. Second, we accounted for individuals' initial BMI scores. Third, we constructed the chronic disease indicator based on a set of four questions: "Do you have difficulty using your hands, arms, legs, or feet because of a permanent physical condition?"; "Do you have a permanent physical condition involving a heart problem?"; "Do you have a permanent physical condition involving asthma?"; "Do you have a permanent physical condition involving other breathing difficulties?". If the respondent answered yes to any of these questions the indicator equals 1 and 0 otherwise. Correlations between the outcome measure and selected Wave I health measures are presented in Supporting information, S2 Table . Although other Wave I health outcome variables were available in the dataset [85]), additional analysis in Supporting information, S3 Table, shows that the selected health measures at Wave I are robust predictors of AL at Wave IV. Table 1 presents descriptive statistics for the described health outcome measure, confounding variables, and initial health status. --- Statistical analysis We used diagonal reference models to identify associations between different socioeconomic positions and AL score, to assess the relative importance of origin and destination socioeconomic positions, and to estimate the consequences of social mobility as a deviation from what could be expected from predicted health status of immobile individuals in origin and destination socioeconomic groups. DRM design allows overcoming multicollinearity problem arising due to social mobility measures being calculated directly from origin and destination socioeconomic position variables. In other words, conventional statistical models cannot simultaneously include origin, destination, and mobility parameters. DRM is argued to be one of the most suitable methods for estimating an effect of social mobility because it disentangles this effect from the origin and destination position effects. An extensive overview of this statistical method, its usefulness in modelling of social mobility effects, and a comparison with conventional regression approaches are described and demonstrated elsewhere [11,14,29]. The key aspect of DRM is that immobile individuals' health is estimated by weighted mean values of AL for those who occupy diagonal cells in our twodimensional five by five matrix . After accounting for immobile individuals' health, DRM estimates the relative strength of the effect of the origin socioeconomic position to that of own socioeconomic position and this so-called "weight" parameter takes values between 0 and 1. A higher value of this weight indicates a greater relative effect of destination characteristics on the outcome measure, AL score in our case. In the case when the weight parameter is equal to 0.5 it can be concluded that the origin and destination characteristics play an equally important role in determining AL. To estimate possible effects of social mobility on AL in DRM, diagonal intercepts and weight parameter are jointly used to specify a cell-specific intercept for each off-diagonal cell in the two-dimensional mobility table. After predicting values for all off-diagonal cells, the DRM approach specifies the effect of social mobility over and above the value of AL conditioned by specific characteristics of origin and destination socioeconomic positions. Social mobility variables and associated point estimates, βs, in DRM approach could be interpreted in the same way as in a conventional regression model, a reference category being a group of individuals with the same socioeconomic position as their parents. To test if the effect of the social origin on AL and the health implications of social mobility varied by the individuals' socioeconomic position, their social mobility experiences, and other sociodemographic characteristics, in subsequent models we also derived point estimates for interaction terms between the weight parameters, social mobility, and confounding variables. Lastly, as described in the Introduction section, we attempted to consider health selection of individuals into social mobility trajectories, which may also explain the later life health outcomes. For this purpose, we accounted for individuals' initial health at Add Health Wave I. We first controlled for initial health variables and then fitted DRMs separately for individuals with good and with poor initial health status. All DRM estimates are derived using "drm" module in Stata 16 statistical software [86]. For various empirical applications of DRM approach in different countries and contexts readers can refer to studies on, among other areas, redistribution preferences [87], likelihood of smoking [88], attitudes toward immigrants [89]. --- Results --- Social gradient and descriptive mobility effects Table 2 presents the mean levels of AL by individuals' origin and destination socioeconomic positions. The diagonal cells consist of AL score for intergenerationally immobile individuals, while the remaining cells above and below the diagonal show, respectively, the mean AL score among upwardly and downwardly mobile individuals. Expectedly, the mean AL score is higher for immobile individuals with low socioeconomic position in comparison to immobile individuals with a high socioeconomic position . Off diagonal cells also suggest that the upwardly mobile individuals have lower AL levels. A similar but inverse pattern can be observed for those who experienced downward mobility. These associations could be partially explained by the fact that the upwardly mobile groups do not include those who ended up in the bottom quintile, while downwardly mobile groups do not include those who ended up in the highest quintile. The latter also suggests that upwardly and downwardly mobile individuals differ by their social origin and destination positions and to disentangle these position effects from social mobility effects, we employed the above-described statistical approach-DRM. --- Origin and destination weights and multivariable mobility effects Table 3 presents findings from multivariable DRM estimations. In all models, we accounted for individuals' age and gender, while in full models we also controlled for individuals' race/ almost twice as much variation in the outcome variable is explained by individuals' destination than by their origin. However, after social mobility variables are introduced, especially when short-and long-range mobility experiences are disentangled in Models 4-5, individuals' own socioeconomic position becomes roughly equal to the effect of parental socioeconomic position. Models also show that age and gender are associated with individuals' AL level. In Model 3, being male and older by one year are both linked to worse health by, respectively, 0.31 and 0.05 standard deviations of AL score. --- Social mobility Upward ---- -0.09 � -0.09 � ---- ---- ---- [-0.18,-0.01] [-0.18,-0.01] ---- ---- Downward ---- 0.05 0.03 ---- ---- ---- [-0.05,0.14] [-0.06,0.12] ---- ---- Short-range upward ---- ---- ---- -0.10 � -0.10 � ---- ---- ---- [-0. Black ---- ---- 0.18 ��� ---- 0.18 ��� ---- ---- [0.11,0.25] ---- [0.11,0.25] Hispanic ---- ---- 0.08 ---- 0.07 ---- ---- [-0.02,0.17] ---- [-0.02,0.17] Other ---- ---- 0.07 ---- 0.07 ---- ---- [-0.07,0.21] ---- [-0.07,0.21] Married ---- ---- -0.00 ---- -0.00 ---- ---- [-0.06,0.06] ---- [-0.06,0.05] Rural ---- ---- 0.08 � ---- 0.08 � ---- ---- [0. Model 2 shows that upward mobility is significantly and negatively associated with individuals' AL score, while the variable for downward mobility has a positive sign but it is not statistically significant. These mobility effects are unaffected when further sociodemographic controls-individuals' race/ethnicity, marital status, and urban/rural divide-are accounted for in Model 3. The results for these variables suggest that there are significant differences between Blacks and Whites, the former having more than a 0.18 higher AL score. Marital status does not play a significant role in explaining variation in our outcome measure but living in rural areas is associated with a higher AL score . In Models 4-5, we disentangle social mobility variables into short-and long-range upward and downward mobility. Confidence intervals for three out of four social mobility variables overlap with zero, but a significant association is maintained for short-range upward mobility. Moving up by one socioeconomic quintile is linked with a 0.10 decrease in individuals' AL score. In Supporting information, S4 Table, we estimated the effects of upward and downward mobility in reference to both immobility and mobility in the opposite direction by removing the latter coefficients from the fitted models. In S5 Table of supporting information we also present DRM estimates which account for neighbourhood characteristics where individuals lived at Wave I, such as poverty rates, unemployment levels, and race/ethnicity composition. These supplementary results are identical to those reported in the main analysis. Lastly, it is possible that the respondents are still too young to be certain that downward mobility will not change as time passes. This may be particularly true in terms of occupational attainment. To address this issue, in Supporting information, S6 education as the only SEP measure and educational mobility parameters. These results show no educational mobility effects, while in terms of health gradient and the importance of the relative weight, no major differences were observed. --- Do origin and mobility effects vary by sociodemographic groups? In Table 4, we estimated DRMs with the interaction terms between the origin weight, social mobility, and a set of covariates-age, gender, race/ethnicity, marital status, and urban-rural divide. We did not find that any interaction terms between the social origin weight and the described parameters were statistically significant, which implied that the effect of origin socioeconomic position on individuals' AL score did not vary by social mobility experiences and sociodemographic characteristics. In Table 4, we also interacted upward and downward mobility experiences with gender, age, marital status, and race/ethnic variables to test if the effect of social mobility on AL score had varying implications for these sociodemographic groups. Past research on various health outcomes in the United States indicates that due to Table 4. Origin weights and point estimates for interaction terms from DRM on AL levels. --------------- historical and structural factors, including discrimination, racial/ethnic differences in social mobility's effect on AL may be present [84,90]. For none of these interaction terms, except marital status, we found statistically significant associations, which indicated that mobility effects on AL did not, as a rule, vary by the considered sociodemographic groups. It should be emphasised that these findings, mostly insignificant, should be interpreted with caution as for the selected interactions the sample size may be too small to provide sufficient variation and conclusive findings. --- Origin weight Interaction terms --- Origin weight --- Social mobility --- Short --- How does health selection matter? We now address the possibility that individuals' health before experiencing social mobility affected both mobility trajectories and their AL score. To account for individuals' initial health status in our models, we used their self-rated health , BMI levels , and having chronic health problems at Wave I . First, we checked if initial health was associated with social mobility in Supporting information, S7 Table, and concluded that those with worse health had, respectively, lower and higher chances to experience upward and downward social mobility, even after the origin socioeconomic position was controlled for. This suggested that health selection has to be accounted for when studying the effects of social mobility on health. Results in Table 5, Models 1 and 2, in turn, show that poor health and high BMI levels prior to social mobility experience were significantly and positively associated with AL score at Wave IV. In comparison to the results in Table 3, we observed a decrease in the size of coefficients for the highest and lowest socioeconomic quintiles of immobile individuals. The earlier detected effect of short-range upward mobility became insignificant in these two models. Models 3 to 6 show the results where the total sample was split by individuals' self-rated poor and good health at Wave I. This exercise created two groups of individuals, one with initial self-rated excellent/very good and another with worse than very good health. For individuals with very good and excellent initial health, AL score of immobile groups did not significantly change in comparison to the pooled sample, but for those with worse initial self-rated health social gradient in AL was less salient. More importantly, we found that shortrange upward mobility had a significant negative association with AL score but only among individuals with initial poor health, even after the initial BMI level and chronic health problems were accounted for. To further explore the role of initial health in the observed positive effect of upward mobility, in Supporting information, S8 Table, we interacted individuals' upward and downward mobility trajectories with their initial health status. Results showed that the interaction term was negative and statistically significant only for those who experienced short-range upward mobility, which again confirmed the positive health implications of upward mobility for the less healthy individuals at Wave I. --- Discussion In this study, we explored how health outcomes of young adults in the United States are conditioned by individuals' socioeconomic position and their movements between origin and destination, also accounting for initial health and health selection effects into specific mobility experiences. The allostatic load score used in this study is one of the most comprehensive measures of health, especially among relatively young individuals who tend to rate their health as excellent or very good in social surveys, rarely experience hospitalization, and have very low levels of mortality. While social gradient in health is not surprising and there is a number of studies investigating the role of various aspects of socioeconomic position for AL in the United States , our paper makes an important scholarly contribution as it identifies the relative impact of social origin in comparison to the social destination ; detects possible independent effects of movements from parental to own socioeconomic position; tests if position and mobility effects differ by socioeconomic groups; and investigates the role of health selection in the observed associations. Using Add Health data and DRM statistical approach, which was specifically designed to distinguish the effects of origin and destination socioeconomic positions from independent effects of mobility between these two, we showed that the combined measure of educational and occupational attainment is a robust predictor of biological markers of health. Those in higher and lower quantiles of socioeconomic position had respectively lower and higher levels of AL even when the standard sociodemographic factors such as age, gender, race/ethnicity, marital status, and rural-urban divide were accounted for. In addition to demonstrating socioeconomic gradient in AL, we revealed that when social mobility is accounted for, socioeconomic origins and destination are of almost equal importance for health. This finding is in line with the results from the United Kingdom where the effects of both parental and own socioeconomic position on individuals' AL were roughly equal [32]. Yet, it contrasts with research on other health and wellbeing outcomes where origin characteristics are less important [80,91]. One explanation for this could be that our AL index based on the selected biomarkers including metabolic and cardiovascular system functioning, is more sensitive to lifetime exposures and experiences, while alternative measures such as, for instance, health-related behaviours and perceptions are more likely to be shaped by individuals' contemporary conditions. While exploring social mobility effects, we found that upward mobility is linked to lower levels of AL, however, in contrast to theoretical expectations [27,29], downward mobility was not associated with health. These are not completely novel findings, as similar positive effects of upward mobility were shown in the previous studies [20,92]. When we disaggregated mobility experiences in short-and long-range upward mobility, we found that the positive effect on health stemmed from the short-range upward mobility experience. The magnitude of the short-range upward mobility' effect on AL is quite large and it is roughly comparable to the effect of living in urban areas or being two years younger, while for those with the initial poor health this effect is even larger. It is important to note that due to relatively young age composition of the analytical sample, for many individuals the downward social mobility observed in this study may be temporary, which could be one possible explanation why we find a null effect of downward mobility on AL. Returning to the initial question posed in the introductory section of this study-which theoretical perspectives on the health implications of social mobility do these findings support? Our results are in line with predictions of "rags to riches" thesis which suggests that psychological benefits of overcoming constraints and moving up in social hierarchy may lead to lower levels of stress and positive life experiences which, in turn, can prevent an increase of AL among individuals. At the same time, our finding that the long-range upward mobility did not reduce AL score could indicate that more extensive mobility experiences may be associated with some negative health-related consequences, as predicted by the dissociation thesis. A more effortful upward mobility experience likely dilutes the positive health implications of moving up in the social hierarchy. This is supported by the observation that when we collapsed socioeconomic positions variables into tertiles rather than quintiles in S9 Table, supporting information, we did not see this positive effect of upward mobility on AL score because mobility between tertiles might simultaneously imply elements of short-and long-range social mobility. We did not detect heterogeneous effects of social origins and mobility experiences across sociodemographic groups. Apparently, both parental characteristics and mobility from origin to destination have similar implications for health, irrespective of individuals' personal characteristics. Our finding contrast with results from past research using the same dataset, suggesting that selected minority groups experience higher metabolic syndrome after college completion [49]. Three main methodological aspects are likely to explain this difference. First, our research strategy is focused on disentangling mobility effect from origin and destination effects, based on SEP derived from educational and occupational attainment, and using DRM approach, while Gaydosh et al. rely only on educational mobility and use conventional Poisson regressions. Second, health measures also differ noticeably as Gaydosh et al. rely on metabolic syndrome based on blood pressure, glycosylated hemoglobin, body to waist ratio and cholesterol, while AL measure used in our study in addition to components such as blood pressure and cholesterol includes other biomarkers . Third, Gaydosh et al. use the restricted-full sample, while we use the public version of Add Health. These differences make any direct comparison across the two studies difficult. Furthermore, we found that accounting for initial health, e.g. health selection, before experiencing social mobility mattered for health outcomes following upward mobility experiences. First, once initial health was controlled, the positive effect of the upward mobility became insignificant. However, when we disaggregated the analytical sample into two groups with good and poor initial health, upward mobility was significantly associated with lower AL score among individuals with poor initial health. One interpretation of this finding is that individuals who had some initial health problems, and presumably high levels of AL, particularly benefited psychologically from moving up in social hierarchy because, regardless of initial adverse conditions, they managed to overcome health-related constraints and consequently developed feelings of life control, achievement, and gratitude. This explanation is also supported by earlier evidence that education is more beneficial for health of those with the lowest propensity to attain higher education based on a wide range of childhood adversities [37]. Despite using a high-quality data set, a comprehensive indicator of socioeconomic position, a validated measure of individuals' health, and DRM-a recommended method to identify the health consequences of social mobility, our study has its limitations. First, due to the age composition of Add Health dataset, we focused on the health implications of social mobility on individuals at a relatively early stage in terms of their life-time socioeconomic position. Although a recent study implies that social mobility might have only short-term consequences observed when mobile individuals are relatively young [39], it is likely that the Add Health cohort at Wave IV is still too young to fully differentiate between mobile and immobile individuals as they are expected to experience further upward or downward social mobility. This seems to be particularly important in terms of occupational attainment and it may be addressed in the future with Add Health's Wave V data, when respondents are 10 years older. Wave V can also provide valuable health information allowing us re-examining the relationship between social mobility and AL of the relatively older cohort. Methodologically, it is important to note that although we mitigated the bias from confounding factors and health selection, our approach cannot identify a causal relationship between social mobility and AL. The main conclusion of our study is that not only does socioeconomic position matter for young adults health in the United States, but also whether the attained status is the result of mobility between individuals' origin and destination socioeconomic environments. This mobility effect, however, can be identified if an appropriate statistical approach is employed and individuals' initial health is adequately accounted for. We also call for more nuanced consideration of the impact of short-and long-term mobility on health. The finding that the short-range upward social mobility is associated with better outcomes among those with poor childhood health suggests that social mobility might be a transformative experience for particularly disadvantaged individuals. Yet, our finding that there is no positive health effect of longrange upward mobility also indicates that more extensive mobility experiences might entail costs which cannot be compensated by positive implications of social mobility. --- The data underlying the results presented in the study are available from Add Health https://addhealth.cpc.unc.edu/ data/. ---

The contemporaneous association between higher socioeconomic position and better health is well established. Life course research has also demonstrated a lasting effect of childhood socioeconomic conditions on adult health and well-being. Yet, little is known about the separate health effects of intergenerational mobility-moving into a different socioeconomic position than one's parents-among early adults in the United States. Most studies on the health implications of mobility rely on cross-sectional datasets, which makes it impossible to differentiate between health selection and social causation effects. In addition, understanding the effects of social mobility on health at a relatively young age has been hampered by the paucity of health measures that reliably predict disease onset. Analysing 4,713 respondents aged 25 to 32 from the National Longitudinal Study of Adolescent Health's Waves I and IV, we use diagonal reference models to separately identify the effects of socioeconomic origin and destination, as well as social mobility on allostatic load among individuals in the United States. Using a combined measure of educational and occupational attainment, and accounting for individuals' initial health, we demonstrate that in addition to health gradient among the socially immobile, individuals' socioeconomic origin and destination are equally important for multi-system physiological dysregulation. Short-range upward mobility also has a positive and significant association with health. After mitigating health selection concerns in our observational data, this effect is observed only among those reporting poor health before experiencing social mobility. Our findings move towards the reconciliation of two theoretical perspectives, confirming the positive effect of upward mobility as predicted by the "rags to riches" perspective, while not contradicting potential costs associated with more extensive upward mobility experiences as predicted by the dissociative thesis.

introduction socioeconomic position is a fundamental cause of health disparities 1 those occupying higher rungs on the socioeconomic ladder tend to experience lower rates of morbidity and mortality compared to those placed lower in the social hierarchy 23 in addition to socioeconomic position attained in adulthood socioeconomic origins exert significant and independent effects on later life health 45 reflecting the long arm of childhood circumstances 6 7 8 the enduring effects of childhood circumstances are thought to represent the downstream consequences of cumulative advantage and disadvantage whereby stresses and strains accrue over the life course to a greater extent among those in socially disadvantaged positions setting in motion more rapid aging or weathering of biological systems under conditions of chronic adversity 910 an unresolved question in social stratification and social epidemiological research is whether the movement between origin and destination socioeconomic positions per se influences health net of origin and destination effects because social mobility is linearly dependent on both social origin and destination traditional regression frameworks are not able to separately estimate the effects of socioeconomic origin destination and social mobility simultaneously 11 12 13 calling into question much of the existing evidence 14 while sobels diagonal reference models overcome this methodological limitation 15 few studies have utilized this statistical approach when investigating the health effects of social mobility particularly in the north american context this represents an important gap in the literature given renewed scholarly interest in intergenerational transmission of advantages and declining social mobility in the united states 16 17 18 key theories on health consequences of social mobility two main theoretical perspectives predict respectively negative and positive health consequences of upward social mobility sorokins dissociative thesis views upward social mobility as a deviation from expected continuity associated with individuals social origins 19 adjusting to an unfamiliar socioeconomic environment while also socially distancing from the familiar and more natural past environment can be a major stressinducing process compromising upwardly mobile individuals psychological and consequently physical health in turn an alternative perspective socalled rags to riches thesis 20 suggests that upward social mobility could lead to better health outcomes by generating a sense of personal control boosting psychological wellbeing from overcoming life course constraints fostering healthy behaviours and lifestyles and developing a health conducive sense of gratitude among the upwardly mobile individuals 21 22 23 24 25 in recent years scholarly interest in health consequences of downward rather than upward social mobility has become particularly salient this is in line with the postliberal theory of social stratification which views social mobility primarily in terms of offspring attaining worse off living conditions than their parents did 26 the socalled falling from grace thesis implies that downward social mobility leads to an undesirable loss of an ascribed socioeconomic position at birth and associated changes in practices behaviours and norms 2728 the perception of downward mobility as undeserved and unjust together with the overall psychological maladjustment to a new environment can precipitate chronic stress and thus compromise the health of downwardly mobile individuals 2930 downward mobility may also increase the stress associated with financial hardship a wellknown correlate of physical and mental health 31 given these multiple perspectives one of the goals of our study is to derive new evidence on the merits of the main healthrelated theories of social mobility independent social mobility and health selection effects an overview of the existing studies does not provide conclusive answers about social mobility effects on health as many studies report null findings 1432 when significant associations of upward social mobility and health are identified these links are not usually detrimental for health 20 while downward mobility in a number of studies was found to be damaging to health 33 inferring from these findings however is problematic because researchers use different indicators of mobility in socioeconomic position such as occupational class status education and income moreover social mobility research is characterised by at least two significant methodological constraints first relatively few studies use a statistical approach which is able to separately identify the relative importance of origin and destination socioeconomic position while also isolating the effect of social mobility on health outcomes and second most studies rely on crosssectional datasets and are thus unable to differentiate between health selection and social causation effects when studying health implications of social mobility referring to the first problem many studies on the health consequences of social mobility continue to apply conventional regression approaches which usually differentiate social mobility trajectories by combining individuals origin and destination positions and subsequently comparing health outcomes between these mobility groups alternatively some scholars simply omit from models either origin or destination socioeconomic positions to produce an estimate for health effect of upward or downward social mobility 1434 these analytical strategies are useful if researchers primarily intend to identify the role of origin andor destination socioeconomic position for individuals health but they are unable to differentiate if health outcomes are independently affected by position and mobility effects to mitigate this concern researchers have proposed a special form of regression model that was developed to estimate the relative effects of two hierarchically ranked socioeconomic positions and the net effect of a movement between these two positions on the outcome variable of interest 11 the second methodological concern implies addressing a likely bias stemming from health selection by which individuals initial poor and good health not only respectively limits upward and facilitates downward mobility but also is causally related to later life health if health before social mobility is not accounted for any possible health effects of social mobility can be erroneously attributed to social causation rather than to the health selection effects 35 the role of health selection has been shown to be stronger for a transition process from adolescence to adulthood than for later life course transitions 36 considering the importance of initial health for educational attainment and resultant success on labour market an intriguing and underexplored question is what are the health implications for those individuals who regardless of initial health constraints still manage to experience upward social mobility both positive and negative consequences can be predicted as mobility for disadvantaged individuals might imply greater costs yet they might also derive greater psychological benefits from overcoming barriers on their social mobility journeys 37 social mobility and health measures adding to complexity social mobilitys effects might differ not only if initial health is accounted for but also depending on the type of health measures used in studies the most prevalent outcome variable employed by scholars due to its wide availability in social surveys is selfrated health 343839 yet selfrated health is not a perfect predictor of objective indicators of health and people might think of different aspects of wellbeing while assessing their health status 4041 some studies also use depressive symptoms to identify possible effects of social mobility on health but they are not able to capture any effects of social mobility on physical health 2042 timing of death on the other hand can be considered as a reliable indicator of health outcome but data on mortality is mainly useful for studying later life health based on panelcohort surveys or registerbased datasets 4344 in this study we use allostatic load an index of multisystem physiological dysregulation among individuals 32 to identify the health implications of social mobility this measure takes into account various aspects of health and provides information on valid variation in health already at a relatively young age 4546 heterogeneous position and mobility effects existing studies on health inequalities suggest that different sociodemographic and socioeconomic groups have vastly different levels of allostatic load individuals age for instance is strongly associated with allostatic load which might imply that across individuals life course mobility effects on al also vary the recent evidence also suggests that mobility effects across european societies are more pronounced among young people than among the elderly 39 one of the explanations for this could be that psychological and stressrelated costs and benefits of social mobility experience have primarily shortterm effects that dissipate later in the life course 36 existing research on the health consequences of social mobility also indicates that the origin socioeconomic position might matter more for women than for men while in turn mobility effects are more salient for men than women 20 social origin attained socioeconomic position and mobility between origin and destination positions might have varying implications for various sociodemographic groups which are known to have vastly different health and wellbeing outcomes due to historical institutional and structural differences race is of central importance in these respects in the united states racial and ethnic inequalities in health and illness are well documented 47 and a growing body of research demonstrates the myriad ways that structural racism contributes to these disparities 48 in addition to contemporaneous inequities gaydosh and colleagues argue that the health effects of social mobility may hinge on the disproportionate stressors experienced by racialized groups 49 the john henryism hypothesis for example posits that african american individuals are exposed to myriad psychosocial adversities throughout the life course and that the active coping strategies employed to cope with such exigencies result in biological wear and tear 5051 recent studies also suggest african americans from disadvantaged backgrounds form a skindeep resilience wherein a higher sense of control may lead to favourable psychological outcomes but greater physiological dysregulation 52 53 54 55 the united states as a case study the united states is an interesting case to study the health consequences of social mobility as it is characterized by widening socioeconomic inequalities 56 and declining levels of intergenerational social mobility 1757 the united states also has one of the most comprehensive panel datasets described in detail below which allows us to investigate socioeconomic origin and destination social mobility and selection effects on individuals health the same dataset used in the present study has been previously employed to investigate different health aspects of social mobility including adolescent stressful experiences 58 early adversity on later life health through psychosocial resources 59 and the effects of life course socioeconomic position on cardiovascular health 60 in turn our contribution to the relevant scholarship is that we study consequences of social mobility on health by constructing a robust indicator of socioeconomic position for both individuals and their parents identifying the relative importance of origin and destination socioeconomic positions on health detecting any residual effects of social mobility testing if position and mobility effects differ by sociodemographic characteristics such as gender and race and examining the role of health selection in the observed associations methods dataset the national longitudinal study of adolescent health is a representative longitudinal study of individuals in the united states who were adolescents in the beginning of the 1990s the study started in 199495 with wave i of the panel which included data on 20745 adolescents aged 12 to 19 by the time of writing in the latest publicly available wave iv conducted in 20072008 the number of interviewed participants declined to 15701 with their average age of 29 attrition did not occur completely at random but rather the main identified predictors of response in wave iv were individuals gender race and parental education 61 for this analysis we use data from waves i and iv due to costrelated considerations in this study we used the publicuse version of add health with about 40 of respondents chosen randomly from the restrictedfull sample the main differences between the public and the restricted versions of add health arise due to confidentiality concerns the full version of the dataset contains more sensitive information on respondents including their romantic relationships and dnarelated data the later information is not of primary interest for our study while the random mode of selection of participants for the publicuse version of add health ensures that it is a representative survey data of the united states population of the relevant age after listwise deletion of observations with missing information 4713 individuals were available for our analysis measures health outcome numerous past studies used the add health to investigate the impact of socioeconomic position on physical 62 63 64 and mental 495565 health outcomes our goal was to construct a measure that would reliably detect health status determined by individuals longterm socioeconomic conditions as well as their experienced stress levels from add healths wave i to wave iv in this regard one of the most appropriate indicators is individuals allostatic load al identifies multidimensional physiological dysregulations that contribute to an onset of disease progression 66 al index may incorporate neuroendocrine immune metabolic and cardiovascular system functioning and is a validated predictor of morbidity and mortality outcomes especially at the earlier stages of life 67 there are alternative approaches to construct al and no consensus exists concerning which is the most appropriate method 68 in this study building on the previous research 326970 we constructed al index using biomarkers data from a blood test and medical examinations collected at wave iv our al index is based on seven biomarkers divided into five categories lipidtotal to highdensity lipoprotein cholesterol glucoseglucose mgdl inflammationcreactive protein body mass index and cardiovascular systolic and diastolic blood pressure and resting heart rate our approach to constructing this measure is closely matched with the previous research in which al is based on lipid and glucose metabolism inflammation body fat deposition and cardiovascular measures 32 we first separately ztransformed the described biomarkers and then estimated the mean score of these transformed biomarkers finally we ztransformed the derived mean al score another approach would be to flag the biomarkers if they are above a relevant medical threshold 71 our preferred measure however is more sensitive as it captures the full variation in individuals al and therefore may help to identify individuals that will develop more serious health problems in the future we consider this measure to be particularly appropriate for our study as it is able to capture even relatively small changes in young adults health this is especially important in the context of social mobility where the sensitivity of health outcome measures has yielded in mixed results 3272 for more detailed descriptive information about each employed component of al index refer to supporting information s1 table 222 social origin destination and mobility variables for individuals social origin variables we utilised information on parental characteristics collected directly from parents at wave i while individuals social destination variables are constructed from their attained socioeconomic position at wave iv a difference between origin and destination variables was classified as upward or downward social mobility out of available measures of socioeconomic position in add health we focused on individuals and their parents educational and occupational attainment which aligns with prior social stratification research in the united states 73 education is a known predictor of individuals health 74 and since the average age of respondents at wave iv is 29 most participants have completed their educational attainment 75 formal educational credentials however measured in the survey did not fully capture individuals socioeconomic position due to unobserved heterogeneity in among other areas specific skills productivity and the quality and type of education especially considering the fragmented and stratified educational system of the united states 76 therefore we also utilised information on individuals occupational attainment which is a validated proxy for their earnings work autonomy and job security 77 combining educational and occupational information allowed us to generate a robust measure of socioeconomic position with known links to health outcomes 78 for parental education we used the highest level of education obtained by parents 79 for example we rely on mothers education if father completed high school and mother completed college to construct our measures we collapsed 10 educational categories for parents and 13 educational categories for respondents into 5 categories the difference in the number of categories arose due to additional postgraduate degrees for respondents we coded education variables as follows some high school and lower completed high school some college completed college 4year degree and completed some postgraduate qualifications next based on the previous research 8081 we created occupational attainment variables for parents and respondents in the case of parents occupational data consisted of 10 occupational groups we used the highest level of occupation obtained by the parents to construct five occupational categories this was done by taking the average nampowerboyd scale score 82 for each of the 10 occupational groups and collapsing them into 5 categories from having no occupation to nampowerboyd scale score from 70 to 100 individuals occupational status was based on the standard occupational classification codes converted into status scores based on the nampowerboyd scale we created quintiles from the converted occupational status scores finally to derive the index of socioeconomic position for parents and individuals we combined educational and occupational attainment variables this resulted in scores ranging from 2 to 10 points for the highest achieving individuals to ensure that each mobility group had adequate representation we collapsed the combined socioeconomic position scores into quintiles where quintile 5 represents the top 20 from these combined measures we calculated intergenerational social mobility variables we subtracted parental from individuals scores this resulted in a mobility measure ranging from 4 to 4 where 0 represents the immobile group for example if the respondent achieved a score equal 5 highest attainment and parental attainment was equal to 4 the difference between the two scores produces onestep upward mobility to ensure sufficient variation we collapse two three and four steps into a longrange mobility indicator separately for upward and downward mobility while onestep mobility represents shortrange mobility fig 1 shows the distribution of social mobility patterns with the immobile group being the largest single category of individuals yet approximately 39 of respondents experienced downward mobility compared with 32 for upward mobility in the empirical analysis we differentiate between shortrange mobility and longrange mobility confounders and initial health status in all multivariable models we accounted for respondents gender and age additionally based on the previous research on predictors of health in the united states 83 in the main analyses we controlled for respondents raceethnicity the type of residential area and marital status 84 to address possible health selection effects due to initial health status which could affect both social mobility experience and wave iv health we first utilised information on respondents selfrated health at wave i more specifically the respondents were asked the following question in general how is your health which they could rate on from 1 to 5 health second we accounted for individuals initial bmi scores third we constructed the chronic disease indicator based on a set of four questions do you have difficulty using your hands arms legs or feet because of a permanent physical condition do you have a permanent physical condition involving a heart problem do you have a permanent physical condition involving asthma do you have a permanent physical condition involving other breathing difficulties if the respondent answered yes to any of these questions the indicator equals 1 and 0 otherwise correlations between the outcome measure and selected wave i health measures are presented in supporting information s2 table although other wave i health outcome variables were available in the dataset 85 additional analysis in supporting information s3 table shows that the selected health measures at wave i are robust predictors of al at wave iv table 1 presents descriptive statistics for the described health outcome measure confounding variables and initial health status statistical analysis we used diagonal reference models to identify associations between different socioeconomic positions and al score to assess the relative importance of origin and destination socioeconomic positions and to estimate the consequences of social mobility as a deviation from what could be expected from predicted health status of immobile individuals in origin and destination socioeconomic groups drm design allows overcoming multicollinearity problem arising due to social mobility measures being calculated directly from origin and destination socioeconomic position variables in other words conventional statistical models cannot simultaneously include origin destination and mobility parameters drm is argued to be one of the most suitable methods for estimating an effect of social mobility because it disentangles this effect from the origin and destination position effects an extensive overview of this statistical method its usefulness in modelling of social mobility effects and a comparison with conventional regression approaches are described and demonstrated elsewhere 111429 the key aspect of drm is that immobile individuals health is estimated by weighted mean values of al for those who occupy diagonal cells in our twodimensional five by five matrix after accounting for immobile individuals health drm estimates the relative strength of the effect of the origin socioeconomic position to that of own socioeconomic position and this socalled weight parameter takes values between 0 and 1 a higher value of this weight indicates a greater relative effect of destination characteristics on the outcome measure al score in our case in the case when the weight parameter is equal to 05 it can be concluded that the origin and destination characteristics play an equally important role in determining al to estimate possible effects of social mobility on al in drm diagonal intercepts and weight parameter are jointly used to specify a cellspecific intercept for each offdiagonal cell in the twodimensional mobility table after predicting values for all offdiagonal cells the drm approach specifies the effect of social mobility over and above the value of al conditioned by specific characteristics of origin and destination socioeconomic positions social mobility variables and associated point estimates βs in drm approach could be interpreted in the same way as in a conventional regression model a reference category being a group of individuals with the same socioeconomic position as their parents to test if the effect of the social origin on al and the health implications of social mobility varied by the individuals socioeconomic position their social mobility experiences and other sociodemographic characteristics in subsequent models we also derived point estimates for interaction terms between the weight parameters social mobility and confounding variables lastly as described in the introduction section we attempted to consider health selection of individuals into social mobility trajectories which may also explain the later life health outcomes for this purpose we accounted for individuals initial health at add health wave i we first controlled for initial health variables and then fitted drms separately for individuals with good and with poor initial health status all drm estimates are derived using drm module in stata 16 statistical software 86 for various empirical applications of drm approach in different countries and contexts readers can refer to studies on among other areas redistribution preferences 87 likelihood of smoking 88 attitudes toward immigrants 89 results social gradient and descriptive mobility effects table 2 presents the mean levels of al by individuals origin and destination socioeconomic positions the diagonal cells consist of al score for intergenerationally immobile individuals while the remaining cells above and below the diagonal show respectively the mean al score among upwardly and downwardly mobile individuals expectedly the mean al score is higher for immobile individuals with low socioeconomic position in comparison to immobile individuals with a high socioeconomic position off diagonal cells also suggest that the upwardly mobile individuals have lower al levels a similar but inverse pattern can be observed for those who experienced downward mobility these associations could be partially explained by the fact that the upwardly mobile groups do not include those who ended up in the bottom quintile while downwardly mobile groups do not include those who ended up in the highest quintile the latter also suggests that upwardly and downwardly mobile individuals differ by their social origin and destination positions and to disentangle these position effects from social mobility effects we employed the abovedescribed statistical approachdrm origin and destination weights and multivariable mobility effects table 3 presents findings from multivariable drm estimations in all models we accounted for individuals age and gender while in full models we also controlled for individuals race almost twice as much variation in the outcome variable is explained by individuals destination than by their origin however after social mobility variables are introduced especially when shortand longrange mobility experiences are disentangled in models 45 individuals own socioeconomic position becomes roughly equal to the effect of parental socioeconomic position models also show that age and gender are associated with individuals al level in model 3 being male and older by one year are both linked to worse health by respectively 031 and 005 standard deviations of al score social mobility upward 009 � 009 � 018001 018001 downward 005 003 005014 006012 shortrange upward 010 � 010 � 0 black 018 ��� 018 ��� 011025 011025 hispanic 008 007 002017 002017 other 007 007 007021 007021 married 000 000 006006 006005 rural 008 � 008 � 0 model 2 shows that upward mobility is significantly and negatively associated with individuals al score while the variable for downward mobility has a positive sign but it is not statistically significant these mobility effects are unaffected when further sociodemographic controlsindividuals raceethnicity marital status and urbanrural divideare accounted for in model 3 the results for these variables suggest that there are significant differences between blacks and whites the former having more than a 018 higher al score marital status does not play a significant role in explaining variation in our outcome measure but living in rural areas is associated with a higher al score in models 45 we disentangle social mobility variables into shortand longrange upward and downward mobility confidence intervals for three out of four social mobility variables overlap with zero but a significant association is maintained for shortrange upward mobility moving up by one socioeconomic quintile is linked with a 010 decrease in individuals al score in supporting information s4 table we estimated the effects of upward and downward mobility in reference to both immobility and mobility in the opposite direction by removing the latter coefficients from the fitted models in s5 table of supporting information we also present drm estimates which account for neighbourhood characteristics where individuals lived at wave i such as poverty rates unemployment levels and raceethnicity composition these supplementary results are identical to those reported in the main analysis lastly it is possible that the respondents are still too young to be certain that downward mobility will not change as time passes this may be particularly true in terms of occupational attainment to address this issue in supporting information s6 education as the only sep measure and educational mobility parameters these results show no educational mobility effects while in terms of health gradient and the importance of the relative weight no major differences were observed do origin and mobility effects vary by sociodemographic groups in table 4 we estimated drms with the interaction terms between the origin weight social mobility and a set of covariatesage gender raceethnicity marital status and urbanrural divide we did not find that any interaction terms between the social origin weight and the described parameters were statistically significant which implied that the effect of origin socioeconomic position on individuals al score did not vary by social mobility experiences and sociodemographic characteristics in table 4 we also interacted upward and downward mobility experiences with gender age marital status and raceethnic variables to test if the effect of social mobility on al score had varying implications for these sociodemographic groups past research on various health outcomes in the united states indicates that due to table 4 origin weights and point estimates for interaction terms from drm on al levels historical and structural factors including discrimination racialethnic differences in social mobilitys effect on al may be present 8490 for none of these interaction terms except marital status we found statistically significant associations which indicated that mobility effects on al did not as a rule vary by the considered sociodemographic groups it should be emphasised that these findings mostly insignificant should be interpreted with caution as for the selected interactions the sample size may be too small to provide sufficient variation and conclusive findings origin weight interaction terms origin weight social mobility short how does health selection matter we now address the possibility that individuals health before experiencing social mobility affected both mobility trajectories and their al score to account for individuals initial health status in our models we used their selfrated health bmi levels and having chronic health problems at wave i first we checked if initial health was associated with social mobility in supporting information s7 table and concluded that those with worse health had respectively lower and higher chances to experience upward and downward social mobility even after the origin socioeconomic position was controlled for this suggested that health selection has to be accounted for when studying the effects of social mobility on health results in table 5 models 1 and 2 in turn show that poor health and high bmi levels prior to social mobility experience were significantly and positively associated with al score at wave iv in comparison to the results in table 3 we observed a decrease in the size of coefficients for the highest and lowest socioeconomic quintiles of immobile individuals the earlier detected effect of shortrange upward mobility became insignificant in these two models models 3 to 6 show the results where the total sample was split by individuals selfrated poor and good health at wave i this exercise created two groups of individuals one with initial selfrated excellentvery good and another with worse than very good health for individuals with very good and excellent initial health al score of immobile groups did not significantly change in comparison to the pooled sample but for those with worse initial selfrated health social gradient in al was less salient more importantly we found that shortrange upward mobility had a significant negative association with al score but only among individuals with initial poor health even after the initial bmi level and chronic health problems were accounted for to further explore the role of initial health in the observed positive effect of upward mobility in supporting information s8 table we interacted individuals upward and downward mobility trajectories with their initial health status results showed that the interaction term was negative and statistically significant only for those who experienced shortrange upward mobility which again confirmed the positive health implications of upward mobility for the less healthy individuals at wave i discussion in this study we explored how health outcomes of young adults in the united states are conditioned by individuals socioeconomic position and their movements between origin and destination also accounting for initial health and health selection effects into specific mobility experiences the allostatic load score used in this study is one of the most comprehensive measures of health especially among relatively young individuals who tend to rate their health as excellent or very good in social surveys rarely experience hospitalization and have very low levels of mortality while social gradient in health is not surprising and there is a number of studies investigating the role of various aspects of socioeconomic position for al in the united states our paper makes an important scholarly contribution as it identifies the relative impact of social origin in comparison to the social destination detects possible independent effects of movements from parental to own socioeconomic position tests if position and mobility effects differ by socioeconomic groups and investigates the role of health selection in the observed associations using add health data and drm statistical approach which was specifically designed to distinguish the effects of origin and destination socioeconomic positions from independent effects of mobility between these two we showed that the combined measure of educational and occupational attainment is a robust predictor of biological markers of health those in higher and lower quantiles of socioeconomic position had respectively lower and higher levels of al even when the standard sociodemographic factors such as age gender raceethnicity marital status and ruralurban divide were accounted for in addition to demonstrating socioeconomic gradient in al we revealed that when social mobility is accounted for socioeconomic origins and destination are of almost equal importance for health this finding is in line with the results from the united kingdom where the effects of both parental and own socioeconomic position on individuals al were roughly equal 32 yet it contrasts with research on other health and wellbeing outcomes where origin characteristics are less important 8091 one explanation for this could be that our al index based on the selected biomarkers including metabolic and cardiovascular system functioning is more sensitive to lifetime exposures and experiences while alternative measures such as for instance healthrelated behaviours and perceptions are more likely to be shaped by individuals contemporary conditions while exploring social mobility effects we found that upward mobility is linked to lower levels of al however in contrast to theoretical expectations 2729 downward mobility was not associated with health these are not completely novel findings as similar positive effects of upward mobility were shown in the previous studies 2092 when we disaggregated mobility experiences in shortand longrange upward mobility we found that the positive effect on health stemmed from the shortrange upward mobility experience the magnitude of the shortrange upward mobility effect on al is quite large and it is roughly comparable to the effect of living in urban areas or being two years younger while for those with the initial poor health this effect is even larger it is important to note that due to relatively young age composition of the analytical sample for many individuals the downward social mobility observed in this study may be temporary which could be one possible explanation why we find a null effect of downward mobility on al returning to the initial question posed in the introductory section of this studywhich theoretical perspectives on the health implications of social mobility do these findings support our results are in line with predictions of rags to riches thesis which suggests that psychological benefits of overcoming constraints and moving up in social hierarchy may lead to lower levels of stress and positive life experiences which in turn can prevent an increase of al among individuals at the same time our finding that the longrange upward mobility did not reduce al score could indicate that more extensive mobility experiences may be associated with some negative healthrelated consequences as predicted by the dissociation thesis a more effortful upward mobility experience likely dilutes the positive health implications of moving up in the social hierarchy this is supported by the observation that when we collapsed socioeconomic positions variables into tertiles rather than quintiles in s9 table supporting information we did not see this positive effect of upward mobility on al score because mobility between tertiles might simultaneously imply elements of shortand longrange social mobility we did not detect heterogeneous effects of social origins and mobility experiences across sociodemographic groups apparently both parental characteristics and mobility from origin to destination have similar implications for health irrespective of individuals personal characteristics our finding contrast with results from past research using the same dataset suggesting that selected minority groups experience higher metabolic syndrome after college completion 49 three main methodological aspects are likely to explain this difference first our research strategy is focused on disentangling mobility effect from origin and destination effects based on sep derived from educational and occupational attainment and using drm approach while gaydosh et al rely only on educational mobility and use conventional poisson regressions second health measures also differ noticeably as gaydosh et al rely on metabolic syndrome based on blood pressure glycosylated hemoglobin body to waist ratio and cholesterol while al measure used in our study in addition to components such as blood pressure and cholesterol includes other biomarkers third gaydosh et al use the restrictedfull sample while we use the public version of add health these differences make any direct comparison across the two studies difficult furthermore we found that accounting for initial health eg health selection before experiencing social mobility mattered for health outcomes following upward mobility experiences first once initial health was controlled the positive effect of the upward mobility became insignificant however when we disaggregated the analytical sample into two groups with good and poor initial health upward mobility was significantly associated with lower al score among individuals with poor initial health one interpretation of this finding is that individuals who had some initial health problems and presumably high levels of al particularly benefited psychologically from moving up in social hierarchy because regardless of initial adverse conditions they managed to overcome healthrelated constraints and consequently developed feelings of life control achievement and gratitude this explanation is also supported by earlier evidence that education is more beneficial for health of those with the lowest propensity to attain higher education based on a wide range of childhood adversities 37 despite using a highquality data set a comprehensive indicator of socioeconomic position a validated measure of individuals health and drma recommended method to identify the health consequences of social mobility our study has its limitations first due to the age composition of add health dataset we focused on the health implications of social mobility on individuals at a relatively early stage in terms of their lifetime socioeconomic position although a recent study implies that social mobility might have only shortterm consequences observed when mobile individuals are relatively young 39 it is likely that the add health cohort at wave iv is still too young to fully differentiate between mobile and immobile individuals as they are expected to experience further upward or downward social mobility this seems to be particularly important in terms of occupational attainment and it may be addressed in the future with add healths wave v data when respondents are 10 years older wave v can also provide valuable health information allowing us reexamining the relationship between social mobility and al of the relatively older cohort methodologically it is important to note that although we mitigated the bias from confounding factors and health selection our approach cannot identify a causal relationship between social mobility and al the main conclusion of our study is that not only does socioeconomic position matter for young adults health in the united states but also whether the attained status is the result of mobility between individuals origin and destination socioeconomic environments this mobility effect however can be identified if an appropriate statistical approach is employed and individuals initial health is adequately accounted for we also call for more nuanced consideration of the impact of shortand longterm mobility on health the finding that the shortrange upward social mobility is associated with better outcomes among those with poor childhood health suggests that social mobility might be a transformative experience for particularly disadvantaged individuals yet our finding that there is no positive health effect of longrange upward mobility also indicates that more extensive mobility experiences might entail costs which cannot be compensated by positive implications of social mobility the data underlying the results presented in the study are available from add health data

the contemporaneous association between higher socioeconomic position and better health is well established life course research has also demonstrated a lasting effect of childhood socioeconomic conditions on adult health and wellbeing yet little is known about the separate health effects of intergenerational mobilitymoving into a different socioeconomic position than ones parentsamong early adults in the united states most studies on the health implications of mobility rely on crosssectional datasets which makes it impossible to differentiate between health selection and social causation effects in addition understanding the effects of social mobility on health at a relatively young age has been hampered by the paucity of health measures that reliably predict disease onset analysing 4713 respondents aged 25 to 32 from the national longitudinal study of adolescent healths waves i and iv we use diagonal reference models to separately identify the effects of socioeconomic origin and destination as well as social mobility on allostatic load among individuals in the united states using a combined measure of educational and occupational attainment and accounting for individuals initial health we demonstrate that in addition to health gradient among the socially immobile individuals socioeconomic origin and destination are equally important for multisystem physiological dysregulation shortrange upward mobility also has a positive and significant association with health after mitigating health selection concerns in our observational data this effect is observed only among those reporting poor health before experiencing social mobility our findings move towards the reconciliation of two theoretical perspectives confirming the positive effect of upward mobility as predicted by the rags to riches perspective while not contradicting potential costs associated with more extensive upward mobility experiences as predicted by the dissociative thesis

BACKGROUND Following the collapse of the "housing market bubble" in 2007, and the ensuing economic crisis and consequent rise in unemployment, housing systems with a large fraction of ownership began to collapse, and the number of families who could not pay their mortgage began to increase rapidly. This situation resulted in serious housing instability problems in several European countries, particularly in Southern Europe, where the crisis has been more severe, triggering a significant increase in the number of foreclosures and the eviction of thousands of families to date. 1 The Foreclosure Process and Health Recent reports have explored the effects of the foreclosure process on mental health and well-being and to a lesser extent on physical health. Cross-sectional studies, conducted mainly in the USA, have reported poorer mental health and well-being among individuals subject to foreclosure than those in stable housing. [2][3][4] In two successive studies, Pollack et al. found that people who were more than 2 months behind on their mortgage payments or who were involved in a foreclosure judgment had a higher prevalence of psychiatric disorders such as depression, anxiety, or dysphoria compared to people without housing instability. 5,6 Houle 7 recently reported that an increase in the rate of mortgage foreclosures at county level was associated with poorer mental health after adjusting for individual and contextual variables, while Fowler et al. suggested that housing loss is associated with increased suicide risk. 8 Foreclosure has also been reported to have physical health effects, including higher rates of hypertension and heart disease compared to the general population. 6,9 This relationship has also been explored using cohort study designs. Data from the British Household Panel Survey in the UK show that individuals with mortgage payment arrears or who are in the later stages of eviction have poorer mental health and well-being than the general population. [10][11][12] Using data from a cohort of 662 women in Detroit, Osypuk et al. found that those who had recently experienced foreclosure had higher risk of severe symptoms of depression. 13 Finally, McLaughlin et al. observed in Detroit that individuals who had lost their dwellings due to foreclosure had higher rates of depression and generalized anxiety syndrome. 14 While the mechanisms underlying this relationship are not entirely clear, foreclosure undermines the health-protecting effects of having a stable home, in addition to the burden and stress of the process itself. Qualitative studies using a psychosocial perspective suggest that the association between foreclosure and health outcomes is caused by fear and lack of control, the impact on social status, and shame or sense of failure. 10,15 The Case in Spain The Spanish housing system has some differentiating characteristics with respect to other European countries that may explain the serious foreclosure problem here. The current housing system is mainly market-driven, which limits the social response to a public need for accommodation, 16 and ownership rather than renting is the main type of occupancy , with a very low percentage of social renting . 17,18 Under Spanish law, a mortgage is a guarantee instated by the bank on a property to ensure payment of the loan. In the case of non-payment of the loan, and after notifying the debtor, the creditor can demand the auction of the property, whose price can be smaller than the original. Thus, while this sale is intended to pay the debt, if it is not sufficient, which is usually the case, the creditor can use the borrower's other assets to pay off the remaining debt; thus, dation, or surrender of the property, in payment is not a right. The outbreak of the "subprime" crisis in 2007 and the international credit crunch strongly affected the Spanish economy and its housing market. This was accompanied by a progressive increase in unemployment rates, from 8 % in 2007 to 26.3 % in the second quarter of 2013 , and a decrease in disposable income, resulting in thousands of over-indebted families who were unable to pay their housing expenses. 19 Many families were compelled to make higher monthly mortgage payments than their income and had higher outstanding debts than the current value of their homes, which had decreased significantly. 20 Between 2008 and 2014, 604,489 foreclosure proceedings were initiated , and 378,693 evictions were ordered, of which 244,267 were executed. 21,22 Only one third of these cases were resolved through dation in payment. 23 Paradoxically, Spain has a stock of close to four million empty dwellings. [16][17][18] The administration has implemented some measures against this situation, such as a "code of good banking practices" and the "urgent measures to strengthen protection for mortgage holders" , but none have effectively solved the problem. 21,24 The Social Response: the Platform for People Affected by Mortgages In response to this housing problem, civil society has self-organized alternatives for families affected by the crisis, including problems with housing payments. The Platform for People Affected by Mortgages was created in 2009 with the aim of responding to problems of foreclosure, eviction and debt faced by thousands of families at various stages of the eviction process. 17 The PAH prevents the eviction of affected families, obtains reasonable relocation alternatives, and lobbies to increase the social housing stock and the creation of a dation in payment law. 20 The PAH has prevented 1663 evictions and re-housed 2500 people to date and have organized campaigns to position the housing issue on the public agenda. 25 --- Objective Given the distinctive characteristics of the Spanish housing market, and the particularly severe impact of the economic crisis in this country, the aim of this study was to generate knowledge on the impact of the foreclosure process on health in Spain. Our specific objectives are to: i. Describe the socioeconomic profile and mental and self-reported health status of members of the Platform for People Affected by Mortgages , and compare these with the general population of Catalonia ii. Analyze the association between the mental and self-reported health of PAH members and employment status, number of children, and various inequality axes iii. Analyze the association between the mental and self-reported health of PAH members and the relationship with the mortgage loan and stage of foreclosure --- METHODS Design, Study Population, and Information Sources Using convenience sampling, we performed a cross-sectional study of PAH members from Catalonia, or from the general population of Catalonia . The main source of information was the 2014 Survey of People Affected by Mortgages, a self-administered web-based survey aimed at obtaining reliable information on evictions and people affected by mortgages. Data were collected from September 8 to November 19, 2014, and respondents were recruited via the PAH website, social networks and through direct socialization by each of the PAH assemblies. One thousand two hundred eightyone responses were received in the Autonomous Community of Catalonia during the survey period. The sample was mainly composed of people related to the PAH and was called "PAH members" in this study. Respondents who reported that they did not have a mortgage or had not had a mortgage in the last 5 years were excluded, giving a final sample of 905 individuals .The sample included only one member per household. Data for the general population were obtained via the 2013 Catalan Health Survey , a cross-sectional study that has conducted two waves of data collection per year since 2010 . This survey recruits a representative multistage probability sample of the non-institutionalized population of each territorial health administration within Catalonia, stratified by age, sex, and municipality size, and updated in each wave. Interviews are conducted in participants' homes using a basic pre-coded and structured questionnaire, which is maintained in successive waves. 26 --- Dependent Variables We used two measures of health status for this study: mental health and selfreported health. Mental health was evaluated using the 12-item version of the General Health Questionnaire , with participants scoring ≥3 classified as having a high probability of poor mental health. 27 Self-reported health was evaluated using the question, "How is your health in general?: Excellent, very good, good, fair, and poor". We created a dichotomous outcome variable, with the responses "fair" or "poor" coded as "poor self-reported health". 28,29 These two variables were asked in the same way in PAH and Catalonian surveys. --- Independent Variables We considered the following independent variables: employment status , variables related to different inequality axes , number of children , and housing instability . Only the analysis of the PAH group considered the number of children, owing to the difficulty of obtaining these data from the Catalan Health Survey. The categories used for each variable are shown in Table 1. Mortgage status was evaluated using the question "Which is your relationship with the mortgage loan?": "I'm a current mortgage holder", "I'm a recent mortgage holder" , "I'm a guarantor" and "I don't have and I haven't had a mortgage recently" . The latter were excluded from the analysis as already mentioned. Foreclosure stages were categorized into those who were up to date with payments , those who were in default , people who were in foreclosure waiting for the judgment of the court , those who were evicted and people who could not be classified into one of the stages . These are the stages suggested by the Platform for People Affected by Mortgage and the researchers and reflect the usual steps of people with mortgage problem who end up evicted in Spain. For evaluate the role of social class, we used the Spanish Society of Epidemiology's classification, which is based on the current or last occupation. 30 We used data on the interviewee's occupation, or if they had never worked, the occupation of another member of the household who was working at the time of the interview; responses were classified as non-manual class and manual class. --- Data Analysis We performed a descriptive analysis of all variables in PAH members and separately in the general population sample; we computed crude prevalence and standardized prevalence by the direct method, with the age distribution in the PAH sample as a reference . We compared these distributions by fitting age-adjusted logistic or multiple/multivariable regression models. We then compared the health status of PAH members to that of the general population sample by fitting robust Poisson regression models 31 to compute age-adjusted prevalence ratios of poor health status and their 95 % confidence intervals ; we estimated PR a s overall and stratified by each explanatory variable. We obtained prevalence differences by subtracting the estimated age-standardized prevalence . We do not present the results for the domestic workers and students categories of employment status as they are not comparable between these samples ; however, all observations were included in the analysis. Among PAH members, we fit a distinct set of robust Poisson regression models to analyze the association between poor health and the explanatory variables, including those related to housing instability. We first estimated the age-adjusted prevalence ratios and 95 %CI, and then fit a multiple/multivariable model including all explanatory variables except social class and the relationship with mortgage loan. These variables were excluded due to collinearity with educational status and foreclosure stage, respectively. All the data analysis was conducted separately for men and women 32 using STATA version 13. --- RESULTS --- Sample Characteristics Age-standardized results of the descriptive analysis of all variables in each sample are shown in Table 1. We observed a higher rate of unemployment and lower socioeconomic status in the PAH sample than in the general population sample, for both women and men. For example, the unemployment rate in the PAH sample was more than double that in the general population . Similarly, the percentage of individuals from manual social classes was higher in the PAH sample, while that of people with a college education was lower. We found no significant differences in the proportion of immigrants between the samples. Considering just the PAH sample, most members had one or two children , and were mortgage holders rather than guarantors. Among mortgage holders, most PAH members were in the non-payment stage , followed by those subject to a foreclosure judgment , those who were up to date with their mortgage payments , and those who had already been evicted, with or without dation in payment. --- Health Status among PAH Members and the General Population The prevalence of poor mental health and poor self-reported health among PAH members and in the general population are shown in Tables 2 and3. --- Mental Health The prevalence of poor mental health was 90.6 % among women and 84.4 % among men in the PAH sample, and 15.5 and 10.2 % in the general population sample, corresponding to a PR a of 6.68 and 9.39 , respectively. As a measure of impact, the prevalence differences also are very high . There were also notable differences between these groups after stratifying by explanatory variables for women from the non-manual class was, and 6.29 for those from the manual class) . --- Self-Reported Health We observed important absolute and relative differences in self-reported health between PAH members and the general population sample, although these differences were less marked than for mental health. The prevalence of poor self-reported health was 55.6 % among women and 39.4 % among men from the PAH sample and 19.2 and 16.1 % in the general population sample, with a PR a of 3.22 and 2.72 , and a PD of 36.4 % and 23.3 %, respectively . After stratifying, self-reported health was more affected in PAH sample in most of explanatory variable categories . --- Association between Socioeconomic Variables and Health Outcomes among PAH Members The results of the association between the explanatory variables and health outcomes among PAH members are shown in Table 4. Mental Health Compared to paid workers, we observed the poorest mental health in unemployed women and unemployed men without employment benefit. These associations remain significant after multivariate adjustment , but only among those without unemployment benefit. Mental health was also worse among manual than non-manual workers, in both women [PR c = 1.10 ] and men [PR c = 1.15 ]. We observed a graded effect of educational level on poor mental health in both sexes, especially women. Finally, we found no significant association between mental health and immigration status or number of children among PAH members . --- Self-Reported Health We observed a significant difference in self-reported health status between female PAH members who were employed and those who were retirees or pensioners , but not between employed and unemployed women . Among male PAH members, the greatest differences with respect to paid workers was observed among retirees and pensioners and unemployed individuals receiving unemployment benefit . Unlike for mental health, we only observed a greater likelihood of poor self-reported health among women with a primary education , and those who were manual workers . The bivariate analysis showed that women with ≥3 children were significantly more likely have poor self-reported health status than those with no children , while those with 1 or 2 children showed no such difference. These effects disappeared after multivariate adjustment. We observed no significant differences for other categories of educational level or immigration status, under either the bivariate or multivariate models . --- Association between Foreclosure Stage and Health Outcomes We observed differences in the distribution of poor mental and self-reported health among individuals in all foreclosure stages, compared to those who were either up to date with their mortgage payments or who had already been evicted. Women in the non-payment and judgment stage of foreclosure had 16 and 12 % greater probability of poor mental health than those who were up to date with their payments. We observed similar results among men, although these associations disappeared after multivariate adjustment, except among men in the non-payment stage of foreclosure . Self-reported health appears to be more affected in the later stages of the foreclosure process. Individuals who had been evicted without dation in payment had more than twice the prevalence of poor self-reported health than those who were up to date with their mortgage payments [PR c : males, 2.24 ; females, 1.89 ]. Men who had been evicted with dation in payment and women who were in the judgment stage of foreclosure had 56 and 50 % higher prevalence of poor self-reported health than those who were up to date with their mortgage payments . --- DISCUSSION This is first Southern European study to show the high prevalence of poor mental and self-reported health among people affected by mortgages, and the striking differences in these health outcomes with respect to the general population. Stratifying by axes of inequality such as gender, social class and education, or by employment status, these differences persist in almost all groups, indicating that the effect of foreclosure is independent of other variables. Moreover, we found significant socioeconomic inequalities in poor health outcomes among PAH members. We observed no marked differences between mortgage holders and guarantors in the prevalence of poor mental and self-reported health. Finally, poor mental health was more predominant during the early stages of the foreclosure process, whereas self-reported health is generally affected in later stages. --- Health Status among PAH Members and the General Population We observed various socioeconomic differences between PAH members and the general population, with the former having higher rates of unemployment, a lower educational level, and a larger proportion of manual workers. This reflects the reality of a disadvantaged group, which in turn has poor overall levels of mental and self-reported health. There is abundant evidence of the association between health and socioeconomic status, an indicator of power and resources. 33 However, this does not fully explain our results, since these differences remain in all categories, including the most disadvantaged groups, even after stratifying by inequality axes. We observe both relative and absolute differences, which reflect health inequalities between PAH members and the general population. Thus, our results indicate that the foreclosure process has a real effect on the health of those affected. These results are consistent with those of previous cross-sectional studies describing how people affected by foreclosure have poorer general health and poorer mental health , compared with unaffected individuals. 2,3 This effect may be mediated by other unmeasured mechanisms, such as loss of one's dwelling, the consequent absence of a daily routine, fear and lack of control, loss of social status, shame, or sense of failure. 10,15 In addition to socioeconomic variables, we also stratified our analyses by sex, as this is widely recognized as an important determinant of health inequalities. We found a higher prevalence of poor mental and self-reported health in women than men, which is consistent with previous evidence. 32 --- Association between Socioeconomic Variables and Health Outcomes among PAH Members In addition to the high prevalence of poor health outcomes among PAH members, we also observed differences within this group. We observed a higher likelihood of poor mental health outcomes in unemployed individuals, manual workers, and people with a primary education or less. The results for self-reported health were similar, although the associations were less clear among men. To our knowledge, previous studies of housing instability and health do not account for inequalities among people affected by foreclosure. This is an important issue because it highlights the ubiquity of social and health inequalities, even within groups that are already severely disadvantaged. Finally, we did not find an association between poor health and the number of children, unlike previous studies showing that family burden is a determinant of poor health in some circumstances. 34 Relationship between Mortgage Status, Foreclosure Stage, and Health Outcomes We did not observed remarkable differences in housing instability between mortgage holders and guarantors, but rather high rates of poor mental and self-reported health in both groups. However, guarantors accounted for only ∼5 % of our study population, so further studies would be necessary in this group. Moreover, we observed differences in the importance of each health outcome between stages, in that poor mental health was more affected in early stages of the process, while self-reported health was affected in later stages. This may be due to psychobiological mechanisms related to health inequalities. 35 Thus, job loss and problems with mortgage payments activate functional stress mechanisms that facilitate a better response to stress, but that also cause psychological distress in the short term. If maintained over time, i.e., during the later stages of the foreclosure process, this can lead to chronic stress, which increases risk of disease or functional disability, as reflected by poorer self-reported health. 28,29,35 However, it is important to note that these findings must be interpreted cautiously because it is a convenience sample and there are small effect sizes, so further research is needed to verify these suggestive patterns. We also observed a higher likelihood of poor self-reported health among individuals who were evicted without dation in payment and those with dation in payment, although this difference was not statistically significant. This difference may be due to the economic and social burden of having to maintain the mortgage debt, despite the loss of housing. The PAH has an important function in this respect, in that its members are more likely to obtain a better solutions to their mortgage problem than non-members: in our study, 83 % of evicted PAH members had obtained dation in payment, versus ∼33 % of the general population. 36 The PAH has been an important pressure group since the beginning of the crisis, advocating for the right to decent housing, helping thousands of families to negotiate with financial institutions, and stopping evictions and re-housing of families. --- Limitations and Strengths This study has various limitations. First, the sample may not have sufficient power to detect significant differences between some categories , so our findings have to be interpreted cautiously. Second, as in all crosssectional studies, reverse causality may occur, and in fact, some authors suggest that poor health is one of the causes of foreclosure. 6 However, some longitudinal studies show greater risk of poor health among individuals with a history of foreclosure or housing instability. 13,14 A recent systematic review on foreclosure and health found only two studies based on individual-level data, which accounted for this potential bias by adjusting for baseline comorbidity. 37 Third, we used a convenience sample, rather than a random sample, due to a lack of adequate records on the population of individuals affected by mortgage problems in Spain. This sampling method can introduce selection bias because it does not consider individuals who are affected by foreclosure but who are unable to actively participate . Such individuals would likely have even poorer health, so the associations would have been stronger. Also, we were unable to consider family type and reproductive work in the analysis because these data could not be compared between the PAH and general population samples. However, in comparable categories, PAH members had poorer health than individuals from the general population . Despite these limitations, this study provides new data on the association between housing instability and health in a distinct context to that of most previous studies, which have mainly focused on the USA and UK. Southern European countries have been strongly affected by the economic crisis, and evidence on it effects in this context is particularly relevant. In addition, the work of the PAH has allowed us to study a hard-to-reach population: we recruited 905 individuals who were subject to foreclosure, which would otherwise not have been possible, due to a lack of records in this country. Similarly, another novel contribution of this study is that analyzes the health of individuals at different stages of the foreclosure process. This allows us to explore the mechanisms that underlie the effects of foreclosure on health. --- Conclusions The serious problem of foreclosure and evictions in Spain is far from being resolved and will likely continue in the coming years. This situation is associated with substantially poorer health in affected individuals, compared to the general population, which exacerbates social and health inequalities. This is an important motivation for further research and especially for implementing public policies that tackle the housing instability that affects a sizeable proportion of the Spanish population. --- APPENDIX

Housing instability has been shown to be related to poorer health outcomes in various studies, mainly in the USA and UK. Affected individuals are more prone to psychiatric (e.g., major depression, anxiety) and physical disorders (e.g., hypertension). This situation has deteriorated with the onset of the economic crisis. One of the most affected countries is Spain, which has high rates of foreclosure and eviction that continue to rise. In response, a civil movement, The Platform for People Affected by Mortgages (PAH), works to provide solutions to its members affected by foreclosure and advocates for the right to decent housing. The aims of this study ware to describe and compare the health status of PAH members from Catalonia to a sample of the general population and to analyze the association between health status and mortgage status, foreclosure stage, and other socioeconomic variables, among members of the PAH. We conducted a cross-sectional study using a self-administered online questionnaire (2014) administered to 905 PAH members in Catalonia (918 years; 559 women and 346 men). Results were compared with health indicators from The Health Survey of Catalonia 2013 (n = 4830). The dependent variables were poor mental health (GHQ 12 ≥ 3), and poor self-reported health (fair or poor). All analyses were stratified by sex. We computed age-standardized prevalence and prevalence ratios of poor mental and self-reported health in both samples. We also analyzed health outcomes among PAH members according to mortgage status (mortgage holders or guarantors), stage of foreclosure, and other socioeconomic variables by computing prevalence ratios from robust Poisson regression models. The prevalence of poor mental health among PAH members was 90.6 % in women and 84.4 % in men, and 15.5 and 10.2 % in the general population, respectively. The prevalence of poor self-reported health was 55.6 % in women and 39.4 % in men from the PAH, and 19.2 and 16.1 % in the general population, respectively. These health inequalities were independent of socioeconomic status. The prevalence of poor mental health was higher among individuals in the non-payment stage of foreclosure than among those who were up to date with their payments (e.g., PR c = 1.16 [95 % CI 1.04-1.28]). In contrast, selfreported poor health was more prominent in later stages of foreclosure, such as in posteviction without dation in payment stage in men (PR c = 2.24 [95 %CI = 1.35-3.72]). We observed a considerably higher prevalence of poor mental and self-reported health 312 Vásquez-Vera, Rodríguez-Sanz, and Borrell are with the

background following the collapse of the housing market bubble in 2007 and the ensuing economic crisis and consequent rise in unemployment housing systems with a large fraction of ownership began to collapse and the number of families who could not pay their mortgage began to increase rapidly this situation resulted in serious housing instability problems in several european countries particularly in southern europe where the crisis has been more severe triggering a significant increase in the number of foreclosures and the eviction of thousands of families to date 1 the foreclosure process and health recent reports have explored the effects of the foreclosure process on mental health and wellbeing and to a lesser extent on physical health crosssectional studies conducted mainly in the usa have reported poorer mental health and wellbeing among individuals subject to foreclosure than those in stable housing 2 3 4 in two successive studies pollack et al found that people who were more than 2 months behind on their mortgage payments or who were involved in a foreclosure judgment had a higher prevalence of psychiatric disorders such as depression anxiety or dysphoria compared to people without housing instability 56 houle 7 recently reported that an increase in the rate of mortgage foreclosures at county level was associated with poorer mental health after adjusting for individual and contextual variables while fowler et al suggested that housing loss is associated with increased suicide risk 8 foreclosure has also been reported to have physical health effects including higher rates of hypertension and heart disease compared to the general population 69 this relationship has also been explored using cohort study designs data from the british household panel survey in the uk show that individuals with mortgage payment arrears or who are in the later stages of eviction have poorer mental health and wellbeing than the general population 10 11 12 using data from a cohort of 662 women in detroit osypuk et al found that those who had recently experienced foreclosure had higher risk of severe symptoms of depression 13 finally mclaughlin et al observed in detroit that individuals who had lost their dwellings due to foreclosure had higher rates of depression and generalized anxiety syndrome 14 while the mechanisms underlying this relationship are not entirely clear foreclosure undermines the healthprotecting effects of having a stable home in addition to the burden and stress of the process itself qualitative studies using a psychosocial perspective suggest that the association between foreclosure and health outcomes is caused by fear and lack of control the impact on social status and shame or sense of failure 1015 the case in spain the spanish housing system has some differentiating characteristics with respect to other european countries that may explain the serious foreclosure problem here the current housing system is mainly marketdriven which limits the social response to a public need for accommodation 16 and ownership rather than renting is the main type of occupancy with a very low percentage of social renting 1718 under spanish law a mortgage is a guarantee instated by the bank on a property to ensure payment of the loan in the case of nonpayment of the loan and after notifying the debtor the creditor can demand the auction of the property whose price can be smaller than the original thus while this sale is intended to pay the debt if it is not sufficient which is usually the case the creditor can use the borrowers other assets to pay off the remaining debt thus dation or surrender of the property in payment is not a right the outbreak of the subprime crisis in 2007 and the international credit crunch strongly affected the spanish economy and its housing market this was accompanied by a progressive increase in unemployment rates from 8 in 2007 to 263 in the second quarter of 2013 and a decrease in disposable income resulting in thousands of overindebted families who were unable to pay their housing expenses 19 many families were compelled to make higher monthly mortgage payments than their income and had higher outstanding debts than the current value of their homes which had decreased significantly 20 between 2008 and 2014 604489 foreclosure proceedings were initiated and 378693 evictions were ordered of which 244267 were executed 2122 only one third of these cases were resolved through dation in payment 23 paradoxically spain has a stock of close to four million empty dwellings 16 17 18 the administration has implemented some measures against this situation such as a code of good banking practices and the urgent measures to strengthen protection for mortgage holders but none have effectively solved the problem 2124 the social response the platform for people affected by mortgages in response to this housing problem civil society has selforganized alternatives for families affected by the crisis including problems with housing payments the platform for people affected by mortgages was created in 2009 with the aim of responding to problems of foreclosure eviction and debt faced by thousands of families at various stages of the eviction process 17 the pah prevents the eviction of affected families obtains reasonable relocation alternatives and lobbies to increase the social housing stock and the creation of a dation in payment law 20 the pah has prevented 1663 evictions and rehoused 2500 people to date and have organized campaigns to position the housing issue on the public agenda 25 objective given the distinctive characteristics of the spanish housing market and the particularly severe impact of the economic crisis in this country the aim of this study was to generate knowledge on the impact of the foreclosure process on health in spain our specific objectives are to i describe the socioeconomic profile and mental and selfreported health status of members of the platform for people affected by mortgages and compare these with the general population of catalonia ii analyze the association between the mental and selfreported health of pah members and employment status number of children and various inequality axes iii analyze the association between the mental and selfreported health of pah members and the relationship with the mortgage loan and stage of foreclosure methods design study population and information sources using convenience sampling we performed a crosssectional study of pah members from catalonia or from the general population of catalonia the main source of information was the 2014 survey of people affected by mortgages a selfadministered webbased survey aimed at obtaining reliable information on evictions and people affected by mortgages data were collected from september 8 to november 19 2014 and respondents were recruited via the pah website social networks and through direct socialization by each of the pah assemblies one thousand two hundred eightyone responses were received in the autonomous community of catalonia during the survey period the sample was mainly composed of people related to the pah and was called pah members in this study respondents who reported that they did not have a mortgage or had not had a mortgage in the last 5 years were excluded giving a final sample of 905 individuals the sample included only one member per household data for the general population were obtained via the 2013 catalan health survey a crosssectional study that has conducted two waves of data collection per year since 2010 this survey recruits a representative multistage probability sample of the noninstitutionalized population of each territorial health administration within catalonia stratified by age sex and municipality size and updated in each wave interviews are conducted in participants homes using a basic precoded and structured questionnaire which is maintained in successive waves 26 dependent variables we used two measures of health status for this study mental health and selfreported health mental health was evaluated using the 12item version of the general health questionnaire with participants scoring ≥3 classified as having a high probability of poor mental health 27 selfreported health was evaluated using the question how is your health in general excellent very good good fair and poor we created a dichotomous outcome variable with the responses fair or poor coded as poor selfreported health 2829 these two variables were asked in the same way in pah and catalonian surveys independent variables we considered the following independent variables employment status variables related to different inequality axes number of children and housing instability only the analysis of the pah group considered the number of children owing to the difficulty of obtaining these data from the catalan health survey the categories used for each variable are shown in table 1 mortgage status was evaluated using the question which is your relationship with the mortgage loan im a current mortgage holder im a recent mortgage holder im a guarantor and i dont have and i havent had a mortgage recently the latter were excluded from the analysis as already mentioned foreclosure stages were categorized into those who were up to date with payments those who were in default people who were in foreclosure waiting for the judgment of the court those who were evicted and people who could not be classified into one of the stages these are the stages suggested by the platform for people affected by mortgage and the researchers and reflect the usual steps of people with mortgage problem who end up evicted in spain for evaluate the role of social class we used the spanish society of epidemiologys classification which is based on the current or last occupation 30 we used data on the interviewees occupation or if they had never worked the occupation of another member of the household who was working at the time of the interview responses were classified as nonmanual class and manual class data analysis we performed a descriptive analysis of all variables in pah members and separately in the general population sample we computed crude prevalence and standardized prevalence by the direct method with the age distribution in the pah sample as a reference we compared these distributions by fitting ageadjusted logistic or multiplemultivariable regression models we then compared the health status of pah members to that of the general population sample by fitting robust poisson regression models 31 to compute ageadjusted prevalence ratios of poor health status and their 95 confidence intervals we estimated pr a s overall and stratified by each explanatory variable we obtained prevalence differences by subtracting the estimated agestandardized prevalence we do not present the results for the domestic workers and students categories of employment status as they are not comparable between these samples however all observations were included in the analysis among pah members we fit a distinct set of robust poisson regression models to analyze the association between poor health and the explanatory variables including those related to housing instability we first estimated the ageadjusted prevalence ratios and 95 ci and then fit a multiplemultivariable model including all explanatory variables except social class and the relationship with mortgage loan these variables were excluded due to collinearity with educational status and foreclosure stage respectively all the data analysis was conducted separately for men and women 32 using stata version 13 results sample characteristics agestandardized results of the descriptive analysis of all variables in each sample are shown in table 1 we observed a higher rate of unemployment and lower socioeconomic status in the pah sample than in the general population sample for both women and men for example the unemployment rate in the pah sample was more than double that in the general population similarly the percentage of individuals from manual social classes was higher in the pah sample while that of people with a college education was lower we found no significant differences in the proportion of immigrants between the samples considering just the pah sample most members had one or two children and were mortgage holders rather than guarantors among mortgage holders most pah members were in the nonpayment stage followed by those subject to a foreclosure judgment those who were up to date with their mortgage payments and those who had already been evicted with or without dation in payment health status among pah members and the general population the prevalence of poor mental health and poor selfreported health among pah members and in the general population are shown in tables 2 and3 mental health the prevalence of poor mental health was 906 among women and 844 among men in the pah sample and 155 and 102 in the general population sample corresponding to a pr a of 668 and 939 respectively as a measure of impact the prevalence differences also are very high there were also notable differences between these groups after stratifying by explanatory variables for women from the nonmanual class was and 629 for those from the manual class selfreported health we observed important absolute and relative differences in selfreported health between pah members and the general population sample although these differences were less marked than for mental health the prevalence of poor selfreported health was 556 among women and 394 among men from the pah sample and 192 and 161 in the general population sample with a pr a of 322 and 272 and a pd of 364 and 233 respectively after stratifying selfreported health was more affected in pah sample in most of explanatory variable categories association between socioeconomic variables and health outcomes among pah members the results of the association between the explanatory variables and health outcomes among pah members are shown in table 4 mental health compared to paid workers we observed the poorest mental health in unemployed women and unemployed men without employment benefit these associations remain significant after multivariate adjustment but only among those without unemployment benefit mental health was also worse among manual than nonmanual workers in both women pr c 110 and men pr c 115 we observed a graded effect of educational level on poor mental health in both sexes especially women finally we found no significant association between mental health and immigration status or number of children among pah members selfreported health we observed a significant difference in selfreported health status between female pah members who were employed and those who were retirees or pensioners but not between employed and unemployed women among male pah members the greatest differences with respect to paid workers was observed among retirees and pensioners and unemployed individuals receiving unemployment benefit unlike for mental health we only observed a greater likelihood of poor selfreported health among women with a primary education and those who were manual workers the bivariate analysis showed that women with ≥3 children were significantly more likely have poor selfreported health status than those with no children while those with 1 or 2 children showed no such difference these effects disappeared after multivariate adjustment we observed no significant differences for other categories of educational level or immigration status under either the bivariate or multivariate models association between foreclosure stage and health outcomes we observed differences in the distribution of poor mental and selfreported health among individuals in all foreclosure stages compared to those who were either up to date with their mortgage payments or who had already been evicted women in the nonpayment and judgment stage of foreclosure had 16 and 12 greater probability of poor mental health than those who were up to date with their payments we observed similar results among men although these associations disappeared after multivariate adjustment except among men in the nonpayment stage of foreclosure selfreported health appears to be more affected in the later stages of the foreclosure process individuals who had been evicted without dation in payment had more than twice the prevalence of poor selfreported health than those who were up to date with their mortgage payments pr c males 224 females 189 men who had been evicted with dation in payment and women who were in the judgment stage of foreclosure had 56 and 50 higher prevalence of poor selfreported health than those who were up to date with their mortgage payments discussion this is first southern european study to show the high prevalence of poor mental and selfreported health among people affected by mortgages and the striking differences in these health outcomes with respect to the general population stratifying by axes of inequality such as gender social class and education or by employment status these differences persist in almost all groups indicating that the effect of foreclosure is independent of other variables moreover we found significant socioeconomic inequalities in poor health outcomes among pah members we observed no marked differences between mortgage holders and guarantors in the prevalence of poor mental and selfreported health finally poor mental health was more predominant during the early stages of the foreclosure process whereas selfreported health is generally affected in later stages health status among pah members and the general population we observed various socioeconomic differences between pah members and the general population with the former having higher rates of unemployment a lower educational level and a larger proportion of manual workers this reflects the reality of a disadvantaged group which in turn has poor overall levels of mental and selfreported health there is abundant evidence of the association between health and socioeconomic status an indicator of power and resources 33 however this does not fully explain our results since these differences remain in all categories including the most disadvantaged groups even after stratifying by inequality axes we observe both relative and absolute differences which reflect health inequalities between pah members and the general population thus our results indicate that the foreclosure process has a real effect on the health of those affected these results are consistent with those of previous crosssectional studies describing how people affected by foreclosure have poorer general health and poorer mental health compared with unaffected individuals 23 this effect may be mediated by other unmeasured mechanisms such as loss of ones dwelling the consequent absence of a daily routine fear and lack of control loss of social status shame or sense of failure 1015 in addition to socioeconomic variables we also stratified our analyses by sex as this is widely recognized as an important determinant of health inequalities we found a higher prevalence of poor mental and selfreported health in women than men which is consistent with previous evidence 32 association between socioeconomic variables and health outcomes among pah members in addition to the high prevalence of poor health outcomes among pah members we also observed differences within this group we observed a higher likelihood of poor mental health outcomes in unemployed individuals manual workers and people with a primary education or less the results for selfreported health were similar although the associations were less clear among men to our knowledge previous studies of housing instability and health do not account for inequalities among people affected by foreclosure this is an important issue because it highlights the ubiquity of social and health inequalities even within groups that are already severely disadvantaged finally we did not find an association between poor health and the number of children unlike previous studies showing that family burden is a determinant of poor health in some circumstances 34 relationship between mortgage status foreclosure stage and health outcomes we did not observed remarkable differences in housing instability between mortgage holders and guarantors but rather high rates of poor mental and selfreported health in both groups however guarantors accounted for only ∼5 of our study population so further studies would be necessary in this group moreover we observed differences in the importance of each health outcome between stages in that poor mental health was more affected in early stages of the process while selfreported health was affected in later stages this may be due to psychobiological mechanisms related to health inequalities 35 thus job loss and problems with mortgage payments activate functional stress mechanisms that facilitate a better response to stress but that also cause psychological distress in the short term if maintained over time ie during the later stages of the foreclosure process this can lead to chronic stress which increases risk of disease or functional disability as reflected by poorer selfreported health 282935 however it is important to note that these findings must be interpreted cautiously because it is a convenience sample and there are small effect sizes so further research is needed to verify these suggestive patterns we also observed a higher likelihood of poor selfreported health among individuals who were evicted without dation in payment and those with dation in payment although this difference was not statistically significant this difference may be due to the economic and social burden of having to maintain the mortgage debt despite the loss of housing the pah has an important function in this respect in that its members are more likely to obtain a better solutions to their mortgage problem than nonmembers in our study 83 of evicted pah members had obtained dation in payment versus ∼33 of the general population 36 the pah has been an important pressure group since the beginning of the crisis advocating for the right to decent housing helping thousands of families to negotiate with financial institutions and stopping evictions and rehousing of families limitations and strengths this study has various limitations first the sample may not have sufficient power to detect significant differences between some categories so our findings have to be interpreted cautiously second as in all crosssectional studies reverse causality may occur and in fact some authors suggest that poor health is one of the causes of foreclosure 6 however some longitudinal studies show greater risk of poor health among individuals with a history of foreclosure or housing instability 1314 a recent systematic review on foreclosure and health found only two studies based on individuallevel data which accounted for this potential bias by adjusting for baseline comorbidity 37 third we used a convenience sample rather than a random sample due to a lack of adequate records on the population of individuals affected by mortgage problems in spain this sampling method can introduce selection bias because it does not consider individuals who are affected by foreclosure but who are unable to actively participate such individuals would likely have even poorer health so the associations would have been stronger also we were unable to consider family type and reproductive work in the analysis because these data could not be compared between the pah and general population samples however in comparable categories pah members had poorer health than individuals from the general population despite these limitations this study provides new data on the association between housing instability and health in a distinct context to that of most previous studies which have mainly focused on the usa and uk southern european countries have been strongly affected by the economic crisis and evidence on it effects in this context is particularly relevant in addition the work of the pah has allowed us to study a hardtoreach population we recruited 905 individuals who were subject to foreclosure which would otherwise not have been possible due to a lack of records in this country similarly another novel contribution of this study is that analyzes the health of individuals at different stages of the foreclosure process this allows us to explore the mechanisms that underlie the effects of foreclosure on health conclusions the serious problem of foreclosure and evictions in spain is far from being resolved and will likely continue in the coming years this situation is associated with substantially poorer health in affected individuals compared to the general population which exacerbates social and health inequalities this is an important motivation for further research and especially for implementing public policies that tackle the housing instability that affects a sizeable proportion of the spanish population appendix

housing instability has been shown to be related to poorer health outcomes in various studies mainly in the usa and uk affected individuals are more prone to psychiatric eg major depression anxiety and physical disorders eg hypertension this situation has deteriorated with the onset of the economic crisis one of the most affected countries is spain which has high rates of foreclosure and eviction that continue to rise in response a civil movement the platform for people affected by mortgages pah works to provide solutions to its members affected by foreclosure and advocates for the right to decent housing the aims of this study ware to describe and compare the health status of pah members from catalonia to a sample of the general population and to analyze the association between health status and mortgage status foreclosure stage and other socioeconomic variables among members of the pah we conducted a crosssectional study using a selfadministered online questionnaire 2014 administered to 905 pah members in catalonia 918 years 559 women and 346 men results were compared with health indicators from the health survey of catalonia 2013 n 4830 the dependent variables were poor mental health ghq 12 ≥ 3 and poor selfreported health fair or poor all analyses were stratified by sex we computed agestandardized prevalence and prevalence ratios of poor mental and selfreported health in both samples we also analyzed health outcomes among pah members according to mortgage status mortgage holders or guarantors stage of foreclosure and other socioeconomic variables by computing prevalence ratios from robust poisson regression models the prevalence of poor mental health among pah members was 906 in women and 844 in men and 155 and 102 in the general population respectively the prevalence of poor selfreported health was 556 in women and 394 in men from the pah and 192 and 161 in the general population respectively these health inequalities were independent of socioeconomic status the prevalence of poor mental health was higher among individuals in the nonpayment stage of foreclosure than among those who were up to date with their payments eg pr c 116 95 ci 104128 in contrast selfreported poor health was more prominent in later stages of foreclosure such as in posteviction without dation in payment stage in men pr c 224 95 ci 135372 we observed a considerably higher prevalence of poor mental and selfreported health 312 vásquezvera rodríguezsanz and borrell are with the

Introduction Despite the approximately 1.25 million young caregivers living in Canada [1], the majority of Canadians remain largely unaware of the lived experiences [2] of this underrepresented group of "invisible caregivers" [3]. For the purposes of this study, we defined young caregivers as a young person, under the age of 25 years old who provides care to a friend/family member who lives with an illness, disability, injury, and/or challenge to activities of daily living. According to the literature, young people in Canada may take on caregiving roles when someone in their immediate family becomes mentally or physically unwell due to addiction, age-related weakness, injury, or unforeseen life events [4][5][6]. For example, in Ontario , there are over half a million young people under the age of 25 years who provide physical, medical, emotional, and other forms of support to a parent, grandparent, or sibling [7][8][9][10]. International literature pertaining to young caregivers highlights their multiple responsibilities including school and paid employment in addition to caregiving [2,11,12]. The unpaid labour of young caregivers averages 14-27 h per week and represents approximately CAD 25,000 to CAD 50,000 in annual savings for the family and/or healthcare system [13]. In this way, young caregivers are subjected to a "young carer penalty" in the form of short-and long-term harms to academic, personal, social, and professional development [14]. If there are inadequate supports for young caregivers, they can experience several adverse health outcomes including stress and depression, low self-esteem, anxiety, loneliness and isolation, suicidal ideation, and difficulty with peer relationships resulting from a lack of support [13][14][15][16]. Importantly, Canada has no existing social policies to support young caregivers at the national level. Additionally, federal social welfare programs are inaccessible to the majority of young caregivers, especially those with high levels of caregiving responsibilities, because the benefits rely on young caregivers earning an income and many are not of working age and/or do not have time to work due to the time they dedicate to providing care [17]. Therefore, as a group, this population can experience unrecognized and significant social, mental, physical, and economic strain. The COVID-19 global pandemic triggered a global health crisis [18] which has significantly impacted communities across Canada and worldwide, and highlighted pre-existing inequities amongst traditionally marginalized, socially excluded, and underrepresented groups [19,20]. The unique socio-economic and socio-emotional challenges faced by young caregivers necessitates an exploration of their experiences of the COVID-19 pandemic in their own voices. A key consideration for this study is that many young caregivers and their families cared for older adults [9,21] who are more vulnerable to adverse health outcomes from COVID-19, including hospitalization and death, according to the Centers for Disease Control and Prevention and the Government of Canada [22,23]. In order to protect their loved ones, these young caregivers can face difficult choices, such as whether to return to in-person learning or engage in extra-curricular community activities that can increase the risk of harm to the older adults they are caring for. Despite anticipating social, economic, and mental health challenges/changes that individuals and families can experience, much less is known about the impact of these challenges/changes on the family unit, and no literature exists on how families are navigating these challenges, especially families with children who must provide care to a loved one who is vulnerable to COVID-19. The "sandwich generation" has gained attention among researchers and policy-makers [24][25][26] but the perspectives of their children and the contributions of a family as a unit have not been explored. Accordingly, we investigated both young caregivers and their families to provide a holistic perspective that is missing from the existing literature related to young caregivers and the sandwich generation. Furthermore, due to the novelty of the pandemic, understanding how young caregivers and their families adjust to ongoing and novel changes to policies and institutions will contribute greatly to our existing knowledge on recovery from the pandemic. Those with caregiving responsibilities have faced compounding and unique challenges including more complex care resulting from concerted public health measures aimed at reducing the community transmission of COVID-19 [27], in addition to the separation from loved ones who have COVID-19 symptoms [28], and financial burdens related to caregiving that the Canada Emergency Response Benefit does not consider [28,29]. Young caregivers and their families face additional challenges, including changes to school and social relationships, as a result of policies and fears surrounding the virus [30][31][32][33][34]. This study is part of a larger study exploring the experiences of young caregivers and their families navigating COVID-19 starting in 2020 ongoing until 2023. The data were collected from young caregivers , family members , service providers who interact with young caregivers, community leaders/allies, and policy/decision-makers at different organizations/institutions. The findings from baseline interviews with young caregivers are reported in this paper. The purpose of this study is twofold: to identify the impact of public health restrictions on young caregivers and their families; and to determine the most appropriate and acceptable strategies to support families and their children who have caregiving responsibilities within and across diverse communities. The central research question guiding this study is the following: What was, is, and will be the impact of changing public health restrictions on young caregivers and their families during the pandemic and pandemic recovery? --- Materials and Methods Baseline interviews were conducted with 9 families and 3 young caregivers who joined the study without their family members. In total, 14 young caregivers joined the study. The social determinants of health [35,36] with intersectionality [37][38][39] guided the development of our interview guide alongside the lessons and findings we gleaned from a study we conducted on the experiences, challenges, and needs of young caregivers living in urban versus rural communities in Ontario, Canada [40]. Importantly, we acknowledge there is significant diversity in young caregiver populations and recognize this is not a homogeneous group. Interviewers were hired if they had a lived experience as a young caregiver and/or had worked directly with young caregivers. Our interviewers consisted of 6 young caregivers and 1 person who worked with young caregivers in order to capture a variety of insight and lived experiences to best match participants with an interviewer who could best potentially understand their lived experiences. The person who did not have lived experience as a young caregiver had worked with young caregivers had 6 years of experience supporting young caregivers through assisting with running programs designed for them, was 27 years old, and identified as a European Canadian woman. The 6 young caregivers who were hired as interviewers were all actively young caregivers at the time data collection took place. They were aged between 23 and 27 years; 4 identified as women and 2 as men. Three of the young caregivers identified as South Asian Canadian, one European Canadian, one East Asian Canadian, and one Middle-Eastern. Four were Master's students, one had completed an undergraduate degree, and one had completed a professional degree. Caregiving responsibilities included caring for a parent who lived with physical disability due to a car accident, a sibling living with a learning disability, a parent living with dementia, a parent living with a chronic mental illness, grandparents/parent living with disability or chronic physical and mental illnesses, and a partner living with chronic physical health challenges. Interviewers were trained in how to conduct a semi-structured interview and were provided with appropriate guidance/supervision by the investigators during interviews to ensure the data collected were both comprehensive and representative of young caregivers' voices. This study used a longitudinal data collection approach using semi-structured interviews. Semi-structured interviews were completed at baseline with young caregivers, or young caregivers and their family members. Follow-up interviews with young caregivers will occur at 6 months, 1 year, and 2 years. Follow-up interviews with family members will occur at 1 year and 2 years. At baseline, young caregivers were asked to participate in a 30-to-45-min interview and answer questions about how the pandemic impacted their life as a whole, how their caregiving responsibilities changed , how they and their families navigated the changes to their lives caused by the pandemic/public health restrictions, and what would make life easier as a young caregiver. Findings from the baseline interviews conducted with young caregivers are reported in this article. --- Sampling and Recruitment Young caregivers were recruited with the help of our community partners who provide services/supports/resources to young caregivers and their families: Young Caregivers Association , Ontario Caregiver Organization , and Young Carer Program . --- --- Data Collection and Analysis To analyze the interviews, reflexive thematic analysis [41,42] was used by the two investigators and a team of four research assistants that included one young caregiver who was 25 years old and had been a young caregiver since the age of 8, a volunteer service provider who worked closely with young caregivers for six years with a background in early childhood education, a Ph.D. candidate in Child and Youth Studies, and a Master's student in public health who had been engaged with research on young caregivers for 5 years. The researchers used inductive analysis, and began with a research question. Participants were recruited through our community partners, young caregiver organizations in Canada. Once screened for eligibility , participants were invited to participate in virtual interviews over Zoom which were transcribed verbatim by research assistants. The transcripts were reviewed several times by members of the research team. Those data were analyzed contemporaneously as data were collected. Initial codes were generated and initial themes emerged through data analysis. Through collaborative discussions between members of the research team, primary themes were identified. The results were written and disseminated by the research team. --- Results There were 14 young caregivers who participated in baseline interviews. Eleven young caregivers joined with their family members and three young caregivers joined the study independently. The age of young caregivers ranged from 6 to 25 years old. Ten of the young caregivers were between 6 and 13 years old and four were between 24 and 26 years old. Three sub-themes arose when looking at types of care. This included caregiving responsibilities, changes in the person being cared for, and protecting the family from COVID-19. --- Caregiving Responsibilities Four participants noted that there were responsibilities they had before the pandemic that they no longer had to do during the pandemic . Due to appointments being on Skype or appointments not allowing more than one person in the room, many caregivers noted that they no longer had to accompany or entertain the people they cared for during these visits. One participant reported no changes in their caregiving responsibilities. Other responsibilities ranged from feeding , washing and general hygiene , helping their grandmother up the stairs , and walking their sibling to school . There were also general household chores such as dishes, which one participant would do if the person being cared for was not feeling well, and laundry. Eight participants reported helping with cooking and meal preparation, ranging from making one or all the meals for the day, with one participant having to puree meals four times a day to make them easier to swallow for the person they cared for. One young caregiver prepared snacks for herself because her mother was busy caring for her brother. Another participant stated, "I would cook for [my grandmother], I will get her snacks, drinks and stuff like that" . Similarly, another participant would help her parents by taking care of her sister: "I'll help make lunch for my sister a lot like, especially on like the weekend, when my mom and dad can't do it, they're working or something like that, I'll make like a lot of like lunches and breakfasts" . Another participant reported ordering food for the family a few times a week. The pandemic made it more difficult to balance home and caregiving roles for two participants, with one having to move back to their home city from university and having to step out of online classes to take care of caregiving responsibilities. Additionally, two participants reported having to navigate financial support and challenges: "I have a lot of travel costs because of where I live, and trying to get to her, that would be the biggest thing because, like I kind of said before, I'm like doing all the organizational things, all the bills . . . like right now we're kind of trying to sell the house because she's moved and now it's just kind of sitting there. Those kind of things end up costing me emotionally along with financially just because there's like more stuff on my plate, but yeah, the main cost is the kind of travel and having to go back there if there is something, you just have to do in-person. And then obviously, visiting and seeing her because I want to". Another participant stated: "Definitely, financial issues have happened, in particular with us, we've experienced a lot of financial hardships with my dad in terms of him being not able to work anymore. That was prior to the pandemic, but the financial issues were also exacerbated because of my dad's chronic kidney disease. He needs to use certain medical supplies, like a catheter and a condom catheter and because of that, it has resulted in additional expenses for him. And I've had to pay out of pocket for things like the ThickenUp that he uses every day and other types of like diapers and things like that. So I see the financial issues existed prior to the pandemic, but more so now as well and, in particular during the pandemic [in 2020]. I unfortunately lost my job due to the reconstructing of our department and, due to budgeting, that had come to an end. And I sort of was feeling the pressure as well, of not being able to financially support myself and so that did add a level of stress and burden, because of course I was a student at the time and it definitely impacted my mental health. And yeah, that was something I experienced due to the pandemic and so now I feel like I am still trying to navigate that world of being able to, you know, persist and continue to move forward". --- Changes in Person Being Cared For A variety of new caregiving roles arose during COVID-19. Due to less opportunity to leave the house on their own, one participant reported having to provide more company for the person they cared for: "It has almost been every day to try to engage [my grandmother living with dementia] so she doesn't get into her hallucination state. I usually take her for a walk for an hour or an hour and a half every day. Sometimes she will sit with me at my desk while I work and she'll do things like colouring or looking at photos, just things to make her mind try to do something". . The participant also reported the new role of consistently reinforcing/reminding her family members about the severity of COVID-19 and ensuring that their family members were adequately wearing masks in public spaces. Two participants reported having a more difficult time with their caregiving as the lockdown had caused an exacerbation of symptoms such as aggression from those receiving care. As expressed by one participant, "When my brother didn't get help [therapy], I was really scared [as explained by mother: "Her brother gets very aggressive because he wasn't getting any therapy as a result of lockdowns, so she was worried..um..there would be aggression in the house towards her because she was only playmate for him at the time"]" . The other participant reported, "Like my grandmother developing dementia. That is definitely really new because we went from maybe helping her once or twice a day to now, 24/7 care. So that has felt pretty dramatic. But sometimes I wonder if maybe part of what made her dementia progress so rapidly was that she wasn't seeing her own friends or because she was kind of isolated herself during COVID-19" . Another participant reported a blend in caregiving and work, as they would have to play games with their family members during their work breaks to keep them entertained. One participant had more caregiving responsibilities because of online schooling and stated, "I had to change the way that I work during the day, because my brother was also at home doing school and sometimes I would need to watch him, so I would have to change my schedule for what I was going to do during the day" . A majority of the participants reported the same type of care with an increased workload due to the pandemic. These included tasks such as supervision of the person being cared for, which four participants reported doing; two of them having to provide 24 h supervision. As one participant described: "[My grandmother's] dementia progressed really rapidly over the last month and before that not very often, maybe one to two times a week [she would request my help]. She was pretty independent. Now, I would say probably seven days a week because she kind of needs 24 h care or supervision. She might wander out or do something dangerous. So I would say I am constantly alert of what is going on now". Entertainment responsibilities ranged from once a week to everyday for some caregivers. Most participants provided comfort and company to the person they were caring for, ranging from sitting in the bathroom with them to accompanying them to appointments and general emotional support when completing daily tasks. For example, one participant reported, "Sometimes [my brother] won't have a bath unless I'm there" and another participant stated, "Me and my brother share the responsibility of bringing [my mother] to appointments and bringing her anywhere she needs to be, she doesn't drive" . Another participant said, "Sometimes I just watch movies with [my grandmother] or sit quite close to her while she's watching something" . Some participants extended care in the form of emotional support to the person they cared for, one by giving hugs and the other by boosting self esteem and keeping them calm throughout the day. One participant stated, "For one of my brothers, a lot of it's anxiety. I'm helping to keep him happy and calm". . Most participants had a role of entertainment, which included tasks such as playing games , watching television, providing companionship on walks, or painting and reading. For instance, one participant stated they played games with their brother in between classes: "On my breaks, we would have a 30-min break and two 15-min breaks, so on my [first] 15-min break I'd play minecraft with my brother or I would have a snack with him and then on my next 15 min break, I would also play with my brother. And on my 30-min break I'd also play with my brother and sometimes I would take breaks, on my own just during the day, and I would also play with my brother" . One participant also reported that the person they cared for was physically injured during the pandemic which increased their workload, especially as it was harder to get the same support from the hospital when COVID-19 was at its peak in 2020: "We couldn't go and see him for the first few weeks when he was there because of the restrictions that the hospital had in terms of the number of visitors that they were allowing. They didn't really have any guests that can go in, so that definitely impacted the quality of care that we could provide to him because we weren't allowed to go and see him. The unit that he was in had an outbreak of COVID-19 and that ultimately impacted his care once again because we weren't allowed to go and see him" . There were also medical responsibilities that caregivers maintained. For instance, one participant assisted nurses during in-home visits: "We do have nurses that come into our home three times a week and they help to assist with the wound care, and so I would also assist them if, let's say, they need a bag, or they want to discard any materials and helping them with just dressing the wound if they need assistance" . Two participants reported administering and monitoring medication. As one participant reported, "I do have to monitor her to make sure that she's taking her medications and then every three months she has to go and get an injection" . One participant also reported having to physically turn the person they cared for in the middle of the night to prevent complications such as pressure ulcers. Two participants were responsible for scheduling appointments and four participants stated that they attended these appointments with the person they cared for. One participant reported that she and her mother had to take on a supportive role for her brother living with autism that a therapist would usually provide due to the program originally available in school being cancelled due to mandated virtual schooling. This participant reported things became easier once her mother found a working solution: "Video therapy wasn't working at all so we've found one therapist that will do in-person visits" . Two participants reported having to take over responsibilities of personal support workers , as the family was no longer comfortable having them come into the house due to the risks of contracting COVID-19. One participant expressed "I guess before the pandemic we had a PSW coming pretty frequently for bathing. And then during the pandemic we discontinued that because we weren't comfortable with having someone moving around to different places and then coming into our home" . The other participant stated, "I also have nurses that come into my home to help my dad with his wound dressing and even some of them don't wear the full yellow gown and once again it's just another reason . . . I don't understand why they're not just trying to be fully protected" . --- Protecting My Family from COVID-19 Caregivers described numerous methods in which they ensured the safety of their families. To begin, some reported not going outside or being extra cautious when they did leave . Some participants reported avoiding public transportation and providing rides to the person being cared for so they did not have to risk exposure on public transportation. Exposure was also avoided in other ways, such as groceries being ordered to the house, mask wearing, frequent hand washing, and receiving the vaccination when it was available. One participant captured the experience of many young caregivers in our study during the height of the pandemic: "And during the pandemic and even until now I'm very, very cautious about the activities that I undertake and how many people I surround myself with and just how I go about my daily life. And so, like, for example in my family, every Friday, we normally do our grocery shopping and normally I would only have like one person in my family go and do it, as opposed to all of us at once, just limit the number of people we were around. And I feel like I've become much more vigilant and always like wearing a mask and if I did go out and always like practicing, you know, washing my hands very frequently and always making sure to just stay as far as the distance from people as much as possible. And just like following all those extra precautions, just as anybody else would, but just being very mindful of that". --- Neighbourhood and Built Environment during the Pandemic There were two sub-themes that emerged during this study. Participants varied in geographical locations, with some living in small towns, suburban communities, or rural communities, but most resided in cities. --- Benefits and Challenges of Living Outside of the City There were two young caregivers who lived in a rural community, one lived in a suburban community, and one lived in a small town; one of the four young caregivers moved to the rural community during the beginning of the pandemic. They shared both the challenges and benefits of living in their communities. Benefits that young caregivers living in less urbanized communities believed were positive compared to a big city included having a big yard, being less stressed due to minimized crowding in their neighbourhoods, and more personal space. As one participant described, "Being in a smaller population density and definitely at the beginning, there was a lot less stress about the cases because, like we were following where everything was and I felt a lot less stress knowing that [my mom living with dementia] was in a community that had zero cases and she wasn't going outside of that community" . Most participants who lived in these communities mentioned there were ample walking trails and conveniences such as groceries that could be bought locally. Alternatively, two participants lived in a community that experienced a food shortage as a result of supply issues during the height of the pandemic. Participants who experienced food and supply shortages resulted in families having to go to nearby towns to get supplies. As one participant described, "The grocery stores got cleaned out a lot and there weren't a lot of food options" . There were also reported challenges with both accessing and finding other resources and programs that served a rural area such as meal delivery, PSWs, and speech therapists. Additionally, some young caregivers living in small towns reported internet outages, which made attending school and completing school work difficult at times. --- Benefits and Challenges of Living in the City The majority of young caregivers lived in a densely populated city and had lived there prior to and during the pandemic. Participants living in cities reported many benefits and challenges. Seven young caregivers reported that parks, grocery stores, and malls were conveniently located nearby. Four participants reported being able to access supplies and medications, including one that had supplies delivered to their home. Another reported benefit of living in the city related to accessibility, including access to reliable and affordable internet, to transportation via the bus, and to timely emergency care. One young caregiver reported the benefit of having a lot of neighbours, and another stated that they were still able to access nature and open spaces while living in the city. Participants living in densely populated cities reported challenges such as exposure to individuals not adhering with masking practices, and parks being busy or crowded. As reported by one participant, "[My grandmother living with dementia] really likes to go to the park. And the park is super busy and same with all the grocery stores in Chinatown. She really likes going to those. We didn't know what was going on at that point so we didn't feel safe going out there because she probably wouldn't know to distance from people or wear a mask" . In one case, a young caregiver's family moved out of the city into a rural community strictly due to the high number of cases: "We wouldn't have moved [to Nova Scotia] at all if it wasn't for the pandemic, we would have stayed in Montreal" . --- Perceptions towards COVID-19 and Public Health Restrictions/Efforts There were four major areas where varying perceptions towards COVID-19 were seen; COVID-19 and Public Health Restrictions, Vaccines and Masks, Online Schooling, and Feelings Towards Re-opening. --- COVID-19 and Public Health Restrictions Almost all participants reported having initial fear and uncertainty about COVID-19 and its restrictions. Many reported feeling less worried in 2021, when individuals started getting their vaccinations. Most reported fear about their family getting COVID-19 due to immunocompromisation, and some worried about their friends getting COVID-19 as well. Many participants were unable to go to places they occasionally or routinely visited due to public health restrictions and fear of the virus, which impacted their mental health. The person being cared for also was not able to go out as much, resulting in them being bored at home which created the new responsibility of entertaining them: "My mom typically went outside every day to the mall and she was no longer able to do that [because of lockdowns], so she was restless at home and I had to entertain her because she had a lack of friends and other social supports outside family" . One participant noted, "Mom and dad were stressed working online" , and another worried that COVID-19 had exacerbated symptoms of dementia of her grandmother due to the social isolation. Public health restrictions caused a lot of frustration, especially with its changes to emergency care. One participant reported that her father was hospitalized at one point during the pandemic and her family was unable to visit due to an outbreak in the unit. The stress of being unable to ensure he was properly cared for along with the existence of an outbreak was mentally challenging for her and her family to cope with. --- Vaccines and Masks Mask mandates were perceived as positive by most caregivers, but some participants expressed annoyance with it sticking to their face, making it difficult to breathe, general discomfort, and inconvenience of wearing it over extended periods of time . As one participant expressed, "Well, I've never liked wearing masks. Sometimes I like wearing masks, like after hockey and my face is all red and sweaty and people can't see my face or after like sports or when I'm in like a bad mood and I don't want people looking at me, I guess the mask comes in handy then, but it's hard to breathe in all day at school" . With respect to vaccines, there was a general willingness from young caregivers to receive it, even when met with some disagreement from their family members. However, there was some worry and hesitation due to fear of needles, fear of its novelty, and fear of side effects, especially if the person receiving the vaccine was immunocompromised. As one participant reported, "Yeah, I feel like I was always pro-vax and it was never an issue of whether or not I was going to get the vax, I know that. I was a little bit worried about my mom getting her vaccines, because of some of the side effects, and you know, we, my brother and I, were a little bit like extra cautious when she did get [the vaccine] in case she got any symptoms, or anything like that. But luckily there weren't any issues" . --- Online Schooling Many young caregivers experienced online schooling during the pandemic. Some caregivers liked the transition to online learning because they were able to learn at their own pace and were able to be home more often to look after the person they were caring for. As reported by one participant, "I think one of the silver linings and one of the blessings in disguise, that happened because of COVID-19 has been virtual [learning]. And for me, navigating school is a big one, because when I went to university all of the classes were in person. And so having everything transition to being online really opened up a huge door for me where I could be at home and help take care of my dad while also balancing school. And the same thing with like employment as well, and that has been a really huge asset" . However, some caregivers were worried about online school for reasons not limited to being afraid of technical issues such as poor internet connectivity, keeping up with assignments, and the general adjustment to the online environment. As reported by one participant, "I was worried, yes, 'cause when I first started online school I didn't know if I was handing in my assignments correctly or if I was getting my marks back or anything and I didn't go on meets like this with my teacher at first" . Additionally, being home for school caused caregiving duties to overlap, and some participants had to skip online classes to supervise or assist the person they were caring for. --- Feelings towards Re-Opening Most young caregivers were happy with the idea of COVID-19 lockdowns ending in the middle of 2021. Likewise, they reported feeling less anxious in 2021, as they were more knowledgeable and accepting of the virus and felt happy with the hope that COVID-19 was ending. Young caregivers were excited to see their teachers/friends again and happy to go back to extracurriculars that were not available during the lockdown. However, one caregiver reported frustration with the downshift in levels of concern despite the ongoing prevalence of the pandemic. --- The Impact of Public Health Restrictions on Relationships The lockdown caused by the pandemic had various effects on friendships and family dynamics. --- Friendships Most participants reported not being able to see friends in person due to school closures and the fear of catching COVID-19 from friends. Some participants were able to go to outdoor spaces such as the park to see their friends. Participants reported using texting, phone calls, social media , and applications to keep in touch with friends. Some caregivers reported connecting with neighbours and extended family for socialization. They also described how difficult it was to stay in touch with friends and that it was not ideal to use technology to maintain relationships. --- Family Dynamics A majority of caregivers reported feeling closer to their immediate family after spending so much time at home with them. Spending that much time also allowed a few younger caregivers to gain more privileges within the house, such as being trusted to use the stove. Being so close to family also had disadvantages, such as more conflicts at home and a crowded feeling. Some caregivers felt as though they received less attention from their parent in the home due to the person being cared for taking up all their time. They also felt that they had to spend more time with the person being cared for, which created more stress, burnout, and conflict in the family. As one participant noted: "I feel like having lived in a crowded area almost made [my mental health] worse because we were trying to keep [my grandmother living with dementia] inside all the time which means usually I had to entertain her or talk to her. Also, my grandmother's dementia is that she has pretty severe hallucinations. She can get really caught up in a fit and sometimes other family members aren't able to de-escalate her but somehow she is responsive to me". . A few young caregivers and/or their family members lost their jobs due to the pandemic, which contributed additional financial stress, especially for those who were responsible for paying for medical supplies. A few caregivers expressed needing more time alone. For example, "I felt like I was trying to go in my room a lot more [sort of laughing]. Like have my own space. Then again, I am getting older and stuff. But I just really liked my alone time during COVID-19" . Some participants were upset with not being able to see other family members due to the risk of catching COVID-19. Only one caregiver reported no change in their family dynamic during the pandemic because, even before the pandemic, they were home-schooled, mostly stayed at home, and their parents could not work due to living with a disability and relied on welfare/social assistance programs. --- Mental Health Challenges of Being a Young Caregiver during a Pandemic As a result of closures of public indoor spaces and lockdowns, many young caregivers experienced mental health issues and had utilize outdoor spaces or figure out ways to cope at home. --- Mental Health Mental health issues were a significant area of concern during the pandemic. Most caregivers reported feeling anxious/fearful of COVID-19 as well as isolated/lonely , especially since they relied on friends heavily for support and for a distraction from their caregiving responsibilities. As expressed by one young caregiver: "I think I mentioned this earlier, but my mental health was already kind of low because of the stress of being a student and being a caregiver and so then adding in the stress to the pandemic gave me a lot of-it just worsened what I was going through, because I didn't have those like outlets. Like I couldn't just go out to a restaurant and have a nice night out with my friends and just shoot the shit or blow off steam in any way, so it was just like . . . And even when you were able to do things, it still was not like fully relaxing because you still have to be like, "What are the regulations?", "Can I even do that thing?". There were so many levels of steps before you got to the place and then, when you got to the place, you're only getting like 75% of the experience. So, it just became like no way to let off stress, so just build up the stress and anxiety". One caregiver reported feeling fear at home because the person they cared for had become more physically aggressive without accessing their therapy. Anxiety was a prevalent feeling amongst the caregivers as well . Some caregivers reported feelings of annoyance and anger, for example, due to entertaining the person being cared for during school breaks instead of being able to have proper breaks from caregiving duties. Participants often felt exhausted and burnt out and struggled to still have time for self-care. As expressed by one participant, "There's so many days, where I feel like exhausted or like I'm so frustrated about something going on, like maybe an assignment or something like a friendship conflict or something and I have to come home and care for her it's like it's like-it's a lot" . One caregiver expressed that they were upset they were not able to go to the gym anymore, which had been a big factor in maintaining their mental health. --- Coping Strategies Young caregivers described various methods of coping during the pandemic. Some turned to video games and social media as a way to combat boredom, relieve stress, and stay in touch with friends. One caregiver reported joining a Facebook group for caregivers to gain support: "I guess reading about other people's stories and feeling less alone and knowing that other people did have similar issues-that kind of helped" . Some turned to parents and talked to friends on the phone or via video calls. Caregivers with pets also reported playing with them when they felt sad or lonely. Playing outside, walks, and exercise was also an aid in combatting boredom and stress. A few caregivers also participated in other activities such as shopping, watching television, and writing. One caregiver reported turning to a counsellor as a coping strategy. --- Recreation For recreation, young caregivers did a variety of activities. Some accessed programs online they were unable to before because of distance and/or scheduling . Some explored different hobbies such as drawing or gaming. Some young caregivers spent their free time playing with toys such as Legos. One individual went to an in-person sports group where they played with their mask on. Other caregivers attended piano classes and dance classes virtually. --- Navigating Formal Services and Supports Young caregivers shared their experiences of finding support during the pandemic to address different challenges they faced. Additionally, navigating changes in services/ supports for the person being cared for as a result of public health restrictions posed a challenge for many participants. --- Supports Accessed by Young Caregivers There were various supports accessed by young caregivers that assisted them during the pandemic. To begin with, one caregiver reported relying on Employment Insurance after losing their job and felt that it was enough to cover expenses. A number of young caregivers attended the programs specifically designed for young caregivers . Some relied on the support of nurses for wound care of the person being cared for, and some relied on PSWs for help with washing, bathing, and meal preparation. For example, "My grandmother has PSWs that come every so often to help her while me and my mom are at work . . . PSWs wash and bathe her. But they also do all the same things I do when I'm not there to help her" . Caregivers also relied on other family members for emotional and tangible support, while some relied on friends or neighbours. Some participants relied on stuffed animals for support, and some turned to pets. A few caregivers turned to Google and internet forums such as Reddit and Facebook groups to seek advice on their caregiving roles. As one participant described, "I have used Reddit forums. It's hard to find information specific to your situation, of course, I think I kind of have a little bit more of a unique situation. But I did find a few Reddit forums and things like that of people in similar caregiving roles and I kind of just like reading about their experiences. I never really contributed to it, but I did like see what they wrote and it kind of like made me feel a little bit like okay, like it's not just me going through this you know" . --- Changes in Formal Services and Support for Person Receiving Care Participants had mixed experiences when it came to virtual appointments. Some participants felt it was easier to attend virtual appointments because of distance and saving time and energy not having to travel to in-person locations. For example, "I was already doing a lot of things from another city, so I was already doing a lot of phone calls and things like that. It did, I think, become a little bit easier to get things done on the phone or through email with the pandemic, because people got more used to like digital signatures and things like that. Previously I had to explain my situation and tell them what's going on in order for me to sign things digitally" . Some participants reported negative experiences with formal services being offered virtually. For example, the lack of face-to-face communication was thought to inhibit the ability to convey vital information. Young caregivers also reported it was harder to reach healthcare workers to make appointments due to a reduced number of work days, and an increased difficulty accessing healthcare services: "For example, my dad is someone that needs physiotherapy and he needs to practice exercises every day-being able to find someone that could come into our home to do it with him was really difficult. Because of course majority of things shifted to be, you know, not in person anymore, so that was a huge impact and I find just navigating access to services in general really difficult, but I do think that . . . because of the pandemic, I think it definitely made it even more so [difficult]" . Additionally, there were a lot more miscommunications when scheduling with physicians. When in-person appointments did occur, participants reported not being able to go into the appointment with their family members, which increased communication errors. One participant worried that the person they cared for would not receive enough care in the hospital due to the heavy workload of healthcare workers. There were also disruptions in other formal services. Some caregivers reported that the person they cared for was no longer able to access social support services that they had once relied on, such as church and community centres: "Yeah, there was this one community program that [my grandmother] could go to for one day of the week that was no longer running in-person. The program was just one, single day of the week, but it felt really different because usually when she [was] away for that day, everyone gets to relax for the day. But yeah, we didn't have that during COVID-19 . . . they started doing half an hour zoom sessions with the people that would go to the program. After a while, my grandmother wasn't super engaged in it anymore, she would talk or do other things on her own during the program. We still had to watch her very closely when she was doing that. Sometimes I think because they were trying to cater to a broader audience-usually the day program is in Chinese so she can understand what is going on, but this was frequently in English so maybe that's why she wasn't as excited about it". Another caregiver reported being inconvenienced by the changes as they had to postpone moving the her mother into an Assisted Living Facility due to the pandemic: "The main thing that happened is that, right before the pandemic, I was talking to my mom and we were like in the process of exploring her moving into an Assisted Living facility and I pretty much just gotten her to the point where she was like starting to be willing to like actually consider it and then the pandemic happened, and they all shut down. And they obviously weren't taking people in, so we couldn't do tours, so it all got put like just on the back burner, and it was like over a year until I felt like I could bring it up again. And then when I did, she didn't feel like she wanted to do it anymore. And so, I was like even further back from step one so that was really, really, really frustrating and difficult". --- Recommendations from Young Caregivers and What Would Make Life Easier When caregivers were asked about recommendations on what would make their lives easier, various ideas were shared. One caregiver stated that there should be a bigger support network for young caregivers but was unsure of what it might look like. Another suggestion involved more support programs for caregivers dealing with individuals who had mental health issues rather than just physical. There were also a few caregivers who reported the need for more respite care supports and breaks from caregiving. A "one-stop shop" for information and organizational resources was proposed, after one caregiver said that it was difficult to know all the resources that were available: "I wish there were more financial resources for young caregivers, and I feel like finding any type of financial help has been so cumbersome and really complicated in terms of different pages and websites and there's just so much information and organizations out there. Just honestly, I wish there was just a one-stop-shop-have one place, that I could go to just see what was available for young caregivers and having that information be accessible, I think can be really useful. Like you know what would be . . . like specific home care support, for example, or having you know that resource that would be easy to access". One young caregiver also suggested attention be paid to the "secondary caregiver role" which involved supporting other caregivers in the family who were having difficulty coping with their caregiving responsibility: "I guess that one other thing that was kind of weird that I haven't heard from other people was that I almost was like a secondary caregiver because my mom was so stressed with what was going on and the relationship with my grandmother. [the person we cared for]. Sometimes it was like looking after my mom, too. Or I guess a lot of the times yeah . . . I did feel like the secondary caregiver role that I felt like I had to take [on] is not necessarily something that I see in the media or hear from other people a lot. I guess looking after a very, very stressed caregiver and how to navigate that too". Young caregivers also recommended social engagement services that are more culturally sensitive and offered in multiple languages. Many participants wanted more financial resources for young caregivers, such as scholarships. Younger caregivers recommended having access to activities, toys, and/or extracurriculars to assist in occupying their time. Additionally, animal therapy was recommended to be an assist in coping. One caregiver expressed that online schooling had been a big barrier and that an alternative solution needed to be in place for those with internet issues and a 24/7 caregiving role. Finally, therapy and life coaches specifically designed for young caregivers were suggested. --- Discussion The aims of this study were to identify the impact of public health restrictions on young caregivers and how they navigated the pandemic, as well as to determine the most appropriate and acceptable strategies to support families and their children who have caregiving responsibilities within and across diverse communities. Through analysis, demographic factors emerged as significant in evaluating the impact of the pandemic on young caregivers. As we previously noted, the majority of participants were between the ages of 6-13 years, while the remaining participants were between 24-25 years of age. Generally speaking, elementary-school-aged children and young people emerging into adulthood will face significant differences in terms of resiliency and vulnerability. Additionally, a paramount difference in legal status and social and emotional development is evident. An intersectional framework [37][38][39] rooted in the social determinants of health [35,36] emphasize the importance of exploring relevant power relations and the marginalization of identities for young caregivers. Overall, the findings from this study suggest the impact of COVID-19 and public health restrictions on young caregivers was varied and differed based on a variety of circumstances. Differences in demographic factors such as age, family income, awareness of caregiving experience, and the needs of the person being cared for account for significant variation in the lived experiences of participants. For example, caregiving responsibilities were reported to be unchanged , decreased , and increased . This aligns with previous research highlighting the differences in lived experiences of young caregivers in the Canadian context as a non-homogenous group [13, 15,21,40,[43][44][45]. Young caregivers reported initial fear and uncertainty stemming from COVID-19 and subsequent public health responses that were aimed at stopping the community spread. Pandemic lockdowns and restrictions exacerbated family stress, which was detrimental for some young caregivers, as evidenced by the concern of contracting COVID-19 and the described steps taken to minimize the risk to themselves and their family members . Further, the young caregivers participating in this study expressed financial concerns and/or strain due to job and income losses. Additionally, support for and attention paid to caregivers was reduced as family resources were allocated to the person needing care. More broadly, the pandemic has drawn attention to pre-existing income disparity and structural inequalities for Canadians with low incomes. Two years in, in 2022, Canada, like many parts of the world, continues to see rising inflation nationally, thus contributing to rising costs of food, gasoline, and housing, and thus placing significant strain on families who are already struggling financially, and in particular those from lower socio-economic backgrounds. This coincides with previous research findings exploring the impact of the COVID-19 pandemic lockdowns and restrictions on the mental health of young people more broadly [46][47][48][49][50][51]. Previous research findings highlight regional variations in social and health services [52,53]. This is supportive of the findings of this study, which suggest that community size and location are relevant in understanding the impact of the pandemic on young caregivers. For example, population size, access to critical infrastructure were significant barriers for participants residing in rural communities. That said, those living in smaller communities pointed to the benefits of greater access to outdoor space and decreased congestion, which arguably reduced their risk contracting COVID-19 from community spread. Notably, health care, education, and social assistance are provincial/territorial jurisdiction in Canada, which contributes to the significant regional variations across the country. Commonly, major city centres have greater resources and a larger pool of professionals available within these communities; however, they also have larger populations to serve, therefore increasing wait times and community competition for access. To mitigate vulnerability, it is critical that young caregivers are consulted and receive meaningful and relevant support in their communities. To this point, building resiliency for young caregivers involves securing and maintaining physical, social, and emotional support and resources in their homes and communities. Strong relationships with family members and friends proved beneficial for young caregivers who reported increased mental health issues stemming from isolation and loneliness and reduced coping outlets as a result of the pandemic. Young caregivers reported a loss of formal support during the pandemic as a result of pandemic restrictions. --- Strengths and Limitations We believe engagement and collaboration with young caregivers is a significant strength in our research and in all research with young people. Our results emphasize the experiences of young caregivers in their own voices. Given that young people have been underrepresented in research, we believe it is essential that researchers evaluate their experiences from their unique perspectives and in their own voices. Traditionally, research has focused on children's health and children's experiences framed within an adult-centric lens from the position of adult caregivers, so engaging with young people themselves in addition to their adult caregivers offers a unique vantage point from which to view their experiences. Additionally, to further increase representation of the voices of young caregivers, we hired many interviewers for young caregivers and only hired those with lived experience as a young caregiver or who were working/had worked directly with young caregivers. Screening questions were also used to match participants with the interviewer on our team that best fit with their experiences and socio-demographic background. For example, three young caregivers of different ages provided support for their mother who lived with chronic health challenges as a result of a car accident was matched with a young caregiver on our team who, from a very young age, provided care for her mother . The limitations of this study include the small sample size. We recognize that this sample represents a small population of young caregivers from across Canada and therefore we in no way suggest that the results are generalizable. The findings from this study point to the differences in young caregiver experiences in Canada, thus reinforcing that young caregivers are not a homogenous group with apparent universal experiences. It would be beneficial to conduct future comparative studies exploring how social factors, such as, gender, cultural, regional, and socio-economic differences amongst young caregiver populations in Canada to gain a deeper understanding of how these factors influence young caregiver experiences. --- Recommendations We recommend that young caregivers are not only considered but consulted whenever governments and social or community-based organizations make investments in services, supports, and resources for young caregivers. It is critical that the voices of these young people are captured in order to ensure that these services meet their unique needs. The results of this study highlight how young caregivers are capable of offering recommendations and suggestions on how to improve social conditions for themselves and their families. Primarily, our participants suggest an increased investment in community-based resources that assist caregivers in maintaining their financial, emotional, mental, and physical health. Importantly, these resources should be available equitably to all young caregivers regardless of their social backgrounds and/or the communities in which they reside . We recommend further studies that explore resiliency and vulnerability in relation to accessibility of community resources for young caregivers and their families. --- Conclusions This study presents observations focused on the experiences of young caregivers in Canada during the pandemic. The primary conclusion drawn from this research illustrates the variable impacts of the pandemic on young caregivers across the country, thus pointing to the diversity within this population, and challenging constructions of young caregivers as a homogenous group. Young caregiver age, along with geographic and social locations, were significant factors in evaluating their resilience and vulnerability as an outcome of the pandemic. This work contributes to current knowledge on young caregivers and highlights their experiences in their own voices. As a result, this study offers a unique representation of a population that has been underrepresented in research to date. In order to further understand issues related to the health and well-being of young people, it is critical that researchers continue to engage young people as active participants in on-going research. We recommend future research that is focused on the longer-term impacts of the pandemic on young caregivers, including research that evaluates the experiences of young caregivers with and without community support and resources as a point of comparison. This would advance an understanding of the effects of these resources on young caregivers' resilience and vulnerability post-pandemic. --- Data Availability Statement: Data sufficient for the reader to validate the article findings can be made available as appropriate upon request to the corresponding author. --- Informed Consent Statement: Informed consent was obtained from all young caregivers who participated in this study via online consent/assent forms. For participants from the ages of 12 to 18, a parental consent form was also obtained from the parent/guardian. For those between the ages of 5 and 11, a simplified assent form tailored to a younger audience was completed by a parent/guardian along with their child who would participate in our study. ---

This qualitative research study is a part of a larger research project exploring the experiences of young caregivers aged 5-26 years and their families navigating the COVID-19 pandemic between 2020 to 2023. Data were collected from 14 young caregivers who participated in baseline interviews. The central research question guiding this study: What was, is, and will be the impact of changing public health restrictions on young caregivers and their families during the pandemic and pandemic recovery? Seven themes emerged through analysis: ( 1) Navigating Care During the Height of Public Health Restrictions, (2) Neighbourhood and Built Environment During the Pandemic, (3) Perceptions Towards COVID-19 and Public Health Restrictions/Efforts, (4) The Impact of Public Health Restrictions on Relationships, (5) Mental Health Challenges of Being a Young Caregiver During a Pandemic, ( 6) Navigating Formal Services and Supports, and (7) Recommendations from Young Caregivers. The findings from this empirical research suggest that young caregivers found it easier to navigate their caregiving responsibilities when public health restrictions and work-from-home mandates were initially implemented; however, this later changed due to challenges in finding respite from caregiving, maintaining social connections with friends, creating personal space at home, and finding adequate replacements for programs once offered in person.

introduction despite the approximately 125 million young caregivers living in canada 1 the majority of canadians remain largely unaware of the lived experiences 2 of this underrepresented group of invisible caregivers 3 for the purposes of this study we defined young caregivers as a young person under the age of 25 years old who provides care to a friendfamily member who lives with an illness disability injury andor challenge to activities of daily living according to the literature young people in canada may take on caregiving roles when someone in their immediate family becomes mentally or physically unwell due to addiction agerelated weakness injury or unforeseen life events 4 5 6 for example in ontario there are over half a million young people under the age of 25 years who provide physical medical emotional and other forms of support to a parent grandparent or sibling 7 8 9 10 international literature pertaining to young caregivers highlights their multiple responsibilities including school and paid employment in addition to caregiving 21112 the unpaid labour of young caregivers averages 1427 h per week and represents approximately cad 25000 to cad 50000 in annual savings for the family andor healthcare system 13 in this way young caregivers are subjected to a young carer penalty in the form of shortand longterm harms to academic personal social and professional development 14 if there are inadequate supports for young caregivers they can experience several adverse health outcomes including stress and depression low selfesteem anxiety loneliness and isolation suicidal ideation and difficulty with peer relationships resulting from a lack of support 13 14 15 16 importantly canada has no existing social policies to support young caregivers at the national level additionally federal social welfare programs are inaccessible to the majority of young caregivers especially those with high levels of caregiving responsibilities because the benefits rely on young caregivers earning an income and many are not of working age andor do not have time to work due to the time they dedicate to providing care 17 therefore as a group this population can experience unrecognized and significant social mental physical and economic strain the covid19 global pandemic triggered a global health crisis 18 which has significantly impacted communities across canada and worldwide and highlighted preexisting inequities amongst traditionally marginalized socially excluded and underrepresented groups 1920 the unique socioeconomic and socioemotional challenges faced by young caregivers necessitates an exploration of their experiences of the covid19 pandemic in their own voices a key consideration for this study is that many young caregivers and their families cared for older adults 921 who are more vulnerable to adverse health outcomes from covid19 including hospitalization and death according to the centers for disease control and prevention and the government of canada 2223 in order to protect their loved ones these young caregivers can face difficult choices such as whether to return to inperson learning or engage in extracurricular community activities that can increase the risk of harm to the older adults they are caring for despite anticipating social economic and mental health challengeschanges that individuals and families can experience much less is known about the impact of these challengeschanges on the family unit and no literature exists on how families are navigating these challenges especially families with children who must provide care to a loved one who is vulnerable to covid19 the sandwich generation has gained attention among researchers and policymakers 24 25 26 but the perspectives of their children and the contributions of a family as a unit have not been explored accordingly we investigated both young caregivers and their families to provide a holistic perspective that is missing from the existing literature related to young caregivers and the sandwich generation furthermore due to the novelty of the pandemic understanding how young caregivers and their families adjust to ongoing and novel changes to policies and institutions will contribute greatly to our existing knowledge on recovery from the pandemic those with caregiving responsibilities have faced compounding and unique challenges including more complex care resulting from concerted public health measures aimed at reducing the community transmission of covid19 27 in addition to the separation from loved ones who have covid19 symptoms 28 and financial burdens related to caregiving that the canada emergency response benefit does not consider 2829 young caregivers and their families face additional challenges including changes to school and social relationships as a result of policies and fears surrounding the virus 30 31 32 33 34 this study is part of a larger study exploring the experiences of young caregivers and their families navigating covid19 starting in 2020 ongoing until 2023 the data were collected from young caregivers family members service providers who interact with young caregivers community leadersallies and policydecisionmakers at different organizationsinstitutions the findings from baseline interviews with young caregivers are reported in this paper the purpose of this study is twofold to identify the impact of public health restrictions on young caregivers and their families and to determine the most appropriate and acceptable strategies to support families and their children who have caregiving responsibilities within and across diverse communities the central research question guiding this study is the following what was is and will be the impact of changing public health restrictions on young caregivers and their families during the pandemic and pandemic recovery materials and methods baseline interviews were conducted with 9 families and 3 young caregivers who joined the study without their family members in total 14 young caregivers joined the study the social determinants of health 3536 with intersectionality 37 38 39 guided the development of our interview guide alongside the lessons and findings we gleaned from a study we conducted on the experiences challenges and needs of young caregivers living in urban versus rural communities in ontario canada 40 importantly we acknowledge there is significant diversity in young caregiver populations and recognize this is not a homogeneous group interviewers were hired if they had a lived experience as a young caregiver andor had worked directly with young caregivers our interviewers consisted of 6 young caregivers and 1 person who worked with young caregivers in order to capture a variety of insight and lived experiences to best match participants with an interviewer who could best potentially understand their lived experiences the person who did not have lived experience as a young caregiver had worked with young caregivers had 6 years of experience supporting young caregivers through assisting with running programs designed for them was 27 years old and identified as a european canadian woman the 6 young caregivers who were hired as interviewers were all actively young caregivers at the time data collection took place they were aged between 23 and 27 years 4 identified as women and 2 as men three of the young caregivers identified as south asian canadian one european canadian one east asian canadian and one middleeastern four were masters students one had completed an undergraduate degree and one had completed a professional degree caregiving responsibilities included caring for a parent who lived with physical disability due to a car accident a sibling living with a learning disability a parent living with dementia a parent living with a chronic mental illness grandparentsparent living with disability or chronic physical and mental illnesses and a partner living with chronic physical health challenges interviewers were trained in how to conduct a semistructured interview and were provided with appropriate guidancesupervision by the investigators during interviews to ensure the data collected were both comprehensive and representative of young caregivers voices this study used a longitudinal data collection approach using semistructured interviews semistructured interviews were completed at baseline with young caregivers or young caregivers and their family members followup interviews with young caregivers will occur at 6 months 1 year and 2 years followup interviews with family members will occur at 1 year and 2 years at baseline young caregivers were asked to participate in a 30to45min interview and answer questions about how the pandemic impacted their life as a whole how their caregiving responsibilities changed how they and their families navigated the changes to their lives caused by the pandemicpublic health restrictions and what would make life easier as a young caregiver findings from the baseline interviews conducted with young caregivers are reported in this article sampling and recruitment young caregivers were recruited with the help of our community partners who provide servicessupportsresources to young caregivers and their families young caregivers association ontario caregiver organization and young carer program data collection and analysis to analyze the interviews reflexive thematic analysis 4142 was used by the two investigators and a team of four research assistants that included one young caregiver who was 25 years old and had been a young caregiver since the age of 8 a volunteer service provider who worked closely with young caregivers for six years with a background in early childhood education a phd candidate in child and youth studies and a masters student in public health who had been engaged with research on young caregivers for 5 years the researchers used inductive analysis and began with a research question participants were recruited through our community partners young caregiver organizations in canada once screened for eligibility participants were invited to participate in virtual interviews over zoom which were transcribed verbatim by research assistants the transcripts were reviewed several times by members of the research team those data were analyzed contemporaneously as data were collected initial codes were generated and initial themes emerged through data analysis through collaborative discussions between members of the research team primary themes were identified the results were written and disseminated by the research team results there were 14 young caregivers who participated in baseline interviews eleven young caregivers joined with their family members and three young caregivers joined the study independently the age of young caregivers ranged from 6 to 25 years old ten of the young caregivers were between 6 and 13 years old and four were between 24 and 26 years old three subthemes arose when looking at types of care this included caregiving responsibilities changes in the person being cared for and protecting the family from covid19 caregiving responsibilities four participants noted that there were responsibilities they had before the pandemic that they no longer had to do during the pandemic due to appointments being on skype or appointments not allowing more than one person in the room many caregivers noted that they no longer had to accompany or entertain the people they cared for during these visits one participant reported no changes in their caregiving responsibilities other responsibilities ranged from feeding washing and general hygiene helping their grandmother up the stairs and walking their sibling to school there were also general household chores such as dishes which one participant would do if the person being cared for was not feeling well and laundry eight participants reported helping with cooking and meal preparation ranging from making one or all the meals for the day with one participant having to puree meals four times a day to make them easier to swallow for the person they cared for one young caregiver prepared snacks for herself because her mother was busy caring for her brother another participant stated i would cook for my grandmother i will get her snacks drinks and stuff like that similarly another participant would help her parents by taking care of her sister ill help make lunch for my sister a lot like especially on like the weekend when my mom and dad cant do it theyre working or something like that ill make like a lot of like lunches and breakfasts another participant reported ordering food for the family a few times a week the pandemic made it more difficult to balance home and caregiving roles for two participants with one having to move back to their home city from university and having to step out of online classes to take care of caregiving responsibilities additionally two participants reported having to navigate financial support and challenges i have a lot of travel costs because of where i live and trying to get to her that would be the biggest thing because like i kind of said before im like doing all the organizational things all the bills like right now were kind of trying to sell the house because shes moved and now its just kind of sitting there those kind of things end up costing me emotionally along with financially just because theres like more stuff on my plate but yeah the main cost is the kind of travel and having to go back there if there is something you just have to do inperson and then obviously visiting and seeing her because i want to another participant stated definitely financial issues have happened in particular with us weve experienced a lot of financial hardships with my dad in terms of him being not able to work anymore that was prior to the pandemic but the financial issues were also exacerbated because of my dads chronic kidney disease he needs to use certain medical supplies like a catheter and a condom catheter and because of that it has resulted in additional expenses for him and ive had to pay out of pocket for things like the thickenup that he uses every day and other types of like diapers and things like that so i see the financial issues existed prior to the pandemic but more so now as well and in particular during the pandemic in 2020 i unfortunately lost my job due to the reconstructing of our department and due to budgeting that had come to an end and i sort of was feeling the pressure as well of not being able to financially support myself and so that did add a level of stress and burden because of course i was a student at the time and it definitely impacted my mental health and yeah that was something i experienced due to the pandemic and so now i feel like i am still trying to navigate that world of being able to you know persist and continue to move forward changes in person being cared for a variety of new caregiving roles arose during covid19 due to less opportunity to leave the house on their own one participant reported having to provide more company for the person they cared for it has almost been every day to try to engage my grandmother living with dementia so she doesnt get into her hallucination state i usually take her for a walk for an hour or an hour and a half every day sometimes she will sit with me at my desk while i work and shell do things like colouring or looking at photos just things to make her mind try to do something the participant also reported the new role of consistently reinforcingreminding her family members about the severity of covid19 and ensuring that their family members were adequately wearing masks in public spaces two participants reported having a more difficult time with their caregiving as the lockdown had caused an exacerbation of symptoms such as aggression from those receiving care as expressed by one participant when my brother didnt get help therapy i was really scared as explained by mother her brother gets very aggressive because he wasnt getting any therapy as a result of lockdowns so she was worriedumthere would be aggression in the house towards her because she was only playmate for him at the time the other participant reported like my grandmother developing dementia that is definitely really new because we went from maybe helping her once or twice a day to now 247 care so that has felt pretty dramatic but sometimes i wonder if maybe part of what made her dementia progress so rapidly was that she wasnt seeing her own friends or because she was kind of isolated herself during covid19 another participant reported a blend in caregiving and work as they would have to play games with their family members during their work breaks to keep them entertained one participant had more caregiving responsibilities because of online schooling and stated i had to change the way that i work during the day because my brother was also at home doing school and sometimes i would need to watch him so i would have to change my schedule for what i was going to do during the day a majority of the participants reported the same type of care with an increased workload due to the pandemic these included tasks such as supervision of the person being cared for which four participants reported doing two of them having to provide 24 h supervision as one participant described my grandmothers dementia progressed really rapidly over the last month and before that not very often maybe one to two times a week she would request my help she was pretty independent now i would say probably seven days a week because she kind of needs 24 h care or supervision she might wander out or do something dangerous so i would say i am constantly alert of what is going on now entertainment responsibilities ranged from once a week to everyday for some caregivers most participants provided comfort and company to the person they were caring for ranging from sitting in the bathroom with them to accompanying them to appointments and general emotional support when completing daily tasks for example one participant reported sometimes my brother wont have a bath unless im there and another participant stated me and my brother share the responsibility of bringing my mother to appointments and bringing her anywhere she needs to be she doesnt drive another participant said sometimes i just watch movies with my grandmother or sit quite close to her while shes watching something some participants extended care in the form of emotional support to the person they cared for one by giving hugs and the other by boosting self esteem and keeping them calm throughout the day one participant stated for one of my brothers a lot of its anxiety im helping to keep him happy and calm most participants had a role of entertainment which included tasks such as playing games watching television providing companionship on walks or painting and reading for instance one participant stated they played games with their brother in between classes on my breaks we would have a 30min break and two 15min breaks so on my first 15min break id play minecraft with my brother or i would have a snack with him and then on my next 15 min break i would also play with my brother and on my 30min break id also play with my brother and sometimes i would take breaks on my own just during the day and i would also play with my brother one participant also reported that the person they cared for was physically injured during the pandemic which increased their workload especially as it was harder to get the same support from the hospital when covid19 was at its peak in 2020 we couldnt go and see him for the first few weeks when he was there because of the restrictions that the hospital had in terms of the number of visitors that they were allowing they didnt really have any guests that can go in so that definitely impacted the quality of care that we could provide to him because we werent allowed to go and see him the unit that he was in had an outbreak of covid19 and that ultimately impacted his care once again because we werent allowed to go and see him there were also medical responsibilities that caregivers maintained for instance one participant assisted nurses during inhome visits we do have nurses that come into our home three times a week and they help to assist with the wound care and so i would also assist them if lets say they need a bag or they want to discard any materials and helping them with just dressing the wound if they need assistance two participants reported administering and monitoring medication as one participant reported i do have to monitor her to make sure that shes taking her medications and then every three months she has to go and get an injection one participant also reported having to physically turn the person they cared for in the middle of the night to prevent complications such as pressure ulcers two participants were responsible for scheduling appointments and four participants stated that they attended these appointments with the person they cared for one participant reported that she and her mother had to take on a supportive role for her brother living with autism that a therapist would usually provide due to the program originally available in school being cancelled due to mandated virtual schooling this participant reported things became easier once her mother found a working solution video therapy wasnt working at all so weve found one therapist that will do inperson visits two participants reported having to take over responsibilities of personal support workers as the family was no longer comfortable having them come into the house due to the risks of contracting covid19 one participant expressed i guess before the pandemic we had a psw coming pretty frequently for bathing and then during the pandemic we discontinued that because we werent comfortable with having someone moving around to different places and then coming into our home the other participant stated i also have nurses that come into my home to help my dad with his wound dressing and even some of them dont wear the full yellow gown and once again its just another reason i dont understand why theyre not just trying to be fully protected protecting my family from covid19 caregivers described numerous methods in which they ensured the safety of their families to begin some reported not going outside or being extra cautious when they did leave some participants reported avoiding public transportation and providing rides to the person being cared for so they did not have to risk exposure on public transportation exposure was also avoided in other ways such as groceries being ordered to the house mask wearing frequent hand washing and receiving the vaccination when it was available one participant captured the experience of many young caregivers in our study during the height of the pandemic and during the pandemic and even until now im very very cautious about the activities that i undertake and how many people i surround myself with and just how i go about my daily life and so like for example in my family every friday we normally do our grocery shopping and normally i would only have like one person in my family go and do it as opposed to all of us at once just limit the number of people we were around and i feel like ive become much more vigilant and always like wearing a mask and if i did go out and always like practicing you know washing my hands very frequently and always making sure to just stay as far as the distance from people as much as possible and just like following all those extra precautions just as anybody else would but just being very mindful of that neighbourhood and built environment during the pandemic there were two subthemes that emerged during this study participants varied in geographical locations with some living in small towns suburban communities or rural communities but most resided in cities benefits and challenges of living outside of the city there were two young caregivers who lived in a rural community one lived in a suburban community and one lived in a small town one of the four young caregivers moved to the rural community during the beginning of the pandemic they shared both the challenges and benefits of living in their communities benefits that young caregivers living in less urbanized communities believed were positive compared to a big city included having a big yard being less stressed due to minimized crowding in their neighbourhoods and more personal space as one participant described being in a smaller population density and definitely at the beginning there was a lot less stress about the cases because like we were following where everything was and i felt a lot less stress knowing that my mom living with dementia was in a community that had zero cases and she wasnt going outside of that community most participants who lived in these communities mentioned there were ample walking trails and conveniences such as groceries that could be bought locally alternatively two participants lived in a community that experienced a food shortage as a result of supply issues during the height of the pandemic participants who experienced food and supply shortages resulted in families having to go to nearby towns to get supplies as one participant described the grocery stores got cleaned out a lot and there werent a lot of food options there were also reported challenges with both accessing and finding other resources and programs that served a rural area such as meal delivery psws and speech therapists additionally some young caregivers living in small towns reported internet outages which made attending school and completing school work difficult at times benefits and challenges of living in the city the majority of young caregivers lived in a densely populated city and had lived there prior to and during the pandemic participants living in cities reported many benefits and challenges seven young caregivers reported that parks grocery stores and malls were conveniently located nearby four participants reported being able to access supplies and medications including one that had supplies delivered to their home another reported benefit of living in the city related to accessibility including access to reliable and affordable internet to transportation via the bus and to timely emergency care one young caregiver reported the benefit of having a lot of neighbours and another stated that they were still able to access nature and open spaces while living in the city participants living in densely populated cities reported challenges such as exposure to individuals not adhering with masking practices and parks being busy or crowded as reported by one participant my grandmother living with dementia really likes to go to the park and the park is super busy and same with all the grocery stores in chinatown she really likes going to those we didnt know what was going on at that point so we didnt feel safe going out there because she probably wouldnt know to distance from people or wear a mask in one case a young caregivers family moved out of the city into a rural community strictly due to the high number of cases we wouldnt have moved to nova scotia at all if it wasnt for the pandemic we would have stayed in montreal perceptions towards covid19 and public health restrictionsefforts there were four major areas where varying perceptions towards covid19 were seen covid19 and public health restrictions vaccines and masks online schooling and feelings towards reopening covid19 and public health restrictions almost all participants reported having initial fear and uncertainty about covid19 and its restrictions many reported feeling less worried in 2021 when individuals started getting their vaccinations most reported fear about their family getting covid19 due to immunocompromisation and some worried about their friends getting covid19 as well many participants were unable to go to places they occasionally or routinely visited due to public health restrictions and fear of the virus which impacted their mental health the person being cared for also was not able to go out as much resulting in them being bored at home which created the new responsibility of entertaining them my mom typically went outside every day to the mall and she was no longer able to do that because of lockdowns so she was restless at home and i had to entertain her because she had a lack of friends and other social supports outside family one participant noted mom and dad were stressed working online and another worried that covid19 had exacerbated symptoms of dementia of her grandmother due to the social isolation public health restrictions caused a lot of frustration especially with its changes to emergency care one participant reported that her father was hospitalized at one point during the pandemic and her family was unable to visit due to an outbreak in the unit the stress of being unable to ensure he was properly cared for along with the existence of an outbreak was mentally challenging for her and her family to cope with vaccines and masks mask mandates were perceived as positive by most caregivers but some participants expressed annoyance with it sticking to their face making it difficult to breathe general discomfort and inconvenience of wearing it over extended periods of time as one participant expressed well ive never liked wearing masks sometimes i like wearing masks like after hockey and my face is all red and sweaty and people cant see my face or after like sports or when im in like a bad mood and i dont want people looking at me i guess the mask comes in handy then but its hard to breathe in all day at school with respect to vaccines there was a general willingness from young caregivers to receive it even when met with some disagreement from their family members however there was some worry and hesitation due to fear of needles fear of its novelty and fear of side effects especially if the person receiving the vaccine was immunocompromised as one participant reported yeah i feel like i was always provax and it was never an issue of whether or not i was going to get the vax i know that i was a little bit worried about my mom getting her vaccines because of some of the side effects and you know we my brother and i were a little bit like extra cautious when she did get the vaccine in case she got any symptoms or anything like that but luckily there werent any issues online schooling many young caregivers experienced online schooling during the pandemic some caregivers liked the transition to online learning because they were able to learn at their own pace and were able to be home more often to look after the person they were caring for as reported by one participant i think one of the silver linings and one of the blessings in disguise that happened because of covid19 has been virtual learning and for me navigating school is a big one because when i went to university all of the classes were in person and so having everything transition to being online really opened up a huge door for me where i could be at home and help take care of my dad while also balancing school and the same thing with like employment as well and that has been a really huge asset however some caregivers were worried about online school for reasons not limited to being afraid of technical issues such as poor internet connectivity keeping up with assignments and the general adjustment to the online environment as reported by one participant i was worried yes cause when i first started online school i didnt know if i was handing in my assignments correctly or if i was getting my marks back or anything and i didnt go on meets like this with my teacher at first additionally being home for school caused caregiving duties to overlap and some participants had to skip online classes to supervise or assist the person they were caring for feelings towards reopening most young caregivers were happy with the idea of covid19 lockdowns ending in the middle of 2021 likewise they reported feeling less anxious in 2021 as they were more knowledgeable and accepting of the virus and felt happy with the hope that covid19 was ending young caregivers were excited to see their teachersfriends again and happy to go back to extracurriculars that were not available during the lockdown however one caregiver reported frustration with the downshift in levels of concern despite the ongoing prevalence of the pandemic the impact of public health restrictions on relationships the lockdown caused by the pandemic had various effects on friendships and family dynamics friendships most participants reported not being able to see friends in person due to school closures and the fear of catching covid19 from friends some participants were able to go to outdoor spaces such as the park to see their friends participants reported using texting phone calls social media and applications to keep in touch with friends some caregivers reported connecting with neighbours and extended family for socialization they also described how difficult it was to stay in touch with friends and that it was not ideal to use technology to maintain relationships family dynamics a majority of caregivers reported feeling closer to their immediate family after spending so much time at home with them spending that much time also allowed a few younger caregivers to gain more privileges within the house such as being trusted to use the stove being so close to family also had disadvantages such as more conflicts at home and a crowded feeling some caregivers felt as though they received less attention from their parent in the home due to the person being cared for taking up all their time they also felt that they had to spend more time with the person being cared for which created more stress burnout and conflict in the family as one participant noted i feel like having lived in a crowded area almost made my mental health worse because we were trying to keep my grandmother living with dementia inside all the time which means usually i had to entertain her or talk to her also my grandmothers dementia is that she has pretty severe hallucinations she can get really caught up in a fit and sometimes other family members arent able to deescalate her but somehow she is responsive to me a few young caregivers andor their family members lost their jobs due to the pandemic which contributed additional financial stress especially for those who were responsible for paying for medical supplies a few caregivers expressed needing more time alone for example i felt like i was trying to go in my room a lot more sort of laughing like have my own space then again i am getting older and stuff but i just really liked my alone time during covid19 some participants were upset with not being able to see other family members due to the risk of catching covid19 only one caregiver reported no change in their family dynamic during the pandemic because even before the pandemic they were homeschooled mostly stayed at home and their parents could not work due to living with a disability and relied on welfaresocial assistance programs mental health challenges of being a young caregiver during a pandemic as a result of closures of public indoor spaces and lockdowns many young caregivers experienced mental health issues and had utilize outdoor spaces or figure out ways to cope at home mental health mental health issues were a significant area of concern during the pandemic most caregivers reported feeling anxiousfearful of covid19 as well as isolatedlonely especially since they relied on friends heavily for support and for a distraction from their caregiving responsibilities as expressed by one young caregiver i think i mentioned this earlier but my mental health was already kind of low because of the stress of being a student and being a caregiver and so then adding in the stress to the pandemic gave me a lot ofit just worsened what i was going through because i didnt have those like outlets like i couldnt just go out to a restaurant and have a nice night out with my friends and just shoot the shit or blow off steam in any way so it was just like and even when you were able to do things it still was not like fully relaxing because you still have to be like what are the regulations can i even do that thing there were so many levels of steps before you got to the place and then when you got to the place youre only getting like 75 of the experience so it just became like no way to let off stress so just build up the stress and anxiety one caregiver reported feeling fear at home because the person they cared for had become more physically aggressive without accessing their therapy anxiety was a prevalent feeling amongst the caregivers as well some caregivers reported feelings of annoyance and anger for example due to entertaining the person being cared for during school breaks instead of being able to have proper breaks from caregiving duties participants often felt exhausted and burnt out and struggled to still have time for selfcare as expressed by one participant theres so many days where i feel like exhausted or like im so frustrated about something going on like maybe an assignment or something like a friendship conflict or something and i have to come home and care for her its like its likeits a lot one caregiver expressed that they were upset they were not able to go to the gym anymore which had been a big factor in maintaining their mental health coping strategies young caregivers described various methods of coping during the pandemic some turned to video games and social media as a way to combat boredom relieve stress and stay in touch with friends one caregiver reported joining a facebook group for caregivers to gain support i guess reading about other peoples stories and feeling less alone and knowing that other people did have similar issuesthat kind of helped some turned to parents and talked to friends on the phone or via video calls caregivers with pets also reported playing with them when they felt sad or lonely playing outside walks and exercise was also an aid in combatting boredom and stress a few caregivers also participated in other activities such as shopping watching television and writing one caregiver reported turning to a counsellor as a coping strategy recreation for recreation young caregivers did a variety of activities some accessed programs online they were unable to before because of distance andor scheduling some explored different hobbies such as drawing or gaming some young caregivers spent their free time playing with toys such as legos one individual went to an inperson sports group where they played with their mask on other caregivers attended piano classes and dance classes virtually navigating formal services and supports young caregivers shared their experiences of finding support during the pandemic to address different challenges they faced additionally navigating changes in services supports for the person being cared for as a result of public health restrictions posed a challenge for many participants supports accessed by young caregivers there were various supports accessed by young caregivers that assisted them during the pandemic to begin with one caregiver reported relying on employment insurance after losing their job and felt that it was enough to cover expenses a number of young caregivers attended the programs specifically designed for young caregivers some relied on the support of nurses for wound care of the person being cared for and some relied on psws for help with washing bathing and meal preparation for example my grandmother has psws that come every so often to help her while me and my mom are at work psws wash and bathe her but they also do all the same things i do when im not there to help her caregivers also relied on other family members for emotional and tangible support while some relied on friends or neighbours some participants relied on stuffed animals for support and some turned to pets a few caregivers turned to google and internet forums such as reddit and facebook groups to seek advice on their caregiving roles as one participant described i have used reddit forums its hard to find information specific to your situation of course i think i kind of have a little bit more of a unique situation but i did find a few reddit forums and things like that of people in similar caregiving roles and i kind of just like reading about their experiences i never really contributed to it but i did like see what they wrote and it kind of like made me feel a little bit like okay like its not just me going through this you know changes in formal services and support for person receiving care participants had mixed experiences when it came to virtual appointments some participants felt it was easier to attend virtual appointments because of distance and saving time and energy not having to travel to inperson locations for example i was already doing a lot of things from another city so i was already doing a lot of phone calls and things like that it did i think become a little bit easier to get things done on the phone or through email with the pandemic because people got more used to like digital signatures and things like that previously i had to explain my situation and tell them whats going on in order for me to sign things digitally some participants reported negative experiences with formal services being offered virtually for example the lack of facetoface communication was thought to inhibit the ability to convey vital information young caregivers also reported it was harder to reach healthcare workers to make appointments due to a reduced number of work days and an increased difficulty accessing healthcare services for example my dad is someone that needs physiotherapy and he needs to practice exercises every daybeing able to find someone that could come into our home to do it with him was really difficult because of course majority of things shifted to be you know not in person anymore so that was a huge impact and i find just navigating access to services in general really difficult but i do think that because of the pandemic i think it definitely made it even more so difficult additionally there were a lot more miscommunications when scheduling with physicians when inperson appointments did occur participants reported not being able to go into the appointment with their family members which increased communication errors one participant worried that the person they cared for would not receive enough care in the hospital due to the heavy workload of healthcare workers there were also disruptions in other formal services some caregivers reported that the person they cared for was no longer able to access social support services that they had once relied on such as church and community centres yeah there was this one community program that my grandmother could go to for one day of the week that was no longer running inperson the program was just one single day of the week but it felt really different because usually when she was away for that day everyone gets to relax for the day but yeah we didnt have that during covid19 they started doing half an hour zoom sessions with the people that would go to the program after a while my grandmother wasnt super engaged in it anymore she would talk or do other things on her own during the program we still had to watch her very closely when she was doing that sometimes i think because they were trying to cater to a broader audienceusually the day program is in chinese so she can understand what is going on but this was frequently in english so maybe thats why she wasnt as excited about it another caregiver reported being inconvenienced by the changes as they had to postpone moving the her mother into an assisted living facility due to the pandemic the main thing that happened is that right before the pandemic i was talking to my mom and we were like in the process of exploring her moving into an assisted living facility and i pretty much just gotten her to the point where she was like starting to be willing to like actually consider it and then the pandemic happened and they all shut down and they obviously werent taking people in so we couldnt do tours so it all got put like just on the back burner and it was like over a year until i felt like i could bring it up again and then when i did she didnt feel like she wanted to do it anymore and so i was like even further back from step one so that was really really really frustrating and difficult recommendations from young caregivers and what would make life easier when caregivers were asked about recommendations on what would make their lives easier various ideas were shared one caregiver stated that there should be a bigger support network for young caregivers but was unsure of what it might look like another suggestion involved more support programs for caregivers dealing with individuals who had mental health issues rather than just physical there were also a few caregivers who reported the need for more respite care supports and breaks from caregiving a onestop shop for information and organizational resources was proposed after one caregiver said that it was difficult to know all the resources that were available i wish there were more financial resources for young caregivers and i feel like finding any type of financial help has been so cumbersome and really complicated in terms of different pages and websites and theres just so much information and organizations out there just honestly i wish there was just a onestopshophave one place that i could go to just see what was available for young caregivers and having that information be accessible i think can be really useful like you know what would be like specific home care support for example or having you know that resource that would be easy to access one young caregiver also suggested attention be paid to the secondary caregiver role which involved supporting other caregivers in the family who were having difficulty coping with their caregiving responsibility i guess that one other thing that was kind of weird that i havent heard from other people was that i almost was like a secondary caregiver because my mom was so stressed with what was going on and the relationship with my grandmother the person we cared for sometimes it was like looking after my mom too or i guess a lot of the times yeah i did feel like the secondary caregiver role that i felt like i had to take on is not necessarily something that i see in the media or hear from other people a lot i guess looking after a very very stressed caregiver and how to navigate that too young caregivers also recommended social engagement services that are more culturally sensitive and offered in multiple languages many participants wanted more financial resources for young caregivers such as scholarships younger caregivers recommended having access to activities toys andor extracurriculars to assist in occupying their time additionally animal therapy was recommended to be an assist in coping one caregiver expressed that online schooling had been a big barrier and that an alternative solution needed to be in place for those with internet issues and a 247 caregiving role finally therapy and life coaches specifically designed for young caregivers were suggested discussion the aims of this study were to identify the impact of public health restrictions on young caregivers and how they navigated the pandemic as well as to determine the most appropriate and acceptable strategies to support families and their children who have caregiving responsibilities within and across diverse communities through analysis demographic factors emerged as significant in evaluating the impact of the pandemic on young caregivers as we previously noted the majority of participants were between the ages of 613 years while the remaining participants were between 2425 years of age generally speaking elementaryschoolaged children and young people emerging into adulthood will face significant differences in terms of resiliency and vulnerability additionally a paramount difference in legal status and social and emotional development is evident an intersectional framework 37 38 39 rooted in the social determinants of health 3536 emphasize the importance of exploring relevant power relations and the marginalization of identities for young caregivers overall the findings from this study suggest the impact of covid19 and public health restrictions on young caregivers was varied and differed based on a variety of circumstances differences in demographic factors such as age family income awareness of caregiving experience and the needs of the person being cared for account for significant variation in the lived experiences of participants for example caregiving responsibilities were reported to be unchanged decreased and increased this aligns with previous research highlighting the differences in lived experiences of young caregivers in the canadian context as a nonhomogenous group 13 152140 43 44 45 young caregivers reported initial fear and uncertainty stemming from covid19 and subsequent public health responses that were aimed at stopping the community spread pandemic lockdowns and restrictions exacerbated family stress which was detrimental for some young caregivers as evidenced by the concern of contracting covid19 and the described steps taken to minimize the risk to themselves and their family members further the young caregivers participating in this study expressed financial concerns andor strain due to job and income losses additionally support for and attention paid to caregivers was reduced as family resources were allocated to the person needing care more broadly the pandemic has drawn attention to preexisting income disparity and structural inequalities for canadians with low incomes two years in in 2022 canada like many parts of the world continues to see rising inflation nationally thus contributing to rising costs of food gasoline and housing and thus placing significant strain on families who are already struggling financially and in particular those from lower socioeconomic backgrounds this coincides with previous research findings exploring the impact of the covid19 pandemic lockdowns and restrictions on the mental health of young people more broadly 46 47 48 49 50 51 previous research findings highlight regional variations in social and health services 5253 this is supportive of the findings of this study which suggest that community size and location are relevant in understanding the impact of the pandemic on young caregivers for example population size access to critical infrastructure were significant barriers for participants residing in rural communities that said those living in smaller communities pointed to the benefits of greater access to outdoor space and decreased congestion which arguably reduced their risk contracting covid19 from community spread notably health care education and social assistance are provincialterritorial jurisdiction in canada which contributes to the significant regional variations across the country commonly major city centres have greater resources and a larger pool of professionals available within these communities however they also have larger populations to serve therefore increasing wait times and community competition for access to mitigate vulnerability it is critical that young caregivers are consulted and receive meaningful and relevant support in their communities to this point building resiliency for young caregivers involves securing and maintaining physical social and emotional support and resources in their homes and communities strong relationships with family members and friends proved beneficial for young caregivers who reported increased mental health issues stemming from isolation and loneliness and reduced coping outlets as a result of the pandemic young caregivers reported a loss of formal support during the pandemic as a result of pandemic restrictions strengths and limitations we believe engagement and collaboration with young caregivers is a significant strength in our research and in all research with young people our results emphasize the experiences of young caregivers in their own voices given that young people have been underrepresented in research we believe it is essential that researchers evaluate their experiences from their unique perspectives and in their own voices traditionally research has focused on childrens health and childrens experiences framed within an adultcentric lens from the position of adult caregivers so engaging with young people themselves in addition to their adult caregivers offers a unique vantage point from which to view their experiences additionally to further increase representation of the voices of young caregivers we hired many interviewers for young caregivers and only hired those with lived experience as a young caregiver or who were workinghad worked directly with young caregivers screening questions were also used to match participants with the interviewer on our team that best fit with their experiences and sociodemographic background for example three young caregivers of different ages provided support for their mother who lived with chronic health challenges as a result of a car accident was matched with a young caregiver on our team who from a very young age provided care for her mother the limitations of this study include the small sample size we recognize that this sample represents a small population of young caregivers from across canada and therefore we in no way suggest that the results are generalizable the findings from this study point to the differences in young caregiver experiences in canada thus reinforcing that young caregivers are not a homogenous group with apparent universal experiences it would be beneficial to conduct future comparative studies exploring how social factors such as gender cultural regional and socioeconomic differences amongst young caregiver populations in canada to gain a deeper understanding of how these factors influence young caregiver experiences recommendations we recommend that young caregivers are not only considered but consulted whenever governments and social or communitybased organizations make investments in services supports and resources for young caregivers it is critical that the voices of these young people are captured in order to ensure that these services meet their unique needs the results of this study highlight how young caregivers are capable of offering recommendations and suggestions on how to improve social conditions for themselves and their families primarily our participants suggest an increased investment in communitybased resources that assist caregivers in maintaining their financial emotional mental and physical health importantly these resources should be available equitably to all young caregivers regardless of their social backgrounds andor the communities in which they reside we recommend further studies that explore resiliency and vulnerability in relation to accessibility of community resources for young caregivers and their families conclusions this study presents observations focused on the experiences of young caregivers in canada during the pandemic the primary conclusion drawn from this research illustrates the variable impacts of the pandemic on young caregivers across the country thus pointing to the diversity within this population and challenging constructions of young caregivers as a homogenous group young caregiver age along with geographic and social locations were significant factors in evaluating their resilience and vulnerability as an outcome of the pandemic this work contributes to current knowledge on young caregivers and highlights their experiences in their own voices as a result this study offers a unique representation of a population that has been underrepresented in research to date in order to further understand issues related to the health and wellbeing of young people it is critical that researchers continue to engage young people as active participants in ongoing research we recommend future research that is focused on the longerterm impacts of the pandemic on young caregivers including research that evaluates the experiences of young caregivers with and without community support and resources as a point of comparison this would advance an understanding of the effects of these resources on young caregivers resilience and vulnerability postpandemic data availability statement data sufficient for the reader to validate the article findings can be made available as appropriate upon request to the corresponding author informed consent statement informed consent was obtained from all young caregivers who participated in this study via online consentassent forms for participants from the ages of 12 to 18 a parental consent form was also obtained from the parentguardian for those between the ages of 5 and 11 a simplified assent form tailored to a younger audience was completed by a parentguardian along with their child who would participate in our study

this qualitative research study is a part of a larger research project exploring the experiences of young caregivers aged 526 years and their families navigating the covid19 pandemic between 2020 to 2023 data were collected from 14 young caregivers who participated in baseline interviews the central research question guiding this study what was is and will be the impact of changing public health restrictions on young caregivers and their families during the pandemic and pandemic recovery seven themes emerged through analysis 1 navigating care during the height of public health restrictions 2 neighbourhood and built environment during the pandemic 3 perceptions towards covid19 and public health restrictionsefforts 4 the impact of public health restrictions on relationships 5 mental health challenges of being a young caregiver during a pandemic 6 navigating formal services and supports and 7 recommendations from young caregivers the findings from this empirical research suggest that young caregivers found it easier to navigate their caregiving responsibilities when public health restrictions and workfromhome mandates were initially implemented however this later changed due to challenges in finding respite from caregiving maintaining social connections with friends creating personal space at home and finding adequate replacements for programs once offered in person

Introduction Diabetes is a chronic disease that occurs when there is too much glucose in the blood because the body is not producing insulin or not using insulin properly . As noted by the WHO , diabetes is at epidemic proportions globally and needs to be addressed. Diabetes management involves a combination of both medical and non-medical approaches with the overall goal for the patient to enjoy a life which is as normal as possible . As there is no cure for diabetes, diabetes must be regularly managed and monitored. Critical to this management regimen is the systematic monitoring of blood glucose levels. However, achieving this goal can be challenging because it requires effective lifestyle management as well as careful, meticulous attention and monitoring by the patient and health professionals . There is a need for identifying a simple and convenient non-invasive approach to monitoring blood glucose . This forms the focus of this research. --- Background --- Invasive, Semi-Invasive, and Non-Invasive Solutions A key factor in the management of diabetes has been found to be the patient's self blood glucose monitoring . As a result of recent research , General Practice Management of type 2 diabetes recommends SMBG for patients with type 2 diabetes who are on insulin. Currently, the dominant method to test blood glucose level is invasive. It requires a blood glucose meter, a lancet device with lancets, and test strips. Further, the patient must prick their finger with the lancet sometimes more than four times a day. Finger pricking in SBGM has been found to have several clinical and psychological disadvantages. These are described below. Clinically, there is a risk of skin infection and tissue damage. Repeated finger pricking associated with the depth and possible vibrations of the needle tip while penetrating the skin were found to cause soreness and damage the skin and in severe cases could lead to ulcer on their patient fingers . Therefore, this SBGM practice can result in damage to the patient body site. Further, SBGM using a finger prick glucometer is not practical for continuous monitoring of blood glucose . As blood glucose levels of a patient change overtime, possible occurrences of hyperglycaemia or hypoglycaemia between measurements may not be recorded. Thus, the measurements may not truly reflect the patient blood glucose pattern . 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES S. Adibi, L. Nguyen, A. Hamper, F. Bodendorf & N. Wickramasinghe: A Systematic Approach to Terahertz-based Glucose Monitoring 9 Psychologically, inconvenience and anxiety of constant performing finger pricking and extracting a drop of blood in patients' daily lives, and associated physical and emotional pain have always been troublesome in SBGM . In a cross-sectional questionnaire survey with 315 patients with diabetes in the UK, about one third of general diabetes patients were found to have anxiety to finger pricking for SBGM . Positive correlations were found between anxiety due to finger pricking and avoidance of testing as well as between anxiety due to finger pricking and general anxiety. In previous studies , pain and discomfort were consistently found to cause a natural resistance to SBGM, and subsequently result in a lack of adherence to this procedure. Anxiety due to the finger prick method and avoidance of testing were found across different ethnic groups and female patients were found to have greater anxiety to finger pricking SBGM . The aforementioned disadvantages served to motivate the need for new approaches to SBGM. They can be categorised into two groups. The first group is to support for measuring blood glucose levels in a less painful manner. Wainstein et al. used a CoolSense device to reduce local pain sensation due to finger pricking. They conducted an experiment with 177 adult patients with type 2 diabetes and concluded that the CoolSense device significantly reduced subjective pain felt by the patients while maintaining the same level of clinical accuracy. Other studies suggest that instead of pricking fingers, patients can prick other areas such as the forearm, knee, earlobe, thigh and abdomen skin . While pricking alternative body sites were commonly found to reduce pricking fingers to some extent, it did not eliminate the pain completely. Disadvantages of pricking other body sites include lack of accuracy, inconvenience and difficulty of pricking in public, and technology switching costs to purchase new equipment for pricking and measurement . The second group of approaches to SBGM is to developing semi-invasive and noninvasive technologies for blood measuring without needle pricks . Du et al. propose a biosensor that can detect low-level glucose in saliva. They conducted a study of ten healthy human subjects and conducted that the proposed biosensor can be seen as a potential alterative to SBGM using finger pricking. The protocol of use is still rather complex, consisting of nine steps requiring the patient to chew a sponge in his/her mouth to collect saliva, and later squeeze the collected saliva into the device with a sensor, thus is not easy to use. More studies are required to investigate the accuracy of sensors in detecting low salivary glucose levels, efficiency and practicality of the proposed approach. Zhang et al. review current developments of non-invasive continuous SBGM methods using ocular glucose. These authors review studies in ocular glucose monitoring: using contact lens-based sensors and using nanostructured lens-based sensors. They concluded that lens sensors have the potential to monitor a wide range of glucose levels quickly and accurately, however there is a safety concern because boronic acid and concanavalin A may be released from 10 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES S. Adibi, L. Nguyen, A. Hamper, F. Bodendorf & N. Wickramasinghe: A Systematic Approach to Terahertz-based Glucose Monitoring the lens into the patient body. Nanostructured lens-based sensors have several advantages , further studies are required to improve resolution and sensitivity of the lens, and to determine physiologically relevance and baseline tear glucose concentration . Another review of current nanomaterial-based solutions using saliva, sweat, breath and tears as a medium for SBGM suggests that they are far from optimal; further nanotechnology sensing devices need to be manufactured at a low cost to compete with established blood glucose meters . One of the most recent advances in the area of semi-invasive glucose monitoring is Abbott's Freestyle Libre System which is based on a body attached sensor and a smartphone loaded with the application . This disposable body attached device is equipped with a thin and flexible fibre needle, which is the only invasive part, however the fibre is inserted only once and under the skin of the back of the arm. The sensor can be used continually for 14 days without the need to be replaced. The sensor captures glucose concentration information and once the smartphone that runs the required app scans the sensor, the current and up to 8 hours of glucose levels are read and uploaded to the smartphone According to Timothy et al. , the accuracy of the FreeStyle Libre system as dependent function of a number of patient-related factors has been found to be above 85.2% up to 14 days of testing. Overall, studies in issues associated with SBGM using finger pricking devices and learnings from in current developments of new SBGM methods suggest the following key factors: technology , clinical accuracy , clinical and safety interference with vision patient vision , ease of use , psychological effects , and costs . We develop Table 1 to present the key aspects of problems and concerns identified in the extant literature relating to SBGM. We conceptualise the problem in diabetes care management with the above factors. Therefore, we propose an approach to solution development consisting of patients analytics to focus on the targeted patient cohort, design science engaging patients in testing when it's safe, not early design, to finally propose a new solution to address their concerns and ensuring appropriate monitoring of the care management plan. Once the specific THz approach is selected, the methodological approach is to model the existing solutions and study the physical behaviour of Terahertz technology when radiated onto the human skin and study the depth of penetration and the variations in the reflections. This requires sophisticated THz lab equipment to run experiments on a test dummy, which mimics the human skin and underlying soft tissues. The results between the traditional needle-based sensing are then compared and the precision figures for the Terahertz-based method are evaluated. Then the approach need to be fine-tuned and also other health issues are then considered. --- Proposed solution A Design Science Research Methodology will be used to operationalize this research. This approach is particularly appropriate where improving an existing solution is desired and/or there is a need for a new solution to address specific unsolved or unique aspects . DSRM as a process model to carry out research is widely used in the information systems research to create new solutions or to improve existing ones. DSRM process model consists of six process elements , starting from identifying the problem and the motivation to conduct research, and concluding with communicating the results and outcomes of the research. Table 2 maps the proposed project to DSRM process elements . 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES S. Adibi, L. Nguyen With the increased diabetes population, and the disadvantages of conventional blood glucose tests, the lack of a reliable and easy to use noninvasive technology to monitor blood glucose motivates this research. --- Definition of objectives of the solution The objectives can be qualitative or quantitative i.e. create or improve an artefact respectively based on knowledge of the state of the problem and current solutions, if any, and their efficacy. The objective is to create and refine an artefact; i.e. the sensors. --- Design and development Creating the artefact, including the desired functionality and its architecture based of knowledge of theory that can be used to bear in a solution. This is usually an iterative process. Through several iterations the exact range for the frequency for the needed Terahertz wave beam will be identified. Once the narrow range for the frequency for the Terahertz wave is identified, the CAD/CAM programming will occur. --- Demonstration Demonstrate the use of the artefact to solve the problem. Simulation-based: This will be done in a lab using their simulation set up and mannequins. Clinical: Demonstration of the use of a new device to a sample of targeted patient population. Evaluation Iterate back to better design the artefact if needed. Simulation-based: As needed, iterations will take place, to fine tune the needed range for the Terahertz wave projections. Clinical: Iterative evaluations to ensure that the prototype is truly tailored to meet clinical requirements for the targeted population. --- Communication Publish and let the value of the solution talk about itself. This will include conference publications, journal publications and other presentation activities. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES S. Adibi, L. Nguyen, A. Hamper, F. Bodendorf & N. Wickramasinghe: A Systematic Approach to Terahertz-based Glucose Monitoring --- Results and Next Steps Based on our systematic review of the literature to date, we have identified problems and concerns with the current methods for blood glucose monitoring as well as the need for a simple, accurate non-invasive solution to it. To address this void we have proffered a technology solution using sensor technology combined with a smart phone. The next steps now include the design and development of the solutions coupled with establishment of proof of concept, usability and fidelity. This involves four key steps as follows: Phase1: This phase will involve the conducting of multi-dimensional analysis of provided data sets from a diabetic population . The results will provide a clear picture of the current state, reveal critical trends and important patterns regarding this population and assist to identify the patient sample. It is anticipated that target patient cohorts and their demographics as well as geographic and clinical characteristics will be identified for the project to identify who would benefit most from the non-invasive smart solutions. This phase aims to address the first DSRM process elements including problem identification and motivation, and definition of objectives of the solution . Phase 2: Phase 2 will include designing and developing the appropriate sensor technology. The patented solution we have developed uses THz to identify blood sugar readings but this requires critical analysis to isolate the specific THz band. Inputs for this are derived from aspects of the data analytics performed in phase 1 above. Once this is done the required specifications for designing the sensors must be generated. Thus the results at the end of this phase include the design specification for the sensors to be used in the specific context so they are truly tailored to that context. This phase aims to address the subsequent DSRM process elements including design and development, simulationbased demonstration, and associated simulation-based evaluation. Phase 3: Phase 3 will focus on the design and development of the software solution necessary to develop the prototype to be used to measure blood glucose readings. Contemporaneously, the health literacy issues will be examined and an appropriate education and coaching program will be developed for the targeted population. This phase aims to continue the DSRM process element design and development. Phase 4: Phase 4 involves establishment of proof of concept, usability, fidelity and functionality. This will be conducted by running a field study on the selected patient population of 50 patients based on results from phase 1. It is anticipated that the filed study will involve and iterative process to ensure that the prototype is truly tailored to the selected population's needs and requirements. In addition, HbA1C the standard diabetes marker will be tested at 3 month intervals over a 6 month time frame to assess success of the solution and changes to health literacy at these points will also be assessed. This phase aims to address the DSRM process elements including clinical demonstration, and clinical evaluation using the key aspects S. Adibi, L. Nguyen, A. Hamper, F. Bodendorf & N. Wickramasinghe: A Systematic Approach to Terahertz-based Glucose Monitoring 17 side effects and safety, ease of use, psychological effects, and costs) and relevant factors presented in Table 1. As a result, the list of factors will be refined to inform future implementations and evaluations. The DSRM process element communication will take place through the whole project when findings from each phase become available. --- Discussion and Conclusion Concurrent and independent from the exponential rise of diabetes has been the rise of mobile and sensor technology. The maturing and sophistication of these technologies has enabled them to be sued in many aspects of healthcare and wellness management. The preceding has served to outline another potential area for the adoption of mobile and sensors; namely, to assist with a non-invasive approach for the monitoring and management of diabetes. Specifically, we have identified an opportunity to use Terahertz frequencies to detect blood glucose levels in individuals. Further, we envisage designing and developing this solution by combining sensors with a mobile phone so that detection of blood glucose can not only be non-invasive but truly pervasive. The implications for theory and practice are wide and far reaching. From a theoretical perspective we combine two technology genres mobile and sensors to address a healthcare issuedetection of blood glucose levels using a design science research methodology. This can lead to a better understanding and application of sensor technology in mobile technology. Scientifically backed roadmaps for including innovative sensors in mobile technology can support further DSRM based research in the field. From the perspective of practice, diabetes as noted by World Health Organization is global and at epidemic proportions with an estimated of 422 million adults living with diabetes in 2014, and 1.5 million deaths caused by diabetes in 2012. Complications from diabetes can lead to other serious conditions such as heart attack, stroke, blindness, kidney failure and lower limb amputation. Further, the number of pre-diabetic individuals is also considerable. Monitoring and management is the only recognised strategy to maintaining appropriate blood glucose levels and thereby managing diabetes and/or preventing a pre-diabetic becoming a diabetic. Given, the problems and criticisms of finger pricking and other invasive approaches to SBGM, the most prevalent approach to testing blood glucose using a non-invasive Terahertz technology solution which we propose is very attractive to individuals. By learning from glucose monitoring, there is an opportunity to transfer the use of Terahertz technology to test other blood values in a non-invasive way. When such a solution is truly pervasive, it becomes even more attractive. Thus, we believe that the proffered solution will enable diabetic and pre-diabetic individuals to enjoy a better quality approach to monitoring and managing their blood glucose levels. Our future work will focus on establishing usability, fidelity and acceptability of the proffered non-invasive pervasive solution Introduction In the era of digitalisation, music has become easier to create, distribute, and access than ever. Music recommender systems are meant to assist listeners in navigating through the myriad of available musical works and provide them with suggestions that would fit their preferences and needs. This paper aims to present the most common techniques in music recommendation and how these affect the positions of non-superstar artists. While previous research on MRS typically takes a technical perspective or focusses on the consumers, the artists' perspective has yet largely been neglected. "The phenomenon of Superstars, wherein relatively small numbers of people earn enormous amounts of money and dominate the activities in which they engage, seems to be increasingly important in the modern world" . Still, the impact of MRS on non-superstar artists is particularly important as the vast majority of artists are non-superstar artists , the economic situation of non-superstar artists is usually precarious , and the technological and managerial skills required to manage and promote one's own business as an artist are usually not part of the typical educational paths of aspiring artists . The importance of non-superstar artists is further underpinned by the "long tail" concept introduced by Anderson ), a model that is specifically applicable to the music industry. This model describes the economic tendency, when there is a concentration of sales on the most popular items , which form the head, and then a long tail of less popular items that may fulfil niche demands of potential customers. This model is considered the opposite of the "hit model" in industries where an item either becomes a "hit" or does not make any profit at all. The implication is that it is more profitable to sell small amounts of the long tail of less popular items than large amounts of a small number of hits. Later, empirical findings confirm this idea, provided there are effective search and recommender systems available that enable users to access these long-tail items easily. At the same time, MRS is an enabler to introduce niche items to a consumer who usually follows hits only in such a sophisticated manner, so that this hit-affine user may start consuming long-tail products . As a result, the employment of recommender systems in the long-tailed online music market enables users to discover and access the work of non-superstar artists. The paper is structured as follows: Section 2 provides a structured overview MRS and their functionality. In Section 3 we explore the influence of MRS on non-superstar artists by explaining the phenomenon of popularity bias, the cold start problem, and superstar economy. Section 4 provides details and results of a semi-structured interview with an artist, followed by the last section containing concluding remarks. --- Music Recommender Systems This section provides an overview of the structure of MRS, its components and functionality, and the most common techniques used. Typically, recommender systems consist of three key components: users, items, and useritem-matching processes. This general structure also applies for MRS, where users are the listeners and items are the music items . The system collects relevant data about its users and applies mathematical models and diverse techniques to find and propose items, which might be of interest for the listener. To recommend items that most likely fit the listeners preferences the system needs to manage data about listeners and music items, the system generates profiles for each of them and determines "good" matches by comparing these profiles . In the following, we discuss in detail the data and approaches associated with the three key components, i.e., user, item and matching. --- User Data In order to be able to make valid recommendations, an MRS requires data about its users' needs. However, getting such exact data is a costly process . Thus, MRS rely on user modeling. The system analyses its users' data and generates profiles based on their differences to model music preferences and thus determine which music items might be of interest for the individuals. Typically, the user modeling process consists of two sub-processes: user profile modeling and user experience modeling. User profile modeling is generally used to determine the "position" of the listener in comparison to others based on their features. One of the approaches suggests dividing user profiles based on three major categories: demographic, geographic, and psychographic . Further, a number of attributes can be assigned to each category, such as age, gender, country, interests, etc. . Whereas, user experience modeling is meant to approach the users with consideration of their music expertise level, which further can be used to determine some of their expectations towards the MRS . Combining both approaches, it is possible to predict some of the users' demands and desires regarding music; for instance, it is possible to predict a user's preferred ratio of new, previously unknown vs. popular, already known music items she would like to listen to when engaging with a music platform . Some data can be obtained through observing listeners in their actions on the music platform, such as listening patterns , other data may be retrieved through input inquiries, e.g., surveys to retrieve profile information . 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES C. Bauer, M. Kholodylo & C. Strauss: Music Recommender Systems Challenges and Opportunities for Non-Superstar Artists --- Popularity Bias One of the most problematic issues that affect the position of non-superstar artists is the so-called popularity bias. In general, the popularity bias phenomenon suggests that over time the most popular music items tend to get more and more attention, while music items in the long tail get less and less attention. In particular, popularity bias is a significant problem when employing CF or context-based filtering due to the nature of the integrated algorithms . As concerns MRS, this phenomenon manifests in several ways. For instance, CF uses listeners' ratings to create recommendations. This implies that popular music items receive generally more ratings than items of the long tail. This, in turn, entails that an MRS recommends popular items more frequently than less frequently rated items. This, however, reinforces the popularity of popular items and, thus, also increases their suggestion rates. As a result, items in the long tail receive less and less ratings, and so the system recommends them less frequently . For example, Fleder and Hosanagar could show this effect in a simulation study. They simulated an MRS based on CF, where music items were recommended based on the results of previous recommendations. Across several different user groups, the overall diversity of consumption by the end of the simulation was decreasing. In other words, the MRS was giving preference to more popular items over time. In a similar way, context-based filtering uses data available about a musical works to derive recommendations. Since popular items are generally better promoted on media and are mentioned in more online sources, overall more information is available about those items compared to items of non-superstar artists . As a result, an MRS employing context-based filtering suggests popular and widely discussed items more frequently than items with less popularity; and this gap grows over time. --- The Cold Start Problem Closely related to the popularity bias is the so-called cold start problem, which refers to the difficulty to get recognition in an early stage when a new user or new item enters a MRSdue to the lack of data related to the user or item . When a listener just starts to use an MRS and has not submitted much information about herself or her preferences, etc. , the MRS will only provide her with general recommendations . Similarly, when new music items are introduced to a system, they do not make it into the recommendation results because there is not enough data available about these items , which would trigger the MRS suggestion . In addition, artists new to the market do not only have merely new music items in their portfolio, there is also not much data available about them as artists, entailed with less frequent discussion, promotion, etc. As a result, the chance that new artists' items are 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES C. Bauer, M. Kholodylo & C. Strauss: Music Recommender Systems Challenges and Opportunities for Non-Superstar Artists 27 recommended by an MRS are even less likely than that for new items of established artists . --- Superstar Economy Speculations In addition to research on the effects of and consequences inherent in the techniques an MRS employs, some sources assume that MRS are biased towards popular tracks not only due to their design and the algorithms employed, but on purpose as hit items generate larger profits than items of non-superstars . For instance, a marketing report by Media Insights & Decisions in Action Consulting concludes that the recording music industry is not at all oriented at longtail items; according to this source, one of the main reasons for it is that MRS do not only offer popularity-biased recommendations, but also that music platforms get polluted with musical works that are created in "bad" quality on purpose, with the aim to enhance the positions of the already popular music items . Such "bad" musical works sound similar to the bestselling songs, but in comparison the listener would still prefer the more popular, "better" song . As a result, the sum of sales for hit songs is higher than that for non-hits, so music platforms are more motivated to sell more of popular music items . This opinion is supported by findings of research investigating users' music preferences show that users who prefer mainstream music are in general easier to satisfy with an MRS). In contrast, for instance, Levy and Bosteels investigated whether the MRS employed by the Last.fm platform is indeed biased towards more popular items, as suggested in earlier literature. They compared three different data sets: the one of Last.fm Recommendation Radio, which recommends specific music to specific users based on their data, the Last.fm Radio data set, which plays music recommended to Last.fm users in general, and and a data set of the Last.fm music streaming services as a whole, which summarizes the information about what users are listening to while using Last.fm. The findings suggest that Last.fm, as one of the largest worldwide MRS, is biased towards non-hits rather than towards hits in comparison to overall user listening experience, and this bias is stronger for Last.fm Recommendation Radio. Based on these results, the authors conclude that real-world data can significantly differ from simulations and also state that not all MRS seem to be biased towards more popular artists. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES C. Bauer, M. Kholodylo & C. Strauss: Music Recommender Systems Challenges and Opportunities for Non-Superstar Artists --- Impacts of Music Recommender Systems While the topic of popularity bias and the recommender system inadequacies seems to be one of the most broadly studied topics with regard to MRS research, it seems that research has been limited on the existence and the reasons of these phenomena. Yet, exploring the impact of these phenomena on different artist groups or differentiating in more detail within an artist group has not been investigated. For instance, as mentioned in a Billboard article , researchers and media tend to focus on disadvantages and flaws of MRS' performances, while neglecting the fact that the existence of the discussed phenomena may be a big advantage for a privileged group of artists. For example, in the "old" music business, when music was either distributed on physical media and/or promoted through live shows, it was tremendously challenging for newcomers to the industry to get recognition, if their music did not "score" to become an immediate hit . Now, newcomers have the chance to slowly make their way up in industry by experimenting with the recommendation mechanisms and promoting their works accordingly . The shift from the short-tail to the long-tail model might not be as significant as in other entertainment industries such as films as books, but it is still present and it continues growing . This view is supported by the case we investigated and is presented in the following Section 4. --- Insights from a Real-world Case To gain some insights on how MRS impact non-superstar artists from their point of view, we drew from the experience of an aspiring, non-superstar music band using the Internet as the main tool to promote their music. --- Approach Several criteria motivated the selection of an interviewee to gain hands-on insights on challenges and opportunities for non-superstar artists: recent release of an album, experience with MRS, use of Internet as a main promotion tool, newcomer on the market, limited information about the artists available on the Internet, and professional attitude and aspiration . Based on these criteria, we selected a Ukrainian oriental metal band, founded in July 2011 under the name "Parallax", renamed in 2015 to "IGNEA". Their first work "Alga" was released in 2015, whereas they released their first full-length album "The Sign of Faith" in 2017 . This band was selected to provide insights on the topic of MRS from the artists' point of view because since their debut in 2011 they mostly use Internet to promote their work The interview indicates that the band's overall experience with them as a non-superstar artists is very positive. For instances, about 80% of their listeners and purchasers discovered the band through MRS recommendations. Furthermore, achieving success on the platforms has led to mentions on the media. Overall, our interviewee pointed out that MRS combined with the power of Internet had helped the band to generate international audience instead of regional listeners; currently the majority of their listeners is located in the United States. The interviewee expressed her opinion that she thinks many artists fail on platforms with MRS due to the lack of knowledge and/or effort that the artists put into managing their activities on such platforms, trying to exploit MRS for their own ends. She emphasized the importance of studying and understanding how such systems work, and pointed out the lack of knowledge that artists seem to have about the tools available. She said that those might not be aware of the tools and possibilities and do not sufficiently search for their opportunities. The observation of the lack of managerial skills is backed up by research findings ). Behaviour on the market, partly resulting from such an educational deficit, may lead to destruction of the economical basis of aspiring artists . She believes that a good artist can reach success with the help of MRS. She stated that her band will continue using MRS to promote their music in the future. --- Introduction Some 720 years ago, a book appeared in Europe, marvelling the travel in Asia that Marco Polo started when he was seventeen and that ended when he came back to Venice 24 years later. Although the book contains omissions and exaggerations, it describes how a merchant perceived the wealth and great size of Asian cities and it soon gained popularity in Europe, while inspiring other travellers to travel even further, one of which was Christopher Columbus. The purpose of this article is to describe an ongoing project for teaching professors to design a training program meant to transform any management students, the same way a long journey to Asia transformed a simple merchant into Marco Polo. We define a study exchange program as a program in which students from a university study abroad at one of their institution's partner institutions. Since such programs might be hard to organize from an administrative point of view, this article focuses on shortterm study abroad, which lasts less than three months and exposes students to an intensive program that increases their understanding of other cultures, communities, and languages. Short-term, non-language-based study abroad programs can have a positive impact on intercultural sensitivity . Moreover, previous studies have already shown no statistically significant differences between the semester-long group and the short-term group . A recent stream of literature has studied how short-term study abroad enhance critical thinking among students , which is defined here as the application of focused reflection and reasoned thought, and how to prepare the pre-departure sessions to properly prepare the students . Although the positive effects of a shortterm study abroad have been discussed in previous studies, a major barrier for teaching professors is the cost to implement it. In this study, we wish to find a way to lower three components of such cost: the effort required to obtain the economic resources needed to do the trip, the effort required to prepare the students and the effort required to assess the acquisition of relevant competences. In this paper we seek for a set of guidelines that reduce the effort required to organize a short-term study abroad for a university course. Such goal seems to be best addressed by a design science methodology, which seeks for utility rather than truth and will be instrumental to develop a framework of guidelines for teaching professors. Therefore, our research question is: how to reduce the cost of a shortterm study abroad aimed at increasing the critical thinking of management students? The rest of the paper proceeds as it follows. Section 2 briefly assesses the state of the art with respect to relevant concepts needed to answer our research question. Section 3 describes our methodology and the proposed solution. Section 4 illustrates the 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students 35 preliminary results obtained. Section 5 concludes the paper by discussing its limitations and by highlighting possible directions for further investigation. --- Literature review In this section we introduce three concepts to address our research question: apprenticeship as a way to gather resources for the trip, massive online open course to standardize the content used to prepare the students, information technology to collect information during the trip. ) point out that the majority of study abroad programs are now short-term and faculty-led, but it does not specifically address the issue of effort required for financing. In this paper, we suggest establishing partnerships with firms and have students do apprenticeship in the firms during the course, in exchange of financial supports for the short term study abroad. This approach is inspired by the Finnish model of education to teach entrepreneurship, the so-called "Team Academy" approach that has already influenced the way management courses are taught . Apprenticeship can be defined as a system of training a new generation of practitioners of a profession with on-the-job training and some accompanying study . With respect to internship, apprenticeship is more structured and it requires a close collaboration between the firm and teaching professors. If one assumes that management students are apprentices, who do a project during a semester that includes a short-term study abroad, the pre-departure sessions meant to enable students to perform critical thinking during the period abroad needs to be consequently adapted. Indeed, existing literature has already offered a set of guidelines to increases the critical thinking of students by means of three sessions that addresses three relevant questions: Session 1: Choosing My Adventures Session 2: What's My Attitude? and Session 3: Building My Skills. Nonetheless, the useful material offered by the authors need to be complemented with other resources that help students solving the problem of the firm. In this sense, one way to train students is to use a massive open online course , which can be defined as an online course aimed at unlimited participation and open access via the web . Online companies, such as Coursera or edX, offer courses from top universities that include videos and tests to assess knowledge acquisition. Although the real value of MOOCs is currently debated , xMOOC are a useful approach to assure that the training of students is in line with what is currently taught in other universities, where "x" stands for "extended" meaning that the MOOC complements a course done in class. Finally, it should be taken into account that, during a short-term study abroad, students do not have constant access to a personal computer or to internet access. Therefore, it would be advisable to combine online tools that allows students from different classes to work together and paper templates to carry on and to fill in during the trip to assist 1. Identify problem and motivate: the overall need of international experience was brought by companies, who hire our students after the completion of their university training. The specific need of reducing the effort required to include this activity in the course was due to the limited resources available at the university. 2. Define objectives of the solution: we looked for an existing solution to adapt our course of digital marketing. Once we found the model of , we tried to extend it in order to allow quantitative analyses and benchmarks among groups of students. 3. Design and development: we developed the course iteratively over three years. Each year, we improved one of the three cost components. The first year we introduced the notion of apprenticeship to lower the cost of financing. The second year we complemented our courses with MOOCS and we started measuring skills acquisition with external surveys. The third year we developed a travel guide with templates to fill after each visit. 4. Demonstration: each year, we tested the model by travelling with selected students of the course of digital marketing to the same location, in order to allow comparison between different years. 5. Evaluation: we assessed the effort required to organize the short-term study abroad, while measuring the satisfaction of students and companies. 6. Communication: We waited until the third iteration to communicate the results of our model, due to the complexity of the task at hand. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students 37 --- Our framework The resulting model has four components that form the acronym POLO, two of which have been fully implemented for a course of digital marketing, and two of which will be implemented in the next iteration. a) Pre-departure sessions: We identified three main themes associated to the experience that students would have done abroad, and that could be improved by digital marketing techniques: tourism, education and strategy consulting for firms. According to , there are three components of the theme-based interdisciplinary approach, which we adapted to our situation: Great questions: in order to perform each experience, students had to combine existing notions of information technology, strategy, market analysis and service design. Glocal awareness: during each experience, students had to report how they felt about being immerse in a foreign country and what changed with respect to the local context they were used to. Global awareness: after each experience, students were asked to propose ways to translate the skills learnt in a global context into the ecosystem of the firm, they were working with. Moreover, we had to take into account the interaction between the students and the firm that financed their trip. Since we did not want to personally attend the meetings between the students and the firm, we decided to use a set of proxy measures. We used two MOOCs from Coursera and training material from Google and Facebook to prepare students to the topic of digital marketing. Students were asked to complete the course at home and to come to class prepared to discuss about how to implement the theory into their group project with the firm. Every month, the students had to complete a set of quiz to monitor their mastery of theoretical concepts. In order to measure retention of concepts, we submitted the same quiz more than once. Hence, the first month, students would have to do quiz 1; the second month, they would have to do quiz 1 and quiz 2; the third month, they would have to do quiz 1, quiz 2 and quiz 3, and so on. Only the first quiz led to a summative evaluation; the result of the other quizzes was known by the students but did not change the initial score. That way, we would monitor how many theoretical concepts were put into practice within each group, and to perform risk analysis at the group level. One month before the trip, the firm had to do an intermediary evaluation, and we checked if there were correlations between our risk analyses and the feedback of the firms. b) Observation while being abroad: According to , there are three components of the cultural immersion : a. Experience: whenever possible, students were advised to observe how locals were behaving with respect to each theme previously defined. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students b. Reflection: at the end of each day, students were brought to traditional monuments and restaurants to familiarize with the underlying culture of the city. c. Application: students had the opportunity to follow university courses and presentations done by international firms on the same topic. In order to assess the increase in the critical thinking of the students, a set of templates to fill were given. The templates to fill in had the same structure for every theme: analysis of the touchpoints between the student and the service, link between the touchpoints and the concepts of digital marketing learnt in class, observation of existing digital solutions used in the context and difference between theory and practice suggestions for improvement and explications of implementation. c) Learning with another class: This component of the framework is currently under development and it has not been tested yet. In its final stage of development, we envisage to create virtual teams composed by students from two universities in two different countries, which will have to perform a joint task, i.e. to attend the Google Online Marketing Challenge. A groupware with project management functionalities, such as LiquidPlanner, will allow students from the two universities to talk before meeting during the short-term study abroad. Then, students will continue working together from two separate countries. d) Ontological changes: This component of the framework is currently under development and it has not been tested yet. Previous research has already shown that the different stages of the U-curve adjustment theory can be shortened by performing pre-departure exposure to the host culture, teaching techniques of anticipatory adjustments to the host culture and increasing the time spent with host country nationals . Accordingly, teaching professors could link the quantitative results obtained during the pre-departure sessions and the data collected during the trip, in order to monitor if the honeymoon and the culture shock stages last too long, and act accordingly. For sake of simplicity, we list here only two propositions derived from the U-curve adjustment theory: students who spent little time to attend to models, will report the lowest levels of perceived dissimilarity between the approach of the host country nationals and themselves at the beginning of the trip, and students that have written more of new and appropriate behavior at the beginning of the trip will receive a greater positive reinforcement and will adjust quicker to the new culture. --- Preliminary test results In this section we illustrate the results of the most recent test the first two components of our model, which was used with a class of 35 students of the course of digital marketing. At the beginning of the academic year, students were split into eight groups depending 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students 39 on their interests and skills. The goal of each group project with the firm was the same: to design and implement a digital strategy for the firm. Nonetheless, each group project slightly changed over time, depending on the stage of digital maturity of the firm or the resources available. Each group received theoretical classes once a week and had to meet the company once a month, as part of their apprenticeship. In the middle of the academic year, a short-term study abroad was meant to let students acquire international awareness, by meeting multinational firms and by attending classes in another university. Accordingly, the city of Dublin was chosen, since it hosts the headquarters for the Europe -Middle East -Africa zone of Facebook , LinkedIn and Twitter, as well as hosting the headquarters of Google Ireland, Microsoft Ireland and Amazon Ireland. In the following paragraphs, we illustrate how we monitored the interactions between the students and the firm during the pre-departure sessions and between the students and their new environment during the observation phase abroad. --- Assessment of knowledge acquisition Since we did not want to personally attend the meetings between the students and the firm, we decided to use a set of proxy measures. Figure 1 illustrates how we monitored the firms. Each student did the quiz 01 three times over the course of one semester. The quiz was composed of 40 questions directly taken from Coursera, and its score ranged from 0/10 to 10/10. After each quiz, we gathered all results of all students and then we extracted the median, the maximum and the minimum for each group. Finally, we assigned the groups to different risk clusters, depending on their maximum and minimum. 1 shows the classification that we used to monitor the groups. If the maximum score was less than 7/10 we assumed that no one was in charge of the team and we assigned a 0 in the first column. If there was a minimum score below 5/10 we assumed that there 40 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students was at least one slugger and we assigned a 0 in the second column. Usually, teams started all at the best position during quiz 1 , where most of the students had 10/10. Nonetheless, over time students started forgetting what was not put into practice. Figure 1: Different trajectories of the eight groups Figure 1 shows that teams L1 and L2 managed to reduce the distance between the maximum score and the minimum score of the third quiz. Hence, one can assume that they managed to involve the potential sluggers in the team. Instead, teams F1 and F2 did not correct the distance between max and min but they managed to keep such distance steady between the quiz 2 and the quiz 3. Team P1 and P2 could not control the amount of free riding in the team and eventually no one took the leadership. Interestingly enough, these two teams did not have problems with the firm. Indeed, by discussing with the firms we realized that the company took the role of the leader and the students decided to follow. Finally, teams T1 and T2 increased the amount of free riding in the team over time and lost the degree of leadership. These teams had issues in their mid-term evaluation, because the two firms did not take the lead. --- Preparation of the theme-based interdisciplinary approach and cultural immersion Table 2 illustrates an example of development of the theme "Strategy consulting". Students received a printed book with templates to complete, such as the one shown in the example. On day 1, students went to an Irish university and conducted a case study, under the supervision of a teaching professor in charge of the course of digital marketing 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students 41 at the hosting university. On day 2, students went to visit the company analysed and where asked to perform reflective tasks to better understand the difference between theory and practice. Table 2: Theme development across day 1 and day 2 Case Study Guinness Dates : Day 01 Part 1: Digital strategy of Guinness Analyze the amount of times the word "Guinness" is searched on Google Ireland, with respect to the word "beer" and "World record". Part 2: Marketing strategy of Guinness Storehouse Read the HBR article "The Brand Benefits of Places Like the Guinness Storehouse" . Then, link the keywords used by the reviews on Tripadvisor to the seven principles. Part 3: Your Google Ads to promote the website of Guinness storehouse Design a Google Ad to increase by 1000 the number of tickets sold online to tourists in the month of April. To estimate the budget, assume that the rate of ticket sold is 1% of the people clicking on the ad. To comply with regulations on alcohol advertising, make sure you do not sell alcohol to teenagers. Finally, assume that every ticket sold online saves 3 CHF to Guinness with respect to a ticket sold on the building. --- Part 1.1 : Digital strategy of Guinness Why is the word «Guinness » searched more than the word « beer » ? ………………………………………………………………………………………… …. Think about an example of how social marketing online allows Guinness to promote its brand, while respecting regulations on advertising of alcoholic beverages ………………………………………………………………………………………… …. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students dynamics, with the exception of the groups with the free riders, where the leader became tired , and one group in "Panic" state, which managed to rebound during the trip abroad. This confirms our first proposition concerning the importance of the pre-departure stage. Since one group has improved its relative performance during the trip, we need additional information to confirm our proposition concerning the importance of positive reinforcement to teams, which properly prepared before the trip and acquired new and appropriate behaviors in little time. --- Discussions and conclusions This article presents the preliminary results of an ongoing study to reduce the cost of a short-term study abroad aimed at increasing the critical thinking of management students and to transform each of them into the Marco Polo of the 21st century. We start by proposing to start by a project that implies apprenticeship in firms and that uses the time spent abroad in order to solve a problem of a company, which could cover the travel expenses in return. Accordingly, we have adapted existing templates for pre-departure sessions of to include the notions required to solve the problem of the firm, and we have devised a way to use MOOCs and standardized tests to monitor the work of the students. Finally, we have extended the framework of to have the summative and formative evaluation under a quantitative form, to allow benchmarks among students. At its current stage, this study has two major limitations: the first one concerns the two missing dimensions of the POLO framework, which makes it hard to assess its validity as an overall; the second shortcoming concerns the way reflective exercises are constrained by the templates to allow simple benchmarking. Nonetheless, we believe that our preliminary results already offers two interesting contributions to previous knowledge: if students work in teams, the team dimensions should be taken into account and if students work with a sponsor, the dynamic with the firm should be monitored to avoid the situation "tired leader". TRANSFORMING OUR LIVES R. Bonazzi, M. Poli & N. Sarrasin: POLO: A Framework for Short-term Studies Abroad to Enhance Critical Thinking Amongst Management Students 45 In the future, we intend to develop the two last components of our framework and to test it quantitatively on a larger scale. In the beginning, we shall limit our observation to two classes in two countries, in order to better control for cultural effects. Indeed, we intend to assess an additional proposition derived from Black & Mendenhall , concerning the sources of anticipatory adjustment, such as training or previous international experience, that increase attention and retention processes will in turn speed up the learning process of some students. In order to properly assess the ontological change, we also intend to try a version of the printed book with templates for students, which constrain less their possibility to express themselves. --- Introduction Open data is an increasingly topical concept which is rapidly growing in popularity amongst governmental organisations, researchers, the business community and other stakeholders. Open data has been defined as 'a "philosophy" or "strategy" that encourages mostly public organizations to release objective, factual, and nonperson-specific data that are generated or collected through the delivery of public services, to anyone, with a possibility of further operation and integration, without any copyright restrictions' . Open data can be viewed as a key signifier of the evolving nature of the relationship between government and the citizen as the use of Information Technologies in government holds the promise of enhanced democracy and increasingly engaged citizen participation. Led by former US president Barack Obamas announcement in 2009 that his government would embark upon a transparency strategy that would see much greater levels of openness in government, many governments around the world have since followed suit with increased emphasis on open data as a key component . The potential benefits accrued are manifold. These have been categorised by Janssen et al. as firstly, political and social e.g. more transparency, creation of trust in government, more participation and self-empowerment of citizens etc. Secondly, economic, e.g. economic growth, stimulation of innovation, development of new products and services etc. Thirdly, operational and technical, e.g. counteracting cost associated with recollection and unnecessary duplication of data, optimisation of the administration process, improvement of public policies etc. With the increased availability of Open Data, intense pressure is being brought to bear on different public organisations to release government produced data. There are myriad reasons for this including public spending cost reduction, increased returns on public investment, wealth generation, service delivery and innovation . The somewhat romantic view is that this will increase transparency and democratic accountability, create trust in government and self-empower citizens . While policy-makers appear to believe that open data will be taken up and used by the public resulting in copious benefits, , this belies the fact that the focus of interest in the literature has been on technical and operationalisation issues and scant attention has been paid to usage, theoretical contributions and the role of the citizen in this process. This research will utilise the theory of value co-creation , and develop a model that explains the factors that influence citizen engagement in the co-creation process. We validate and expand on previous work by Voorberg et al. , to create a theoretical model which we hope to validate through future research. 30 TH --- Repositioning The Role Of The Citizen The movement towards openness in government with open data as a key component has the potential to forever alter the relationship between the state and the citizen. Largely, the participation mechanisms enacted over the last quarter of a century have been consultative in nature resulting in little influence over public policy . These have taken the form of citizens' assemblies, referendums, citizen juries, public meetings and opinion polling . These have been largely unsatisfactory in most cases and act as 'a supplement to traditional representative democracy, rather than an alternative to representative democracy' . In addition, Dryzek has argued that since the 1990's, democratic theory has taken 'a strong deliberative turn. Increasingly, democratic legitimacy came to be seen in terms of the ability or opportunity to participate in effective deliberation on the part of those subject to collective decisions'. He further argues that democratisation takes place along three dimensions: franchise, scope and authenticity. He states that 'authenticity is the degree to which participation and control are substantive as opposed to symbolic' . This search for "Dryzekian authenticity" has come about as a result of 'declines in traditional forms of participation associated with representative democracy' . --- Co-Creation Co-Creation as a concept has evolved continuously since its antecedents appeared in the form of co-production in the 1980's. In the sphere of public administration, the seminal papers produced, , added a solid foundation which was initially built on by Prahalad and Ramaswamy . There has been a great deal of discussion in the academic literature concerning the issue of definitional differences relating to co-production and co-creation . Voorberg et al. found that when they compared the record definitions of co-production and co-creation, to a large degree, both terms were defined analogously. In addition, they concluded that co-creation and co-production have been used as interchangeable concepts while questioning the feasibility of conceptual clarity. Given the definitional murkiness of the co-creation concept and its interdisciplinary nature, this research will draw from Galvagno and Dalli more broad definition of co-creation as a 'joint, collaborative, concurrent, peer-like process of producing new value, both materially and symbolically'. --- Barriers To Open Data Use From The Citizen Perspective In order to determine whether non-technical barriers exist to open data use, we reviewed the pertinent literature in the field. We found that there is a lack of articles that examine Ohemeng and Ofosu-Adarkwa examined the Ghana Open Data Initiative from a demand side perspective which was initiated in 2012 with the primary aims of administrative efficiency and economic development. They described the level of civil society involvement as 'abysmal' and one the main non-technical challenges has been the involvement of citizens in the process. This is explained as a consequence of a skills deficit and a lack of awareness . They further point out the necessity of balancing high and low technology approaches such as adopting a mobile government path . Shadbolt et al. analysed the socio-technical aspects of linked open government data from data.gov.uk. They make clear that the makeup of the user interface is a crucial issue by explaining 'the ease with which ordinary citizens can access and query the data is a crucial factor for open government data's value' . Huijboom and Van den Broek examined the open data strategies in five countries . They found that one of the top barriers of open data policy was the issue of limited user friendliness. They point out that 'technical experts of several countries stated that the existing databases should be converted into more userfriendly datasets to be of use for citizens and businesses' . This sample of case studies which address the user perspective endorse the idea that there is a dearth of studies investigating usage of open data from the citizen perspective. They further point towards the existence of non-technical and socio-technical barriers. --- The Research Model Currently, there is a dearth of literature examining theory contribution and development in the open data field . Furthermore, as Zuiderwijk et al. point out, 'little is known about what predictors affect the acceptance and use of open data'. To address this shortcoming this research paper will attempt to contribute to the advancement of theory by developing a research model that will explain intentionality to use open data. To do so, the authors adapted and extended previous research conducted by Voorberg et al. in the area of co-creation. Through a review of the pertinent literature, we were able to validate the first three constructs identified by Voorberg et al. . We further validated the risk aversion construct and added trust as a supplementary factor owing to a symbiotic relationship which exists between the two constructs. Finally, we developed the construct of simplicity of task as the academic literature pointed towards its importance and necessity. TRANSFORMING OUR LIVES (JUNE 18 -21, 2017 It is our belief that these prominent factors in citizen co-creation represent moderating variables that have the potential to alter the relationship between the citizen and the outcome of open data usage. This is visually represented below in figure 1. Figure 1: Research Model --- Conclusion and Future Work The next step of this ongoing research will be to design and conduct an exploratory crosssectional pilot survey with current open data users, focusing on the individual as the unit of analysis. To establish the strengths of our survey constructs this will be followed by a series of semi-structured interviews with selected users. It is hoped this will lead to validation of the constructs mentioned previously. Special attention will be paid to theory building and theoretical contribution. Following Doty and Glick theory must contain at least three principles to be defined as theory; ' constructs must be identified, relationships among these constructs must be specified, and these relationships must be falsifiable'. Opening up governmental data is riven with potential and pitfalls. How this is managed by the state will determine the accrual of potential benefits for the private sector and society as a whole. For understandable reasons, previous and current research has focused on technical and operationalisation issues. However, if tangible benefits are to be realised greater attention needs to be paid to the end user. The authors propose a research model from the perspective of the user by employing the theory of co-creation that will help in developing increased understanding of intentionality to use open data. The contributions of this study are twofold. Firstly, adapting and extending prominent factors in co-creation with a view to applying them to intentionality to use open data. Secondly, the attempt to build theory in the area of open data which has been under investigated thus far. --- Background The proportion and socioeconomic relevance of ageing citizens is already high in most EU countries and there is growing political pressure to find trade-offs between the costs and the sub-stance of the care programs. The young elderly age group represents 18-23 % of the popu-lation in most EU countries; this is a large segment of the population that according to recent statistical estimates will be about 97 million EU citizens by 2020. For ex-ample, this age group will represent 22.6 % of the Finnish population by 2020 and has already reached 1.7 million in Sweden and 10 million in Italy . Furthermore, given their income level and accumulated wealth, the young elderly represents very large and growing markets for digital wellness ser-vices, especially in higher per capita income EU countries. This demographic trend has clear economic and scientific implications .The opportunities and challenges offered by the young elderly market in most EU countries, is a market that so far mostly has been ignored by mobile service developers and providers, offering progressive companies new areas for expansion across the EU and beyond. It also provides fertile ground for collaborative research as it offers potential for researchers to work to find innovative solutions for large user groups, testing and anticipating the benefits and impacts of deploying digital wellness services among the young elderly. We have seen the need to build an industry/research collaboration program to work out the means to build sustainable wellness routines for young elderly that would be progressive and innovative enough to get their interest, be adaptive and use-ful enough for their individual needs to get adopted as part of daily routines, and be flexible and meaningful enough for the users and their changing context so that wellness routines would become sustained and con-tribute over time to better health and quality years for the ageing population. The program, which has been worked out in both a national and a H2020 version, is called Digital Wells and has the ambition to help form and support interventions in the daily routines of young elderly so that the interventions form wellness routines. In turn, these routines will help to preserve physical, cognitive, mental and social wellness for the young elderly and help to build the basis for healthier elderly years. To make the interventions usable, practical and sustainable a virtual coach -VAIDYAhas been designed to ease and support the adoption of digital well-ness services among the young elderly and to pave the way for some quickest possible go-to-market initiatives is a Sanskrit word meaning "physician"; Pranabhisar Vaidya -the ones who protect lives by curing diseases and exhibits complete knowledge theoretically as well as practi-cally ). --- Introduction The society needs to have a strategy and priorities for the young elderly which areand need to bedifferent from the strategy and priorities for the senior age group. A majority of the young elderly are healthy, active and socially in-teractive and do not require much intervention or support from the health and social care systems of the society. The logic behind working out digital wellness services for the young elderly is that improved health in this age group will significantly raise the probability for continued improved health in the senior age group, for which ill-health among large numbers of citizens turns out to be very expensive . We use wellness as the target concept as wellness will tackle different aspects of functional impairment. The WHO defines wellness as "the complete mental, physical as well as social well-being of a person or groups of persons in achieving the best satisfying or fulfilling life and not merely the absence of disease or any form of infirmity . There has been lively debate over the years about the dimensions of wellness; UCR [12] has compiled the following seven dimensions :  Social Wellness is the ability to relate to and connect with other people in our world. ---  Emotional Wellness is the ability to understand ourselves and cope with the challenges life can bring.  Spiritual Wellness is the ability to establish peace and harmony in our lives. ---  Environmental Wellness is the ability to recognize our own responsibility for the quality of the air, the water and the land that surrounds us. ---  Occupational Wellness is the ability to get personal fulfilment from our jobs or our chosen career fields while still maintaining balance in our lives. ---  Intellectual Wellness is the ability to open our minds to new ideas and experiences that can be applied to personal decisions, group interaction and community betterment.  Physical Wellness is the ability to maintain a healthy quality of life that allows us to get through our daily activities without undue fatigue or physical stress. Adams and Els & de la Rey show the need for holistic wellness models and have tested this approach with a large empirical study. Here we will avoid any conceptual debate and use the following definition: wellnessto be in sufficiently good shape of mind and body to be successful with all requirements of everyday routines. The choice of wellness instead of health has the benefit that we are not dependent on access to health data that is strictly regulated in most EU countries with confidentiality and privacy limitations. In this paper we will operate with wellness in two dimensions -intellectual wellness and physical wellness. There are of course challenges for introducing digital wellness services; the first challenge is that common wisdom has it that young elderly do not have smartphones. Statistics now show that smartphones are becoming affordable general purpose instruments and will be even more so by the year 2020 . Recent statistics shows that the number of smartphones in Finland was 6.029 million in 2016 ; on an average Finnish consumers had 20 apps installed on their smartphones, of which 4 were paid . A second challenge is the doubt that digital wellness services will be at all attractive to the young elderly; this follows on a belief we have found in the market for mobile value services that elderly people will not learn how to use services on mobile phones, there is no real use for mobile services in their daily routines, advanced technology should be developed for young peopleand if elderly people use the services it will create the wrong brand image for the service developers. We have now been run-ning a research and development pro-gram for digital wellness services 2014-17 with support from two associations for elderly with more than 100 000 members; our findings show that the mobile service market beliefs are misconceptions. A third challenge is to work out empirically verifiable results on the intervention with digital wellness services, valid, theory-based results on how the design of digital wellness services will match the multiple wellness criteria, and empirical verification on how digital wellness services will help reduce functional impairment. There are several research methodologies avail-able to meet this challenge; here we will summarize the three methodologies we are using. Action research has been one of the key directions of service design and work with information systems for a couple of decades and would in our present case tackle problems with the development and implementation of digital artefacts. The development work is often described as co-creative -"to find solutions that work and to not care too much about scientific precision". Design science is another possibility; this is fundamentally a problem solving para-digm with roots in engineering and science and is working out designs in order to find ways to tackle real-world problems. Design science research is described as a paradigm in which a designer answers questions relevant to human problems via the creation of innovation artefacts that will contribute new knowledge . The designs build on an under-standing of what is needed to deal TRANSFORMING OUR LIVES C. Carlsson & P. Walden: Digital Coaching to Build Sustainable Wellness Routines for Young Elderly 61 with the problems; the design is both a process and a product and both can be validated and verified to be logically consistent and technically free of errors. Action design research found that design science is too technologically oriented and is not paying enough attention to the organisational or user context of the artefacts. The ADR works with digital artefacts that are ensem-bles shaped by the user context both when designed and developed and when used. The ADR deals with the dynamics and the complexity of the contextin our case the interventions to create wellness routines -that are problems for engineering-inspired methods; we use the ADR in our research program. The fourth challenge is the realisation that we cannot just create digital services and everything will then take care of itself. This shows that we need to support the building of an infrastructure for design, development, implemen-tation, commercialisation and maintenance; the approach that we propose is to build an ecosystem of service and infrastructure developers and providers and to support them with theory and methodology for agile business SCRUM processes . The paper has been structured in the following way: in section 1 we gave the back-ground and in section 2 the key definitions and a summary of the methodology; in section 3 we summarize results from a study of the acceptance and use of mobile apps and attitudes to wellness among young elderly on the Åland islands; in section 4 we introduce the principles of digital coaching and synergistic hybrid wellness solu-tions; section 5, finally, gives a summary and some conclusions as a basis for the continued work on wellness services. --- Young Elderly on Mobile Apps and Wellness We will start by addressing two of the challenges we identified . In a recent project we cooperated with the associ-ation for elderly in the city of Mariehamn and asked them to invite their young elderly to participate in a survey in the fall 2015; we collected 101 usable answers . The proportion male/female is 44.6/54.5%; 83.1% of the respondents belong to the young elderlly, and a further 14.9% are a bit older; 65.3% are married and 14.9% are widowed; 77.2% have a university or technical/commercial degree , 20.8% have a basic education. In the sample 75.2% are retired and 23.8% are working full-or part-time or are carrying out voluntary work; the most typical annual incomes before tax is < 30 k€ , 30-40 k€ , 40-50 k€ and >50 k€ . These profiles are typical for the Åland Islands and are representative for their group of young el-derly; here we will use these profiles as a snapshot of the young elderlywe will add to the profiles in the following to get a fuller description of the potential users of digital wellness services. As we plan to run the digital wellness services over smartphones we need to find out how frequent they are in the sample; we asked about the phones in use and found out that a majority use smartphones; this was con-firmed by the result that 72.9% of the respondents use mobile apps for navigation, weather forecasting, Internet search, etc. . We added to the profiles of the young elderly by asking how useful, easy to use and valuable mobile apps are for them following Davis and Venkatesh et al. structure of questions. For the about 70 respondents that use mobile apps we found that the adoption of mobile apps scored high on a 5-grade Likert scale on several items:  mobile apps are useful in my daily life [4.32];  I will continue to use mobile apps [4.19];  mobile apps help me to carry out my tasks faster [4. The results give us some insight to build on: the young elderly use of smartphones is sufficient to launch digital wellness services; the young elderly are confident users of mobile apps, which is a prerequisite for getting the wellness ser-vices adopted. This settles the first challenge and as mobile apps are digital services we can also claim that the second challenge is settled for the sample in the Åland Islands. The research contin-ues, but so far we can stick to the proposal that digital wellness services could be developed and offered on smartphones for the young elderly. Then we moved on to get an understanding of what perceptions the young elderly have of two wellness dimensions, physical and intellectual wellness. A number of proposals scored high on a 6-grade forced scale :  intellectual challenges are important for my wellbeing [4.91];  I get sufficient intellectual stimulation from my everyday life [4.61];  my physical health has been good compared to people around me [4.38];  my resistance to illness is good [4.24]; 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES C. Carlsson & P. Walden: Digital Coaching to Build Sustainable Wellness Routines for Young Elderly 63  the amount of information I have to process in my daily life is suitable for me [4.20];  I expect my physical health to remain good [4.14];  I expect my physical health to deteriorate with increasing age [3.94]. The results we got show that the young elderly have clear perceptions of the two wellness dimensions; thus it makes sense to develop digital wellness services. In a next step we intend to cover also the emotional and social wellness dimensions. Then we need to find out if there are any characteristics that could single out the most promising potential users as we want to get good, strong initial adoption of the wellness services. Our idea was that relations between socio-economic charac-teristics, attitudes toward the use of mobile applications and perceptions about wellness would help us to identify promising potential users; details can be found in Carlsson & Walden and Carlsson & Carlsson . We first run a factor analysis with 19 statements on mobile applications and 11 statements on wellness. The results gave an indication for possible sum variables which were tested for reliability by calculating Cronbach's alpha coeffi-cients; the target value was met for the constructed sum variables . A non-parametric Mann-Whitney U-test was run in order to explore possible differ-ences be-tween gender, age , highest level of education , marital status , current work status ; retired), annual in-come and the level of experience of using mobile applications . We found that there were significant differences in the positive attitudes to using mobile apps between the two age groups ; the younger age group was more positive . The more educated group was experi-enced in using mobile apps . The more educated group was socially active in using mobile apps . The group with higher income gave more value to mobile apps . Males with higher income had a positive perception of physical well-ness . The group with a more active work status had a posi-tive perception of their intellectual wellness . We need of course to take some care with making conclusions from the collected data; the sample of 101 respondents was not fully randomly selected and the survey was not fully reliable as we had no possibility to check the circumstances under which the questions were answered. Nevertheless, the results are interesting as the young elderly have not been much studied in this way before. The insight we gained from the Åland island material relative to our overall vision, to get young elderly interested in digital wellness services, to get them to adopt them and to make the services part of their daily routines, we should start with young elderly, who are,  --- Digital Coaching through Digital Fusion In early work with the young elderly we found that the interest in using digital well-ness services on smartphones started to decrease after 2-3 months of continued use; when the services were combined with activity bracelets the period of active use doubled to about 4-6 months. These are early indicators and have something to do with the fact that there is a one-time cost for the activity bracelets . This follows the pattern, that if you have paid for a bracelet you keep up the wellness routines in order to get value for the money you have spent. In an Insight report it was found that 95% of applications on smartphones are abandoned within 1 month of download; Gartner found that the abandonment rate of smartwatches is 29%, and 30% for fitness trackers in a study with more than 9500 participants in Australia, U.K. and the U.S. This creates a dilemma for building wellness routines. In order to get health effects among the young elderly the wellness routines need to be sustained for at least 3-5 years, the ideal would be to keep them up for 15-20 years, i.e. well into senior years; there is a need to build variety and advanced, intelligent functionality into the digital wellness services. A way to deal with this dilemma is coaching, i.e. to make variety and innovative, advanced functionality part of the digital wellness services, which will keep the ser-vices interesting. The material we worked out in section 2 already gave us some insight about the young elderly and this should be a starting point for giving the us-ers individual advice and guidance on how to improve their wellness routines as a function of how advanced they are and what their goals and objectives are. Personal trainers/coaches have been proposed but will be too expensive. We have worked out the functional requirements of the digital coach called VADIYA: ---  The coach builds on digital fusion: fusion of heterogeneous data sets individual data, group/cluster data, big user group data) from 100+ applications and devices; algorithms to build information from data sets; fusion of sets of information with computational intelligence methods; ontology to build knowledge from sets of information; approximate rea-soning and soft computing for knowledge fusion  Coaching is built with data, information and knowledge of different granularities context dependent, individual wellness, goals, "good practice"  Coaching is adaptive to national language, cultural habits, changes in legislation  VAIDYA coaching is continuous and is built to change dynamically; should be maintained, supported, enhanced, changed, developed  VAIDYA is unobtrusive technology: virtual coach on smart phone + omnivore platform that will have 100+ interface solutions for sensor data + data from wearables + new innovations TRANSFORMING OUR LIVES C. Carlsson & P. Walden: Digital Coaching to Build Sustainable Wellness Routines for Young Elderly 67  VAIDYA builds on ideal wellness profiles that are worked out; for individuals, for groups/clusters of similar service users, for countries with similar cultures and traditions, etc.; deviations from the ideal profiles worked out with MCDM methods to offer recommendations of how to make optimal steps towards the ideal profiles A digital personal coach was proposed by Schmidt et al. to help fitness tracker users to personalize their training. The coaching builds on partially observa-ble Markov processes and Markov decision processes that use data from the fitness trackers; when reported the coach was in first prototype development. The imple-mentation and use of Markov processes may offer some challenges. The digital fusion is needed as data will be multi-dimensional in each one of the four different wellness aspects. Some of the data can be collected with sensors other parts will need a gamification interface and support . Part of the data needs to be in real time; part of it can be daily and weekly summaries. We will need digital fusion to operate with heterogeneous data from different contexts and for different forms of wellness. All of it should be presented in an understandable and tailorable form for young elderly users, which is known as knowledge fusion. The fusion methods and technology will add value to the digital wellness services:  data fusion offers summary statistics from apps and devices, goal attainment over days, weeks, months  information fusion produces trends, deviations from trends, targets and tar-get revisions; shows levels usually reached by similar service users  knowledge fusion compiles activities to combine, add, enhance information for advice & support; tailors enhanced activity programs An illustration of the differences between data, information and knowledge in the wellness con-text was collected from a Polar A360 activity bracelet and is shown in fig. 1. In work with young elderly groups discussion quite often focused on wellness as a sum of different activities and it was pointed out that "my best wellness is not achieved by maximizing my physical wellness, but by finding some smart combination of intellectual, physical and social wellness". Further study showed that wellness could be synergistic, i.e. that combinations of different forms of wellness could be "more than the sum of the individual wellness forms". Orienteering can produce synergistic wellness: it offers cognitive and in-tellectual challenges in finding the optimal paths through the forest; it is one of the physically most demanding sports; the "family of orienteers" is closely knit -also internationallyand promotes social wellness. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES C. Carlsson & P. Walden: Digital Coaching to Build Sustainable Wellness Routines for Young Elderly Similar versions of synergistic wellness activities can be found among the young el-derly con-certs offer intellectual, emotional and social wellness; volunteer help and support of senior citizens offer physical, emotional and social wellness; singing in choirs offer emotional and social wellness, and so on. The digital coach VADIYA should provide advice and support for synergistic wellness activities -and for hybrids of wellness activities that work out innovative and some-times unique combinations that would offer new challenges for the young elderly users. There is of course the question of time for various activities and support for trade-off between wellness activities, i.e. how to get the best wellness value for time allocated to various activities . Figure 1: Data, information and knowledge fusion --- Summary and Conclusions We noted that the proportion and socioeconomic relevance of ageing citizens is high in most EU countries but that the young elderly has been ignored by the politicians worrying about the ageing population as they are "too active, and in too good shape" to request any budget-funded support from the society. Thus there are two cases of missed opportunities: there is a potential market for digital services that represents 18-23% of the population in most EU coun-tries; the young elderly are estimated to be 97 million by 2020 in the EU countries ; interventions that create sus-tainable wellness routines among the young elderly will reduce the probability for serious illness among the senior citizens. We use wellness as the target conceptto be in sufficiently good shape of mind and body to be successful with all requirements of everyday routines. In the study in the Åland islands we could identify some first groups of supportive users of digital wellness services; the first group is young elderly who are active in full time/part time/volunteer work and are experienced users of mobile apps and are < 70 years; the second group is young elderly who are experienced users of mobile apps and are more educated; the third group is young elderly who are males with good physical health and an income > 30 k€ per year; the fourth group is young elderly who are more educated and find mobile apps good value for the price. Work with young elderly groups pointed to a dilemma: interest for mobile and digital services tends to diminish rather quickly but well-ness routines need to be sustained for at least 3-5 years to give positive health effects. We proposed to introduce digital coaching as part of the digital wellness services to make the use of them sustained. There is no doubt that much work remains to get wellness routines built and adopted by the young elderly. --- Introduction During the last few years there have been many changes for organisations on a global level. Nowadays, through globalisation and the internet, markets change quicker and organisations have a limited amount of time to adopt new trends or change their business models. Therefore, the European Commission states that innovation is critical in order to improve existing products, services and processes or develop new ones that add value to an organization and increase Europe's competitiveness on a global economic level. However, besides innovation, organizations are also focusing more and more on the efficiency and effectivity of their processes and therefore business process management is getting more attention . BPM plays a vital role in addressing the priorities of current Chief Information Officers because BPM is a key instrument in managing and improving organizational processes with information systems . Scientific studies that find that BPM maturity models support organizational performance are not new . However recent research shows that BPM could also be an enabler to the innovation level of an organization . What is not described in these studies is whether there is a difference in how BPM and innovation are related between different industries. A relatively young industry such as IT might be expected to be a lot more innovative compared to more traditional industries such as manufacturing. Therefore, the objective of this study is to determine if such a difference exists. The research question for this study is as follows: What are the differences in the relation between BPM and innovation in a comparison between the IT industry and the manufacturing industry? This comparison is made in order to create a broader understanding as to whether and, if so, why the software industry is more innovative when compared to more traditional industries. To be able to analyse this research question a quantitative study is performed based on data collected in three IT companies and two manufacturing companies . The remainder of this paper is organized as follows, the next section will discuss the literature on the main constructs in our study, followed by the research method in section 3. Section 4 continues with the results and the paper concludes with the main findings in section 5. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES T. Cats & P. Ravesteyn: The Relation Between Process Management and Innovation -A comparison of the IT and Manufacturing Industries 73 --- Literature The theoretical framework of this study consists of three main constructs: Business Process Management Maturity , innovation value chain and innovation adoption . In this section each of these constructs is discussed in more detail. For the literature study Google Scholar and the databases of Science Direct, Springer, and Wiley Online Library are used in combination with the following keywords: 'BPMM and innovation', 'Business process management and innovation', 'innovation value chain', 'innovation adoption', 'innovation', 'process management and innovation'. The papers that were found were accordingly analysed to determine the relevancy, the findings are discussed below. --- Business process management maturity Business Process Management is a management methodology that exists at different organizational levels on which processes are assessed stepwise with the goal to improve the capabilities of the organisation . The maturity of BPM is studied by Rosemann & de Bruin , who created one of the first widely accepted BPMM models. This model is multi-dimensional since it analyses different factors, stages and contexts . This is in line with Vom Brocke et al. whom argue that most models in BPM have a "one-size-fits-all approach", which causes problems that will not account for the situational contexts necessary to gain benefits. Furthermore, Vom Brocke et al. state that business process management supports an organization in their innovativeness. Rosemann & de Bruin based the factors of their model on BPM critical success factors, which consist of independent and dependent variables. The assumption is that the higher the score on these variables, the higher the level of success in BPMM. Moreover, they state that an individual organisation should translate process success into the most important BPM-independent success measures. Furthermore, Rosemann & de Bruin find that there is not a standardized toolkit for every organisation to put BPMM into practice. Fisher states that a one-dimensional five-stage model for BPMM is not enough. Fisher's model exists of two parts, the first part is referred to as the "Five Levers of Change", which are used to assess the capabilities of an organisation. The second dimension also exists of five factors, representing the five maturity stages of BPMM. This dimension is used to measure the performance of the "Five Levers of Change". Fisher measures BPMM by using two different measure points. In contrast, the model of Rosemann & de Bruin measures BPMM on three levels . Evidence is yet to be provided to see whether a multi-factor model is superior when compared to a two-factor model. Finally, Fisher concludes that the advantages of using BPMM models for companies is that they will improve the efficiency 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES T. Cats & P. Ravesteyn: The Relation Between Process Management and Innovation -A comparison of the IT and Manufacturing Industries and lower their costs which, in turn, could result in higher profits. All these advantages combined provide companies a competitive advantage. Another BPPM model is constructed by Ravesteyn et al. whom used the Capability Maturity Model Integrated as a foundation to establish seven maturity dimensions. The CMMI model has also been used by Rosemann and colleagues in their research . As the BPMM model by Ravesteyn et al. is extensively used to research the relation to process performance this model is applied in the conceptual model of this study, here performance is substituted with innovation. In order to measure the level of BPM maturity within an organization Ravesteyn et al. used 37 items divided over the seven dimensions. To measure the maturity level of the 37 BPM capabilities a Likert scale from 1 -5 is used. --- Innovation value chain Hansen & Birkinshaw developed the innovation value chain framework. Their approach requires executives to have an end-to-end view of the innovations in their companies. Their framework will also force executives to focus on the weakest links in the innovation process of the company. The first phase is to "Generate ideas", come up with new products or services, either from within the company or outside the company; "Convert ideas" is the second phase. At this stage the company has selected the ideas, collected the funds and started the development of the product. The third and final phase is to "diffuse" the developed product or service, this means that the developed product or service concept is used in the organisation or launched in the market. Hansen & Birkinshaw state that when a manager wishes to use these three phases of the innovation value chain the manager has to focus on six critical tasks: "Internal sourcing, Cross-unit sourcing, External sourcing, Selection, Development and Company wide spread of the idea" . Ganotakis & Love's state that the company's resources have a significant influence on the innovation process and on the growth of the company. Ganotakis & Love's , find three main implications in their research: first, the innovation value chain makes it possible to identify the factors that enable a company's level for growth and productivity when compared to new technological based firms. Secondly, companies which develop and market disruptive innovations show fast growth leading to better productivity and performance. The third and last implication is that the innovation value chain makes it possible to identify the innovation behaviour, focusing on the important role of R&D which influences the success of innovation. Based on the studies by Hansen & Birkinshaw and Ganotakis & Love it can be concluded that the innovation value chain is a method that explains the process of innovation from generating ideas to converting ideas and subsequently its diffusion, which leads to new business opportunities in order to generate new revenues. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES T. Cats & P. Ravesteyn: The Relation Between Process Management and Innovation -A comparison of the IT and Manufacturing Industries 75 Furthermore, this approach also helps to draw the attention to an organisation's strengths and weaknesses in the innovation process. --- Innovation adoption Damanpour & Wischnevsky distinguish innovation-generation from innovation-adopting. When organisations use innovation adoption the purpose is to change the organisation in such a way that it becomes more effective and develops a more competitive mind set, in order to adapt more easily to new trends in the market. In In an earlier study on the adoption of internet banking, Tan & Teo concluded that subjective norms lack a significant relationship with intentions. Perceived behavioural control and attitudinal factors can be used to predict the intentions . They describe three factors which influence someone's or an organization's intention to adopt a new product or service. This is similar to the study by Al-Jabri & Sohail's in which it is concluded that the six factors together provide a solid measurement tool for innovation adoption. --- Conceptual model Derived from the theory and concepts described in the literature study above, the conceptual model for this research consists of three main constructs: BPM maturity, innovation value chain and innovation adoption . For BPM maturity, the framework has the seven dimensions with corresponding BPM capabilities from Ravesteyn et al. . The capabilities are used as input in order to develop survey questions to measure each dimension. The innovation construct in the conceptual model is split up into the two constructs innovation value chain and innovation adoption. The innovation value chain is very focused on the analysis of how innovations come up, whereas innovation adoption focuses on acceptance of the innovation by the final user or adoption of new innovations by the organization. This co-dependency results in the assumption that both theories strengthen each other. Finally, based on this reasoning, the hypothesis is that there is a positive relation between the BPM maturity and Innovation. --- Research Method --- Data collection For this study data is used that has been collected as part of a larger research project on BPM and Innovation. For this an online survey tool was used as this makes it very convenient for the respondents to answer the questions in their own time. The data is collected across cultures and in different countries at seven companies. Three out of seven were located in The Netherlands and the other companies were located in Austria, Belgium, China and Ireland. Most of the companies are active in the software industry whereas the other companies are active in manufacturing or the finance sector. The data was collected by a team of six researchers. To ensure the data was collected in the same manner a coding manual was developed to ensure all collected data had the same definitions. In total 200 completed surveys have been collected. In all organisations --- The questionnaire The survey was constructed by using the structure of the conceptual model. As explained above, the conceptual model shows how many items are used for every dimension of BPMM and for the two innovation constructs. The survey contained 50 questions on the main concepts, 37 questions were divided over the seven dimensions to measure the level of BPM maturity and 13 questions addressed the innovation part. For each statement a Likert scale from 1 to 5 was used to indicate whether the participants strongly disagreed, strongly agreed or stayed neutral. In addition to that, there were also some general questions concerning how knowledgeable the participants were regarding BPM, how the respondents would define BPM, and what position they had within their organisation. --- Validity of the research instrument To analyse the validity of the constructs, a Varimax method was used within the factor analysis, which was developed by Kaiser . A rotation factor analysis is the most commonly used method in this type of analysis . The results, of the factor analysis showed that only six components were recognised for BPMM despite the fact that the BPMM construct consists of seven dimensions in the conceptual model. The variable innovation showed three components and there were only two in the conceptual model . Based on this analysis it could be argued that the conceptual model could benefit from adjustments, since not all components were recognised. Therefore, a second analysis was performed: the Cronbach alpha was used to determine the reliability of separate components . Tavakol & Dennick suggest in their article that a Cronbach alpha should be in the range of 0.70 to 0.95 . However, the recommended maximum value is 0.90 . Furthermore, a low indication could be influenced by the number of questions asked for one item or poor interrelatedness between the items . The results in Table 1 showed that all dimensions have a value above the minimum of 0.70 and did not exceed the score of 0.90, which indicated that the results of the collected data were statically reliable. --- Analysis As Cohen states that a T-test is widely used to compare means and that it also shows whether the difference between two elements is significant or not, a T-test is conducted to compare the survey results of two sets of companies . This is done by adding three variables in SPSS: company name, industry branch and bucket. This last variable is used to define the groups. Three companies are labelled IT and two were labelled OLD . --- Analysis Results --- Level of knowledge on BPM First the respondents were asked to assess their knowledge of BPM. For this they could choose between four different levels. Out of 200 respondents 35% had little to no knowledge and practical experience with BPM, 27% had some knowledge of BPM, but no practical experience, whereas 29% had some knowledge and limited practical experience with BPM . Only 10% of all the respondents had both knowledge and practical experience with BPM . The percentages out of 200 respondents show that a small group of respondents was very experienced and is considered to have a high level of knowledge on BPM. Furthermore, the category OLD shows a higher percentage in this level in comparison to IT. It must be noted that the majority of respondents either had no knowledge of BPM or a limited amount of knowledge and practical experience with BPM, this might have influenced the results. --- A comparison of IT and Manufacturing Table 2 shows the mean scores for the BPM maturity dimensions between IT and OLD. The smallest difference between both groups is for measurement of process, meaning that both groups use performance indicators that assess and check processes and use this to improve processes . Additionally, BPM maturity dimensions' process awareness, process description and management of processes show that IT has a higher maturity level in comparison to the companies in the OLD catagory. From these results, it can be concluded that group IT is more aware of the impact that processes, process descriptions and process owners have within their organisation and they incorporate this in their strategy . The results also show that group OLD has a higher level of maturity in dimensions' process improvements and process resources and knowledge. This means that group OLD organizations try to improve their processes more often and also have a support system for process improvements in place. Group OLD also has more resources and employees with process knowledge. Finally, the information technology dimension shows a large difference between the two groups. This indicates that IT companies make more use of information technology to design and carry out processes to produce real-time measurement information in comparison to the manufacturing companies. In comparison to the findings described above, the results of the T-test analysis only show a significant difference on information technology with 95% confidence interval of the difference. --- .05224 Table 4, shows all means of the innovation dimensions. The results of the phases of the innovation value chain construct show that there is a small difference in regards to idea generation for both groups: both groups tend to agree that their employees are good at creating ideas on their own, but also across the organization. Furthermore, the results show that group IT has a higher mean on idea conversion whereas group OLD has a higher mean on idea diffusion. From these results, it might be concluded that group IT tends to be better in selecting, screening, and funding ideas as well as turn ideas into a minimum viable product, whereas group OLD tends to be better in getting new ideas out of the organisation. The results of Table 4 also show that group IT has a higher mean on attitude to innovation and perceived behavioural control in comparison to group OLD. This shows that group IT agrees that the latest innovations benefit their organization and believe that it does not present any risk to their organization. In addition, group IT also scores higher on perceived behavioural control, which indicates that software organizations tend to use the latest innovations, but also agree to have time, money and resources to keep using these latest innovations. Furthermore, based on the subsequent T-test , only the difference on attitude to innovation and perceived behavioural control show significance between the two categories . Moreover, the smallest difference between both groups is created by subjective norms, within the innovation adoption construct, which means that both groups use the latest innovation to stay competitive in the market. On top of this, customers also expect both groups to use the latest innovations. As a result of the analysis described above it is possible to conclude that group IT only differs on two dimensions of the conceptual model when compared to other companies. This indicates that, based on this analysis, IT companies tend to be more innovative than manufacturing companies. For traditional organisations this is confirmed by Rosemann and vom Brocke et al. , who both suggest that BPM does not support the innovation process because it only provides methods and techniques, which support the development of a structure to analyse an organisation. --- Conclusion --- Main findings In this research the objective was to answer the question: What are the differences in the relation between BPM and innovation in a comparison between the IT industry and the manufacturing industry? Based on our analysis of the differences between IT industry and manufacturing we find that these industries are very similar when it comes to the relation between BPM and Innovation. They only differ significantly on the BPM dimension information technology and the innovation adoption dimensions' attitude to innovation and perceived behavioural control. As Tan & Teo concluded in their study on mobile banking adoption that perceived behavioural control and attitudinal factors are the key elements that can be used to predict the intention to adopt a new technology, it might be concluded that the IT industry is a step ahead of the manufacturing industry in terms of using information technology and are also able to adapted more quickly to new innovations that are beneficial to their organization, this is something which is to be expected given the nature of IT companies. --- Implications The IT industry and manufacturing industry are surprisingly similar. However, based on this study we find that the manufacturing industry should put more effort towards adopting new technologies in order to be more innovative. For example, organizations can invest more in the latest technologies that could produce real-time measurement information in support of the daily business operations. Besides, investing in new technologies it is also essential to invest in the knowledge of people in order to get the optimal performance out of the latest technologies. --- Limitations A limitation of this study is that data is collected across different industries but also from different countries within Europe and China. Thus, cultural differences could have influenced the answers as Lee et al. showed that different cultures have different perceptions, therefore our scale for answering the statements could be interpreted differently. Additionally, in this study a Likert scale is used to measure all the dimensions of BPM and innovation based on the most well-known scale from 1 to 5 , however, literature suggests that a five-point Likert scale is a minimum but it is better to have a broader scale . Hinkin researched scale developments and within his review a majority of the researched studies used a five-point scale. Although, the second biggest group used a seven-point scale. According to these results the cultural influence on the Likert scale and the scale-size are arguable and therefore seen as a limitation in this study. Furthermore, in this study a T-test is conducted to investigated the significant differences based on the means between two constructs. As there are also other techniques available to analyze the data, this is also considered as a limitation. --- Recommendations for future research This study has gone some way towards enhancing the understanding of the relationship between BPM and innovation. The conceptual model still needs some refinement because the factor analysis only recognised six out seven BPM dimensions and for innovation three instead of two dimensions. Moreover, more research is required to improve the understanding of the relationship between BPM and innovation within and between different organizations and sectors as well as across cultures. --- Introduction This paper reports on experience gained during a research project. The project involved the use of a new body of theory to critique the papers in a Special Issue of a leading eCommerce journal. The resulting paper was submitted to the same journal, and rejected. The grounds were a combination of claimed lack of robustness of the research method and dismay about the fact that the Special Issue papers had been subjected to criticism. I found both of these grounds bewildering. The research method had been carefully prepared, had been previously applied and the results published, and it was, I considered, suitably documented. Moreover, the suggestion that papers should not be subjected to criticism sounded to me like the antithesis of the scientific method to which the journal and the management disciplines generally claim to aspire. I accordingly set out on a deeper study of meta-questions that were affecting the project. What guidance is available in relation to secondary research whose raw data is published academic papers? What particular approaches need to be adopted when the theory-lens through which the observation is being performed arises from critical theory research? What guidance exists for expressing the outcomes of research of this nature? This paper's objective was accordingly to enhance the publishability of the underlying research, by grounding the content analysis technique more firmly in the research methods literature, demonstrating the appropriateness of constructive criticism of published works, and improving the expression of the results. The paper is structured as follows. Brief explanations are provided of the underlying theory, the Special Issue to which it was applied, the research method adopted, and key aspects of the review process. A series of investigations is then outlined, involving searches of relevant methods literatures. This encompasses several variants of literature reviews and content analysis. The nature of criticism is discussed, and critical theory research reviewed. It is concluded that two particular techniques provide the most useful guidance on how to approach a project of this nature. The paper concludes by showing how the insights arising from the journey have enabled enhancements of the research method, and of the manner in which the method and the findings are communicated to the reader. --- Researcher Perspective The underlying research project adopted the particular theoretical lens of 'researcher perspective'. This was defined in Clarke as: the viewpoint from which phenomena are observed The papers postulated that: In each research project, at least one 'researcher perspective' is adopted, whether expressly or implicitly, and whether consciously or unconsciously. The researcher perspective influences the conception of the research and the formulation of the research questions, and hence the research design, the analysis and the results. Each particular perspective is specific, not universal. Because the interpretation of phenomena depends on the perspective adopted, the adoption of any single researcher perspective creates a considerable risk of drawing inappropriate conclusions. IS researchers generally adopt the perspective of a participant in an information system commonly the organisation that runs it, or an organisation that is connected to it, but sometimes the individuals who use it. Occasionally, researchers may adopt the perspective of an external stakeholder or 'usee', by which is meant a party who is affected by the IS but is not a participant in it. Studies of several samples of refereed publications in the IS literature have shown that a very large proportion of research adopts solely one particular perspectivethat of 'the system sponsor'. By that term is meant the organisation that develops, implements or adapts a system, process or intervention, or for whose benefit the initiative is undertaken. The theory advanced in Clarke ) argues firstly that the single-mindedness of IS researchers is frequently harmful to the interests of other stakeholders, but secondly that the interests of system sponsors are also badly-served by such single-perspective research. Higher-quality research will be achieved through greater diversity in singleperspective research, by dual-perspective research, and by multi-perspective research. --- The Critique of the Special Issue The above theory relating to researcher perspective was applied to a Special Issue of the journal Electronic Markets, on 'Personal Data Markets', which was published in Volume 25, Issue 2 . A market is a context in which buyers and sellers discover one another and transact business, and inherently involves at least two participants, but usually considerably more participants and other stakeholders. The digital surveillance economy that has emerged since c. 2000 is a complex web of markets. Moreover, it involves vastly more capture of consumer data than has ever previously been the case, expropriation of that data for a wide variety of purposes by a wide variety of corporations, and its application to 90 30 In order to investigate the researcher perspectives adopted in the papers in the Special Issue, a research method was applied that had been developed and refined in several previous studies, some of them reported in Clarke ). The process specification used is in Annex 1. One important aspect is the extraction of the Research Question . In some papers this is explicit, and in others implied, but in some it needs to be inferred. The most vital part of the study is the identification and interpretation of passages of text that disclose the perspective adopted by the researcher. Again, this may be explicit, but it is more commonly implicit, and in many cases it has to be inferred. In order to enable audit, the process includes the recording of the key passages that led to the interpretations made, and publication as Supplementary Materials of the process specification, key passages, codings and interpretations for each paper. The paper was submitted to Electronic Markets in February 2016, went through two rounds of reviews, and was rejected in January 2017. The primary grounds were "[the research article format is not] appropriate, legitimate, or even warranted", "[inadequate] description of the research method used" and "overstated criticism". Each of these was a major surprise, given that copious information was provided about the research method, and critiquing of the existing state of theory is fundamental to any discipline that claims to be scientific. It was plainly necessary for me to assume hostility on the part of reviewers, step back, and gather the information needed to convey to reviewers the appropriateness of the research method and of criticising prior published works. This led to works on content analysis in its many forms, and on the role of criticism in the IS discipline. --- Related Content Analysis Techniques A significant proportion of research involves the appraisal of content previously uttered by other people. This section briefly reviews categories of research technique whose focus is adjacent to the topic addressed in this paper. --- Qualitative Research Techniques Qualitative research techniques such as ethnography, grounded theory and phenomenology involve the disciplined examination of content, but content of a kind materially different to refereed papers. The text may be generated in natural settings , in contrived settings , or in a mix of the two The issues arising with analysis of these kinds of content are very different from those associated with the analysis of carefully-considered, formalised content in refereed articles. --- Informal Literature Reviews A context that is more closely related to the present purpose is the examination of substantial bodies of published research. "Generally three broad categories of literature reviews can be distinguished. Firstly, literature reviews are an integrative part of any research thesis ... Secondly, literature reviews can be an important type of publication in their own right ... However, the most common form of literature review appears as a part of research publications. ... As part of research articles, literature reviews synthesize earlier relevant publications in order to establish the foundation of the contribution made by an article" . A succinct, although rather negative, description of the approach that was common until c. 2000 is as follows: "Traditional literature reviews ... commonly focus on the range and diversity of primary research using a selective, opportunistic and discursive approach to identifying and interpreting relevant literature . In traditional 'narrative' reviews, there is often no clear audit trail from primary research to the conclusions of the review, and important research may be missing, resulting in biased and misleading findings, and leading to puzzling discrepancies between the findings of different reviews" . --- Systematic Literature Reviews In 2002, the Guest Editors of an MISQ Special Issue expressly set out to drive improvements in literature review techniques in IS. Their declared aim was "to encourage more conceptual structuring of reviews in IS" Webster & Watson . The Editorial is highly-cited and appears to have had considerable impact on literature reviews published in the IS field. The conduct and presentation of literature reviews has subsequently been influenced by the 'evidence-based' movement in the health care sector. This adopts a structured approach to the task: "Systematic reviews ... synthesise the findings of many different 92 30 It was subsequently argued within the IS literature that a "rigorous, standardized methodology for conducting a systematic literature review" was still needed within IS , and the authors proposed the 8-step guide in Figure 1. --- Directly-Relevant Content Analysis Techniques The focus in this paper is on the appraisal of published research papers. In some cases, the body of work is large. For example, many researchers have studied all articles in large sub-sets of papers. The sampling frame is typically one or more journals, most commonly the 'Basket of 8' IS journals. In other cases, the body of work whose content is analysed is smaller, carefully-selected collections, perhaps as small as a single article, book or journal Issue. In order to understand approved practices in this field of research, I adopted a twopronged approach. Firstly, I searched out papers on the research technique. The findings are outlined in this section. In parallel, I identified relevant exemplars. Extracts from 10 such papers are in Annex 3. Citing Weber , Indulska et al. offer this definition: --- Content Analysis is the semantic analysis of a body of text, to uncover the presence of strong concepts A critical aspect of content analysis is that it seeks to classify the text, or specific aspects of the text, into a manageable number of categories. In Hsieh & Shannon , the following definition is adopted : --- Content Analysis is the interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns The authors indicate a 7-step process which they attribute to Kaid As with any research technique, all aspects need to be subject to quality controls. Krippendorff , Weber and Stemler emphasise steps 3-5 in relation to the coding scheme and its application. They highlight the importance of achieving reliability. Possible approaches include coding by individuals with strong experience in both the review of articles and the subject-matter, parallel coding by multiple individuals, review of individuals' coding by other parties, and publication of both the source materials and the detailed coding scheets, in order to enable audit by other parties. Content analysis techniques exhibit varying degrees of structure and rigour, from impressionistic to systematic, and they may involve qualitative and/or quantitative assessment elements. Quantitative data may be on any of several scales: nominal, ordinal, cardinal or ratio. Data collected on higher-level scales, especially on a ratio scale, is able to be subjected to more powerful inferencing techniques. Qualitative data, on the other hand, may be gathered on a nominal scale or on an ordinal scale . Quantification generally involves measurement, most fundamentally by countingwhich raises questions about the arbitrariness of boundaries, and about configuration and calibration of the measuring instrument. Some research methods involve sleight of hand, most commonly by making the largely unjustified assumption that 'Likert-scale' data is not merely ordinal, but is cardinal , and even ratio . Many authors implicitly equate quantification with rigour, and qualitative data with subjectivity. They accordingly deprecate qualitative analysis, or at least relegate it to pretheoretical research, which by implication should be less common than research driven by strong theories. The majority of authors spend only limited time considering the extent to which the assumptions and the processes underlying the act of quantification may be arbitrary or themselves 'subjective'. Positivism embodies an implicit assumption that computational analysis necessarily leads to deep truth. The assumption needs to be tested in each particular circumstance, yet such testing is seldom evident. A positivist approach to categorising content analysis "along a continuum of quantification" distinguishes "narrative reviews, descriptive reviews, vote counting, and meta-analysis" (King & King & He's categorisation is helpful, but it involves a switch from largely textual sourcematerials in the first three categories to wholly quantitative source-materials in the fourth. More usefully still, three approaches are distinguished by Hsieh & Shannon . These are examined in the following sub-sections. --- Conventional Content Analysis / Emergent Coding In this approach, "coding categories are derived directly from the text data". The approach is effective when used "to describe a phenomenon [particularly] when existing theory or research literature on a phenomenon is limited" . In such preliminary research, it is normal to allow "the categories and names for categories to flow from the data". Hsieh & Shannon suggests that only selected text is examined , and that the context may not be well-defined. The external validity of conclusions arising from this approach may therefore be limited. They conclude that the technique is more suited to concept development and model-building than to theory development. Depending on the degree of generality of the conclusions claimed by the author, full disclosure of the text selection, coding and inferencing procedures may be merely desirable or vital. --- Directed Content Analysis / A Priori Coding In this case, "analysis starts with a theory or relevant research findings ... to help focus the research question ... and as guidance for [establishing and defining] initial codes" . Segments of the text that are relevant to the research question are identified, and then coded. To the extent that the declared or inferred content of the text does not fit well to the predefined categories, there may be a need to consider possible revisions of the coding scheme , or even of the theory on which the research design was based. It may be feasible to draw inferences based on counts of the occurrences of categories and/or on the intensity of the statements in the text, such as the confidence inherent in the author's choice of language . As with any theory-driven research, the evidence extracted from the text may have a selffulfilling-prophecy quality about it, i.e. there is an inevitable tendency to find more evidence in support of a theory than in conflict with it, and contextual factors may be overlooked. In order to enable auditability, it is important that not only the analysis be published, but also the raw material and the coding scheme. --- Summative Content Analysis This "involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context" . The first step is to explore usage, by "identifying and quantifying certain words or content in text with the purpose of understanding the contextual use of the words or content" . Because of the complexity and variability of language use, and the ambiguity of a large proportion of words and phrases, a naive approach to counting words is problematic. At the very least, a starting-set of terms needs to be established and justified. A thesaurus of synonyms and perhaps antonyms and qualifiers is needed. Allowance must be made for both manifest or literal meanings, on the one hand, and latent, implied or interpreted meanings, on the other. Counts may be made not only of the occurrences of terms, but also of the mode of usage . The degree of analytical rigour that quantification can actually deliver depends a great deal on a number of factors. Critical among them are: • the text selection; • the express judgements and implicit assumptions underlying the choice of terms that are analysed; • the sophistication and comprehensiveness of the thesaurus applied; and • the significance imputed to each term. --- Quantitative Computational Content Analysis A decade later, it is useful to break out a fourth approach from Hsieh & Shannon's third category. This approach obviates manual coding by performing the coding programmatically. This enables much larger volumes of text to be analysed. The coding scheme may be defined manually, cf. directed content analysis / a priori coding. However, some techniques involve purely computational approaches to establishing the categories, cf. 'machine-intelligent' emergent coding. The processing depends, however, on prior data selection, data scrubbing and data-formatting. In addition, interpretation of the results involves at least some degree of human activity. In Indulska et al. , a distinction is made between: • conceptual analysis, in which "text material is examined for the presence, frequency and centrality of concepts, [which] can represent words, phrases, or more complex definitions"; and • relational analysis, which "tabulates not only the frequency of concepts in the body of text, but also the co-occurrence of concepts, thereby examining how Given that the 'big data analytics' movement is highly fashionable, vast volumes of data are available, and there is a comfort factor involved in office-based work much of which is automated, it would appear reasonable to anticipate that Quantitative Computational Content Analysis techniques will be a growth-area in the coming few yearsat least until their limitations are better appreciated Clarke . --- Content Analysis Within the IS Discipline Content analysis is accepted as a research technique within the IS discipline, but its use has been somewhat limited. For example, in a survey of the papers published in six leading IS journals during the 1990s, Mingers found that the use of content analysis as a research technique was evident in only four of the journals, and even in those four in only 1-3% of all papers published during that time. In February 2017, of the nearly 15,000 refereed papers indexed in the AIS electronic library, 13 had the term 'content analysis' in the title, and 69 in the Abstract. Annex 3 presents 10 instances which together provide an indication of the range of applications and approaches. A total of 770 papers of the 15,000 contained the termc. 5%. This is, however, subject to over-inclusiveness . It is also subject to under-inclusiveness . In recently-published papers, the most common forms of text that have been subjected to content analysis appear to be social media and other message content, with other categories including newspaper articles and corporations' 'letters to shareholders'. The literature relating to the above four categories of content analysis provides a considerable amount of information relevant to the current project. However, there is a dimension of the project that is not addressed by these techniques, and guidance needed to be sought elsewhere. --- The Role of Criticism in Research The previous sections have considered the analysis of content. The other area in which further insight was sought relates to the purpose for which the analysis is undertaken. In some cases, the purpose of undertaking content analysis may be simply exposition, that is to say the identification, extraction and summarisation of content, without any significant degree of evaluation. There are benefits in undertaking content analysis in a positive frame of mind, assuming that all that has to be done is to present existing information in brief and readily-accessible form . Alternatively, the researcher can bring a questioning and even sceptical attitude to the work. Is it reasonable to, for example, assume that all relevant published literature is of high quality? that the measurement instruments and research techniques have always been good, well-understood by researchers, and appropriately applied? that there have been no material changes in the relevant phenomena? that there have been no material changes in the intellectual contexts within which research is undertaken? Criticism is the analysis of the merits and faults of a work. The word can be applied to the process or the product . There are also common usages of the term 'criticism' in a pejorative sense, implying that the critic is finding fault, is being destructive rather than constructive, and is failing to propose improvements to sustain the merits and overcome the faults. The term 'critique' is sometimes substituted, in an endeavour to avoid the negative impressions, to indicate that the work is systematic, and to bring focus to bear on the contribution being made by both the criticism and the work that is being subjected to it. Criticism plays a vital role in scientific process. The conventional Popperian position is that the criterion for recognising a scientific theory is that it deals in statements that are empirically falsifiable, and that progress depends on scrutiny of theories and attempts to demonstrate falsity of theoretical statements: "The scientific tradition ... passes on a critical attitude towards [its theories]. The theories are passed on, not as dogmas, but rather with the challenge to discuss them and improve upon them" . However, senior members of a discipline commonly behave in ways that are not consistent with the Popperian position. This might be explained by the postulates of 'normal science', which view the vast majority of research work as being conducted within a 'paradigm' and subject to its conventions . In more practical terms, the problem may arise because senior members of any discipline have strong psychic investment in the status quo, andnomatter how cogent and important the argument -100 30 Two examples are commonly cited within the IS discipline as suggesting that conservativism is important and criticism is unwelcome. In a section on the tone to be adopted in a Literature Review, Webster & Watson To make assertions about a population without providing sufficient detail about the individual instances invites reviewers to dismiss the analysis as being methodologically unsound. It is, in any case, essential to progress in the discipline that each of us be prepared to accept criticism. The advice continued: "Do not fall into the trap of being overly critical ... If a research stream has a common 'error' that must be rectified in future research, you will need to point this out in order to move the field forward. In general, though, be fault tolerant. Recognize that knowledge is accumulated slowly in a piecemeal fashion and that we all make compromises in our research, even when writing a review article" . Here, the authors' expression failed to distinguish between the two senses of the word 'critical'. The authors' intention appears to me to have been to warn against 'overly critical expression'. On the other hand, it is an obligation of researchers to 'think critically' and to 'apply their critical faculties'. I submit that it would be inappropriate for readers of the article to interpret the quotation as valuing politeness among researchers more highly than scientific insight and progress. In the second example, a senior journal editor, providing advice on how to get published in top journals, wrote that "the authors' contributions should be stated as gaps or new perspectives and not as a fundamental challenge to the thinking of previous researchers. To reframe, papers should be in apposition [the positioning of things side by side or close together] rather than in opposition" Straub . This is Machiavellian advice, in the positive, or at least amoral, sense of 'if the Prince wishes to be published in top journals, then ...'. Unfortunately, it is all-too-easily interpreted as expressing a moral judgement that 'criticism is a bad thing'. The inferences that I draw from the above analysis are as follows: • criticism of previously-published ideas is vital to progress • criticism encounters strong opposition from a discipline's gatekeepers, relevantly in the form of journal editors and reviewers Design research is concerned with constructing an artefact, variously of a technological or an intellectual nature. Both positivism and interpretivism, on the other hand, are concerned with description and understanding of phenomena. Sometimes the focus is on natural phenomena, but frequently the interest is in natural phenomena have been subjected to an intervention. Importantly for the present project, however, both positivism and interpretivism involve strenuous avoidance of moral judgements and of 'having an agenda'. Critical theory research, on the other hand, recognises the effects of power and the tendency of some stakeholders' interests to dominate those of other stakeholders. It brings to light "the restrictive and alienating conditions of the status quo" and expressly sets out to "eliminate the causes of alienation and domination" . The original theoretical work on 'researcher perspective', on which my current paper is based, is appropriately framed within a critical theory research design. The paper whose rejection stimulated these Notes, on the other hand, uses content analysis to apply that theory to a set of papers in a new and potentially very important research domain. The notions discussed in this section are therefore of general relevance to the establishment of a satisfactory content analysis research design, but do not directly address the issues that I am confronting. --- The Recognition and Critiquing of Ideological Assumptions Although the references discussed above are of relevance to the problem, they fell short of the need. Two particular sources appeared to provide an appropriate foundation for content analysis of the kind that my research project undertakes. One is an approach to In Boell & Cecez-Kecmanovic it is argued that a constructively loose and iterative process is needed, to avoid undue constraints and unlock insight and creativity: "Highly structured approaches downplay the importance of reading and dialogical interaction between the literature and the researcher; continuing interpretation and questioning; critical assessment and imagination; argument development and writingall highly intellectual and creative activities, seeking originality rather than replicability [MacLure, 2005, Hart, 1998]" . The authors "propose hermeneutic philosophy as a theoretical foundation and a methodological approach for studying literature reviews as inherently interpretive processes in which a reader engages in ever exp[a]nding and deepening understanding of a relevant body of literature. Hermeneutics does not assume that correct or ultimate understanding can be achieved, but instead is interested in the process of developing understanding" . The framework, reproduced in Figure 2, comprises two intertwined cycles: a search and acquisition circle, and a wider analysis and interpretation circle . The authors perceive the mapping and classification of literature as being "a creative process that builds on a deeper understanding of the body of literature achieved through analytical reading. This process may lead to new questions and identify new relevant publications to be included in the body of knowledge" . The approach embodies "questioning and critical assessment ... of previous research" , and analysis of "connections and disconnections, explicit or hidden contradictions, and missing explanations" and thereby the identification or construction of "white spots or gaps" . "A critical assessment of the body of literature ... demonstrates that literature is incomplete, that certain aspects/phenomena are overlooked, that research results are inconclusive or contradictory, and that knowledge related to the targeted problem is in some ways inadequate [Alvesson and S[an]dberg, 2011]. Critical assessment, in other words, not only reveals but also, and more importantly, challenges the horizon of possible --- Critical Discourse Analysis Wall et al. proposes an approach to content analysis that the authors refer to as 'Critical Discourse Analysis'. Their starting-point is that "the information systems discipline is subject to ideological hegemony" . They see this as being harmful, and they argue that "review papers can ... challenge ideological assumptions by critically assessing taken-for-granted assumptions" . They explain the idea of 'ideological hegemony' as being "the conscious or unconscious domination of the thought patterns and worldviews of a discipline or subdiscipline that become ingrained in the epistemological beliefs and theoretical assumptions embedded in scientific discourse . In academic literature, a hegemony may manifest as common framing of research topics and research questions, the domination of theories and research methods that carry similar assumptions, common beliefs about what constitutes the acceptable application of research methods, and common beliefs about how research results should be interpreted. "By ideology, we mean those aspects of a worldview that are often taken for granted and that disadvantage some and advantage others. Ideologies are not falsehoods in an empirical sense, but are a constitutive part of researchers' and research communities' worldview ... that are removed from scrutiny . Thus, ideologies can be harmful to individuals who are disadvantaged or marginalized by them, and they can be problematic to scientific research because they represent blind spots" . Wall et al. proposes that a critical review method "based on Habermasian strains of critical discourse analysis " can overcome the limitations of working only within ideological assumptions. CDA "examines more than just a communicative utterance. Foucauldian analysis also examines the context in which an utterance was uttered by assessing power relationships between actors and the structures and processes that guide behavior and constrain the development of knowledge " . The process involves the assessment of "violations of four validity claims" : 1. the communication's comprehensibility, by which the authors mean "technical and linguistic clarity of communication " 2. the communication's truthfulness, which "refers to the propositional content of communication as represented by complete arguments and unbiased assertions " The hermeneutic approach to literature review and the CDA approach to content analysis, overlaid on the prior literature, enable the design of a content analysis research method with the desired attributes. That research method has a good fit with theory developed using critical theory research. It prioritises depth of insight over narrow, positivist quantification. It encourages the analyst to focus on key validity claims and the hidden assumptions within the text under study. It forces the researcher to confront, and to take into account, their own ideology and agenda. It pushes the researcher in the direction of critique for the purposes of theory construction or re-construction, rather than criticism for its own sake. --- Application of the Research Findings The preceding sections provide a basis for adapting the research method for my research project. The most significant implications for my work, reflected in Annex 2, were as follows: ---  It is necessary to convey more clearly that 'researcher perspective' theory is a product of critical theory research, that it has a "focus ... on the power structures that lie behind accepted interpretations", that it "takes a value position" , that it "demonstrates ... that certain aspects/phenomena are overlooked" , and that it sets out to "challenge ideological assumptions by critically assessing taken-for-granted assumptions" and that it is accordingly necessary for the content analysis to identify the elements of existing works that reflect the existing power structures  The iterative nature of Boell & Cecez-Kecmanovic 's hermeneutic approach for conducting literature reviews provides a clear explanation of the need for repetitive loops and introspective questioning by the researcher about their analysis and interpretation of the works. This is reflected in step 7 of the revised process in Annex 2  The distinction between preliminary 'orientational reading' and deep 'analytical reading' can be used to explain how confidence is gained in the appropriateness of the selection, coding and interpretation of passages in each work. This is reflected in steps 1 and 3 of the revised process in Annex 2  The research method needs to be expressly described as directed content analysis using a priori coding, as described by Hsieh & Shannon . However, greater efforts may be needed to "introduce some quantification [such as] frequency analysis" , and "tabular, graphical, or pictorial presentations" , in order to upgrade from a 'narrative content analysis' to 'descriptive content analysis'. This is reflected generally, and particularly in step 6 of the revised process in Annex 2  Greater efforts may be needed to convey the means whereby reliability is achieved in selection, coding and interpretation activities, in line with Krippendorff , Weber Care is needed to avoid attributing intent on the part of authors whose papers are criticised, and instead the analysis should "assume that hegemonic participation is unconscious" . This is reflected in step 7 of the revised process in Annex 2 --- Conclusions This paper has reported on the results of a study of meta-questions affecting a content analysis project. A range of guidance has been located and summarised in relation to secondary research whose raw data is published academic papers. The role of criticism in IS research has been clarified. The particular challenge has been confronted of how to perform content analysis when the theory-lens through which the observation is being performed arises from critical theory research. The primary purpose of the work has been fulfilled, in that the process specification for the analysis of the relevant papers has been adapted in order to better reflect existing theory relating to content analysis of published works, particularly in a critical theory context. Further, a set of changes to the research method section has been identified, which have implications for the interpretation of the papers and the expression of the critique. In addition, guidance has been assembled on how to, and how not to, commuicate the results. This paper has implications for IS researchers generally. Much of the material that has been summarised applies to all content analysis of published papers, nomatter whether the research approach adopted is positivist, interpretivist, design science or critical theory. A small qualification is appropriate, in that the majority of the material relates to research that goes beyond mere exposition of existing literature and is at least modestly questioning about that literature's quality and/or continuing relevance. This paper goes further, however, in that it contains guidance in relation to constructive criticism of existing works. I contend that IS will become increasingly static, and its outputs will be decreasingly valuable, if it values politeness to authors too highly and puts too little emphasis on constructive criticism of existing literature. The method adopted includes proposals about how a researcher can detect and avoid excessively sharp expression, focus the discussion on the message, avoid shooting the original messenger, and in turn avoid being shot themselves. --- Introduction In recent years organisations have realigned their information and communications technology strategic objectives to provisioning and/or sourcing lower cost, flexible, resilient supply and delivery options as a means of responding to the impacts of globalisation and the associated cost pressures . Cloud computing represents an innovative technological advancement which appears to offer a solution to these aforementioned objectives . Subsequently, incumbent organisations are undergoing cloud-based digital transformation journeys in order to reap the multitude of anecdotal business and strategic benefits. In order for organisations to perform effectively in a digitized and networked economy, an "understanding of the role and relevance of strategy is necessary for effective competitive behaviour" . The role of ICT in developing effective strategies has been well documented . Strategic ICT can not only support and shape strategy but can also be pivotal in determining commercial viability and represent a source of competitive advantage when used in innovative ways . However, the concept of ICT-enabled strategy formulation is relatively ambiguous. For instance, Ward opines that the "knowledge we have developed [over the past 30 years] about information systems strategies appears to have had little impact in some organisations, even though they invest hundreds of millions of pounds in new information systems and digital technology every year. This is evidenced by a global survey conducted by McKinsey of 807 executives which revealed that while they acknowledged the strategic importance of digital technologies to their business goes beyond cutting costs , they were also dissatisfied with its effectiveness pertaining to enabling overall strategic objectives . In the context of cloud computing, strategy can be defined as "a set of decisions required to create and deploy a network-based, information service delivery strategy that results in both cost savings and organisational agility . However, the current state of art pertaining to cloud-based digital transformation strategies that might be appropriate for ICT service providers is relatively ambiguous. As ICT service providers begin to formulate their cloud strategies, "they need to understand the inherent capabilities that are afforded by cloud computing…[which] can help them gain a competitive advantage by creating opportunities for cost advantage and organisational agility". Having a comprehensive understanding of cloud-based digital transformation is "critical to forming a cloud strategy that will unlock business value worth orders of magnitude more than the costs" . ICT are strategic insofar as they successfully implemented and are also used to realise strategic intent transitioning to provisioning cloud services. The authors identified that as a result of the emergence of disruptive cloud-based digital transformation, the strategy formation process encompasses a "collective experimental learning process revolving around a number of alternative strategic intentions ranging from incremental evolution and transformation to complete replacement of the existing business model" . Currently, there is a dearth of research relating to how cloud-based digital transformation impacts ICT service providers' strategies. Consequently, research relating to how these concepts develop, interact and harmonise is also underdeveloped. This is pertinent now as the cloud computing paradigm has reached a level of maturity which lays the foundation for IS researchers to investigate how ICT service providers have moulded and sustained their cloud-based digital transformation arrangments . In order to ensure the long-term business viability and sustainability of the cloud computing paradigm, further research is required to elucidate exemplars of successful and unsuccessful ICT service provider digital transformation arrangements . Thus, the objective of this research is to: Explore how cloud-based digital transformation impacts ICT service providers' strategies? The remainder of the paper is structured as follows: The next section builds the theoretical foundation for the study. Then we elucidate our research method. Next, the findings are presented and discussed. Finally, we conclude with implications for theory and practice. --- Theoretical Underpining --- Cloud-Based Digital Transformation Digital transformation is concerned with "the changes digital technologies can bring about in a company's business model, which result in changed products or organisational structures or automation of processes" . The long journey towards digital transformation is often fraught with complexity and ambiguity for incumbent ICT firms . This is compounded by the fact that the transformation of mature business models to digital-based business models encompasses potential nuanced legacy liabilities and issues. This is prominently evidenced by ICT service provider stalwarts such as Dell, Intel, IBM and Hewlett Packard whose struggles pertaining to how to best leverage the benefits of cloud-based digital transformation have been well documented. Frequently, these organisations are operating in unchartered digital waters and as a consequence lack the strategic clarity pertaining to what steps they need to consider prior to and during their digital transformation journey. 2011). Cloud computing enables ICT service providers to virtualise their computational resources and concurrently provision them, via a service orchestration process, typically in the form of Software-as-a-Service , Platformas-a-Service or Infrastructure-as-a-Service . While there is anectotal evidence which highlights the transformative business and strategic value afforded by cloud computing for ICT service providers , our understanding of how these organisations can develop digtal transformation strategies that effectively align with the value propositions inherent to cloud computing technologies is still limited . --- Bounding the Concept of Strategy In order for IS researchers to have a comprehensive understanding of an organisation's ICT strategy, it is useful to understand the evolution of their intended and realised strategies . Mintzberg and Waters propose a widely cited comprehensive categorization for strategy which identifies intended, realised, deliberate, unrealised and emergent strategy as constituting key components of the strategy formulation process. This categorization of strategy is suitable for investigating the "peculiarities" of modern emerging ICT and thus provides a backdrop for this study to better explore the strategy formulation process of ICT service providers . Intended strategy represents the organisation's official strategy and realised strategy which reflects the outcomes of decisions undertaken by the organisation stakeholders which may manifest from deliberate, emergent, and unrealised strategies. Deliberate strategy is defined simply as "realised as intended", emergent strategy as "patterns or consistencies realised despite, or in the absence of, intentions" and finally unrealised strategy as "intentions that are unsuccessful in its consequences" . We selected the aforementioned seminal categorisation as a basis for conceptualising the concept of strategy for the following reasons. First, no single strategy can be a panacea for an organisation and that the most optimal strategic variables alter due to certain conditions and factors . Given the rapidly evolving nature of the cloud computing paradigm , and the subsequent dynamic nature of cloud-based digital transformation , the categorization is well suited for delineating the strategy formulation process and chronicling how ICT service providers have arrived at their current realised strategy. Second, in the context of cloud-based digital transformation, the categorisation enables the identification of problematic issues and emerging patterns of events and behaviours which may have resulted in ICT service providers deviating from their intended strategy . Third, the categorisation enables business strategy to be "viewed in a non-descriptive manner, being conceived in terms of how companies actually decide and act, not how they should decide and act" . In the next section, we delineate the research method operationalised in order to elucidate our research objective. --- Methodology This paper's research objective is to explore how cloud-based digital transformation impacts ICT service providers' strategies? Due to the dearth of empirical research pertaining to examining the relationships of the focal phenomena under scrutiny, our study is exploratory. Thus, a multi-method, comparative case study research design was selected for the study . The research sampling approach was directed by evolving theoretical concepts, whereby we identified organisations and people from which we expected to elicit the majority of insights into the phenomena of interest . For instance, this study encompasses an analysis of both large and small and medium enterprise ICT service provider firms. The large business model mature ICT ventures represent organisations that have significantly longer tenure as ICT service providers that are currently transitioning from 'pre-cloud' to 'cloud-based' business models. The SME born-on-the-cloud ICT ventures represent organisations who do not possess the requisite existing maturity or tenure of pre-cloud business models. These firm's business models originated on the cloud. Data collection took place between January 2015 and August 2015 using semistructured interviewing based on a common protocol across 15 ICT service provider organisations. Following the standard practice of using senior management as data sources, we chose a senior manager from each targeted organisation. Interviews lasted between 70 and 120 minutes. The interviews were conducted until theme exhaustiveness was reached, which manifested when similar themes were being identified and no new themes emerged. All interviews were transcribed, proof read and annotated and then coded using NVivo 10. In order to improve the credibility of the data and provide cross and complementary perspectives on emerging elements, secondary evidence in the form of archival documents and published materials sourced from the ICT service providers' websites were collated and analysed. While the study did not undertake a grounded theory approach, in analysing the data, the researcher used an analytical hierarchical data analysis process adopted from Ritchie, Spencer and O'Connor incorporating open and axial coding techniques based on the recommendations of Strauss and Corbin . --- Findings In this section, we report the empirical results obtained during the analysis of the semistructured interviews , archival documentation and published materials. It was evident from the study that cloud-based digital transformation not only have a dynamic and turbulent impact on ICT service providers' strategies but also have a cogent collective impact in terms of agility and competitive positioning . The strategies for ICT service providers encompassed short and longterm objectives such as cogent market impact, increasing return on investment , enhanced agility, reinvestment of capital, and reducing capex and opex. For example, study participants in Levatte and Sigmathen Systems described how their strategy is focused on broadening their cloud geographic footprint and growing their customer base in order to increase revenues while the CEO at FieldZuite explained that their primary strategy is about increasing revenues through repeat customers. All ICT service providers confirmed that their cloud-based business model have significantly impacted the realisation of their company's strategic objectives which has been largely the cumulative result of a combination of deliberate, emergent and unrealised strategy. In terms of deliberate strategy, all ICT service providers identified that their main objective for operationalising cloud influenced business models was mainly for agility reasons. For instance, the CTO at INNO described how their cloud strategy was focused on enhancing the agility of the organisation, stating that "the new religion is cloud and we are all about agility and DevOps principals. Our objective is to develop new or improved services faster than we did in the past. All new offerings must be agile and be able to be provisioned at low cost". This CTO further elucidated that "our new strategy is that we are going to become a SaaS organisation and get out of the hardware business". The CEO at Braavos pointed out that their cloud-based business models "foster agile and cost effective operations which are currently enabling our strategic objectives of becoming a market leader as a cloud integration service provider". While the CTO at Zeta2k described how their "cloud enabled business model has allowed us to be very agile and nimble in order to provide a service to a large number of users very quickly, thus facilitating strategic objectives". Similarly, the CTO in FieldZuite explained that their business model has had a significant collective impact on the company's strategic objectives by not only enabling them to compete with larger ICT service providers but also to deliver their cloud services with greater efficiency to multiple global locations around the world. Moreover, the CTO in MobCon elucidated on two examples of the cloud business model impact on their strategic objectives. First, he described how cloud computing facilitates enhanced efficiency and faster innovation in terms of supporting accelerated cycles of development. For example, cloud computing enables the early deployment of demonstration environments that would otherwise require substantial capital expenditure as a precursor to a full business case. Second, MobCon's strategic partnering with Amazon Web Services facilitated stability in their business model components, thus minimising strategy-business model misalignment issues which may have manifested because of the disruptive nature of cloud computing technology. The CTO in SandstemTech added, "the cloud has enabled us to be more responsive. We have sales pitch for a large airline next week and cloud computing has enabled us to create an enterprise demo environment for them in a matter of hours. The traditional method we would have utilised three years ago would have taken weeks in order to create the same infrastructure for the demo environment". Strategic acquisitions were also identified as deliberate strategy by all large ICT service providers. For example, the CTO in Sigmathen Systems explained, "it was a deliberate strategic decision to acquire an established managed hosting in ACD ". Prior to this acquisition, the company were losing customers to public cloud offerings. In order to streamline the on-boarding process for cloud customers, the company also acquired an independent software vendor start-up company who specialised in subscription billing. The CTO in INNO also pointed out that their decision to acquire an established cloud provider such as CEES was pivotal to their cloud success, stating that "INNO's acquisition of CEES in 2013 accelerated its cloud computing strategy overnight. We can now use the CEES infrastructure and platform to rapidly deploy existing software services as SaaS". Partnerships were also identified as an example of deliberate strategy by ICT service providers . Both the interviewees in LYS and VClazz confirmed that it was a deliberate decision for their organisations to operate as value added resellers in order to avail of the economies of scale provided by their large ICT service provider partner. All ICT service providers confirmed that their emergent strategy manifested from cloud enabled accelerated rate of business growth and incidences of unrealised strategy. For instance, the CTO in VClazz opined, "as a result of the exponential rate of growth we have experienced provisioning cloud services, we have successfully transitioned from the enduser market to the channel markets". Similarly, the CEO in Yet3 pointed out that the company's current realised strategy has manifested as a result of emergent strategy based on their accelerated growth in niche global target markets. In relation to unrealised strategy, IaaS was provided as an example by ICT service providers . For example, the CTO in INNO explained how prior to acquiring CEES, their efforts to build their own IaaS proved vexatious, further describing how "it really was a painful process trying to develop our own bespoke IaaS. It didn't have the scale of AWS, Rackspace, and Azure. It failed simply as there wasn't a big enough pool of resources for all the customer requirements we had. We did not invest in it aggressively enough and were far too conservative about investing in it". The CTO in MobCon described how the company were initially going to build their own cloud infrastructure. However, MobCon decided to partner with AWS, a partnership that enabled the company to accelerate its move to provide cloud services to its existing customers. The study identified that the dynamic and recursive nature of ICT service providers' strategy formulation, business model experimentation, organisational learning and subsequent adaptation when attempting to explore disruptive and/or innovative cloud business models. Figure 2 below depicts the process model we have developed to reflect this recursive process. All ICT service providers confirmed that their cloud strategy formulation and review decisions were largely management-led with changes being dictated by business model component performance . For example, the CTO at Zeta2k surmised, "our organisation's strategy is management-led and informed by business model performance, strategic roadmaps, whitepapers, analyst research reports and customer communities' feedback", while the CTO at INNO explained how they have a committee of fourteen people responsible for developing corporate strategy for the company's four divisions . However, on the contrary, the CEO at Yet3 described how their strategy is more leadership-led, which is facilitated by the flat structure of the organisation. The CEO elucidated, "while the advisory board help the company to see the forest from the trees, we have employees in Israel, Vietnam and Japan who can influence strategic decisions without ever having met the CEO or the advisory board as they know more about the lay of the land than we do". The CEO asserted that the ability of their globally distributed employees to provide strategic insight on their national landscapes has been a cornerstone of the company's continued success. Figure 2: The relationships among strategy formulation, business model experimentation and organisational adaptation when exploring an emerging disruptive and/or innovative business model In an effort to maximise the realisation of their strategic intent, all ICT service providers are engaging in business model experimentation and iteration. For example, the cloud manager at Levatte described how they are experimenting and iterating their business model constructs at varying levels within the organisation. The CTO in INNO also explained how their organisation was utilizing a bespoke component business modelling technique for formalising and reviewing their product business models. The CBM technique breaks an enterprise down into its constituent segments and enables INNO to take the aforementioned areas and break them down and identify elements which bring business value to the company. The outcomes of this organisational adaptation served as an input for re-evaluating the strategic intent of the organisations. 0ur analysis complements and extends existing research -in particular Khanagha et al., . On the one hand, it confirms the dynamic nature of ICT service providers' strategic intent in response to disruptive cloud-based digital transformation and also identifies the salient roles of adaptation, business model experimentation and the resulting accruement of new knowledge. However, on the other hand, contrary to their findings that presented structural adaptation as a precursor to business model experimentation, our findings indicate that business model experimentation and iteration and the subsequent derived organisational learning serve as salient inputs to ICT service providers evaluating whether the level of organisational adaptation required to pursue their strategic intent is feasible. This would suggest that ICT service providers are operationalizing a cautionary and evolutionary approach prior to committing substantial finances and resources to restructuring their organisation in order to realise their strategic intent. In the next section, we conclude with implications for research and practice. --- Introduction The decision whether or not to discharge a patient is one of the most frequent and complex decisions of clinicians . It involves a multidisciplinary team and careful evaluation of several medical and non-medical factors to determine the best time to send a patient home. According to Armitage , "the discharge of medical patients consists often not of a single event but of a lengthy process of negotiation involving professional staff, patients and their relatives" . Thus, a variety of stakeholders and influencing factors are to be considered in this decision. While the implications and requirements of effective discharge planning have been analysed in various studies , the specific time of patient discharge that leads to the best outcome has not yet been considered in detail . Finding the optimal time of discharge can lead to fewer unnecessary readmissions, enable cost reductions and therefore allow for a better allocation of resources within the hospital. Therefore, this study focuses on the influencing factors that can determine the optimal time of patient discharge, both from a qualitative and cost perspective. For this purpose, involved stakeholders, as well as medical and non-medical criteria that are considered in the discharge decision, have to be identified. To specify the best outcome from a qualitative view, readmission rates are used as a comparative value. From a cost perspective, we utilize, patient length of stay as the comparative indicator for the time of patient discharge, as this represents a common cost factor over time. Hospital reimbursements are based on case rates, according to so-called diagnosis-related groups . For each DRG, a cost weight is set by the Department of Health that determines the reimbursement rate for the hospital for each episode within that DRG. To allow for different types of stay and moderate financial risk, the case mix model has been adapted to include cost weights for shorter or extended hospital stays. In Victoria, a "Weighted Inlier Equivalent Separation " is used, where the DRG cost weight is adjusted for time spent in the hospital. Thus, the length of stay highly influences a hospital's reimbursement rates . Figure 1 displays the development of costs and reimbursements over time. The cost curve includes all costs incurred for procedures, accommodation and maintenance costs. We assume that the curve flattens with increasing time, as cost-intensive procedures occur in the beginning and accommodation costs in the later stages of the stay. A balance of revenues and costs, i.e. the Break-Even-Point , for a DRG is assumed at the determined average length of stay for a single DRG. As a result, the shading to the left represents the profit zone . For each additional day, the patient is hospitalized in the hospital, the hospital suffers losses. The actual cost curve is hospitalindividual and can, therefore, deviate for each episode. For a hospital, it would, therefore, seem most profitable to discharge a patient as soon as possible within the inlier range. However, if the patient is readmitted to the hospital for a related cause of the preceding episode, reimbursements can be suspended for the readmitted episode or other penalties might occur . Studies have shown that the length of stay has a potential impact on the quality of care and thus the potential risk of readmission of a patient . While some argue a longer length of stay to be beneficial , other studies show a negative effect with a longer length of stay on outcomes and risk of readmission or even suggest lower readmission rates with a shorter length of stay . Thus, it is vital to determine the point of patient discharge that also considers the lowest risk of readmission. To reach this goal, the process of patient discharge and the involved stakeholders have to be known. --- Figure 1: Correlation between patient length of stay and costs The purpose of this study is to determine the decision makers and criteria that are relevant in the patient discharge process. For this purpose, focus group interviews are held in an Australian hospital group in Victoria. Based on the results of these interviews, propositions about the patient discharge decision and its implications are derived from the qualitative results. In a subsequent study, these results will be further developed into hypotheses and tested with episode data collected at the respective hospital group. This paper is structured as follows. The related work section briefly describes relevant stakeholders and decision criteria that have been previously identified for the patient discharge process. While a lot of studies suggest qualitative approaches to determine these criteria, we propose a mixed-methods approach to quantify the influences on patient length of stay and the patient discharge respectively. Section three afterwards describes our proposed method and the research design. Subsequently we present the results of the qualitative study and based on that, derive propositions on factors influencing patient length of stay. Finally, the limitations of this study as well as future research opportunities are discussed. --- Related Work The following section describes the results of our literature analysis concerning decision makers and decision criteria in the patient discharge process. The results form the basis for our qualitative analysis by supporting the selection of our focus group participants as well informing the development of our semi-structured interview guidelines. --- Decision makers While the final decision to discharge a patient resides with the primary physician, other groups have been shown to influence the time of discharge from the hospital. According to Armitage , relatives play a vital part in the discharge negotiation, where both a shorter or a longer stay than necessary could be requested. Depending on their personal situation, their environment after discharge or their general well-being, a patient can also act as an influencer in the discharge decision. From the hospital personnel perspective, nurses tend to give suggestions and actively participate in the evaluation of a patient's well-being. As they are the closest caregiver to the patient in the hospital setting, they can sometimes better determine a patient's status and have a deeper understanding of a patient's personal situation than the treating physician . Finally, the treating physician, as well as other consulting doctors primarily, evaluate the clinical factors. They provide the final discharge decision with respect to the input of other stakeholders, clinical guidelines or other underlying conditions, such as ethical considerations . --- Decision criteria A literature review conducted by Harun et al. identified 17 studies analysing the patient discharge process to determine influencing factors in this context. They found several medical and non-medical influences on discharge decision making through either prospective or retrospective studies . Literature shows, that mostly qualitative studies are conducted to identify impacts and behaviours of patient discharge. Thus, the results solely rely on subjective opinions of the interviewees. The factors identified in these studies can be assigned into two major categories: Measurable and non-measurable factors Table 1). While non-measurable items can only be gathered and interpreted through qualitative methods, measurable information can be collected and used to quantitatively test their impact on the patient discharge decision and their outcomes. This way, quantitative factors can be used for decision support to complement qualitative factors, such as ethics and intuition. The decision criteria as suggest in this study form the basis for our focus group interview guideline. We thereby especially focus on the measurable factors to initially derive proposition and testable hypotheses in a next step. --- Method This paper presents the first part of a mixed methods approach either concurrently or sequentially , to understand a phenomenon of interest" . This study is conducted sequentially, i.e. the results of the qualitative study in this paper will be evaluated with a quantitative analysis afterward. The aim of this study is to derive propositions on the impacts and implications of time of patient discharge. Thus, in a first step, focus groups are conducted at an Australian hospital group to determine decision makers and criteria for patient discharge and the relevance of readmissions in this context. Figure 2 shows the proposed approach as well as the areas under study. Figure 2: Mixed methods approach --- Study population We held three focus groups with 4 participants each, consisting of 7 men and 5 women, thus 12 participants in total. Each session was facilitated by a moderator and lasted about one to two hours. According to Krueger , focus groups should follow five key criteria. First of all, small groups of people are assembled, usually ranging between five to eight people. However, so-called mini-focus groups with four to six people, are becoming increasingly popular as they provide a more comfortable environment for participants and allow every person to be able to participate. Furthermore, the select participants should possess certain common characteristics to be suitable for the topic under discussion. In our study, the homogenous environment of an Australian hospital group is selected as the main criterion in group member selection. The groups consisted of medical and non-medical personnel from various departments, such as the ICU, Research, Clinical Audits, Quality Management and the Emergency Department. The focus of these focus groups, on the one hand, was the determination of stakeholders and decision makers as well as their concerns and criteria for the time of patient discharge. On the other hand, we addressed the topic of the risk of readmission, and how readmissions are detected and handled in the hospital. Next, the goal of focus groups is to collect qualitative data to gain different insights and opinions across groups that can subsequently be compared and contrasted. Finally, this method utilizes a focused discussion "to get a range of opinions about a something like an issue, behaviour, . A semi-structured interview guideline was prepared and reviewed to ensure consistency throughout all focus groups, yet allow for some flexibility within the specified topics. For this purpose, focus group questions were developed by the research team according to three main areas: --- Decision makers and criteria --- Risk of readmission  Decision makers and factors influencing the time of patient discharge  Factors influencing the risk of readmissions  Information availability The aim of the focus groups was thereby to identify the issues, behaviours and needs for patient discharge with regards to the risk of readmission and the available information in that process. --- Results In the following section, we describe the results of our focus group interviews according to our three main areas. We identify decision makers and influencing factors on the patient discharge decision as well as the impact of the risk of readmission. To specify, we utilize the patient length of stay as the comparative indicator for the time of patient discharge. --- Decision makers The results of the focus group support the results from our literature analysis but give a deeper understanding of the discharge negotiation. Requests from family members and patients to stay longer are taken into consideration in accordance with medical necessity and availability of resources. "Family members or patients often push for a longer stay; […] the requests are taken into consideration, but it requires a conversation about the medical necessity", "Patients and family often ask to stay longer. Since it's a private hospital that can sometimes be arranged, depending on the available beds." According to one interviewee, this especially happens with readmission cases, stating that "if they're nervous, especially if the patient already had multiple readmissions they want to be on the "safe side". Similar to the results from literature, the focus groups agreed that usually "nurses make the suggestions for discharge, when they feel that the patient is well enough", but that in the end "the consulting physician has the final say and makes the decision when the patient is discharged". In case a patient stayed at multiple wards or "saw multiple doctors, they will make a decision together". Depending on the ward a patient is treated at, there can be specific people in charge that lead the decision. In ICU, one interviewee stated that "the decision to discharge […] is made by the intensive care specialist in conjunction with the treatment team, so the physician, surgeon, etc. The physician will determine if the patient has been stable for a certain time, if the blood tests are, if not normal, at least trending in the right direction." In the special case of private hospitals as in the case under study, insurance can also play a role in the sense that "if the patient runs out of insurance, then the patient is transferred to a public hospital". --- Influencing factors on time of patient discharge Within all groups, the type and severity of the diagnosis were concluded as the most prominent factor. One person stated that "The time of discharge depends on how what they come in with and how frail the patients are and why they needed the medical care in the first place". Similar, others referred to this as "the complexity of admission" or proposed that the best time of patient discharge mainly "depends on what he/she comes in with". Our first proposition that is derived from our interviews, therefore, suggests a significant difference within the durations of patient visits: P1: There are significant differences in patient length of stay between different diagnoses. Going further, not only the type of diagnosis but also the severity of the condition and frailty of the patient were mentioned as relevant factors. Therefore, we further propose to differentiate time of patient discharge and length of stay within diagnoses groups: P2: There are significant differences in patient length of stay within diagnoses groups depending on the disease severity. --- Influencing factors on risk of readmission Next, our interviews show a varying perception of the benefits and threats of a later time of patient discharge. While some participants argued that a shorter length of stay is more beneficial for patients , some interviewees propose that they tend to keep critical patients for longer to make sure a patient is healthy enough to leave. One participant stated "The more critical a patient is, the longer the required "period of normality" before they are discharged." Thus, the time of patient discharge shouldn't be both too early or too late, leading to our following proposition: P3: The length of stay has a significant impact on the risk of readmission. Furthermore, the interviews show that this applies even more to certain patient groups, especially for chronic diseases. "Especially patients with chronic diseases are often "frequent flyers" in the hospital, for example, renal failure, Diabetes, Airways disease, Cardiac disease. […] These patients make up 80% of medical activity and cost". We, therefore, conclude the following propositions: P4a: There are significant differences in risk of readmission between different diagnoses. P4b: There are significant differences in risk of readmission between within diagnoses groups depending on the disease severity. Figure 4 displays the theoretical model of the derived propositions, visualizing the relationships between diagnosis, disease severity, the length of stay and risk of readmission. Figure 3: Theoretical model of influencing factors on length of stay and risk of readmission --- Information availability The third part of the focus group interviews focused on the type and amount of available data that is required in the discharge process. In general, one interviewee stated the discharge decision requires input about "the objective, medical factors as well as subjective factors", i.e. intangible information that cannot be measured. These subjective factors are usually determined by the physiologist. The availability of information can also negatively impact the length of stay i.e. lead to a delayed time of patient discharge. " […] Having the data available sooner or digitally may or may not improve the decision of patient discharge, but It could improve the efficiency of discharge because a delayed discharge is bad for the patient and the hospitals." A delayed discharge can increase the risk of hospital infections and can result in penalties for the hospital if the length of stay is continuously too long across multiple episodes. Besides increasing efficiency through digitized data, the advances of more complex data analysis and visualization were discussed within one of the focus groups. "It wouldn't be enough to digitize the information, but to combine the information and use more complex information to show doctors more sophisticated overviews of risk etc." In that sense, --- LOS --- Diagnosis Disease severity individual data points might not be critical, but in combination, they might show relevant information to the clinician. As one physician stated: "The complexity [of data] outpaces the availability [of clinicians] to digest the information". Within this discussion, the application of Business Analytics or Machine Learning methods was proposed as helpful to counteract this complexity. An intuitive visualization is thereby key to filter out the relevant information. "It's important to quantify and visualize the results from such analyses, e.g. % likelihood of deterioration". Especially information concerning the potential risk is not yet assessed in detail, even though unnecessary readmissions could be avoided with this knowledge. "The information of risk assessment of a patient is collected, but not really used. If that information was visualized properly , that would be very helpful." --- Risk of readmission This information could be both helpful for treatment of individual patients as well as on a more organizational level. For this purpose, aggregated data for each DRG group or specialty could be displayed to improve hospital coordination and management. On an individual level, the risk for each patient could support clinicians to determine the best time of patient discharge. --- Discussion In this study, we identify decision makers and influencing factors in the patient discharge process and for risk of readmission and shortly discuss the potential of data analytics and visualization in the healthcare context. As the first part of a mixed method study, we develop semi-structured focus groups interviews that are carried out at a not-for-profit tertiary Australian hospital group. The results of the interviews show similar findings as our initial literature review considering decision makers and criteria in patient discharge, but give a deeper understanding of the discharge negotiation. The analysis of these focus groups results in five propositions on the influencing factors on length of stay and risk of readmission in private hospitals. Our aim is to further develop these propositions into a testable model and derive hypotheses on the relationships between these influencing factors. For this purpose, we will collect data on patient episodes at the case hospital to further specify our proposed theoretical framework in a follow-up study. By following a mixed methods approach, the qualitative results of the focus group interviews can be further supported by quantitative evidence and therefore strengthen our initial results. Thus, the identified stakeholders involved in the patient discharge decision can be supported during this process by utilizing data-driven insights to find the optimal time of patient discharge. The results of the focus groups also show a high interest and applicability of data analytics in the healthcare context to enable faster and more evidence-based decision making. This study aims at providing a deeper understanding into the patient discharge process and gives suggestions on how the use of data analytics could support this process in the future. From a research perspective, the quantification of influencing factors on patient The results of this study have to be considered under certain limitations. First, the participants of the focus group were selected from a single hospital group. To provide generalizable results, further studies have to be conducted at different sites. Second, the propositions developed in this paper are not yet quantitatively evaluated and are based on the authors' interpretation of the qualitative results. This restriction will be approached in a follow-up study using patient episode data at the hospital under study. --- Introduction In the new era of technology-enabled competition, many organizations have to deal with disrupting technologies, emerging new competitors, challenging IT-based innovative models. In many industries, digital transformation is a key enabler of future success or survival, by better connecting digitally with consumers, partners, by improving internal efficiency through improved process, by facilitating deeper insight and business intelligence, and by providing enhanced products and services . The increasing use of integrating digital technologies has a transforming impact on companies and on how their businesses work. The depth of changes is dependent on digital maturity. Digitally less-matured businesses have limited opportunities by concentrating on solving discrete business problems, using individual digital technologies. Digitally most matured organizations develop digital strategy based complex innovations to transform the business . Digital business is a complex approach influencing all aspect of operations, provides several benefits, like improved transparency and control of operations, extension of IT based systems, data collection and analysis, increased integration of business applications, transforms analogue process to streamlined and efficient digital ones. Typical organizations have internal efficiency and operational focus, while the digitally matured organizations the priorities are: automation of processes, distant control and execution of procedures and automation of human activities. Pressures for digital transformation are also present in Hungary. --- Survey Results: Digital Transformation in Hungary Research results confirmed that the investigated organisations consider digital business transformation as a key issue. The research also points out that there are many uncertainties on the way towards digitization: organizations cannot foresee the challenges and opportunities, and only some of them marked out clearly their digital business strategy, or even just a few implemented digital transformation projects. Most of the companies are not so enthusiastic about the risk related to the introduction of innovative digital solutions. So, digital strategy in a cross-functional strategy, that address all functions and processes of an organization. The role of IT strategy is to fulfil the requirements of the digital strategy, that is interpreted as a business strategy. --- Digital Strategy Our research showed, that almost half of the surveyed organizations include digital transformation issues into their organizational strategy, while a little more than a quarter of the organizations include digital transformation questions into their IT strategy. Moreover 10% of the organizational have an independent digital transformation strategy, and 15% of the organizations have no digital strategy at all. The results partly follow the insights of Bharadwaj el al , as most organizations integrate digital questions into their strategy, but there is still a huge number of organisations which still believe the role of IT in these questions. Moreover, if we analyse how the business and IT strategy is related to each other, we can realise, where strategic alignment of business and IT could be accomplished, higher share of business integrated digital transformation is present , and there is no independent digital transformation strategy at all. Companies developing IT strategy as a derivative of the business strategy are less interested in digital transformation, some of them have an independent digital strategy, and the IT unit's influence on digital strategies is weaker. Companies having integrated business and IT strategic planning are more active in digital transformation, and they tend to involve digital innovation to their existing planning activities. Based on these results, an adequately aligned IT strategy can be a catalyst of digital strategies. --- Innovation Process -The Origin of New Ideas Even though there is the willingness and implementation capacity, solutions are needed that meet external and internal requirements. Therefore methods and approaches of idea-generation and collection in companies are key issues. Based on the survey results idea-collecting activities of companies are somewhat stronger than the medium in average, but there are various levels of emphases on the different sources of innovative ideas. The two most important area mentioned are the external and internal related ideas, there is no significant difference between the importance of these sources. Companies put much less emphases on systematic exploration of the operations, collection and evaluation of data related to operations. In addition to these feedback sources the statistically analysed data and focused customer and employee data collection, process monitoring, problem detection may be the best basis for organizations to identify the improvement opportunities of activities, processes customer experience. Although placed backward in the survey, outside opinions can be also a valuable source of innovation. --- Planning and Implementation Recently many CEOs generally understand the strategic opportunities and threats of digital transformation, and developed a vision or even a strategy for their companies to initiate changes. On the other hand, most organizations have only insufficient skills and knowledge in digital business, which can be a major impediment of executing the digital strategy . Digital transformation has become the major facilitator of business success, it provides new approaches to optimise processes, improve data analysis and extend customer relationships. Although technology can be mentioned as a key enabler of recent business innovations, it is generally accepted that strategy is the key driver in the digital arena . The digital business transformation can bring significant changes in the life of organizations, but it means also significant risks. This dichotomy can be observed in most of the companies: despite the importance of digital transformation for many organizations, organizational readiness is a key factor in the assessment of risks. While the domestic entities reported the strategic importance of the issue , they evaluated their own preparedness to a much lower level. Organizations estimated their technological knowledge and skills necessary for digital transformation just slightly higher than the medium level. 2017), just as cultural and organizational issues. From this perspective, the situation is promising , but the key aspects of the implementation capabilities are just slightly better than medium. Culture of innovation is not the strongest feature of many organizations , so the Hungarian results are also not surprising. In this sense, we can understand the risk-avoidant behaviour of the organizations, since taking a risky step requires preparation and knowledge: • Employees should have IT knowledge and digital skills , and organizations should consequently develop these skills • The organizations should consciously monitor and evaluate technology trends, innovative solutions should be piloted • companies should set up a group with well-defined goals, roles and responsibilities to implement digital transformation. According to the results of Weill and Aral high IT savviness is originated from five characteristics of successful organizations, amongst them companywide IT skills and management involvement. Our results showed that companies recognized the strategic importance of the digital transformation, but the implementation related competencies should be developed further. Analysed companies evaluated their ability to give quick response to the fast environmental changes at lower than medium level, so the implementation capability should be significantly improved. Most of the leading service providers reported in a survey , that they are still in the early stages of their transformation program. The overall observation of our survey was somehow similar, but in Hungary many companies are just in an experimental phase, complaining about many issueslack of experiences, lack of skills, etc. Figure 5: There is the will for digital transformation --- The Role of IT in Digital Initiatives In 2016 digital transformation primarily occurred in cloud and mobile platforms, but companies improved their communication technologies and great attention was paid to the integration of social media solutions. The transformation does not only mean the introduction of IT solutions, but also requires the change of organizational operations or the transformation of processes, even with the introduction of radical, new solutions. Our results are similar to other surveys , where the most widespread disruptive technologies are the cloud , mobility and collaboration ; while the popularity of data related initiatives were much less frequently mentioned in Hungary than on international level . --- 2,96 3,02 The organizations in our research think, that IT knowledge is necessary to the digital business transformation in all areasthe difference may be in the extent. Not surprisingly, the leader of the list is the IT area, but more importantly, the responders evaluated the existence of digital knowledge in most areas higher, than 'medium'. What's more, the business respondents evaluated digital knowledge in marketing, finance, accounting and logistics more important compared to respondents from IT. While IT knowledge necessary for the business transformation is required from IT professionals by organizations, the role of IT seems to be more supporting: to address security issues, the implementation capacity , architecture design. Interestingly, participation in innovative projects pushed to the end of the listbut it is worth noting that even this category is stronger than 'medium' . It seems that IT, and IT leaders have to manage an interesting situation: their knowledge is essential to the successful implementation of digital business transformation, but our research showed that in the making of ideas or innovation business areas do not rely on them. Business areas often go their own way, and involve IT areas latersometimes too late. As evidence, we have seen that most organizations consider the digital transformation strategy distinct from IT strategy, and they put the emphasis on business issues such as how will my business processes change, what can be used from an existing digital toolbox. --- 8% Since the use of cloud services is increasingly widespread in Hungary, it can happen easily that business areas decide to use IT services without involving the IT -then of course they need integration, standardization, and raise security issues. This leads IT to lose control and the opportunity of proactiveness. --- Conclusion Our research results showed that the Hungarian companies have a positive attitude towards the digital transformation concept, the general level of awareness is high. Among the analysed topics we discovered some general patterns: Another important area to be developed is speed: if IT is not capable of quick changes or supply fast solutions, business areas can take over control. --- Introduction Although the banking industry is a traditional and conservative industry, it has to follow the required changes of digital transformation. Although the banking industry is heavily dependent on technological solutions, this change is not encoded in the genes of the banks. Moreover, identifying possible digital developments is harder, than the banks think. The goal of our research was to analyse to identify customer challenges of Hungarian retail banks, to develop and to test digital ideas to address these challenges. For this research, we were collaborating with seven Hungarian banks, and analysed both online and offline customer challenges. The goal of this paper is to overview the related concept in the literature, and present the results of this research. --- Related concepts The goal of this chapter is to analyse the current challenges of digital transformation, presenting the challenges of the banking industry, and analysing how customer centric digital innovations can be delivered. --- The challenge of Digital Transformation Digital developments were traditionally dedicated to the responsibility of IT Departments. Although the alignment between business and IT goals was a never-ending discussion of both practitioners and researchers ; Kahre et al, 2017), the leading role of organizational IT was not really questioned, and outsourcing of IT services usually arose mostly in operational issues. By now, the exclusivity of developing new IT services, and delivering digital innovations has loosened, mainly because of the following reasons: ---  As digitization reached business departments, the requirement of IT knowledge, and IT savvy employees became vital of organizational success . Therefore business leaders and employees had to acquire digital skills, so IT departments' knowledge monopoly is under demystification.  As Software-as-a-Service solutions, especially cloud-based solutions became more and more accepted, business units have the opportunity access IT services without involving their IT departments . Moreover, introducing a new IT service into business operations via the SaaS model takes less time than the traditional implementation projects .  Not only the speed of implementing new services is an issue, but also the quality of new services. As IT solutions, like infrastructure, or access to internet became , the transaction cost of choosing or changing SaaS services decreased, therefore organizations can select innovative SaaS solutions with lower costs and lower risks. As Carr urged, "it's time to rethink IT management". Therefore, Bharadwaj et al claim that business units lead the way of digitization, and digital business strategies are separated from traditional IT strategies, as digital strategies address cross-functional business objectives, and changing business processes by utilizing IT resources. Digital strategy is treated as business strategy itself. --- Digitization challenges of the banking sector Digital technologies have been entering the banking industry for years, and the banking industry and banking operations and highly dependent on the IT services . Shaikh and Karjaluoto originates automated retail banking services into the mid-1960s, because of the requirement of processing the huge number of credit-card related electronic transactions. Since then, digital solutions are not uncommon in the financial sector: ATMs in the late 1960s and 1970s, telephone banking and POS solutions since 1980s, online banking and even mobile banking since late 1990s. Motivations of digitization was faster and cheaper customer service. Despite of these efforts and digital achievements, banking services still seem to be lagged behind general digital technology trends, and behind the digitization of other sectors, especially commerce . The situation is more challenging for the banks, as their customers take their financial services from different service providers . Easy to access internet-based services make this situation even worse: using SaaS services on the internet provides low transaction costs for trialling, selecting or changing alternate service providers. Moreover, Y-Generation and technology-savvy customers demand and appreciate digital services, and these segments are ready to change for a better digital customer experience . Beside the changing customer behaviour, banks have to face new challenges :  As new entrants, FinTech companies offer digital financial services in several niches. FinTech companies act as startups, frame a very specific customer challenge, and offer very specific solutions . One FinTech service probably will not endanger banks, or the banking sector, but together they target small but very profitable slices of the banks' value chains. Surprisingly banks didn't start to address this challenge, yet , although this hybrid financial model seems to stick in the market, and questions the role of banks in the following years .  Technology companies also enter to the market of financial services, as financial services became an integrated segment of their value offerings: Alibaba, Google, Apple, Samsung, etc. provide more and more financial services, which are technologically advanced, and moreover, they can target their existing user base. ---  Since the financial crisis started in 2008, government and industrial regulations became stricter, and require banks to apply and report these requirements . These compliance issues require additional investments in technological solutions , and makes their service offerings less flexible, and sometimes less user friendly. --- Customer centric digital innovations As customer behaviour is changing, it is not enough simply to offer new digital services, or just to copy the existing services of the competition. Even before the age of digitization, customer experience questions were highly important, and loyalty of banking customers was related to perceived value, service quality, service attributes, satisfaction, image and trust . Digital services are expected easy to use, comfortable, natural, but moreover, the solutions should service the need of the customers. FinTech companies, and digital innovators not simply digitalize or automate existing processes, but adequately understand customer challenges or new requirements, in which customer experience has a vital role . The need of a better-grounded design of products and services started by Herbert Simon ), as defining the role of design as "the transformation of existing conditions into preferred ones" Because of the nature of a general design thinking approach, it is able to be a basis of digital innovations . Inspired by the overview of different design thinking approaches by Gioia and based on the collection of Dam and Siang of the Interaction Design Foundation, and processing additional widespread models, a general design thinking process includes the following steps : The goal of our research was to explore and identify customer challenges in retail banking. To achieve this goal, 7 Hungarian banks joined to the project, of which total balance sheet altogether represents 68% of the Hungarian banking industry. Nature of the research, exploring digital banking possibilities, the research was considered explorative. We wanted deeper insight than the traditional surveys and case studies, therefore we decided to select design thinking approach among the qualitative research methods. The Design Thinking approach can provide a deeper understanding of customer-centric challenges than traditional surveys or case studies through deeper involvement of observation. The Design Thinking approach also help to identify and evaluate as many challenges, as possible, and ideate as many solutions, as possible. For the basis of the applied methodology the 5 steps approach of IDEO and Riverdale was selected . Because we have limited time and limited resources we had to adapt the methodology to fit into these frames. To achieve our goal, we used the following additional sources to construct our research methodology: ---  The book of Knapp et al presents the methodology that Google uses for rapid prototyping of their ideas. Although we applied different phases and steps, this book helped a lot how to organize the week. This approach, the agile project blocks also inspired the name of our methodology. ---  Although we heavily relied on the "Design Thinking for Educators" methodology, we used parts of additional design thinking approaches: Brown ; Ambrose and Harris ; Stickdorn Mootee ; Kumar ; Cosovan and Horváth . ---  To enhance creativity, we used additional creative techniques during workshops, based on the works of Sibbet ; Gray et al ; Michalko ; Zichermann and Cunningham and Vogel . Based on these resources, we created the "One Week Sprint" format that consists of the following steps and content . During the research, each team was dedicated to a selected bank. Coordination of the teams and methodological assistance were provided by two leading researchers, in the role of design thinking coaches. The research team invested more the 1000 working hours during the 5 days to explore and analyse customer challenges, and provide viable ideas for the banks. In the discovery phase the main goal was to identify as many challenges as possible, while in the interpretation phase the teams prioritised these challenged and reduced them into a few for further work. In the ideation phase the teams brainstormed a huge number of ideas, but during experimentation only a few viable were selected and tested, and the successfully tested and iterated ideas got only the final phase. In the last phase the surviving few ideas were developed further: costs, benefits, risks were analysed, and a project timeline was added . Following this methodology Project teams delivered their research findings at the end of the 5th day, concentrating on the main problems and main solutions. After the One Week Sprint, all the identified challenges, and possible solutions were collected and analysed further by the coaches. This paper presents these aggregated results. TRANSFORMING OUR LIVES (JUNE 18 -21, 2017 --- Research findings Our main findings can be grouped to three main areas: ---  The changing role of branches  Online, mobile and phone-based services  Products and services In each problem area, we present the identified customer challenges, based on our observation, then we present the possible solutions identified by the project teams. Although each project team was dedicated to a specific bank, customer challenges and problems overlapped of the different banks. --- The changing role of branches Customers articulated their most problems related to branches in Discovery phase . As we investigated the area of branches in Interpretation phase, it appeared that no one loves to go to bank branches, especially not the younger generation. The traditional functionality of bank branches was to serve as the central point of customer relations. However, for customers visiting the branch may be "only" a drag, or worse, it can mean frustration for them. From the banks side, the reducing number of customer visits should motivate branches to take advantage of these rare opportunities, improve customer relationships and trying to sell new products and services using their personal presence. From the customers' side, the branch visits are considered as a task with no significant added value, so they would like to do it as fast as possible. And they consider all the things that prevent this as annoyance. To manage these problems, nowadays it is considered natural to direct all possible administrative tasks to appropriate online channels . The question remains: what to do with the bank branch where customers do not want to appear in person; and how to convince customers to choose the closest relationship: personal appearance? The question is complicated because of the heterogeneous composition of the banks' customers, and there is no solution that would be appropriate for everyone. There are customers, who prefers personal presence in their sensitive banking affairs -and the customer experience should be ensured for them as well. Suggestions made up during Ideation phase and tested in Experimentation phase: • Enrich waiting time: Waiting is typically a lost time, both for customers and for banks. It is worth to make this time more meaningful, and provide an opportunity for interaction with the bank through personal assistants or electronic solutions. what is required for an agent to visit community offices, appearing elsewhere day-by-day as a mobile branch clerk to arrange matters? After all, the branch is not necessarily the physical space, but the place where the issues can be arranged. One full project proposal from the Evolution phase was dealing with how to reduce waiting time and to understand the intentions of customers. If the waiting time may be longer than a few minutes, the customers should not draw a line number, instead, a tablet serves as a personalized caller. Through this device, the authentication of the customer and identification of the customer's preferences can be easily done. The customer can get familiar with the bank offers, and even express their interest in banking products. The customer needs can be assessed in the form of tablet games. It is important, that in these cases the bank can identify the real customer needs and offer those products only, that meet the real needs -even in a personal administration -rather than products typically offered to all customers. If the customer needs can be identified in advance, or detect lack of interest, the personal administration will be targeted, so it can be faster. --- Online, mobile and phone-based services Empowering customers to manage their issues in an online channel seems to be an obvious solution to most of the problems outlined in the previous section. Arranging issues online reduces the need of personal contact, which may ease the customers' life and lower operating costs for the banks themselves. At the same time, managing issues outside the branch leads to challenges , that would have been easy to handle in the branch itself, such as inadequate supply of information, lack of consultation and the functional limitations of the different platforms. Regarding the non-branch channels, the most frequently expressed counter-argument is the issue of security: whether the data of the customer will be stolen, what can ensure the customer that they are communicating with the bank itself, what can guarantee the ---  Provide adequate, professional support to online channels: In the back office of online and mobile applications there are no clerks -because of these channels nature. But if the customer gets stuck, or has questions, it would help them a lot if there is an opportunity to redirect to a more personal channel: online chat, video call, call centre. In addition, because the customer has been authenticated online, no other authentication should be performed again during the transition to the new channel. This solution can reduce the number of lost cases. ---  The customer should be a partner in security issues: Even though the issue of bank security belongs to the banks, a significant proportion of fraud attempts are targeting customers' credulity. To prevent this, banks should improve customers' security awareness and manage their business transparently. In Evolution phase, teams were making project plans to solutions which were targeting existing mobile applications without meaningful functionality, or to a augmented reality branch, where customers can manage their issues in the well-known environment of their own branch, with professional clerks as avatars, using internet-based telephony. --- Products and services Regarding to administration in branches, the interviewed and examined customers highlighted in Discovery phase the lack of transparency in the bureaucracy of banking, and that there is a lot of paperwork with all issues . The loan and investment administration turned out to be the most effected with the problem, that the rules and the processes laid down by banks are too complex, complicated and incomprehensive for customers. Customers typically get information from these rules and processes from clerks during the administration -and sometimes different clerks give different information to them for the same issue. That is a common customer complaint that the rules seem to be articulated in a way that the customer may not understand or do not want to understand them. Banks must meet several legal requirements and a significant part of these apply on the cooperation with customers, so the banks have no other option than to enforce the rules applicable to customers. This make the rules and the banking operations for customersbut often also for the clerks -difficult to understand, and what is even worse, following the legislative changes the rules and processes are frequently changing as well. Because of the above mentioned, the customers -regardless of the intention of the banks can feel that they are at the mercy of these institutions. From the bank's side, ensuring customer experience is becoming more challenging and this can lead to churn of customers. This is one of the most important findings from Interpretation phase. The extent banking services can be customized or personalized, which is also part of the customer experience. Many customers have indicated that there are only a few options of banking services available, and they cannot find those services that meet their own, sometimes not so unique needs. Therefore, if they can find appropriate services in another bank, they consider the possibility of switching banks. From Evolution phase, a project plan visioning an online bank, where personalized advertisements can be seen based on the data gathered from the chronologic and personal data from the customer is important to mention. --- Conclusion Although most bank realized the importance of digitization, customer centric approaches are quite new in the Hungarian banking sector. Development is not only a technological question , but also a methodological one. In our research we demonstrated a useful, rapid, very focused approach of explore customer challenges, but for a successful project we required a good, and prepared team members. The two coaches were able to provide adequate methodological support. The findings of the project were discussed with the participated banks, given them better insights of customer-centric approaches, through defining the demand. But additional challenges also pressurise banks to develop their systems: eIDAS compliance, PSD2 challenge, GDPR regulation. It is a limitation of this research, that its focusing only on customer related challenges, that mainly visible in front office services. But for Hungarian banks, they have the opportunity to apply matured solutions and technologies: what is still innovative on the Hungarian market, that is already tried out on other market, and we can know the success and failure stories. Therefore, it is important to benchmark the international market, even before deciding on It is a strategic choice of the incumbent banks, how to manage their relationship to FinTech companies. They can be considered as competitors, as possible partners to work with, but we have also seen a Hungarian bank, that itself developed a Fintech Incubator program. Fintech companies are considered either partners or competitors, but they definitely increase the competition in the sector, and support the digitization efforts. Generally, the applied research identified several customer challenges and offered also several possible digital solutions. Although the project teams couldn't finish complete, detailed, ready-to-ship products, they made rapid progress, generated and designed a huge number of ideas, and they tested if they are headed in the right direction. In future researches we would like to expand the size of the research: the used one-weekspring approach should be expanded with additional surveys to validate the findings, and to generalize the results. --- Introduction The development of information communication technologies brought various opportunities and prospects for small and medium enterprises. Very often SMEs are described as slower adopters of innovative information communication technology solutions in comparison to large companies, which have capacity and possibilities to develop and adopt the latest ICT-based innovations. Such situation is caused by the lack of knowledge, strategic forecast, and finances. Facing such situation, SMEs tend to use information communication technology solutions, which can be provided by third parties and third parties take care of the solutions. Such solutions might be provided on various platforms, which offer new opportunities for SMEs. Recently a growing discussion about platforms, their development, and their business models has been observed. These discussions as well as related research address how platform business models might be developed and how successful platform business models are run. However, SMEs usually act as users of the platforms in order to fulfil their needs and gain an advantage in the market. The success of the company is determined by defining and implementing the business model that allows understanding the key aspects of the success. In order to sustain longterm advantages, SMEs should innovate their business models in response to the changing market conditions, i.e. find new ways to expand their value propositions, find new markets and segments. Use of platforms provides various options for SMEs. According to researchers, companies need to consider platforms such as Google, Facebook, Amazon, Apple . Our research aims to contribute to understanding how SMEs use platform possibilities to innovate business models and how these decisions are made. SMEs make strategic decision to deploy various platforms as they provide different opportunities, e.g. Google and Apple help to reach customers, Facebook to develop relations, Amazon to use more effective services. The research presented in the paper aims to understand how SMEs evaluate platform possibilities, how the needed functionality of the platform is selected, how SMEs change the business model and how SMEs assess the success of business model change. The four platforms in particular become important partners in business to consumer markets as GAFA takes about 55 percent of user digital life . The phenomenon, when new companies appear online by using only the infrastructure of GAFA are also observed. In this paper, we contribute to the research body by analysing the use of Google and Facebook products for business model innovation among Lithuanian SMEs. --- Business Implications of Digital Platforms The term "platform" has been attracting the attention of practitioners and researchers in the last decade. The term became so popular that practitioners and researchers started using a new term "platform economy" . Initially, the term "platform" was defined as "digital infrastructure on which different applications can be run, or allowing for a finite and clearly defined set of uses" . Techopedia suggests the following definition: "a platform is a group of technologies that are used as a base upon which other applications, processes or technologies are developed." This approach is clearly related to the technical point of view as key characteristics of platform refer to hardware/software aspect and clearly defined set of action. Such definition addresses Google or Facebook platforms at the beginning of their activities as Google served as search engine allowing users to find information, while Facebook served as communication tool providing an attractive and simple way to socialise. However, due to the development of technologies and more active role of platforms in the digital economy, the new term "platform company" appeared. The term aimed to describe company offering a platform or several platforms aiming "to provide marketplaces, distribution of media content, and/or coordination of activities" . This definition demonstrated managerial approach emphasising functionality which platforms were offering as a key value proposition. Ballon even suggested the term "platformisation" referring to new societal trend when companies are developing and offering platforms, and new platform-based business models appear. Platform phenomenon became popular and new term "platform economy" appeared. According to Kenney and Zysman , platform economy is "one in which tools and frameworks based upon the power of the internet will frame and channel our economic and social lives." Authors identify four essential elements that ensure the functioning of platform economy: infrastructure, training and skills, social protection, and regulatory transition. The growing importance of platforms was also addressed during World Economic Forum 2016 by outlining the importance of platforms for companies and organisations, naming disruption of economic activities, lower market entrance barriers, and in some cases changes to the logic of value creation, capture and transfer to market . As companies face new challenges in adopting platforms these challenges mainly refer to functionalities platforms offer. Companies using platforms can dedicate more focus for business development and business differentiation. As platforms act mainly as facilitators, companies need to understand how to adopt platforms in their daily activities and how to measure the value platforms bring to their business. The growing number of platforms also indicates the differences between the platforms. Some platforms are oriented to reach consumers , some facilitate communication and provide services , some facilitate trade . In many cases, platforms act as facilitators enabling companies to enhance value proposition and optimise their activities, but the value for both parties are created through orchestration. Platforms also might be described as "frameworks that permit collaboratorsusers, peers, providersto undertake a range of activities, often creating de facto standards, forming entire ecosystems for value creation and capture" . Gawer and Henderson suggested an approach to defining a product as a platform. According to Gawer and Henderson , a product is a platform when "it is one component or a subsystem of an evolving technological system, when it is functionally interdependent with most of the other components in the system, and when end-user demand is for the overall system, so that there is no demand for components when they are isolated from the overall system." Platforms might be described by several important components : . Despite growing popularity, business model research area attracts academic exploration as according to Teece , this area resides somewhere between economics and business strategy and more elaborated research is needed. The related area is business model innovation, which according to Spieth et al. , remains "a slippery construct to study" . Within our research context, it is considered that platforms bring new opportunities for value creation and capture, and companies need to rethink their business model logic. This refers to business model innovation concept, which can be defined as "changes in business logic that are new to the firm, yet not necessarily new to the world, and have to result in observable changes in the practices of a BM" . A --- Research Framework There are many approaches to business model analysis. One of the most popular approaches widely accepted by practitioners is Business Model Canvas . This approach defines key components of the business model: value proposition, customer segments, channels, customer relations, key activities, key resources, and key partners. As a consequence, decisions regarding these components result in revenue streams and cost structure. In our research, we decided to address two important platforms, namely Facebook and Google. Facebook is easily identified as a platform and companies might obtain various services through "one-stop shop" approach. Google situation is different as Google offers several different services and use of these services causes some confusion for SMEs. SMEs are interested in using such products as AdWords, increasing their position in Google search listing , use a Google Drive. The comparison between traditional business versus opportunities of Facebook and Google platforms for business model innovation is presented in Table 1. Platform adoption is strongly driven by the spread of ICT and many new start-ups adopt platforms for the benefits platforms are offering. Considering such situation, many entrepreneurial SMEs also move towards platform adoption, as this should give them the opportunity to run the business more efficiently. Research method. An analysis of several cases of Lithuanian SMEs using Facebook or Google in their activities was carried out. No distinction was made if SMEs use a platform by themselves or are they supported by business consultants. We believe, that even if SMEs use consultant services they understand benefits of platforms well enough as SMEs invest in the utilisation of the platform. We tried to identify SMEs using Facebook or Google platform. In many cases, we found it complicated as SMEs tend to use both of them, but we identified cases there one platform is key platform and use of the second platform is limited, and therefore the role of the specific platform is more expressed. Interviews were carried out with SME representatives that are most knowledgeable about the use of a given platform within their organisation. Additionally, an observation of actual use of a platform was carried out where possible . The company is developing its toy brand ačiū pačiū, and expects that in future the brand toys will become the main product of the company, and there will be no need to take orders for other sewing services. --- Empirical Findings For online marketing, the company uses an e-shop http://www.aciupaciu.lt , e-catalogue, and Facebook page . They also plan to start using the Instagram account. The company also writes articles, but rarely. The primary reason to start using Facebook was the fact that Facebook was the cheapest and easiest to use way to reach the target customers of the business. At the beginning of the business it was important that the means used would allow reaching customers without larger investments. The other important reason was the responsiveness of the customers, as "it is significantly easier to communicate with them here and now". It was noticed by the company, that customers nowadays find it simpler and more convenient to write a Facebook message than to write an e-mail. That was important to the company, as they want to be accessible to customers, have personal communication with them, and to have the opportunity to offer personalised products. Facebook provided a platform enabling that kind of communication. Compared to other social media platforms, activity on Facebook achieves the highest engagement from followers. Key features of the Facebook used by the company are: the Facebook page of the brand, instant messaging function, paid advertising options . Facebook page is administered by an external agency, while the company itself maintains the content. How platform affects business model innovation? First of all use of Facebook enables the company to reach its target customers. In fact, company representative claims that "if not Facebook, I do not know how else we would have reached the customers at that moment when we needed that." Facebook enabled the company to reach new customers as well. The company was targeting people from Lithuania. However, they soon discovered getting orders from abroad as well. Facebook is also used as a source for modifying the product, namely the core of the value proposition. Personalised and customised products are offered to customers based on personal communications with them via Facebook messenger. Also, the company uses feedback from their Facebook community to make decisions regarding the products . The latter option is rarely used, however. The communication with the community on Facebook helped the company to understand that customers prefer simple products and designs. "Whenever we placed a more unusual or interesting offer and expected people to prefer it, they would surprise us by choosing more simple and basic option. That helped us to provide more relevant products to our customers." Facebook page is used as one of the main channels to raise awareness of the products, by introducing and promoting novelties. Advertising possibilities are used for this, e.g. every post is boosted for few days by targeting target customers of the brand. As mentioned, it is also the main channel to communicate with customers. Therefore, to provide post-sales support as well . Facebook is also a crucial platform for maintaining relationships with customers. The messenger is used for personal service, to chat with customers, answer their questions, to find out their requests and preferences. Community relations are also maintained on Facebook page of the brand. --- Case 2. Use of Google Platform The company Transer was identified as SME case with the use of Google platform for business model innovation. Interview was carried out with one of co-owners of the company . The company Transer offers translation services for technical text . The company is SME and have five persons directly involved in company activities. There is an extensive partner network as the company hires different interpreters for specific tasks. The company revenues reach about 100K euro per year in the last three years, and according to company CEO, revenues are stabilised. There is no specific reason why Google platform was selected, but the decision is based on a variety of information available in newspapers and journals about Google benefits for business. The first attempt to use Google platform was in 2010 trying to reach a larger number of customers via PPC advertising . However, this initiative was not successful for several reasons. First of all, the company lacked knowledge and The second attempt to use Google products was much more successful. This time it was decided to use Google Drive and Google Documents in order to save costs and make internal operations more efficient. According to the company owner, the ability to use documentation in a more comfortable way was the reason to start. "I use two separate computersone in the office and another one at home. Typically, in a rush, I forget the documents, and it means I cannot access them because documents are on another computer. By using Google Drive/Documents, I can access all documents from any computer." The next step in using Google platforms was to use Google Documents on various cooperation tasks. "As we realised we can all use the same document, we started using this solution for implementing some activities." After successful use of Google Documents, the company decided to replace CRM system with Google Documents. The attempt was made to share information through Google Documents with partners/interpreters, but it was not successful. Interpreters preferred to call or send email, but not use online documents. --- How platform affects business model innovation? The company used Google platform for several business model innovations, but only one of attempts was successful. The first attempt was to reach new segments and new customers using Google AdWords, but the lack of knowledge did not result in a desirable outcome. The attempt to use AdWords lasted just for several months. Second attempt related to the optimisation of internal operations and affected key resources and key activities. The Google platform improved internal operations and became part of company infrastructure. As a consequence, the company decreased costs around 500 euro per year. Those are not significant savings, but company CEO considers them as important ones. --- Discussion From the theoretical research, assumptions were made on the contribution of Facebook and Google platforms on business model innovations. Based on interviews with SME representatives we might state that the impact of Facebook is easily recognised and valued by SMEs as Facebook acts as one-stop-shop. It is more complicated to determine the impact of Google products from SMEs perspective as Google offers various services which might be used by different departments. Facebook platform is perceived as a marketing tool mainly, and in the case of Google, only some features are related to the From case studies, we observe that platforms are used for reaching target segments. In the case of Facebook, this associated with a "typical feature" of modern brand and company successfully maintains its presence on Facebook. From the perspective of Google platform, AdWords were used to reach target segment. However, the company did not manage to do it appropriately as lacked skills to use AdWords. We also find out that companies can successfully use Facebook platform as communication tool allowing to customise value propositions. Facebook messenger plays a major role in getting information about small details of a product . Therefore, Facebook Messenger plays an important role in building customer relations. We also observed that platforms might act as one of the main channels ensuring information flow and communication between company and target segment. As Google platform offers features targeted towards various activities of companies these features are used to make companies performance more efficient. We observed a case then Google Documents are used for operation coordination and customer relationship management, so the impact of Google platform on key activities is significant. None of the companies referred to platforms as partners, but it is evident that both platforms play an important role as partners in activities of companies. --- Conclusion Platforms play a greater role in SMEs activities as they give new opportunities for SMEs to innovate in the context of a business model. SMEs typically approach the four main platforms -Google, Apple, Facebook, and Amazon. Some platforms act as one-stop-shop offering different functionalities , some platforms offer features that are distributed . Platforms can bring opportunities for innovation in all business model components. None of the companies recognised platforms becoming important partners, but platforms role as key partners was observed. --- Introduction Optimal healthcare access, quality and value have become global priorities for healthcare domains to combat the exponentially increasing costs of healthcare services . Information systems/ information technology have been promoted as a critical enabler to achieving these priorities ). Presently, we are witnessing a staggering range of IS/IT applications in healthcare that have promised to deliver higher quality and safety with greater value . However, the data supporting these claims is often lacking or poorly supported . Advocates, in particular, point to the potential reduction in medication errors as a critical advantage . These singular advantages do not reflect the enterprise viewpoint that is so needed . Further, the debate about the difference IS/IT solutions can make to healthcare quality, efficiency, and safety has only intensified . In the light of these complex circumstances, there is a critical need for a framework to evaluate the business value of IS/IT in healthcare . Previous research has discussed examining the business value in healthcare IT by leveraging four groups of IS/IT according to their business. These groups classify IS/IT into infrastructural, transactional, informational, and strategic domains . Socio-technical aspects with healthcare projects are also important to consider. Thus, they are mapped in previous work with the different layers of healthcare delivery including healthcare ecosystem, system structure, delivery operations, and clinical practices . This research evaluates the developed model of The Business Value of IT in Healthcare . This model was designed to help evaluate the business value of IT in healthcare . The model itself takes technical and socio-technical perspectives in mind. The former is presented by the work of Weill and Broadbent , which classifies IT investments into four categories based on their business objectives , while the latter is presented by the work of Rouse and Cortese which classifies various healthcare delivery activities into four levels, namely healthcare ecosystem, system structure, delivery operations, and clinical practices. Specifically, three clinical IT systems at both private and public healthcare settings in Australia were evaluated. The first system is an American made computerized physician order entry system. The second is an Australian made nursing documentation system, while the third is an Australian made incident reporting system . The selection of these systems was based on their characteristics as they address the needs of different stakeholders i.e. the ND system helps streamline the --- Methods and Settings A multiple case study approach was adopted, as this enables contrasting results for predictable reasons to enhance the generalisation to other case studies . Two case studies were used in this study. The selected cases were chosen based on 1) the volume of IT investments they both made during the last 5 years, 2) their nature to help identify any differences could result as a result of differences in care delivery models, and 3) having vast ranges of clinical specialties The first is ABC Hospital, a Victorian public hospital established in 2000 and provides care for more than 750,000 people. ABC Hospital has been providing around one million episodes of patient care each year through the efforts of about 10,000 staff. ABC Hospital provides a comprehensive range of clinical services and high-quality acute, sub-acute and palliative care, mental health, drug and alcohol services, and residential care, community health and state-wide specialist services to people and communities that are diverse in culture, age, socio-economic status, population and healthcare needs. The second case study is XYZ Hospital, which is a private hospital and counted as one of the largest not-for-profit private healthcare groups in Australia. With seven sites and two rehabilitation centres, XYZ Hospital has invested more in IS/IT during the last few years than in the past and hence was one of the reasons they were chosen to be included in this study. According to the Chief Financial Officer , approximately 30% of the capital budget during the last five year was set aside for IT investments in business, infrastructure and clinical systems. Three clinical IT systems were examined; the ND, IRS and the CPOE systems. The ND system was studied within ABC and XYZ hospitals, while the IRS and CPOE systems were studied solely within XYZ Hospital. Prior to conducting the data collection, all ethics approvals had been acquired from both hospitals. For the ND system two sources of data were used; survey 1 data collected from ABC Hospital , and semi-structured interviews at XYZ Hospital. First, the survey was distributed pre and post implementation of the ND system and consisted of six sections. The survey used the unified theory of technology acceptance and use of technology as the studied ND system is a new system. UTAUT was used as a technology acceptance model to uncover intentions of users regarding the use of a new system. Inclusion criteria for the survey was: 1) being a nurse, 2) worked for more than 5 years in similar settings, and 3) willingness to participate in the survey. The survey used the lens of UTAUT, and was validated using extensive discussions with academics and experts in the healthcare domain. Required changes were made accordingly. This method is widely used to measure the different aspect of interaction between human resources and health IS/IT, see for example . Due to the nature of nurses' duties, and to our intention to gain instant understanding of how the nurses found the investigated system, a hard copy of the survey was prepared and provided to nurses at the completion of their shift. Those who met the criteria across two sites at ABC Hospital were 39 in site A and 48 in site B with response rates of 60% and 70% respectively. Due to the complexity of the CPOE and IRS systems, and given they both were new during the data collection phase, 23 semi-structured interviews were conducted for healthcare better understanding of the possible business value of these systems. From these interviews specific themes emerged with critical information and insights from three major groups of professionals in the healthcare industry: executives, clinicians , and IT personnel. Selecting the participants was based on their role and/or affiliation with the group, as well as their level of interaction with IS/IT investments and projects. The first protocol for the interviews was reviewed by conducting three pilot interviews with medical and IT experts. This phase resulted in a shorter and more focused protocol. Three questions were deleted as they had been designed to ask about systems that never existed in the case study , and two questions were added to explore insights from clinical IT experts, i.e. clinical people who are IT savvy. After modifying the interview protocols, the main interviews took place. All of the interviews were audio recorded with full permissions from interviewees, professionally transcribed, verified, and then qualitatively analysed using QSR Nvivo 10 software . Data collected from these interviews were analysed also to understand the business value of the studied systems. These interviews were also used as a primary source of data about the CPOE and IRS systems . --- Results Data analysis was initiated by mapping the three systems using the Business Value of IT in Healthcare model. Based on the their functionalities, the studied systems were classified as informational IT, which provides information for managing and controlling the firm, as well as supporting decision making, communication and control . These systems, though, have other components from the IT Portfolio as Table 2 depicts. For example, the CPOE system is informational in nature, as it helps produce and share information on treatment plans and medication scheduling. However, it has a transactional component, which enables data entry/input like identification, progress notes, medication scheduling, discharge checklist, and treatment plans. In addition, it utilises the IT infrastructure like Internet, Intranet, workstations, servers, and databases. --- The CPOE System The CPOE system, specialized in oncology care, has three modules focused on radiation, medical, and surgical oncology care. At XYZ Hospital, the radiation and medical modules have been implemented, while the surgical module has not yet been acquired. The aim of implementing this system is to replace the manual patients scheduling with an electronic means on a quest to improving the integration of the cancer care process and eliminating prescription errors. The radiation module was implemented in XYZ Hospital two years ago, while the medical module has been recently acquired. Globally, the system has been in use in the market for 10-15 years while in the Australian market, it is been in use for 7 years. Investigating the impact of this system showed that CPOE systems have high potential to optimize both patient outcomes and healthcare efficiency by better aligning with care standards and protocols. Since the introduction of this system, "there's been a significant reduction in errors because we prescribe according to the protocol. These protocols are quite common and human error in prescribing is common. It has enhanced legibility, all that sort of stuff" as one interviewee descried. For the financial performance, a number of interviewees expected that the system would enhance the financial performance by receiving more referrals from independent oncologists , but this is subject to complex agreements that have to be reached between the hospital and the VMOs and that is beyond the scope of this paper. --- 3.2 The ND System The ND system has been envisaged by the developers to replace the paper-based nursing documentation applications in hospital acute wards in both private and public hospitals. The objective of this system is to eliminate time assigned for non-medical duties and allocate more time for patients' care. This is facilitated by putting smart terminals at patients' bedsides, creating more direct interaction between nurses and patients. Providing these smart terminals directly at the bedside should facilitate higher levels of collaboration between ward nurses and other healthcare professionals according to the system's designers. Results revealed from the UTAUT survey at ABC Hospital showed that this system increased the time for patient assessment from 5.2% to 9.1% of the total time spent by a nurse during a regular ward visit. This was achieved by reducing the time consumed for nursing documentation from 15.7% to 6.4%. Not only did the care time increase, but also the level of transparency, as patients could witness more details about their care provision, and an extra 48.1% of nursing activities were performed at the bedside compared to the process before introducing the ND system. The system helped increase patients safety by having a 'one-stop-shop' for patient records as one interviewee described. On the other side, a number of interviewees did not see a direct translation between 'longer care time' and 'better care'. One interviewee noted that it is "much more complex than just taking some aspects of the role away", and even with this new system "I think that even with our new technology that we're testing now, nurses find other things to do" as another interviewee explained. The scope of the system is limited to ward and nursing station. This does not allow the system to cover the end-toend process of healthcare provision as one interviewee noted in their concerns. In addition, the ND system has demonstrated high potential to increase the healthcare efficiency by reducing the time dedicated for paper records and following patients' information and records. The nature of the system allows for a "higher number of processes to happen ever than before" as one interviewee noted, which has direct impacts on the efficiency of healthcare delivery through prompts and real time documentation. Also, this system seemed to have some impacts on the clinical decision making process. With all patient data available in the ward in one electronic pool i.e. the ND system, nurses can make clinical decisions or recommendations quicker, and based on more evidence than the paper records as agreed to by the interviewees The results show that the system may have indirect impacts on the financial performance of the facilities. This is by enhancing the reputation of the hospital through their use of state-of-the-art systems that are visible to the patients. A number of interviewees noted that this system has what was termed "face value". As a private hospital, reputation is a "fundamental part of the business" as one interviewee described. Thus "if patients feel that even just on face value, that the nurses are not scribbling on a piece of paper, but actually, they've got an IT system that provides confidence in the organization". Other aspects of enhancing the financial performance by using this system included better resource allocation. As the time spent by nurses to perform documentation duties is reduced, nurses are expected to capable to provide care to higher number of patients. --- The IRS System This system is used across almost all of Victoria and beyond in large parts of Australia as well for capturing abnormal clinical incidents. It serves two purposes: documentation of an incident at the time it occurs, to support the classification via an inbuilt algorithm into how serious the incident is, and standardizing the information that's being captured through validation fields, distribution of that information to where it needs to be and then to drive it through into a larger data set of all clinical incidents to support more detailed analysis. This reporting system is web-based and enables all stakeholders to report different levels of incidents irrespective of their criticality. Along with capturing clinical or non-clinical incidents, the IRS enables sharing information with different levels of management and employees without any delay, as one of the closet administrators of this system explains: "that's about people anywhere in the organization reporting clinical -or incidents of any sort -that a staff or patient. That's dependent upon an IT system having someone locally There are some benefits in terms of information provision". This system is relatively inexpensive, simple, intuitive, and easy to use, as a majority of the interviewees agreed during our discussions. These features make this system very popular in the Australian Healthcare context. XYZ Hospital purchased this system a few years ago to address an obvious gap in the information flow regarding incidents across the hospital as a number of interviewees agreed: "... [without IRS] we will have no capacity to know, or no realistic capacity, to know what things are going wrong with our patients, and therefore the ability to monitor them, to improve them and to attract that improvement". Using this system has created a 'cultural shift' towards reporting in the group as one interviewee notes: "We've got numbers of things that happened at the time we implemented it. We've seen the cultural shift towards reporting; so increased numbers of incidents being reported not occurring because we don't know what occurred. Then we've seen the severity of those events go down in the time we've used it. Then the frequency of things happening goes down, while we have other indicators implying that reporting is still up". This shift, in turn, has other impacts on the overall performance of the group. A number of the interviewees emphasized that the use of IRS is associated with increased patient safety, healthcare delivery efficiency, as well as reduced cost of healthcare provision: "If we're not having patients stay longer because something went wrong, then it's more efficient. If a patient comes to have a heart operation, and then falls over and breaks their leg, then they stay for another week, have another operation; all of which we potentially are not paid for, so there's a cost imposed. So there are real benefits." --- Discussion This study analyses the business value of IT in three specific healthcare contexts. This was done by using the Business Value of IT in Healthcare Model, which builds upon the IT Portfolio model and the Enterprise of HealthCare Delivery model . The results suggest that looking at IS/IT solutions based on their business objectives helps identify which IT systems in the healthcare industry may help create more business value for the studied hospitals. Informational IT was shown to be the most relevant category for the healthcare context. This is consistent with the findings of Weill and Broadbent that informational IT is important to facilitate seamless information flow between different stakeholders. This is particularly crucial for healthcare providers as clinical decision making is a sophisticated process, and most of the time it requires inputs from different craft groups. Thus, finding an electronic platform that provides dashboard capabilities to nurses and other physicians is prudent for today's and tomorrow's healthcare. The results from the interviews showed that information sharing that is facilitated through the use of the systems evaluated in this study, IRS, ND, and CPOE has positive impacts on patients' outcomes, efficiency of operations, and the overall performance of the studied hospitals. The CPOE system shows a potential to increase both patient outcomes and healthcare efficiency by facilitating smoother cancer care delivery and reducing drug prescription errors. The private public nature of hospital did not have any visible impacts on patient outcomes and healthcare efficiency, as the core business is the same between private and public hospitals i.e. patient care.. Private hospitals seem to build upon brand and 'face value' elements to attract more patients by introducing state-of-the-art systems, the use of these system was not the first factor the patients took into consideration when making the decision on where to receive the care they need. However, the adoption of such systems attracted patients given everything else in the care delivery was the same with the studied hospitals. On the other side, the results show that embedding IS/IT into various healthcare delivery operations in the studied hospitals has introduced a significant change to both care givers and patients. In addition, given the CPOE is internationally developed, the results from the interviews showed that it still needs some 'domestication' to better attend to the uses' requirements. Similarly, the ND system was still under development during the data collection phase, which resulted in a number of technical problems and thus frustrated the nurses. No downsides were reported with the use of the IRS system. --- Conclusion Correctly and completely identifying the business value of IT in healthcare contexts remains a challenging task. To address this, three clinical systems were examined to better understand how information technology can facilitate the generation of business value in healthcare. The BVIT model was constructed to map the studied systems, and to understand what role private/public classification can play in the context of the two tier Australian healthcare system. All of the systems had direct and indirect impacts on generating business value. The BVIT model was found to be helpful to investigate the business value of a vast range of clinical IT systems. The next stage of research will study the CPOE system in Australian public hospitals as the systems are implemented. Given that the Australian healthcare system supports both public and private healthcare delivery models and the model in this study was shown to be as relevant in both spheres, this provides strong support for the applicability of this model in other healthcare contexts; namely UK or US where, as discussed earlier, the healthcare systems tend to be essentially public and private respectively. In general, investigating the business value of IT in healthcare is a challenging undertaking, due to the complexity and uniqueness of the healthcare industry. Unlike other industries such as finance, retail, and manufacturing, various non-monetized aspects need to be taken into consideration with evaluating the business value of IT in healthcare. This study has implications for both theory and practice. For theory it significantly describes the development of a systematic and rigorous framework to enable and facilitate the establishment of business value of IT in healthcare and also to value the IT solutions in healthcare irrespective of the public or private nature of healthcare system being studied. For practice it provides a systematic approach that can be applied to any healthcare context irrespective of the underlying healthcare system to facilitate a fuller and deeper identification of the actual business value of IT in a specific healthcare context. --- Notes 1 For ethical and commercialisation considerations, the reference is available upon request. --- Introduction Digital transformation provides opportunities also for start-ups and early stage companies to innovate products and new ways of doing business. Where New Product Development takes radical, technology-push disruptive change process as its starting point for new, competitive products , an evolutionary view about market-pull incremental effects on operations and products is provided by Business Modelling . These alternative views have been under debate on innovation in corporations . Moreover, studies on micro, small and medium sized organizations' survival provide growing evidence that entrepreneurial passion and originality can, indeed, compensate limited resources . This intrinsic motivation and aspiration of abstract nature, i.e. effectuationis expected to help SMEs in business model innovation, BMI . The effectual view supplements the above rational, causal theories of market-pull with incremental adjustments and technology push of radical, disruptive change. But are there links between NPD, BMI, and effectuation to performance in the real-life of SMEs? For this purpose, we synthesize a framework for inquiry to find out the elements of failure, survival and performance in select case SMEs. We first discuss NPD and its connection to BMI. Then, we present effectual reasoning and bricolage, and how they are related with BMI. Third, building on the previous discussion, we compose a framework for analyzing innovation activities, strategic intent, and performance of SMEs with five selected SME cases. Finally, we discuss our findings, innovation performance of SMEs, and directions for further research to confirm our tentative results. --- Lessons from innovating new products General finding in NPD literature is that radically new products built on novel technology fail often, mature slow, and are accepted on the market gradually over time due to tardiness of diffusion and negative attitudes towards new technology . But, if such a product offers clear advantage in comparison with competing products, the success rates are improved significantly . New technology becomes even more attractive in the light of the findings that on unfulfilled markets novel products tend to sustain longer than products built on minor developments, or product line extensions . Spending big on new product R&D works in increasing the number of new successful products . High-quality development teams consisting of dynamic, motivated, experienced and talented developers improves the odds of success further, especially if the management provides direct support, or introduces systematic methodology for NPD . Furthermore, speed of NPD has become increasingly important due to continuous reduction in the product life-cycle time and increased competition due to global, technological progression. Rapid NPD, prototyping, and testing increases likelihood of success, as iterations help in discovering errors, and provide flexibility and better understanding of the product potential on the market early . As an indication of this, Sarja raised scalability, visibility, and timing as additional factors important to the success on digital products business landscape. As trying to build innovations only on internal technology-push is unlikely to succeed , companies are encouraged instead to focus on their customers' needs already during the development of the product . This also helps to prepare unfulfilled product-markets for innovation. The same applies, if the novel technology and market analysis are used in combination during NPD-process beyond regular interviews with customers and end-users. Careful examination of alternative technologies, products, and markets during the development by product developers with end users further enhances the likelihood of success . Interestingly, while the most growth potential in markets is attributed to SMEs , SMEs often are limited in capabilities of the above NPD success factors . Thus, creating NPD capability is the first requirement SMEs must fulfil. Noke and Hughes , for instance, show, how SMEs employed strategies that combine their internal capabilities while minimising their internal weaknesses by partnering and outsourcing. Their study thus highlights that it is essential for SMEs to get involved in external NPD partner networks to kick-start the change process and to gear up for superior product-market innovating capability . We conclude that NPD literature separates technology-push and market-pull as drivers of innovation. Because customer involvement is to help in incremental innovation, involving customers may be detrimental to radical innovation . The reasoning is that when a firm focuses on existing customers, it may not recognize opportunities that arise in emerging markets or customers being offered disruptive solutions by innovators . In the light of the above, it is claimed that the process driven by technology-push leads often to radical innovations, whereas market pull is more often served with incremental innovations to the user needs. However, recent research argue that the two forces are complementary and necessary in NPD . Therefore, building successful new products on new technology is lucrative, because of the potential upside benefitsfast adoption, long lifetime, low competition. However, most of the means for successful new product launch do not depend on the technical skills only, but on the capabilities of the product development teams, systematic management support, ample resources combined with the knowledge and skilled, iterative probing, realization, and shaping of the market, technology and needs. --- Business Model Innovation Effectiveness Business model innovation means notable changes in the logic how an organization creates, delivers, and captures value. Foss and Saebi sum 'mainstream' BMI outcomes and research directions by analyzing 150 peer-reviewed scholarly articles on BMI published between 2000 and 2015. Their analysis reveal external and internal antecedents that drive the BMI with expected outcomes . This process is moderated by macro-, firm-, or microlevel variables, and emergers as cognitive structures 1 . The structures can either respond to exogenous technological and regulatory changes , or operate as a learning process of iterative analysis and experimentation in response to changes in the environment . We see these as fine tuning the previous view on the NPD incremental adjustment of internal resources. Yet, as evidence suggests, new business models have often been the source, and not the outcome, of industry change . Companies on 'traditional' industries have been able to generate supernormal profits by designing new business models in the presence of major technological progress, or in the absence of regulatory limitations. These new business models have boosted large-scale disruptive industry change reaching far beyond reacting to changes in business environment, or developing new products. It is about being active in innovating and implementing radically new ways of doing business by the management. BMI drivers of SMEs mostly differ from those of previously mentioned industry-changes a typical high-tech start-up or growth venture builds its future on one product to the global market . Furthermore, we do not know too well what facilitates BMI in entrepreneurial firms, and how are these drivers and obstacles different from incumbents . A recent empirical study reports that 37% of SMEs in Europe are involved in BM Innovation, but only 15% of them are familiar with mainstream BM methods like CANVAS, STOF, Visor, or BM Cube. Diverse tools are used, but their use is limited in scope and sophistication, compared to method-based BM-toolsets. More than 50% of the SMEs use consultants for BMI, which may explain the unexpectedly high penetration of BM among the studied SMEs. To conclude, despite the lack of sophistication, BMI is about to become mainstream in SMEs, leveraging their BMI capabilities and capacity. But does our contemporary BMI research capture the unique features of SMEs? TRANSFORMING OUR LIVES J. Heikkilä & M. Heikkilä: Innovation in Micro, Small and Medium Sized Enterprises: New Product Development, Business Model Innovation and Effectuation 201 --- Effectuation, bricolage and entrepreneurial survival Whereas BMI and NPD literature is mostly focused on causal approaches on developing business towards given goal, the entrepreneurial literature emphasizes the effectual side of businesses, which is considered as the inverse of causal. Causal rationality starts with a pre-determined goal and a given set of means, and seeks to identify the optimal, such as fastest, cheapest, or most efficient alternative to achieve the given goal. The effectuation process is highly subjective, starting from the capabilities and resources of the entrepreneur, and takes this "set of means as given and focus on selecting between possible effects that can be created with that set of means". Figure 1: Causal and effectual reasoning . Sarasvathy proposes four aspects that differentiate causal and effectual reasoning. She builds on her conceptual study, and on her empirical enquiry on serial entrepreneurs: Effectuation Entrepreneurs have been shown to have high tolerance for ambiguity. Whereas causation models aim to maximise the potential returns by selecting optimal strategies, the effectuation predetermines how much loss is affordable and focuses on experimenting with as many strategies as possible with the given limited means . Causation models, such as Porter , emphasise detailed competitive analyses. Effectuation emphasises strategic alliances and pre-commitments from stakeholders as way to reduce uncertainty and to create barriers of entry . Present business modelling requires extensive partnering from the very beginning for developing new products and viable services. Causation models are appropriate, when, e.g., knowledge or expertise of a specific new technology pre-exists. Effectuation is better for exploiting contingencies that arise unexpectedly over time . This is where also recent BMI studies have paid attention to , defines a marketassumed to exist independent of the entrepreneur -as the universe of all possible customers. An effectuating entrepreneur would define her market as a community of people willing and able to commit enough resources and talent to sustain her enterprise's survival, and creates the market by bringing together enough stakeholders, who buy into her idea . BMI researchers have identified the tendency of entrepreneurs to seek familiarity in business models , and the challenges they face when confronted with unfamiliar concepts. Later research show that effectuation may play a role in search of BMI effectiveness: e.g. Sosna et al. suggest that initial BM design takes form on the owner-manager's cognition and sense-making and in the early phases of NPD and BMI processes may be characterized by effectuation behavior. Effectuation is closely related with bricolage . The term was coined by Weick in organizational studies, later adopted Baker and Nelson, , and Ciborra in Information Systems field. Bricolage means good understanding of the resources at hand; innovative, 'good enough' use of combinations of resources at hand to problems, or, opportunities; and active self-correcting trial-and-error "make do"behaviour. For example, Stenholm and Renko suggest that the entrepreneurs passionate about developing their firms and inventing new solutions are more likely to engage in bricolage. This involves "creative manipulation of 'existing' or 'available' resources, such as materials and financial resources, to solve a problem at hand or to create new opportunities" . Furthermore, bricolage is a form of effectual reasoning of an entrepreneur to avoid the hazards embedded in the critical early stages of a new firm . They conclude that "passion for inventing and developing enhances entrepreneurs' "make do" behavior and, consequently, indirectly increases the chances for entrepreneurial survival". This is an addition to more rationalistic success factors by NPD and BMI literature. However, there is mixed evidence on the effectiveness of bricolage. For example, in Ciborra's early study on a multinational high-tech company, bricolage helped it to adapt, but simultaneously constrained its effectiveness. To summarize, many of the earlier justified criticism towards business planning , business modelling, and BMI has been alleviated in recent BMI techniques. Sarasvathy's original effectuating entrepreneur resembles recent lean startup ideologies . Their main argument is that it is rational to bricolage and iterate, because it eventually leads -through an unpredictable groping process -to rational goal . Lean startup emphasizes also effective and measurable outcomes, like BMI does . Therefore, effectuation and bricolage should be explicitly embedded in innovation effectiveness evaluation at SMEs. . summarizes the concepts of this paper, and spans the framework of inquiry. It links three potential drivers with three methods for innovating . These are in turn accompanied with three market strategies ). Eventually, the decisions and steps taken are expected to influence performance, which can range from failure to survival and success. --- Innovation drivers: Technology push: Technical evolution triggers, or enables new ways of doing business as much as it does create new products. Often the starting point is basic scientific research, or applied research and development in organisations. These proceed through design and development into a product that can be manufactured effectively and economically and then sold on the market. Radical breakthroughs are more likely to be achieved through technology push. Market Pull refers to the need for a new product or a solution to a problem, which comes from the market. These needs might be perceived by an entrepreneur, for instance through market research, which assesses what needs exist, how far they are met by existing products and how the needs might be met more effectively by means of a new or improved innovation. Market pull more often leads to incremental innovations. Effectuation: highly subjective approach, where innovation starts from the capabilities and resources of the entrepreneur. Implementation NPD: Product idea passes through a series of stages from ideation through design, manufacturing and market introduction Recent research suggests that technology push and market pull are complementary and necessary for NPD . BMI: Organization, finance, customer, service and technology are main components of the BM. Change in one or several of these may result in business model innovation. Bricolage: utilising the combinations of resources at hand to act on problems, or, opportunities. Self-correcting trial-and-error "make do" -behaviour. --- Market Strategy High-end strategy: incremental improvements to the current products on markets Low-end strategy: provide a simple or low price solution offering good value for money. New Markets: Serve customers, who were not previously served by existing incumbents. --- Performance Failure: the business/innovation fails. For instance, the product is redrawn from the markets, or business is in solvency, or bankrupt. Survive: the business/entrepreneur is hanging on, or at high burn rate; avoiding failure, but not profitable. Success: the business is clearly profitable --- Research Methodology and case selection We use multiple case study approach to analyse BMI effectiveness in five SMEs . Multiple cases serve as repetitions, extensions and contrasts to the emerging theory, and the researcher develops an understanding of why certain conditions did or did not occur, and then offers interpretations . Data was collected by the authors of this paper and the other consortium partners in a multi-national EU-funded project. The research collection follows a case study protocol, which forms the basis for data gathering and case data repository. This makes the data well- structured and suitable for cross case analysis. The protocol is available on request from the authors. Using subjective sampling, we selected five SME cases with different performance outcomes . Under these outcomes, we can first detect whether the drivers, implementation approaches, or market strategies are different for outcomes and then pursue explanations to the differing outcomes with the synthesized framework . The cases are listed in Table 1. In the Appendix, we describe and analyze the cases in more detail. Atelier started as self-employed artist 12 years ago. The entrepreneur was devoted to creating handicraft products by combining raw materials in novel ways. Despite the innovative products, the production does not scale up, visibility is hard to get, and timing depends on fashion rather than on Atelier's action. The atelier had a store where she sells her products to tourists , or locals looking for a birthday gift etc. She also imitated the competitors by being present in Facebook and in online store. In 2015 she switched from a self-employed person to an independent entrepreneur. Then she could hire a person to run the store and administrative matters. Unfortunately, the sales could not to cover increasing costs. The business was closed one year after she became an entrepreneur with company status and consequent legal obligations. But, already the same year she started experimenting with a new business idea related to remote life style coaching which she marketed in her Facebook. The case is typical case driven by effectuated entrepreneur and bricolage. --- Analysis Everyone Deserves Plants is an SME initially established by a designer, who had the vision to create a beautiful consumer product for cultivation of herbs inhouse. With partner networksuch as researchers specialized in greenhouse cultivation -the micro-sized start-up company developed, and recently patented world-wide its unique IT-controlled led light and growth system. In parallel with NPD, they started using BMI tools to design and revise their business model and value proposition , analyze the potential markets, and to create user profiles . This way they dared to abandon a fancy and fashionable mobile app for the users, but their analyses proved that there were no markets for remote control feature. The product is competing with other high-end consumer products, because there have not been direct competing products. To increase its sales, the company refocused its sales channel strategy from design shops to high-end malls and warehouses. In four years of operation the size of the company has been growing from four to 13 people. Thanks to its awarded and patented product the SME is attractive to the investors to raise capital, but it has not been able to reach the planned turnover targets and is making loss. Scaling up the production is possible, but the market is still emergingit seems the visibility of the product and timing of market entry are not optimal. Case c , Fresh Natural Air, started from the idea of the founder, who suffered from poor in-door air quality. He wanted to improve the air quality by bringing part of nature inside, i.e. living plants. He started to build a green wall with a fellow university student, who had both practical and theoretical knowledge on purifying water with ecological means. The first prototypes were put together of plastic and vent duct tape. Simultaneously, they were designing business models using BM canvas. The challenge was to make the product look good and the plants flourish. So, they developed a remote sensing system with embedded sensors to measure the status of the green wall and its environment. This data is analyzed automatically in a cloud software. The adjustments to the plants growth parameters are fed back to the green wall at customer's premises. Yet, the system needs regular manual maintenance . Imitating benchmark companies from other industry sectors, the SME decided to bundle allgreen wall, remote control and maintenanceinto one service, which it leases to b-to-b customers. Right timing is hard, despite the good visibility, because the maintenance does not scale up well. Initially the target was new market entry, but later they refocused on clean tech markets, and have an alliance with a large air conditioning incumbent firm, which could help in securing maintenance services in selected cities. The personnel of the company has increased from 3 to 60 in five years. It is making loss, but has doubled its turnover for the last two years. Thanks to its iterative BMI and NPD, , the SME is seen attractive by the investors. Event Management Service, case d , was established in 2007 by two cofounders. They worked in hotel and travel business, and found managing events a constant struggle with reservations, cancellations, detailed HoReCa 2 -arrangements, etc. They were looking to find a service or product to help in this task, but to their surprise they could not find neither affordable services, nor suitable products , so they started developing one for themselves, in true NPD sense. In parallel, they made a market survey that confirmed the existence of a niche market for automating of the event arrangement and management in businesses and public sector organizations. The initial in-house, back-office version was further developed to a web-based SaaS service for event management. The market survey made them also known to the potential customers, and their revised product got a flying start from the beginning. The aim was to provide affordable service to cut costs of arranging events on the current market, but they could also reach new customers that were not served by the existing incumbents. Nowadays, the awarded service is available worldwide, and runs constantly through NPD iterations, which ensures compatibility with customers' information systems. Their initial timing was good, product gained good visibility through the market survey. The current implementation of the platform scales up well. Case d has grown during the last four Electronic Medicine Dispenser, case e , established in 2003, is a high-tech company with technology-push approach. Its innovative new dispenser service was expected to have pull from the market: in addition to its main value proposition of providing improved dispensation safety and quality of medication to the patients, it could promise cost savings to the hospitals and nursing homes. The company is experienced in NPD, but in this case, they used also BMI tools to support the process. Business modelling revealed that the envisioned product was not lucrative enough for one of the key partners in terms of business. Therefore, case e decided to discontinue the development, and instead, focus its NPD & BMI efforts onto more potentially profitable and feasible products. Even though the dispenser service failed first, company's partners eventually implemented a derivative design and brought it to market with SME's major incumbent partner, which is a visible actor with a credible reputation on the market. SME is employing around 120 persons and runs profit. Their present implementation of the service scales up well, and was synchronized on time with the incumbents' product launch to gain momentum. To us, case e appeared least driven by effectuation, but rather relying on NPD combined with customer and partner network based BMI. --- Findings and Conclusions Researchers have observed that business model schemas are complex structural representations of the underlying activity systems. As such, they are also difficult to ideate from scratch due to the challenges of working out at once all the attributes and interrelationships comprising a complex system . This means that ideation anchors to a known way of developing new products, elements of a business model, or available resources , when met by changing circumstances. This all is expected to depend on entrepreneurial effectuation. Therefore, we expanded the concept of BMI with elements of NPD, effectuation and bricolage of entrepreneurs. Our framework also can depict the market strategies with profitability and sustainability. We used the framework to analyze five case SMEs. Most of the case companies are awarded thanks to their innovative product/service and/or business models, too. The case companies were established around 10-15 years ago. One of them filed in bankruptcy, two are surviving along investors' funding rounds, and two companies are going strong. Most profitable business model has a scalable product that meets directly a customer need outside the customers' core business. BMI plays a minor role, because the business has hit a 'sunspot' from the beginning, and is able to keep that position due to constant product updates in close development co-operation with their customer. The other successful case innovated an idea, which could scale-up by cooperating with its partners. However, they could not convince all partners to commit to the service at the first place, even though the market was there. The launch did not appear profitable according to business modelling. BMI helped the company, first, to put the market entry on halt, and then, to reconfigure the fundamental idea with more powerful partners and reschedule the launch. Fast business modelling iteration seemed to be a key to successful adjustment to the market needs, improving visibility, and timing in addition to its originally good scalability. Survival cases' business models both have a physical, fancy product with extended, IT-based features and lucrative stories, but their business models need constant revisions due to the bottlenecks in expanding to new markets with logistic, linguistic, and product related complications. Fast iteration is a necessity, but contracting, subcontracting and building the physical operations on various markets takes a time and a lot of entrepreneurial effectuation, but the problems with scalability and timing persist. Finally, the failure had high-end sustaining product strategy, improving the quality of the existing product and service by formalizing business. However, the SME did not survive on the market with that approach, because it was accruing extra costs, and losing entrepreneurial agility. All the cases follow different paths of evolution and market strategies, and in all survivor cases the take-off has taken years, even with the most successful of the selected case. It hit a bulls-eye niche with NPD, thanks to its effective indirect pre-marketing for the clientele, and has been able to maintain that position by iteratively co-creating integrated new features without losing its core product simplicity. The need for BMI is marginal. It is a textbook example of successful NPD. The companies that could create a viable business model can implement product and BMI very differently. It seems that innovative physical, high-tech products take a long time to develop to a mature profitable business even though entrepreneurs know and iterate their business model regularly . On the other hand, the most profitable of the pack, case d, has a business that is virtual by nature, builds on platforms, and scales up to thousands of users by self-service and has high demand in a niche market. It shares some similarities with case e, which used to develop a portfolio of new products at constant rate, but later to direct their development efforts according to BM analyses towards most potential business prospects. Their business modelling thus articulated the product and business roadmaps in a way that they could be put aside for a while and ramped-up in short notice, as the opportunity emerged. The cases show how effectuation has a strong influence in the initial stages of the innovation. Typically, the idea for the business came from the life or work experiences of the founder. What is remarkable in most surviving cases is that the companies/entrepreneurs learned to broaden their business thinking with BMI. The initial mindset is product-centric, many times with altruistic mind-set of improving the lives of the people, or their environment. Typically, after the rounds of BMI they can improve timing and visibility of their products better to the needs of the markets. However, the problem of scalability with physical products remain. Finally, In SME context, the value of BMI is in iteration and as the means to identify and react upon exogenous changes. The idea of combining NPD, BMI and entrepreneurial effectuation by bricolage seems to reflect the reality in the case companies mostly well. It is also worth noting that BMI improves the entrepreneurs' product and business development skills, and helps to time innovations entry to the market. --- Bricolage: The first prototypes were created of duct tape and some plastic boxes. --- NDP: The founders created the product first for internal use, then offered it to markets. BMI: market analysis showed the lack of products on the market. --- Market strategy High end: Highquality, unique products. --- Low end: The --- Introduction The term Educational Technology is defined as "the study and ethical practice of facilitating learning and improving performance by creating, using, and managing appropriate technological processes and resources" . E-learning, web-based learning, online learning, and IT-based learning are just a few examples for technological processes and resources based on Information Technology . However, IT is a constantly evolving sector influencing many areas of all our lives. Thus, education is changing since IT allows for many new possibilities; especially in combination with the playful approach to learning. Playful learning, often also called edutainment, is a recent trend in academic education which focuses on the hands-on practice of learning instead of on the sit-and-listen approach, spanning between free play , and guided play . In the digital economy, there is a huge demand for skilled IT workers, not only in the IT departments but across entire organizations . This demand can be satisfied by a broad introduction of students to the digital world and further education in IT skills early on. Additionally, in today's society, it has become a standard for students to have constant access to the internet and the immediate on-the-spot knowledge provision opportunities that are provided by it. Students use digital means to learn, communicate, access knowledge, and for other professional application . A case study involving undergraduate students in Slovenia, stated that 37,5% of the students reported to use the web frequently in more than half of their courses, and 50% even stated that they always use web resources . This trend in students' behaviour can be observed growing rapidly. In 2002, a case study, involving 2054 students at 27 institutions of higher education across the United Stated, stated that 73% of respondents claimed to use the internet more than the library, while only 9% said they use the library more than the internet for information searching . Thus, our nowadays educational systems are facing both, students with highly developed digital skills and the necessity to evolve the digital skills of students in order to support self-regulated personalized learning . IT-based learning approaches gain momentum in our digital economy as countless numbers of software projects, for computers as well as for smartphones, are realized with the goal to educate students on different topics. The importance of digital mediums as a form of education is increasing , and many academic researchers, such as McGonigal , Prensky , Gee , Fabricatore , and Pivec and Moretti , put increasing effort into the exploration and validation of teaching techniques using the playful approach as a core concept. Many of these playful approaches use hands-on and self-regulated or personalized learning as a medium to transfer knowledge to students and the usage of the self-regulatory processes has shown strong correlations with high academic achievement in all kinds of fields of education are widespread, although the majority of them supplies no scientific results concerning a structure on how to implement such a playful teaching model. Thus, this paper aims to fill this gap and hence to answer the following research question: What would be a best practice for programming lessons by using a playful approach? Fullan asserted that the moral purpose of education is to equip students with the skills that enable them to be productive citizens when they finish their studies. Thus, in the age of the digital economy improving the digital skills should be one of the topics students ought to learn in school. Trilling and Fadel called education in information, media, and technology skills vital for the 21st century job market, differentiating between the traditional education subjects and upcoming subjects such as information transformation and coding skills which are much needed in today's economy. As the structure of a teaching approach is always to some level dependent on the subject and because of the dire state of the computer science education throughout Europe, we focus on the area of computer science, with the special topic of learning how to program, as a framework in which the structure is developed. However, the structure is easily transferrable to other school subjects as the core composition stays the same. Next to the success factors identified for teaching with a playful approach in Heininger, Prifti, Seifert, Utesch, and Krcmar , other factors also need to be taken into account concerning a successful implementation of a study course. Examples are the relevant curriculum , and specific environment factors of the respective school or university . The development of the structure will manipulate certain environmental factors as well as provide opportunities for the students to become motivated, interact in class, and engage with the content of the curriculum on a deeper level than in a "traditional" course in which the lecturer just transfers knowledge by lecturing. The overall goal is to promote continuous passion and motivation to look beyond the box and to become interested in programming. The ideal outcome would manifest in students wanting to code even if there is no extrinsic reason to, such as good grades in school or any other rewards from the outside. The development of the curricular structure and the structure of implementation targets this endeavor. --- State of the Art Driven by rapidly advancing information technology, many academic researchers have lately delved into the topic of different approaches to education. The benefits and theoretical as well as practical outcomes of playful approaches in education have been 218 30 , at high school , universities , and even at an US Air Force Academy . However, scientifically developed and afterwards validated structures for implementation are rare and often not documented. Only Simionescu and Marian present a proposal for a change of paradigm, based on a playful approach in course structures for efficient student evaluation. In a previous research paper the success factors concerning the playful teaching approach were discussed and evaluated by conducting a literature review of the current state of the art. With this contribution, we aim at answering our research question, by using these success factors as the theoretic part of the basis for our structure. Table 1 shows the five key success factors influencing the outcome of such an endeavor: motivation, integration and involvement in class, the audience-centred focus, giving feedback and enhancing interaction, and the fluent integration of the educational content into the gameplay . The basic reason why people do anything; The variation of individual differences; The attitude, behaviour and study practices Integration and involvement --- Self-involvement and active participation by students; The shift from the passive recipient to an active integrated partner Adaption to the audience Specification of the target audience; The adaption to the curriculum and environment; The game shall be easy to understand and to play Interaction and feedback Formal as well as informal; The individual response to the student's difficulties; The examination of different ideas and multiple perspectives Integration of educational content into gameplay Finding an application of the curriculum inside of a gameplay; The balance of gameplay and educational content in a game --- Method Curriculum decision making is generally an iterative and lengthy process, carried out by a broad range of participants and influenced by a wide variety of stakeholders . Cho noted on the same subject that the implementation of curricula is not an event, but a longer change process. Following Biggs and Tang , there are three levels of learning outcomes at major institutionsat the institutional level, at the degree programme level, and at the course level. As we concentrate on the curriculum of a school, our focus is on the course level learning outcome, while the degree programme level is less distinctive. Furthermore, we limit the computer science curriculum to the subject of learning how to program in order to be able to provide a clear and comprehensive structure. Van den Akker and Voogt noted that the curriculum should offer materials, which provide concrete and illustrative elaborations of the general program, as well as a framework for broad categories. Biggs and Tang further remarked the importance and analysed the 'intended learning outcome' for the student as it defines the goals of the curriculum. Based on this outcome-based learning concept by Biggs and Tang we will describe the current state of computer science curricula and point out some major design decisions for our curriculum in this chapter. --- Linking to a School Curriculum Many countries have adjusted their curriculum in the last years, adapting to the changes of the digital economy, which requires new skills . However, specific curricula are often set at state or city level, not at national level. An example outside of Europe is New York City where a computer science course will be a graduation requirement by 2018 . In Europe, many countries have begun to adjust their curricula as well, but major changes are still awaited by both, the industry and the academia. Austria for example requires a mandatory course devoted solely to computer science only in grade 9, teaching students about software, hardware, operating systems, and data privacy . Slovenia offers a mandatory computer science course in grade 10 , while offering elective courses in the grades 7-9 and 11-13, teaching students about processing data, computer networks, and programming as well as algorithmic thinking and problem solving . However, in 2016, Mori and Lokar criticized the outdated Slovenian computer science curriculum, dating back to 1998 with minor updates in 2008 as well as the short duration of the mandatory course of only one year. In Germany, the education system is mainly the responsibility of the federal states. In 2012 only two out of sixteen German federal states had mandatory computer science courses -Free State of Saxony in grades 7 and 8; and Free State of Bavaria in the grades 6 to 12, including topics such as introduction to software and hardware, terminology, basic concepts of information technology, computer networks, algorithms, and data modelling . However, the curricula for the different types of schools in Germany, respective in each individual state, are often vastly different and some of them do not teach about computer science at all . In 2015 a survey with 1002 German parents stated that the majority considered the children's preparation by the schools for the digital job market 'bad', 5% even considered it 'very bad', while only 32% considered it 'good' and 3% considered it 'very good' . Overall, the changes in The emphasis lies on students learning to independently break a problem down into smaller parts and create advanced pieces of software. The modulation of problems is explained with the use of procedures, functions, giving parameters, and multiple usage of blocks of code. Knowledge about array data structures as well as objects of pre-defined classes are part of the curriculum as well. The overall goal is to teach students about complex structures like loops and functions to give them the ability to differentiate between the use of procedural structures and functions. Object oriented programming is the last part of the computer science curriculum of the vocational schools in Bavaria. "Students ought to gain insight to how coding and handling objects work. Their ability to generate a solution creating functions based on problem is in focus." The curriculum for object-oriented programming contains knowledge about classes and objects, their attributes and methods, as well as class instantiation. The focus lies on the definition of classes and calling functions and attributes of the instances, as well as handling the transfer of parameters. This includes calling functionality in other functions as well as setting optional return values. The goal is to teach students about well and systematically designed structures of classes and functionality to ensure their ability to solve complex problems and give them the tools to code on their own in the future. At this point of our contribution, we deem it important to note that the curriculum of vocational schools in Bavaria will be changed in the near futurecomputer science will soon not be a mandatory subject anymore at all, but rather a voluntary subject in grade 12 and 13 . The content of the voluntary subject will also consist of multiple optional topics from which only a few can be taught as the course will probably not have the required length in order to cover all of them thoroughly. --- Choosing the Programming Language Python The focus of an introduction to programming in secondary schools lies on giving insights into writing software and understanding the basics of programming. The usage of languages developed for children , which are based on graphical drag-and-drop handling, seems to be missing the point in this endeavor. Choosing a programming language for beginners, means not only considering technical aspects, for instance run time efficiency, memory consumption, and reliability , but must be evaluated even more concerning the difficulty of learning the language without prior coding experience. Furthermore, there is the possibility of teaching an industry relevant language like Java, Python, and C++, or a language specifically designed to introduce programming to beginners. In a case study Ivanović, Budimac, Radovanović, and Savić note that the choice of programming language does indeed not affect the success of students in the course. They also note that "the main goal of the introductory programming course is to teach students essential programming concepts in order to develop their ability to think and solve problems by algorithms, and to acquire new/other programming languages and techniques efficiently" . This allows students to change to other, differently structured programming languages later on, if desired. The language should have a simple syntax, provide easy I/O handling as well as output formatting, use meaningful keywords, and give immediate feedback . Python offers many advantages concerning grammar and writing of code: Time wasting matters of style are avoided and indentation not only structures the code grammatically but also visually helps beginners to easily understand which block of code belongs to which functionality. Another advantage of Python is its compactness and that unfamiliar code in Python is usually easy to read. Choosing Python as a programming language affects the curriculum concerning the time, which must be allocated for specific concepts within the language. As an example, Python is a language that most people consider easy to learn though it still finds use in 'big' software companies like Google: "Python where we can, C++ where we must" and in games like EVE Online, Battlefield, Mount&Blade, or Civilization IV . Thus, we consider Python as an industry-relevant language. Unlike other languages proposed for teaching to novices, Python is not just a teaching language, it is a language that is suitable for developing real-world applications . An important goal of the Python developers is making Python fun to use, as also can be noticed by the origin of its name, while focusing on code readability, extensibility, and clear error message handling . Focusing on gaining insight into what it is really like to code and at the same time considering the shallow learning curve of Python, leaves us at the conclusion that Python is a good start for beginners without prior coding experience. --- Results In order to clarify the developed structure we divide the topic into its three major components in this chapter. First, we will present the organization of the lectures, which consist of four parts: plan, do, check, and act. Secondly, we will draw up a timeline of the progress of the lessons, tackling the curriculum apportionment and the general concept of introducing students to new knowledge. In the last part of this chapter, we will introduce the educational content, the means of the playful approach, and the main design principles for an educational game. --- Organization of the Lectures The lecture optimally is held by an experienced teacher with previous experience in the playful teaching approach, as well as extensive knowledge in computer science and coding. Computers with the pre-installed software are provided by the school, but the students should still be encouraged to bring their own laptops in order to be able to take notes, and to code in their own environment, as they would back home on their own. Every school student should play and code independently. In the first five minutes of each unit, the teacher repeats the knowledge learned in the last unit, combined with an outlook to what students are required to learn in the current unit, and how it is connected to previous knowledge. As the students will have progressed at different speeds and hence be at different levels of knowledge, the repetition is based on their remarks and input. The underlying idea is to not set a common learning goal for the students for each unit, but to clear up eventual difficulties with previous contents. The students themselves set interim learning goals . During the course of each unit the teacher helps and coaches the students if needed. The teacher does not need to approach students but let them work independently in order to give them the freedom to solve problems on their own. The aim behind this endeavor is fostering their motivation, self-value, and to increase their confidence in their own skills. A solution for a problem should not merely be offered by the teacher, but be worked towards together . The last five minutes of the units are for a short repetition of the current content in order to gather more information on the difficulties the students experienced and how they felt about the learning process while playing the game. The students should use the time for self-reflection . The teacher provides handouts for each stage of the game to give the students something tangible to study and base their learning effort on before the exam. In order to keep track of the school student's progress, homework will be assigned to the students. To ensure quality, one of the underlying concepts of this approach is the Plan-Do-Check-Act Cycle 1 of W. Deming as illustrated in Figure 1, showing the general lesson structure. The students will receive instant feedback on their code by the game. The teacher should help if difficulties come up and the students cannot solve a problem based on the feedback of the game or do not understand the error messages. By observing the students play, the teacher will also be able to identify complications in the game-play or during the execution of coding tasks . --- Lesson Structure The length of each lesson is 45 minutes as it is custom in the German school system. The time planned for computer science, and more specifically to teach how to program, are six lessons, spread over the course of six weeks. In the Bavarian technical upper vocational schools, the course is mandatory for the students, most of which have no prior experience in coding. In this chapter, we explain the specific content of each lesson. Whenever possible, concepts should be introduced completely and at once, as an exception some concepts are initially introduced in a limited fashion and then revisited in a later topic for full coverage . The lesson structure introduces the students to different concepts and knowledge about coding with a gradually advancing learning curve. The content is structured to build on previous knowledge learned in earlier units and allows for a start without any prior coding experience. The lesson structure is adapted to the curriculum set by the Bavarian Education Ministry and the pre-defined situational and environmental circumstances in the school. The course is divided into six individual units, which are presented in the following and summarized in Table 2. --- st Unit Students are introduced to coding and its use in our daily lives. The educational game will be implemented and its controls will be explained. Beginning with small pieces of code the school student gains knowledge on how to handle the IDLE Python GUI editor to be able to solve tasks and experiment at home on his own. Basic knowledge about assignment of values to variables, mathematical operators, and output, as well as basic data types including integers, floats, and strings. --- nd Unit The students learn about boolean values and conditional structures to give software the ability to react on different types of input. The students learn basic commands to handle arrays and to calculate with boolean operators. The goal is to deepen the knowledge about dealing with different types of output and data while introducing branching structures. Manipulation of arrays and decision structures based on boolean variables, or by analyzing the input, complete this chapter. --- rd Unit The third lesson will give a deeper understanding and further foster the ability to handle more complex data structures. More commands in order to handle arrays are given, such as sorting, reversing, inserting, indexing, and popping elements in arrays. This will be combined with handling the "for"-loop functionality. Iterating over arrays and building decision structures to connect the new knowledge to the 2nd Unit are at the core of this Repetition by connecting previously learned knowledge with complex tasks Discover and close gaps in knowledge, deepen the comprehension of the content --- th Unit In this unit, the students learn about repetitive use of code using methods and classes. Methods are introduced in a functional coding style and afterwards connected to classes. Classes will be used as a way to describe objects in a compact way and give functionality to them in order to change their attributes based on input and parameters as well as handling the interaction between classes. Examples of their use will be given and students are expected to add functionality and attributes to an existing class before creating a class on their own. --- th Unit This unit focuses on knowledge about classes while introducing new features involving multiple instances and parameter transfer as well as optional return values. Furthermore, the while-operator in connection with boolean operators and values will be introduced. The emphasis of this unit lies on good systematic design of software to ensure readability and transparency of the code. --- th Unit The last unit holds no more additional new knowledge but means to give students the tools to code on their own in the future. It combines previous knowledge of the first six units. The students are given complex tasks in order to recognize potential in coding. The goal of the unit is to discover knowledge gaps in order to help students repeat or deepen specific units in order to achieve full understanding of given code. --- Game, Features, and Educational Content An educational video game is being developed with the single goal of connecting the curriculum with a game that is interesting and fun to play; and simultaneously puts learning into perspective and gives incentive to learn more. The students will be able to see that their own learning environment was created by using the same knowledge they will have at the end of the course. Furthermore, by creating an educational game for learning how to code in a gameplay setting, which resembles widely used and popular interactive development environments , could incite the motivation, self-esteem, and knowledge in students to carry on coding on their own. Necessary features in an educational game can easily be derived by approaches to satisfy the success factors for the PLA : motivation, integration and involvement in class, the audience-centred focus, giving feedback and enhancing interaction, and the fluent integration of the educational content into the gameplay. Main design principles for an educational game can also be derived from the iterative processes of conducting case studies by other authors and evolving and improving an educational game: interaction and iteration of those interactions, adaptive and personalized feedback, clear winning criterion, and no or few opportunities to cheat the game . Those criteria have been confirmed by another often cited study of educational games proposing practical steps for designing educational games . A good game is easy to learn but hard to master meaning the handling of the basic game is easy, but to be good at it becomes more and more difficult the further you advance. The playful approach motivates the students to become more interested in their own education and willingly sacrifice time for it. The game achieves this by students having to work for their knowledge by beating the game, defeating numerous enemies and mastering obstacles. A basic rule of good game-play is to provide the player always with clear short-term goals . In an educational game, this may mean partly beating enemies, collecting coins and jumping over obstacles, but also means solving coding tasks to advance in the gameplay. Beating enemies and collecting coins may obviously not have a direct impact on the students learning success, but very well can create the joy and motivation to keep on playing, and thus to keep on learning. Examples of collectibles for the sake of their own can be found in numerous games: coins in the Mario series, spraying graffiti in GTA San Andreas, or visiting viewpoints in the Assassins Creed series. Players often do not try to find all collectibles for the purpose of getting a reward but for the sheer pleasure of the treasure hunt. After all, games are supposed to be fun and not purely work. --- Conclusion Based on former research, concerning the success factors for teaching with a PLA we were able to develop a lesson structure which shows the structures used for a playful approach to teaching. The content is based on the curriculum for technology classes of the Bavarian technical upper vocational schools, as well as Bavarian school norms. However, it can be transferred to other types of schools and curricula as well by customizing the proposed structure to fit different circumstances, such as timeframe of a lesson, length of course, programming language, and previous skill level of students. The lesson plan can be especially useful to be implemented in different German vocational schools, but also in other cultures as the structure's core is based on outcome-based learning, which was analysed and evaluated by Biggs and Tang and is used worldwide as a framework for good teaching and assessment. The curriculum was adapted to Python and its specific language constructs. The development of an educational game as an exemplary playful learning approach would be based on the structure created and paired with the educational content of the curriculum. The educational game as an electronic learning platform brings together practice , teachers , scholars , and students in one environment. We chose python as the favourable programming language based on its compactness and intuitiveness, which makes it easy to learn and to use for beginners. Whenever possible, concepts are introduced completely and at once, as an exception some concepts are introduced in a limited fashion and later revisited for full coverage . A professional teacher, who is experienced in the topic of computer science, optimally accompanies the lecture. Five minutes in the beginning as well as at the end of each lesson are used to repeat the knowledge of the last lesson, respectively to recap the knowledge learned in the current lesson. The use of an educational game as shown in this paper and the implementation of a playful teaching approach in a case study at a Bavarian upper vocational school will be part of the research in the future in order to validate the lesson structure. These merging technologies represent a considerable problem for standardisation. They will require co-operation between standardisation entities with very different cultures, from equally different backgrounds and used to very different technology life cycles. While this is a general problem, this paper aims to contribute to an answer to the question how well the ESS is likely to fare in this increasingly important and complex environment. Is it future-proof? And if it isn'twhat needs to be done to change that? The remainder of the paper is organised as follows. In sect. 2, a SWOT analysis is used to discuss the ESS. The resulting policy issues are addressed in sect. 3. Finally, sect. 4 presents a rudimentary roadmap and outlines some future steps that the ESS might consider taking to overcome these issues. --- The European Standardisation System -A SWOT Analysis The SWOT analysis of the ESS aimed at the identification and analysis of the major standardisation-related issues in general and in the field of smart infrastructure and applications in particular. Tables 1 and2 show the outcome. The tables show that both strengths and weaknesses of the ESS result from it being a well-established, long-standing system. On the one hand, good relations with policy makers and their international counterparts together with time-honoured processes have made CEN and CENELEC major players in many fields and entities to be reckoned with. In addition, a contradiction-free set of standards is a major asset. Yet, such systems tend to become self-complacent. For example, until very recently the ESS largely ignored the importance of private standards consortia in the ICT sector. A fairly recent European Regulation [EU, 2012] certainly points in the right direction on this and several other aspects, but it still remains to be seen how things will develop in practice. Specifically, it is still unclear how the call for both greater speed and more inclusiveness can be answered in practice. That said, greater speed is not a desirable feature per-se. In particular, supposedly long-lived technologies like e.g. communication infrastructures may well benefit from a longer, more thorough and less error-prone process that involves all stakeholders. Inclusiveness would be of special importance for smart applications, where many stakeholders will be involved that are typically absent form 'normal' ICT standardisation . Moreover, it remains an open issue how the contradiction-free system is to be maintained in the face of the likely wealth of consortium standards eventually used and referenced. From the SWOT analysis it also would seem that there is a real risk of international marginalisation of at least CEN and CENELEC in the fields of smart infrastructure and, particularly, applications. This is primarily due to: --- • Overly strong European focus If this focus leads to inadequate international links the situation will become worrisome. This will hold especially if it occurs in a field where global standards are a sine-qua-non. --- • Limited activities on smart applications Limitations materialise in two ways. Most notably, CENELEC focuses the majority of its activities on transposing IEC standards into European ones . Secondly, with the exception of ITS, the 'smart' aspects of applications have largely been ignored so far; foci, if any, are on the underlying communication side. The latter is all the more surprising as one of the ESS' strengths is its close link to policy making. This could be exploited through new European standards setting activities that focus on the upper layers of smart applications. Here, the associated governance aspects imply the needs for such close links between standardisation, government and policy making. Unfortunately, some of the perhaps less obvious issues that may nevertheless have potentially considerable long-term ramifications do not get the attention they deserve. These include primarily the link between R&I and standards setting and the education about standardisation. A weak link to research may imply that important findings never make it into the standardisation process and that, accordingly, standards will be developed that do not take into account the state-of-the-art. As a result, such standards will either not be taken up by the market or be very soon superseded by others. Inadequate education about standardisation may, in the medium to long term, lead to poorly equipped European standardisers in the international arena. --- Policy Issues This section looks at some of the issues the ESS faces or is likely to face in the near future. This includes some general ones as well as a number of aspects that relate specifically to the standardisation of smart infrastructures and applications. --- General European Standardisation Issues European standardisation still needs to deal with a number of issues that were identified already many years ago and have been discussed ever since, but in several cases without a satisfactory outcome. These include the need for speed in standards. But speed is not a value in itself. If it supports the timely production of a standard, speed will be beneficial. Otherwise, it may stand in the way of quality and completeness. Accordingly, the popular unqualified focus on speed needs to be questioned. In addition, achieving both 'speed' and 'inclusiveness' is next to impossiblethe larger the number of interested parties around the table, the longer it will take to reach consensus. A case-by-case balance needs to be struck -'speed' must not be the overriding issue when it comes to e.g. standards for security and privacy in smart applications and 'inclusiveness' must not be the showstopper for standardisation of e.g. interfaces to peripheral devices. That is, the necessary and desirable levels of inclusiveness and speed vary between standards (see also e.g. [Sherif, 2003]. The link between R&I and standardisation is another long-standing issue, which also links to education about standardisation. The European Commission's recent 'Joint Initiative on Standardisation' [EC, 2016a] is but the latest attempt to overcome the barriers that still exist between standardisation, innovation and education and the respective communities. Its eventual outcome remains to be seen. In any case, without a closer integration of these domains neither policy makers nor industry will be able to reap the full benefits standards and standardisation offer. Close links between policy making and standardisation exist in the EU. This is a bit of a double-edged sword, though. On the one hand, some standards are not so voluntary anymore . "If the producer does not manufacture in conformity with these [harmonised European] standards, he has an obligation to prove that his products conform to the essential requirements" [CEU, 1985]. 30 TH BLED ECONFERENCE: DIGITAL TRANSORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES K. Jakobs: Emerging Smart Technologies and the European Standardisation System 237 On the other hand, these links may well be beneficial when it comes to the standardisation of smart applications where regulatory aspects may well play a role. --- European Smart Application/Infrastructure Standardisation From a standardisation perspective, the development over time in both the application areas and the infrastructural technologies show considerable similarities. In all cases, the complexity of the respective web of SSOs has increased dramatically over the past 20 years, as has the number of relevant entities within individual SSOs . The most notable proliferation of such entities could be observed for the past five to seven years, with the exceptions of ITS and mobile communication, where the development was more homogeneous and far less pronounced peaks occurred around 2005 and in the late 2000s, respectively [Jakobs, 2017]. Another similarity lies in the fact that in all cases but one the establishment of formal SDOs predate those of consortia by decades . Overall, it would seem that up to now consortia play a less important role in the development of smart applications and IoT-related technologies than they do e.g. in the mobile communication sector. ICT systems span the globe and, by definition, the associated standards need to be global as well. The task of regional standards then is to introduce regional specifics into international standards, while maintaining global interoperability. Alternatively, some such regional specifics may find their way into international standards. However, both cases require dedicated regional standardisation activities. Against this background, a look at the developments in Europe yields a somewhat ambivalent picture. On the bright side, ETSI's activities on smart applications and, particularly, smart infrastructure through its smartM2M TC and its Partnership Projects are well positioned in the global context. However, the focus is on rather more low-level wireless telecommunication services. On the other hand, the eight CEN Technical Committees identified as being active in the field of 'Smart Technologies' in [CEN/CENELEC, 2016] focus almost exclusively on metering and do not really link to ICT, the IoT or CPSs. The one exception is CEN/TC 294 . However, as the name suggests the focus here as well is on the communication system. Perhaps more notable, CEN has long been playing a prominent role in the ITS sector, also covering more application-oriented services. Apart from that, however, CEN and CENELEC seem to have adopted a 'laggard' role, with CENELEC largely focussing on the transposition of international standards. According to the 'Rolling Plan for ICT Standardisation' [EC, 2016b], CENELEC "works out methods for safe and secure communication protocols for wired and wireless industrial automation applications" in the field of Smart Manufacturing [EC, 2016b]. Yet, this work as well has so far moastly been limited to the adoption of IEC standards. Given the pioneering role that Europe in general and Germany in particular play in this field 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES K. Jakobs: Emerging Smart Technologies and the European Standardisation System , it seems a bit strange that such a leadership position should not be translated into indigenous European standards that could eventually be adopted by ISO or IEC . In fact, the apparent reluctance to play a more active role in smart manufacturing standardisation is also at odds with [EC, 2016a]. This document highlights Europe's long standing leadership in factory automation and that standardisation has an important role to play in helping European industry to secure this leadership The ESOs' Coordination Groups on the Smart Grid, Smart Meters and Smart and Sustainable Cities and Communities, respectively, have so far been more policy advisory entities rather than actually active in standards setting. With respect to the IoT, CEN/CENELEC's standardisation activities are limited to the field of automatic identification and data capture, where a newly formed WG addresses IoT related issues. In this context, the lack of any approach towards truly multi-disciplinary standardisation is worrying. It is also surprising since the European Commission has identified the need for such an approach in [EC, 2016b]. The document calls for multi-disciplinary standardisation in several application areas, including Smart Grid and Smart Cities. Given the almost frantic activities that are going on at the international level this seemingly rather restrained European approach appears a bit odd. In fact, it is in stark contrast to the recommendations made already in [ProSE, 2011]. While these recommendations relate to the field of embedded systems , they are equally valid for the standardisation of the IoT and smart applications. The relevant ones read: "Recognise the need to value standardisation and to take leadership of standardisation . Recognise the need to co-operate on standardisation across competitive boundaries and to reconcile and manage the differences that presently inhibit such co-operation. Invest in the efforts required to bring about standardisation, allowing staff the time and support to bring about long-term benefits. Invest in people and RTD in order to feed the technology pipeline that provides the basis for standardisation". The above recommendations should be applied at least to those sectors where Europe has assumedor aims to assumea leadership position, technologically and/or in standardisation. Specifically, this holds for the ITS sector, where CEN has been leading the way for a number of years now. Likewise, existing strengths in Smart Manufacturing should be exploited in the standardisation arena . This section aims to deepen these insights by identifying actions potentially to be taken by the ESOs to meet external challenges. Fig. 1 shows the underlying framework. In an environment characterised by uncertainties a roadmap offers a visual representation of alternative paths towards a strategic goal or a vision . Here, the overall goal is a global standardisation environment within which the ESOs play a central role in the standardisation of a smart communication infrastructure and smart applications. To this end, a number of external influences have been extracted from a literature review , a survey8 and the SWOT analysis. They are depicted in Fig. 2, along with the associated actions to be taken to adequately address them and to eventually make the vision a reality. It would appear that two already ongoing trendsstrong Asian/Chinese participation in standards setting for smart applications and infrastructure and the need for truly interoperable implementations may well imply a further reduction of the ESOs' international importance . The same holds for the possible trend towards all-IP networks . This is hardly going to happen anytime soon, but may well be expected in the medium term. The same holds for a wider deployment of CPSs and of smart applications. Given the current fragmented standardisation landscape and the infancy of the associated standards setting activities, these developments are a) unlikely to be aligned and b) likely to deploy proprietary technology. However, this may increase the need for interoperability and thus for international standards. This, in turn, would represent an opportunity for the ESOs if they managed to position themselves as relevant players in the meantime. Figure 2: A very rough 'roadmap' for 'smart' standardisation Fig. 2 shows that the ESOs do not always play the role they could play in the standardisation arena for smart infrastructure/applications. The SWOT analysis revealed a number of issues that need to be addressed. These issues fall into three categories : • Limited relevant activities. This has two dimensions. For one, not all relevant technical areas are covered by the ESOs. Moreover, especially CENELEC frequently limits its activities to the transposition of IEC standards into European ones. • Inadequate international interconnectedness. While very good links exist to the ESOs' respective international counterparts the same may not be said for private international standards consortia. • Process aspects. This refers to limited links to relevant research activities, to the equally limited activities in standards education, to the disregard of implementation aspects and to the lack of multi-disciplinary standardisation. These weaknesses will be discussed in the following. --- Limited relevant activities of the ESOs A number of gaps in the ESOs' standards setting activities may be identified in the realm of smart infrastructure/applications. For one, with the exception of ETSI's smartM2M group hardly any activities are to be found. This comes as a bit of a surprise since both CEN and CENELEC have been venturing into the field of communication systems and for the smart grid ). Moreover, a smart infrastructure is the basis for all smart applications. Similarly, the activities relating to smart cities are in their infancy at best. Given the necessary tight integration of standards activities on smart applications on the one hand and a smart infrastructure on the other it would seem that joint ESO activities in the 'smart' realm are called for. How exactly such joint activities may look like would have to be discussed. Joint CEN/CENELEC entities have already been established ; an extension of this concept to also include ETSI should be considered. This would, on the one hand, strengthen the expertise on the communication side and support multi-disciplinary and integrated standardisation on the other. Along similar lines do the virtually non-existing global standardisation activities for CPSs represent an opportunity for Europe. Research in this field has been going on for quite a while now in Europe . This accumulated know-how could be used as basis for European standardisation activities, also e.g. through a TC managed jointly by all ESOs. The other issue relates to the fact that in many cases CENELEC's main activity seems to be the transposition of IEC standards. For example, in the field of Smart Manufacturing almost all but ten standards passed by CLC TC65X originated from the IEC. It certainly makes sense not to unnecessary duplicate any work. However, the thought of CENELEC standards solely being based on IEC documents for both ITS and the Smart Grid is a bit worrying. After all, there are European specifics, most notably in the highly regulated field of the Smart Grid. Specific European boundary conditions may also be assumed for e.g. Smart Cities. A higher level of autonomy in these fields is called for. --- Inadequate international interconnectedness The focus of both CEN and CENELEC is clearly on Europe. This is not a bad thing perse for an ESO. Nevertheless, CEN and CENELEC together have so far established links with only four international organisations that are of some relevance for the standardisation of smart infrastructure and applications. It may be assumed that this isolation also contributes to the fact that regional standards bodies' importance in the field is seen as either limited to the identification of specific regional requirements and the associated adaptation of global standards or is questioned altogether [Jakobs & Wehrle, 2017]. As a first step, links to relevant non-European players should quickly be established through formal co-operation and co-ordination mechanisms. --- Process aspects A number of rather diverse aspects fall under this heading. For one, the need for education about standardisation has been highlighted by several sources. , 2016a] has commenced after initial difficulties; its outcome remains to be seen. Moreover, links between standardisation and Research & Innovation need to be improved. This issue has also been on the agenda for quite a while now. Both the 'Interest' [Interest, 2007] and, more recently, the 'Bridgit' project [Bridgit, 2014] made a number of similar recommendations on how to bridge the gap between standardisation and R&I. In unison, they highlight the need to increase awareness on both sides and to mutually promote and educate. Likewise, incentives need to be offered to researchers to spend resources on standardisation activities; this should be of relevance for research funding organisations . For the ESOs, this would include adapted or new processes that are more 'research-friendly', i.e. short-lived . CEN/CENELEC Workshops and ETSI's Industry Specification Groups are certainly steps in the right direction. However, their usefulness is limited by the fact that no mechanism exists to feed their output into the standardisation process proper . Taking the various recommendations made by the two projects on board would definitely help improve the situation. Not unlike their international counterparts, both CEN and CENELEC stay clear off any implementation aspects. The situation for ETSI is slightly different; their 'Plugtests' represent at least a step towards taking implementation issues into account. In any case, 30 TH BLED ECONFERENCE: DIGITAL TRANSORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES K. Jakobs: Emerging Smart Technologies and the European Standardisation System 243 the success of SSOs like the IETF and the W3C may to no small part be attributed to the fact that they consider implementations and proven interoperability as part of their respective standardisation process . It seems highly unlikely that CEN and CENELEC will change their stance on implementations. Nevertheless, at least for the ICT sector steps ought to be taken to provide the market with what it needsinteroperability. Perhaps a new entity that develops and/or certifies interoperable implementations might be a way forward. The lack of multi-disciplinary standardisation is another issue. The need for such a new way of setting standards for the field of smart infrastructure and applications has been corroborated by survey respondents in [Jakobs & Wehrle, 2017]. A standards setting platform jointly managed by the ESOs has already been suggested above. Such a platform would have the potential to kill two birds with one stone. On the one hand, it would help improve the level of the ESOs' involvement in the international standardisation of smart infrastructure and smart applications. As the European expertise from the different relevant fields would likely be concentrated on this platform it would also contribute to the goal of multi-disciplinary standardisation. A 'third bird' would be the fact that such a major 'hub' of standardisation in the 'smart' field could also attract other SSOs to enter into co-operation agreements. Such a platform would allow experts from different backgrounds and from several SSOs to meet and to address inherently multi-disciplinary standardisation problems . --- Introduction Hardly a day passes without reports of large-scale attacks against IT infrastructures launched by internal and external perpetrators. These attacks frequently result in the unintentional disclosure of confidential information and proprietary data . Previous research on the economic impact of IT security breaches on affected firms focuses on realized unsolicited disclosure of information and proprietary data . However, we argue that it is equally likely that stock markets punish firms for creating the mere possibility of a data theft. This is because of a diminished trust in the firms' capabilities to protect sensitive data with adversarial effects on future sales and thus its stock price, which resembles the discounted value of expected future dividends . Thus, within this study, we examine the overall research question of the impact of potential IT security breaches on stock prices. We draw on information boundary theory to investigate our research question. Specifically, we study the impact of the Heartbleed vulnerability within the widely used cryptographic library OpenSSL on the value of 4,147 publicly traded firms. OpenSSL is used to secure connections in computer networks and was enabled on approximately two-thirds of all webservers worldwide when Heartbleed was publicly announced . Examples of affected services include Facebook, Instagram, Google Search, Gmail, Youtube, Yahoo Search, Yahoo Mail and Dropbox . Our exploratory findings reveal a time-delayed response of stock markets to potential IT security breaches as well as a discrimination among firms operating in different industries. The remaining portion of this paper is structured as follows. Section two provides background on related research, privacy theory as well as our research model. Section three provides information on our research methodology. Section four presents the results of our study and discusses its implications. Section five concludes the study. --- Background and Research Model --- Research on Realized IT Security Breaches As summarized in Table 1, previous research can be largely divided into the impact of data & security breach announcements on firms and vulnerability disclosures on software vendors . 30 TH First, results regarding the overall impact of security & data breach announcements are mixed. While some authors find negative cumulative average abnormal returns of publicly traded firms' stock prices ranging from -0.58% to -3.17% over short-horizon event windows below 10 days others don't. For example, numerous studies find limited evidence of overall abnormal price effects but strong evidence for discrimination among firm and event characteristics . Campbell et al. finds no evidence for an overall effect but strong and statistically significant support for negative effects of security breaches that involve unauthorized access to confidential data . Exemplary for evidence of discrimination among the type of firms are Hovav and D'Arcy , who find a statistically negative CAAR of internet-centered firms only and Ettredge and Richardson , who find a negative CAAR of internet-centric firms. Second, software vendors that created vulnerable products were negatively affected and experienced a CAAR of -0.63% associated with the announcement of a vulnerability within their products and services . In summary, previous research focuses on the impact of realized IT security breaches. However, little research exists on the question whether stock markets punish firms for creating the mere potential to breach their IT security. --- Heartbleed Vulnerability On April 7th, 2014, the existence of Heartbleed, a vulnerability within the cryptographic library OpenSSL was publicly announced . Heartbleed is the result of an improper implementation of the Heartbeat Extension --- Research Model to Study Potential IT Security Breaches The concept of privacy is considered to be of undisputed importance to societies of modern economies and has been studied for centuries . However, grasping the concept of privacy is cumbersome because of its manifold definitions . Acquisti et al. notes that attempts of precise definitions of privacy oftentimes "remain ambiguous, changing with the perspective of the observer", a view that is shared by Introna and Pouloudi . Nevertheless, in a landmark paper called "The Right to Privacy", published in 1890 by Warren and Brandeis, the authors reasoned that the concept of privacy gradually evolved over time to "the right to be let alone" . This view is still reflected by modern definitions with "the notion of privacy as freedom from the judgment of others" . Acquisti et al. , defines a privacy incident roughly as a failure of mechanisms designed to protect personal information of customers', partners' or employees from threats of technical, managerial, organizational or human nature. The Heartbleed vulnerability thus represents an IT security related privacy incident. IBT is the result of a research program to investigate the impact of monitoring and surveillance technology on the perceived privacy of workers . Xu et al. describes IBT as an explanatory framework that allows for studying social impacts of information disclosures: IBT states that people possess unique physical or virtual informational spaces. These spaces are limited by clearly defined boundaries. Attempts of external entities to cross these boundaries might be perceived as an intrusion into the informational space. The extent of this perception is dependent on situational and personal conditions . According to Stanton and Stam , IBT represents the synthesis of three separate constructs: First, the communications boundary management theory . Second, the group value approach to organizational justice . Third, a general expectancy valence framework for privacy protection . IBT is comparable to attempts of Moor The Case of OpenSSL Heartbleed 249 reasoning that "the unifying feature of privacy incidents is the violation of certain expectations about how data will be handled" . Xu et al. show that IBT can be applied in an information privacy context to describe the formation of an individual's privacy concerns. Table 2 distinguishes two groups of firms by the overall news the public announcement of Heartbleed conveyed to firm stakeholders. Group A includes firms that were protecting their webserver by a vulnerable version of OpenSSL, allowing for the exploitation of Heartbleed. Group B covers firms that were protecting their webserver with an unaffected SSL/TLS solution. Research hypotheses set H1 deals with the overall impact of potential IT security breaches within Group A and B and is based on IBT. We hypothesize that firms within Group A experience a reduction in shareholders' equity value, approximated by free-float stock prices, at the time of the public announcement of the Heartbleed vulnerability. Primarily because we assume that the announcement induced a re-assessment of firm stakeholders regarding the risk of unwanted information disclosure. This reassessment may result in a change in outcome from an acceptable-to an unacceptable risk as suggested by the IBT. This outcome is primarily driven by an increased perception of privacy intrusion induced by Heartbleed. In other words, stakeholders experienced negative news and responded with a decreased willingness to provide confidential information, which ultimately decreases business opportunity of affected firms. This reduced ability to conduct business will decrease future revenues and ultimately the amount of dividends a firm is able to pay out. Ceteris paribus and assuming that stock prices are primarily determined by the present value of expected future dividend payments, this results in a decrease in stock value . The resulting research hypothesis, in which negative stock market reactions refer to falling share prices, is explicitly stated as: H1a. Negative stock market reaction in Group A around the public disclosure of potential IT security breaches. Additionally, we hypothesize that Group B firms experienced a positive effect on shareholders' equity valuations at the time of potential IT security breach announcements. Especially because the knowledge that the firm was not affected by Heartbleed, despite being protected by SSL/TLSmay lead to a positive outcome of the re-assessment of the risk of unwanted information disclosure. This in turn attracts new 250 30 The Case of OpenSSL Heartbleed business opportunities through stakeholders, which previously assessed the risk as unacceptable. Furthermore, it is likely that stakeholders of Group A switched to Group B after assessing the risk of Group A firms as unacceptable, which again results in an increased ability of Group B firms to conduct business. Thus, and under the same assumptions regarding the effect on future dividend payments introduced in the last paragraph, this should result in an increase in the stock price of Group B firms: H1b. Positive stock market reaction in Group B around the public disclosure of potential IT security breaches. IBT states that people construct personal informational spaces within boundaries thatamong other thingsdepend on the nature of information in question. We assume that firms in different industries process different types of information, of which some are considered of greater importance than others to the overall risk-evaluation process of firm stakeholders. For example, firms in the Communications or Financial Services industry may process more confidential information than firms in the Materials sector. Thus, we hypothesize that there are industry specific differences in the outcome of the reassessment of the risk of unwanted information disclosure, which in combination with the reasoning of the last section yields the second set of hypotheses : H2a. Existence of industry specific differences in negative stock market reaction of firms within Group A around the public disclosure of potential IT security breaches. H2b. Existence of industry specific differences in positive stock market reaction of firms within Group B around the public disclosure of potential IT security breaches. --- Methodology --- Event Study Design Event studies are commonly used to examine the effect of specific events on the value of firms . While MacKinlay broadly defines event studies as "using financial market data [to] measure the impact of a specific event on the value of a firm", others developed a more narrow understanding and note that "event studies examine the behavior of firms' stock prices around corporate events" . In event studies, the timeline is divided into the estimation window, the event window and the post event window . Returns are indexed in event time t, where t=0 represents the event date. Returns prior the event date are typically indexed with negative integers relative to the event date . At its core, event studies assess the effect of an event on the performance of a security in the event window by subtracting the expected return of a security from actual observed returns to get abnormal returns and subsequently The Case of OpenSSL Heartbleed 251 aggregating these over time and/or securities. Thus, the estimated abnormal return _it of a given security i at time t can be written as 𝐴𝑅 ̂𝑖𝑡 = 𝑅 𝑖𝑡 -𝐸, where R_it represents the actual observed ex-post return and E the ex-ante normal return with X_it as the conditioning information of the normal return model . Two predominant normal return estimation models are the constant mean return model and the market model, in which X_it is the market return that is the same for each security i but changes with t . The market model R_it= α_i+β_i R_mt+ξ_it, linearly relates the return R_it of a security i at time t to the return R_mt of market portfolio m at time t with disturbance term ξ_it that exhibits an expected value of zero and variance σ_^2 . Parameters of the market model are the intercept α_i and the slope β_i of security i, which can be empirically determined by means of OLS regression using estimation window data . The abnormal return _it of security i at time t within the event window using the market model can then be estimated as 𝐴𝑅 ̂𝑖𝑡 = 𝑅 𝑖𝑡 -𝛼 ̂𝑖 -𝛽 ̂𝑖𝑅 𝑚𝑡 , where α _iand ̂ are OLS estimators of the market model. Event studies typically deal with more than one security and event windows that span over multiple days. Abnormal Returns are therefore aggregated to draw overall inferences of the events' impact on returns , which can be done across time, across securities and both across security and time . The cumulative average abnormal return of n securities over a time-period within the event window spanning from t=a to b can be written as 𝐶𝐴𝐴𝑅 ̂ = 1 𝑛 ∑ ∑ 𝐴𝑅 ̂𝑖𝑡 . 𝑏 𝑡=𝑎 𝑛 𝑖=1 Empirical research indicates that stock prices are not normally distributed . This is typically addressed by using non-parametric tests when analysing abnormal returns of a single day . However, problems arise when non-parametric tests are applied over multiple days on a CAR basis . Thus, Kolari and Pynnonen The Case of OpenSSL Heartbleed event day clustering. Additionally, GRANK often has good or higher empirical power when compared to highly popular parametric tests such as the ordinary t-test or BMP ttest. This holds true for event windows of any given length. Therefore, we rely on GRANK in the following. --- Economeric Design Table 3 summarizes the econometric design of each event study designed to put research hypotheses sets H1 and H2 to test and are repeated for good and bad news firms. The event of interest is the public announcement of the Heartbleed vulnerability within the cryptographic library OpenSSL on April 7th, 2014. The market model with daily close prices was chosen for estimating the normal returns. First, because gains from more sophisticated multi-factor models such as CAPM and APT based as Fama-French-3-Factor over statistical models are limited . Second, the market model is slightly less affected by cross-sectional return correlation in the presence of event-date clustering than the Fama-French-3-Factor-Model . The estimation window length to estimate the regression coefficient is 200 trading days, which roughly equals the mean of 52 papers including event studies in IS research originally compiled by Konchitchki and O'Leary . Three different event window lengths, covering 3, 13 and 23 days respectively are applied. The short-horizon event window of three days complies with the econometric reasoning of superiority of short-horizon event windows by Konchitchki and O'Leary . The mediumand long-horizon event windows are designed to capture potential information leakage prior to the event and delayed stock market reaction and act as a robustness check. --- Overall Impact Hypotheses set H1 is concerned with the overall impact of potential IT security breaches on stock prices of publicly traded firms. Table 5 presents empirical results by providing CAARs and results of two-tailed non-directional GRANK-T tests over short-, medium-, and long-horizon event windows. The null hypothesis tested by the tgrank test statistic states that there is no mean effect while the alternative is that there is a mean effect . The Case of OpenSSL Heartbleed 257 in the latter two cases at the 10% and 5% level. However, Figure 2 reveals that firms in the Group B performed better, relative to firms in Group A. --- Industry Specific Differences H2a predicts the existence of industry specific differences in negative stock market reaction of firms within Group A around public disclosure of potential IT security breaches. Results presented in Table 6 seem to support this prediction. Most industry specific CAARs in the short-horizon event window are of no statistical significance according to the two-tailed GRANK-T test. However, firms operating in the Consumer Discretionary and Health Care industry experienced CAARs of -1.43 and -2.59%, which are significant at the 10% and 5% level, respectively. Interestingly, when looking at the results of the medium-horizon event window, the statistical significance of the effect on firms in the Consumer Discretionary sector vanishes. Instead, the CAAR of -4.9% of firms in the Communication sector becomes statistically significant at the 1% level. In addition, the effect on the Health Care industry becomes significant at the 1% level with a CAAR of -6.55%. In the long-horizon event window, eight out of ten industries experienced an effect of statistical significance at the 10% level ranging from CAARs of -9.47% to +4.4%. H2b predicts the existence of industry specific differences in positive stock market reaction of firms within Group B around public disclosure of potential IT security breaches: Table 6 indicates that there is little support for this prediction in the shorthorizon event window, as only the CAAR of -1.40% in the Consumer Discretionary sector is of statistical significance. Additionally, there is little support for the predicted positive effect as the vast majority of industry specific CAARs is negative. In the medium-horizon event window, three industries experienced a significant effect with CAARs ranging from -3.14 , over 3.91% to -8.82% . In the long-horizon event window, these negative effects increases even more. In addition, the negative effects within the Consumer Discretionary and Financials sectors are statistical significance. 1997). First, regarding the efficient markets assumption, we assumed that people are both able to find and make sense of publicly available information. While easy to find, it is possible that firm stakeholders were unable to make sense of it due to the technical sophistication of the Heartbleed vulnerability. Thus, even if large investors were aware of the problem, they may have concluded that other stakeholders were not and assumed no re-evaluation of the risk of unintentional disclosure of private information would take place. Second, event anticipation is unlikely as search query data of Google and Wikipedia revealed no interest in Heartbleed prior its public disclosure. Third, it is not possible to control for confounding events when analyzing a sample of 4,147 firms. However, effects are likely to be wiped out due to the large sample size and are especially unlikely in the short-horizon event window where the economic calendar provided by ECONODAY reveals no event window contaminating news. Typical additional issues of event studies are the sample size, the identification of outliers, the length and justification of the event window and further explanation of abnormal returns . Because of the large data sample, explicitly defined outlier return thresholds, theoretically justified event windows and research hypotheses, these should not pose a significant issue. Next to these limitations, future confirmatory studies must examine comparable large scale IT security issues where a multitude of firms are affected. --- Conclusion and Outlook This paper provides empirical evidence on the global impact of potential IT security breaches on stock markets. Thereby, it enhances the understanding of the full economic impact of information privacy measures by shedding light on previously neglected hidden costs. By drawing on IBT, research hypotheses are developed and put to test by means of multiple large scale event studies covering 4,147 firms headquartered in 43 countries. First, our exploratory study indicates that stock markets react with a time delay to potential IT security breaches. Second, we provide evidence for a discrimination of firms operating in different industries. Therefore, this work extends the understanding of consequences of jeopardized IT security by adding a previously neglected hidden cost component to information privacy considerations. Future scientific research in this field could investigate additional determinants of the discrimination of stock markets between potential and actual IT security breaches. --- Introduction The emergence of new technologies has changed the nature of work since the early 1980s in two ways. Firstly, the ongoing transformation has an impact on work relations and lead to an increase in nonstandard work arrangements . Secondly, even within standard work relations, the organization of work is undergoing a significant change, resulting in new ways of collaborating with stakeholder groups inside and outside of organizations. Although the changed nature of work relations is the driver for the phenomena coworking, the focus of this paper is not on the rise of the freelance or gig economy, but on the question how traditional organizations deal with the new work scenario coworking and how they integrate it in the portfolio of existing ones. It is thereby of particular interest, in which ways their usage scenarios are different from the ones of freelancers and microbusinesses and how the collision of the two entities in these third places could be beneficial for both. Since coworking is a rather new phenomenon it is not yet elaborately discussed in the academic literature; this is even more the case for coworking from a company's perspective, where only few articles exist, e.g. Ross & Ressia who look at coworking as an alternative for "home-based telework" in the public and private sector. The focus of this article is however not on the potential for replacing a work scenario, but on adding it to existing ones. --- The changing nature of work Remote work scenarios are not new -it was the first oil crises in 1973 that helped telework and telecommuting to its triumph . However, today's highly mobile and connected digital nomads have little in common with these early teleworkers, who completed work outside of the office in an isolated manner, supported by stationary computers, fixed telephones and fax machines . The emergence of mobile devices, cloud computing as well as social software is drastically transforming the way in which companies conduct work and organize collaboration . Today, work is no longer tied to a time or place which makes the assignment of all employees to a fixed space obsolete . science to rethink existing models and assumptions. The focus of this article is however not on new forms of employmentwhich have beyond doubt been the catalyst of the whole coworking movementbut the question, which value proposition coworking offers from the perspective of established firms. While "working alone together" is one of the main promises for freelancers and microbusiness, coworking spaces only represent an alternative work scenario for established firms, at least in a short-term view. The relevant question from their standpoint is therefore how these third places will complement the existing work scenariosin contrast to freelancers and microbusinesses, who chose coworking as primary work location. These user groups have been subject to various studies in the last decade . The key question to expand the existing studies on coworking is therefore "what is it for whom?". As this definition focuses strongly on ideologic goals, the definition has limited validity from a company's perspective. Based on the accurate overview of the most important aspects of coworking provided by Bouncken and Reuschl the following own definition shall be used in this article: --- The emergence of coworking "Coworking spaces are neutral places, where affiliated and unaffiliated professionals work side by side or in collaboration. The spaces are used by individuals, teams or other cross-organizational groups, during a specific project phase or for an unlimited period, in addition to other work scenarios or exclusively." The most significant difference between coworking as envisaged by freelancers and microbusinesses in the early years and companies, who only started developing interest recently, is the community aspect. Whereas participating in an active diverse community is for most companies an important benefit, it is not an exclusion criterion. As the present field experiment suggests, coworking also offers attractive opportunities from a boundary management perspective, where the benefit of individual flexibility is more important than mingling with others and fostering "accelerated serendipity" . Coworking is far more than a hype, as a look at the growth rate since 2005 confirms. According to Deskmag , both the number of coworking spaces and members continue to grow rapidly; by the end of 2016, 11 300 Coworking Spaces and 835 000 coworking members were counted worldwide, thereof 70 in Switzerland, where the experiment took place. Not included in these numbers are coworking spaces and seats offered by companiesit can be expected that the number of corporate powered workspaces will also rapidly increase, as can for example be seen in --- Research Methodology This research was undertaken with two main goals. The first was to understand the value proposition that coworking offers from the perspective of companies who operate corporate offices, but are interested in alternative work scenarios in addition to the existing ones. The second was to identify different usage scenarios and based on these to derive insights, how companies can integrate this new work scenario in the existing ones. Research was done in an exploratory way, as both the subject coworking and in particular the perspective of established companies is relatively new in the academic literature and not all relevant aspects are yet discovered . In-depth, semi-structured, qualitative research interviews were conducted. This methodology was chosen as the focus was on understanding the new scenario from the point of view of the participants of the field experiment. --- Study participants The basis for this study is a field experiment, in which voluntary participants of two Swiss ICT companies, 9 from the smaller and 16 from the bigger one , took place. During 4 months the 25 volunteers were asked to try out coworking. No specifications were made regarding the expected frequency of usage, the combination with existing work scenarios or the visited coworking spaces; they could choose from over 100 coworking locations within Switzerland 8 . The participants were informed about the project via social intranet, email, face-to-face discussions with their managers and an optional kick-off event. As all participants volunteered, the group was very heterogenous and consisted of members from different teams and with different job profiles; most of them were in marketing or sales roles. All participants came from a company and team culture where it was normal and accepted that work was also done outside of the corporate office or the client's facility. Except for two participants all were employed with a fulltime contract. They varied quite strongly in their degree of mobilityabout half of them still had their personal desk, the others worked with a shared desk concept with or without a clearly assigned home base. Some of them had already been in coworking spaces but no participant was experienced with coworking. As the boundaries between mobile knowledge workers and more stationary knowledge workers are blurring , no further distinction regarding degree of mobility was made. During the four months field experiment a few interventions were made as the utilization of the coworking spaces was on a very low level from the beginning. The interviews were done at the end of the experiment. --- Data collection The study is a qualitative inquiry based on semistructured interviews with 25 participants of a coworking field experiment. The interviews were mostly done in person in meeting rooms provided by the respective employer, a few were done via Skype. Prior to the interview, the interviewer briefly explained the most relevant facts about the field experiment and the focus of the study. This information was already provided in written beforehand in the process of recruiting the voluntary participants. The interviews were audio recorded and transcribed; they ranged in length from 40 to 65 minutes and were conducted in German or English. The interview protocol was open-ended with the goal, to get a detailed understanding of the person's work disposition as well as of their experiences with the new work scenario coworking. --- Data analyses Data analyses was done based on the exploratory grounded approach chosen as methodology for this study. The audio recordings of the interviews were transcribed, imported in to ATLAS.ti and coded in an open way. Based on the first interviews the interview guidance was slightly adapted, however after 15 interviews a certain saturation could be remarked, where no new themes related to the core focus came up. The usage scenarios, personae, and recommendations were done based on the interviews and an extensive literature research on coworking and new work scenarios from the perspective of companies. --- Findings The findings are presented as follows: first the insights into factors that were analysed by means of the semi-structured interviews are presented in the form of a general evaluation. It is then followed by the identified benefits and obstacles of coworking from the perspective of companies, which is derived from the interviews in combination with literature research. --- General Evaluation  Utilization: The most surprising finding of the coworking experiment was the low utilization figures. On average the participants went 2.9 times in the coworking spaces within the four months and spent 3.6 hours per visit there. It can be expected that the utilization would have been on an even lower level without the interventions which reminded the participant of the project. Whether the low utilization was based on the short experiment duration, the low eagerness to experiment or the schedules of the participants, which did not allow for more time spend in coworking spaces, was not inquired.  Perception of the experiment: Despite the low utilization, the general feedback of the participants towards the project was throughout positive. Most of them interpreted the pilot project as a sign, that their employer not only tolerated working outside of the office but also invested in new ways of working.  Individual productivity: A small majority stated that they were more productive in the corporate office compared to the coworking spaces. It is noteworthy that most of the participants who said they were most productive in the coworking space, do not like to work from home. It might be interesting to do further research on the question, in which ways the personal boundary management strategies and the individual coworking use cases are interlinked. Since all participants used the coworking spaces for individual work and not for team collaboration, only the individual productivity could be observed. The results of the study might be different if whole teams use coworking space.  Individual creativity: The participants rated the corporate office followed by the home office as the location where they were most creative, coworking only ranked as third. Given that coworking spaces are often referred to as creative hubs, at least from the perspective of freelancers and microbusinesses, it was surprising to see that the corporate workers did not choose them as preferred location for creative work. Nonetheless mentioned a small majority when asked that they had gained new impulses in the coworking spaces -be it by meeting new people or stumbling across new ideas. Some interviewees attributed the lower creativity to the fact, that they did not have whiteboards, flipcharts or other or other visualization tools available in the coworking space or they did not want to transport them after use to continue working with them.  Use of technology: All interviewees stated that they used the same communication and collaboration technologies as they use in the corporate office, at home or when working mobile. What was different was the amount of time they spent in calls compared to the corporate office. A lot of participant went to the coworking spaces especially to make calls or to conduct virtual meetingsthis was in particular the case, when they were traveling the whole day and tried to use time in-between external meetings in a productive and way. This usage scenario -coworking as a "filler" for productivity -conflicts with the original purpose and focus of most coworking spaces, which is to bring people together and not to foster undisturbed work and retreat. Besides the disturbance by noise or the fear of disturbing others when doing a call in the open space zone, the participants raised concerns regarding data privacy and protection. ---  Online and offline community management: Belonging to an active community is one of the main reasons for freelancers and microbusinesses to engage in coworking. One aspect of the interview was therefore, whether this element was also looked for by the participants of the experiment. When asked about contacts with other coworkers in the space, the majority reported that they were hardly any exchanges with others. although most of them did not actively look for new encounters, they saw in networking and informal exchanges with new contacts a big advantage of coworking compared to other work scenarios. Some interviewees mentioned, that they would plan their coworking journey differently in the future, e.g. having lunch with the community, participating in local events or blocking time for informal discussions instead of spending the whole day in virtual meetings or working rigidly through their task lists. Most participants were in contact with the coworking host for the check-in procedure; however, they did not notice any community management measures , such as an active introduction to other members. Professional Coworking chains such as WeWork offer also a virtual community management platform, which is mainly used to communicate with the members or to facilitate the exchange between the members. The project team in charge of the field experiment set up a group on the enterprise social platform Yammer, which could be accessed by employees of both participating companies. The goal of using an enterprise social network was to facilitate the project coordination between the project leads and the participants, but also to enable networking amongst the participants, for example to coordinate physical meetings in the coworking spaces. Despite the users' familiarity with enterprise social networking, the group did not attract any interest from the participants and was not used except by the project leads to share background information about the experiment in the beginning. --- Benefits and Obstacles The following table aims at summarizing the gained insights by listing the most important benefits of coworking as well as the perceived obstacles from the point of view of --- Obstacles of Coworking --- Relevance Mitigation --- Possibility of retreat The interviewees were missing separate spaces for calls and virtual meetings. Because of their spatial separation from internal and external stakeholders, this is an obvious need; however it showed at the same time, that most of them did not adapt their behaviour and work schedule to the new space concept during the observed phase. Despite the positive attitude towards the new work scenario, a lot of interviewees mentioned their fear of increased coordination efforts within the team and the organization. Some of them mentioned, that complexity was already high because one fraction of the team was always traveling or working from home. This concern raised the question, whether the reduced face time for formal and informal interactions within the organization would not lead to a decrease of team productivity, connectedness and identification with the organization. The introduction of new work formats should be well accompanied by corresponding measures and team discussions. Team chats and enterprise social platforms can support the coordination. --- Equipment of space and workplaces Whereas about half of the experiment participants expected to have the same equipment available in the coworking space as in the corporate office the other half was indifferent; most appreciated the variety and "used what was there". Coworking spaces should actively communicate about their equipment to facilitate the selection of the right space. Other important success factors mentioned by many interviewees as important requirements were the network quality and ease of access, a simple booking and billing process for the coworking hours consumed , the geographical location and the proximity to public transportation as well as good quality of coffee. As these factors do not differ from the needs of freelancers and microbusinesses they were not in the focus of the study. --- Coworking Personae Based on the interviews and literature research, the study author tried to identify different poles of usage and expectations and grouped them into different personae. The goal of the personae is not to identify a distinct behavior, but to visualize the different needs which in turn allows to build different coworking journeys. The personae might also be 274 30 helpful when it comes to discussing different situational preferences and spatial needs in the corporate office. A similar attempt to classify the different users was done by Bilandzic & Foth , who distinguish in their studies about coworking in libraries between those who use coworking-spaces mainly because of the offered infrastructure, learners who use coworking-spaces to acquire knowledge and have an exchange with peers, and socializers who search for recognition and acknowledgement. Figure 3: Coworking Personae As Figure 3 shows, the interviewees diverged most regarding the two following axes:  Connectedness: are coworking spaces primarily used to get access to a community or to dissociate from the team/office or family/home?  Disposition: are coworking spaces primarily used to get inspiration from the different space and community or with the goal to increase of efficiency, e.g. bridging time between meetings. --- Discussion The duration of the observed experiment was a rather short period when it comes to analyzing the acceptance and embedding of this new work scenario into existing ones. It is above all too short to observe the changed behavior based on new interpretations of coworking, which in turn will also lead to new interpretations of the corporate office, home office and mobile work. Orlikowski's practice lens addresses changes in technology use over time, where users "may, deliberately or inadvertently, use it in ways not anticipated by the developers". These new interpretations lead to new work practices and as these work practices change, interpretations of the technology's function change too . It would therefore be interesting to observe and discuss theses multiple interpretations and associated changes in work practices over a Addressing these different expectations and perceptions and dealing with the multiple interpretations over time as mentioned is an important management aspectwhen companies want to benefit from new work practices, they also need to assume responsibility for the organizational learning process. One concrete example is to address whether it makes sense to go to a coworking space when the agenda is fully booked with calls and virtual meetings. The measured utilization figures are also an interesting point of discussion. Whether they were so low, because the pilot duration was too short or because the participants schedules did not allow much time for experimentation or if they preferred working from home or on the road instead of discovering new scenarios is unclear. The conclusion, that they were not interested in coworking or that it offers no value to companies falls short also with regard to the very positive reactions they expressed in the interviews. --- Conclusion The biggest consensus amongst all study participant was reached with the question, whether they would like to trade in their corporate office for coworking. None of the interviewees opted for this scenario; most of them mentioned the importance of their office as center of gravity and/or identification. Part of this reaction can be explained, that they were scattered to over 100 locations and participated as individuals, not as teams in the pilot project. One element which came out clearly in the study is that networking, serendipitous encounters and informal knowledge exchange with other members do not come for free in coworking spacesit needs concrete measures if these benefits are the main motivation for companies to invest in coworking. These findings are in line with other research, e.g. Parrino who showed in two case studies that co-location does not automatically lead to interactions and knowledge exchange between individuals. Both the focus of the coworking space as well as the policies that promote interactions amongst members are decisive factors that determine whether interaction and knowledge exchange takes place . Similar findings are presented by Spinuzzi who differentiates between "good neighbours" and "good partners", depending on whether people just work side by side on their own projects or collaborate in a more intense way. The interviews also highlighted the relevance of the work and leadership culture for the successful adoption of new work scenarios. --- Introduction During the past years, individuals and healthcare sector have become increasingly interested in measuring and promoting various aspects of wellness and health by using different technological solutions. Although different technological solutions for personal wellness have been around for quite a while, the whole business field of wellness technology is still at a relatively unmature stage and rapidly growing . There is a wide variety of products ranging from exercise and wellness applications to activity trackers and versatile sport watches in the market, and completely new solutions are released constantly. Typical to these devices is that they can be used for self-tracking purposes . The findings of Miyamoto et al. suggest that tracking wellness related data alone may result in heightened awareness of daily activity, but it may not be adequate to sustain the use of wellness technologies, which often have low retention rates. Wang et al. found that a wellness application is more effective the more frequently it is used, and more effective when used over a longer period of time compared to short-term use. Such reports and findings demonstrate the growing need for studying the usage of these technologies. Regardless of the business field, it is essential to understand as much as possible about the target audience. Studying consumers' motives and habits is important to deepen the understanding about their desires and needs. There exists a wide variety of user characteristics within the wellness technology users, and different target groups have different set of requirements . As wellness technologies are ever more used, there is a growing need to deepen the understanding on their users and thus, it is important to research them to gain new understanding on this matter. The purpose of this study is to deepen the understanding of how people use and perceive wellness technology in their everyday lives. Besides the many aspects regarding wellness technology use itself, the focus of the study is also on how wellness technology gamification is perceived and whether it motivates people in their wellness related activities. Third point of interest is how people think integrating wellness technologies into their lives is seen by other people, and how these thoughts might influence their wellness technology usage in general. The main research questions studied in this paper are: 1) What kinds of feelings do wellness technologies and their use wake among their users? 2) How do people experience gamification with wellness technology and how does technology support gamifying? 3) How do people perceive other people's views on their wellness technology usage and gamification? The term wellness technology is used as an overall term for different kinds of technological health, wellness, and sports related solutions that people use in their The results of this study can help the wellness technology providers in deepening their understanding on wellness technology usage and in providing solutions that are better welcomed by their target audiences. The findings may also assist people working in the healthcare sector in implementing different wellness technologies for health and wellness related purposes. The paper comprises of six sections: introduction, theoretical background, methodology, results, conclusion, and finally the limitations and future research section. --- Theoretical Background --- Motivation and Wellness Technology The actions and behaviours of individuals are influenced by observations on how other people act. According to Bandura's social cognitive theory, observational learning and social experience play an important role in people's personality development and in the development of their self-efficacy . Self-efficacy refers to one's own belief in one's own capability to do a task, which in turn affects their motivation to attempt that task. People with high self-efficacy feel a task more attainable and less difficult and trust their abilities to perform it, whereas people with low self-efficacy might perceive a task as too difficult and may be less motivated to perform it . According to Ryan and Deci , motivation can be divided into intrinsic and extrinsic motivation. Intrinsically motivated people perform activities such as exercising just because of the pleasure of doing it, whereas more extrinsically motivated people do the activity because they see it as a tool of gaining something else they are interested in, such as competition prizes from a race or acceptance from their peers. A person who does not have any motivation to perform a task is considered amotivated. There has been a substantial interest in the role of wellness technology to motivate people to be more physically active or to adhere to physical activity guidelines as this research finding suggests that the main motivation for the increase has to be based on personal and intrinsic motivation and it can be strengthened with technology. The reasons why different kinds of wellness technologies are acquired seem to vary. Previous research has shown that the usage intentions of different solutions can be driven by both utilitarian or hedonic perceptions . --- Gamification and Exercise Motivation Gamification refers to the use of game elements in non-game contexts . The common purpose of gamification is to motivate users to behave in desired ways by making the user experience more playful and enjoyable . Implementing gamification has become very popular in various different contexts . As the utilization of gamification has grown, it has become a subject of growing interest in academic research as well . Kari et al. proposed recently that a division should be made between the process of gamification and the experience of gamification. Kari et al. define the process of gamification as "using a set of activities with the aim to implement game elements to non-game context" and the experience of gamification as "a use experience in non-game context that the user perceives as gameful". Commonly, the process of gamification aims to create an experience of gamification for the user. Yet, the experience of gamification can also arise from non-gamified features . In this study, the focus regarding gamification is especially on the experience of gamification. Gamification can be an efficient approach to influence user behaviour and use of an application . It can also have a positive impact on motivation in general, but differences occur between different solutions, elements, and also between individuals . In the context of wellness technology, these individual differences can be traced to such personal characteristics as attitudes towards sports technology, exercise habits, and competitiveness. Different people also experience gamification in different ways . Overall, the experience of gamification can influence a user's exercise motivation positively . A recent study shows that the relevance of gamification in wellness domain will continue increasing --- Methodology This study followed a qualitative approach. It can be defined as a diary study based on phenomenographic approach. Phenomenography is a research method originally developed by Ference Marton Phenomenographic studies are usually based on textual data, e.g. transcribed interviews, essays, or diaries. In the research setting of this study, user diaries were selected as data collection methods. Diary study was selected as the method because its ability to provide more authentic information on human-technology relationships and technology use in situ , as the so-called presentation effects are diminished . The voluntary participants for this study were recruited from a list of participants from an earlier study. They had expressed to be available to participate in research related to sports and wellness technology. The goal was to get 15 to 20 participants for the study. To recruit the participants, during late 2015, invitation e-mail to participate in the study was sent out to 50 potential participants, out of which 35 replied. Out of those 35 who replied, 22 signed up for the study. No restrictions were placed regarding the participants , as the goal was to reach varying kinds of participants. However, all the participants were from Finland. The participants were asked to keep a diary of their wellness related technology usage and perceptions for six weeks. They were also asked to provide basic demographic information on a separate sheet. All the participants received an information letter, in which the central termswellness technology and gamificationwere explained. The participants were also given instructions regarding keeping the diary. They were especially asked to focus on three different aspects in their diaries and write down opinions, thoughts, feelings, experiences, and perceived effects regarding: 1) Wellness technologies and their use, 2) wellness technology and gamification , and 3) perceptions on other people's views on one's own wellness technology use and gamification. They could choose how to keep the diary themselves. All the participants wrote it electronically. The participants were not given any strict time limits regarding when the six-week period should take place. The return dates of the diaries ranged from December 2015 to February 2016. After the six-week period, the diaries were returned electronically to one of the authors. Out of the 22 participants, four dropped out during the study. As a result, diaries were received from 18 participants. This can be considered to be an adequate amount for this qualitative study. To analyse the data, thematic analysis was used. This analysis method is often used especially when researching matters of common everyday life, since it provides practical answers to the research problems . It is also the most widely used analysis method of qualitative research and enables organizing and describing the data with rich detail . The actual data analysis was guided by Braun and Clarke . Following their suggestion, the guidelines were adjusted to fit the research subject and the data. Thematic analysis was used to identify, analyse, and report patterns within the collected data. The analysis started with familiarizing oneself with the data and marking all the interesting features of it. The data was then divided into three different themes for each individual. The themes were as follow: 1) wellness technology use and perceptions in everyday life, 2) wellness technology and the experience of gamification, and 3) perceptions on other people's views regarding one's own wellness technology usage and gamification. After this, all three themes were separately studied by examining all the participants' answers under that particular theme and searching for similarities and differences. These were then reviewed in relation to the data. The analysis also aimed at interpreting specific aspects and exceptions of the investigated matter. Finally, the report was produced. As Braun and Clarke propose, the analysis process was a recursive and non-linear, as it moved back and forth between the different phases of analysis. --- Results In total, the study had 18 participants. Four of the participants were male and 12 were female. The age of the participants ranged from 18 to 70 and the average age was 39.6 years. More detailed description of the sample can be found from the appendix. --- Wellness Technology Use The wellness technologies used by the participants varied from activity trackers and heart rate monitors to smart scales and step counters as well as different mobile applications related to wellness and physical activity. Few also reported the usage of exergamesdigital games requiring aerobic physical effort from the player or other gamified applications. The most common reason for acquiring a device or an application was to get more accurate data on personal exercising or health; data that is not only based on own feelings. GPS features were also considered as important by many participants. Most participants liked how they were able to get varying and interesting data with the help of wellness technology. Many were using the technology to control their exertion level during physical activity either by checking that they were not training with too high intensity or that they were training with intensity high enough. Wellness technologies were also considered to have motivational elements, since they provided a reliable tool for setting goals. Most of the participants reported that wellness technologies had positively affected their motivation by enabling them to see and compare their own exercise data. Seeing longer-term improvement regarding exercise Some participants reported they were intrinsically motivated to exercise and for some of them using wellness technology did not bring any extra motivation. Some participants reported wellness technology being able to increase their motivation during their more active exercise periods. However, when they feel less physically active, using wellness technology and seeing your own data could actually decrease exercise motivation. Respectively, some reported that when things are going well, the information from the technology makes one happy, but when things are going badly, the information from the technology can be annoying. For some participants, wellness technology also had some educational effects such as learning more about training intensity, calorie consumption, and heart rate levels, and being able to better compare objective data to subjective feelings. This kind of learningeffect could also lead to discontinuance in using the technology, as it was felt that the technology could not provide any new or interesting information. Some participants raised the question about the reliability of wellness technology. They highlighted the fact that their devices sometimes do not work properly. Participants found this annoying since they would rather focus on their own performance during the exercise than thinking whether their device works at that moment. Some participants also emphasised that people should not always blindly trust the information received from wellness technology since the information is never completely individualised for them. Some participants were also reluctant to value wellness technology data and its accuracy over their own feelings. Some were commenting that "Why can exercise be considered hard only then if the result is proven by a sport watch?". The most common negative remark about wellness technology was related to technical problems that occur during exercise. For some, this might even bring the feeling that the exercise has gone to waste; "If the heart rate monitoring stops working during exercise, I want to throw the device into a rubbish bin". Another case when technology might bring negative feelings is when people forget to take it along to their exercises or when some wellness application does not work on a specific device. Some participants considered sport watches to be so big in size that they did not want to use them during any other time than while exercising, which limited their usefulness in tracking other everyday wellness related activities such as sleep or general activity. While some participants felt it was "easy" to wear wellness technology devices, others felt wearing them was uncomfortable and sometimes even pointless, for example, when TRANSFORMING OUR LIVES T. Kari, E. Kettunen, P. Moilanen & L. Frank Wellness Technology Use in Everyday Life: A Diary Study their training focus was on strength training instead of aerobic training. In other words, the willingness to use technology was also partly associated with the conducted activity or sport. Few participants reported that keeping a log of their own exercises was hard work with or without the help of wellness technology. Some also emphasised the fact that some wellness technology devices and applications are too difficult to use. For one participant, tracking exercises created too much stress about exercising and therefore woke the need to stop using all devices. Several participants associated wellness or sports technology use with hard and intensive training with set goals. They did not consider themselves as athletes and therefore did not see why they would need to use or how they would benefit from using wellness technologies. Some of them were afraid that adding new technologies to their exercise routines would take some of the fun away by making it more goal oriented and strict, subsequently decreasing the intrinsic motivation to be physically active. The study also included four participants from the "young elderly" age group, i.e., 60-75 years of age . Studying the young elderly age group is deemed important, as they are a growing and a very large group of individuals with a rising need for different digital wellness solutions . Bearing in mind that the study only had four participants from this category, the data supports this notion by Carlsson and Carlsson , as all the young elderly participants were using some sort of technology to support personal wellness. However, among the young elderly, the polarisation was quite apparent. At its simplest, the technology used by two participants was restricted to just a blood pressure meter or an electronic scale, whereas the other two were using sports computers with their various features and electronic training diaries. Interestingly, only one saw age as any kind of limitation regarding the use of these technologies. --- Wellness Technology and the Experience of Gamification Almost all participants who were using wellness technology reported they were comparing their own previous health and exercise related results to their current ones to keep track of their development and fitness level. This data was often received from a sport or wellness technology device. Some participants reported they compared their old and new data also to see how their technique had developed. This kind of comparison also seemed to wake experience of gamification. However, when it comes to sharing data in social media or comparing own data with other people's data, the situation was different. Most participants felt their exercise data is personal. Few participants compared any of their data with family members' data or to other people's data that can be seen, for example, in some web service. Only those participants who did some level of competitive sports, more constantly compared their results or data with their training partners. Considering this, it seemed that the experience of gamification rather comes from comparing own data with own data than comparing own data with data from others. An exception to this seems to be different voluntary physical activity When participants explicitly reported about the type of gamifying they do, they also most often referred to comparing their own results with their own exercise history and data with the help of some technology. Some participants set a goal to reach enough daily activity, to walk or run the same route with a faster pace than before, or to be able to maintain a lower heart rate than in previous runs. Strength training was also reported to be something where the gamified aim is to reach the "next level". More competitive exercisers reported gamifying by comparing their own training and race results to previous ones or trying to improve their own scores in competitions or lap times during training. Some participants reported to challenge themselves by tracking their weight on a regular basis. One participant reported using a gamified application to drink enough water. Overall, different technologies were regularly mentioned to support these gamified activities. Considering the motivational effect, many participants reported that this kind of gamifying brought extra motivation. One participant described that the activity tracker reminds a Tamagotchi with the need to "feed it and keep eye on it on a regular basis". Few participants were also using gamified applications or doing geocaching, which as an activity is all about integrating technology into exercise by adding extra gamified elements into regular hiking, walking, or running session. For these participants, having the gamification element made them venture further and visit different places. Exergaming was also mentioned as a one form of exercise. Among the young elderly, the participants' reports were similar. Most commonly, the experience of gamification came from comparing own current data with own previous dataoften with the help of some technology. This was also considered motivating and an enjoyable means to support reaching personal goals. One also mentioned occasionally playing exergames. It seemed that some people also engage in a sort of self-gamification, which can be defined as a desire-based action to gamify some recurring activities or bodily functions. Pursuing the experience of gamification by self-gamification could begin as nontechnical, but later on, some technology was implemented to support the gamifying. --- Perceptions on Other People's Views of Wellness Technology Use Most of the participants neither shared their wellness related data with other people nor felt the need to tell anybody that they were tracking their wellness. Some felt exercising was their own personal thing and no one else's business, and some were reluctant to show their results to anybody because they felt other people exercise more and have better results. Some believed that no one would be interested in whether or not they track their wellness or exercise, because it is considered so normal these days. Some had the 288 30 perception that many others usually view tracking as too difficult or time consuming and therefore not worth doing. Some reported that other people had asked them about their use of the device they were wearing. Some participants were even a little bit ashamed of their exercising and results. One participant was worried to be seen as too old-fashioned if anybody knew about the habit of doing exercise with an exercise video. Another participant reported to be sure other people would consider geocaching to be a too childish hobby. Some applications also seem to have a negative image, and people were not eager to admit they were using such application. One such example was a calorie-tracking application, which was associated as a tool for overweight people. One participant felt embarrassed to wear a sport watch due to feeling concerned to be seen as an athlete by others, even though being just a regular exerciser; "In badminton it can be embarrassing to wear a sport watch since my opponent is better than I am. It makes me feel I take this too seriously. I try to start my watch in a way that is as unnoticeable as possible". The perceptions were similar among the young elderly. If anything, they seemed to feel even more strongly about not wanting to share their own personal data with other people. They also believed that their friends would not be interested in their own data. Respectively, they reported to be very uninterested in the data of their friends. Even though there were more negative perceptions regarding other people's views on personal wellness technology use, a few participants reported they felt proud and got extra motivation when other people saw them doing something different and positive such as running or using a wellness technology. --- Conclusion The purpose of this study was to deepen the understanding of how people use and perceive wellness technologies in their everyday lives. The focus was also on related gamification and perceptions regarding other people's views. A qualitative diary study based on phenomenographic approach was conducted. The study included diaries from 18 participants who kept diaries for six weeks regarding their wellness technology usage and related issues. The most common reason for acquiring a wellness technology was to get more accurate and objective data. Motivational effect was also an important factor behind acquiring one. Based on the data, it seems that the use of wellness technologies can positively influence wellness motivation. For some, a mere buying of a device brings additional motivation, but for the majority, being able to follow personal progress by receiving objective data and that way comparing own results to previous results is the key motivational factor. This implies that it would be worthy for the designers and the parties aiming to increase In general, wellness technologies can help people to learn more about the level of physical activity and training effects. Regarding the finding that a learning-effect could lead to discontinuance in using the technology, it demonstrates that even if the user would stop using the technology, it does not necessarily mean that the technology or its use would have been a failure, but instead a success in a way of being able to teach the user the things he or she wanted to know. This was an interesting new finding and something to consider, for example, when investigating the retention or use continuance with these technologies and also IS in general. The biggest concerns the users seem to have are related to the situations where the device stops working during an exercise or for some reason does not record the entire exercise session properly. For some, this may even be a reason to stop exercising. Therefore, to achieve longer-term motivation, for some people it would be better to use devices and applications they are already familiar with. Both users and those promoting wellness should acknowledge this. Another concern was related to wearing a wellness device, such as a sport watch. Whereas some described wearing one to be perfectly "easy" and normal, some reported not feeling comfortable wearing one outside exercising or sometimes not even when exercising. This obviously limits their usefulness in tracking other daily wellness related activities. Thus, these devices should be designed as ubiquitous and as easy-to-wear as possible, also acknowledging the look of the device and the different user groups. Regarding gamification, the most common type of gamifying seems to be comparing personal results or data with previous personal datausually with the help of some technology. This kind of comparison also seemed to wake experience of gamification, which, in turn, was reported to influence motivation positively. It also seems that some people engage in self-gamification, which we define as a desire-based action to gamify some recurring activities or bodily functions. Interestingly, pursuing the experience of gamification by self-gamification can begin as non-technical, but later on, be supported by the use of some technologies. In general, including a gamification element to wellness related activities seems to bring extra challenge, motivation, or even make the activity as more enjoyable. Thus, people struggling with their wellness motivation could try selfgamification or some gamified technological wellness solutions. The designers should undertake the process of gamification, for example, implement their devices and application with gamified features. The societal parties working with wellness promotion might be able to increase the effectiveness of their interventions with gamification. With the exception of more competitive individuals, most participants did not feel the need to share their training data with other people since the information was generally considered personal. Some were also concerned how other people view their wellness technology use. This implies that the marketers of these solutions could benefit from 290 30 making it seem that the use of these devices is common and socially acceptable among their target audiences. Regarding the young elderly, experiences of gamification were similar with people of other ages. Compared to others, they felt more strongly about the personality of their own data and felt it to be uninteresting to others. Regarding the usage in general, there seemed to exist polarisation among the participants. These findings support the call made by Carlsson and Carlsson about the need and importance of studying the habits and experiences that the young elderly have with digital wellness solutions. This study provides interesting insights into people's everyday use of wellness technologies. The results assist the scholars and wellness technology providers in deepening their understanding on wellness technology usage. The developers can utilize the findings in providing and marketing solutions that are better welcomed by their target audiences. The findings may also assist people working in the healthcare sector in implementing different wellness technologies for health and wellness related purposes. --- Limitations and Future Research There are few limitations to the study that should be noted. First, studies concerning wellness and exercise behaviour at some level have been known to include the challenge that research subjects may intentionally report their behaviours as more positively than in reality, thus biasing the responses. However, the participants of this study were emphasized that the wellness and exercise behaviour itself are not relevant regarding the study but rather the experiences and perceptions regarding wellness technologies and their use. The intention of this was to minimize the possibility that participating in the study would lead the participants to intentionally change their behaviour. Second, the study was based on the diaries from 18 participants. Although providing a great amount of information, the amount of data should be considered when assessing the results of the study. Especially so in regards with the young elderly, as there were only four of them. One should also consider the female-dominance in the sample. Third, the level of detail in reporting in the diaries varied between the participants. Despite these limitations, this study provides some highly valuable new insights into the subject. Future research could collect diary data from a longer time period and focus on possible behaviour changes regarding wellness behaviour and the usage of wellness technologies. Future research could also repeat similar research with particular focus on some specific user group, for example, the young elderly or athletes. Overall, the whole area of wellness technology usage continues to be an important topic of research. Activity trackers and other wearable devices have been found to bring a variety of benefits for their users. For example, Hagströmer, Oja and Sjöström found that objectively obtained estimates of physical activity yielded different activity patterns and lower values compared to those that were obtained by self-reports. This shows that wearable devices often provide more accurate data compared to self-perception and, therefore, serve as more reliable information source when planning and executing health behaviour change programs. Kari et al. found that using a mobile exercise application can enhance the awareness of personal physical activity and motivate towards being more physically active. Moreover, activity trackers could have even more potential in increasing the amount of physical activity, as suggested by Kari et al. . Yet, it seems that the perceived increase in wellbeing would require a long enough use period for the user to notably perceive any changes . A mere tracking of wellness related data may result in increased awareness of daily activity, but may not be sufficient to maintain the use of wellness technologies . The use of wellness related technology is also more effective the more frequently it is used . The intention to use such devices is mostly based on utilitarian reasons but also hedonic perceptions play a role . O'Brien et al. evaluated the utility and feasibility of activity trackers among older adults, and found that most users experienced positive outcomes. They also suggested that activity trackers could be useful in improving older adults' health by monitoring and promoting physical activity . As the popularity of activity trackers is growing tremendously, there is an increasing need to conduct more research on their use. These kinds of investigations enable a deeper understanding of the influences activity trackers have on people's behaviour. Much of the prior research has concentrated on the feasibility of individual solutions rather than the human aspects, such as psychological and social variables. For companies producing wearable devices or using the devices with their clients, sustained consumer engagement has been named as one of the key challenges. To achieve sustained consumer The aim of the study was to investigate how using an activity tracker can influence participants' physical activity behaviour and motivation. It was not the aim of the study to encourage participants to increase or change their exercise behaviour in some way, rather, it was to investigate how the activity tracker influences their exercise behaviour. The main research questions of the study are: 1. Do activity trackers influence fitness centre members' gym attendance and overall physical activity level? 2. Do activity trackers influence the fitness centre members' awareness of their physical activity and health related issues? 3. Do activity trackers have a different influence on members with different lengths of membership history or personal trainer members? The activity tracker used in this study was the Polar Loop by Polar Electro Finland . The group using an activity tracker is referred to as the Loop group. The study includes 100 fitness centre members divided into a test group and a control group. Both groups were also divided into three sub-groups: OLD, NEW, and personal trainer members. Considering the claimed benefits and the rising popularity of wearable activity trackers, the results of this study can benefit several stakeholders. The new knowledge it provides can have theoretical implications for scholars as it increases our understanding on the usage of these devices. The study can also provide practical implications for exercisers, manufacturers, fitness centres, and those working with physical activity promotion. --- Theoretical Framework --- Motivation and Physical Activity Motivation can be divided into intrinsic and extrinsic motivation . Self-determination theory is a major component in the discussion of intrinsic and extrinsic motivation and physical activity. Self-determination consists of three psychological needs: autonomy, competence and relatedness. Autonomy refers to the need to be self-initiating in the regulation of personal behaviour, competence represents a person's need to interact effectively within their environment, and relatedness reflects the person's need to feel connected to other people. The feeling of these needs can separate or together facilitate intrinsic motivation . The most common motives for getting involved with physical activity and exercise are extrinsic factors, such as improved health, improved fitness, or weight loss. However, although extrinsic motives act as catalysts, the focus can often change between initial adaptation and subsequent adherence. This change also applies to the change in the level of self-determination: from non-self-determination to limited, to moderate and finally to full self-determination . This study included participants who had different membership periods. "OLD" members were defined of having been going to the gym for more than 9 months, and "NEW" members had been going to the gym for less than 2 weeks. Therefore, it can be assumed that OLD and NEW participant groups might have different levels of self-determination and differences in their types of motivation. Goal setting techniques have been used extensively to enhance motivation and adherence and to improve performance. Studies conducted in exercise settings showed that 99% of participants set multiple personally motivating goals for their exercise participation. These goals were perceived as influencing actual exercise behaviour and helped people acknowledge what exercise behaviour is needed in order to meet their goals. Goal setting also helps people maintain their exercise program and keep up motivation to maintain their level of activity. Goal setting can therefore be seen as a way to maximize effectiveness in reaching exercise and physical activity objectives. The most effective goals in exercise settings tend to be flexible goals that people have set for themselves. . According to Abraham and Michie there are various behaviour change techniques, all of which have different positive aspects. The key is to find the right technique to apply in the correct setting and with the target group. Techniques promoting specific goal setting, self-monitoring of behaviour, review of goals, and performance feedback are considered to be effective . Health behaviour change interventions tend to be more effective if they are firmly connected with a health behaviour change theory . Participants were not asked to set any specific goals for themselves. However, Polar Loop users were asked to set their activity tracker to a setting that best fit their everyday life. This affected the daily activity goal provided by the tracker. Even though Loop group members were not asked to try to meet the daily activity goals, the activity tracker can still be seen as a goal setter by giving people a target for how physically active they should be according to their set activity level. --- Transtheoretical Model of Health Behaviour Change Most health related behaviour change programs have concentrated on negative behaviours, such as alcohol consumption, smoking, or obesity, rather than focusing on increasing positive behaviour such as physical activity and exercise. . The transtheoretical model has been applied to many health behaviour programs . In this study, the transtheoretical model was used as a theoretical background for designing the questionnaire. Participants self-evaluated their current stage in becoming more physically active before and after the 10-week test period. However, it is important to remember that 10-weeks is a short time to make any real changes between the stages and therefore the results concerning behavioural change should be interpreted with caution. According to Bandura's social cognitive theory there are different reasons why people might need outside help in order to better reach their set goal. Firstly, people might have lost their means to reach their desired outcome. Secondly, they might think that a third person is more capable of facilitating the achievement toward the desired outcome. Finally, people may want to give control over to somebody else because they want to shift the responsibility of the direct control . In an exercise and physical activity setting the use of proxy agent, often a personal trainer, helps a person to manage environment and task demands as well as gives extra help in regulating and controlling exercise behaviour, developing new skills and helping in lifestyle management . Having a proxy agent also provides a person social support which increases positive outcomes. This can lead to greater likelihood of experiencing full involvement, focus, and enjoyment . --- Methodology --- Study Design and Data Collection The study follows a quantitative experimental design. The study was carried out among members of a fitness centre located in Finland. The study consisted of two main groups: the test group and the control group. The Loop group members were given Polar Loop activity trackers and H7 heart rate sensors in the beginning of the test period, whereas the control group did not receive these devices. After the study, the Loop group got to keep their devices, and the control group were also given Loops as a reward for participating. The two main groups were further divided into three sub-groups: OLD members , NEW members and personal trainer members . Participants were recruited via the fitness centre's e-mail newsletter. All club members were allowed to apply for the study and the first 100 suitable candidates were selected and randomly split into the Loop Group or control group. Both groups had the same number of male and female participants. From the 50 participants in the Loop group, 25 were OLD, 13 were NEW, and 12 were PT. The Loop group was asked to create a Polar Flow account, which made the training observable for research purposes. Data was also collected from the fitness centre's visitor database, which recorded all the fitness centre visits participants did during the 10-week test period. In addition, a questionnaire concerning the members' perceptions regarding their own health and fitness and the possible changes the 10-week test period had on them was collected from the participants before and after the test period. The questions were identical both times. The questionnaire included questions regarding current physical activity, sleeping time, daily sitting time, and awareness regarding their own overall wellbeing. The participants could also give feedback regarding their experiences during the study period after the study ended. In the results section, the experiences concerning Loop are reported. The full questionnaire is available from the authors by request. In total, three different data sets were used: 1) One obtained from Polar Flow service, which showed weekly activity goals based on the activity level set on the device, and how well these goals were achieved. 2) One obtained from the fitness centre's visitor database, which was used to compare the Loop group and the control group as well as their sub-groups to see whether there were differences in physical activity measured by gym visits. 3) One obtained by the pre-and post-study questionnaires, which was used to investigate the changes in the perceptions of the participants. --- Data Analysis The quantitative data from Polar Flow and the visitor database was analysed with IBM SPSS Statistics 21. The data from the questionnaires was transformed into numeric data and also entered to SPSS for further analysis. Means, age range and frequencies were computed in order to obtain the basic information of the test group. This was followed by Next, the analyses concentrated on the first measurement, which related to gym visit activity. An independent sample T-test was done in order to test differences between the Loop group and control group. Here, the independent variable was the group and the dependant variable was the number of average weekly fitness centre visits within the 10week period. The same test was also done to compare the sub-groups between the Loop and control group. When testing differences within the Loop group or control group the test method was oneway ANOVA. The same method, oneway ANOVA, was also used in measurements concentrated on Loop group weekly activity percentages and their development. Here the independent variable was the sub-group and the dependent variable was the weekly average activity percentage within the 10-week test period. The last phase of the SPSS analyses was done by using repeated measures MANOVA to test for differences before and after the 10-week period among groups. --- Results The tests of normality were conducted to investigate normality for the main variables; average gym visits and average activity percentages . The normality tests were done after dividing the data into different sub-groups. Results for the Kolmogorov-Smirnov test for normality indicated that average gym visits were normally distributed within OLD sub-group . Due to the smaller sample sizes for other sub-groups, the results from the Shapiro-Wilk test were more appropriate. These tests indicated normal distribution in all sub-groups. --- Gym Visits and Activity Percentages Regarding the amount of gym visits, T-test was done in order to investigate differences between the Loop group and control group. No statistically significant difference was found, but it can be seen that the average visit amount for the 10-week test period was higher with the Loop group compared to the control group . NEW members' gym visits, it was the opposite. Within both PT and NEW, the Loop group average gym visits were higher than in the control group . 100% measurement means a user has achieved that goal. It is also possible to exceed the weekly goal and have a measurement higher than 100%. No statistically significant differences were found between Loop sub-groups in weekly activity percentages. Similar to gym visits, all Loop groups experienced a slight decrease in weekly activity percentages during the test period. However, the decrease was larger with gym visits . When comparing different Loop sub-groups, the decrease in activity percentages was strongest within OLD, whereas within PT and NEW groups, the decrease was almost non-existent. Figure 2: Loop group activity percentage and gym visit trends Pearson correlation test revealed that gym visits and activity percentages were positively correlated . questions that participants answered based on their own subjective feelings. There were no statistically significant differences in the results of the questionnaires, but some trends were seen. Participants were asked how active they perceived being before and after the 10-week test period. The overall trend was that participants felt they were more physically active after the test period. The only sub-group that perceived a decrease was the Loop group OLD . After subjectively estimating their own physical activity level, the participants rated their own satisfaction related to their activity level. Satisfaction levels of all groups increased after the test period, with the exception of the Loop OLD group, which experienced a decrease in their level of satisfaction . One question measured how satisfied the participants were with their sleeping time and whether they thought it was sufficient. Results showed that all Loop group sub-groups experienced an increase. The result was opposite in the control group. This indicates that Loop usage increased the Loop group participants' awareness of their own sleeping, and perhaps also persuaded them to sleep more . One question concerned the daily sitting time and whether participants thought they sit too much during the day. The Loop group experienced small increases in all sub-groups except the NEW group. In the control group participants were more certain after the test period that they do not sit too much during the day . One of the questions concerned participant's awareness of own state of wellbeing. The results show Loop group participants had an increase in their perceived awareness during the test period. The results of the control group show a small decrease in their perceived awareness . One question was based on the transtheoretical model measuring the participants' progress toward a more physically active lifestyle during the test period. The Loop group experienced a small positive increase, and after the test period they perceived to have a more physically active lifestyle than before . The results were the same with the control group OLD sub-group, but otherwise the control group experienced a It should be noted that ten weeks is a relatively short time period to make significant changes or even take a step between levels, so these findings should be considered with caution. Figure 8: Perceived state of transformation --- Feedback Most of the feedback related to the Polar Loop was that participants had learned more about their own wellbeing no matter what their initial starting point was. Some participants mentioned that Loop had changed their awareness and perceptions of their sleeping time, sitting time, and overall physical activity. Some critical comments were related to Polar Loop functions and how the activity tracker was not suitable with the participants own existing devices. A few comments were also related to the pressure that the Loop and goal setting had created; whereas some people felt it was positive and motivating, others first experienced it negatively but eventually learned to cope with it. Only one participant quit using Loop in the beginning of the test period because they felt too much pressure to reach the set goal every day. --- Conclusion The purpose of this research was to study the role of an activity tracker in influencing fitness centre members' motivation and awareness regarding their own health and physical activity. The study followed a quantitative experimental design and included 100 fitness centre members divided into test and control groups. Although the investigation revealed no statistically significant differences between different groups, some interesting findings can be reported. On average, participants with a Polar Loop visited the gym more often than those without, though the difference was not statistically significant. There was a small decrease in gym visits and activity trends during the 10-week test period in both main groups and in all sub groups. Thus, it can be assumed that an activity tracker alone might not be enough to sustain motivation to visit the gym or to be physically active, but can bring some benefits. Regarding the transformation towards a more physically active lifestyle the difference between Loop and control groups was not statistically significant. On a sub group level, the differences were also not statistically significant, but the results suggest that for new fitness centre members, an activity tracker could provide some tools for achieving intrinsic motivation, which is important when trying to maintain a more physically active lifestyle in the longterm. The results also suggest that there might be a reciprocal benefit where a personal trainer can use the extra information provided by the device to plan the training, while the user can utilize the personal trainer's knowledge to better understand the data. Overall, it can be concluded that an activity tracker may not significantly influence fitness centre members' gym attendance and overall physical activity levels but might make them more aware of their health and physical activity which is needed in building long lasting motivation. Considering the high number of fitness centre members who volunteered for the study, it is probable that the Polar Loop worked as an extrinsic source of motivation. Previous studies have shown that exercise applications may increase exercise level and health outcomes leading to increased level of self-efficacy . Based on some of the participants' feedback, it was appreciated that Polar Loop offered a tool for personalized goal setting and also provided the participants with personalized information. Providing personalized feedback and increasing awareness about health related issues, the activity tracker may have increased the participants' level of perceived competence, which is one element in enhancing intrinsic motivation. Thus, in order to help turn the motivation more intrinsic, an activity tracker should provide personalized information and offer a tool for personalized goal setting. Regarding the awareness of personal health and physical activity, on average, both main groups claimed to be more physically active at the end of the study period. This subjective feeling does not match the fitness centre data, which showed that participants in all groups went to the gym less often in the latter part of the study period. Loop group members also seemed to be less active at the end of 10-week period based on the Loop activity percentages. The satisfaction towards one's own physical activity level followed the development of perceived activity level. These findings support the ones by Adams et. al. , that there can be some biases in self-reports of physical activity. The finding that the Loop group were more concerned about their daily sitting time at the end of the test period, suggests that the information the Loop provided made them more aware and more concerned about their daily sitting time. Thus, activity trackers could be used to educate users about their sitting or other inactivity habits. The results also suggest that an activity tracker might increase a person's perceived awareness of their own state of wellbeing. Whereas the Loop group perceived an increase in their awareness, the control group perceived a decrease. A similar result was found regarding the perceived sleep amount, as the Loop group reported being more satisfied with their amount of sleep, while the control group reported a decrease in satisfaction. Overall, it can be concluded that there are several influences an activity tracker has on one's awareness of personal physical activity and wellness related behaviour. However, given the contradiction between perceived and measured physical activity levels, the influence can be both positive and negative. Electronic monitoring of daily physical activity can offer tremendous opportunities for people to independently improve their health and wellbeing. However, it is important for the stakeholders working in related fields to acknowledge that the key is not to just implement a device but to find out how the electronic devices are able to deliver useful information that is also motivating and easy to understand for diverse populations. --- Limitations and Future Research This study has some limitations. The first limitation concerns the sample size, which could have been higher. Even though the sample size is large enough for conducting the statistical analyses and can present the situation among the members of the particular fitness centre, it somewhat limits the generalizability to activity tracker users in general. The second limitation concerns the length of the study. A 10-week period is not necessarily long enough to facilitate changes in awareness or gym visit habits. Particularly, as according to the transtheoretical model of change, it might take several months to generate changes in habit formation. One potentially interesting avenue of future research would be to do a similar study with a larger number of participants, which would provide better statistical representation of the target population. This study could also be done by having a longer study period which would give more reliable results and allow to the transtheoretical model assessment tools to track changes. A follow up questionnaire and measurements could also be done in order to see how the training motivation has developed after end of the study period. Similar study could also be conducted in different fitness centres. Future studies could also include gamification as a motivation driver as well, and examine it more deeply, as it seems that its relevance in this domain will continue increasing . --- Introduction Conceptually, crowdsourcing is not a new concept at all. It is simply the process of calling upon the general public -the "crowd"to contribute, by whatever method appropriate, to solving a business problem. In the 1700's the Alkali Prize was established to solicit from the general public a less expensive method of producing sodium carbonate . And in the 1800's the Oxford English Dictionary asked the general public for new words which might be added to the dictionary . Successful examples of crowdsourcing can be found throughout history; but the exponential growth of the concept did not begin until the Internet gave quick and easy access to the "crowd"and particularly, the enabling characteristics of Web 2.0 . Although the concept is nothing new, the term "Crowdsourcing" was coined as recently as 2006 when it appeared in a seminal article, "The Rise of Crowdsourcing" . Initially, Howe only described the phenomenon, without providing a succinct definition. After the 'crowd' had some time to explore and discuss the concept, Howe proposed a formal definition: "Crowdsourcing is the act of taking a job traditionally performed by a designated agent and outsourcing it to an undefined, generally large group of people in the form of an open call." Capability and awareness are the two most important factors in Crowdsourcing. First, the Internet provides the capability of reaching and communicating with the crowdthe general public to which the open call is placed. Second, public awareness of the concept of CustomerSourcing as a new business tool . As awareness quickly lead to popularity, a wide variety of sub-categories arose, each with varying purposes and characteristics. For example:  CrowdFunding  Cloud Labor  Crowdvoting  Crowdsearching  Crowdsolving  Crowdsourcing  CrowdReviews  CustomerSourcing As a subcategory of crowdsourcing, CustomerSourcing is the focus of this article, as first described by Crane & Kitchens . In particular, the focus will be on the intrinsic motivation which individuals have for participating in CustomerSourcing activities. --- Rise of CustomerSourcing Many traditional business processes have been altered with advancement of the Internet and e-business ; CustomerSourcing is one such example. It can be described as a modification from the traditional value chain and supply chain models; as described here. --- Supply Chain Model The supply chain model is traditionally depicted as a chain of business entities, one leading to the next, in a linear fashion. The supplier leads to the firm, which leads to the distributor, to the retailer, and finally to the customer . This represents the flow of goods from raw materials to finished product, as depicted in Figure 1: Supply Chain Model. Figure 1: Supply Chain Model --- Value Chain Model The value chain model depicts the primary activities and support activities occur within a business unit . The activities included in the traditional value chain are depicted in Figure 2: Value Chain Activities. Figure 2: Value Chain Activities The effect of the Internet and disintermediation has, in many cases, caused the elimination of the middle-man . Thus, by eliminating the Distributor and retailer from the supply chain model, and by inserting the value chain model in place of the manufacturer/service provider, the resulting new model depicts the customer, a business In the realm of e-commerce, all of the traditional functions of the supply chain continue to exist; but the individual firms have been disintermediated. The result is fewer middlemen; perhaps reduced to a single entity providing the services of the entire supply chain. This single firm is then collecting the resources from suppliers, performing some operation on the material to produce a product or service, and supplying the end product to the customer. In the case of Crowdsourcing, the "suppliers" may actually be the "crowd." The resources generated from the crowd-suppliers could conceivably be anything. Recalling a few of the various sub-categories of crowdsourcing reveals the wide variety of CustomerSourced resources available to a firm:  --- CustomerSourcing CustomerSourcing is a unique category of crowdsourcing in which the customers are also serving in the model as the suppliers. The resources which are being provided by the suppliers are actually coming from the customers themselves . Perhaps the easiest resource to supply in an e-commerce model would be data. There are many examples of situations where data is supplied to a firm; in which the firm processes the date in some way, and provides it back to the customers. Examples of CustomerSourcing abound. In the most pure form of CustomerSourcing, the customer-suppliers are a closed group; all customers are suppliers, and there are no suppliers who are not customers. A popular example of this situation is found in onlinedating sites . In this situation the potential customer is required to create an account and upload certain data describing themselves before they are allowed to download any information about other people who might be potential dates. Thus, the customer is forced to first become a supplier, before they may become a consumer of the online-dating site's services. There are other situations, where the customer-suppliers are not necessarily an exclusive group. Customers might be "potential suppliers;" or suppliers might have an interest in improving the output, but may never choose to consume the resulting output themselves. The social networking industry is built on this concept. Facebook, for example, is the largest social networking site in the world with 1.1 Billion unique monthly visitors . They allow anyone to browse a limited portion of their content . To see more content, a potential customer is required to create an account and befriend other customers. This model is depicted in Figure 4: CustomerSourcing Model. --- Motivation The financial aspect of CustomerSourcing has been explored by Kitchens & Crane ; in which the customer-supplier participants were found to fall into 3 broad categories: those with net income, those who broke even, and those who experienced a net outflow. The prospects of breaking even, let alone volunteering to knowingly experience a net financial outflow, gave rise to the question of motivation. Specifically, why do the customer-suppliers participate in an endeavour in which they know they will experience no financial benefit, or will result in a net financial loss? In addition, if these situations harbour ulterior incentives, then perhaps the prospect of financial gain is not the only incentive in the net income category. It has been shown that the motivation for individuals engaged in crowdsourcing can be a mix of intrinsic and extrinsic factors . --- Intrinsic Motivation Traditionally, intrinsic and extrinsic motivation were thought to be mutually exclusive categories of motivation. The more contemporary view is that these exist as to distinct types of motivation which create a continuum . While multiple motivators may exist simultaneously, the strength of each motivator may vary from person to person, and from task to task . While financial incentive is one possible motivator on the extrinsic end of the motivation continuum, it may not be the only motivator . On the other end of the continuum, intrinsic motivation can be categorized into sixteen basic desires . The sixteen categories of intrinsic motivation are:  Acceptance, the need for approval  Curiosity, the need to learn  Eating, the need for food  Family, the need to raise children  Honor, the need to be loyal to the traditional values of one's clan/ethnic group  Idealism, the need for social justice  Independence, the need for individuality  Order, the need for organized, stable, predictable environments  Physical activity, the need for exercise  Power, the need for influence of will  Romance, the need for sex and for beauty  Saving, the need to collect  Social contact, the need for friends  Social status, the need for social standing/importance  Tranquillity, the need to be safe  Vengeance, the need to strike back and to compete --- Crowdsourcing and Intrinsic Motivation Using these categories, it is possible to classify the major motivators for each of the main crowdsourcing sub-categories. Crowdfunding for example is where the crowd provides financial resources for anything from business start-ups to study-abroad trips for students. Crowdfunding could provide multiple forms of intrinsic motivators. Selecting from the list of 16 intrinsic motivators , those that most likely apply to Crowdfunding are:  Honor: such as the satisfaction of supporting a family member studying abroad  Curiosity: the opportunity to learn more about a new invention, possibly even being one of the first to own a prototype  Idealism: the opportunity to aid in correcting social justice by supporting an underdog  Saving: the chance to add to a collection in exchange for a financial contribution  Social Status: the chance to be a major investor in a promising start-up business The classification of forms of crowdsourcing into the 16 forms of intrinsic motivation can be performed for every category. --- CustomerSourcing and Intrinsic Motivation Focusing specifically on the CustomerSourcing form of Crowdsourcing, it is easy to imagine how each CustomerSourcing site might embody a specific set of intrinsic motivators. Even within the same industry, specific sites may have differing sets of motivators. For example, within the social media industry, two of the leading sites are --- Conclusions Identification and classification of intrinsic motivation for crowdsourcing, and more specifically CustomerSourcing, websites is not an activity without consequence. Websites need users. In particular, CustomerSourcing web sites are vitally dependant on their customers as users in order to receive some form of supply for their Value Chain. Yet, some of these sites have no extrinsic benefit to the usersfinancial or otherwise. Studying these intrinsic factors is vitally important. Site developers need to identify the motivators, and create web sites which support and enhance the users' intrinsic motivators. The ultimate goal when a site relies on users for some of its value chain items is for an increased number of users, with increased frequency of visits. Further research should seek to quantify the most important motivators which result in increased users and increased frequency of use. --- Introduction Data analytics is already applied in many industries. The educational domain, however, has only recently started using data to improve its processes . Analytical activities aimed at improving education at a micro-level of educational institutes is called learning analytics: "the measurement, collection, analysis and reporting of data about learners and their contexts, for purposes of understanding and optimizing learning and the environment in which it occurs" . Common research objectives include modelling student behavior in virtual learning environments and prediction of performance . The learning analytics process comprises four steps: 1) learners generate data, 2) these data are captured, collected and stored, 3) analysis and visualization of the data, and 4) the design and use of data-driven pedagogical interventions . The process is a cycle, as the effects of the interventions can again be measured, analyzed, visualized et cetera -see Figure 1. The remaining of this paper is structured as follows. First, the background of learning analytics processes and our experiment will be provided. We then elaborate on the primarily findings of the experiment conducted thus far. Finally, future work will be described. --- Background Higher educational institutes implementing learning analytics processes face several difficulties, e.g., changing existing information systems by implementing a learning records store and customizing data streams ; managing the increase in workload for teachers ; and making sure all activities are in compliance with privacy legislation . Greller & Drachsler provide a generic learning analytics framework with six critical dimensions to consider whilst setting up learning analytics services -see Figure 2. Figure 2: Learning Analytics Framework In order to help Dutch higher educational institutes overcome the aforementioned difficulties, SURFnet set up the learning analytics experiment . The experiment provides all instruments -IT-architecture, data standard, algorithmsrequired to answer five pre-defined pedagogic questions. These questions are sourced from previous research aimed at identifying questions relevant for Dutch educators . Setting up the tool is relatively easy, as the only necessarily activities involve putting tracking codes on the pages and learning materials in the virtual learning environment. Since the codes can easily be copy-pasted, only basic computer skills are required. Once placed, the codes allow data to be stored in a learning records store, from which the data can be analyzed and visualized in a dashboard. See Figure 3 for the learning analytics architecture and Figure 4 for the resulting dashboard as seen with a teachers' account. Teachers can see the anonymized activities of all learners in the experiment; learners have their individual dashboard and can view their own activities. To ease compliance with Dutch privacy laws, students must opt-in to allow their data being captured and analyzed. --- Research objectives and method The objective of this study is to research to what extent it is possible to perform learning analytics activities in the case organization's virtual learning environment and what barriers are encountered when doing so , and to research in what way pedagogical interventions can be designed and performed during the course by teachers based on the visualizations in the learning analytics dashboard . We do this by answering the following research questions: 1. What issues are encountered when implementing an experimental learning analytics tool in the case organization's virtual learning environment? 2. In what way can the visualizations in the learning analytics teacher dashboard be used to design and perform timely pedagogical interventions? We use the framework of Greller & Drachsler After the first phase of the experiment, all involved teachers and researchers from SURFnet evaluated the process and outcomes during a focus group. Based on open observations, all experiences worth pointing out by the participants were discussed and notated. As all teachers involved encountered the same issues, consensus was reached fast. This led to the description of the preliminary results, as shown in the next section. --- Preliminary results The first round of the experiment resulted in several experiences and insights. In this section, we will elaborate on the most pressing results. First, an overview of encountered issues is provided. These are then categorized according to the dimensions of the learning analytics framework . --- Technical issues Although it is relatively easy to set up the tracking at the virtual learning environment, some technical issues arose. During the experiment, it became clear that not all activities were tracked. Root cause for this anomaly were the necessity to opt-in for the experiment; students who opted-in only provided permission to capture data from the specific device they used to subscribe. This results in incomplete datasets and renders extensive data Implementing an Experimental Learning Analytics Tool 329 analysis useless. The causing issue has been resolved, so this problem will not appear in the second round of the experiment. Another encountered technical issue relates to the SURFconext connection between the case organization's virtual learning environment and the SURFnet learning analytics dashboard. With SURFconext, it is possible for students to log in the learning analytics dashboard by using their own institutional username and password. This saves the need to create a new account. To establish the connection, the institutional SURFconext contact person must login his administrator account and provide permission to do so. At the beginning of the experiment, however, the connection was not allowed until only a few hours before the start of the courses. This almost led to cancellation of the experiment as the researchers did not want to confuse students with non-working dashboards and connections. This experience shows the need for institutional-broad support and cooperation in order to make learning analytics work. --- Self-selection bias Students need to opt-in for the experiment, allowing their data being captured and analyzed. Of the 234 Business Engineering students who enrolled in the course , 89 opted-in only 38%. Similar proportions were found at the other institute. After the final exam of the course, the difference between the final grade of the students who participated in the experiment and those who did not were calculated using SPSS. Participants scored an average grade of 5.1 and non-participants an average grade of 4.3 . An independent t-test shows there is a significant difference between the two groups and students who participated in the experiment scored on average better than those who did not. As no interventions were initiated based on the information in the dashboard, it is suspected that self-selection takes place. Future initiatives involving voluntary participation must account for this effect. --- Need for more data In order to perform effective interventions, rich data is required . In our experience, the current data is too poor to use for interventions. The lack of sufficient data can partly be traced back to the teachers who put too few tracking codes on their course page of the virtual learning environment. As one of the involved teachers puts it: "next time I will track everything: every page, every article and every video." The experiment also relied on data from the virtual learning environment only. This provides only one side of the story -anecdotal observations of students using the online materials showed that they sometimes jointly sit together at a single computer to work on assignments, having the system only registering one student. Similarly, interaction between these students cannot be measured this way . In our experiment, data from other resources was not aggregated with the data in the learning records store. For example, the virtual learning environment provides students the possibility to take quizzes. Quiz data , however, are yet not stored and processed in the records store. In order to design and perform effective interventions, these data must be aggregated in future experiments. --- Problem categorization based on learning analytics framework In order to analyze which dimensions of the learning analytics framework are causing problems during the implementation of the tool, we mapped the identified issues to the frameworksee Table 2. This shows that four out of six dimensions faced difficulties so even though an almost 'plug-and-play' tool is provided, implementing it is a non-trivial endeavor. --- Future work The experiment will be continued in the Fall of 2017. At the Institute for Engineering and Design, two courses will implement the learning analytics tool in their course design. One of the courses is taught to fulltime students, the other one to part-time students. This provides the opportunity to explore behavioral differences between participants of the two programs. Furthermore, to date, no interventions were performed based on the data analysis and visualizations in the experiment. Learning analytics research in general often focuses on data collection, management or how data will help to improve education but designing effective pedagogical interventions becomes a critical element . Now we have demonstrated the tool can be implemented in the case organization's virtual --- Introduction Being physically active is not only beneficial for an individual, but also for the society . Modern world health problems like obesity have become common and people are facing difficulties in maintaining physical activity in their everyday lives which emphasizes the possibility of encouraging more active lifestyles by changing individual exercise habits. Thus, it is evident that people should be encouraged and motivated to maintain their mobility behavior. In recent years, a number of mobile devices and applications that aim at supporting people in their athletic endeavors and other physical activities have emerged and these applications, with various tracking features, encourage people to exercise more . These exercise applications provide opportunities for personalized health services, which make use of digital data in proactive and personalized ways . In this study, we examine the use of narratives in motivating users to engage in physical activity. We collected data using participatory observation, a focus-group, and semistructured interviews, after which we analyzed users' reasons and motivations for exercising and use of the exercising application applying a nexus analysis approach. With nexus analysis, the aim is to deepen the understanding of the qualitative data collected . The concept of user experience is widely applied in the fields of human-computer interaction and interaction design and it is used for collecting subjective experiences, comprising the interaction between people and products . By analyzing these experiences, we search for techniques for personalizing narratives. Our research increases the understanding of narratives as a motivational strategy and their impact on individuals' motivation. --- Related Work As modern life has increasingly been intertwined with digital technology, leisure activities are an important arena that have seen a lot of digitalization . In recent years, for example, sports and overall wellbeing are topics receiving increased interest from research as well as from industry . For this reason, both software developers and the general audience should be aware of the various ways of and the approaches to how people may be, are being, and will be influenced through the design of computer systems . The HCI community has strived to promote wellbeing by developing applications and technologies that monitor and track users' activities. This has mainly been through use of theoretical frameworks derived from persuasion and social psychological theories, which make use of behavioral components like regular feedback and reminders to users in their physical activities . A related concept, gamification, the application of game design elements in non-game contexts has also become prevalent. Gamification can have a positive impact in health and wellbeing and there have been increasing interests in using game principles in non-game contexts to make a challenging activity, such as exercising, more enjoyable and integrated into the users daily lives . One basic element in gaming are narratives. In gaming, narratives are used to structure games into logical series'. Unlike traditional narratives in movies, for example, which are linear and fixed, in games, players interact with the narratives, and the structure of the narratives is typically nonlinear . Among the motivations for exercise is usually a discrepancy between the desired and actual lifestyle, and technology is used to support people towards a lifestyle they would like to lead . Motivation is an essential feature in exercising as it highlights individual differences in behaviors when engaging in exercise . Using exercise applications is a complex mix of motivation towards exercising, satisfaction towards the application, external pressure, and actual effect of the usage of the application . In this study, we consider both intrinsic and extrinsic motivation . Intrinsic motivation refers to exercising for internal reasons like fun and pleasure. Extrinsic motivation emphasizes the role of external factors in motivating behavior. For example, exercising because of the expectation of a reward . Recently, motivational factors for exercising have been studied, for example, in the context of young adults doing physical activity . Capel et al. , found that goal achievement, staying healthy, and social aspects were the key motivational factors for adolescents. More sustainable motivational factors have been studied by Fritz et al. where the authors interviewed users that had been using persuasive technology devices constantly for at least three months. The authors found that, routinized usage, integration to daily life, numerical feedback, and awareness of the value provided were the key factors that motivated users towards a more sustainable use of technology . --- Research Methodology The research method applied in this study is nexus analysis , a research strategy that uses discourse analysis and other methods well-suited for studying complex social action. In nexus analysis, each social action is thought to be mediated by the interaction order among participants in a particular environment; the historical body-previous knowledge, experience, attitudes, and assumptions that the participants bring into the action; and, the discourses in place, that is, the discourses that are associated with or embedded in the scene of the action . In this study, the concepts of historical body and interaction order are used in our analysis. --- Study Context The artefact under examination is Zombies, Run! Zombies Run! is an exercise application that is available for mobile devices through Google Play and Apple's App store. It is a running game with zombies as a survival story, is meant to be an immersive adventure, and "the game takes the player into a post-zombie-apocalypse world" . The idea is to be outdoors as the application is story-based and at certain intervals, during the story, one is instructed to do certain things. Users can pick a mission before they start their run or follow a predefined series of missions culminating in an entire season. The unique characteristics related to apocalyptic narratives make the game as a good example of a gamification-based application . The application includes gamification elements such as, rewards, distance challenges, points, as well as supplies to be collected during the runs. Runs can be synced online and progress can be shared in various social media outlets like Facebook. Zombies Run! initially started as a premium service, but recently launched a freemium version-the basic application is free, but additional services and storylines that can improve the user experience come at a fee. --- Data Collection and Analysis Six participants were recruited for this study. All participants were female postgraduate students. We were interested in studying the users' motivational factors for exercising, usage of the application, and to examine the role of narratives in motivating exercise. According to their level of familiarity with the application, participants were categorized into two groups: Experienced and Inexperienced and were assigned aliases that will be used henceforth to represent them. Inexperienced users had minimal or no prior experience with the application, whereas experienced users had been using the application for at least 2 months. Multiple qualitative data collection methods were used for achieving methodological triangulation. Data was collected using three different methods: 1) a focus group which was video recorded, 2) semi-structured interviews, and 3) participant observations, where participants were asked to think aloud and also video recorded during exercise. Data collection occurred between September and November 2015 and recruitment was mainly done using snowball sampling . The focus group had 3 participants. One inexperienced user, Abbey and two experienced users, Becky and Carla. The focus group consisted of open-ended questions, starting from basic questions related to participants' motivations for exercise and covering exercising habits, role of technology in exercising, hindrances towards exercise and their experiences of Zombies Run! Following the focus group, participant observation while using the application and three semi-structured interviews, each lasting 40-60 minutes, were conducted. Interviews consisted of similar questions to those in the focus group, and the aim of recording was to capture users' authentic feelings and user experiences when using the application. Interviews were transcribed and the data was analyzed using NVivo11 software. Data analysis process was twofold: first we identified, and categorized general discourses regarding motivations for exercising, and the role of narratives in exercising. Second, the concepts of interaction order and historical body were applied, in order to understand the motivations and the role of narratives more clearly. --- Results Generally, all participants had positive thoughts about exercising, but some of them pointed out the need for extra motivation, which could be provided, for example, by exercise applications. --- Historical Body Historical body refers to an individuals' background, experiences, beliefs and practices, which may influence their view of and interactions with different media . Abbey, Debbie and Ellen had not used the application prior to the study, whereas Becky, Carla and Felicia had. Two of three experienced users participated in the focus group and one in a semi-structured interview. Abbey regularly went to the gym, went jogging, and also walked. reason to use the application. Debbie was video recorded while jogging and participated in a semi-structured interview. She stated that she was physically active and exercised regularly, but at times finding time to exercise was a problem. Debbie also occasionally used activity tracking applications. Ellen participated in a semi-structured interview. She used to exercise in various ways but the frequency had been decreasing due to tight time schedules and difficulties in starting to exercise again. Becky participated in a focus group. She had been using the application for about half a year and prior to that she hardly exercised. The main reason for using the application was because it was different and she needed something interesting to get her to exercise regularly. The role of narratives was very important in her decision to purchase the application, as can be seen in the following quote: "I bought it because it is geeky and fun, and it sounded more interesting than other running apps" . Carla had been using the application for a longer period of time. She enjoyed the zombie genre and liked listening to the narratives. Prior to using the application, she was not very active and she stated that the application helped her to improve her exercise habits. The narratives and pre-set goals motivated her to exercise more because she saw pre-set goals as challenges that had to be completed, which she was incrementally able to do as illustrated by the comments below: "The 5k which I tried first is perfect for anyone who has not been running, but wants to start. You start with really small steps and in the first parts you just run for 30 seconds or something" . "It really improved my running a lot. I would say, within six months. In the beginning I would run for five kilometers, and after six months I could run twenty, so there is a big difference" . Felicia participated in a semi-structured interview. She stated that she was physically active but finds it difficult to be consistent. Her motivation to exercise was related to wellbeing as exercising made her feel more energetic. Felicia mostly exercised alone because she wanted to focus on only that when doing it. The quote below illustrates this: "I like exercising alone. For example, if I go to gym, I try to go there as late or as early as I can, so that there is no one else. Also when running, I prefer to run alone" . --- Interaction Order Interaction order is about how relationships and technical affordances affect people's interaction. The interaction order entails studying how mediated actions occur: whether alone, in groups, the time, what precedes or triggers an activity and so on . The different kinds of interactions that can take place are supported or encouraged by different design/feature implementations and these in turn control or limit users' actions. Other than supporting the primary intent, which is jogging, in Zombies Run!, there are game-like features where users collect various supplies that help protect from a zombie attack and can be used to rebuild one's virtual town. Users can also share information about their exercises via social media channels or via Runkeeper that offers more social features than Zombies Run! Abbey felt that the narratives in the missions were a distraction and they could be shorter. Although the narrative and game-like features are what initially attracted her to the application, Becky felt that they were not an integral part of the running experience. After using the application for a while, Carla and Felicia also stated that the narratives could be improved on by making them shorter or by reducing the time in between stories. There are long pauses in the stories when running that make it difficult to continually concentrate on a mission because one's focus is, every now and then, shifted away from a particular mission. Carla needed a distraction from the narratives because of the long pauses, and according to Abbey, the option of listening to music during the breaks in the mission was even more of a distraction as one had to switch between "two states of mind"the joy provided by the music and the concentration needed in the mission. Abbey and Carla also felt that social features were not important for enhancing their experience of or engagement with the application. Becky, on the other hand, felt that social elements were important and a key feature needed to give her that extra motivation to exercise. For Ellen, a lack of actual interactivity in the stories negatively affected her experience with the application. All the participants felt that the virtual rewards did not add any value or interactivity to a mission and the running experience would have been the same with or without them. Debbie, and Ellen felt that it would have been much better if collecting or winning something in the mission would have been linked to a physical activity. For example, in order to win a first-aid-kit, one had to either increase their speed or do jumping jacks that were directly linked to the item collected. --- Personalization of Narratives Nexus analytic concepts of historical body , and interaction order enabled us to study narratives as a motivational feature. Instead of a generic narrative, narrative adaptation is one method for personalized gaming . Personalized narratives are related to interactive storytelling, where the game content is personalized according to user preferences . We thus agree with Göbel et al that it is not feasible to create a narrative for each individual user. Therefore, based on our analysis, we propose three different narrative personalization techniques in the form of use cases. --- Personalizing Narratives for Goal Achievement This technique proposes that narratives are personalized based on users' goals. Once the user sets a personal goal, narratives are personalized to support the achievement of that goal. By monitoring users, the system identifies that achieving a personal goal requires a longer run, for example, and by personalizing the narrative, the system systematically persuades users to achieve their goals. The following quotes present some of the user goals: "You have a certain goal for every exercise you do, and that gives structure to your exercise. I think that is one of the most motivating things for me. To have a certain specific goal" . "As for me, I think what I find motivating about running is the improving, getting faster, going further" . "That is one motivation. Losing a little weight" . "…I have run for twenty-five minutes this week even though last week I could only run for fifteen minutes. The number of kilometers I have been running is more related to personal goals. Not that much of the goals set by the system" . Personal goals between users vary; some try to lose weight, whereas some want to improve in running. The following use case illustrates this narrative personalization technique: A while back, Ellen was an active young woman but recently she has been demotivated and her husband constantly reminds her about her New Year's promise to exercise more. Previous sports applications supported her goal settings, but this application also provides narratives tailored to her goals. Her goal is to lose weight and increase the distance she can run. After one month has passed, Ellen is not likely to achieve her goals. Therefore, the application adjusts the narratives to last for 60 instead of 40 minutes . Goal setting is supported on many sports applications, but personalizing narratives to certain goals set by users is not that common. Once users set their goals, the system personalizes a narrative by either lengthening or shortening an episode to support the achievement of those goals. --- Personalizing Gamification level of Narratives This technique proposes that gamification level is personalized. Some users preferred to passively listen to the narratives without game elements, whereas others would have liked more "playful" elements in the narratives, whether it was related to goal achievement, building a virtual base, or the integration of narratives into their surroundings: "Application did not succeed in motivating me because it was not actually interactive at all. I was expecting some interactivity related to achieving my goals" . "In the game, base can be improved, but improving that base has no effect on the missions or how the story goes on" . "Because I wanted to experience something I started to 'play the storyline', like when I heard that bandages or whatever were picked, I started to pick some leaves fallen from the trees" . By personalizing gamification level, system could provide more gamification elements, tasks for users to complete for building the base, or provide "sub" missions that are integrated to certain locations and surroundings of the user. The following use case illustrates this technique: Debbie has heard about Zombies, Run! from her friend Carla. Carla persuades her to try the applications and upon installing it, she is asked to set her location and level of gamification . After a while, zombies are chasing her as she collects virtual bandages. Concurrently, in the narrative, there are facts integrated to Springfield, where zombies have captured the town hall. To rescue the town hall, she has to run intensively to the hall in order to expel the zombies. Debbie does this and the she is rewarded by getting an extra town hall badge that can be used in her virtual base also. --- Personalizing Genre or Intensity of Narratives This technique proposes that the narrative genre is personalized based on users' preferences. Some users were willing to have more intense storylines, whereas others preferred milder ones. The following quotes present the ideas of genre based personalization: "You should have different storylines for other people as well, I could never imagine my mom going running with the zombies" . "There could be some adjusting in the storylines. You could for instance exclude the zombies or choose a different kind of narrative" . As zombies are 'the selling point' in the application, excluding the theme fully may not be appropriate. However, letting users personalize the intensity/genre of a storyline, from scary to light, could attract a wider audience to the narratives. The following use case illustrates this technique: Felicia, is a true zombie freak who has been organizing annual zombie parades in her local area. She was an early adopter of the application and now she is listening to the narratives again, but with a new scary-mode on. As she jogs, the zombies are ultraaggressive, and she loves it. This is something she wants to show to her sister. As her sister Abbey tries the scary-mode, she does not like it and quits right away. She blames Felicia for even suggesting her to try that. Felicia calms her sister down and lets her know that the intensity can be adjusted. Switching it from 'scary' to 'light' she persuades Abbey to try the application again. Abbey decides to go for a jog and instead of an avalanche of zombies, just a few zombies appear and, some of them are even having a "vegetarian picnic" in the park. She enjoys the mode and agrees that it provides a joyful experience. Personalizing narratives for different genres can consist of different levels of storylines. Some can be scary and involve personalization based on the difficulty level , where the run could end up with 'game over', if ultra-aggressive zombies catch the user. Vice versa, on the lighter storylines zombies are not aggressive at all. --- Concluding Remarks Technology plays an important role in motivating people to exercise and pervasive devices like smartphones can provide an accessible and personalized platform for applications supporting regular physical exercises . In this study, the focus was on investigating the use of narratives as a motivational feature. Findings related to motivations and the role of technology are first discussed, and this is then followed by the use of narratives. All participants exercised and had positive thoughts towards exercising. Although, their intentions to use exercise applications varied. Ahtinen et al. found that motivation to use exercise applications required both simultaneously enjoying to exercise and satisfaction with the application. In our study, not all participants were satisfied with the application's features and its technical stability which negatively influenced their intentions to use the application in future. Staying healthy, socializing, and achieving certain goals are key factors that motivate young adults to be active . Social sharing was found not to be a key motivator, which is consistent with findings in Ahtinen et al. , as most of the participants did not want to/feel the need to share their exercise logs with other people or on online social platforms. The participants were primarily motivated to exercise for health reasons and even though some did not exercise consistently, they considered exercise to be an important part of their overall wellbeing. All participants found goal setting and data tracking as good motivators for exercise. Some users preferred setting goals themselves, and others used the system-set goals. The system-set goals were considered by some to be challenging, whereas others felt that these goals did not match their own personal goals. Gamification improves attitudes and enhances exercise , and the gamification elements supporting goal setting and monitoring were appreciated by all participants. A recurring observation was that the gamified elements should better support the monitoring of pre-set or personalized goals, i.e. to better merge narrative elements of the application with individual's goals and their tracking. Combining personalization strategies with persuasive systems rather than offering generic solutions has potential for better outcomes and can enhance users' experiences and achievement of their goals . However, support for personalization is still at a low level within these systems . Personalizing narratives for each user may not be technically feasible , but as users' motivations vary, personalization should be supported. In our study, three narrative personalization techniques were proposed to support users' motivation for physical activity. The present study had a limited number of participants with relatively homogenous backgrounds. User experiences were collected using a focus group, participatory observation and semi-structured interviews. Our intention was not to focus on women only, but with snowball sampling, we ended up with such a homogenous user group. Furthermore, at the time we conducted the study, women were the most willing participants and not all of them were available to participate in all the data collection phases. Nevertheless, this provided us an opportunity to combine several qualitative data collection methods, and get detailed qualitative data, but sets limitations for the generalizability of the results as it was limited to a small group of Finnish users. Gender, age and cultural differences were also not considered in this study and therefore the findings cannot be assumed to be widely applicable to different contexts. With different application and users, results may differ. Nonetheless, the study highlights the importance of tailoring and personalization and presents ideas on how this can be done for different user groups. In summary, technology for supporting motivation towards healthier lifestyles has remained a key topic in the fields of HCI and computer science. Development and evaluation of exercise applications with various features have been studied comprehensively. This study qualitatively analyzed the role of narratives to motivate people to exercise by using a nexus analytic approach. The focus was on user experiences related to an exercise application that utilized narratives to motivate users. Our study revealed that features like tracking and goal orientation did motivate users to exercise and so did narratives, however, their usage in wellbeing technology is still in its infancy. Personalization techniques have been used for setting personalized goals, or objectives, but in narratives, these techniques, are not widely studied. In this study, we have proposed three techniques for personalizing narratives. --- Introduction The current study analysed how earlier studies have approached and presented serious games in healthcare. The term serious game, or applied game, is used to classify a game in which its main purpose is something other than pure entertainment . This group includes several subgroups, including edutainment, advergaming, edumarket games, political games, and training and simulation games, to educate, train, advertise, and influence people . Games can work as motivators or to help change players' behaviour . Healthcare services are looking for new functions to empower their customers. SG in healthcare can provide methods for maintaining and developing health in different age groups. The goal can be to provide a new kind of model for self-help or rehabilitation. Play and entertainment can be effective foundations for serious interventions in healthcare. Nevertheless, there is a need for more research studies that show a causal link between playing video games and health outcomes. We wanted to understand how SG are seen by researchers. The main research question was: How are serious games in healthcare perceived and approached in the literature? To get the answer, three supplementary questions were presented:  Which journals include papers on serious games in healthcare?  What are the most investigated areas of serious games in the health sector and how have these changed over time?  What research type and methods are most frequently applied? A method of systematic mapping was selected for getting a broad overview of the chosen area. Systematic mapping study is a proper method to reveal whether there is research evidence on a topic, and to provide any indication of the quantity of evidence . The guidelines provided by Petersen et al. ; Petersen, Vakkalanka, and Kuzniarz ; and Kitchenham, Budgen, and Brereton were applied. Existing criteria on research approaches given by Wieringa, Maiden, and Roland were utilised in the evaluation. This paper presents a systematic mapping study of SG in healthcare and is organised into four major sections: background and related work on SG, research approach, mapping results, and conclusions. --- Background and Related Work The concept of serious games was introduced in the 1970s when it referred to an activity among two or more independent decision-makers seeking objectives in a limited context. In that time, SG were focused on educational functions . The concept involves a digital game whose main purpose is something other than pure entertainment and is designed to be used in training, education, and healthcare . Zyda games that engage the user and contribute to the achievement of a defined purpose other than pure entertainment . Fullerton described a digital game as a system in which the whole is greater than the sum of its parts. A digital game creates a structured conflict and provides an entertaining process for players to resolve that conflict . Game design combines psychological aspects with mechanical and artistic aspects . Game designers empathise with players, and their main task is to ensure that the game will be entertaining Juul defined video game as a game played using computer power and a video display that can be a computer, cell phone, or console game. Video games not only can tell stories, but also allow players to live them . Figure 1 illustrates aspects of SG design. the challenges presented to players and the actions players are permitted to take, both to overcome those challenges and to perform other enjoyable activities in the game world . The healthcare sector has strong interests in using new technologies related to health. SG in the health sector can be divided into game-based education of health professionals and improving therapeutic outcomes of patients. Today's increasing challenges with aging populations and chronic diseases suggest that serious games in healthcare may be one strategy to help with survival . Health games can be classified also by their main purpose, type of players, and the stage of disease of patients. The stages of disease of patients include stage of susceptibility , pre-symptomatic stage , stage of clinical disease , or stage of recovery or disability , as divided by Wattanasoontorn, Hernandez, and Sbert , who indicated three main purposes for health games: 1. Games that are designed originally for entertainment and in which a health purpose comes secondary, but can be found in the games. . Figure 2 illustrates these classifications. Figure 2: Classification of SG in healthcare There are many different stakeholders in the health-game market, such as hospitals, clinics, private-practice physicians , government, corporations, other organizations, and individual consumers . Social Security systems and healthcare providers differ significantly among different countries and on a global scale, with each market area having its own methods to facilitate a healthy lifestyle . Significant changes should be expected, for example, in medical simulations, serious games, and mobile serious games, and an increased need for serious-game analysis is already present . Supporting players' motivations and enhancing behavioural changes are essential in health-game design . Design includes using game elements such as surprise and simulation to engage players and enable immersion . On the other hand, developing a health game requires a multi-disciplinary team to work together successfully . It is important to define both the target group and main objective, then design a game accordingly using sound game-design principles in collaboration with health professionals and involving patients as early as possible . Braad, Folkerts, and Jonker describe the health-game design process as a game-based intervention process. Their human-centred design method consists of four phases: analysis, design, development, and evaluation. Like Braad et al. , Friess, Kolas, andKnoch and Deen et al. use similar processes in SG development in the health sector. They all include strong research and analysis phases at the beginning, and involving different stakeholders is essential. Iterative development processes or the use of prototyping are among their development methods. The game-development process then ends usually with user-group testing and evaluation or validation phases. In the design of SG in health games, the target group should be considered during the development process . A multi-disciplinary team is necessary to develop a successful and effective health game, and professional knowledge is an essential part of the development process . --- Research Approach To get an overview of SG in healthcare studies, the guidelines for a systematic mapping process were followed. This chapter describes the chosen research method and how it was applied. --- Overview of Systematic Mapping Study A standard systematic literature review is usually conducted over a specific research question that can be answered by empirical research . A mapping study, on the other hand, aims to provide an overview of a topic area through multiple research questions . Mapping questions are about what we know with respect to a specified topic . The results of a systematic mapping --presented as a visual summary, the map --help determine in which areas to conduct a conventional systematic literature review . A systematic mapping process . Figure 3: Systematic mapping process . Mapping questions often are formulated around what we know with respect to a specified topic and include questions regarding venues, research methods, and trends . The search is conducted in relevant databases for all papers in the research field, and, as recommended by Kitchenham and Brereton , the use of IEEE and ACM, as well as two indexing databases, is sufficient. A search string is defined based on the research questions . The third step in the systematic mapping process is the screening of papers. Inclusion and exclusion criteria are needed to find relevant papers that answer the research questions . Inclusion and exclusion criteria can be related to the relevance of the topic of the article, venue of publication, period considered, requirements for evaluation, and restrictions with respect to language . The selection of papers is performed on titles and abstracts, thereby building a classification scheme first, then later reading is extended to introductions and conclusions . For classifying the type of research, Kitchenham et al. and Petersen et al. ) recommended using a classification system developed by Wieringa et al. with six categories: 1. Validation research, which concerns evaluating novel techniques not yet deployed in industry 2. Evaluation research, which concerns evaluating industrial practices 3. Solution proposals, which discuss new or revised techniques 4. Philosophical papers, which structure the field in new ways, such as taxonomies 5. Opinion papers 6. Experience papers, which discuss how someone did something in practice In the data-extraction phase, relevant articles are sorted into a scheme, such as an Excel spreadsheet. The mapping process ends with a presentation on the frequencies of publications for each category using maps for visualization . --- Research Questions To get a broad overview on how serious games in healthcare are perceived and approached in the literature, the following supplementary questions were asked:  RQ1: Which journals include papers on serious games in healthcare?  RQ2: What are the most investigated areas of serious games in the health sector and how have these changed over time?  RQ3: What research types and methods are most frequently applied? The objective of RQ1 was to identify the forums of discussion. The objective of RQ2 was to discover trends in research and possible gaps. The objective of RQ3 was to determine the methods of research used. --- Search and Screening of Papers To get a broad overview of the research area, searches were first conducted on these scientific databases: IEEE, ACM, Scopus, Web of Science, and Google Scholar. At the second stage, the database of Web of Science was left out of the process due to technical problems with remote access. The following inclusion criteria were applied to titles in the screening of papers :  Topic of study focuses on serious games in healthcare. ---  Studies are in the field of software engineering or information systems. The following exclusion criteria were applied to titles in the screening of papers: This yielded a total of 479 papers, of which 71 were found to be duplicates, leading to a final total of 408 papers .  --- Keywording and Study Selection The basic information in papers, such as authors, titles, years published, source titles, abstracts, digital object identifiers , and links were exported into an Excel spreadsheet. This table was used in keywording to find the classification scheme as follows: Abstracts from ACM, IEEE, and Scopus search results were downloaded as text from the Excel spreadsheet to TagCrowd to create an overview of used keywords in the filtered-out abstracts. These keywords are presented in Figure 4 to visualise the volumes of used words in the abstracts. The classification schemes were formed based on the chosen keywords and included research articles. From these keywords and connecting the information with research questions, the following classification schemes were formed: 1. Source Title 2. Aim/target and focus , Year : using keywords such as behaviour change, cognitive, education/learning, rehabilitation, therapy, exergaming, design/development, user/patient, interaction, persuasive, usability 3. The frequencies of keywords or index terms of 'serious games in healthcare' are presented in this order: ACM , IEEE , and Scopus in Figure 4. --- Data Extraction and Mapping Process To answer research questions, the data was sorted on an Excel spreadsheet with basic identification information from papers such as identification number , authors, titles, years published, source titles, DOIs, and links. The classification schemes were added: aim/target and focus, research type, and research method. Since the search results totaled up to 408 papers, it was decided that RQ1 and, partly, RQ2 would be based on the whole body of articles. On the other hand, to be able to answer RQ2 and RQ3 required reading through papers and gathering needed information in classification schemes. It was decided that this would be done in publications that have 10 or more papers in each source publication, restricting the upper limit of read papers to 112. Each of these papers was read to find the above information, which was added to the spreadsheet. At this phase, 18 papers were considered to be not fully in the realm of health games and thus were excluded, and 11 were not available as full text, which brought the number of papers down to 83. If information was not available on the abstract, or the paper was not accessible in full text, it was excluded at this point. Papers were arranged in ascending order by publication time. The analysis of the results focused on presenting the frequencies of publications for each category. The quality of the sample of studies selected in the inclusion/exclusion process, generalizability of the results of the mapping, and reliability of the conclusions drawn in relation to the data collected were identified as possible threats to the validity of the research. --- Analysis and Interpretation This chapter is structured with the help of the assisting research questions. --- Venues of Publication To find out which journals include papers on SG in healthcare, the distribution of papers in different publications is visualised in Figure 5, and the publications that have 10 or more papers in each publication are listed in Table 3. The papers were published in 163 different publications, which indicates quite a vast distribution over different sectors; 93 publications included only one paper in this area. --- Topics and Frequency of Publication To analyse the annual distribution of SG articles in healthcare, the annual distribution was calculated between the years 2005 and 2016. Some of the papers were published in 2017, but those were excluded due to the scheduling of the study. Figure 6 shows the number of papers over the years, and the trend has been increasing until 2014. According to a content analysis of 83 papers, the most investigated areas of serious games in the healthcare sector regarding games' aims are presented in Figure 7. The five top subjects of serious games were:  Education  Exergaming  Cognitive rehabilitation  Psychology and  Rehabilitation Figure 7: Number of papers according to aim/target of the serious game. Most of the papers focus on describing design and development of a serious game . The next most popular focus areas were user-centred design and participatory design . This is presented in Figure 8. One way to categorise the most investigated areas of health care was to analyse the target group of developed games. As illustrated in Figure 9, the targeted demographic groups of most serious games in these papers were children , the elderly , and patients of certain diseases . --- Research Types and Methods To analyse the research type and methods, the papers were categorised according to the research types in the classification system by Wieringa et al. . None of the analysed papers were considered Opinion or Experience research. 55% of them were categorised as Solution Research, 19% Philosophical, 15% Validation, and 11% Evaluation Research, which is presented in Figure 10. --- Conclusions The purpose of the study was to analyse how SG in healthcare are perceived and approached in the literature. To solve the research problem, systematic literature mapping was applied in the study. A total of 408 studies from 2005-2016 were found, and after screening and exclusion, 83 studies were analysed. The results of this systematic mapping could be used to identify gap areas in research of SG in healthcare. Although the concept of serious games is from the 1970s , we found out that there were just a few publications who wrote about the phenomenon before 2009. The number of publications increased until 2014, after which there was a gap in 2015, then the number increased again in 2016. Most of the analysed papers came from conferences. The most popular forum of discussion was the IEEE SeGAH conference, with the Lecture Notes in Computer Science coming in second. Since the development of SG in healthcare is multi-disciplinary , some of these papers were published in medical journals and thus were not included in this study. Wattanasoontorn et al. classified health games by their main purpose, types of players, and patients' stage of disease. The biggest target groups of SG described in this mapping study were children, the elderly and patients with certain diseases. In the analysed studies, the main purpose and type of player were easily found, but none used classifications for stages of disease. In educational games, the players were 1) healthy people of a certain group: children, adolescents, the elderly, etc. 2) patients with certain diseases or 3) students and professionals in a certain medical area . Considering the focus and methods of research, the most common approach was to describe design or development of SG by using a case study. Most of these were considered solution proposals as defined by Wieringa et al., thereby discussing new or revised techniques. The focus of most studies was in using user-centred, participatory, and collaborative design models. This supports prior research involving different stakeholders in SG development . Also, there were some literature reviews that were deemed to be philosophical papers, structuring the research field in new ways. Kato brought up the need for validation of SG in healthcare, but it was not seen as a topic in many papers. One RCT and a controlled experiment were found, as well as a couple of intervention studies. Few papers covered guidelines for assessment of SG. Many described prototypes of SG were tested with focus groups, but there were no further studies found. There were just a few papers focusing generally on SG design or providing guidelines for SG developers in healthcare, even though there were plenty of cases described. The study unearthed new knowledge on the topic of how serious games in healthcare are perceived and approached in the literature. The results provide a foundation for deeper analysis of the use of SG in the health sector, and suggest that the next focus will be on developing general guidelines for SG developers in healthcare, focusing on validation of SG and research of SG maturity models to improve level of development. The study points to future avenues of research integrating both the gaming industry and healthcare professionals. There are limitations to the study of research mapping, and further studies should be conducted to validate and further extend the knowledge of SG in healthcare. --- Introduction Commercial and industrial sources in the US produced three times the CO2 emissions of residential sources in 2010 , while the buildings sector also consumes 20% of the total delivered energy worldwide . At the same time, the commercial sector features the fastest-growing energy demand, with its consumption projected to grow by an average of 1.6% per year until 2040 . More importantly, buildings account for 30-45% of the global energy demand, with commercial buildings, and primarily office and university buildings, classified amongst those presenting the highest energy consumption and savings potential . Therefore, it is important to increase our efforts towards energy conservation in commercial buildings and workplace environments, towards addressing the worldwide recognised issue of energy wastage. Albeit the documented effect of public buildings on energy consumption, only a limited body of research focuses on employees' energy consumption behaviour, which can certainly play a significant role in the buildings' energy footprint. Aiming to contribute to this research path, we are participating in an H2020 EU project that develops a platform, which utilizes Internet of Things -enabled smart meters, smart plugs, and low-cost sensors to monitor energy use and, simultaneously, wastage per work device, area and employee. The ultimate goal of this research project is to use the accurate energy consumption data collected from the interconnected devices/things in order to transform the employees' energy usage behavior. Gamification, "the use of game design elements in non-game contexts" , has been identified as an instrument that, when appropriately utilised, could lead to employees' energy behaviour change. It can support companies to change behaviours, increase and sustain employee engagement and productivity , . Furthermore, the active use of gamification for the improvement of business processes results in amplified workers' positive psychology, and strengthens positive emotions, engagement, relationships, the sense of meaning, as well as accomplishment . Thus, we were inspired to build, in the course of the project, a gamification application that receives input from the IoT-enabled platform and provides real-time recommendations to employees in three participating pilot sites, motivating and educating them to adopt a more green behavior. To design an effective gamification app that the employees will adopt and use, we had to consider two important factors during the app's user requirements analysis: employee personal profiles, needs and preferences, as well as workplace contextual characteristics. We first performed on-site visits to identify the contextual characteristics of the three different workplace environments that participate in the project. Then, we conducted a series of semi-structured interviews with representative employees , to formulate a more holistic view of the three sites' special requirements. Our primary focus was on collecting useful insight towards the design of a gamified app that matches the needs and preferences of its end-users, as well as serves the contextual limitations and opportunities of the pilot workplaces. In the next sections of the paper we begin by reviewing related work presented in the literature, discuss our observations through the site surveys, as well as our findings through interviews with employees, and conclude with our future research plans. --- Related Work --- Energy consumption in Workplaces Energy in public buildings is mostly consumed through space heating and cooling systemstypically the largest energy consumption sources both in the EU and the US lights, refrigerators, computers, and other equipment. Additionally, occupant behaviour is an important factor in the consumption of energy in buildings, as it can add, or save one-third to a building's designed energy performance . However, unlike private households, users at workplaces have by default no direct financial incentive to minimize energy use within their office workspace. Therefore, motivations, as well as incentive structures, for users in organizational settings are different, as no personal monetary gains are normally expected from a change in behaviours. Hence, more altruistic motives, like supporting the organization in energy and monetary savings, contributing to environmental protection, or complying with expectations from colleagues and superiors, can be leveraged to engage in energy saving behaviour at the workplace . Studies in energy consumption behaviours emerged with the oil crisis of the 1970s, from a wide range of disciplinary perspectives . Specifically, the findings of a meta-analysis of 156 published information-based energy conservation experiments encouraged us to explore the occupants' energy behaviour in public buildings : non-monetary, information-based strategies can lead to an average reduction in electricity consumption by 7.4%, monetary incentives, in contrast, lead to a relative increase in energy usage rather than inducing conservation, energy conservation through behavioural change should be considered alongside efforts to reduce energy consumption through technological improvements. Overall, a limited number of studies exist regarding energy conservation in a work environment, compared to household contexts. Very few studies have also investigated employee energy-related behaviours, none of which involving interorganisational comparisons . --- Gamification for Energy Efficiency purposes The basic and most well-known gamification elements are points, badges and leaderboardsa useful starting point for gamification effortsbut a number of additional game elements exist functions, but in interaction with each other they can have varying and complex motivational effects . The MDA framework is widely used to categorise gamification elements . Α commonly stated objective behind using gamification is to encourage behaviour change, in the form of increased participation, improved performance, or greater compliance . At the same time, gamification in a work environment can focus on business processes, or outcomes, involving participants, or players, both from outside and/or inside a firm, to improve employee satisfaction . When organizational goals are aligned with participants' goals, organizations can achieve their goals as a consequence of players achieving their goals, and employees can become fully engaged with new company initiatives . Furthermore, since gamification often involves storing and processing personal, potentially sensitive data, this could lead to "transparent employees" within company boundaries and, at the same time, inappropriate extrinsic incentives might crowd out intrinsic motivation . Workplace gamification also needs to apply to long-term, apart from initiative-specific, objectives . In a corporate setting, players have also tend to be more invested in intra-group, than in inter-group, competition . Gamification might also contradict with some personality types and cultural norms , highlighting the importance of designing gamified applications to match their potential users' profile, by assessing their respective characteristics, as well as preferred game mechanics . More specifically, various studies have suggested gamification as a means for motivating energy efficient behaviour. Grossberg et al. conducted a thorough review of gamified energy efficiency initiatives concluding that saving energy is highly rewarding in itself, and the greatest achievement a gamified app could aim for is to outline this fact to its users. Furthermore, they note that energy savings in the range of 3-6% have been reported on a number of studies featuring the application of gamification to reduce energy consumption, with an achievable possible savings of more than 10% . Inspired by the forementioned information, we decided to conduct a thorough observation of the three targeted workplaces, as well as a detailed exploration of the characteristics and preferences of our prospective gamified app participants. Our ultimate goal was to ensure that we will design and develop an effective gamified app that motivates employees towards a more energy-conscious behaviour. --- Identifying Context and User Requirements --- Physical observation of the workplaces The gamified app will be deployed and pilot-tested in three different workplacesparticipating in the forementioned EU-funded projectthat are located in different European countries. The first workplace is a public office in Athens, Greece, which provides IT support to the facilities of its home organisation, both locally, as well as in External temperature and humidity conditions affect energy consumption, while around 40% of electricity consumption is due to air conditioning, as heating is provided by natural gas consumption. Smart meters are installed for monitoring the energy consumption per category of use , but no specific strategy for reducing energy-consumption has been set. The third workplace is a public museum at the old City of Luxembourg. It comprises of 4 buildings, containing the exhibition rooms and 25 administrative offices. There are 100 employees in the museum, 40 of which administrative staff. Lights are always on in the exhibition area and visitor restrooms, during the museum's visiting hours. There are very few automated light switches and, although the daylight prevails in the museum rooms, many lights are kept on for security reasons. The largest part of energy consumption is due to lighting and the climate system in the exhibition rooms, which ensures the museum exhibits are secure and properly preserved. Heating in the administrative offices is controlled per office where there is no air-conditioning. Employees cannot alter the climate or lighting conditions in the largest part of the facilities, and museum visitors cannot act on the climate controls or any other energy consumption actuator. At a first glance, only the lift usage of visitors may alter their contribution to energy consumption in the museum. Overall, through the physical observation process a number of common, as well as contradictory significant characteristics of the three pilot workplaces were highlighted. The museum is different to both the other workplaces, in that it hosts a very large number of visitors per year, whereas close to no visitors are expected in the other two sites. At the same time, the climate and lighting conditions in most of the areas of the museum are very specific and, therefore, lights and climate control cannot be used in a gamified app for these areas. Furthermore, it consists of four whole buildings, as opposed to a single floor office space. The only area of the museum that resembles the other two workplaces is the employees' backend office area. A special, distinctive feature of the museum is that its visitors could conserve energy by opting to use the stairs instead of the elevator. Regarding the office spaces in all three sites, a lot of similarities exist in the possible targeted behaviours. PCs, monitors and printers can be switched off more often, as well as lights, when not needed. Common area equipmentkettles, coffee makers, toasters and microwave ovens, depending on their availability on each sitecan also be --- User Interviews: Method and Results We performed in-depth, semi-structured interviews with a representative sample of employees per workplace, as a small amount of interviews can produce data capable of addressing a set research goal, selected with careful sampling and a thorough collection technique . Furthermore, following the theoretical saturation rule of qualitative research, we sampled until no new information or insight was produced -26 employeesalso exceeding ten cases in consistence with the suggested valid range of case sampling . Our intention was to gain a first understanding of the employees' habits, needs and preferences regarding energy consumption and gamified apps. We conducted a discussion starting from specific questions, but the order of questions was changing according to the order of the subjects discussed. We intended to elicit mostly spontaneous answers and we encouraged the participants to add their remarks in the end of the conversation, as they saw fit. Moreover, all information collected during the interviews was content analyzed and coded by three independent coders into categories pertaining to the present research. A number of categories were decided upon ahead of time while other categories were identified based on the employees" responses . In the case of disagreement on the classification of any particular statement, the disagreements were resolved upon joint discussion. Table 2 includes the questions used to stimulate the conservation. Respectively, Table 3 Based on the interview results, we can deduce a number of suggestions, regarding the differences and characteristics that a gamified application towards energy conservation should respect. First of all, the varying roles of the participants in the three sites seem to affect their daily duties, as well as their opportunities to act upon specific energy For example, some need to print a lot of documents according to their duties, while others not at all. At the same time, the employees in the exhibition area of the museum, for example, do not have access to many energy saving actions in general. Secondly, working in a shared space presents further challenges towards designing a gamified app, as the individual actions of the participants also affect their colleagues, and therefore a level of cooperation towards common goals in the game may be preferable in these situations. Comfort levels are a parameter that also needs to be addressed, as the actions of the participants in a game, should not impede on the personal comfort of their colleagues, or lead to tension and disagreements. We should also take into account that some of the participants feel colder/hotter than their colleagues and this issue should not preferably be exacerbated by an app. Interestingly, when asked whether personal or collective actions have an impact on energy conservation at their respective workplaces, the participants were somewhat equally divided, indicating that the game should provide opportunities for both personal and collective actions to be acted upon. The necessity of interviewing the prospective participants of a gamified app towards energy conservation was also demonstrated by the fact that different cases where energy is wasted are unanimously identified by the participants in the three different sites: At the "Public Office", monitors and printers left on standby upon leaving, at the "Energy Agency" lights and appliances left on afterhours and, at the "Museum" heating, printers and elevators. As per the main problems that employees identified at their respective workplace, regarding energy consuming devices: Employees at the "Public Office" suggested that air conditioner temperature is not always set optimally, lights are left on after operating hours or used when ambient light suffices, screens and printers are left on stand-by mode when leaving and windows opened with the air conditioner on. At the "Energy Agency", the air conditioner temperature may be very low during summer, all lights are left on even when a few people are present in commonly used areasor when ample natural light suffices, screens and printers are left on when unused, excessive printing is reported, coffee makers are often left on afterhours, windows are opened with the air conditioner on, and the elevator is overly used by the employees that avoid using stairs instead. At the "Museum", employees have no control over air conditioning, lights, or opening windows in the exhibition areas due to restrictions, screens, printers, PCs and monitors are often left on standby mode and elevators could probably be used less. All these actions can be targeted through a gamified app, according to the specific needs of each site, towards attaining the optimum behavioural effect on energy conservation. As only some of the prospective participants, in two of the three sites, consider saving energy at work their own personal responsibility, the ones that do could be selected as leaders in a team-play scenario, so that they can provide positive role models for their fellow team mates. Furthermore, since both personal and collective actions are considered to have an impact on energy conservation by some of the participants, a gamified app towards that end should instigate both individual, as well as collective actions. This is further supported by the fact that on all sites the majority of the participants prefer a collaborative game with team competition, while the minority a competitive game featuring solo play. The same stands for collective vs competitive goals. An additional interesting finding is also that varying percentages of employees in the three sites believe that a reward is deserved for being energy-efficient at the workplace as well as that the existence of even small rewards is motivating towards the same target. Therefore, a gamified app would be more efficient through the inclusion of tangible rewards, only for a percentage of employees. Depending upon the general trend on each site, as well as their availability by employers, the app could also selectively include these extrinsic means of motivation, to adhere to each specific situation. Finally, as only about half of the participants on all sites play games in general, a gamified app featuring only basic game elements and not an overly complex narrative or gameplay, could be more universally accepted, as well as effective, towards behavioural change. Through the interviewing process, the participants' also provided some additional interesting insight, regarding what we should consider when designing a gamified app towards energy conservation at their workplace. The most prominent suggestions were:  "Every single small action is important but in the end only collective actions will have a really deep impact."  "We have to conserve energy responsibly for our future and because we want to do it, not to collect rewards"  "If we combine all the small consumptions, they may add up to a considerable amount of energy saving. The information of how much each device consumes in standby mode should be provided to the users"  "In view of the great differences between the tasks of the Museum's staff, I do not see any possibility for competitive games. A collective goal can be more interesting."  "The game should have specific rules and a clear target"  "Any awards should be divided between users, based on their contribution in the game."  "The gamified system should not make people feel guilty about their energy consumption" --- Conclusion A body of research exists, regarding energy conservation in public buildings, due to their large share in energy consumption worldwide. The use of ICT has also been featured in a number of studies aimed at energy conservation in public buildings. However, the effect of such solutions is limited by the building occupants' intentions to follow specific energy consumption behaviour. Gamification has been introduced in various contexts to instigate behavioural change, including energy conservation initiatives, where it has been utilised as a means to affect occupant behaviour. The results from the relative studies have been mixed, as well as difficult to compare, due to the vast differences in both the actors' and contexts' characteristics. Aiming to amend this issue, we have followed a structured process, involving two steps: On-site visits to prospective pilot sites, as well unstructured interviews with a representative sample of the participants in future gamified apps aimed at energy conservation. We have provided the questionnaire used in the interviewing process, so that it can be used in future similar studies. Through our analysis, we have discovered a number of contextual differences between the pilot sites, as well as in the prospective participants' available, suggested and preferred actions towards energy conservation at their respective workplaces. At the same time we have also gathered insight, regarding the game related preferences of our participants in our field of application. By combining all this information, we can design a gamified application to better match both our future participants' context, as well as preferences, leading to an overall better-suited solution to a better-defined problem. Therefore, we expect the effectiveness of our resulting application to be enhanced, compared to cases where neither the context, nor the preferences of the prospective participants of a gamified app have been analysed in advance. Based on our findings, we have identified the main elements that affect the design of a gamified application towards energy conservation in the three workplaces surveyed. Employee roles and daily routines, existing limitations towards specific behaviours within the workplace , the layout in the workplace , existing employees' comfort levels, and different opportunities to conserve energy in each workplace, affect the accessibility, as well as impact of specific energy saving actions that can be included in a gamified app. As per the app design itself, in our pilot sites, both personal and collective actions, individual and team play should be considered, whilesince only a few of the employees play gamesa basic game play could be more effective in energy behaviour change. Apart from its merits, our study also bears some limitations. First of all, we have investigated our prospective participants, by interviewing a sample of employees. Therefore, our findings would be better grounded, if we were given the opportunity to interview all of the employees at the sites we visited. In addition, we conducted the on-site visits only once in each site, whereas a longitudinal study could provide more accurate results, as well as additional insight not currently recorded. Finally and more importantly, we expect that the validity, as well as usefulness of the methodology we propose, would be significantly enhanced, by a practical application of our findings in an actual gamified energy conservation experiment that would be conducted in our surveyed pilot sites. We aim to proceed towards this direction through our research in the future. --- Introduction Recent statistics show that consumers are more committed to electronic commerce than ever. The prediction is that 46.4 % of all Internet users worldwide will purchase products online in 2017 . The growing interest in e-commerce also means that varying consumer emotions are likely involved before, during, and after online shopping encounters. Emotions are important during these encounters as alongside trust they attempt to moderate the relationship quality between the consumer and the service provider of online services . New technologies can enhance the shopping experience, but long-lasting evidence shows that online users are individuals with unique characteristics and emotions . Almost two decades ago, scholars indicated that affective and emotional dimensions truly matter as part of the consumer decision-making process on-and offline . Emotions differ from similar concepts, such as sensations and feelings, and emotions "are also initiated by some particular objects or events, real or imagined, and they tend to motivate particular kinds of behavior" . In this paper, the focus is on e-emotions, which are seen as emotional states of a consumer that are somehow apparent and visible in an online environment. Consequently, consumer e-emotions matter at multiple levels of the service relationship, including pre-and post-consumption stages. Thanks to the development of technology and the expansion of social networking environments, the online environment has changed drastically in recent years making especially post-consumption behaviors more public. For example, electronic word-ofmouth has a significant role in consumer emotion build-up and affects other consumers' pre-consumption stages . The current development has led to the situation in which communication is also more dynamic and active than ever before . Active interaction between consumers, stakeholders, and organizations is part of the socalled engagement process . Additionally, online users engage with various objects, such as brands, products, and virtual brand communities . These engagement processes are often accompanied by different emotions and behaviors that thus play a central role in ecommerce, as well as in stakeholder relations in general . Although literature reviews of online shopping motives and intentions , as well as of the adoption of computer-mediated services , exist, there is an emerging need to generalize the current state of the research related to consumer emotions in the context of online shopping. As technology and consumer behavior are changing, management must understand this development and identify possible consumers' and customers' pain points . Currently, the research related to e-emotions and e-commerce This study responds to this need and is implemented as an integrative literature review. This paper is a preliminary attempt to gather the research literature related to consumer e-emotions in the context of online shopping and the current state of the research across various disciplines-information technology, psychology, communication, and marketing-was synthesized and analyzed. By gathering previous articles published in peer-reviewed journals, the goal in this paper is to classify the literature related to the topic, and through review and synthesis introduce the key findings. This paper is organized as follows: First, the process of the integrative literature review is introduced. Second, the relevant literature gathered during the process is assembled and the results introduced. Third, the results are combined, and the synthesis and analysis of the literature review are presented. The key findings in the literature are addressed. Finally, the validity and reliability of the study are discussed, and suggestions for future research are provided. --- Methodology: Integrative Literature Review This study utilized the integrative literature review method . Integrative literature reviews balance between less structured descriptive literature reviews and more structured systematic literature reviews . This method "is a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated" . Although this study was integrative, it followed Fink's model of systematic literature review consistently to add more validity and reliability. The first step in Fink model is to select the research questions. This step is critical because the research questions aim the researcher in the decision-making process and address what kind of articles should be included . This study answers the following research questions: 1) According to previous literature, what kind of research and studies have been put into practice related to consumer emotions in online shopping? 2) According to the literature analyzed in this study, what are the recent key findings related to consumer emotions in e-commerce? The second step was selecting the databases from which to look for literature . In this study, the goal was to cover interdisciplinary literature related to emotions in e-commerce across the following disciplines: information technology, psychology, communication, and marketing. The following bibliographic databases were utilized: ABI/INFORM Complete , Business Source Elite , Computer and Information Systems Abstracts , Emerald Insights , ProQuest Psychology Journals , and PsycARTICLES . 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES M. Lievonen: Consumer Emotions and E-commerce: A Literature Review After the databases were selected, search terms were chosen . Search terms should frame the topic enough so the appropriate literature can be found. However, the framing should not be too tight . The search terms were defined based on the research questions. The literature searches were conducted in February 2017. Advanced or multi-field searches were used in the databases, and the following search terms were applied in order to find relevant literature: emotion* AND online AND shop* OR ecommerce. The search terms were restricted to be present in the key words or subject terms. The author also applied the limitation of the search to peer-reviewed content if this option was applicable in the databases in the advanced search options. The ProQuest and EBSCO databases offered this option and the Emerald and American Psychological Association databases did not offer this option in the advanced search. The input of the search terms in the databases gave the following results: ABI/INFORM Complete , 73 results; Business Source Elite , 13 results; Computer and Information Systems Abstracts , 73 results; Emerald Insights , 251 results; ProQuest Psychology Journals , 73 results; and PsycARTICLES , 1 result. As can be seen from the search results, all ProQuest databases offered the same amount of literature. The results were also similar in content so the three ProQuest databases were treated as one entity during the review process. According to Fink , the preliminary literature searches usually give many results. Therefore, it is important to screen for articles with certain criteria to find the relevant articles . After the searches were conducted in the databases, the practical screen and methodological quality screen was applied by executing following inclusion criteria: peer-reviewed journal articles , published since 2006, and studies related to emotions in the context of e-commerce or online shopping. The following research designs and content were excluded from the review: literature reviews and conference proceedings. The review was conducted in two stages. In the first stage, the headings and abstracts of the studies were read. Through this, the most likely relevant literature to include in the final review was found as Jesson et al. suggested. In the second stage, the literature was scanned more thoroughly. At this stage, it was also important to analyze research designs, findings, and conclusions of the studies before deciding what literature should be included for the final review . The articles in the review are shown in Table 1 in the next section. After the literature for the final review was apparent, it was time to synthesize the results . These conclusions are introduced in a more specific manner in the following sections, where the content of the review is interpreted and analyzed. The key findings of the studies are also reviewed more thoroughly in later parts of this paper. --- Results of the Literature Review After a careful scan of the available literature, 66 peer-reviewed articles were included in the final review. Studies that had interfaces with consumer emotions in the context of ecommerce were included. This was evaluated through keywords, and how, at the same time, the studies focused on the topic in a recognizable way in the research design and/or findings. Articles that did not match the criteria or did not cover the topic clearly enough were excluded from the review. The literature consisted of studies covering information technology, psychology, communication, and/or marketing. The articles were classified into four groups: studies related to website design, characteristics, or atmosphere and how they generally affect consumer emotions and behavior; studies related to preconsumption emotions and predictors of consumers' online shopping intentions and activities, such as the effects of online user reviews; studies related to consumer emotions during actual online shopping encounters, for example, decision making in purchase situations; and studies related to consumer post-consumption emotions and behavior, such as repurchase intention and commitment to eWOM. In general, recent studies focused on consumer e-emotions during all stages of the relationship. This result supports the assumption that e-emotions are not just restricted to the purchase or buying situation. In fact, consumer emotions and behaviors are under scrutiny in multiple situations. People eagerly read reviews and participate in public discussion before making a purchase decision, and even after the consumption stage, there is a possibility that the experience turns either good or bad. Consumers possibly continue the service relationship, disengage with the service provider , or even engage in eWOM after ecommerce encounters. --- Analysis of the Key Findings in the Reviewed Articles The literature was analyzed in the four groups. The idea was to explore and compare the key findings within the groups and draw conclusions based on these findings. The literature is presented in Table 1. In addition, the most relevant and synthesized key findings of the studies of each group, and the authors, are introduced. As can be seen in table 1, the studies indicated that the research in e-emotions is diverse and versatile. Moreover, the perspectives in these articles were broad and interdisciplinary. The studies explored consumer online emotions, behaviors, and their relations to e-commerce at multiple levels from pre-purchase to post-consumption stages. Next, this paper takes a closer look on the key findings presented in Table 1. --- Website Design Effects on Consumer Emotions According to the key findings in the articles in Group 1, the website characteristics, design, and atmosphere usually have a major influence on consumers' emotions, as well as on behavior. First, cultural differences exist in emotional responses and perceptions in online shopping environments . Emotions are crucial in the perception stage of the atmospheric and characteristic cues of websites and affect consumers' attitude toward the site, level of involvement, and purchase intention . Studies show a website that uses images of humans, instead of generic cues, stimulates higher levels of positive emotions and enjoyment . Music and colors used on these sites also have an effect on the emotional responses of potential customers and users . Product presentation and store layout are also important as they are emotionally valid characteristics and part of a pleasant shopping experience . Interestingly, emotional trust has a role in influencing consumers' purchase intention , and cognitive and emotional responses play a key role in communication through the websites . In addition, website patronage intention is affected by pleasure, arousal, entertainment, and esthetic experiences consumers receive . --- Pre-consumption Emotions According to the key findings in the articles in Group 2, pre-consumption emotions and expectations of certain e-commerce services are usually influenced by the information available online. The information is often available through user reviews, and through public discussion on social media and discussion forums. However, information overload has a negative effect on consumer emotions and thus affects purchase intention . Short-or long-term price drops significantly affect how consumers respond in public product reviews . If online user reviews are inconsistent, cognitive trust and emotional trust are affected . As Zhang et al. claimed, emotional trust most likely affects purchase intention . Anxious or enthusiastic online reviews are considered more helpful than angry reviews . The amount of review manipulation also matters. If there is proof that the potential e-commerce retailer has had severe trust violations in the past, reconciliation efforts are meaningful when consumers ruminate on their potential options . Strategies for repairing trust are effective in building a positive mood, which, in turn, is an important mediator in rebuilding consumer trust . Additionally, positive emotions mediate the relationship between personalization and purchase intentions , and the consumer's experience affects these intentions as well . However, the reconciliation tactics should be moderate, as consumers are affected by the tactics used . Moreover, the severity of the trust violation also affects consumer perceptions . How these efforts are documented and presented publicly is also important. Consumers seek this information, and they evaluate the firm's reputation so that they can be certain and trust the online shop they are going to use. To create an emotional attachment to browsing and increase purchase intention, online retailers should focus on consumer pleasure and community relationships . Hedonic choice options are also important as they are more strongly related to positive emotions and pleasurable experiences than utilitarian online shopping options , even though hedonic performance expectancies are not always positively related to usage intentions . Cognitive and emotional responses, as well as the interaction, play a key role in communication through websites . This also indicates how tempting the websites look to potential customers and how easy the sites are to use . --- Consumer Emotions During Actual Online Shopping Encounters According to the key findings in the articles in Group 3, emotional and rational routes, as well as e-service quality, influence consumers during the online shopping process . Not only high-quality website design but also consumers' product involvement elicits positive emotions during these encounters . Emotions encompass pleasure, arousal, and dominance, and they precede cognition . Moreover, a linear relationship exists between the level of interactivity provided by an online store and pleasure . Pleasure increases the likelihood of purchasing during the e-commerce encounters , and at the same time, consumers' previous emotional experiences can affect their behavior . In these circumstances, using human brands, and utilizing enhanced perceptions of human connections and the formation of emotional bonds, could provide a competitive advantage for online retailers . Incidental moods tend to increase process impulsivity in online shopping decisions . Differences in users' emotional experiences on e-commerce 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES M. Lievonen: Consumer Emotions and E-commerce: A Literature Review 395 websites are primarily embodied in subjective emotional ratings and eye movements . Mixed emotions are likely to lead to consumers leaving the stores . A common issue for e-commerce retailers is that customers are not ready to proceed through checkout procedures. For example, emotions can have a significant impact on the decision to give personal information that is necessary to complete a purchase on a website . The consumer's online shopping cart might already be filled with various products, but especially first-time customers might be suspicious . Trust and distrust coexist in online e-commerce relationships and can result in ambivalence when they have high attitudinal values represented in emotions, beliefs, or behaviors . Use of the principles of web usability guidelines and trust indicators will improve consumers' emotion about adopting e-commerce and increase the likelihood that consumers complete the checkout process. The purchase encounter must be as reliable as possible because perceived risk in e-commerce has a significant negative effect on consumers' satisfaction . Hedonic values and aspects are important for online store users. Hedonic values increase online impulse buying tendencies . Interestingly, consumers who are under stress have a higher impulse buying tendency as well . High or low hedonistic emotional commitment seems to be important to the perception of the usefulness of an online store . For utilitarian products, therefore, it is important to offer a high-quality web design interface and move toward enhancing consumers' product involvement, as they are also crucial for eliciting positive consumer emotions . --- Post-purchase Emotions According to the key findings in the Group 4 articles, the post-consumption or postpurchase stages are crucial for e-commerce retailers. Customers and consumers tend to expect that after the purchase has been successfully executed, the service relationship will continue, ordered products are received on time, and the product qualities are as expected . Positive emotions increase post-satisfaction, which positively affects post-purchase intentions as well . Emotional stability moderates the relationship between the perceived usefulness of a website and satisfaction in online shopping . Emotions felt after visiting a website positively influence consumers' perceptions of the website atmospherics that, in turn, influence a set of behavioral variables ending with intention to purchase again . For example, transaction cost advantage, preview, and trust significantly and positively affect satisfaction, which, in turn, influences repurchase intention . Moreover, satisfaction and perceived usefulness of the website contribute to individual online shopping continuance intention . Interestingly, shopping habit increases the influence 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES M. Lievonen: Consumer Emotions and E-commerce: A Literature Review of emotional evaluation on continuance, while at the same time habit weakens the impact of rational evaluation on continuance intention . Online shoppers' excitement leads to positive word-of-mouth and increases the intent to return . Moreover, online service quality has a positive effect on satisfaction, while also influencing, directly and indirectly through satisfaction, consumers' behavioral intentions: site revisit, word-of-mouth communication, and repeat purchases . Although electronic WOM has a positive direct effect on consumers' intention to repurchase, quantity has a negative influence . Thus, it is necessary to monitor the tone of consumers' public discussion during the post-purchase stage. If service failures have occurred, the switching intentions of consumers who are affected by negative emotions become stronger when the failures are controllable factors that could be managed and prevented . However, if consumers are treated in an appropriate way after the failure, the studies show that distributive justice increases positive emotions and decreases negative ones . Furthermore, negative emotions also affect repurchase intention . In addition, procedural justice, such as received fairness from the company, enhances satisfaction, especially after the consumer has complained and the company seeks service recovery . --- Conclusions This study was a preliminary attempt to group and analyze peer-reviewed journal articles related to consumer emotions in the context of e-commerce. The author aimed at contributing to academia and practice, and introduced four groups of the current state of consumer e-emotions research in the context of online shopping. Groups 1 and 2 included studies on the effects of website design on emotions and studies on pre-purchase emotions. Groups 3 and 4 included studies on actual online shopping encounters and their effects on emotions, as well as studies on post-purchase emotions and behavior. In addition, the author synthesized and analyzed the key findings of the reviewed studies. By recognizing the emerging need and timely challenge of understanding online users and their emotions better, the goal of this paper was to increase the knowledge of the topic, and the paper brought up new perspectives by combining the previous research findings. According to the analysis, consumer emotions are present at various stages of the ecommerce relationship. For example, website design and characteristics affect consumer emotions, which, in turn, mediate site involvement. In the pre-consumption stage, emotions initiate the purchase intention, and during actual online shopping encounters, positive emotions and trust increase the likelihood of purchases. Post-consumption emotions are also interesting as they mediate the behavioral responses of the consumer, such as word-of-mouth and intention to return to the web store. 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES M. Lievonen: Consumer Emotions and E-commerce: A Literature Review 397 As a preliminary attempt, this study has several limitations. Most noticeably, the search terms and databases used in the process affected the availability of the reviewable literature. Using different search criteria and databases could, naturally, provide alternative results and guide the indications to alternative directions than presented in this paper. However, using similar search terms should be possible in almost any academic database and give similar results. From a research method perspective, an integrative literature review has advantages and disadvantages. The most recognizable difference between this study and systematic reviews was the analysis. Systematic reviews aim at offering a systematic descriptive review analysis or even perform a meta-analysis , while the goal of this paper was simply to combine the current state of the research in a condensed form and reconstitute the current knowledge by utilizing conceptual grouping. The author also wanted to synthesize the results and analyze the key findings with flexibility in mind to add something new to the topic as Baumeister and Leary suggested. Reviews that were conducted too systematically and mechanically might lack essential details. Additionally, integrative literature reviews do not have to differ much from systematic reviews, if they follow a clear pattern and utilize a structured methodological grasp . The author accomplished this by implementing Fink's systematic method diversely during the review process. These actions also added credibility and validity to the study . This mixed approach was also flexible, as the literature related to the topic was fragmented across various fields and disciplines. Finally, yet importantly, the author's goal was to follow Torraco who implied that an integrative literature review has "an important role in stimulating future research on the topic" . As the tendency of positive and negative consumer e-emotions in e-commerce is still somewhat unclear, the author suggests that future studies should answer the following research questions: What usually causes positive emotions in the context of e-commerce when customers are motivated and intend to buy from an online store? What emotions are present when consumers have negative e-commerce experiences? What prevents consumers from buying from an online store? --- Introduction In several prior studies , technology readiness has been found to significantly influence the acceptance and use of information systems . Typically, individuals who rank higher in terms of TR have been found to be more apt adopters of IS in contrast to those whose ranking is lower. However, in spite of this central role, TR has gained relatively little attention in IS research. For example, little is known about how TR varies in terms of different demographic variables and how these demographic variables moderate the effects of TR on IS acceptance and use as well as its main antecedents. In this study, we aim to address this gap in prior research by examining the aforementioned issues in the case of one highly important demographic variable: age. Age is a demographic variable that has been of high interest in several prior studies on IS acceptance and use. For example, in the well-known and widely used unified theory of acceptance and use of technology by Venkatesh et al. as well as its extension UTAUT2 by Venkatesh, Thong, and Xu , age is hypothesised to act as an important moderator for the effects of various antecedent constructs on IS acceptance and use. However, no studies that we are aware of have examined age as a moderator for the effects of TR on IS acceptance and use as well as its main antecedents. We conduct our examination in the case context of online electricity services offered by electric suppliers, which allow their customers, for example, to manage their electricity contracts and track their electricity consumption over the Internet. Such services have become increasingly common in the recent years and offer an ideal case context for the current study because they are often used by individuals with a widely varying age range. The only main exceptions are typically the very youngest and the very oldest individuals, who either still live at their childhood home or live in some sort of communal accommodation, such as a student apartment or a retirement home. As a theoretical framework for conceptualising and operationalising IS acceptance and use, its main antecedents, as well as TR, we utilise the technology acceptance model by Davis and the technology readiness index by Parasuraman , which have also been integrated together in several prior studies . This paper is structured as follows. After this brief introductory section, the theoretical foundation of the paper is discussed in Section 2. After this, the methodology and results of the study are reported in Sections 3 and 4. The results are discussed in more detail in Section 5, concentrating especially on the implications for the so-called "young elderly" segment consisting of individuals aged 60-75 years. Finally, Section 6 considers the limitations of the study and some potential paths of future research. TAM by Davis is an adaptation of the theory of reasoned action by Fishbein andAzjen to the IS context, which posits that the acceptance and use of a particular system can be best predicted by the use intention towards it. Use intention, in turn, is hypothesised to be predicted by two main antecedents associated with the perceived system characteristics: perceived usefulness , which has traditionally been defined as "the degree to which a person believes that using a particular system would enhance his or her job performance", and perceived ease of use , which has traditionally been defined as "the degree to which a person believes that using a particular system would be free of effort" . The more useful and easier to use a particular system is perceived to be, the higher should be the intention to use it. In addition, perceived ease of use is hypothesised to act as a predictor of perceived usefulness, so that systems that are perceived as easier to use should also be perceived as more useful. These hypotheses are illustrated in Figure 1. Although TAM was originally developed to explain and predict IS acceptance and use only in the organisational context, it has since been applied also outside it. To promote its applicability to other contexts, numerous extensions to the original TAM have been suggested, such as TAM2 and TAM3 as well as the aforementioned UTAUT and UTAUT2 . In this study, we utilise only the original TAM as our theoretical framework for conceptualising and operationalising IS acceptance and use as well as its main antecedents because we consider it highly applicable to our current case context of online electricity services, which can be characterised as utilitarian self-service technologies. Thus, their use intention is likely to be influenced mostly by the usefulness and ease of use aspects included in the original TAM rather than, for example, the more hedonic, social, and resource related aspects added to it in extensions like UTAUT and UTAUT2. However, like many prior IS studies, we omit the empirical examination of the linkage between use intention and actual use because this would have required a longitudinal rather than a cross-sectional study setting, which was not possible due to practical reasons. As a theoretical framework for TR, we utilise TRI by Parasuraman , which defines TR as "people's propensity to embrace and use new technologies to accomplish goals in home life and at work" and postulates it to comprise of four co-existing dimensions defined as follows :  Optimism: "a positive view of technology and a belief that it offers people increased control, flexibility, and efficiency in their lives"  Innovativeness: "a tendency to be a technology pioneer and thought leader"  Discomfort: "a perceived lack of control over technology and a feeling of being overwhelmed by it"  Insecurity: "distrust of technology, stemming from scepticism about its ability to work properly and concerns about its potential harmful consequences" Of these four dimensions, optimism and innovativeness are hypothesised to increase TR, whereas discomfort and insecurity are hypothesised to decrease it. TAM and TRI have also been integrated together in several prior studies. For example, in their technology readiness and acceptance model , Lin, Shih, and Sher examined the effects of the aggregate TRI construct on TAM constructs, whereas the studies by Walczuch, Lemmink, and Streukens as well as Godoe and Johansen concentrated on effects of the four composite TRI constructs, hypothesising optimism and innovativeness to have a positive effect on PU and PEOU and discomfort and insecurity to have a negative effect on them. In this study, we follow this latter approach by examining the individual effects of the four composite TRI constructs on not only PU and PEOU, but also use intention because in the study by Lin and Chang , TR has been found to affect use intention not only indirectly through PU and PEOU, but also directly. This research model is illustrated in Figure 2. --- Methodology To examine the potential age differences in TR and its effects on IS acceptance and use, we conducted a self-administered online survey targeted at Finnish consumers between December 2015 and January 2016. Due to the case context of the study, the survey was promoted via the online channels of two electric suppliers as well as via the internal communication channels of our university and several discussion forums. To raise the response rate, also several gift cards with a total worth of 356 € were raffled among the respondents. In the survey questionnaire, the 9 items measuring the three TAM constructs of perceived usefulness, perceived ease of use, and use intention were adapted from Davis as well as Davis, Bagozzi, and Warshaw , whereas the 16 items measuring the four TRI constructs of optimism, innovativeness, discomfort, and insecurity were adapted from the TRI 2.0 scale by Parasuraman and Colby . The exact wording of each item, translated from Finnish to English, is presented in Appendix A. All the items were measured on a five-point Likert scale ranging from 1 to 5 . More information about Mplus can be found in its user's guide and technical appendices . As the model estimator, we used the MLR option of Mplus, which stands for maximum likelihood estimator robust to non-normal data. The missing values in the construct indicators were handled by using the FIML option of Mplus, which stands for full information maximum likelihood and uses all the available data in the model estimation. The potential age differences in the construct means and regression relationships were examined by dividing the sample into three age groups with an approximately equal age range and using multiple group analysis . --- Results The conducted online survey was completed by a total of 1,370 respondents. However, to promote the quality of data, 194 of them were excluded from the final sample in two phases. First, we excluded 124 respondents who had not reported being customers of any electric supplier and, thus, were not likely to be able to give reliable assessments on the online electricity services offered by the companies to their customers. Second, we also excluded an additional 70 respondents who had reported missing values in all the items measuring the three TAM constructs. This resulted in a final sample size of 1,176 respondents to be used in the model estimations. Descriptive statistics of this sample are reported in Table 1. All in all, the gender and age distributions of the sample corresponded quite well with those of the adult Finnish population at the end of 2015, which are reported in the final column of would be no adverse effects on the content validity of the two constructs that they were measuring, we decided to eliminate them and to re-estimate the model. In the re-estimated model, all the indicators now met the criterion or at least were very close to meeting it , meaning that the reestimated model could be considered to exhibit satisfactory indicator reliability and validity. --- Construct Reliability and Validity Construct reliabilities were evaluated by using the composite reliabilities of the constructs, with which it is commonly expected that each construct should have a CR greater than or equal to 0.7 in order for it to exhibit satisfactory reliability . The CR of each construct is reported in the first column of Table 2. As can be seen, all the constructs met this criterion. In turn, construct validities were evaluated by examining the convergent and discriminant validity of the constructs, which were evaluated by using the two criteria proposed by Fornell and Larcker . They are both based on the average variance extracted of the constructs, which refers to the average proportion of variance that a construct explains in its indicators. In order to exhibit satisfactory convergent validity, the first criterion requires that each construct should have an AVE greater than or equal to 0.5, meaning that, on average, each construct should explain at least half of the variance in its indicators. The AVE of each construct is reported in the second column of Table 2. As can be seen, all the constructs except for DIS and INS met this criterion. However, they this correlation was expected due to the hypothesised effect of PEOU on PU in TAM and, thus, does not warrant the elimination of either of the constructs. --- Estimation Results Figure 3 presents the standardised estimation results of the research model, which was able to explain 56.4 % of the variance in INT, 79.3 % of the variance in PU, and 31.2 % of the variance in PEOU. The effects between the three TAM constructs followed the hypotheses of TAM, with the exception that PEOU was actually found to have a negative, although a very weak and statistically not significant, effect on INT. In contrast, the effect of PEOU on PU as well as the effect of PU on INT were both found as positive and statistically significant. This also caused the total effect of PEOU on INT, which takes into account both the direct and indirect effects , to be positive and statistically significant. OPT on INT to be 0.316. All these effects were statistically significant. The second TRI construct INN was found to have positive effects on INT and PEOU, but surprisingly a negative effect on PU, causing the total effect of INN on INT to be 0.179. In this case as well, all these effects were statistically significant. The third TRI construct DIS was found to have a negative effect on PEOU, but surprisingly positive effects on both INT and PU. Although these two latter effects were weaker than the former one, they were all statistically significant. However, they caused the total effect of DIS on INT to be only 0.051, which was statistically not significant. Finally, the fourth TRI construct INS was found to have negative effects on both INT and PU, but surprisingly a positive effect on PEOU, which was the only one of these effects that was statistically significant. However, the total effect of INS on INT was only 0.036, which was statistically not significant. The goodness-of-fit statistics of the model are reported in the top-right corner of Figure 3. As can be seen, the χ2 test of model fit rejected the null hypothesis of the model fitting the data. However, instead of actual misfit, this may have been caused by the tendency of the test to underestimate the fit especially in the case of large samples and more complex models . For this reason, also four alternative fit indices were used to evaluate the fit: the comparative fit index , the Tucker-Lewis index , the root mean square error of approximation , and the standardised root mean square residual . Their values clearly fulfilled the commonly accepted cutoff criteria , meaning that the model could be considered to exhibit a good fit with the data. --- Age Differences in Construct Means and Regression Relationships In order to examine the potential age differences in the construct means and regression relationships, we first divided the sample into the age groups of under 40 years, 40-59 years, and 60 years or over and then tested whether a sufficient level of measurement invariance existed across the groups to allow meaningful comparisons between them. At the minimum, the comparison of the regression coefficients requires the existence of configural and metric invariance, whereas the comparison of the construct means requires the existence of configural, metric, and scalar invariance . The testing followed the method formalised by Steenkamp and Baumgartner , in which increasingly strict constraints on parameter equality are added across the groups and the fit of the resulting constrained model is compared to the fit of the unconstrained model. As the main test criterion, we used the χ2 test of difference, corrected with the Satorra-Bentler scaling correction factor due to the use of the MLR estimator. However, because the χ2 test of difference suffers from a similar sensitivity to sample size and model complexity as the χ2 test of model fit, also the changes in the four aforementioned fit indices were considered as suggested by Steenkamp and Baumgartner . The results of the tests are reported in Table 3. As can be seen, the fit of this full configural invariance model remained approximately as good as the fit of the model without the group separation. Thus, the hypothesis on full configural invariance was accepted. Second, metric invariance was tested by constraining also the indicator loadings equal across the groups and comparing the fit of this full metric invariance model to the fit of the previous full configural invariance model. As can be seen, the χ2 test suggested no statistically significant deterioration in the model fit = 42.862, p = 0.095), which was supported by the four fit indices as well . Thus, also the hypothesis on full metric invariance was accepted. Third, full scalar invariance was tested by constraining also the indicator intercepts equal across the groups and comparing the fit of this full scalar invariance model to the fit of the previous full metric invariance model. As can be seen, in this case, the χ2 test suggested a statistically significant deterioration in the model fit = 192.894, p < 0.001), which was supported by the four fit indices as well . Thus, the hypothesis on full scalar invariance was rejected. As a result of this, we tested for partial scalar invariance by relaxing the added constraints concerning the equality of indicator intercepts one by one based on the highest modification indices of the model and comparing the fit of these The results of the comparisons of the construct means are reported in Table 4. The first and the second columns list the differences in the construct means of the age groups of 40-59 years and 60 years or over in comparison to the age group of under 40 years as well as their statistical significance, whereas the third column lists the differences in the construct means of the age group of 60 years or over in comparison to the age group of 40-59 years as well as their statistical significance. All the reported differences are unstandardised in order to ease their interpretation. As can be seen, of the four TRI constructs, statistically significant differences were found in case of all the constructs except for INS. Finally, we tested for the invariance of the regression relationships by constraining also the regression coefficients equal across the groups and comparing the fit of this full path invariance model to the fit of the previous partial scalar invariance model. As can be seen from Table 3, the χ2 test suggested no statistically significant deterioration in the model fit = 37.993, p = 0.150), which was supported by the four fit indices as well , although there was a significant increase in the value of SRMR. Thus, the hypothesis on full path invariance was accepted, meaning that there were no statistically significant differences in the effects of the TRI constructs on the TAM constructs or on the effects of PU and PEOU on INT as well as PEOU on PU across the groups. --- Discussion and Conclusions In summary, the findings of this study on the potential age differences in TR and its effects on IS acceptance and use suggest several differences in the TRI constructs of optimism, innovation, and discomfort, but no differences in the effects of any of the TRI constructs on the TAM constructs of PU, PEOU, and INT. All in all, the effects of the TRI constructs on the TAM constructs were found to be in line with those found in prior studies , which have also suggested optimism and innovation having the strongest effects on PU and PEOU, whereas the effects of discomfort and insecurity have typically been weaker and often statistically not significant. From a theoretical perspective, the findings of the study promote the understanding on the effects of TR on IS acceptance and use by considering also the vital role of various demographic variables like age. This promoted understanding can be utilised, for example, to better explain and predict the potential differences in the antecedents of IS acceptance and use as well as in IS acceptance and use itself between various user segments. Respectively, from a practical perspective, the findings of the study can be utilised by IS developers and marketers to promote the acceptance and use of the newly introduced systems and services especially in user segments that have traditionally been found more challenging in terms of IS adoption. One example of such a segment is the so-called "young elderly" segment, which consists of individuals aged 60-75 years and has often been overlooked, for example, in the development and marketing of digital services in spite of its vast market potential . This segment can be considered as practically equivalent to the age group of 60 years or over in this study because, although this age group contained also individuals that were older than 75 years, about 95 % of the individuals in it were aged 75 years or younger. Thus, if we use the age group of 60 years or over as its proxy, the findings of the study suggest that the young elderly segment is characterised by a slightly lower level of technology optimism in comparison to the individuals aged under 40 years and also a considerably higher level of technology discomfort, especially in comparison to the individuals aged under 40 years but also in comparison to individuals aged 40-59 years. In addition, the young elderly segment seems to be characterised by a lower level technology innovativeness in comparison to individuals aged 40-59 years. Thus, in spite of being on par with the younger individuals in terms of technology insecurity, this all suggests that individuals in the young elderly segment have a somewhat lower level of TR in comparison to younger individuals, which should be taken into account if one wants to maximise the acceptance and use of the newly introduced systems and services in this user segment. Of the aforementioned differences, the most important ones are obviously the differences concerning technology optimism and innovation because these two TRI constructs were the ones that were found having a statistically significant total effect on the intention to use IS when considering both the direct and indirect effects on it. Consequently, when developing and marketing new systems and services to the young elderly segment, special attention should be paid to making them as easily approachable as possible for also people who are typically not at the forefront of adopting new technological innovations as well as to highlighting the benefits that the usage of these new systems and services can bring to their everyday lives. The strategies that aim at doing this may include, for example, marketing and advertising campaigns as well as various technological solutions, such as the usage of tutorials, which lower the threshold to trial the systems and services and make their overall learning curve less steep. The implementation of such strategies is likely to result in two synergetic advantages. First, in the short term, they are likely advance the adoption of the systems and services amongst the users in the young elderly segment with a lower level of TR. Second, in the long term, through this adoption, they are also likely to advance the level of TR in the whole young elderly segment, especially if the use experiences of the adopted systems and services are positive and they are able to fulfil the user expectations towards them. --- Limitations and Future Research This study can be seen to have three main limitations. First, the study was conducted by analysing the survey data collected from only Finnish consumers, which obviously limits the generalisability of its findings to other countries and cultures. Second, the study was conducted in the case context of online electricity services, which poses limitations on the generalisability of its findings concerning the effects of the TRI constructs on the TAM constructs, but not on the generalisability of its findings concerning the mean differences in the TRI constructs themselves, since their measurement was conducted independently of the case context in question. Finally, the third main limitation of the study stems from the selection of TAM as the theoretical framework for conceptualising and operationalising IS acceptance and use as well as its main antecedents, which obviously omits the antecedents that have been added to the original TAM in its subsequent extensions, such as UTAUT and UTAUT2 . However, as already stated in Section 2, we consider this selection well-justified because of the utilitarian case context of the current study. Future studies should aim to address the aforementioned limitations by replicating the study also in other countries and cultures as well as in the case context of other types of IS. The selection of the case context should also be reflected in the selection of the theoretical framework for conceptualising and operationalising IS acceptance and use as well as its main antecedents. In addition to age, we also encourage future studies to concentrate on examining the potential differences in terms of other interesting and important demographic variables, such as gender and income. It is likely that I will use the e-services in the following year. --- PU1 Using the e-services to manage my electricity affairs would be convenient. --- PU2 Using the e-services would make it easier for me to manage my electricity affairs. PU3 I would find the e-services useful in managing my electricity affairs. PEOU1 I would find the e-services easy to use. PEOU2 My interaction with the e-services would be clear and understandable. PEOU3 Learning to use the e-services would be easy for me. --- OPT1 New --- Introduction Internet with its promise for lowering the cost, potential for increasing the quality of services and efficiency enabled a rapid development for e-business. Nevertheless, the possibility that anyone can have a web page with almost no investment has presented a huge opportunity for creating and advertising business online. The promise of reaching a global market no matter neither the size nor location of the organization seems to raise the hope of many companies. Therefore, in the last few decades almost every company has been trying to leave some presence in the World Wide Web. Mostly due to the promise of "no matter how small you are there is a whole world for you". The globalization of markets was believed to supplant the multinational commercial and corporations. The future was in offering the same things in the same way everywhere since the global corporations should operate as if the whole world is a single entity . Technological progress made this future even more real. Nowadays, ecommerce is having a larger share of commerce in more and more regions . Yet, the promise of internet and the possibility to reach the whole world was not equally successful for all. In the digital era there are again some global organizations dominating the world, while contrary there are several market leaders in local markets that are completely unknown outside their local region. The same applies to the providers of different online platforms offering vouchers, tourism services, auctions and web browsers or social media as well. Despite having global online platform providers like Groupon, Airbnb, e-bay, Google, and Facebook, there are several local online providers in different regions more than successfully facing with the global well known competitors within their regional borders. The purpose of the research is thus to examine the factors that influence the success of local online platforms. The aim is to identify the reasons why some local online platform providers that have been market leaders failed, while other local providers remained successful or even a market leader in a local environment despite the existence of global well-known providers. This research-in-progress paper will present a research program together with the methodological steps that will be performed in our research. Therefore, the paper is divided into two main parts. Firstly, a short literature review is presented followed by the methodology and a research plan. Finally, some concluding remarks and future research possibilities are outlined. --- Digitalization The digitization initiative began decades ago; however, it has become more prevalent in the last years and will certainly have an important effect in the next decades . It is becoming the most significant technological trend with global consequences since it is affecting individuals, organizations, communities and entire regions. It is believed that digital transformation will change business processes, customer experience and the entire business models due to the more and more information available for individuals and organizations; and therefore, enables to perform activities even more efficiently . It was even claimed decades ago that business models from the industrial age were not suitable anymore to deal with the forthcoming challenges of the information age . The same may be valid today, where past business models are not suitable to deal with the challenges of the digital transformation era. Moreover, innovative business models were namely claimed to be one of the most important reasons for the success of several organizations tightly connected to the online business like Amazon, Microsoft or eBay . However, is it merely about the innovative business models? Are innovative models enough to penetrate to global market or to become a global leader? Digitization is spreading out in almost all industries sectors; and therefore, it is anticipated that there will be even more "online" competition in a global market. Hence, the question about important factors needed for local companies to survive in a digital world becomes more important as ever before. --- Local versus global providers The debate about local and global providers has its roots in the glocalization concept. It has been denoted as a mixture of globalization and localization balancing the universal of globalization and the particular of localization. Ideas of glocalization are mainly associated with the international contexts; however, glocalization can be also related to the understanding of cultural differences within regional and national boundaries . Several key areas were distinguished in relation to when and how different cultures access information or use the technologies, including literacy, linguistic difference, physical environment, cultural norms and technological infrastructure . All these areas and specifics should be considered when launching new web services or online platform in local market. . Even in Japan the second strongest provider is with 40% share much above the global average, while Google with its 57% much below the average. At the moment there is an increasing pressure on global services providers to grow along with the needs of their customers in order to offer classier range of services both in terms of extent and geographic coverage . --- Research Program We decided to delve into this issue with a research program that will identify and validate the factors that influence the likelihood of the success of a local online platform and build a framework for successful deployment of local online platforms when competing with global online platforms. Different research methods will be used in several steps. The first step of our research will be a focus group by which we will be able to clearly define the outline of our further research. The focus groups are restricted to early, exploratory stages of research . They offer an insight to the discussed topic . The focus group will consist The second step will be based on the literature review and results from focus groups. We will conduct a Delphi study with the goal to identify the factors for success of local online platform providers when competing with global online platform providers. Delphi study is a group iterative method that uses controlled opinion feedback group of respondents . It can be used in management disciplines to shape a group consensus of relative importance of issues by using a ranking system . It can also be used as a method for concept or framework development . The Delphi study will include two separate groups. One group will be practitioners from the field of online platforms while the other group will be the experts/researchers. This split panel approach is advocated because of the ability to create a joint reality shared by both groups . The number of steps in the Delphi study will depend on how fast the consensus will be reached. While some authors suggest that a certain percentage of participants in the study need to reach consensus , other authors suggest a more qualitative approach to estimate when consensus is reached . The Delphi study will be designed based on the principles presented in . After identifying the factors for success of local online platform providers, we will conduct several in-depth case studies of local online platforms. Case studies are used in research which is still in the process of understanding, detection and characterization . The case studies will be used to verify the identified factors for success of local online platforms by analysing real companies. --- Conclusion The companies that are offering local online platforms often have to compete with global online platform providers. The purpose of the research is to identify and examine the factors that influence the success of local online platforms when competing with global online platforms. Contrary, the research will also ease the understanding when creating local online platforms has no potential. Our research will include several steps that will help us rigorously identify the factors and verify them. --- Introduction The advent of information and digital technologies -the time characterized by use of information and communication technologies as well as mushrooming of new digital technologies , their adoption and use , presents a new form of transformation: digital transformation . In business organizations, this form of organizational transformation, which is technology-enabled, is concerned with the use of information and digital technologies to impact different aspects of the organization. For example, organizations adopt emerging technologies such as social media, mobile technologies, internet of things, cloud technologies, big data analytics, etc. to enhance their daily operations . As a result, these technologies transform the way business entities operate, creating value and bringing different experiences to various stakeholders involved. Several studies have been carried out to demonstrate how organizations and industries have adopted digital technologies as well as demonstrating their transformational impacts. An MIT Sloan Management Review Research Report revealed that 78% of executives and managers across various industries, believed achieving digital transformation would be critical to their organizations. Another study by Harvard Business Review Analytics Services revealed that 50% of business and technology leaders said their organizations were already missing out on new technologyenabled business opportunities. Berman argues that the key transformational opportunities are: creating new business models; improving operational processes; and enhancing customer experiences. Bharadwaj et.al. reflect on digital transformation era as a time for organizations to rethink the role of IT strategy from that of a functional level strategy to one that integrates IT strategy and business strategy. All these indicate how organizations are increasingly being involved in digital transformation. In fact, in today's digital era, digital transformation has become an everyday agenda item in business boardrooms. As a result of this, the digital transformation phenomenon has created new research interest across different disciplines, . Although substantial amounts of work is ongoing in this area, this study reveals that research carried out in this regard is still at a nascent stage. There are indications of an immature literature landscape coupled with a limited understanding of the phenomenon. The few literature review papers on digital transformation that were encountered during our search . While some researchers associate digital transformation with business models and strategy, others view digital transformation as a paradigm or as a process . In light of this, we argue for the extension of literature that describes and articulates the phenomenon of digital transformation; what it is; how it behaves; what drives it; what impacts it creates, as well as where the impacts are felt. We believe that a solid foundation for this phenomenon is required. To this end, a systematic literature review is carried out and a concept centric matrix is developed. Drawing on this matrix, a more inclusive and general definition is constructed. The selection of keywords in this comprehensive definition of digital transformation is explained and avenues for further research are also highlighted. --- Methodology A scholarly literature search was performed with the aim of retrieving credible peer reviewed and academic research articles in this area . 3 Articles retrieved were scrutinized to extract similar traits and patterns that build up towards the phenomenon, where variables such as: "description of what is"; "characteristics"; "drivers", "impacts" and "transformed areas" were identified as constructs to the fundamental conceptualization of the phenomenon. The concept centric matrix process was adopted to synthesize the retrieved articles. This process was carried out within the period of March to October 2016 using Gass, et.al. 's 4 Phase Approach to literature analysis. Table 1 below illustrates the approach and how it was utilized in this review. The literature search yielded many articles. Criteria from the screening processes were applied to narrow the search and set the final inclusion and exclusion criteria. For searches that yielded many results, the search was sorted according to relevance and only first 10 results were considered. On analysing the metadata, articles that did not meet the criteria set were excluded. While there was a deliberate focus on articles published in the basket of 8, articles from other peer reviewed sources and academic conferences were also considered. Articles included in the final selection were then downloaded and perused in more detail. Analysis revealed that some of the articles retrieved stated the definition of digital transformation, also giving different descriptors such as characteristics, drivers, impacts and transformed areas while others gave a perspective approach of what digital 2 summaries the type of articles downloaded, defining each type, the number of articles in each type that provided the definition of digital transformation as well as the total number of articles downloaded for each type. --- Digital Transformation: The Current Situation An in-depth analysis of the articles was carried out to determine how authors describe digital transformation. In this process, retrieved articles were used to identify the definition, characteristics, drivers, impacts and the transformed areas as articulated by the authors. A concept centric matrix was developed to capture the different variables for each construct as they are identified. Table 3 is an illustration of the concept centric matrix developed from analysing these articles. A further in-depth analysis of both concept centric matrix and the current definitions revealed that there are significant differences regarding how digital transformation is conceptualised. Nevertheless, a common pattern has been identified in the structure of digital transformation definition, which suggests how the keywords and variables have been used to describe the concept. To qualify and refine this pattern, an iterative process was carried out several times, alternating different variables and keywords in order to attain a more precise yet general structure of the definition. After several iterations, we propose a pattern that suggests that digital transformation is: "… something with certain characteristics; that is driven by something; to create certain impacts; on certain aspects of the organization" Using the proposed definition structure, we illustrate the inconsistencies in the literature of this phenomenon using both concept centric matrix and current definitions. In order to reconcile these differences and 'square this circle', we draw upon these tables to construct an inclusive and general digital transformation definition. --- Characteristics of Digital Transformation The literature assessed views characteristics of digital transformation as behavioural traits displayed by this phenomenon. Different authors used adjectives to describe these traits, perhaps because of the long term impacts digital transformation have on business organizations. From the analysis, only a few of the articles described the digital transformation phenomenon in terms of its behavioural characteristics. However, notwithstanding the few descriptions, these characteristics could not be ignored because they serve a purpose of putting into perspective the extent of the impact that is created during the transformation: whether the impact is small or large, gradual or abrupt, etc. In this instance, the analysed literature characterizes the behaviour of digital transformation as radical, disruptive, evolutionary, continuous and complex. We propose that for a more inclusive and comprehensible description, digital transformation displays more of an evolutionary trait. --- Drivers of Digital Transformation Drivers of digital transformation are attributes that influence and enable the process of digital transformation to take place. Although insufficient, the existing literature identified attributes such as digital capabilities and maturity, digital technologies, strategies, business models etc. as factors that drive the digital transformation agenda in organizations. Ezeokoli et.al. notices that several studies have articulated digital transformation drivers as: profitability and new revenue growth, customer satisfaction, increased operational efficiency, convenience and the same high-quality technical standard, increase business agility, increased employee productivity and competitive advantage. While it was also observed that in some instance there was an overlap between digital transformation drivers and impacts, caution was exercised to separate the two such that drivers remain attributes that influence and enable while impacts are emerging benefits realised from the process of digital transformation. However, while it is arguable which attribute would be possessing more digital drive, we argue that digital technologies play a vital role in the digital transformation process. We believe the capabilities that these technologies possess, coupled by other factors, such as culture, strategy and digitally savvy human capital is what enables the digital transformation process. Kane et.al. argue that simply using digital technologies to drive the digital transformation process is not enough and that it also uses digital capabilities, strategies, culture and talent development. --- Impacts of Digital Transformation Digital transformation impacts are the effects that business organizations experience as a result of the transformation process. While analysed literature has not classified these impacts, we categorize these impacts into customer-focused and organization-focussed categories, customer focused are the effects that impact customers and organizationfocussed impact the organization itself. We further argue that these impacts can have a positive or negative effect on both the customer and the organization. Different studies have used different verbs to describe actions that digital transformation has on organizations, however we believe the ultimate impact that organizations want to leverage on digital transformation is value creationto both the organization and customers. 30 --- Transformed Areas Different authors identify different areas which are impacted during the digital transformation process. Westerman et.al. alludes that digital transformation takes places in three key areas of the firm: customer experience, operational processes and business models, suggesting that the effects of digital transformation in business organizations are felt in these three key areas. While Westerman et.al. allege that these three key areas are what business leaders focus the enterprise's transformation efforts towards, from an "orchestrating the organization" lens, it is established that not all key elements that ensure a perfect organizational orchestration have been included. For instance, Bouee argue that employees should not be left out in the digital transformation journey. Other researchers, including Matt et.al. , Bharadwaj et.al. , etc. demonstrate how digital transformation impacts organizational structure, while Piccinini , Loebbeck & Picot , etc. allude that digital transformation impacts relationships. In determining the transformed areas, we however argue that as the benefits of digital transformation are to be felt by both the organization and the customers, it is important to ensure that the transformed areas considered for the general description of digital transformation should be inclusive of both organization and customer. We therefore propose that Westerman et.al. 's three key transformed areas are more general and inclusive of both the organization and customer. The process was repeated several times, alternating different keywords and variables to ensure rigor and relevance in the proposed definition. It is after iterating several times that the definition below was proposed: Digital transformation is: "an evolutionary process that leverages digital capabilities and technologies to enable business models, operational processes and customer experiences to create value" --- Towards a More Comprehensive Understanding of Digital Transformation This section discusses the concepts used in our proposed definition and further describes the meaning of each concept. Table 6 gives a simple definition of each of these concepts and subsequently, a justification is provided of why each concept was selected for inclusion in the definition. Liu et.al. 2011, Bharosa et.al. 2013). While digital transformation was referred to as a radical change more than as an evolutionary process, we believe an evolutionary process is a more inclusive term that captures the fact that digital transformation evolves with time, and whenever this evolution takes place, the impacts bring about a radical change to the organization. Also, digital technologies as key drivers of digital transformation are in their nature evolving. While earlier forms of digital transformation entailed the introduction of computer based systems and automation of processes, present day digital transformation is more concerned with adoption and use of emerging technologies, which are in their nature evolving. Drivers of Digital Transformation: Digital Capabilities specifies that in order to thrive in a digital transformation journey, organizations require particular skill set, mind-set and culture that is digital. We argue that relevant skill set and culture -digital capabilities, should be incorporated with digital technologies to achieve the best digital transformation results . The second key driver identified in our definition, Digital Technologies, indicates that at the foundation of all digital transformation efforts are digital technologies. For technology enabled organizational transformation to take place, technology based systems are at the core of the effort . Digital technologies create opportunities that organizations leverage. These opportunities have the potential to transform certain aspects of the organization, especially business models, operational processes and customer experiences. As a result, the organization benefits from impacts of this transformation. Impacts of Digital Transformation: Value Creation is identified as the key impact brought about by digital transformation. This value is realized by both the organization and its TRANSFORMING OUR LIVES . Key Transformed Areas of Digital Transformation: Business Models, Operational Processes & Customer Experiences are acknowledged as the key transformed areas of digital transformation initiatives . Focusing transformation on these 3 key areas naturally engages transformation in other aspects of the organization, thus, enabling the transformation impacts to be felt across the organization. For example, transforming operational processes within the organization has the potential to create an impact in other aspects of the organization, such as improving efficiency, costs saving for both the organization and the customer, resulting in value creation. --- Conclusion This study has highlighted the lack of a unified and overarching definition of digital transformation as well as inconsistencies in the existing literature. In order to address this gap, a systematic literature review was carried out in order to conceptualize this phenomenon. A concept centric matrix was used to describe the phenomenon in terms of what it is, its characteristics, its drivers, impacts and the transformed areas. Inconsistencies in the definition are also identified and a new and more inclusive definition of digital transformation is constructed and explained. Other gaps that have been identified during the literature review process include insufficient literature on transformational effects of digital technologies on different aspects of the firm and as well as specific to industries. While digital transformation involves the use of digital capabilities and technologies to impact different aspects of the organization in order to create value, it is also important to understand specifically how different types of digital technologies, paired with capabilities, impact particular aspects of the organization. Moreover, it is important to understand the nature of the value that is created through this transformation. Such research would have significant impact on both theory and practice. --- Introduction In Nigeria, studies have shown social media's influence in different sectors such as education , health promotion , security issues , political participation . Fink, Kopecky, Bos and Thomas, described how certain aspects of an online population can be characterized. However, there is a paucity of research in the context of social commerce which is the focus of this study. Nigeria has a potential for social media and mobile commerce as the Facebook users in Nigeria increased to 16,000,000 which account for 8.4% of its population. This datum makes Nigeria one of the leading Facebook users in Africa. Also, Nigeria is advancing in mobile commerce, and its ultra-connected population is impacting the revenue of the mobile commerce merchants. Averagely, Nigerians are online once every hour and 20% use the internet at least ten times a day . Mobile commerce is growing with innovative add-on feature that is influencing the existing value networks and turning around the global economy . One of the leading appurtenances of mobile commerce is social media. The union of mobile commerce and social media is multifarious and involves different actors such as online retailers, customers, service and content providers and regulators across various business sectors . Mobile commerce entails mobile devices, social media and mobile applications . Kaplan and Haenlein classified social media into six groups such as social networking sites , virtual social worlds , blogs, collaborative projects , content communities and virtual game worlds . In 2009, the estimation of Facebook active users reached 175 million but according to the Facebook active users real-time counts on the internet in February 2017 the user's number has soared to 1.8 billion. In the space of eight years between 2009 and 2017, there was an increase of 1.6 billion Facebook active users. This is more than the population of many countries in the world, for example, China, whose population is now 1.3 billion. This implies justifications of fusing mobile commerce with social media because of its capability to hold a large online community. The sudden surge of Facebook active users is an interesting insight for mobile commerce vendors to capitalize on for customer's engagement, sales conversation and profit making. Some authors have impacted the body of knowledge in the context of mobile commerce in Nigeria and social media as a separate research domain discovered a gap in social media data collection and analysis and came up with a computational model that combined the strength of topic and sentiment classification to draw out consumer perception on important subjects in social media. On the other hand, Kaplan and Haenlein endeavoured to clarify the notion about the real meaning of social media in comparison with close concepts like Web 2.0 and User Generated Content and apprise the companies that wish to adopt social media with the major points of advice. Despite the contribution of recent studies , there is still need for more academic impact in the research stream of social commerce. The different researches that focused on the topics relating to the union of mobile commerce and social media are rare and statistical reputation in the developing country such as Nigeria actuate further study of mobile social commerce. Studies have fused social media and mobile commerce . This study seeks to use hybrid approach that combines different methodology and data analysis techniques. We used netnography, a form of online participant-observational technique . The study also employed sentiment analysis for mobile commerce Facebook followers' opinions, sentiments, evaluations, appraisals, attitudes, and emotions towards entities such as products and services . This paper is guided by a general objective to analyse the interwovenness of mobile commerce and social media with these specific objectives: to state the importance of social media in online shopping, to analyse online Facebook reviews, sentiment and examine customer service to develop an explanatory theory that associates mobile commerce with social media. --- Theoretical Framework Appraisal theory claims that people evaluate the personal meaning of an exciting event or events before emotional responses are generated . The appraisal theory of emotion has been used to examine the relationships between appraisals, consumption emotions and post-consumption behaviors . The form and emergence of emotions depend on cognitive appraisal process which are their byproducts . Bloom , said the theory of appraisal shift sentiments classification further and considers the assessment expression as a basic grammatical unit by which an opinion is expressed. Opinion are classified in previous studies mainly to their polarity as positive, negative or neutral besides which appraisal expressions covers additional attributes of opinions that extend the core description of the expressed opinion . The basic attributes attitude, which are engagement and graduation are complementary with polarity/orientation . The identified attributes of appraisal theory are: Orientation -It recognizes if a term is positive or negative. Some studies refer to this attribute as polarity . In contrast, the polarity attribute represents the fact that a sentimental term can be unmarked or marked. That means that the term "orientation" can be influenced by an expression that negates the meaning of the phrase or a sentence. If a term contains such a negation , it is labelled as marked. According to Šimko and Korenek , the main advantage of using the appraisal theory in sentiment classification is that it helps to take a look deeper inside the mind of authors who wrote texts and find out their real meaning using linguistic and psychological analysis of their texts. TRANSFORMING OUR LIVES (JUNE 18 -21, 2017 --- Methodology The growth of technology most especially in the area of social media is aiding the researchers to adopt different research methodology. This paper seeks to use a hybrid approach that combines different methodology and data analysis techniques such as entity and aspect-level sentiment, manual techniques, data mining, text mining and netnography to overcome some of the problems that existing researchers had identified concerning sentiment analysis of social media in their studies. Some of the authors have identified the problem of using slangs, disjointed words, incomplete phrase or sentence and buzz words that lack proper understanding and meaning. Kozinets defined netnography as "a form of ethnographic research, adopting the participant-observational approach and taking online interactions as its fieldwork". Netnography preponderates tourism research stream , but Kozinets recommends Netnography methodology to researchers that work with social media and other online platforms. The study followed five-stage outlines mapped out by Kozinets to extract data from electronic commerce Facebook online community as a participant-observer. We planned the data collection, the extraction and the coding to get insight from the data. One of the authors represented himself on the e-commerce Facebook online community as an observer, and we extracted the data with NCapture, a browser plug-in that allows us to capture the data of e-commerce product and service reviewers. We opted for TRANSFORMING OUR LIVES (JUNE 18 -21, 2017 --- Sentiment Data Analysis The emergence of the social media has turned things around in mobile commerce. In social media, retailers can only measure their Return on Investment through advertisement in form of sales but to appraise the sold-out products and services rendered to the customers, is a bit challenging. Through online reviews and posts on social media like Facebook, it is easy for online community members to learn from one another, state their experience, express their opinion and synchronise cultures. We adopted five steps process posited for sentiment analysis from the work of Nikumbh, Nikumbh and Gaikwad, . We skipped data collection and text preparation postulated by Nikumbh et al. because we had earlier used Netnography approach but we used NVivo with manual techniques for sentiment detection, sentiment classification and output presentation. We exported data extracted with NCapture to the NVivo which consists 15,790 General Merchants Retailers reviews, 1,559 Specialty Retailers reviews and only 256 Agency Retailers reviews. All together for 33 electronic merchants in Nigeria, we had 17,605 Facebook reviews. We used the word query to analyse the most frequent one thousand words. The result gave us a clue to the keywords that are necessary for coding to discover emerging themes from the data. We also performed word frequency clustering analysis for the General Merchant Retailers, Specialty Retailers and Agency Retailers . We performed Jaccard similarity coefficient analysis between positive and negative review of Facebook online community reviews for e-commerce products and services. We performed Jaccard statistic test with NVivo 11 Plus to compare the similarity and diversity of positive and negative online community sample. If the sets data result would be 100% similar, it means the closer to 100% signify the intensity of the similarity, and in comparison, 80% will be more similar than 70%. NVivo generates Jaccard's coefficient result of 0.038961 based on 7235 positive and 1783 negative references. We multiplied the result by 100, and it gives us 4%. The word similarity of positive and negative reviews is 4%. To get the dissimilarity of the positive and negative review, we subtract the Jaccard index from 100% . The Jaccard distance between the positive and negative reviews is 96%. --- Facebook Online Community Engagement Rate The tables below show the mobile commerce engagement rate on Facebook online community in Nigeria. As shown in the tables 1, 2 and 3 above, the Engagement Rate is calculated by taking the total PTAT and divide by the total number of 'likes'. Surveys show that to have success on Facebook, an engagement rate greater than 7% should be met as revealed by Facebook LikeAlyzer tool. In the GMR categorization, it shows that only two of the mobile commerce successfully engaged their customers with 80.36% and 12.87% respectively. All the specialty retailers sampled shows very low engagement with their clients while two of the retail agencies sampled indicated that they recorded success in engaging their customers at 17.77% and 7.89%. This result reveals that generally, most of the Merchants and Vendors do not actually engage their customers. It is very important to note that it is not sufficient to have many 'likes' but to have many 'PTAT' as well. Many 'likes' and low 'PTAT' yields a very low engagement rate as seen for example in Shoprite, Jumia and Konga. Recording a high or low 'PTAT' and a corresponding number of 'likes' will yield a very high engagement rate as evidenced in Katadeals, Payporte and Jiji. It is not enough to have millions of 'likes' on the Facebook platforms of mobile commerce while 'PTAT' is very low as it is crucial for a successful engagement rate with customers. Our results, based on sentiments detection from the reviews on the e-commerce merchant social media platform are classified under four headings. These are: views on Products and Services, Online Discussion, Merchant's Response and Online Community Benefits. These classifications identified the attributes of appraisal which include attitude, graduation, engagement and polarity. All these constructs are interlinking in the expressed opinions of consumers on products or services. --- Product and Service Sentiment The analysis starts by investigating polarity, which is useful for determining the overall sentiment orientation or bias of a document or person towards an object or services. Consumers shared their views on products such as electronics, computers, mobile phones, clothing and food items. We extracted the reviews of product and services from the Facebook page of mobile commerce platforms. The excerpts below depict the mind of the reviewers: Positive: I love GMR I like RA stores Negative: GMR is selling products that are of low standard, inferior and low quality because I bought a 32-inch Sharp TV and after two weeks the TV couldn't power on. . Neutral: I have never had any issues with GMR… . People have been talking about GMR but I never patronize them . Lagos, November 20, 2016). I enjoyed the Lenovo tab I bought from them just that it doesn't have flash so painful . The above quotes from the online shoppers depict their experience and show their positive, negative, neutral and polarity comments on products and services rendered to them by the General Merchant Retailers and Retails Agency. --- Online Discussion The most discussed topic that generated contributions from consumers on the ecommerce platforms as identified are price, product order, customer services, delivery time, product quality, shopping experience, shipping, return items, store location. This is evidenced in figure 2 above. The excerpts below express the mind of the reviewers: Price: how can your price of shipping be more than the goods or items being Bought…If you keep going like this, it will get to a stage where no one will buy anything from GMR . Product Order: Very poor. You place an order and never get a response. If a large company like Amazon with millions of daily orders can easily manage them, why can't… . Customer Services: The attitude of your rep AO is appalling. Enlightenment as a benefit brings about passing knowledge about something to others. This is shown in the statements made by the reviewers under enlightenment, teaching others how to do new things. Customers advertises, exchange ideas and present business opportunities for other customers alike. --- Merchant's Response The merchant response is very important for whatever brand to communicate, engage the customers or consumers and redeem the image or solve issues relating to patronage and many more. Some of the excerpts below are from merchant responses to comments on their products and services. So sorry for this experience. Sadly, the item delivered is the item ordered. Since the seal has been broken, we'll be unable to retrieve the item. An agent has been assigned to contact you regarding this. Thank you . We're delighted to receive your feedback and are super glad that you enjoyed our service. . Thank you for your kind words VO, quite appreciated. Please spread the word... And we welcome referrals… . The first response given above represent the attitude and the information passed as evident in the merchant comment reveals that the terms and condition of the agency is not known by the consumers as alluded to in the comment. The other responses received encouraging feedbacks about their product and services and they appreciated them. Going by the reviews generally, the rate of reply of the merchant to the reviewers is slow as there are complaints about response rate. It seems there is no personnel designated to answer the queries of customers. --- Conclusion and Implication Despite the prevalence of e-commerce, mobile commerce and social media as an interwoven study in diver disciplines , it is noted that few scholars in the field of electronic marketing have fully explored the connectedness of mobile commerce and social media for customers' service improvement. This study applies the hybrid technique to sort out social commerce customers' reviews, appraise the quality of the extracted data and identify the opinion that transpired between online retailing merchants and online customers. The unicity of this study lies in the accessibility of large dataset of online multiculturalism douse with emotion. Although this study is an overture of social commerce in the context of developing countries such as Nigeria, we are able to gain insight into the sentiment of online shopping. Due to this development, it is viewed that this study will set a pace for online shopping customer engagement through social media in electronic marketing. It makes this study one of the foremost in This study demonstrated the importance of social media in e-commerce in a new way by identifying the benefits of online community reviews and exhibited reviewers' emotions. Though our findings were based on Facebook data generated from 2014 to 2017, the result reflects how online shopping experiences ensued emotion in Facebook Commerce reviews. The study reveals the intensity of positive, negative, neutral and polarity sentiments. This study furthermore emphasized the explanatory power of theory for the union of mobile commerce and social media. The appraisal theory used for the pairing of mobile commerce and social media explain how attitude and graduation connect engagement in the context of products and services review. The equilibrium of mobile commerce and Facebook social media stands to improve customer service. Some managerial implications were offered as it advocates the significance of social media in mobile commerce to the electronic marketing practitioners due to its vastness. Many online consumers have turned Facebook into their second home, and it will be easy for the mobile commerce merchants to reach them for feedback in real-time. The study also emphasizes the importance of Facebook followers and clarify the differences between the Facebook 'likes' and 'PTAT' as the determinant of customer's online engagement. The engagement rate is one of the useful metrics for Merchants that uses Facebook online reviews. This study is not without limitations, and its explanation should be treaded carefully. It is a common argument that social media data validity is not a clean-cut but recommends heterogeneous Facebook users and generalized result as a standard for online data validity. Rife et al. , testify to the viability of Facebook data over traditional samples. Demographic data is hard to extract, but we limit the quotes to the reviewers that make their name, sex, domicile available on their Facebook page. There were more positive reviews than the negative , the neutral and polarity were scanty. Another limitation was that the sample represents general merchants retailing, specialty retailing and agency retailing and only 33 of the mobile commerce retailers were available for this study. According to Fink et al. , social media is a viable means of getting enriching social and cultural data for studying the developing nations. Future studies should endeavour to examine online reviews of social media such as Twitter, Instagram, Google+ and Pinterest regarding mobile commerce as a comparative study. --- Introduction Deal sites, also referred to as Group Buying Websites, are a well established trend in online commerce to get a better price by volume discount. Original idea behind a deal site is to group consumers together forcing the merchants to offer wholesale prices to these groups. Merchants sell products and services at significantly reduced prices, usually 40% off or more, on the condition that a minimum number of buyers would make the purchase. When the minimum number of orders is reached, the deal becomes activated and all the customers that signed up for the deal become eligible to purchase. If the minimum number of orders is not reached within agreed time period, usually 1 -7 days, then the deal is cancelled. Group buying promotions can generate a large number of sales in a short period of time thanks to the viral nature of this promotion, often promoted on social networking sites. Merchant's sales can be boosted by the order of hundreds to thousands of orders in a single day/week. Because deal sites take up to 40 % of the price, the merchant is only making slight margin, sometimes even sustaining short-term loss for the following reasons : --- Cash flow boost Payments for vouchers are processed within short period after the deal is closed so the merchant receives a quick boost in cash flow. --- Effective advertising Daily deals promoted by group buying websites are fairly inexpensive and they are much more effective at generating real sales rather than just increasing brand awareness. --- New customers Deal sites are able to attract new clients by offering large discounts that get the first-time customer in the door, although retention of such price sensitive clients can be problem. Groupon is possibly the most well-known deal site. From a business model perspective, it can be classified as affinity club , round-up buyers buying club), and trade show third-party marketplace) in the framework compiled by Taran et al. . In spite of Groupon being the so well-known, group-buying is not the main, nor the mandatory feature of deal sites. Slevomat.cz is the clear leader among Czech deal sites. It offers the widest range of experiential services such as adrenalin and cultural events, gastronomy and weekend stays. Slevomat stopped selling fashion goods, they focus on services with higher value, especially with the advent of shopping via mobile phone. The portal also provides assurance to its customers, since in the competitive market, it is crucial to guarantee satisfaction. --- Literature review To the best of authors' knowledge impact of personality traits on gift giving specifically linked to deal sites has not been investigated yet. The literature search has brought only couple of journal articles and a few conference papers investigating gift giving in general. Personality trait can be defined as habitual patterns of behavior, thought, and emotion . Traits are relatively stable over time, differ across individuals , and influence behavior. Traits are in contrast to states which are more transitory dispositions. Agreeableness is a personality trait manifesting itself mainly in such behavioral characteristics that are generally perceived as kind, cooperative, sympathetic, warm and/or considerate. Narcissism could be defined as the pursuit of gratification from vanity or egotistic admiration. There is a published study of relational signaling over recipient preferences in their gift choices , which point out, that givers balance their goal to please recipients with gifts that match recipient references against their own goal to signal relational closeness with gifts that demonstrate their knowledge of the recipient. Close givers' divergence from the gift-registry is not the result of their altruistic search for a "better" gift but is a strategic effort to express relational signals: it occurs only when givers will receive attribution for their choice. Same authors in 2013 also point out, that gift giving creates giver identity threat as a function of social closeness . They established, that gift giving, in which individuals may make product choices that run counter to their own identities in order to fulfil the desires of the intended recipient. Purchasing an identitycontrary gift for a close friend who is an integral part of the self can itself cause an identity threat to the giver, who subsequently engage in behaviors that reestablish his identity such as indicating greater identity affiliation with the threatened identity and greater likelihood to purchase identity-expressive products. The role of narcissism, self-esteem and gift giving was discussed by in their exploratory study that identifies romantic gift-giving motivations and examined these motivations in relations to the two personality constructs. A factor analysis found three motivations for romantic gift giving: intrinsic, maintenance, and power motivation. When self-esteem, age, and sex were controlled, narcissism was positively related to maintenance motivation in the past, and maintenance and power motivation in the future. Self-esteem was negatively related to power motivation in the past and maintenance motivation in the future, controlling for narcissism, age, and sex. An exploration of influences on attitudes to giving and receiving gifts reports the results of a study that examined the influence of organisational level and education on attitudes towards giving and receiving gifts in exchange for preferential treatment in three cultural groups. Analysis of the data using hierarchical regression revealed that after controlling for age, gender, cultural background, business sector and years of service, respondents' organizational level and education positively influence attitudes to accepting gifts, while only education influences attitudes to giving gifts. Contributions to gift-giving theory from an identity-stripping context measured by the Identity-Based Motivation model to examine gift giving within the identity-stripping context of Nazi concentration camps, as reported in the memoirs of Holocaust survivors is a bit extreme example of gift-giving oriented scientific paper. By exploring gift giving in this crisis-laden context, authors demonstrate the fundamental role gifts can play in re-establishing personal and social identities and provide insights into the motivations for giving that go beyond the existing paradigms that emphasize social exchange, economic exchange, or agapic giving. The role of adolescents' gift giving in managing their impressions among their peers examines adolescents' gift giving using a qualitative methodology, based on impression management theory. Gift-giving motives and the characteristics of the chosen gifts indicated that adolescents use gift giving instrumentally to manage and protect their impressions among their peers. The research provides evidence regarding different types of gifts such as joint, neutral, and twofold gifts. While research on self-gift consumer behavior has shown evidence of the importance of this behavior in Western cultures, there is no understanding of self-gift giving in collectivist cultures. Tynan et al. . used personal interviews to establish the existence of self-gifting in China, and further to compare motivations for and the emotions associated with it. Their findings indicate that self-gifting is less self-oriented for the Chinese than for the British. Gittell and Tebaldi found that charitable giving by households in the United States is significant. They estimate, that private giving represents more than 2 % of total gross domestic product and is a significant factor in funding the nonprofit sector. Their research adds detailed data and analysis supporting and supplementing research that identifies personal income, capital gains, religious group affiliation, age, volunteerism, and educational attainment as the main factors affecting household giving. The aim of our paper, based on the identified gap in the literature, is to analyze impact of gender, age, and personality traits on purchasing coupons from deal sites as gifts. The rest of the paper is organized in the following way: In the next section, there is a description what data were collected and how, and how they were analyzed. In the following section, results of the analysis are presented. The last section offers conclusions. --- Data and Methodology The data was collected in December 2016 to January 2017 using an on-line questionnaire. Respondents were 264 university students from the Czech Republic, of which 140 respondents indicated that they use deal sites, and 124 do not. The analysis of use versus non-use of deal sites from this data set was published in . SurveyXact was used for the questionnaire. Unlike Qualtrics, it does not allow to show/hide questions based on answers to questions on the same page. Therefore, the questionnaire was split into two pages and questions for deal sites users appeared on the second page. Seven respondents stopped after the first page and one respondent provided random high numbers as answers for multiple open-ended questions, hence this row was excluded from the analysis. So, the effective sample size is 132 . On the second page of the on-line questionnaire, there was a question regarding the number of coupons purchased on deal sites as gifts. The distribution of the answer is provided in Figure 1. Since the distribution of the number of gifts is right-skewed, ordinal logistic regression is used for the analysis. SPSS software was used for the analysis. Personality traits were measured using Rammstedt and John's Big Five Inventory-10, i.e. a shortened 10-item version of the Big Five Inventory questionnaire developed by John and Srivastava , and translated to Czech by Hřebíčková et al. . The instruction was to rate "How well do the following statements describe your personality" with statements "I see myself as someone who. on a 1-5 Likert scale where 1 meant strongly disagree and 5 stood for strongly agree. Extraversion was calculated as an average of the 1st and the 6th answer, agreeableness as an average of the 2nd and the 7th answer, conscientiousness as an average of the 3rd and the 8th answer, neuroticism as an average of the 4th and the 9th answer, and openness to experience as an average of the 5th and the 10th answer. The researchers are aware of the new version of Big Five Inventory -Big Five Inventory-2 with 60 items , and of 30-item short and 15-item extra short versions but there is no validated translation available yet. Narcissism was measured right after Big Five Inventory-10 using the same instruction, with the statement ... is of narcissistic nature The statement was adapted from The Single Item Narcissism Scale developed and validated by Konrath, Meier and Bushman . They recommend SINS for online studies. The questions related trust issues have been summarized in an article Trust, innovation, prosperity . The questionnaire contained additional questions which were not used in the analysis presented in this paper. The impact of age was significant. Impact of agreeableness and of narcissism were borderline significant. All of them have positive effectolder, agreeable and narcissist people are more likely to use coupons as a gift. --- Conclusion Purchasing coupons from deal sites and then using them as gifts is significantly influenced by age . Age could be mediated through several variables, e.g. somewhat older people lived longer, so they gave gifts for a longer period; somewhat older may have a better income; somewhat older people may have a better overview what is available on deal sites that their friends could enjoy. In light of the literature mentioned previously, our research is filling the gap in understanding, how the coupons are used in gift-giving mode and which personal traits can be traced to such behavior. As for implications for marketers, there would be problematic recommendation: either to focus coupon campaigns on older clientele with narcissistic inclinations, or controversy focus on the customers, who are empathetic and altruistic. Rammstedt and John mentioned that the two-item measure of agreeableness does not have as good properties as measures of the remaining four of Big Five Inventory traits. Therefore, in the future research, it may be worth to add a third item, namely "...is considerate and kind to almost everyone." It could possibly improve significance of agreeableness. Now that there is an indication of impact of narcissism on purchasing coupons as gifts, it is justifiable in future research to use more items to measure narcissism, such as Narcissistic Personality Inventory which is probably the most widely used measure of the narcissism and contains 40 forced-choice items. If a longer instrument is to be chosen, such as Five-Factor Narcissism Inventory , which contains 148 items, it may be advisable to select only certain factors. --- Introduction Governments and healthcare organizations in many countries are looking for ways to transform traditional healthcare services and to develop new services within a digital format. There is strong impetus for this development from legislation and government target setting to increase service availability and to deliver those services cost effectively . For healthcare organizations with limited resources, the ever-increasing demand for healthcare services and the complexity of customer situations present huge challenges . Digitization offers new possibilities in meeting these challenges, as more active, empowered customers interact with healthcare professionals , requiring the redesign of service processes. Digitization of health care services is typically discussed from a technological, medical science or customer perspective, and the role of the service provider is less widely studied. The present study aims to enhance understanding of how service providers can address issues of service process change through digitization. For value co-creation, the service provider must consider certain risks and seek to enhance identified benefits, which are dynamic rather than static, making the development of digital services more complex. Risks in the health care service process are often linked to issues of quality, which in this sector relates to the fundamental need for security and high standards of care . In digital format, risks of quality failure or variation can be said to diminish as the service is standardized and variation can be controlled . Digitization entails a technological approach to customer and service issues, but the managerial dimension must also be considered. The present study contributes to the discussion on digitized healthcare services by highlighting the need for standardization of work processes. The DARIO value co-creation model of digitized services described here is derived from Prahalad and Ramaswamy's value co-creation building blocks. The key development is the model's focus on service processes implemented through standardized work, providing opportunities for value co-creation. --- Literature review Healthcare service systems are transforming rapidly to become more customer-focused, shifting from value proposals to systems of value co-creation . This shift is strongly supported by the changing role of the customer and significant technological developments, offering opportunities for secure and collaborative value cocreation. For health care professionals, the challenge is to integrate digital healthcare services with the overall service process and operations, which inevitably become standardized through digitization. --- Value co-creation According to service-dominant logic, both customer and service provider become resource integrators in value co-creation . Service-dominant logic further designates the customer as the focal actor in defining value . The customer's perception of value relates not only to value as service outcome but also as experience or value-in-use . In a healthcare context, value is generally understood as the outcome of the service process, but the customer experience during the treatment process and the value co-created during the process is seen to be of even greater relevance, irrespective of the final outcome. The changing role of the customer also changes expectations about how healthcare services are delivered, requiring a shift of mindset in service development. Digitization brings the customer into focus, and the digital service process offers mechanisms supporting value co-creation . In a knowledgeintensive sector such as healthcare, the service provider is especially well positioned to influence the process of co-creating value with the customer through professional expertise and knowledge. As well as interaction, value co-creation involves processes in which the service provider and the customer operate independently in their respective domains . The nature and existence of these independent processes is of course arguable, as according to Grönroos et al. , value is always co-created only in direct interaction-in other words, there has to be simultaneous interaction between the stakeholders in value co-creation. However, as well as value related to the service provider-customer interaction, there is also value derived from or related to the service process that is actually co-created among stakeholders other than service provider and customer. These independent domains include processes that for the service provider involve co-creation opportunities , planning and implementation and metrics connected to implementation. For this reason, the service provider can exert significant influence on the creation of customer value by providing opportunities for value co-creation . Digitized services provide opportunities for mutual benefits, with joint targets set for the entire process according to the principles of value co-creation . The dialogue between customer and service provider itself becomes an ongoing element of the digitized service process . Further, digitization increases potential availability of the service as well as better customer access by departing from the traditional direct appointments approach. In addition, risk-benefit evaluation is considered a further building block of value cocreation and can be utilized to analyse the impact of digitization on the service. Shared information is one element that enhances the service system by creating opportunities for value co-creation. Digitization creates these opportunities by establishing a platform for sharing information, so introducing transparency to the service process . In healthcare settings, transparency is closely linked to shared information and to the related concept of shared-decision making . Based on shared information that the service provider contributes to and facilitates, the customer is empowered to participate actively in shared-decision making. However, transparency does not necessarily deliver value for the customer unless the digital service process is properly integrated into the practical operations through which concrete value co-creation opportunities emerge . The digital service process requires a new way of operating and a different approach on the part of the service provider. It is therefore necessary to properly define the new processes and to integrate the digital service portal into the service process and operations to ensure that professionals do not act sporadically on the basis that "it is just a gadget or a tool" . Given that transparency can be seen to relate to information and to operations, which differ in certain respects, the present study proposes a modification of the DART model in the form of DARIO, a new value co-creation model. As described in Figure 1 below, DARIO operationalizes the concept of transparency into information and operations as two distinct features introduced by digitization for value co-creation and the development of digitized services. The model's key contribution is the focus on service operations through customer activities within the portal and the professional's standard work as opportunities for value co-creation . As indicated, operations are an essential contributor to value co-creation, as both customer and service provider use the digital service portal, offering opportunities for value co-creation. For the service provider, operations represent an organizational aspect of value co-creation, as processes and practices need to be integrated with digital processes to operationalize the service. Many eHealth services fail because insufficient attention is paid to actual implementation of the service . Based on the value co-creation definition of the customer as the focal value-defining actor, operations must be value-driven-in other words, digital service processes must be developed in close cooperation with the customer, enabling work processes to be successfully integrated. However, developing digital solutions customer needs and changing capabilities require that development is a continuous process, including re-evaluation of processes following actual implementation. --- Operations as standardized service processes The present study views the service provider's operations as an opportunity for value cocreation and as an element of that value co-creation. Digitization of healthcare services requires effective implementation so that the service provider or the professional can integrate the digital service portal with operations, enabling value to be co-created. If implementation of the digital service portal is not given due consideration but is instead seen as something that "just happens," implementation may fail or fall short of its full potential for service delivery due to a lack of proper planning . Here, implementation means successful integration of the digital service with the overall service process to ensure seamless care. Professionals who must learn new ways of interacting with the customer do not always receive sufficient support to ensure successful implementation, and the consequences for professionals' work must be carefully considered and planned in the development phase of the digital service portal. Many healthcare organizations have made huge advances in their operations through standardized procedures and defined targets based on the lean method . Lean is based on continuous improvement and a focus on people, both customers and personnel . Lean essentially means following the customer's path through the service process and monitoring that process through the customer's eyes to become a customer-centered service organization . Following the customer path through the service process and developing and planning the new process contribute to more successful implementation of the digital service. Lean philosophy takes the customer as the starting point for the organization's operations and processes. Understanding the customer's actions and path through the service process are the key objectives for lean value stream mapping . Value stream mapping as a lean tool starts from the customer at the threshold of the service process and follows on through operations, multiple interaction points and sub-processes that the customer encounters. Taking the customer as starting point in the planning of the digital service process is closely analogous to the founding premises of value co-creation. For the service provider, this means keeping the customer in view when developing service processes and operations or work processes. It follows that planning for implementation of the digital service should consider the professional work processes with which use of the digital service portal must be integrated. Risks in the health care service process are often associated with issues of quality. The requirement for quality reflects the requirement for security and high standards of care and treatment . In the digital service format, the risks of quality variation or failure arguably diminish as the service is standardized, enabling variation to be controlled . By the very nature of the technology, digitization necessitates definition of work processes and operations. Further, according to lean philosophy, the operations defined in the digital service format help to reduce the risks of quality failure or variation, as the service process becomes standardized and variations can be controlled. The concept of standard work refers to how professionals perform operations in a unified and similar way. Standard work looks to create a consensus in the practice of procedures and operations to reduce any variation among practicing professionals. Reduced variation of treatment increases the consistency of quality of operations and outcomes . Standard work is very often misunderstood as excluding the possibility of interpretation and the use of professional expertise. However, this is not the objective; on the contrary, standard work reduces wasted time and effort in the service process and so releases the professional's time and expertise to make a more meaningful contribution to the service process. Digitization of processes can too easily be regarded as a threat to professionals' work, and more emphasis should be placed on how a standardized work process facilitates non-routine work requiring advanced expertise and knowledge . --- Methodology The study is based on single case data gathered from a large healthcare organization, using the qualitative methods of thematic and focus group interviews. The single case study facilitates exploration of an industry embarking on a new approach to value creation and implementing processes for value co-creation opportunities through digitization. It is also appropriate when studying a new phenomenon under unusual or complex circumstances . The material obtained through the interviews was further enriched by observations within the organization while participating in two seminars and workshops on digitizing healthcare and its services. The organization in question identified mental health and weight control digital services development groups, from which the interviewees were drawn. Participants in the thematic interviews were selected by means of snowball sampling , with each interviewee identifying the next. Interviews continued until the information gathered became repetitive and no longer added to the information from previous interviewees. There were two focus group interviews, involving mixed combination of people who were active participants in the development of these digital healthcare services. In total, 26 people participated in the individual or group interviews. The observations in seminars and workshops consisted of several discussions and workshop tasks with multiple health care professionals who were interested in or participating in digitization of healthcare services. The personal thematic interviews were tape-recorded, and the group interviews were video-recorded with participants' permission. The recorded material was typed, grouped and organized, utilizing the guiding thematic issues for the purposes of analysis. The material casts light on the attitudes of the organization and its professionals toward digitization, and on understandings and measures concerning the need to define internal processes to meet the challenge at the customer interface for value co-creation. --- Findings The case organization has several ongoing projects developing digitized healthcare service portals. Very often, implementation of these services would not progress or even seem to fade away because of deficits in service process integration planning, poor understanding of the implications for work procedures and low managerial commitment to implementation. This lack of managerial commitment owed to uncertainty about the The development groups comprised voluntary participants, ensuring their motivation and commitment to developing the services. However, voluntary participation also means that management commitment may be low. While some development groups proceed well and people are committed, there are others whose work lack management commitment, and the lack of sufficient organizational participation resulting in poor planning and potential failure of implementation. --- "This is a journey toward understanding what this could mean for us." Based on the interview findings, it seems obvious that careful planning of digital service processes is fundamental for successful implementation enabling value co-creation. --- "You have to plan changes in the way of working before implementation." There are now ongoing efforts to formalize the development work based on a strategic approach to which services to digitize, how to proceed with planning and whom to involve in development. However, there is an evident lack of experience within the organization in defining services, service processes, roles and work descriptions, which is rather resource bound for ICT supporting this development work with less support from the management or from the human resources organization. --- "We proceed with the lean plan-do-check-act of continuous improvement, with small steps in the development work." The organization utilizes lean methods for digital service development, involving both personnel and customers. Services are planned and developed on the basis of a customer forum of customer experience experts-that is, real customers for the services to be digitized. For the professionals, defining the service process for digitization introduces the concept of standard work, which assures quality and reduces waste in the process such as missing or lost information, which are also essential features of digitization. The planning of digital treatment paths is an iterative process, and courage is required in order to learn through an iterative process. " "We learn from our experiences and utilize that in subsequent services." Results improve each time and enhance the functioning of the digital service process. However, training for new work processes remains secondary in terms of planning, although its importance for the successful implementation of the services has been recognized. --- Discussion --- Theoretical and managerial contributions The study findings can be discussed in terms of the DARIO model, which links transparency to information and operations as indicated in Figure 1. This more precisely captures what the service provider must consider for successful value co-creation in digital services. The DARIO model contributes to the discussion of digitization of healthcare services, which requires new cross-disciplinary inputs. The findings have several managerial implications. The service provider, who has a huge impact on value co-creation opportunities, must also be a resource integrator-that is, they must be able to integrate the digital service into the overall service along with defined work processes and standard work. This highlights the importance of developing digital services through close interaction between customers and professionals. The development of digital services is based on voluntary involvement by the participants in the development groups. However, from a managerial perspective, this voluntary participation fails to deliver the necessary understanding of the digitized service process to the organization and of the related workload to management. The findings suggest that a lack of clear targets for implementation, including voluntary participation in the development work, hinders integration of resources, which further slows the implementation process and increases the risk of low adaptation. Both of these effects undermine achievement of the ultimate targets of increasing service availability and cost effectiveness in the delivery of healthcare services. Based on these findings, there is an imminent need for systematic involvement of management in the development processes and in defining targets for implementation in terms of number of users and timespan for integrating the digital service within the overall service. The mental therapy service offers a huge range of possibilities to proceed with the customer. There seems to exist uncertainty of and lack of a common description for the proceedings how to combine the digital mental therapy service with sufficient amount of empathy and presence. With the weight control house these are services for various combinations of conditions like anorexia or severe obesity with linkages to mental therapy services as often there is a connection with these issues. During the interviews or in the focus group interviews there was less remarks on the implications to work processes or operations in general concerning the mental therapy services or weight control house services. However, as digitization changes these work processes and service operations tremendously, there emerges a need to redefine work processes or the work. Algorithms behind the service process guide how the service proceeds, but these do not define operations or how the professional integrates the digital service portal into the service process. Lean's standard work introduces a coercive formula to follow a defined work process in the digital service portal. These findings suggest that the organization still lacks the necessary systematic planning for implementation of the service portals of mental therapy or weight control with defined standardized work processes and training for the professionals for integration with the overall service processes. This suggests a need for systematic involvement of management in defining implementation, training and standardized work in order to gain commitment and ensure successful implementation and value co-creation opportunities within the service process. --- Limitations and directions for future research The study has several limitations. The first of these relates to the theory-building process. An approach combining value co-creation and lean standard work through operations may seem risky, as there is no readily available theoretical precedent, and the model can therefore be considered limited in this regard. Nevertheless, the idea of combining value co-creation and lean offers multiple possibilities for future research. Second, the focus here is on single professionals and their standard work; multiprofessional teams were not considered because of practical constraints. This limitation invites more thorough and separate research on standard work in multiprofessional teams in the context of digital healthcare services. Third, there was no possibility of studying customer operations within the digital service portal for practical reasons of permissions and the need to focus on the professionals. However, customer use of the digital service portal represents an interesting and fruitful area for further research. --- Introduction The ever increasing global competition leads industrial companies to engender organisational changes and drive innovations. A new generation of information technology can contribute to the transformation of the shop floor: on the one hand by advancing the automation of manufacturing processes and on the other hand by putting shop floor workers and their skills more in the focus . However, so far, manufacturing companies have been slow in taking advantage of the possibilities offered by the current wave of digitalization . Yet, we know little about the information needs and possible benefits of IT for the manufacturing sector . Therefore, the goal and main contribution of our study is to identify, describe and explore current challenges that companies are facing due to emerging sociotechnical trends in the manufacturing sector. For this context, we define a digital challenge as the combination of 1) the identification of the problem situation 2) the implementation of a sociotechnical solution to address the problem and 3) the continuous transformation of the existing work practices. We start this paper by presenting emerging sociotechnical trends that are currently engendering changes in manufacturing. We start by discussing technology as catalyser of this transformation process and then discuss its impact on individuals and the organisation . In Chapter 3, we explain how the close collaboration with six industrial companies in a European project for more than two years has allowed us to identify and then further specify four digital challenges. Those are 1) Digitally augmented human work, 2) Worker-centric knowledge sharing, 3) Self-learning manufacturing workplaces, and 4) In-situ mobile learning). Next, we illustrate each digital challenge with an example of a company from the project. For each case, we describe the problem situation and then the proposed solutions to overcome problems being faced by each that have been implemented or are currently implemented. Thus, drawing on the insights from these companies we demonstrate how the manufacturing industry can leverage challenges they are experiencing. Beyond practical relevance, this conceptualisation of the current situation as "digital challenges" for manufacturing companies helps building the basis for a better theoretical understanding of the changing nature of IT on the Shop Floor. In Chapter 5, we discuss how to take a step forward by proposing sociotechnical solutions for the workers in response to these digital challenges, to support their work practices and increase job satisfaction. In the following, we present sociotechnical trends that emerge in the context of manufacturing. In order to identify these trends, we thoroughly reviewed the latest literature, the public media as well scientific publications. We categorize the trends into three pillars, as summarized in Figure 1, and discuss them in the following sections: Technology, which is the basis for this transformation and catalyses the other changes on Individual and Organisational levels. Figure 1: Emerging sociotechnical trends in the manufacturing sector --- Technology New technological developments can serve as drivers for change on organizational and individual levels . The following recent technological trends have the potential to substantially affect the workers' situation on the shop floor and also the organisation of manufacturing environments. The web-based linking of machines, sensors, computers, and also humans, is rapidly moving towards the idea of the connected factory . The benefits of the so-called "Internet of Things" technologies include reduced down time, increased quality and less waste as well as greater visibility of the manufacturing floor. This connectivity enables companies to leverage the value of their plant floor information and promises an increase in productivity, improved utilization of assets, and better decision-making . Whereas recent technical advances in interoperability have resulted in higher maturity of product and process models , companies still face the task of building coherent services when the individual components are technically different and managed by different units. IoT technologies allow devices to communicate automatically and enable companies to monitor, collect, process, and analyse huge amounts of data, which may lead to more precision and the chance to get deep insights into manufacturing processes. Measuring and monitoring real-time data from across the factory leads to rapidly growing data sets that are increasingly gathered by cheap and numerous sources and often so large or complex that traditional data processing applications are inadequate to deal with. In this context, the term big data was coined. To capture business value and meet the demands of smart manufacturing, companies need to be able to manage these large data sets and extract meaning out of them . This large quantity of data leads to new questions and solutions concerning especially the analysis, search, sharing, updating, and visualization. Advanced analytics in the form of predictive analytics, user behaviour analytics, or certain other methods that extract value from data, are needed to cope with this great amount of data . It offers possibilities to make extensive use of analytical tools often capable of providing diverse reporting on any device, anytime. These tools are able to deliver data about companies' productivity and security as well as supporting decisions according to product configurations, service bundles, and pricing options. The utilization of metrics is evolving at a rapid pace and will become even more pervasive in the future . Danson et al. state that "industrialized analytics" is increasingly influencing business strategy and commanding substantial investment and connecting analytics capabilities is crucial for manufacturing companies. --- Individual Level As with any new way of working, or even more general -of doing -individuals need to learn and adopt it, get used to it, and, in the best case, benefit from it. Striving towards a smart factory may have an enormous impact on work practices on the shop floor. Employees face changed processes, they need to handle new technologies and accomplish different tasks. As one out of three trends for the future of manufacturing the World Economic Forum, therefore, identified the focus on the workforce's skills . With the spreading and growing importance of technology in the manufacturing sector, the need to be able to acquire new skills to get the work done properly increases. Individuals are not only facing changes of technologies, but, as a consequence, also the increasing complexity. Providing workers with information where and when it is needed and, more generally speaking, supporting the employees in their daily work promises significant benefits . As a consequence, shop floor workers are expected to solve occurring problems as fast as possible and to constantly improve their work-related knowledge and skills . People who were not born into the digital world have learnt to use different kinds of technology at some stage in their adult lives and are likely to experience some difficulties in accepting technology related changes at work. Conversely, the "digital natives" have grown up with diverse IT. The entering of digital natives into the workplace might mark a paradigm shift . The way people process information fundamentally differs and depends from how and when they grew up. Thinking patterns have changed and it is very likely that even their brains have physically changed . It could be shown, that this implies an ease with which digital natives learn to make use of unfamiliar technologies . They need, however, to be provided with the opportunity to use them for meaningful purposes . In order to remain competitive, companies need to take this into account. Another perspective on the same phenomenon is that some employees may be faced with fears about whether digital natives and smart machines will soon take over their jobs . However, humans with the most diverse skills and competencies as well as with valuable experience have always added value to manufacturing processes and this is likely to continue . There is a variety of possible ways in which people and machines will work alongside each other . Of course, some will build, implement, maintain, and operate upcoming technologies. Others will be in roles that machines can't perform well, such as those involving high levels of experience, intuition, creativity, or empathy . Therefore, manufacturing companies should not overvalue digital skills at the expense of "traditional" skills. Instead, they are advised to recognize and promote experience and handicraft talent, too. Focusing on all different kinds of skills is a great challenge but it may create advantages for manufacturers, and also positively impact workers' employment and incomes . When facing this challenge appropriately it is important to rethink and develop group specific learning arrangements and individual work place designs . Organizations will need to examine knowledge-intensive processes and determine which tasks can best be performed by machines and which by humans . Early training and supporting employees to prepare for a collaborative future with smart machines is essential . --- Organisational Level The exponential growth of data and the convergence of different affordable technologies are transforming organizations. Key infrastructures are underlying considerable changes that play a vital role in securing competitive positions in the manufacturing industry. Anytime retrieval, monitoring and operating of technology infrastructures, even over huge physical distances, enables simultaneous control and coordination of complex technological processes. Consequently, a shift can be observed, away from centrally controlled processes towards decentralized, distributed structures and processes. As a result, today's strategies, value chains and business models will come under increasing pressure . Companies need to decide whether to react on emergent demands or to proactively contribute to a transition's design or they can choose between an incremental change versus a radical change . In each case an appropriate change management is crucial. The prevailing view of IT strategy has mostly been that it is a functional-level strategy that must be aligned with a company's business strategy. The business infrastructure has become digital, though, with increased interconnections among products, processes, and services. The arrival of IoT, Cyber-Physical Systems and others allows everything to be networked in order to create a smart environment where people and machines communicate with each other naturally . This has led to fundamentally transforming not only business processes, products and services but also business strategies. Accordingly, the role of IT strategy has to be rethought, from that of an aligned but subordinated functional-level strategy to one that reflects a fusion between IT and business strategy. Key themes to guide this are, the scope, the scale and the speed of digital business strategy, as well as the sources of future value creation and capture in digital business strategy . When addressing a change in strategy, its success strongly depends on a firm's ability to evolve its corporate culture. Thereby, companies are advised not only to take advantage of emerging technologies, but also, critically, to embrace the new business strategies that those technologies drive. Enterprises must focus on enabling people to accomplish more with technology . They will have to create a new corporate culture that looks at technology as the way to enable people to constantly adapt and learn, continually create new solutions, drive relentless change, and disrupt the status quo. In times where the focus is locked on technology, it is important, in fact, to place people first . Thus, it is the task of managers to promote an organizational climate that supports decentralized and self-responsible use of information assets. For this, many leaders are likely required to develop new skills, resulting in training recommendations for supervisors, who have a prominent position in digital workflows . The rise of the generation of digital natives, as stated above, brings a new kind of employee not only with different attitudes towards technology but also with different outlooks, aspirations, and expectations regarding their employer, their workplaces, and about how work should be organized . It appears that preferences are shifting towards aspects such as connectivity, information or entertainment . The push towards new forms of working challenges organizations. On the one hand, it is important to thoroughly plan and execute the change, on the other hand, there is strong competition between manufacturers for new employees. A successful employer branding would create sustainable competitive advantages. With the right engagement . --- Research Design This study is a part of the international research project FACTS4WORKERS. The objective of FACTS4WORKERS is to create attractive and intelligent work places in a factory of the future. Therefore, we initially studied how practices on the shop floor can be supported through human-centred IT solutions. A deep understanding of workers' individual practices has been our basis to deliver suggestions for sociotechnical solutions that support smarter work. Guiding through the process of exploring smart factory solutions, we identified four digital challenges together with our six industrial partners from the manufacturing domain. The identification was done in the constitutional phase of the project by conducting a focus group with all six companies. The intense collaboration with the companies over a span of more than two years allowed us to deepen our understanding and to further explore the four specific digital challenges. Further field studies at each of the six companies enabled us to collect data from more than 60 interviews, various observations as well as at least one further focus group at each partner. For further information about first phases of the data collection please refer to and . This has all contributed to describe their individual challenges in more detail. --- Digital challenges for manufacturing companies The role of knowledge in manufacturing companies has grown over the last century and innovations and technologies have changed it radically a number of times . Currently, the focus has drifted towards knowledge-intensive and human-centred manufacturing. Currently and in the future, human workers have an important role in manufacturing environments, as they are capable of complementing modern technology and performing knowledge-intensive work tasks more effectively compared to solely technical approaches. However, this also will require more knowledge management skills from the workers and manufacturing environments. The data gathered from six companies allowed us to identify four digital challenges: 1) Digitally augmented human work, 2) Worker-centric knowledge sharing, 3) Self-learning manufacturing workplaces, and 4) In-situ mobile learning. These fall into different facets of knowledge management. While for example predictive manufacturing focuses stronger on the technological aspects of knowledge aspiration, human-centred manufacturing rather focuses on the social aspects . Beyond identifying the digital challenges we illustrate all of them with a case vignette eachthat gives insights into the situation at the industrial partners' production environments. Figure 2: Digital challenges for manufacturing companies --- Digitally augmented human work Human shop floor workers deal with information that is increasingly more complex and transforming, combined from multiple sources and types. Augmenting human work with digital technologies means to provide them with an immediate and personalized provision of information at the shop-floor-level, which can be interacted according to their needs, roles, preferences and constraints . Our research reveals, that one common request of many assembly and manufacturing workers is to have a better awareness of the process status in order to have a more conscious decision making process and increase their responsiveness to process breakdown/change. To date in many companies the operators need to actively seek the required information and select the correct information from a large number of data sources to carry out their tasks. Thus, the main idea of the challenge is to create a "personal" information feed for a specific worker that could support his activity and empower him to become a smart worker with more autonomy and problem-solving capabilities. The solution should provide also the appropriate tools not just "see" the correct data but also to analyse them in the smartest and personalised way. Not only the access to data has to be personal but also the analysis should be developed and selected in order to provide an understanding of the process that will be profitable for the specific worker. Hidria Rotomatika is a Slovenian automotive tier-1 supplier that produces electric stators and rotors for automotive use. We observed operators of the machining departments, who deal with turning and milling machines. A preliminary analysis of the workers needs has highlighted how some operations could be time-consuming and require the acquisition of paper-based data or knowledge from an experienced colleague. These data must be processed manually in order to obtain a smooth process. Especially machine setup processes and measurements of each part could be very complex and time-consuming. This challenge addresses the core issue of providing natural interfaces that allow workers to interact and access knowledge effectively when performing their regular tasks. The challenge is to enable the workers to utilize big data analytics fuelled by automated electronic measurements to make decisions more effectively when calibrating production equipment. Better access to information and analytics would allow to cut production times while increasing product quality and reducing waste due to making better-informed decisions and detecting patterns and trends in product deviations. For the worker, being able to benefit fully from information generated by machines and previous decisions could reduce frustration and help retaining a productive flow of work. In the proposed solution, the workers automatically receive all relevant information in a digital format and obtain a fit solution to fix the problem directly at their current work station. Moreover, the operators acquire more autonomy due to the implementation of a trend analysis of the process, which usually means the degradation of some components or machines. In this case the operator becomes a leader of a proactive analysis phase for the machine maintenance that is actually carried out using a traditional reactive approach by the maintenance team. This allows the operator to gain more autonomy and take charge of advanced tasks that are beneficial both for the process and its satisfaction . --- Worker-centric knowledge sharing Worker-centric knowledge sharing means the utilization of worker-generated content and peer sharing about best practices, problem solving and ideas to fuel organizational learning and even worker-driven innovation . This includes not only equipping workers with appropriate tools, but also with specific use cases for utilizing these tools . Empowering workers to share their knowledge transparently with others reduces the risk of productivity bottlenecks e.g. through redundant work and improves the pace and depth of on-the-job learning. At the same time, the worker feels more valued, more socially connected to the work community and better motivated. thyssenkrupp Steel Europe is an international provider of flat steel. We observed the practices of the mobile maintenance team in the areas of air-conditioning technology and electricity. The occurrence of a fault is reported via phone, email, or fax. Rough information on the type of fault and system is then passed onto the mobile maintenance employee in paper form. Frequently, neither local information of the production site in which the disruption is located nor particular safety instructions are provided. The necessary knowledge is usually acquired through the accompaniment of an experienced colleague or through systematic trial and error, despite a structural knowledge transfer. Since approximately 3,000 different types of systems must be serviced and possibly debugged, employees rarely possess all the relevant information, tools and spare parts to solve a specific problem without a considerable communication effort or multiple journeys. The direct communication in the process of fault elimination is currently supported by mobile phones without access to mobile data. The paper-based, asynchronous information exchange between the employees who are involved in the fault process often leads to delays or redundant work. Furthermore, at the site of the disruption, there is often a lack of knowledge that other employees could deliver. In this case, the opportunities to directly communicate with other colleagues, e.g. to exchange pictures and documents, are missing. Due to the above-mentioned mobility and the numerous and varied challenges which the maintenance personnel faces, it is important that the workers are provided with the necessary information in a bundled, contextual and mobile way. This will be realized through the implementation of a mobile employee-centred knowledge management system that places the maintenance staff at the centre of attention. The solution can provide necessary information on maintenance in two ways: 1) Context-specific information on all systems can be called up by the employee through a mobile information system. 2) Access to colleagues' practical knowledge can be realized through a chat function with the possibility of exchanging images and videos. These two components support the maintenance employee on his way becoming a smart worker who has access to all necessary knowledge. Through this form of knowledge networking, the communication between colleagues can be increased, practical knowledge exchanged and the process of eliminating faults thereby designed in a more efficient way. Due to the accessibility of relevant information, unnecessary journeys can be avoided and the certainty in the employees' actions increased. --- Self-learning manufacturing workplaces Self-learning manufacturing workplaces support workers discovering and sharing knowledge during manufacturing, enhancing their competencies and worker satisfaction. However, the manufacturing knowledge and information is currently often scattered across a plethora of information silos without a centralized platform to connect, combine, analyse and organize the information according to the present needs of the shop-floor worker. Mastering the complexity of data and information requires sophisticated semantic and data mining technologies to discover the relationships between different sources , allowing intelligent search and exploration. With the implementation of advanced IT solutions, IoT technologies and sufficient knowledge management procedures, new possibilities for leveraging the manufacturing knowledge arise. One such concrete advance is the creation of a self-learning manufacturing workplace. Utilizing detailed and consistent data from manufacturing operations, enterprises are able to implement e.g. predictive maintenance and machine-assisted decision making for calibrations that allow reducing unplanned process disruptions and maintaining a smooth workflow . --- Case vignette 3 Hidria Technology Centre is a Slovenian company, which designs and manufactures a wide spectrum of partially or fully automated assembly lines, ranging from simple conveyer belt designs to fully automated lines. These complex and automated manufacturing lines incorporate lots of fault conditions. The loss in efficiency is due to either time-consuming setup and maintenance activities or lacking supplies. In such cases, the line comes to a halt or produces parts that have not been specified. The increase of operating time and the reduction of maintenance time of the assembly lines are therefore in the focus. The main worker needs in this case are derived from one of the customer's sites: Hidria Dieseltek plant, which produces glowplugs and pressure sensors. One of the challenges in this case is that operators at the shop floor cannot predict up-coming problems or breakdowns, but instead they work mainly on tasks related to reactive maintenance. Thus, supporting tools for shifting operators' workloads towards more predictive maintenance tasks are desired. Further, operators have to react quickly to resolve problems during manufacturing. The team of operators aim to directly fix small problems like the replacement of defective parts. With larger defaults or more complex problems, the internal maintenance team helps to bring the production up to speed again as quickly as possible. Thus, in this case it is aimed at better supporting the problem-solving activities of the line operators by a new integrated knowledge base of the production line fault analysis. In addition, the solution finding to a problem/breakdown is highly dependent on the experience of the worker, and this knowledge is important to be shared also to less experienced workers for enhancing peer-learning at workplaces. The information and knowledge of manufacturing processes, technologies and solutions is currently scattered across the factory without a centralised platform to store, share and analyse the information according to the present needs of the worker at the shop floor. A proposed self-learning approach will monitor a combination of human, process and machine parameters, and supports human-machine interaction. The solution offers: 1) a reactive , 2) predictive and 3) proactive decision support to shop floor workers. Reoccurrence of problems will be minimized by storing and sorting the problems systematically and combining them with user generated solutions into the machine bookthereby enabling self-learning workplaces. The solutions to a specific problem can also be rated by the workers. In addition, an employee can generate new solutions in forms of comments, videos or pictures. As a conclusion, self-learning manufacturing workplaces are able to increase the workers' autonomy and competence by providing them the knowledge required for carrying out specific tasks. --- In-situ mobile learning The increasingly needed flexibility of workers leads them to perform a wider range of tasks and share more responsibilities in manufacturing . This causes the pervasive need of overall on-the-job knowledge, available at the right time in the right place. Furthermore, knowledge is subject to continuous change as work practices evolve and requirements change. So far, declarative and often abstract generic knowledge is acquired "off-the-job", and it appears that this gap can be bridged by mobile learning in the right context . Workers need context-aware learning in real-life situations for continued education and training. Since in-situ learning is relatively new to manufacturing environments, the challenge includes finding the optimal way to utilize contextual and real-time machine-generated data, and to design and deliver the learning service so that it is effective, efficient and widely accepted. --- Case vignette 4 Schaeffler is a large German automotive supplier. The studied plant recently changed the former functional shop floor organization towards a new value stream design. Along with these organizational changes came changes to the role of the individual worker. Formally deeply specialized personnel now works in diversified areas requiring a variety of skills and knowledge. However, expert knowledge is still needed to solve tough problems. Currently there are three steps for competence development within the company: formal trainings for learning factual knowledge, mentoring for the transfer of expert knowledge and the learning directly on the shop floor within real working contexts right at the machines. In these settings, several problems surface: the knowledge transferred in formal trainings is not directly related to specific workplace requirements. Mentoring defines the learning content and its recipients only through specific circumstances. Learning directly on the machine is difficult as the complexity of the problem often requires an expert onsite which induces a resource problem. As a solution, a mobile learning approach enables the company to detach knowledge transfer from formal contexts and enables the learner to consume the knowledge when needed. Four core components allow individual, context specific learning and therefore facilitate a sustainable learning arrangement. 1) The learning system includes a sensory interface to the workplace, sensing the machine state as well as the operator. 2) An automatic evaluation of the incoming sensory data provides context-and situationsensitive problem-solving and learning content. In case of an unknown or currently unresolvable problem, expert assistance is necessary. 3) In such cases the expert would be included into the situation virtually first using audio/video tele cooperation. 4) With the usage of wearable Augmented Reality devices, such as data glasses, the learning context becomes completely immersed into the work place and the current work situation. As the worker has both hands free, true parallel working and learning is possible. With the introduction of appropriate learning systems, the transaction costs for identifying and consuming necessary information can be reduced. Also, the breakthroughs in mobile device technologies over the past years now allow the design of innovative learning arrangements whereby the boundaries between working and learning will disappear in the future. --- Discussion In the last years technical infrastructures have become more and more sophisticated, with large bandwidth networks, affordable software solutions and large storing capacities. Notwithstanding, as we have shown in this paper, a number of sociotechnical trends lead manufacturing companies to change the way they work. One of these changes includes designing people-centred workspaces that pay more attention to their employees and put them into the centre of their efforts . Creating an environment that contributes to more efficiency and increasing workplace satisfaction requires more than just implementing appropriate technical solutions. As technology matures, the focus of IT development can shift from a largely technical perspective to a more holistic sociotechnical perspective. Rather than focusing on centralized computer systems and treating the worker as an entity, not yet replaced by machines, the humanistic view focuses on human-human interactions where IT serve as tools to deliver support for specific tasks . When we acknowledge that the human worker keeps a preferred role in future manufacturing systems through the ever-rising demand in complexity, knowledge work and decision making, the humanistic perspective might be the only sustainable point of view to take. Taking this view, it also seams easier to design for basic human needs as autonomy, relatedness and competence as well as variety in the first place, as these can be formulated as core objectives enabling a humanistic design approach. Advances in technology and organizational themes as well as changes in the society are important input variables that stimulate the creative process of designing future work environments. Although called "digital challenges" they have one common theme: Keeping the worker "in the loop" with appropriate information. Moreover, the digital challenges aim to extend the natural sensory reach and information processing capabilities of an individual human worker , the field of interaction, e.g. vision, touch or hearing and further aim to strengthen knowledge absorption capabilities of individuals and knowledge distribution within communities . --- Conclusion We started this paper with an overview of emerging sociotechnical trends in manufacturing that coalesce to establish new ways of work in smart factories. Technological advancements in terms of IoT, Big Data and others drive organisational change in a manner not previously seen. Organisations must simultaneously incorporate and leverage the increasing shifts in technologies whilst maintaining a corporate culture that facilitates the most efficient and effective work force. Consequently, employees on the shop floor are expected to adjust their work practices to take into account the changing technologies and increasing complexity. Drawing on the detailed insights from six manufacturing companies that we gathered as part of a European project aiming to create attractive and intelligent work places in a factory of the future, we demonstrate how the manufacturing industry can leverage challenges they are experiencing. With this conceptualisation of the current situation as "digital challenges" for manufacturing companies, we contribute to a better theoretical understanding of the changing nature of IT on the Shop Floor. The four illustrated digital challenges span a wide range and are capable of supporting different facets of the knowledge practices in manufacturing companies. Taking into account different knowledge management facets helps to better understand and meet the needs and requirements as expressed by prospective users moving them in the focus of the implementation efforts. We have observed that workers expect new digital solutions to draw on what they already are familiar with from their private lives, e.g. designing, commenting, searching or networking functionalities in the style of well-known internet platforms. In this context, ICT seems to play more and more the role of a hygiene factor that supports the workers in an "invisible" way. This implies that the pure existence of a new solution is not in itself able to give increased satisfaction or lead to higher motivation, however dissatisfaction often results from its absence or inadequate design. This calls for more research that contributes to creating worker-centric factory solutions of the future. --- Introduction International airports are operating in a competitive environment. The requirements of low cost airlines and prevalence of cost-cutting measures in aviation is forcing airports to optimise their operations and reduce costs while still offering efficient and high quality airline and passenger services. Efficiency, quality and costs are conflicting criteria, presenting airports with a difficult optimisation problem. To improve efficiency and reduce costs, an airport can optimize the availability, i.e. schedule, of resources used for passenger and airplane services. However, airports are complex logistics systems, and the analysis and optimization of processes can be a tedious and time-consuming task. Airport processes have their own specifics since they can be interleaved and can therefore not be analysed separately. Since they are also subject to frequent changes, they cannot be modelled with an exact mathematical approach. A wide range of scheduling problems can be found in the airports and elsewhere in the airline industry. Scheduling problems in these environments do not have straightforward solutions. Their complexity varies according to the number of constraints addressed. Typical scheduling problems in the airport domain are: aircraft scheduling , ground crew scheduling , disruption management , aircraft landing sequence scheduling or personnel training scheduling . Particularly in the domain of personnel scheduling, the most popular type of scheduling problem is the aircraft crew scheduling, while the problem of ground crew has mainly been neglected. Nevertheless, if an airline wishes to produce a high quality service for their passengers, the ground crew is as important as the aircraft crew. The aim of our research was to produce a viable approach to solve ground crew scheduling problem at the airport. The contribution of our research is an IT artefact used to automate workforce scheduling and shift generation at a small international airport. The system produces floating shifts adjusted to variation of workforce requirements throughout the day in a fraction of the time needed for manual schedule preparation, and allows dynamic rescheduling in case of unforeseen events or disruptions. In order to achieve optimal workforce deployment, we needed to minimize the criteria of personnel costs and aircraft delay costs. Prevalent methodology for this purpose is discrete event simulation methodology, which is well suited for well-defined processes. The dynamics of airport operations however requires a certain level of adaptability, and the modelling of adaptable business process requires a flexible methodology, such as ABM. In this research, we addressed the problem of ground crew scheduling in a more efficient and innovative way. A similar solution for a small airport in need of an adaptable system This paper presents the development of a novel hybrid DES-ABM simulation model of regional airports ground crew operations, which will be used for schedule verification and optimization, specifically for the optimization of workforce quantity present in work groups covering specific types of tasks during the working day at the airport. The simulation model can be used to support the scheduling process in international airport of similar size. --- Literature review Since 19% of delays in air traffic are caused by airport operations , these operations cannot be neglected. Diverse approaches and simulation studies have been presented in the literature. As discussed in Bazargan , to efficiently cover the aircraft maintenance operations, aircraft were classified according to the stopover time. Based on the length of stopover, the entire maintenance program with exact numbers of technicians and daily shifts are proposed. Kleinman, Hill & Ilenda have used stochastic methods to calculate the delay costs in air traffic. Attempts were even made to influence the schedule of aircraft landings in order to balance the workload of ground staff. Boysen & Fliedner have tried to adapt the landing schedule in order to efficiently schedule the ground crew. In general, most of the research in the area of airport operations is focused on optimization of airport surface operations , in some cases divided into passenger-related tasks and aircraft-related tasks . Most of the solutions for ground crew scheduling are focused on only one work group . Herbers covers some aspects of ground staff planning with proposed procedures for requirement planning. Some of the solutions are limited to fixed shifts and static demands , while others use mathematical models not appropriate for complex systems . In general, the approaches to shift planning and crew assembly often use assumptions with strongly limited validity, or deal with simplified problems, thus limiting wider practical applicability. --- Methodology --- Design science research Design science research is a process of creating new knowledge through design of novel and innovative artefacts and analysis of their performance with reflection to enable improvement and understand the behaviour of aspects of Information Systems . According to Hevner, March, Park & Ram , design science research in IS addresses the so called "wicked" problem, characterized by unstable requirements and constraints, complex interaction between subcomponents, inherent flexibility to change design processes, dependence on human cognitive and social abilities. Considering all these characteristics, we concluded that the problem of ground crew scheduling matches the description given. Similar to other design science research our objective is to develop a technology-based solution to a relevant problem of personnel scheduling . Hevner introduces the three design science research cycles in a design research project: the relevance cycle, the rigor cycle and the design cycle. The research process model as presented in Vaishnavi & Kuechler consists of awareness of the problem, suggestion, development, evaluation and conclusion. These steps and cycles, together with the design science research checklist were used as a guideline to develop the artefact. Our main research question, that we have sought to answer, was:  how can the addition of ABM components to a DES airport ground crew model be used to improve the model in terms of adaptability and comprehensibility? --- Modelling and Simulation A part of the IT artefact development phase was the development of a simulation model for validation and optimization of heuristic scheduling algorithms. According to Borshchev , three different types of simulation methods can be applied to a given problem, based on the abstraction level of the model. System dynamics , discrete event simulation , or Agent based modelling can be used to map the real world problem to the model. Most of the simulation solutions for ground crew scheduling at the airport are based on DES method. Although this approach has historically had a significant success in scheduling process optimization, the addition of ABM based components can add more flexibility to a simulation model. Using ABM, we can model the movement of individual crewmembers who can make their own decisions about the performance of the tasks assigned to them according to a predefined set of rules. Most of real events are much easier to model using agents; therefore, the model is more realistic and flexible than the DES model. Nevertheless, both models enable monitoring of resource utilization and other important statistics. According to Siebers, Macal, Garnett, Buxton & Pidd , ABM is a better choice for dynamic process modelling since descriptive models of decision making processes can be included in the model, whereas DES models are more appropriate for the normative approach. Although ABM can be considerably more difficult to develop than SD and DES models, it allows the spatial or geospatial aspect to be included in the behaviour of an individual agent. --- Proposed research design In our research, we combined the design science research project with the simulation modelling approach. At the beginning of the research, the identification of opportunities and problems in the actual ground crew scheduling environment took place. Afterwards, the criteria were set to enable evaluation of the efficiency of the proposed artefact. Semi structured interviews were conducted with scheduling experts for each service group with the goal of identifying the tasks and scheduling criteria. In this paper, the second major iteration of the relevance cycle is presented. Outputs from the experimental and field-testing were used to improve the artefact. In the rigor cycle an exhaustive literature and related work study in the knowledge base was conducted to ensure the presented solution is not only a routine design based on the application of known design process and artefacts. Since the combination of DES and ABM has not been previously used to solve the ground crew scheduling problem, our contribution can be seen as an improvement. In the final phase, our artefact came in a form of an instantiation. In the following section, we present the development of our artefact. Following the steps proposed by Vaishnavi & Kuechler , the problem is defined and the model suggestions are given. The model is then developed and evaluated with proper conclusions given. In the phase of development, simulation modelling techniques were used to achieve the given goals. --- The problem definition The aim of this step is to generate problem awareness. The modelled airport is a regional hub located in the southeast Europe with over 30.000 flights and over 1.400.000 passengers per year. The airport has a single 3300 m long runway equipped with CAT III/B Instrument Landing System, a 23 m wide taxiway, and 25 independent parking positions. Airport's Aerodrome Reference Code is 4E. The terminal capacity is 500 passengers per hour, with 13 check-in counters and 2 baggage claim conveyors. The total area of the airport is 320 hectares. The airport was selected for the design research project due to similar size and organization to other regional airports and the established R&D relationship with the faculty. Ground crew scheduling problem at the considered airport and therefore also the operation of the simulation model is confined with the arrival and departure of the aircraft, i.e. tasks can only be performed on aircraft, present at the airport. The tasks are performed in a predefined time sequence according to several criteria . The execution times specified by the airport scheduling experts are deterministic, i.e. fixed, making the model deterministic as well. The execution times are determined from experience and represent the maximum expected task duration. Until the proposed IT artefact based solution was introduced, management at the airport used spreadsheets to manually generate schedules based on their knowledge and prior experiences. Ad-hoc solutions and schedule changes due to frequent disruptions of the aircraft timetable required a lot of effort and were too slow to allow a timely but optimal response. In addition, the workforce requirements in peak and off-peak times were not properly addressed and have been only partially solved with the employment of part time workers . Interviews with manual scheduling experts, e.g. crew managers, were conducted to extract the decision criteria and heuristic rules for scheduling. All the criteria identified were stored in the Flight Information System , enabling a smooth transition to the algorithm based scheduling. The identified scheduling criteria were as follows:  Type of stopover ,  Flight type ,  Aircraft type ,  Carrier ,  Destination. --- Ground crew operations The scheduling criteria presented in previous section were used to define tasks which have to be performed for the arriving and departing aircraft. The tasks of the ground crew are performed by crewmembers with appropriate skills. An individual crewmember can have one or more skill groups defined. Each skill group incorporates several different tasks therefore; crewmembers in this skill group are able to perform all the given tasks in their skill group. Some tasks are simple and can be performed by almost any skill group , while others require specific knowledge or other skills and can therefore be performed only by certain skill groups. With the workforce requirements calculated, shifts have to be defined. Several rules are given to define a start time and the duration of the shift: maximum and minimum duration, allowed start times, number of shifts an employee can be scheduled to during one workday. The availability and schedule of resources used also have to be defined. During one shift, each skill group performs only one type of a task. In general, tasks are divided into three main groups: a) aircraft supply, b) passenger service and c) technical service. Figures 1 and 2 describe the process of passenger service for the arrival and departure of a scheduled passenger flight . The passenger service department included six different operational tasks, which were mapped to skill groups with the same name, listed in Figure 1. Most of the skill groups required two persons to be assigned to the skill group. The two exceptions are the skill groups lost luggage referee at the arrival and Sales desk referee at the departure, where according to the requirements; two workers should be assigned to the task. The required number of individual workers in specific task group is As it can be seen from Figure 1 and 2, most of the tasks overlap and must be performed simultaneously. The tasks that require a strict sequence are the tasks of guidance and transfer in Figure 2, which cannot be stared before the check-in task is finished. The sales desk in this particular case is opened three hours prior to the departure of the aircraft and stays opened one hour after the departure. The arrival services are mostly completed long before the departure of an aircraft, however they affect the availability of ground crew groups and equipment. Our work in the relevance cycle has so far resulted in two versions of heuristic workforce requirement scheduling algorithms and a shift construction algorithm. The algorithm for generation of floating shifts and assignment of individuals to shifts is described in . The shifts are generated according to the generated workforce requirements and shift length demands. In order to automate the validation of algorithm-generated schedules and shorten the algorithm tuning-verification cycle we have developed a simulation model of airport operations used, which combines DES and ABM. The model development is described in the following chapters. --- Selection of modelling methodology Different simulation methodologies can be used in airport scheduling. While the most frequently used discrete event simulation has been used to simulate airport situations for decades, agent based modelling has only recently gained attention of the researches in the area of airport scheduling. According to Piera Eroles, Ramos & Fernandez Robayna , DES has proved to be efficient in the case of airport ground crew scheduling problem. ABM has been used in various cases, from optimization of the air transportation system , to airport capacity prediction . Due to efficient usage of DES and ABM combination in other personnel scheduling domains, we can expect that the combination of both methods can also add significant value in the case of airport ground crew scheduling. While the DES methodology is efficient to represent the flow of agents and diverse resources in the case of airport ground crew scheduling, ABM components allow us to model the activities and the communications between crew groups, their supervisors and aircraft management in detail. Using this methodology, we can lower the level of abstraction and enable a comprehensive insight on the ground crew problem, making it clear and presentation friendly when presenting it to the airport management. In addition to the advantages of the DES, where the resource utilization and time agent spends for individual activities can be addressed and optimized, the ABM allows the spatial insight on agents with detailed ground movements and estimation of time needed for the movements from one site to another. According to Clausen , ground crew tasks can be divided into passenger-related tasks and aircraft-related tasks, where the latter include maintenance, cargo, baggage, loading, cleaning, catering, towing and operations. While some personnel scheduling problems are not constrained with the availability of equipment, ground crew uses several different types of equipment within their tasks. In addition, skills of personnel have to be considered. Only few tasks performed by ground scheduling crew are plain, with no sequences and dependencies defined. Several overlapping tasks have been identified, while other tasks are interconnected. Due to these attributes, the ground crew scheduling problem gains complexity, number of constraints and variations of schedules. Mathematical models used to resolve the personnel scheduling problem in advanced scheduling tools could be used at the level of individual work group, but due to interconnectivity of tasks and resources in a case of ground crew, other techniques need to be employed . Since high level scheduling solutions can be too costly for small airports, many of them still use solutions which combine manual scheduling with basic spreadsheets or similar basic tools. --- Model development Since most general-purpose modelling tools are limited to a single methodology , the combination of DES and ABM methodologies within a system model generally required the utilization and integration of several general-purpose modelling tools or the development of proprietary code for the implementation of the ABM model. However, the AnyLogic tool allows the use of all three simulation methods, and from version 7 it also enables the usage of agents in DES and ABM model, allowing easier combinations of both methods to be implemented in one simulation model. Borshchev emphasizes the possibility of a DES servers and entities to be implemented as agents and use of agents to introduce inter-component messaging into the model. The latter approach is used in the presented case. DES and ABM models are linked via passing a message between aircraft and work group agents, where aircraft traffic model is presented as a DES model and ground crew work model is presented as ABM model. --- Model data The simulation model generates arrivals and departures of aircraft based on the flight schedule data transferred from the FIS into internal Anylogic database. Table 1 shows an example of parameters stored in the database, assembled from the FIS. DD1 defines the date of the flight, FLTNO_A and FLTNO_D describe the aircraft's arrival and departure code. The type of traffic is defined in column TRFTYP, ST_A and ST_D show the time of arrival or departure, and ROUTE_A and ROUTE_D designate the arrival or departure airport, and ACTYP defines the type of aircraft. --- Aircraft traffic simulation model The level of abstraction and autonomy has to be identified prior to the development of the simulation model. According to available data, we have identified the DES as the most appropriate method to model the aircraft traffic simulation model. For the purpose of personnel scheduling, only arrivals and departments of the flights are important in our simulation model. Further on, the model was upgraded to the ABM elements where the movement of an element on the surface is easier to implement. The arrivals and departures constitute of several discrete tasks that involve ground crew members. Delay elements are used to model a simple delay in the process. In our case, the delay elements include the state of arrival or departure services depending on the To make the model more transparent, a physical layout of the airport was used and paths of the aircrafts were added to the model. Due to focus on workgroup tasks and client specifications, taxiing and parking logistics were not modelled and are excluded from the model statistics. The aircraft traffic model consists of two submodels: the Arrivals submodel, and the Departures submodel. The separation was a logical sequence of the airport business rules and inability to track individual aircraft in FIS after the arrival. The arrivals submodel uses the arrival schedule from the FIS to generate the aircrafts. Aircraft taxi to the gates already waits on the apron for an assignment. The submodel of arrivals ends with an element of parking or exit point from the system. While the model of departures assumes the aircraft is present at the airport and available to start the tasks when needed. The departure tasks start times are based on the departure times given in the FIS schedule. The modelled departure times depend on the execution of tasks and should not be delayed when scheduling constraints are defined properly. In the Departures submodel an aircraft first has to move to the gates , where it is serviced , with the delay modelled with ServiceDept element. Afterwards, the aircraft moves to the runway . The queues were modelled to enable the simulation of an aircraft waiting until a taxiway or a gate or a parking area is available. The FIS data is gathered in the elements arrivals and depts., linked to a local database with arrival and departure schedule and service requirements for each flight. The service requirements are assigned to every aircraft at the moment of its entry in the model according to the ideal heuristic requirements, where the availability of workforce is not an issue. The service task parameters are contained in the messages generated by aircraft agents and sent to the relevant ground crew work group agents. Work group agents maintain an internal queue of tasks, which are executed according to the FIFO rule and specified service start time. Since AnyLogic models all DES entities as agents, the addition of the message feature to the DES aircraft traffic model was straightforward. --- Ground crew model Due to relatively rigid process modelling in DES methodology, which hinder the modelling of dynamic aspects of ground crew operation, the decision was made to incorporate ABM to allow dynamic ground crew process modelling, while preserving the required level of abstraction. ABM has allowed us to model the dynamic aspects of ground crew operations with better analogies with the actual processes, making the model more comprehensible. ABM allows us to model the entities and processes in a way that is closer to reality, i.e. the ground service work groups have the role of service stations, however they travel to the aircraft and not vice versa; the sequence of services depends on the availability of service work groups, and the place of an aircraft within a service work groups' internal queue; and perhaps most important, an aircraft can be serviced by several work groups simultaneously. Each work group agent has an internal state chart model of its task process, as shown in Figure 4. The initial state is Waiting, and here the agent waits for a service request message from an aircraft, with service requirements specifications . These requests are added to the internal queue and processed according to the FIFO rule. If an agent is in the Waiting the work group agent moves to the aircraft, and begins the requested service, and performs until specified end time. After the servicing is complete, the work group agent sends a message to the aircraft and proceeds to the next aircraft in its internal queue or returns to the waiting area. --- Evaluation The FIS serves as a database for the ground crew scheduling, providing an accurate source of data about arrivals and departures at the airport. The start, end and work requirements of tasks, which have to be performed at an aircraft, are determined by the attributes of the aircraft to be serviced. The availability of workers is determined by the workforce requirements schedule. The schedule is generated and optimized by the heuristic algorithm. By combining the schedule of optimized workforce numbers and ideal requirements of a flight, we can verify the effects of a generated workforce requirements schedule in practice and foresee the potential flight delay costs. Workforce requirements generated by the heuristic method described are used to vary the availability of workers during the simulation run. Workers are modelled as resources and arranged into work groups. Each work group performs only one type of task. A work group is then modelled as an agent. Flight delays in the simulation results are mainly caused by the occupancy of personnel with other tasks . Therefore, the discrepancy between ideal and modelled workforce requirements exists. Delays in the presented model are calculated for departures. Delays are measured by comparing the scheduled departure time as recorded in the FIS, and the departure time as recorded by the simulation model. The modelled delays are however exaggerated because the start times of tasks are not yet optimised and the start of a task is delayed unless all required workers are available. Further development of the model will include the execution of tasks with a reduced number of workers and longer execution time and the execution of tasks at earliest opportunity and should model flight delays more accurately. --- Conclusion Although managing disruptions of airport ground processes is a complex task , suitable personnel and equipment scheduling solutions are vital for efficient operation of an airport as a system. International airports face a constant challenge to coordinate all the departments, efficiently perform all operations needed and provide an excellent service to the passengers. Airport ground crew scheduling system does not have a straightforward or mathematical solution which could easily be implemented. The complexity of the problem and the necessity to solve it is not only an attribute of large airports. In our research, no appropriate solution or algorithm to solve the ground crew scheduling problem in a small international airport was found. Therefore a research was conducted to develop and evaluate an artefact to solve the ground crew scheduling problem in a small international airport. Two versions of heuristics were developed in this artefact to implement an efficient scheduling algorithm. The algorithm for generation of floating shifts and assignment of individuals to shifts is described in previous publication . Further, on, a simulation model was built to verify the proposed algorithm and enable further optimization of the processes. The simulation model presented used two simulation methodologies, DES and ABM. This combination provides us with an efficient and realistic model, which is used to simulate the results of the developed scheduling algorithm. According to the design science research checklist, all questions were answered during the presented phases. We were able to answer our main research question "How can the addition of ABM components to a DES airport ground crew model be used to improve the model in terms of adaptability and comprehensibility?": using a suitable tool , we can combine the ABM and DES methodologies within a single model. Since ABM modelling requires more effort and produces a more complex model, it should be limited to the modelling of system elements, that are by nature dynamic and cannot be suitable modelled using DES methodology. Such an approach improves model comprehensibility --- Introduction The Information Technology innovation continuum is creating new and innovative solutions for different industries. Particularly, the healthcare industry is witnessing a new era of innovation as new emerging technologies such as Mobile Health , is being adopted to assist in fighting and managing diseases at both global and individual levels to deliver better health management platforms . The technology is delivering innovative solutions through mobile devices that facilitate a number of initiatives that include but not limited to health call centres, treatment compliance, appointment reminders, mobile telemedicine, and patient monitoring . These innovative solutions can empower people and patients to be proactive in managing their health through self-management , as self-management can prove critical in reducing healthcare costs while delivering optimal healthcare services . The empowerment of patients to self-manage is through the delivery of information that allow them to understand their medical conditions and it is through the devices, as the devices act as a getaway for accessing healthcare services through the exchange of data and information. The exchange of data is through secure data transfer mechanisms between patients and healthcare professionals. The data contains valuable information and it is primary driver for the treatment of diseases and empower of individuals to self-manage their health. The technologies are new to the health domain and require a well-established research method to understand how they operate, specifically the IT solution that is delivering healthcare services to people and patients. Although today's modern data analytics platforms are extracting new insights from such technologies to create business value and answer some of the business questions , yet from a scientific perspective it can be challenging. A way to approach the analysis of secondary data from new, emerging technologies can be accomplished through Hermeneutics. Hermeneutics has long been applied in studies where the texts/artefacts are distant from its original authors. The application of Hermeneutics in new emerging technologies is to gain a window through interpretation, into the phenomena lived by the patients interacting with healthcare professionals for the management of diseases while using any of the technologies. The essence of interpretation in such cases, is to understand how the technology is operating, the quality of the primary driver of the technology being data, and the integrity of the information based on the data. The purpose of this study is to understand what data accuracy is, discover the sources of data inaccuracy in health data and the impact inaccurate data has on the Integrity of the Information while determining the most appropriate Machine Learning Algorithm that can detect inaccurate data. The accuracy of the data is understood through Interpretation and it is done through Hermeneutics and Thematic Analysis. --- Literature Review This section of the paper introduces Hermeneutics with a background around Hermeneutics in the Information Systems domain and an example from a current research in progress where Hermeneutics is used for analysing secondary data based on an mHealth solution for diabetes. --- Hermeneutics The term Hermeneutics is a modified transliteration of the Greek verb "hermeneuein", a term that means to express aloud, to explain or interpret and to translate as explained by Kennedy Schmidt and it is a technique derived from the Interpretive Paradigm . It is also known as the process for making a meaning . Hermeneutics was thought to have originated as the study of the interpretation of the Bible and has been applied in the interpretation of previous work of authors who studied the Bible . Historically, in ancient Greek, it was believed that Hermes, the mythological messenger god was equipped with language and understanding that enabled him to interpret the messages from the gods and deliver them to the mortals . This mythological example illustrates the process for interpreting messages and communicating them with people. The four key terms of language, understanding, interpretation and communication, from the example, are key to Hermeneutics. In research, the researcher must be equipped with the language of the subject understudy, understand the messages , has a method to interpret the texts to effectively communicate the results from the study to the audiences. Although equipped with language and understanding, the interpretation can become an issue. When interpretation becomes an issue, it is an issue of unintelligibility and it occurs when a person does not understand an artefact that he or she came across, and it is known as rebelling against successive smooth understanding . In research, unintelligibility can occur when the researcher accesses secondary artefacts that are distant from their original authors and has no access to the language that would enable an understanding of the artefacts. The objective of using Hermeneutics in research is to interpret texts that would allow an understanding of phenomena, peoples' actions and behaviour to address questions that fall under the interpretive paradigm. IS research can be classified as interpretive if it is assumed that our knowledge of reality is gained only through social constructions such as language, consciousness, shared meanings, documents, tools, and other artefacts . Interpreting texts through Hermeneutics is not an easy task and requires an in-depth understanding of Hermeneutics and the interpretation process. The problem with interpretation is that it is a two-fold problem. The first problem is avoiding projecting one's own viewpoint on the text and blur the interpretation of the texts as one's preconceived ideas may influence the interpretation. The second problem is the need to successfully communicate to a variety of audiences . However, ones' own perceptions and experiences in a subjective, cultural, and historical, as referred to as the lifeworld, can be included in the interpretation of the texts . In the IS domain, Hermeneutics has had a dominant role in the interpretation of Information Technology /IS related studies and the results are quite interesting as they provide a fresh view of the IT systems. The widely-known paper of Klein & Myers set out principles in conducting Hermeneutics in IS, Robert, Wendy and Lucas for Hermeneutics and meaning making in IS, Boydens and van Hooland using Hermeneutics in quality of empirical databases and Acker toward a Hermeneutics of data, are a few examples where Hermeneutics is key ingredient to the study. They all seek to make meaning of the study and providing guidance in finding a meaning to the study . 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES Z. Zekiria Sako, S. Adibi & N. Wickramasinghe Understanding New Emerging Technologies Through Hermeneutics. An Example from mHealth captured and exchanged to achieve a desired state of well-being. Yet, while the data has served its purpose, it contains valuable information that can help in different scenarios. From the technological side of the solution, it sheds light on how the technology functions, how the underlying data quality help achieve the desired health outcome and what exactly does the data contain that enables this transaction. While mHealth being a new technology where prototype solutions have been developed and commercially available, studies in the actual quality of data is not looked at thoroughly as the technology is still in its early stages. The following section will elaborate on how Hermeneutics is applied to study the emerging technology of mHealth with specific focus on Data Quality. --- Hermeneutics in a Case Study Research of mHealth The preceding section has defined Hermeneutics and its application in IS studies. This section illustrates with an example, the process of applying Hermeneutics in the study of a new emerging technology used for health and disease management. The illustrated example in this paper is from a current research study. The objective of conducting the study is to evaluate data accuracy and information integrity in mHealth solutions, identify how data inaccuracy can occur, test different Machine Learning Algorithms, and evaluate the accuracy of the algorithms in detecting inaccurate data. The selected case study is mHealth for diabetes with the case being patients' data. The selection of the case study was based on the research question, in which it posed as following: 'How can Machine Learning be applied in mHealth Solutions to Address Data Accuracy and Information Integrity?' The research question aligns with the study objectives as it is broken into sections. Starting by which type of Machine Learning, how it can be applied in mHealth, what defines Data Accuracy and Information Integrity. The selection of the case study was based on the research question, as it is one that conforms to Yin's criteria for selecting case study, as the form of question is 'How', requires no control of behavioural events and focuses on contemporary events. With using case study, the data is secondary, de-identified data of people with diabetes and there was no control of behaviour when the data was produced and it presented a contemporary event. The two sources of data present both structured and unstructured cases of data. The first dataset is of patients with diabetes who have glucose measured through both a device and recorded on paper. The second dataset is extracted from hospital admission records where diabetes was either a factor in admission or was recorded during the admission. These two datasets assist in addressing the research question by using the interpretive paradigm as it allows for the reconstruction of understanding of the social world . Both The Hermeneutics method used in this study is adapted from Kim using the 3 layers consisting of Text, Translation and Interpretation layer . The 3 layers separate the text into layers where each has its own purpose and that allow for the data to be analysed using Hermeneutics. The text layer is all the text/data in the study and it is the first layer of Hermeneutics. The text starts with the actual datasets. The datasets are reviewed to form an understanding of what the datasets contain, the format they're in and all the properties of the data including data dictionaries. Once reviewed, the data is then aligned with codes from the Literature review that cover Data Quality , Information Integrity and Machine Learning. To simulate the process of disease management for patients with diabetes, the data is mapped against the Omaha Client Care Plan that segments the data into Problem Classification Scheme, Intervention Scheme and Problem Rating Scale for Outcomes. The simulation helps in understanding the role of each instance of data in disease management. After the data is examined and mapped against Omaha System, the data is then divided into training and testing data, and that is to test different Machine Learning Algorithms. These parts form the text layer as they are mainly text and are yet to bring a meaning that would assist in addressing the research question. The text is translated using Thematic analysis. The second layer is the Translation Layer where Thematic Analysis is applied to generate themes that can extract meaning from the text. The Thematic analysis is adapted from Braun and Clarke . Boyatzis explains Thematic Analysis as a process for encoding qualitative information. The text in this study is secondary data, one where there's no access to the patients or the medical professionals and they are open for research. The state of the data does not have a meaning and is therefore stateless data. To understand what the text is, Thematic analysis look for patterns in information that at minimum describe and organize possible observations while at maximum interpret aspect of the phenomenon . The interpretation of the data occurs at the third layer of Kim's model. The Interpretation Layer is interpreting the themes to form an understanding about the phenomenon. The interpretation method is adapted from Taylor, Francis, and Hegney , and it starts with turning to the nature of the lived experiences, that is accessing people who would tell about the phenomenon understudy. The lived experience comes from investigating the experience as it has been lived rather than conceptualizing it by accessing data or people who have an experience related to the research question, that is real and has occurred. Combining the three layers with the Thematic and Hermeneutics analysis is to divide the sections with clear and concise objectives that would allow for Hermeneutics technique --- Findings The purpose of Hermeneutics is to derive understanding from the text under study as explained by Phyl & Carol . The adoption of Hermeneutics in this research has moved the study from analysing electronic data to understanding the meaning of accuracy and how it occurs in a technology based solution such as mHealth. The data was first measured and evaluated against a set of criteria derived from the definitions of Data Quality that were based on World Health Organization data quality standards and definitions of Information Integrity from the literature review. To date, the study has found that accuracy occurs at multiple levels with each instance of accuracy intended for specific use . The first level of accuracy occurs at the validation layer where data is simply validated as either accurate or inaccurate based on the input. The model of this validation measures the input against type of data and whether they fit the range. This form of validation ensure that the data passes its basic test of meeting the minimum level of accuracy before it is passed on to the next level of validation. This made the Classification Algorithm an appropriate Machine Learning Algorithm that could be applied to filter through the data and test the validity of the data before it is processed. Modern electronic forms apply a simple 'rule based validation' where data is tested at the time it is entered and no learning is taken into consideration when the next set of data is entered. Machine Learning powerful capability The second level of data accuracy examines the properties of the data. Although the data might have passed its first instance of validation, yet the properties might still not be appropriate for its intended purpose such as timely medical reminders, currency and completeness of readings of a patient or symptoms. Achieving this level of accuracy can be accomplished through the Prediction Algorithm that can predict future datasets based on the existing and historical data. This allows for the current values to be cross-examined against what the algorithm have predicted and raise an alert if major discrepancies in the data is detected through the algorithm. Figure 3: Levels of data accuracy in a digital health context The third level of accuracy occurs at the behavioural level where the human behaviour, based on the data, is analysed to understand the meaningfulness or the usefulness of the data and its intended use. This includes decision based behaviour or health outcomes that can detect if a treatment is being adhered to as planned or if there's a gap in the intervention program for the specific disease. Behavioural accuracy is reflected through the decisions that are being made which can be mapped through Decision Trees or Neural Network algorithms that can simulate a person's decision making process that would 528 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES Z. Zekiria Sako, S. Adibi & N. Wickramasinghe Understanding New Emerging Technologies Through Hermeneutics. An Example from mHealth allow the medical professional to understand the thinking behind patients' decisions. This satisfies the collection of the data in an mHealth scenario and in the absence of a medical professional when the data is entered by the patients. While still at an early stage of analysis, these findings are a result of Hermeneutics where the technique has shifted the focus from simply cross-examining the data against certain definitions, to understanding the meaning of accuracy in an mHealth context. --- Limitations A key drawback for this study is the datasets. The data was not obtained from an actual mHealth solution as the mHealth solutions are still in early development stages. However, the use of the algorithms against data like the ones produced by mHealth solution, particularly one designed for chronic diseases such as diabetes, make the results more appealing and relevant to technologies. The results do not only consider the accuracy of the data but highlight some key areas of where data accuracy might be influenced by behaviour of patients and users of mHealth technologies. --- Discussion and Conclusion Emerging technologies can hold valuable data that require beyond traditional analytics platforms for the analysis of data from a scientific perspective. Hermeneutics has had a role in previous IS studies and has provide to provide a fresh perspective of IS systems. The new technologies are changing the way patients seek advice from medical professionals, manage their disease, and delivering healthcare services through the platform. This change can have many undiscovered, unexplored phenomenon attached to the technologies that are yet to be studied. The role of Hermeneutics in this study is to assist in the interpretation of the data through a well-designed process that extracts meaningful information from the themes generated by the data. The study is of qualitative nature and not quantitative as it seeks to understand the data, and particularly application of Machine Learning in mHealth. To understand what the data means, and how Machine Learning can be applied, Thematic analysis and Hermeneutics provide rich and detailed coded information with techniques to extract information that provide insights about data and how information is produced. The data is of quantitative nature and the study focuses on understanding a single instance of mhealth designed to assist in a case of chronic disease. It does not aim to statistically evaluate the instances of accurate or inaccurate datasets in a mHealth transaction but instead its objective is understanding in detail the cause of inaccurate data. IS studies have become richer in information, and Hermeneutics has found its place in IS domain as an interpretive technique that seek and explore a deep, powerful meaning of a phenomena. The mHealth technology is capturing peoples' actions and health --- Introduction Mobile games have become a booming branch of gaming industry over the past years. This is mainly due to new smartphones with better displays, faster internet connections, much higher computing power than before and easy and powerful app delivery platforms with monetization abilities. Globally, in 2016, mobile game industry brings in revenue of $36.9 billion yearly, and is expected to grow to $47.4 billion by 2018 . As the number of games increases, so does the competition to get visibility and share of the players' interests, and on the other hand to keep the players to play the game they have started once. Keeping players engaged in the mobile game is referred to as player retention. In particularly, in the free-to-play mobile games, player retention is important to the game's business model. Free-to-play games are freely available to the player, but they typically contain mechanisms that include in-app purchasing in the game, where virtual currency can be bought with real money. Such purchases offered to players are usually virtual items that bring benefits, modifications or personalizations to the game world. Other ways games monetize on their players are for instance selling advertisements; players watch ads in order to proceed or gain advances in the game. Getting the player to spend money one way or the other is vital to the free-to-play games, and in order to retain the players, new ways to get them to returning to the game are needed. Games developed or published by the same gaming house are looking for ways, beyond traditional advertising, to get the player to stay inside their gaming business. At the same time, game industry aims to grow beyond the boundaries of the industry to other fields of entertainment. At the same time, cryptocurrencies, virtual currencies, loyalty programs, etc. are reaching new areas of digital business. The traditional view of economy is being splintered and new ways of payment and currencies are coming every year. Loyalty programs are frontrunners in a trend where ability to spend points is extending rapidly and the loyalty points are more and more becoming a currency in traditional sense. Cryptocurrencies like Bitcoin approach this from another direction where the currency is well controlled by rules, but the places where to spend the cryptocurrency are still limited. Spending is often done by first exchanging the cryptocurrency to more traditional vehicle of credit like euros or dollars and then are spent especially in cases where anonymity of the transaction is not crucial. Cheah point out that Bitcoin and other cryptocurrencies often behave as an asset and not like a currency as it is subject to lots of speculative actions and the value is changing rapidly. This upheaval in economy and influx of new currencies are affecting the gaming industry as well where games are usually considered as islands where in-game economy is affected only by game mechanics and influx of resources created by players buying virtual items and purchasing power with traditional currencies. In this research, we investigate the possibilities to design a common market for crossgame purchases that can be used in several free-to-play mobile games. The motivation TRANSFORMING OUR LIVES E. Siira, E. Annanperä, O. Simola, S. Heinonen, J. Yli-Kantola & J. Järvinen: Designing and Implementing Common Market for Cross-Game Purchases between Mobile Games 533 for this is to have stronger gamer cross-pollination between games and to cross-promote and advertise other games in better targeted ways for players. Using the common market platform the players could also buy virtual items to other games, creating more interest for them to stay within the boundaries of the common market. The designed common market would connect the games on game mechanic level through the cross-game purchasing and subsequently creating an exchange rate between game currencies. Instead of using in-game currencies only in one game economy, the target is to expand this thinking to link game economies loosely together. To clarify the scope of the research there is no single currency in games and the designed platform does not allow virtual currencies to be exchanged directly. It means that for instance, 'gems' in Game X cannot be exchanged to 'gold' in Game Z. However, what the platform would allow to do is to spend 'gems' in Game X to purchase virtual items in Game Z. The publisher of Game Z in this situation dictates the selection what is available to be bought. The common market approach does not have to stop only to games, but there will be also a possibility to add non-game items to the common market. For example, coupons to web stores etc. could be bought in-game as well. Our research question are 1) how the cross-game purchasing between mobile games could be designed and implemented and 2) what kind of limitations can be identified regarding game economies, game design and implementation? In our research, we study singleplayer games that are free to play mobile games, but our findings may extend further. In Chapter 2 we introduce the related research on how virtual currencies and game economies have been studied. In Chapter 3 the methodology for the research is delineated and the use case for the single market cross-game purchasing is described in more detail. In Chapter 4 the implementation of the system is described and in Chapter 5 the findings based on the design concept are discussed. Finally, in Chapter 6 we offer conclusion of the study. --- Related Research No comparable system for cross-game purchasing between mobile games has been found in our investigation of the pre-existing systems. Therefore, we have studied game economy and virtual currencies, as both are important part of the creation of the common market. Lehdonvirta Yamaguchi notes that traditional economics do not consider in-game currencies as real, but in his research the virtual currencies in games do have enough same characteristics than government-issued currencies, so in-game currencies may be considered as real currencies at least in some games. For example, no one is going to buy a Monopoly hotel with a real money, but may buy a virtual item in a MMORPG. Thus, an exchange rate is formed between virtual game currency and traditional money . Sasson has studied free-to-play mobile games and noted how the most successful ones have two currencies used in the same game. He names these currency concepts as a hard currency, which is more closely related to the real money the players are using to the game and soft currency, which is more virtual currency. Soft currency is what players earn in the game by playing it and hard currency needs to be bought with real money or the player needs to earn it somehow which is not directly linked to game flow. If only one currency is used, it limits the user's spending abilities as monetisation of the game requires the single currency to be hard to obtain and players may not be able to continue without spending real money into the game. Balancing game economy is important as source of currencies need to be in line with the ability to spend the currency. Both soft and hard currency needs to be of value to the user. Sasson shows that if the currencies are a bit scarce when comparing to the players' want to continue, the player is more likely to buy some aid to the game with real money. Cryptocurrencies have entered the mainstream of currencies after the launch of Bitcoin in 2009. They have no physical manifestation, but work only in digital environment. From the cryptocurrencies, especially the Bitcoin has gathered trust around it to make it a currency, which can be used in many places. It excels in use cases of anonymous digital transactions where traditional currencies are heavily tracked and have slow and cumbersome processes to transfer money from person A to person B. Bitcoin and other cryptocurrencies -altcoins -are based on the Blockchain technology which is a public distributed ledger with a mechanism for arriving to consensus between all nodes. Cryptocurrencies are very flexible to design and configure. Due to the flexibility, there has been several implementations for different use cases but very few has gathered enough popularity around it to make it as a workable currency. Sharp and Sharp define loyalty programs as structured marketing efforts which reward and therefore encourage loyalty behaviour. One trend in loyalty programs is to expand the industries participating in the loyalty program. This is especially true in airline industry. This adds value for the customer and make program more attractive to join. Loyalty programs are inherently virtual currencies with restricted abilities to use them. Buchinger et al. studied four different cases of virtual currencies in loyalty programs and defined how they are different in terms of what they are achieving. Generating and spending currencies are two pillars of the currency behaviour. For example, Bitcoins are created by "mining" them which means performing difficult 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES E. Siira, E. Annanperä, O. Simola, S. Heinonen, J. Yli-Kantola & J. Järvinen: Designing and Implementing Common Market for Cross-Game Purchases between Mobile Games 535 mathematical puzzles to ensure the transaction coherence in the system. In loyalty schemes, the company creates from thin air the currency, which is promised some value in the loyalty scheme network. The value might change and perhaps the currency has an expiration date. Cryptocurrencies are indestructible in a sense that the "coin" does not leave the system. In transaction, the ownership is changed. In loyalty schemes, the value of the credit is nullified after the purchase, as it has no intrinsic value. Bitcoin and other cryptocurrencies have brought an interesting discussion about the fundamentals of currencies themselves. Mallard et al. argue that the Bitcoin has a distributed currency model without any issuing organisation. There is only an original ruleset, which has been updated along the evolution of the Bitcoin. The trust is based on the rules and if everything is running normally there is no party, which can change the rules on their own. Traditional currencies like euros and US dollars have a centralized organisation which is responsible of the issuing the currency. Due to history, the ability to issue currency is detached from the daily politicians and central banks have been created. Central banks are deemed the trustworthy organisations, which should behave predictably and not be intimidated by politics and quick gains. --- Research Method and Context The aim of this study was to design an implementable solution for cross-game purchasing that would make possible to use earned currency in one game to buy virtual items in another game. The possibilities for earning currency was either to play certain games, or import exercise data from wearable sensors . No matter how the currency was earned, it could be used to make purchases in other games belonging to the system. The additional goal of the currency was that it could be used to gain discounts for purchases made in selected web stores or brick-and-mortar stores. This aim was deemed specific to the needs of the project companies and it was anticipated that the solution for the virtual currency system would have to be tailor-made to the companies in the project. The existing virtual currency systems reviewed above were not seen fitting to the purpose. Therefore, we adopted case study research methodology . Case studies are commonly used in software engineering field to study practical phenomenon in a real life context . Here, research needs were first to understand the requirements of the multi-game virtual currency system, and then design a working system to purchase virtual items between games and interaction with real life contexts. In later stage, the system will be tested in the real life context. Due to the complex nature of the studied system, this research presents first the vision of the planned cross-game purchasing. The real world complexity determines the limitations of the study, where we first present the created vision of the cross-game purchasing before considering the real-life use. In our study, we also consider the challenges of building such system in real-life, and therefore the trade-offs that can be anticipated at this stage of the study. The selected case under investigation in hailing form a research project, where companies identified the need for the multi-game currency with options to collect and use it also in real world. The case study comprises of two gaming companies. Fingersoft has made and produced mobile games since 2012, and has several games out at the moment. These games are free-to-play games, and the company has approximately 100 million Monthly Active Users globally. Fitness Village is a new gaming company, focused on developing their first game that targets gamification of exercise, including exercise related virtual game play, and exercise data imported from wearable exercise sensors. In the centre of interest of the participating companies is to design and implement an entire service platform, which imports real world exercises from sensors, and exports the data to selected mobile games as virtual currency, through conversion rate. This currency could be used to buy virtual items from other games. This exercise data part of the research is not studied in this paper, only what happens after the exercise has been changed to an in-game currency. On the other hand, most free-to-play game also have their own internal point or currency systems as the enabler for in app purchases. This currency works in isolation within the game and is often too specific to the game logic in question, to be transferred to other games as such. Meaning, that some type of point or currency conversion is needed for cross-game purchases, as well. The overall vision is to have a so-called common market for cross-game purchasing that combines all the elements together and allows expansion by adding new games and web stores or retailers to the system. Ultimately, this would enable the creation of a functional and powerful digital ecosystem on the top of the technical solution. For the companies in the digital ecosystem, this will give excellent opportunities to monetize their business in various ways. Starting from the existing means in mobile games industry , to also giving an unique selling points for businesses in other domains to market their services and products for the mobile gamers and exercise oriented customers. It is envisioned that this way the players will be more engaged to stay in the gaming ecosystem, since they receive tangible rewards from the time and effort they use on playing and thus improving the game retention. A vision of the common marketplace with virtual currency earning use possibilities is shown in Figure 1. It is understood that the realization of the full service platform and virtual system would require a type of banking solution that would keep track of transactions in a secure way. Yet the companies aim not to build too heavy and complicated system that would not allow scalability and would be too complex to maintain. Next, the first working design to be build is constructed and the next steps and foreseen challenges elaborated on. --- Results The implemented case presented in this paper is only the first part of the research to design and implement the above presented vision as a whole. Although there are two selected games in this case that are part of the interconnected system, the design is still done by taking account that it could serve several games in future and the games can be different kinds of free-to-play mobile games. One selected game is an established game and the other is a game is to be released during year 2017. Both games do have their own currency systems, but there 538 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES E. Siira, E. Annanperä, O. Simola, S. Heinonen, J. Yli-Kantola & J. Järvinen: Designing and Implementing Common Market for Cross-Game Purchases between Mobile Games is a possibility to buy in-game products from another game by using a currency from that game. In this case the possibility to buy virtual items is unidirectional where products in Game A can be bought from Game B. Implementation does not yet cover the buying the products to other direction because in the more established game the user interface part is not yet able to provide this. Both games have dual-currency model similar to what Sasson described. The currency used to buy virtual products from another game is a "hard currency" which is more difficult to obtain than the "soft currency" making the virtual product more valuable and rare. The publisher of the Game A uses the marketplace platform to put products available for purchase and prices them in the currency, which is used in the Game A. The marketplace has an exchange rate table, which tells how much Game B currency is worth in Game A currency. This exchange rate is determined when new games or entities are entered to the system. Concurrently, other limitations are determined like from which games can the virtual item be bought, how many of the items can be bought in certain amount of time or how much of currency can be used for this. For example, no more than two times per day can the purchases be made per player. The single virtual item can have its limitations as well. For example, one item may be bought five times or just one time. In the Figure 2 is described the high-level architecture of the common market. In the centre is the combination of marketplace and bank. Marketplace is responsible for keeping count of virtual items that are available for purchase and which of the items has been sold to which player. Sellers can add, edit or remove the items or check how their items have been sold. The marketplace will offer the list of purchasable virtual items for the games. Bank is responsible for the transactions between the games and keeps track what assets are located where and how they are being paid. In addition, the bank has abilities to roll back the transactions if the customer is unhappy and demands his resources back or some technical error has occurred and the purchase did not succeed perfectly. The bank accounts do not store value. They only exist to track the transferred resources and receipt is created from it. The value is afterwards nullified. The reason for this is that the philosophical approach of the bank is not to mimic a traditional bank but provide platform for assets to be exchanged between the games. Both games are benefitting from the exchange from other means than keeping the in-game resources of the other game, thus the in-game resource may be nullified after use. The similarity to a real bank extends to the reliability and robustness of the system. The system needs to be able to detect in vast majority of cases if the transaction was complete and the virtual product bought was actually delivered. In some cases the delivery may be delayed due to problems in networks or servers but in our case the limit for delivery is 24 hours and if the product has not been delivered during that time, it is reimbursed for the customer. When designing the bank entity there was a design choice to be made on how to implement the bank entity and the transactions. In this implementation, the bank is controlled by one actor , but one choice could have been to create more independent platform by utilising blockchain technology which would offer higher scalability and possibly more trustworthiness for other game publishers to join the common market as well. In the end, the closed and controlled system was decided to be the implementation as that is more in line with the business plan. Marketplace platform is for game publisher and third party web stores to control what they have available to be sold in games. For example Game A publisher can put "pink running shoes" for sale and value it at in Game A currency, for example in 'gems'. The item may have some in-game abilities or be just aesthetical upgrade. Visibilities to different demographics and games has been under discussion, but not yet implemented. In Figure 3 In games, there is a shopping module, which is common for all games that are implementing the common market for cross-game purchasing. When player navigates to the in-game shop, the game asks for a web page, which is created and populated in the marketplace but the visual style can be set by Cascading Style Sheet in the game. A default page without modifications can be used as well, but how games are showing the list and how it is navigated to can be up to the game in question. When an item has been bought for a game from another game, it is checked and deployed when game is launched and then user is informed that the item has arrived and it references the other game as a source. The product is deployed only once, after that it is the responsibility of the game to track. Identity management in the common market is important as it should not encourage sharing resources between players but it should encourage one player to play multiple of games. How the identity is shared between games and how they are linked through the bank entity has multiple possible solutions and it has to be taken account how the chosen solution affects the user experience and privacy. The platform does not need to know who the user is but it needs to know that the player playing Game A and Game B is the same person. The reason for this is that even if it would be valuable to know who the player really is, it cannot be a requirement. It is identity provider's responsibility to know who the player really is. Apple and Google are dominating the mobile game distribution by their AppStore and Google Play -markets. Both are taking their cut from the purchases made in games by 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES E. Siira, E. Annanperä, O. Simola, S. Heinonen, J. Yli-Kantola & J. Järvinen: Designing and Implementing Common Market for Cross-Game Purchases between Mobile Games 541 real traditional money. The companies are closely guarding their share of the profits. The cross-game purchasing needs to be created in a way that it conforms to the rules set of Apple and Google. Especially this needs to be in line in cases where the games and identities are ranging from one ecosystem to another. In cross-game purchasing there is no money moving between games and the virtual items available must be exclusive for the common market. --- Discussion According to our research, the common market for cross-game purchasing is a novel solution for higher player retention and advertisement of other games. For players the advertisement part is more subtle than state-of-the art advertisement videos we see now in mobile games. For them the cross-game purchasing is offering value as they are getting something out of it. Implementation is now only between two games and it is likely that the concept would need more games to make impact and be more meaningful for the players. However, as a proof-of-concept it shows that the concept can be implemented and it has some merit. For future research is left the analysis of the impact and how the players are reacting to this concept. Some potential issues have been identified during the design of the common market. First of all the cross-game purchase might affect the game balance in unhealthy way if the items bought from another game are disrupting the player path. This balancing of purchasable items is noted also in Oh and Ruy's research for Korean games. For example buying too powerful item too early in the game might derail the whole game and take out the feel of accomplishment from the player. Aesthetic-only items without game effect are easier to add from the game design point of view, but they might leave a subset of players uninterested about the purchase. Implementing the cross-game purchase to a game needs to be part of the game design and designers should weigh what they want from it and how it might affect the game. Another point is the effect of the cross-game purchase to the game where the buying was initiated. When a player is pondering whether he or she should use resources in Game A to purchase something to Game B, the player faces a dilemma where he or she needs to think, if the resources used would help more in Game A than in Game B. Making the player to compare the games and the willingness of progressing in either of the games might lead to feel-bad moments, which should be avoided. Hard-earned currency in Game A is valuable for the player and squandering it to a wrong item might hurt the player desire to play the game further. This dilemma of putting the games against each other in terms of resource usage needs to be researched in future more thoroughly to see how it should be solved in more elegant and user friendly way. Another point for discussion and further research is the data ownership in games. The currency earned by a player in one game and used in another can be tricky from data authorization point of view in cases where Games A and B are developed by companies 542 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES E. Siira, E. Annanperä, O. Simola, S. Heinonen, J. Yli-Kantola & J. Järvinen: Designing and Implementing Common Market for Cross-Game Purchases between Mobile Games that are not in a formal business relationship. Since the currency in game A is owned by the player the marketplace platform is required to request access to the currency from the player him or herself. Only after player has granted access to his or her Game A currency, it can be utilized in game B by the same player via the marketplace platform. It is anticipated that this dilemma can be solved using a standard OAUTH mechanism, but this will be in the scope for further implementations of the system. --- Conclusions In this research, we studied a novel concept of how common market for cross-game purchasing could be designed and implemented. State-of-the-art mobile games have dual currency system, which provide us the possibility to build on top of that. Any kind of connection between different mobile games is not in mainstream today. In our research, the connection is based on ability to buy virtual items from other games by using in-game currency. The motivation for this to game publishers is to increase player retention in games and use the system to advertise other games. Incentive for the player to take part of this instead of watching periodic advertisement videos he or she gets value by installing new games and playing more. The implementation connects two games and makes it possible to do cross-game purchases to one direction. In future, the connection should be bidirectional and possibly new games are added. The cross-game purchasing needs a marketplace entity and a bank entity. The marketplace entity will manage the items available in games and provide UI for sellers and buyers to interact with the system. The bank entity's responsibility is to monitor how resources are moving between games and additionally it has the right and the ability to roll back faulty purchases. There are open questions on how the players like the functionality to buy items from other games or even discount coupons from web stores. In Chapter 5 we brought up some open issues and future research directions, which we have encountered during this work. --- Introduction Our Western lifestyle plays a large role in the onset and progression of DM2: type 2 Diabetes Mellitus . Several lifestyle interventions improved outcomes in type 2 diabetes patients on insulin therapy, most notably: lower blood sugar and lower medication needs . However, these are often costly, highly controlled interventions. Moreover, the longer term sustainability of behaviour changes is limited. The question is: can we do this on a more 'Do-It-Yourself' and e-Supported basis? This would have two advantages. First, since behaviour improvements are implemented within patients' lives, it improves the chances of sustained health behaviour . Second, it is cheaper. Since 2010 the Health Coach Program has been used to improve lifestyle and metabolic outcomes patients), via eSupport, improved self-management and rapidly improved health behaviours . To promote rapid health results, a HINTc intervention of 12 weeks was developed for this patient population, plus lightweight eSupport and mostly self-management in weeks 13 -50. The intervention combines improving health literacy with active behaviour change support. This paper discusses follow up results and design lessons after 50 weeks, as part of a larger biomedical study. An important goal of the biomedical pilot study was to promote long term healthy lifestyle adoption in senior DM2 patients. Even in wellfacilitated settings, a majority of interventions lack sustained health effects after 6 months . Moreover, in eHealth initiatives, there is always the risk of falling victim to the 'eHealth law of attrition' : meaning that 90% of users are often already lost within a few usage instances. In this study population, there were additional challenges due to their low average ICTand health literacy. This exploratory design analysis formulates design lessons based on 50 weeks follow up. We focus on feasibility and attractiveness of the HINTc e-supported lifestyle intervention, plus on formulating design lessons. Given the desire to develop cost-effective long term eHealth support relationships with these types of patient groups, a focus is on long term e-relationship support lessons. Medical results will be discussed in another paper. As part of the design analysis we address: efficacy of the service mix deployed in eSupported lifestyle interventions. We combine the 50-week results from our measurements with a design analysis based on an evaluation framework of requirements for ICT-enabled healthy lifestyle interventions. --- Theory The eSupported lifestyle program combines coach sessions with electronic dashboarding and self-management. Hybrid programs have been indicated to be attractive for some time . Finding the right mix between offline and online contacts is an ongoing design research challenge . In summary, a hybrid or multi-channel service mix is recommended , combining electronic and face-to-face interactions. Still, there are many design challenges, given the multitude of options. For a more extensive discussion, see Simons . Key functionalities to increase health motivations and behaviours in this eSupported lifestyle program are ):  Daily logging of insulin and blood sugar levels: for close progress monitoring of the health coaches, physicians and participants themselves. ---  Close cooperation with physicians, for rapid medication adjustments initially , plus medical monitoring/coaching in the following weeks. ---  A personal online health dashboard with graphs of progress towards adherence targets on the various health behaviours;  Automated feedback on lifestyle aspects where positive scores have been achieved ;  coaching by a health coach, generating online reports on progress towards adherence targets in the personal dashboard;  The coaching sessions can be flexibly planned, based on convenience and participant preference: during in-clinic visits or phone based from home;  Options to ask questions to the coach: via messaging within the dashboard or via email;  Online schedule indicating upcoming events: group sessions, individual coach sessions , physical measurements, surveys; It was theorized and tested elsewhere that the design challenge of persuasive technology ) for health is not just located in the ICT design, but also in the design of the overall service scape, including health effects and coach relationship . It should generate positive, mutually reinforcing service experiences across communication channels and activate long term health motivation andbehaviours, in order to deliver long term health results. This is reflected in the following design evaluation framework for health improvement ICT solutions , see Figure 1. --- Methods, Study Design, Intervention This is a non-randomized, one arm, pilot intervention study of 12 weeks Sept-Nov 2015, plus effect measurement at 50 weeks follow up; approved by the Leiden University Medical Center Ethics Board. The biomedical results will be addressed in a separate paper. The study participants were 11 insulin-dependent Diabetes Mellitus Type-2 patients. Patients were volunteers and provided written informed consent prior to the study. They were recruited by LUMC from the larger Leiden area in the Netherlands. They were 8 men and 3 women, ages 39-70 years, with widely varying levels of education and of comorbidity. Challenges regarding design of individual training schedules were posed by all the physical constraints in this group: 7 had significant movement restraints , 5 had neuropathy, and 7 had cardiovascular disease. On average they had been a Type 2 Diabetes patient for more than 10 years and they were motivated for trying lifestyle improvements. -Health literacy -Health behaviors -Health outcomes -Quality of life and well-being --- ICT value adding: -Quality of motivators, triggers, experiences -Simplicity: familiar interfaces, ease of use -Embedded in and enhancing coach relation --- Coaching performance: -Promoting health actions -Supporting self-efficacy -Activating intrinsic motivation Health effectiveness: Venkatesh 2000) were used at weeks 4 and 12 to assess intervention feasibility and attractiveness. In this study, TAM is only used qualitatively, as a tool for user evaluation, not to make technology acceptance calculations or predictions. For this purpose, its eight dependent variables provided us with ample user evaluation insights, compared to the four dependent variables of UTAUT . Furthermore, user satisfaction evaluations were user plus the RAND SF-8 Health Related Quality of Life survey . Besides, a standardised sit/stand test is used to assess strength As an umbrella overarching the personalized coaching per participant, the general lifestyle advice follows the guidelines of the Harvard Epidemiology and Nutrition Group for nutrition and physical activity, with specific modifications for diabetics. The guidelines are to increase intake of vegetables and low sugar fruits , to choose whole grains instead of refined grains, to limit sugar and other high glycaemic load foods, to have one daily serving of nuts and/or legumes, to limit intake of red meat and processed meat, to limit intake of trans and animal fats, and to have no more than 2 or 1 alcoholic beverages/day. Physical exercise guidelines are: at least 60 min/day moderate intensity activity and at least 3x30 min/week intensive activity, which was also supported with group training sessions at the LUMC location three times per week . Stress management guidelines are: relaxation exercises for >10 min/day. --- Results We discuss several types of results. We address answers to the first research question: What are the 50-weeks-follow-up feasibility and attractiveness of the HINTc e-supported lifestyle coaching program, including the positive feedback provided by the improvements in quality of life and physiology ? And to answer the second research question , we analyse efficacy of the service mix deployed in eSupported lifestyle interventions, following the framework of Figure 1 from Theory. First, regarding attractiveness and feasibility, satisfaction and recommendation were not only high after 4 weeks and 12 weeks , but also after 50 weeks: 9,6 and 9,5 out of 10 respectively. This is in contrast with usual patterns where the initial enthusiasm of the first weeks wanes after 3 months. Regarding 'Health Related Quality of Life' as measured with the RAND SF-8 an interesting pattern emerged over the 50-week period, as illustrated in Figure 2. ). Experienced Mental Health seems to peak at week 4. This coincides with the large positive surprise that the patients experience in the first 4 weeks: fast improvements in fitness, quality of life, medication, self-efficacy, health literacy, fun and group support, plus a hope for a better future. In the following period between weeks 4 and 12 there is a continued building up of strength and fitness, losing weight, building patterns/habits and gaining longer term self-efficacy. After 12 weeks, group training stops and patients are much more on their own. Patterns diverge, with some continuing to improve further, whereas others decline. Second, some of the physiological improvements of the first 12 weeks were sustained at 50 weeks : average 8% weight loss , roughly 20% lower fasting glucose and 65% lower insulin medication . Clearly, the results in the first 12 weeks helped motivate patients and provided positive feedback that they were on the right track. The TAM user evaluation at weeks 12 and 50 shows three main patterns. First, these patients were relatively positive at 12 weeks and 50 weeks about all TAM constructs. Aspects that scored particularly high were: usefulness and the support offered by the multidisciplinary health team. Second, some patients were not ICT-literate and clearly had trouble with eTools like the Health Quiz of food/exercise logging. See Simons for a more extensive discussion on their differences in ICT adoption, which became apparent in the first 12 weeks. Third, we observed that over the course of roughly weeks 12 to 50, attention of participants shifted, also visible in their TAM scores. After initial attention on tools and start up challenges, attention later shifted to health literacy, plus sustaining healthy food and exercise patterns. In hindsight , participants started appreciating the intensive start menu and start workshop more, the exercise support continued to be highly valued, plus sustaining healthy patterns in weeks 12 to 50 was top of mind: see the high scores for these elements in TAM constructs 8 and 9 . On the level of social support and maintaining a healthy lifestyle focus, the group spontaneously organized monthly meetings together, outside of the hospital setting. The final set of study results regard research question 2, analyses to enable lessons for long term eHealth relationship building. As a basis, we use an efficacy evaluation of the hybrid eSupport mix deployed, at 50 weeks follow up. ICT-illiterate.) -Health Quiz and food logging being complex for some. Fit with coach processes: ++ eTools: integral part of coach processes and effectiveness. +/-Much motivation support still from the coaches, less from tools. Table 2 contains several lessons. First, looking at Health Effectiveness, we see mixed results. Biologically, there are large, positive effects for all 11 participants, even at 50 weeks. Even despite the large health, education and psychology differences within the group. However, regarding health literacy and self-management competence, the large differences that were observed at the start, became increasingly pronounced during the 50 weeks follow up. This relates to the second column: Coaching Performance. Promoting health actions and intrinsic motivation worked relatively well. But with those patients that have less self-management skills, it is hard to maintain coaching effectiveness in the 12 to 50 weeks period. Third, regarding ICT Value Adding, it was good that there was a variety of eTools, given the large differences in the patient group regarding ICT literacy and preferences. The simple mail based tool for sugar/insulin monitoring was highly valued by all. And for the multi-disciplinary coach team the eTools were very useful for progress monitoring and pro-active coaching. See section 5.1, design lessons and implications for practice, for further reflection and improvement ideas on eTools. --- Design Lessons and Implications for Practice Several lessons can be learned from this study in relation to the intensive healthy lifestyle approach and in relation to the suitability of hybrid eHealth support. Plus, we will address options for improvement. Third, opinions varied regarding the suitability of most of the eTools provided . In the short term of the first few weeks, virtually all tools were used by virtually all patients. After several weeks, usage patterns diverged. Two factors appeared important in determining adoption and use of these tools: availability of time, plus ICT literacy , because he liked this form of explicit monitoring. Two other participants continued using the Health Quiz throughout the 50 weeks . Several others continued reading week tips and other health content during the 50 weeks follow up. Clearly, user preferences for the various eSupport tools differed. Fourth, the exception to this varied eTool adoption pattern was the simple, daily mail reminder Tool for sugar/insulin inputs, also described in Simons . This tool was used daily again by the patient group in weeks 48 -50 to assemble user pattern data. . We think that the combination of high simplicity with high usefulness was the key to its high adoption. The tool was an important basis for the coaching from the multidisciplinary support team. In conclusion: eSupport was not only useful for the patients, but especially for the care givers, providing them with much more extensive views on the users. Fifth, besides eTool support, the group effects and the multidisciplinary support team were highly valued. The patient group arranged several social events together during the weeks 12 -50 period and every 6 weeks there was a 1-hour gathering at the hospital again with the support team. The hospital team meeting was valued socially, but also for health literacy and practical support. These group effects fostered high levels of interpersonal commitment, which is important for long term relationships and something that is more challenging to achieve with eTools. Finally, if we look at future improvement suggestions, several innovation opportunities emerge. First, in the coaches' professional opinion, strength and endurance improvements could have been significantly larger with more effective training. Thus, in the next diabetes lifestyle project better training equipment will be used. Second, the training progress feedback loop will be used more, with a mail based self-management monitoring tool similar to our sugar/insulin tool. So that even after completion of the group training period together, the coaches can continue monitoring and guiding patients better on their exercise progress. Third, regarding building long term e-relationships, it would not be correct to label the phase of 12 to 50 weeks as 'maintenance'. Patients are continuously renewing their patterns, experiences and lessons. All in relation to health literacy and health competence. Better Support is needed for these renewed learning processes. Within long term support relationships, there clearly are patient needs for continued learning, growth and discovery. Hence, more functionality will have to be developed to stimulate online, effective search-, interaction-and question/answer behaviours of patients. Both in relation to health literacy questions as well as in relation to health routines, goals and competencies. --- Implications for Theory As stated before for several of the patients in this group, their learning styles were highly non-cognitive. An understanding of health cause and effect seemed to have less impact than experiencing cause and effect. Daily feedback loops between behaviours and sugar values were useful in this regard. For this group, learning is not very much about explicit awareness, intentions, goals, behaviour and maintenance plans, as postulated in models like HAPA and i-change . This appears to resemble mental models of impulse purchasing in marketing: first acting, then experiencing and opinion forming . Next, the term 'maintenance' seems a miss-qualifier for the longer term phase of health behaviours observed here . What we observed was closer to processes of: iterative circles, continuous renewal, reinterpretation and discovery. These processes of course include pitfalls for those who have fragile health literacy. The latter group easily tend to fall prey to misbeliefs and misadvise from others around them . Thus, finding effective and efficient formats for continued coaching is very valuable for long term support as part of long term e-relationships with patients. Finally, four of the eleven participants simply disliked using ICT for either reading, checking mail or inputting data. Still, the overallattractiveness of the intervention was rated high, because of a) the large benefits and b) the extensive practitioner-and group support. Thus, the eHealth law of attrition TRANSFORMING OUR LIVES was bypassed, partly thanks to benefits in the context of the ICT. Plus, some cognitive dissonance may have worked to our advantage: if something is a challenge, then people may appreciate their own achievements and results more. This appears to have helped increase motivation for ICT-adoption as well as the extensive lifestyle improvements. Especially in the longer run, their increased self-appreciation and self-efficacy appears to have helped. --- Conclusion Summarizing from this study, we can conclude a few key points. This preliminary analysis has several limitations. First, this is only a pilot study with 11 participants. Second, the 50-week data analyses are not complete yet; more biometric and behaviour data analyses still need to be done. Third, regarding external validity, these study results may only apply to motivated individuals, who volunteer for lifestyle training. Fourth, it can be argued that TAM is not the only suitable instrument for evaluating technology adoption. For example, UTAUT is also viable. However, UTAUT was developed and validated in organisation contexts, where functional aspects of information systems adoption are relatively important. In consumer contexts, items regarding 'Attitude towards Use' are relevant as well , and those are part of TAM. Still, on the positive side our results prove relatively robust across the 11 participants, even though they are diverse in background . And this pilot provided an opportunity for design analysis regarding the hybrid service mix deployed and opportunities for long term e-relationship building. --- Introduction In this paper, we study a mobile application for supporting anaphylaxis patients. The app was proposed by a team from the department for allergology at the University Medical Center Utrecht , a large academic teaching hospital in the Netherlands. The app will be developed in collaboration with physicians and patient groups supporting anaphylaxis patients. Anaphylaxis is a type of immediate allergic reaction categorized as type 1 hypersensitivity , further defined as "... an acute, systemic reaction caused by mast cell-mediator release [which is] potentially life threatening" . Anaphylaxis may be caused by a number of triggers, also called anaphylaxis agents, such as foods, medication, insect bites or contact with latex . Anaphylactic reactions cause symptoms which may be life-threatening and require an emergency response . The proposed app is intended to support anaphylaxis patients and their caregivers by providing step-by-step assistance in the case of an anaphylactic reaction. Exposure to allergens that cause anaphylactic reactions may occur via ingestion, inhalation, injection or direct contact . Anaphylaxis manifests itself through symptoms such as flushing and itchiness of the skin, difficulty breathing, swelling of the mouth or eyes or an abnormal heart rate . An anaphylactic reaction is usually treated by administering a dose of epinephrine intramuscularly into the thigh using an auto-injector, after which the patient should be admitted to a hospital for further treatment and observation . The exact prevalence of anaphylaxis is difficult to establish, as people may develop sensitivities to allergens at different points in life, or may be unaware of sensitivities to allergens they have not yet been exposed to. Different studies indicate a 0.5% to 2% prevalence in the world's population , a 1.21% to 15.04% prevalence and a 1.6% to 7.7% prevalence in the US population . Data provided in the app's proposal indicates the prevalence of diagnosed food allergy in The Netherlands at 1-2% in adults and 1-3% in children, with 90% carrying emergency medication. For insect bites, the prevalence is 1-3% among the Dutch population. The morbidity and mortality of anaphylaxis are believed to be underestimated due to limited data on its incidence . Evidence points towards an increase in anaphylaxis prevalence , which may be attributed to changes in diet and medicine use . Besides the physical symptoms, anaphylaxis is shown to have a societal impact by leading to a decreased quality of life and limiting of social activities for children , as well as proneness to school absence and decreased participation in the labour market for adolescents . Several patient groups aim to support anaphylaxis patients by providing information on the internet. Examples are the National Foundation of Food Allergy (in This study aims to determine the critical success factors for the adoption of the proposed anaphylaxis app. To achieve this, we conducted a mixed method approach, containing a literature review, a domain expert interview, and a patient survey. The research question addressed in this paper is defined as follows: RQ: "What are critical success factors for user acceptance of an app to support patients suffering from severe allergic reactions?" The remainder of this paper is organized as follows. First, we provide information with regards to the anaphylaxis app that will be developed by UMCU, analyze similar apps and identify success factors for the adoption of such apps in literature in the background and related work section. This is followed by the research method in section three. In section four, the results of the mixed method approach are presented. Lastly, in section five, we reflect on the results and applied research methods in the discussion, conclude upon our study, and propose possible directions for future research. --- Background and related work In this section, the anaphylaxis app will be presented and compared to existing applications. Additionally, the literature with regards to Critical Success Factors is explored and discussed upon. --- The anaphylaxis app The anaphylaxis app studied in this paper was proposed by a team at the department of allergy at the UMCU. The proposal entails a request for funding, which will be needed to start the development of the app for Android and iOS. Currently, no actual app or prototype exists. Development of the app will be performed by the Medical Apps Cocreation Center, also known as MAC³. MAC³ provides centralized services for the development, testing, and research of medical apps. The author of the proposal was interviewed in order to gather background information on the app. The team at UMCU collaborates with the National Foundation for Food Allergy, the Dutch Anaphylaxis Network and the domain group for eczema, which is a part of the Dutch Society of Dermatology and Venereology. These contacts are used to establish requirements for the app and to foster its acceptance in the medical community. The purpose of the app is to provide a better alternative compared to the leaflets that are usually given to patients by physicians, alongside anaphylaxis medication. Such leaflets provide information on emergency procedures but are not always carried by the patient. The app should improve the availability of this information by residing on the 564 30 The information provided will be personalized depending on the type of reaction , the severity of the reaction and the medication the patient uses. Information on reactions caused by other, less common triggers is not explicitly included, but may be covered by the available information on treating reactions caused by food or insect bites. Besides providing assistance in the case of an allergic reaction, the app will provide background information on allergic reactions to be consulted at any time. While similar apps already exist in countries such as the UK and Australia, an app geared towards the Dutch market that is endorsed by patient organizations and contains validated medical information and instructions is not yet available. Country-specific apps are also needed because of differences in medications available per country. --- Related apps/games The current offering of anaphylaxis-related apps was studied in order to explore similarities and differences compared to the proposed app. Apps were collected by performing the search query: 'Anaphylaxis' and 'Allergy' on the Google Play Store and the Apple App Store, including related apps for any identified app that resulted from our search. The apps and their characteristics, features, and ratings are compared in Table 1. 30 --- Target market Most apps provide similar functionalities, some being more extensive than others. Such functionalities may include general information about anaphylaxis and allergies, instructions for emergency procedures and the use of auto-injectors, medication expiration reminders and interactive maps for finding nearby medical facilities. All apps found are aimed at anaphylaxis patients or caregivers. As evidenced by the available data on the number of installations, there does not appear to be one particularly popular anaphylaxis app. Install base data is only available on the Google Play Store and not on the Apple App Store. In terms of ratings and evaluations of the app, no information was found originating from independent sources. Some of the compared apps are free to use, while others require a small fee. Apps such as the one made by Coventry University are intended for a more general audience of anaphylaxis patients, while the Jext app developed by ALK-Abelló is to be used specifically by patients using Jext-branded auto-injectors. The former app is also the only app found that is endorsed by a local patient organization, namely the UK Anaphylaxis Campaign. --- Critical success factors The current body of knowledge on critical success factors in the context of this study consists of research on both allergy management in general and anaphylaxis management. The available literature, which consisted of nine relevant papers, is presented in three main categories; preventative information, providing assistance, and mobile healthcare. --- Preventative information Mobile technology is used in several ways to support patients suffering from allergies or anaphylaxis. One of these ways is providing preventative information by enabling patients to scan food items or medications through the use of barcode or NFC technology. A general study into smartphones and barcode scanning by Eichler & Luke describes a prototype developed by Deutsche Telekom Laboratories called 'Allergy Warner', which provides an alert message when scanning barcodes of food products in the supermarket. The app will contain a personalized allergy profile which looks for matching ingredients in the scanned products. Eicher & Luke argue that modern smartphones can quickly and easily scan and recognize multiple types of barcodes, making them suitable for this purpose. A similar study by Gassner, Vollmer, Prehn, Fiedler, & Ssmoller concludes that reliable information about food products is difficult to obtain because of different interests of stakeholders in the food value chain. A mobile app that provides such information would fill a gap in the market. Ottenhof provides a proof of concept for a device-based solution that allows customers in supermarkets to scan product packages for allergy information. However, Ottenhof concludes that a lack of information provided by manufacturers proves to be an obstacle. Stierman found that scanning product packages make it easier for patients to retrieve allergen information. Patients were more likely to buy products they were unfamiliar with thanks to a scanning solution. A study by Möller, Diewald, Roalter, & Kranz evaluated an application called MobiMed, which allows users to scan medicines in different ways, either through text search, barcode scanning, visual search or Near Field Communication . This app could then be used to warn patients for medicines that would put them at risk of allergic reactions. Extracting information through NFC was found to be the fastest and most preferable method because the user does not need to search for and scan a barcode. However, the integration of NFC technology in smartphones and packaging is not yet widespread. Ottenhof found that NFC technology provides the best matching capabilities because of its high storage capacity and the possibility to tag products on an item level rather than by product type. While this information is easily extracted by modern smartphones, the implementation of RFID/NFC on packaging is A backend that provides additional information would be needed. Problems could occur when the composition of one type of product with the same barcode changes over time. When looking at the current literature on providing preventative allergy information to patients, we can conclude that there are still some improvements that can be made to cater to patients. In terms of retrieving the information, a universal, fast and cost-effective method needs to be found to provide contextual information about physical products on a smartphone. Additionally, manufacturers of medicines and food products need to provide allergen information that is easily accessible for consumers. --- Providing assistance A series of works by Hernandez et al. describes a personal mobile health device and the associated app used to alert emergency services automatically when an auto-injector is administered to a patient . The solution, called PervaLaxis, uses an accelerometer connected to an auto-injector to detect its usage, which is signaled wirelessly to a smartphone using Bluetooth. Emergency services can be contacted automatically through the phone. In a later study, PervaLaxis was further validated by involving patients . A pilot study was performed, after which the patient sample was increased over time. Use case diagrams were used to test usability and determine important success factors for the solution. These success factors are reported to be: adrenaline injectors expiry alerts, an emergency support button, and adrenaline injection sensing. Limitations identified for this solution were the reliability of the mobile phone transmission and the accuracy of the injection sensor. Other works suggest that instructions for providing assistance to patients should be segmented towards different user groups. This may be done based on the age of the patient and the number of years of experience they have with their illness. Further personalization of the app could be of use here . --- Mobile healthcare Obiodu studied the top 500 medical apps in the Android market and concluded that the majority of apps are designed for healthcare professionals, while it is plausible that most end-users are patients rather than healthcare professionals. One significant problem is that it is often unknown whether medical apps intended for patients provide information that is validated by medical professionals . In practice, it is found that medical professionals are often not involved in the development process of medical apps, or that there is a lack of validated sources available in the app . Beyond this, there are no obvious signs to distinguish medically validated apps from apps that have not been validated, such as an international mark of quality. When an app does not offer a diagnosis, treatment or cure, it cannot be classed as a medical device and will not be subject to the thorough scrutiny of such medical devices. However, the general information or advice provided by such a medical app may still cause harm to the patient. An increasing number of apps published and the lack of an international safeguard for monitoring medical apps undermines patient safety . --- Critical Success Factors The literature contains 9 relevant contributions with regards to CSFs applicable in our study. The CSFs of the app can be defined as follows: 1. The information is context-aware through scanning of physical objects; 2. The information is easy to retrieve; 3. The information improves the user's understanding of the subject. When looking at the ability of the app to provide assistance in the event of an allergic reaction and general characteristics of mobile healthcare, the following success factors were identified: 4. The app should provide advice that is validated by medical professionals; 5. The app should provide advice that is tailored to the user's medicines; 6. The app should provide advice that is tailored to the characteristics of the user, such as age or level of experience. In Table 2, the critical success factors are linked to the papers from the literature review. In the header row, the six CSFs identified earlier are transformed into keywords. ✓ ✓ --- Research method --- Interview In this section, we describe the setup, deployment and the evaluation of the interview with a domain expert who is a representative and the founder of the Dutch Anaphylaxis Network, known as NAN in Dutch. The NAN informs and provides support to patients while also keeping in touch with stakeholders, such as food producers, on current issues surrounding allergies. As the interview is semi-structured of nature, the following topics are discussed: 1. The current necessity of an app; 2. Existing knowledge on mobile applications concerning allergy or anaphylactic patients; 3. Critical success factors concerning user acceptance of an app; 4. Additional comments or advice. With regards to CSFs, the domain expert was first invited to provide his own insight into possible CSFs and then asked to evaluate the CSFs identified during the literature review. This was done in order not to create a possible bias by first presenting our findings derived from literature. --- Survey Following the literature review and domain expert interview, a survey was conducted among a sample of patients in order to gather further data on CSFs. As described in section one, the proposed app is aimed at the Dutch market, with a prevalence of diagnosed food allergy at 1-2% in adults and 1-3% in children, with 90% carrying emergency medication. For insect bites, the prevalence is 1-3% among the Dutch population, as indicated by the proposal of the app. All patients in The Netherlands who may be at risk for anaphylactic shock are included in the scope of the survey. The survey was designed to first establish basic information about the patient, such as their age and the number of years of experience they have with anaphylaxis. The patient was also asked if they are familiar with smartphones, including the total years of use and a self-assessed competency rating. A number of possible functionalities for the app were presented to the participants, for which they could indicate their desire for such a functionality in an anaphylaxis app on a Likert scale. These functionalities were adopted and where needed adapted from results of the literature review and domain expert interview. An open-ended question provided respondents the possibility to provide additional functionalities. The ratings given for the functionalities were then used to determine the most valuable functionalities and therefore CSFs for the adoption of the app. Another set of questions adopted from the System Usability Scale and Technology Acceptance Model determined which usability factors were deemed most important by patients, such as the clarity of the presented information and the interactivity of the app. Finally, the respondents were asked to rate the likeliness of using an anaphylaxis app on a scale of 1 to 10. --- Results In this section, the results of the interview and the patient survey are presented. --- Domain expert interview The domain expert was positive about the concept of an anaphylaxis app. There is a necessity for such a solution in the domain. With regard to replacing paper leaflets, an app may be useful, but only until the patient has familiarized himself with the information. After this, the app will need additional functionalities to engage and support the patient, such as training users to identify and avoid possible anaphylactic triggers. The domain expert identified the following CSFs for the adoption of an anaphylaxis app: 1. The app should focus on including avoidance strategies for potential anaphylactic triggers. 2. The app should include gamification, such as a quiz used to test knowledge on allergens and emergency procedures, both for the patient, caregivers as well as friends or family. 3. The app should focus on different user groups since the information needs of each group can differ. Adolescents may more easily ignore food warnings, for example, making it necessary to address them in a different way. 4. The app should be interactive, rather than just providing static content. 5. The app should be free. Earlier research by the domain expert concluded that paid-for apps lead to low adoption rates among patients. --- Patient Survey Contacting patients directly through UMCU proved to be difficult and time-consuming due to the clearance procedures involved. The decision was therefore made to deploy the survey on the website of the NAN, with help of the domain expert interviewed earlier. The NAN receives about 500 unique visitors per day on their website. The survey was featured on the front page for a period of 6 days between from the 21st up until the 26th of June 2014. Patients could voluntarily and anonymously fill out the survey on the website. 276 respondents filled out the survey. The sample consists out of 16.7% male and 79.7% female respondents , with an average age of 40.96 years . Our respondents have an average of 9.81 years of experience with anaphylaxis . 93.1% of respondents indicate owning a smartphone. With a 46% percent share, Android is the most used mobile operating system, closely followed by iOS at 39.1%. The remaining share goes to other or unknown operating systems and Blackberry . The average number of years respondents have been using a smartphone is 3.95 years . They rate their own competency in the use of mobile phones with a 7.75 on a scale of 1 to 10. The desirability of an app to support anaphylaxis patients is rated with an average of 8.34 on a scale of 1 to 10 , while the probability of the respondents using such an app is rated with an 8.75 . The three most compelling app features indicated by respondents are the clarity of the information, the medical validation of the information, and the availability of information regarding emergency procedures, with average scores of 6.68, 6.62 and 6.48 on a scale of 1 to 7, respectively. The aspect rated as least important are the presence of an element of play , a quiz to test allergy knowledge and interactivity of the app, with average scores of 2. The open-ended question in the survey asking patients for other desirable functionalities yielded many results. The functionalities provided were categorized by similarity. 22 respondents indicated the desire for a functionality that helps to translate allergens and emergency instructions into another language for when the patient is traveling. 12 respondents wish for an alarm button that can quickly contact emergency services and other predefined contacts, and another 12 respondents wish for a newsfeed containing updates on medication or treatments. --- Conclusion & Discussion The research questions addressed in this paper was defined as follows: What are the critical success factors for user acceptance of an app to support patients suffering from allergies? To answer this research question, we looked at the results of the analysis of the In literature, a number of studies were found concerning food allergies in general and specific measures for anaphylaxis. The studies on food allergies noted the possibility to scan food packaging as a critical success factor for user adoption in their specific context. The studies related specifically to anaphylaxis, such as the study concerned with automatically detecting the activation of an adrenaline injector through a Bluetooth accelerometer, were more concerned with the validity of the information provided by the accompanying app. However, the UMCU has already indicated that such features will not be included in the app at this time. The factors that remain, based on literature, are that the app should contain medically validated information, be easy to use and improve the user's understanding of the subject, and be sensitive to different user groups. The proposed app will adhere to these factors. The domain expert indicated a number of new factors mainly relating to the interactivity of the app and having certain quiz or gamification elements that test the knowledge and train them to avoid allergens. Another factor mentioned was that the app should be free in order to boost user adoption. Patients surveyed agreed with this, although they did not appear to be very enthusiastic about gamification or quizzes. Once more, new factors were introduced after the patient survey such as the ability to translate allergens and procedure information, providing a newsfeed and a list of predefined emergency contacts. The factors for the medical validation of the information and the availability of clear emergency procedures were also rated highly by patients. Another interesting factor is that patients indicated they would overall be very likely to use such an app. In relation to all of the features that were established in this study, the proposed anaphylaxis app appears to be relatively limited in features. However, the team at UMCU has indicated that the proposed app should be simple and straightforward to use. The decision was made not to include features such as scanning of objects or giving extensive information on types of food that contain allergens. Even though the app does not contain all functionalities that may be seen as critical success factors, the app may still prove to be of added value for patients when its functionalities are fit for purpose. The simplicity of the app will also contribute to the clarity of the information, which was another success factor. An effectiveness study will have to reveal the actual usefulness of the app for patients. The current body of knowledge related specifically to anaphylaxis apps is rather small and anaphylaxis apps are a relative niche market within the medical app landscape, making it difficult to predict the effects the CSFs will have on actual user adoption. Beyond this, we recommend the team at UMCU looks into the possible expansion of the app in the future, in order to include some of the features that were indicated as being desirable for patients. Moreover, our results also indicate a selection of lower rated functionalities for the app. For example, the functionality that was rated lowest in our results was the functionality regarding the addition of a challenging game element . While we believe that our survey was conducted with the aim to gather data from the appropriate user groups, some of the respondents indicated to be a parent or caregiver. This is usually the case with younger children. There could be a difference between how a sample drawn solely from patient groups versus our sample rate the functionalities presented in a survey. Currently, our results are difficult to link with the existing body of knowledge as no uniform opinion exists on the importance of CSFs and related functionalities. Besides the methods used in this study, further validation should be performed using other patient organizations, medical professionals, domain experts, and patients. In this study, we were only able to contact one medical professional and one representative of a patient organization . Therefore, the results of the survey could be affected by the input from the results of the interview, which were derived from one subject-matter expert. The generalizability of our results could be improved by involving more subject-matter experts from different perspectives . In addition to the Dutch market, the development team could also get into contact with other international organizations who have previously developed similar apps in order to find out more about their lessons learned. All in all, we believe that the current potential success of the app lies in the fact that it is being developed by medical professionals in collaboration with patient organizations, which is a highly regarded success factor. In addition, the app will be available for free and is targeted towards the Dutch market, where no such app currently exists. The information given about emergency procedures may indeed prove to be a useful replacement to paper leaflets, once doctors start prescribing the app alongside anaphylaxis medications. From a theoretical perspective, our study provides an overview of CSFs and the importance of those CSFs in the context of a substantial Dutch sample geared towards the development of an app to manage anaphylaxis. From a practical perspective, our results provide direct evidence and directions for development and help in the prioritization of the development of functionalities in similar apps. --- Introduction Medical protocols are used by physicians as guidelines to perform a diagnosis and subsequently a treatment that fits that diagnosis. These protocols, also referred to as Clinical Practice Guidelines , are defined and maintained by medical organizations such as hospitals, but also by national or international governing medical institutions. A CPG may offer specific instructions on which diagnostic or screening tests to use, how to provide medical or surgical services, the duration that patients should stay in a hospital, or regarding other details of clinical practice. These CPGs may contain overlapping content between different medical specialties. To help to determine the right decision for an accurate diagnosis, despite the redundancy , it is possible to implement the different protocols into one Clinical Decision Support System . A CDSS can be described as the provision of the knowledge of clinical experts in combination with patient-related information in an information system . Medical knowledge and patient-related information combined are filtered and presented at the times necessary. These actions are performed to improve patient care by providing an accurate decision on what medicine and corresponding treatment to adhere to . Essentially, CPGs are an accumulation of rules with regards to diagnostics, medication and treatments, thus these rules can be programmed in a CDSS. This research paper will explore how the existing anti-clotting CPGs at the University Medical Centre Utrecht can be embedded into a knowledge model to be implemented in a CDSS to support decision making. A similar study by Ozel, Bilge, Zayim, & Cengiz focused on the development and evaluation of a web-based CDSS that supports Intensive Care Unit providers in making decisions more efficient and effective. This particular study states that "The aim of the study was to develop a supportive web-based system which was constructed in line with the needs and preferences of intensive care physicians and evaluate its efficiency, effectiveness and usability" . In contrast to this study, the challenge addressed in this paper is the development of a CDSS containing eight CPGs, each from different specialties at the UMCU. Currently, when the diagnostic, medicine and treatment variables have to be determined for a patient, all involved specialties have to discuss the best course of action, based on their specific CPG. To ensure that medical professionals with different specialties and backgrounds follow decision-making processes in a consistent manner, it is important that the different CPGs are combined . A successful implementation of CPGs into a CDSS will provide stakeholders in medical processes with the ability to systematically make decisions in an effective manner, without the need to discuss medicine and treatment variables with each specialism. Furthermore, the utilization of a CDSS for decision making could result in a reduced error margin as the decisions supported can be 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES K. Smit, P. Koornneef, J. Nysingh, M. van Zwienen, M. Berkhout & P. Ravesteyn: Transforming Clinical Practice Guideline Usage Through the Use of a Clinical Decision Support System: An Explorative Study at the University Medical Centre Utrecht 579 evaluated appropriately . The evaluation of the output is important as it enables the CDSS to 'learn' to provide more accurate decision-support . To ground our goal to develop a CDSS for the determination of anti-clotting medicine and treatment, the following research question is formulated; RQ: "How can the available anti-clotting CPGs of the UMCU be combined into a CDSS with the aim to support decision making and increase adoption of the CDSS?" The remainder of this paper is organized as follows: in section two the background and related work with regards to CPGs and CDSSs will be explored. Next, the research method is presented in section three. This is followed by section four in which the data collection and analysis are described. Finally, in section five the results of our study are presented and in section six we draw conclusions from our results followed by a discussion with regards to the research study conducted, after which we provide directions for future research. --- Background and Related Work In literature, several definitions for a CPG exist. In our study, the following extensively cited definition from Field & Lohr will be used: "systematically developed statements to assist practitioner decisions about appropriate healthcare for specific clinical circumstances." Since CPGs are developed and implemented in the clinical practice, it has shown a lot of potential for the improvement of the quality of the healthcare . The combination of scientific literature and evidence with insights from clinical experts form the basis for a CPG, usually published by national medical governing bodies, for example, the Dutch College of General Practitioners or the American Institute of Medicine and are further specialized and instantiated per hospital. Based on this, recommendations are developed on specific clinical subjects. For example, a clinical subject is given a score based on the insights from the clinical experts, the height of the total score determines what treatment is supposed to be given. The recommendation according to the score is always backed by scientific literature. These recommendations provide professionals working in healthcare guidance, whom in some cases don't have the expertise required to effectively and/or efficiently determine medicine and treatment for a patient . A couple of proven benefits that CPGs realize in the clinical domain are: 1) decision making on appropriate care for patients, 2) promote education and improvement of care processes, 3) reduce unwanted variation in the delivery of health care, and 4) help contain costs. Most of these positive attributes are similar with the benefits from CDSSs . However, the utilization of CPGs also poses stakeholders with challenges like how to maintain CPGs so that state-of-the-art knowledge is guaranteed and how to ensure the validity of its contents . --- Implementation of CPGs For a CPG to be effectively utilized, it needs a successful implementation. Multiple studies show that in some cases, after the dissemination of the CPGs, there is a lack of usage in the clinical practice . A part of the problem is the lack of behavior change by the physicians, this is mostly caused by a lack of agreement with CPGs itself . The lack of agreement can be based on specific factors, for example, a lack of confidence in the author, or it can be based on the lack of agreement in general . Other identified reasons for a failing implementation of CPGs can be the wrong distribution of the CPGs . Although these are serious concerns for the adoption and utilization of CPGs, two studies show that, in the Netherlands, a high acceptance and feasibility level is achieved for the development and implementation of CPGs . Although CPGs help stakeholders in the diagnosis and treatment of diseases, another challenge exists. Most CPGs are printed on paper, which limits practical clinical use . This is one of the reasons that Clinical Decision Support Systems are developed . The combination of the knowledge of clinical experts with patient-related information is filtered and presented by a CDSS when it is required. There are different sorts of CDSS archetypes. According to Power those are 1) Model-driven, 2) Data-driven, 3) Communication-driven, 4) Document-driven and 5) Knowledge-based CDSSs. --- Clinical Decision Support Systems Knowledge-based systems are used most and proved most efficient in the CDSSs setting . Knowledge-based systems hold knowledge about a domain. In the domain, this knowledge is the understanding of the problems and skills for solving these problems . Knowledge-based systems mostly use ontologies for structuring the knowledge. In this paper, we use ontologies that refer to an engineering artifact, as formulated by the popular work of : "These are constituted by a specific vocabulary used to describe a certain reality, plus a set of explicit assumptions regarding the intended meaning of the vocabulary words. This set of assumptions has usually the form of a first-order logical theory, where vocabulary words appear as unary of binary predicate names, respectively called concepts and relations." Some of the benefits that CDSSs provide are: 1) Providing knowledge to medical professionals at appropriate time and manner, 2) Facilitating an efficient and effective decision making, 3) Reducing preventable medical errors, 4) Improving the overall quality of healthcare for patients and 5) Serving as a didactic tool for critical learning for medical students . Several studies have proven that CDSSs improve the clinical practice and practitioner performance by respectively 64% and 68% . A recent implementation of a web-based CDSS in an intensive care unit in Turkey shows that the CDSS significantly contributed in the accuracy of the decision-making by the physicians . Although the time for making decisions wasn't reduced, this study did show that user satisfaction and usability were high. In two test scenarios, 150 questions were posed. In the first scenario, the participants needed to answer these questions without the support of a CDSS, in the second scenario, the CDSS supported the decision-making by the participants. Without the support of a CDSS, 24% of the answers were correct, with the support of a CDSS the number of correct answers increased significantly to 83,2%. Finally, the study states that there is a great need for research and development of CDSSs, especially in the Intensive Care Unit , since the ICU produces large volumes of data . Since the clinical environment is always developing and changing, the knowledge in CDSSs requires a high level of modifiability and maintainability. However, when changes are made in CPGs, it is hard to implement these in the CDSS. This is because it requires both the expertise of the clinical domain as well as the informatics domain . A possible solution for the problem is simplifying the manner in which knowledge can be modified within CDSSs. This particular functionality is referred to as knowledge editing. If this functionality is simplified in a way that requires less expertise in the informatics domain, adoption of the change process by clinical experts increases as it becomes more easy to modify the CDSS knowledge based on changes in CPGs. For example, this can be achieved with the visualization of the knowledge in schematic plans such as an event-based decision tree . --- Study Design To construct a CDSS and assess the value of the knowledge in the CDSS, a three-phase research design has been implemented. The first phase comprised the analysis of eight anti-clotting CPGs, followed by the construction of the actual knowledge in the CDSS. The second phase consisted of the validation of the content of the knowledge in the CDSS by a group of medical stakeholders at the UMCU. The third phase comprised the refinement based on the feedback that was received from the medical stakeholders, which was followed by another round of validation, but in an individual setting with the additional goal to evaluate the utilization of CPGs through a DSS. An important factor in determining the appropriate research method to validate the CDSS is the maturity of the research field. In literature we identified several developments and trends regarding the use of DSS in a medical context, however, the research field of CPG usage through a DSS in the Dutch context, to the knowledge of the authors, is still nascent. According to Edmondson & Mcmanus fields should be on identifying new constructs and establishing relationships between identified constructs. Therefore the construction of the consolidated anti-clotting CPG will be performed using a round of secondary data collection and analysis, consisting of documents regarding the eight anti-clotting CPGs available at the UMCU. As our goal is to validate the CDSS and to explore the challenges related to the adoption of a CDSS at the UMCU, a wide range of possible ideas or solutions should be explored from different stakeholders. An adequate research method needs to be used to explore a broad range of possible ideas and/or solutions from a complex issue and combine them into one view when a lack of empirical evidence exists. In this light group-based research techniques are adequate . Examples of group based techniques are Focus Groups, Delphi Studies, Brainstorming and the Nominal Group Technique. The main characteristic that differentiates these types of group-based research techniques from each other is the use of face-to-face versus non-face-to-face approaches. Both approaches have advantages and disadvantages, for example, in face-to-face meetings, provision of immediate feedback is possible. However, face-to-face meetings have restrictions with regard to the number of participants and the possible existence of group or peer pressure. To ground our research results and to eliminate the disadvantages, we combined the face-to-face and non-faceto-face technique by means of applying a focus group as well as individual semistructured interviews. --- Data Collection & Analysis Data for this study is collected over a period of two months, between November 2016 and December 2016, through 1) secondary data analysis, 2) one round of validation utilizing a focus group session, and 3) one round of validation utilizing individual semi-structured interviews, see also Figure 1. All three methods of data collection and analysis are further discussed in the remainder of this section. --- Modeling of UMCU CPGs In the first phase, the eight CPGs of UMCU had to be collected and transformed into ontologies to understand the process of a medical examination and to be able to model them in the CDSS pilot at the UMCU. One challenge was that the team of researchers, consisting out of three researchers with experience in knowledge modeling and three researchers with experience in the field of CDSSs, quickly came to the conclusion that the CPGs are predominantly textual documents that rarely visualize the process. The CPGs included in this study were: 1) Bridging Vitamin K Antagonists, 2) Direct Oral Anticoagulants, 3) Heparin-Induced Thrombocytopenia, 4) Unfractionated Herapine Use, 5) start Vitamine K Antagonists, 6) Profylaxe Venous Thromboembolism, 7) Venous Thromboembolism, and 8) Nerve and Neuraxial Blockade with Anticoagulant. The process of transformation of the CPGs into ontologies was conducted as a cyclic approach. First, the researchers with experience in knowledge modeling analyzed the secondary data and modeled the ontologies to be implemented. These ontologies were then submitted for review by the CDSS researchers. This process was repeated five times before the final CDSS pilot for validation in the focus group was established. In order create the CDSS, eight CPGs were developed into a model. This model links ontologies collected from the CPGs in the pilot of the CDSS. To make sure that the modeling of the CPGs was performed adequately, the researchers started with the analysis and modeling of only one ontology, which was then validated by the CDSS researchers. When the first CPG was modeled and found valid, the knowledge modeling researchers started with the development of all CPGs involved and repeated the internal validation 584 30 process with the CDSS researchers. Based on the developed ontologies, the researchers had to analyze which of the ontologies was characterized by the highest uniqueness as the analysis resulted in overlapping rules and content in the included CPGs. Based on the analysis of the created ontologies, the hemorrhage risk ontology was found most unique and therefore the largest contributor to the determination of anti-clotting medicine and treatment. For this reason, we selected the hemorrhage risk ontology to serve as a basis for the creation of the 'bridging' ontology, which contained all decision knowledge from all ontologies to determine anti-clotting medicine and treatment at the UMCU. The ontologies were built using the Decision Support System of BeInformed, a supplier of DSS. The output of the modeling phase was used to prepare and structure the validation of the ontology by means of the focus group session. --- Focus Group Validation Subsequently, to the modeling of the knowledge into the CDSS, the focus group session was prepared and conducted in December 2016; the session had a duration of one and a half hour in total. Before a focus group is conducted, first, a number of key design concepts need to be considered : 1) the goal of the focus group, 2) the selection of participants, 3) the number of participants, 4) the selection of the facilitator, 5) the information recording facilities and 6) the protocol of the focus group. The goal of the focus group was to validate the anti-clotting CDSS. Based on this, we selected eight participants. The selection was done in collaboration with the UMCU. The selection consisted of five specialized physicians, from which each one was responsible for one or more of the CPGs included. Furthermore, two pharmacists and one laboratory expert were involved. The focus group was chaired by an experienced facilitator, one of the CDSS research team members. Additionally, one knowledge modeling research member was present to take notes. As the contents of the 'bridging' ontology are confidential, the focus group meeting could not be captured via audio or video. Lastly, the protocol of the focus group was based on the CPGs modeled, which were presented one-by-one during the focus group session. This protocol provided each participant the opportunity to provide feedback per CPG. The results from the focus groups were also utilized to get an impression of the attitude of stakeholders and challenges for stakeholders with regards to the use of a CDSS and develop a list of topics to address in the individual interviews. These particular questions were not posed during the focus group as it would allow for peer pressure amongst the participants, thus would be more appropriate during the semi-structured validation interviews. After the focus group session was finished the researchers continued to refine the CDSS, for example, by changing the sequence of questions posed by the CDSS and the formulation of the questions. After this, the third phase of this study was conducted, comprising the semi-structured interviews with the same five physicians that participated in the focus group session in phase two. The main goal of the interviews was to validate the refined CDSS based on the feedback provided in the focus group validation session. Furthermore, based on the input of the participants in the focus group session, we managed to develop the following set of four topics that were discussed with each interviewee:  Experiences with regards to the current use of CPGs  Improvements with regards to the current use of CPGs  Problems that are anticipated with regards to the use of a CDSS  Significant features that should be included into the CDSS to promote adoption As stated in subsection 4.2, each of the interviewed physicians was responsible for one or multiple CPGs. Furthermore, none of the participants had knowledge on what their coworkers had answered. The individual interviews were audiotaped and transcribed within 48 hours. The interview data was analyzed by linking and categorizing answers from the physicians. If several responses matched they were labeled by the researcher on perceived advantages and disadvantages with regards to working with a CDSS. This was then crosschecked by other researchers from the research team to ensure coding accuracy. This approach resulted in patterns with regards to the four topics that were addressed in the interviews. --- Results In this section, the results of the three phases executed in this study are reported. First, we present the results of the modeling phase, where we collected, analyzed and transformed the CPGs into ontologies to be implemented into the CDSS. This is followed by the results of the validation focus group session in which we validated the first version of the CDSS and used to prepare the semi-structured interviews. Lastly, the results of the interviews are presented that comprise the validation of the refined CDSS as well as an exploration of the experiences, problems, improvements and significant functionalities with regards to CPGs and CDSSs. --- Modeling phase The first and most complex CPG was transformed in an understandable way to model in the CDSS. on top of those ontologies is a proven method to model medical knowledge . The hemorrhage risk showed to be the most important factor in determining which treatment should be started and therefore, the first ontology the research team started with. When the hemorrhage risk is known, a treatment could be prescribed. The ontologies modeled that comprised the vitamin K antagonist bridging CPG were as follows: 1) Specialism type, 2) Treatment type, 3) Action at anti-clotting treatment, 4) Indications, 5) Anti-clotting treatment Periopera, 6) Thromboembolic complication risk factor, 7) Hemorrhage risk and 8) CHA2DS2-VASc risk factor, see for an example Figure 2. As stated above, the determination is mostly depended on the level of hemorrhage risk, i.e. whenever a type of surgical intervention depicts a certain risk level, which triggers a certain treatment, none of the other questions about other indications are posed. In the final model, the surgical interventions were categorized in the different kinds of medical specialism. This resulted in a better overview in the first version of the CDSS. First, the medical specialism was posed, before showing the surgical interventions. As soon as the model behind the first version could make a decision based on the different ontologies included, the CDSS would stop posing questions with regards to possible indications and provides a treatment as a suggestion. Figure 2: Example high-level excerpt from the vitamin K antagonist bridging CPG --- Focus Group The first version of the CDSS was presented to the hemorrhage risk commission, consisting of the hemorrhage-related CPG owners, of the UMCU. At this presentation, the bridging CPG was shown in the CDSS. The participants expressed mixed feelings about the first version, although it was predominantly positive feedback. Most of the positive feedback concerned the model-driven method of the CDSS. The participants acknowledged that this was a "powerful" method to overcome the complexity of the CPG. A large amount of feedback with regards to the CDSS was provided by the participants and noted by one of the researchers. This feedback comprised errors in the contents of the model. The feedback was used to refine the CDSS after the focus group session. Another topic that was addressed during the focus group meeting was the possibility to store decisions made by physicians. It became clear that the focus group saw this as an opportunity to improve the CPGs. Whenever a physician would execute the CDSS and document his or her decision, statistics could provide or suggest which CPG needs alternation. After the presentation of the first version of the 'bridging' CPG, the focus group had some input for the actual functionality of the CDSS. A clear majority of the focus group participants addressed the need for an integration with the Personal Health Records or at least an import of patient data from EPD, which also should eliminate the overlap between different CPGs. One participant proclaimed that the CDSS would result in 'cookbook' medical care. This argument is in conformance with the results of a study about physicians barriers for utilizing CPGs. Cookbook medical care was labeled as a bad attitude against the CPG, showing a lack of agreement with guidelines in general . --- Semi-Structured Interviews After the CDSS was refined by the research team based on the feedback acquired in the focus group session in phase two, the semi-structured interviews were conducted. With regards to the first goal, the final design of the CDSS was presented per interviewee. All interviewees provided feedback as part of the validation of the CDSS, which was processed after the third phase of data collection and analysis. The average duration of the interviews was one hour, consisting of 40 minutes for the second round of validation of the CDSS and 20 minutes for the additional topics on experiences, problems, improvements and essential functionality of the CDSS. With regards to the second goal, four topics provided insights into the experiences and preferences of the physicians in using CPGs in a CDSS. In this subsection, we report on 588 30 With regards to the first topic, the attitude of the current use of the CPGs, the majority claimed that the use of CPGs in the daily practice is an improvement of medical care. This amplifies the conclusion that CPGs are found to be successful in the Dutch clinical setting . The majority thought the CPGs, although improving medical care, are indistinct. They claimed this is a consequence of CPGs with a large amount of text. Also, the majority confirmed that the current CPGs are not always stateof-the-art when applied in practice. Some improvements the participants addressed in using CPGs are discoverability, the amount of text and coverage. The majority would like to see that the discoverability of the CPGs is improved. The CPGs should be listed on the intranet, but should also be stateof-the-art when listed. Furthermore, the majority stated that large amounts of text should be prevented in CPGs, which aligns with the attitude of the use of CPGs. The majority also mentioned the need for improvement with regards to the existing amount of overlap between CPGs. Overlap in CPGs is a factor that increases the difficulty in maintaining the CPGs, because if one CPG changes, other CPGs get outdated instantly. Next, we asked what challenges the participants would find in using a CDSS. The majority fear that the implementation of a CDSS will create a large dependency on IT. The interviewees stated that physicians do not want to be dependent on IT too much. Whether this is because of earlier failures of DSS or other IT-related influences remains unknown. Furthermore, the majority doubt the CDSS will be a user-friendly system. Lastly, one particular property of a CDSS was deemed indispensable by the majority of the interviewees; linking to the CPGs that are available on the intranet. Such a construction will not replace how the CPG is used but merely simplify its use. We believe that this preference is caused by the low amount of trust that the interviewees have in a CDSS, specifically with regards to their requirement of state-of-the-art CPGs in the CDSS, which is not always safeguarded, even in the current paper practices at the UMCU. --- Discussion & Conclusion In this paper, we aimed to find an answer to the following question: "How can the available anti-clotting CPGs of the UMCU be combined into a CDSS with the aim to support decision making and increase adoption of the CDSS?" In this question, two subjects are of relevance; 1) How to combine different anti-clotting CPGs in a CDSS and 2) What do the physicians need to increase the likelihood that they will adopt the CDSS. The data shown in section five shows that a majority of the physicians have uncertainties in the overlap of the various CPGs and the correctness when modifying versions. More --- Introduction Deal sites, in one form or another, exist for over two decades. They received a lot of publicity before Groupon's initial public offering. According to a recent study cited by Kotler et al. , "digital coupons now outpace printed newspaper coupons 10 to 1". In other words, use of deal sites is reasonably wide-spread for hackers to also link presumably leading to deal sites for infiltration. To the best of authors' knowledge, nobody investigated impact of personality traits on phishing that is specifically linked to deal sites. Google Scholar search for phishing personality traits yielded more than 2000 results, of which the first 100 were checked. There were two journal articles and a few conference papers investigating impact of personality traits on phishing in general. Pattinson et al. discovered that from Big Five Inventory personality traits, higher extraversion and higher openness to experience led to better dealing with phishing emails. They state that the findings are interesting because they appear to be counterintuitive since both of these personality traits should lead people to be more trusting of others which would mean treating some phishing e-mails as genuine. But they do not cite any source that would support the link between any of the two personality traits and trust. On the contrary, our results indicate a link between some of the three remaining personality traits and trust or mistrust; but extraversion and openness to experience were not linked to trust nor to mistrust ) -though the findings were not published yet). A more comprehensive study, in a sense of using more variables than only personality traits, was conducted by Welk et al. . The impact of extraversion was significant but the sign was negative when only five personality traits were included in the model, the sign was positive in the full model, and the extraversion was not significant when only five personality traits and three trust/distrust variables were included. The remaining results are unclear as the terms used to describe personality traits were anxiety, reservation, calmness, and ability to keep emotions under control. The two items measuring neuroticism are "anxious, easily upset" and "calm, emotionally stable"; they seem to cover 3 of 4 remaining personality traits mentioned by Welk et al. . The remaining term -reservation -looks like the second item to measure extraversion -"reserved, quiet" , so even the findings for extraversion mentioned at the beginning of the paragraph possibly do not hold. There were published a few conference papers on the topic. The most relevantconsidering the research design and quality of description of source data, including data collection -is . They tested impact of Big Five Inventory 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES F. Sudzina & A. Pavlicek: Propensity to Click on Suspicious Links: Impact of Gender, of Age, and of Personality Traits 595 personality traits on susceptibility to phishing e-mails in two phases. In the first phase, none of the personality traits was significant. In the second phase, openness to experience was significant and extraversion was borderline significant. But the direction of the impact is not clear from the published figures; they provide S.E. in the Table 2 for these two personality traits, not parameter estimates. Alseadoon, I. et al. Forgas et al. users' emotions impact their ability to detect deception. The second most relevant conference paper is . Although they do not describe respondents, nor what instrument was used to measure Big Five Inventory personality traits, they state that agreeableness and neuroticism influence whether a given information is received as either trusted or distrusted. Moreover, they state that high neuroticism deteriorates decision performance under low openness and conscientiousness. Other conference papers were theoretical and some of them proposed also a model but they did not collect data nor tested the model. The rest of the paper is organized in the following way: In the next section, there is a description of data collection, and how they were analyzed. In the following section, results of the analysis are presented. The last section offers conclusions. --- Data and Methodology Data were collected between December 2016 and January 2017 using an on-line questionnaire. Respondents were 264 university students from the Czech Republic, of which 140 respondents indicated that they use deal sites, and 124 do not. .) SurveyXact was used for the questionnaire. Unlike Qualtrics, it does not allow to show/hide questions based on previous answers on the same page. Therefore, the questionnaire was split into two pages and questions for deal sites users appeared on the second page. Seven respondents stopped after the first page. So, the effective sample size is 133 . On the second page of the on-line questionnaire, there was a question "Would you click on suspiciously advantageous offer if it led to a deal site?" and respondents were supposed to answer on a 1-5 Likert scale where 1 meant certainly yes and 5 stood certainly not. In other words, a high number corresponds to positive/responsible behavior. is more responsible, three of 133 respondents still stated that they would certainly click on the link, while 20 stated that they certainly would not.) This is the dependent variable for the model presented later in the paper. A generalized linear model was used. SPSS software was used for the analysis. A multivariate approach to testing was used. Parameter estimates tables from GLM were provided in order to be able to see signs of parameter estimates . The results should be equivalent to a multiple linear regression model estimates in case the dummy variable is set to 1 for male and to 0 for female. R2 and R2adj are provided in order to be transparent about how much a model explains though it may be significant. Personality traits were measured using Rammstedt & John's Big Five Inventory-10, i.e. a 10-item version of the Big Five Inventory questionnaire developed by John & Srivastava , and translated to Czech by Hřebíčková et al. . The study by used Big Five Inventory-44 . Alseadoon, I. et al. ... has an active imagination on a 1-5 Likert scale where 1 meant strongly disagree and 5 stood for strongly agree. Extraversion was calculated as an average of the 1st and the 6th answer, agreeableness as an average of the 2nd and the 7th answer, conscientiousness as an average of the 3rd and the 8th answer, neuroticism as an average of the 4th and the 9th answer, and openness to experience as an average of the 5th and the 10th answer. Authors are aware of the new version of Big Five Inventory -Big Five Inventory-2 with 60 items , and of 30-item short and 15-item extra short versions but there is no validated translation available yet. Narcissism was measured right after Big Five Inventory-10 using the same instruction, with the statement  ... is of narcissistic nature The statement was adapted from The Single Item Narcissism Scale developed and validated by Konrath, Meier & Bushman . They recommend SINS for online studies. The questionnaire contained additional questions which were not used in the analysis presented in this paper. --- Results The Openness to experience had also a significant and positive impact in ; moreover, the same impact had also extraversion in their study. Higgins et al. linked openness to experience to IQ in students. This could possibly explain why they are less likely to click on suspiciously advantageous offers. --- Conclusion The Openness to experience was found to be linked to IQ in students . This could explain more responsible behavior. In addition to that, it may be relevant to consider the extent of use deal sites. It may be possible that people open to experience visit them more or purchase from them more, i.e. they get involved with them more; therefore, they have a better understanding of them, i.e. they are more smart, and this could explain more responsible behavior. Now that there is an indication of impact of narcissism on purchasing coupons as gifts, it is justifiable in future research to use more items to measure narcissism, such as Narcissistic Personality Inventory which is probably the most widely used measure of the narcissism and contains 40 forced-choice items, Hypersensitive Narcissism Scale with 10 items or Pathological Narcissism Inventory with has 52 items. If a longer instrument is to be chosen, such as Five-Factor Narcissism Inventory , which contains 148 items, it may be advisable to select only certain factors. The study was conducted in the Czech Republic where there were fraud cases -coupons for services of non-existent companies were sold on regular deal sites. So, findings are generalizable possibly only for markets with similar negative experience. Further research should establish whether the same findings hold also on markets with no reported fraud cases. Moreover, university students as respondents are possibly more IT literate and tech savvy than the general population. Therefore, it is possible that they are more responsible when it comes to on-line behavior. It is not clear whether it brings any limitation the findings presented or not -if the current signal-to-noise ratio uncovers relationships hard to spot in the whole population (i. --- Introduction The impact of social media on various economic sectors has been widely noted in the literature . To remain relevant in the competitive landscape of contemporary business, marketers must remain active on different social media platforms . Consumers see the emergence of social media as an emancipatory platform, migrating them from their previous perceived status as peripheral stakeholders to strategic partners whose inputs are critical for successful product and service innovation . Consequently, the agglomeration into online communities of consumers sharing similar interests and values has witnessed phenomenal recent growth. Interestingly, for about 80% of consumers who participate in online communities , 74% of those communities are owned by large corporations , and 77% of those corporations report that online communities have significantly improved their brand exposure, awareness, and credibility . According to Kang, Tang, and Fiore , consumers participate in online communities for social, psychological, hedonic, and monetary benefits; the need to meet new people, share one's feelings and access better product and service options are fundamental motivations for that participation. For instance, researchers have found that participation by professionals in online peer communities enhances research collaboration . As a consequence, both firm-hosted and independently owned communities are increasing rapidly in number . However, online communities have also affected firms and individuals negatively through counter-and alter-brand communities, deceptive posting, lurking, and invasion of members' privacy . Online travel communities have recently become a hot topic in the tourism literature because they unofficially occupy a boundary spanning role, so influencing consumer interest in destinations . As tourism is a hedonic experience that cannot be comprehended prior to consumption, consumers rely on the advice and experiences of others concerning the best travel decisions. A thorough search of the wider literature identified only one review study of online communities , with none in the OTC research. On that basis, the present systematic literature review has a number of objectives: first, to understand travelers' motivations for participation in OTC; second, to understand the consequences, at both firm and individual level, of OTC participation; third, to understand the contexts and platforms through which OTC interactivity is fostered; and finally, to provide a conceptual framework that will schematically encapsulate the activities of OTCs. Against this backdrop, the study contributes to the literature by providing a solid platform that integrates the fragmented studies in this research stream. This represents a useful tool for subsequent studies , as managers in tourism and destination marketing organizations will also find the concepts and arguments adduced here useful as levers to optimize the value of OTCs for their firms. The rest of the paper is structured as follows. Section 2 discusses the background to OTCs; section 3 describes the research --- Background: Online Travel Communities OTCs can be defined as "groups of people trying to achieve goals, with similar interests, and interested in building relationships, making transactions, and engaging in fantasy, governed by rules and using new information technology as the means" . Development and acceptance of IT means that tourism has undergone continuous transformation, and OTCs attract travelers through reviews and recommendations on platforms such as TripAdvisor, Fodor, Qunar, virtual tourist and Lonely Planet . Although better understanding is needed, it is known that people join online communities for several reasons: to share views on products; to obtain valuable information; and to create, enhance and sustain social ties between online members . In short, consumers join OTCs for psychological, social, and utilitarian reasons . OTCs offer travelers an opportunity to share their travel experiences and opinions by posting reviews. These then serve as information references for other travelers, providing valuable information about points of interest , gastronomy, weather forecasts, news and safety bulletins. However, there is also a negative side to this increased information sharing within online communities; as reported by Wang et al. , biased, non-credible, or deceptive information can be very challenging for travelers seeking reliable advice. A further problem is that a member of an OTC may be a lurker: someone who does not participate or contribute to any discussion but only reads and reaps the community's ideas by becoming a part of that community . Additionally, in their evaluation of technological modus operandi and social motivations for membership in 11 OTCs, Dippelreiter et al. found that although most of the communities are integrating new technologies, some still lack integrative emerging technologies such as SSL encryption and hashed user-id security features. OTCs also need to improve personalized on-trip services to members. --- Research Methodology --- Literature Search and Selection To conduct the literature search, we first defined key terms for the study, which included online tourism community, virtual community in tourism, tourist online community, Web 2.0 enabled community in tourism, virtual space in tourism, and social media community in tourism. Given the uniqueness of the present study and the need to capture as many relevant articles as possible, we followed Shaikh and Karjaluoto's --- Results --- Statistics of Findings Geographically, the highest number of publications came from the USA, followed by countries in the European bloc , and then the East Asian bloc . Most of the studies were published in 2016 while 2005, 2008 and 2009 each returned the same number of publications , with none in 2006 . The most frequently used theory was the technology acceptance model . However, inspite of the extensions to TAM2 and TAM3 , all but one study utilized the original TAM. Other theories included social identity theory, flow theory, expectation-confirmation theory, situational strength theory, and interpersonal relationship theory, and some studies used a combination of theories , see Table 1. A majority of studies adopted a hybrid model to characterize use of OTCs, integrating different variables to create a model. . Figure 3 shows the percentage frequency of the various methodological approaches. Among the quantitative studies, survey administration and retrieval were performed primarily through the different online communities and used structural equation modeling as the main analytical tool. However, some of these studies adopted a big data approach, analyzing the credibility of reviews in TripAdvisor and Qunar. While a few of the qualitative studies used face-to-face structured interviews, a majority adopted a netnographic approach; netnography is a qualitative, exploratory, . Figure 3: Methodologies used in the selected studies --- Motivations for Joining Online Travel Communities --- Psychological motivations User involvement-that is, the degree of interest in a piece of technology-has been studied across many information systems. In OTC, Wu, Xiao, and Wu examined the relationship between breadth and depth of involvement and members' loyalty. They argued that depth of involvement exposes the individual to other activities in the OTC that increase flow experiences, pleasure, satisfaction, and fun. According to Elliot, Li, and Choi , members' satisfaction increases site stickiness, which also influences transaction intention. However, in evaluating customer purchase involvement and OTC website design, Sanchez-Franco and Rondan-Cataluña suggested that while OTC website aesthetics and usability increase satisfaction, these effects are moderated by purchase involvement, and level of involvement influences members' perceptions of the usefulness of OTC websites. Another important psychological factor for OTC membership is escapism. As argued by Lee and Hyun , social, family, or romantic loneliness drives peer identification in OTCs; in other words, involvement in OTC activities is primarily a means of overcoming loneliness. Members experience a sense of fulfilment and satisfaction when OTC managers create additional platforms to enhance peer interaction through services like meeting a new companion through a certain travel product, forming a virtual family based on a particular travel view, and talking with a romantic partner about a certain travel product. The conceptual framework in Figure 4 summarizes motivations for participation, the range of OTC contexts, interaction platforms, and consequences . --- Social Motivations Self-expression is an innate human attribute, and participation in OTCs is driven by the individual's desire for self-expression . For this reason, members assign greater importance to the transmission of information than to its reception. Investigating the antecedents and moderators of members' social satisfaction in OTCs, Yang, Zhang, and Gallagher identified entertainment, social interaction, and reciprocity as predictors of satisfaction. To enhance members' interactivity, then, OTC managers should incorporate entertaining features and activities that will maintain and strengthen members' social ties, whether online or offline. Luo and Huang proposed that OTC participation is driven by functional, social, psychological, and recreational motives, and that most people join online communities because of the social desire to make more friends. These findings challenge Vogt and Fesenmaier's argument that functional needs are seen to be the most important influence on information search. Finally, member reputation, built through exotic profiles shared on members' pages, influences evaluations of similarity and community that often lead to bonding, offline interaction, and enduring relationships . --- Utilitarian motivations The utilitarian approach asserts that a morally correct action is one that provides the greatest benefits over harms for every individual . Chung and Buhalis argued that, of the three motivations for OTC participation, information acquisition most strongly influences participation and attitude toward the OTC. For this reason, information such as best price, service quality, best destination, and safety are the most common search criteria among travelers. In some cases, OTCs offer specific utilitarian services that increase subscription to its membership. For instance, Luo and Huang reported that, aside from socio-psychological motivations, participation in couch-surfing OTCs is driven by the utilitarian drive for recreation; those who subscribe for couch-surfing believe that the community has specialists with the requisite skills to ensure that their recreational needs are met. Jeon, Jang, and Barrett suggested that utilitarian value and online trust mediate the relationship between website interactivity and repurchase intention. Conversely, the importance of utilitarian motivation for OTC participation was challenged by Kang, Tang, and Fiore , who contended that OTC participation on Facebook fan pages was largely driven by hedonic and socio-psychological benefits while functional and monetary benefits had no impact on participation. --- Contexts and Interaction Platforms Our systematic review also revealed different platforms of interaction among community members . These include chatrooms, forums, newsgroups, blogs, websites, and review sites. However, the choice of platform depends on one's motive for participation. For instance, Facebook fan page members are likely to visit Facebook fan pages of restaurants when they gain socio-psychological and hedonic benefits from such visits . To increase visit to their fan pages, then, restaurants should constantly upload content that appeals to the hedonic instincts, such as games or live streaming videos of music and current events that will facilitate real-time interactions among members. Additionally, members who use blogs and websites to share their experiences are motivated by communal feelings, unlike the sense of self-recognition that motivates the sharing of experiences on Twitter . It is also argued that the use of e-mail as an interaction platform is fundamental for OTC managers seeking to foster social, friendly, and romantic togetherness among community members . E-mail facilitates close-knit interactions, where members can communicate freely about private issues in a way that may be more difficult on open platforms. However, to sustain OTCs, forums and chatrooms are also necessary, where members freely share travel experiences that will assist others in making travel decisions . In summary, members see the OTC as an attraction where they can learn from the experiences of other members, reducing the time taken to search other sources for information about a destination. --- Consequences of Online Travel Communities --- Negative effects Studies of online social relationships report negative effects such as extreme verbal inhibition and aggression, bullying, denigration, privacy issues, and lurking . The present systematic review revealed both firm-and individualrelated negative effects of OTCs. For instance, Cova and White , suggested that firm-related negative effects of OTCs have led to the emergence of counter-brand communities-"a phenomenon of aggregation against a company that manages the brand and which leads to the creation of competing brands by members of the community"and alter-brand communities-"a phenomenon of aggregation around not-for-profit projects that nevertheless creates a brand that can compete with the brands of certain companies." Members of these alien communities are former adherents of a brand who have moved away because of their frustration with the firm and float activities and programs parallel to the brand, aimed at damaging its reputation. In terms of individualrelated negative effects, we also identified socio-psychological deviant behaviors that engender repulsive reactions from other members of the OTC. For instance, complaints of bullying and posting of irrelevant topics and lurking are common in OTCs. As argued by Ruiz-Mafe, Tronch, and Sanz-Blas , these negative emotions constitute psychological, social, and privacy risks, and OTC managers should incorporate technologies to curb any such deviant behaviors. --- Positive effects Similarly, positive effects of OTC membership are observed at both firm and individual level, including increased brand awareness, functional brand image, brand use, and visit intention . Lee and Hyun argued that trust is a fundamental driver of membership stickiness, leading eventually to loyalty. To promote loyalty, managers should ensure navigation functionality, security, and privacy protection . Trust in the community also fosters a sense of belonging and sharing of emotions and experiences; in most cases, such relationships transfer to the offline world , ending in some cases in strong bonds such as romantic affairs . --- Discussion The aim of the present study was to elucidate the motivations and consequences of OTC participation through a systematic review of existing studies. A thorough and rigorous literature search yielded 63 studies, comprising journal articles, conference papers, and PhD dissertations. Through OTCs, tourists assume the status of destination evangelists, whose gospels about destinations are believed and trusted more than marketers' messages. Both firm-hosted and independent OTCs promote a range of activities that engender agglomeration of membership to a critical mass, which is seen as an antecedent of success for OTCs . Interestingly, the threat of OTCs emanates from the question of brand ownership, as the emergence of brand communities has shifted brands from private control to publicly socialized phenomena . By taking an interest in and promoting the activities of OTCs, tourism firms serve a boundary spanning role, with concomitant favorable effects on destination image and visit intention . Our review revealed three main motivations for participation in OTCs: psychological, social, and utilitarian. Psychologically, participation in OTCs is motivated by escapism; those seeking travel advice from OTCs do so as an escape from social, family, or romantic loneliness . Additionally, as an individual stays longer in the OTC, they are more likely to continue , increasing flow experience, enjoyment, and involvement . As the social desire to forge ties and bond with others also influences OTC participation, interactivity is a key . Additionally, Arenas-Gaitan, Rondan-Cataluna, and Ramirez-Correa argued that members assign greater importance to the transmission of information than to its reception, as a platform for highlighting and maintaining social status. Finally, information acquisition for best travel decisions, product purchase, and service quality evaluation represent utilitarian motives for participation in OTCs , as website interactivity is the cornerstone of members' functional satisfaction. --- Contributions of the Study Our study contributes to existing knowledge in a number of ways. First, no previous literature review has focused on OTCs. Studies of OTCs have followed different trajectories, with no coherent integration, resulting in disparate and in most cases conflicting findings that resist meaningful interpretation by scholars and managers. This systematic review provides a solid platform that integrates and aggregates these fragmented and disparate studies, offering a useful tool for subsequent studies in this area. Second, by identifying motivations for OTC participation and its positive and negative consequences, both at firm level and for individuals, our study extends prior research on online communities . Additionally, by explicating the interaction platforms and contexts of OTCs and the arguments adduced herein, this study offers destination managers levers for optimizing the value of OTCs to their firm. Finally, from our synthesis of prior studies and findings, we conclude that online travel communities do indeed matter, and that tourism and destination marketing organizations neglect their strategic importance at their own peril. --- Limitations of the Study and Future Research Direction One of the present study's limitations is that the data obtained were restricted by date . Future research might usefully increase the sample size by including relevant articles published before 2005. It is also acknowledged that additional factors beyond those investigated here also influence participation in online communities, and further study should more fully investigate these other factors. Finally, extraction and analysis was conducted manually here, which may exclude relevant studies, and automated extraction and analysis should be utilized in future research of this kind. --- Introduction While many social media platforms are created for worldwide consumption, it is usually a significant challenge to develop these platforms for users from various cultural backgrounds . This is increasingly important as the use of a social media platforms often re-flects the cultural values of the user . While there have been quite a few papers recently published that examine a user-centred approach i.e. how cultural contexts shape social media use , there are fewer studies that examine the influence of cultural values on social media platform design. A study by Van Belleghem highlights the differences in social media penetration between Western European countries and others such as India and Brazil. Together with Gong, L. Stump, and G. Li they conclude that the differences in diffusion of social media across countries highlights the need for global e-marketers to appreciate why people in a particular country may be more receptive to and prone to adopt online social media than people in other countries. This paper attends to this research agenda by reflecting on the underlying cultural values that moti-vate the design of a Chinese social media platform, WeChat. The exploration of cultural values in-herent in the design of social media platforms is motivated by Aral, Dellarocas, and Godes and Kane, Alavi, Labianca, and Borgatti . Both set of researchers present research frame-works and research agendas to encourage scholars to explore the impacts social media has on or-ganisations and society. Features built into social media platforms either enable or constrain user behaviour, while providing the building blocks to allow interactions of social processes. The design of social media platforms is important to understand because they enable interactions of social pro-cesses and culture that affect the fabric of society . In the current research in progress paper, our goal is to explore the cultural values inherent in a Chinese based social media platforms using WeChat as an example. While the idea that culture is entwined in the design of information systems and applications is not new Kim, Triandis, Kâğitçibaşi, Choi, & Yoon, 1994;Triandis & Trafimow, 2001), especially in the context of social media platforms . In this paper we use this dimension as a starting point to explore the partic-ular values inherent in Chinese culture that are in turn reflected in the design of WeChat. To this end, we begin by proposing a model which encapsulates one of the key Chinese cultural values -Collectivismand then use this model to evaluate key features of the WeChat application. This paper serves as the first step of the research process by building the model and providing a preliminary implementation of it. The paper is structured as follows. Firstly we examine WeChat and Chinese cultural values and present our proposed research model. Next we apply our pro-posed model to a social media platform called WeChat. Finally we conclude with our limitations and suggestions for future work. --- Social Media and WeChat --- Social Media Social media provides a platform for different social groups and communicate and exchange infor-mation . SNS is defined as a webbased software application that helps users to connect and socialize with friends, family members, business partners or other indi-viduals . Features and functionality designed into social media af-fect how users interact, coordinate and form relationship networks . There are different types of social media platforms, which provide businesses with many types of interactive communication methods . Social me-dia, text and instant messaging applications, blogs, wikis and other web forums are growing as a means of supporting additional, often critical and accurate information within the public sphere . Social media provides a platform that allows users to communi-cate news and information to others as an alternative form of communication such as television, radio, and print . --- WeChat Chinese use of social media is increasing faster than the rest of the world. Chinese consumers tend to consider products or services if they see them mentioned on a social media site. Because social media such as Facebook, YouTube, and Twitter are blocked in China , WeChat is one that marketers could use to directly communicate with their Chinese audience. WeChat is the most widely used social networking service in China and has become an important social media platform for computer-mediated communication . . --- Chinese Values in a Social Context Traditionally speaking, Eastern cultures such as China, are collectivistic. They value family, friends and their groups over self. Members of Eastern cultures tend to have fewer, closer and more en-during friendships than members of Western cultures. Collectivism in Asian societies is maintained through a general value placed on social obligations and commitments and familial ties . While, Hofstede, and Trompenaars, have their critics ). Criticisms are mainly focused around the fact that that there is no such thing as a 'national' cultural identity, and that the cultural dimensions are formulated from a Western perspective. There is however, many countries where the major cultural group is such a dominating factor that, nationally, cultural values do have a national cultural identity, albeit with cultural sub-groups within that national identity. With regard to Hofstede and Trompenaars having a Western viewpoint, in the words of Hampden-Turner and Trompenaars themselves : "...social science methodology is not culture free. There is no neutral point 'above' culture from which to view the universe. It follows that many different ways of viewing culture are legitimate" We look beyond these critics and eval-uate Chinese values of collectivism in cultural dimensions which may bring valuable insights in terms of explaining behaviours, in particular the designers' perspective, which has been largely over-looked. Subsequently, this section is going to develop a framework that assembles Chinese cultural attrib-utes and centralising Chinese collectivistic culture, this is based primarily on Hofstede's work. This framework helps to explain the various interre-lated cultural attributes that inherent in the design of Chinese social media platform. 1 within the context of application de-sign. We aim to have at least 5 interviews, and will continue interviewing until saturation has been reached, should more participants be available. To triangulate the data collected from our interviews, we will also consult doc-umentary sources such as design specifications and screenshots of the WeChat design. All data will be collected in Chinese and translated into English by the Chinese speaking author. Data Analysis will use thematic analysis to identify common themes and ideas emerging from the data. --- Preliminary Results In this section, we present preliminary results from our analysis of WeChat features, which are based on the Chinese culture elements presented above, and the proposed model in Figure 1. This will help us formulate a basis for our interviews with designers and users of this platform in the next step of the research. A feature that demonstrates the cultural attribute of Respect for Authority is the Subscribe func-tionality which enables users to subscribe to a celebrity or to newsletters. The owner of the ac-count has the absolute right to choose and decide what comments to put on under the post. In ad-dition, the creator of a chat group who assembles the group chat has the power to dissolve group, whilst other chat group members can only join or exit the chat group. The Chinese cultural attribute of guanxi can include both the creation of new ties as well as the strengthening of existing ties with people. This attribute is reflected in the features of Shake and People Nearby which spontaneously match people with strangers virtually. Through this feature, WeChat allows people to form instrumental ties with strangers. In addition, Holmes, Balnaves, and Wang explore the recently introduced feature, Red Packet. This feature digitally imitates the Chinese Lunar New Year tradition of 'hong bao' where elders pass money to the young to encour-age prosperity and provide good blessings. The red bags themselves imply a range of expectations that do not need to be made explicit. Unlike the tradition of senior people giving to junior people, the WeChat feature encourages people to give money to anyone. Thus this feature is a way to strengthen or build up social tiesanother demonstration of guanxi. And finally, the nuanced design of moments within WeChat emulates the concept of keqi. For ex-ample, while one can post images and links for all of their friends to see and comment on, the comments are only visible if the commentators are friends with each other. This features enables the appearance of "well-mannered politeness" by not allowing acquaintances to necessarily see each other's comments. The need for privacy which is encapsulated in the attribute of keqi is fur-ther seen in the ability of WeChat users to restrict broadcasts to specific users. The current design of WeChat affords the practices of these three key cultural attributes -Respect for Authority, guanxi and keqi. Hsu emphasizes that Chinese are social and psychologi-cally dependent on others and have a strong group orientation; therefore, individualistic behaviour is regarded as an expense to others. For example a number of WeChat features such as Go Dutch and Group Buy further reflects this group orientation. --- Conclusion Research on social media platform design presents interesting opportunities to examine how plat-form designers can structure and influence user interaction in particular ways . This research can help shed light on cross-cultural differences related to social media design and will be of great value to social platform designers who are pursuing a mobility strategy targeted to a global audience. Culture is often reflected by or perceived through shared practices in a commu-nity . Cultural differences influence communication, behaviour, and values. Asian-based social media tend to have tighter social relationships, with their practices reflecting an indirect communication style and less open self-disclosure; whereas, western based social media tend to have wider social networks, with their practices reflecting a more direct communication style and bolder self-disclosure . While social media platforms like WeChat have a potential to modernize elements of Chinese cul-ture, they simultaneously act as a vehicle for the reinforcement of traditional Chinese collectivist cultural values . We have demonstrated in this paper how a particular social media platform, WeChat, reflects the broader shared cultural values inherent in Chinese society. Our findings do not imply that other cultures other than Chinese are unsuited for using WeChat, as the application is now becoming popular outside of China. However, as it is developed in China, there are Chinese cultural values inherent in its design. Additionally, many of its features are not available outside China. A future part of our larger study will analyse and contrast social media de-signs from other cultures, for example Whatsapp and Facebook, in contrast to Wechat and Weibo. However, this paper only includes the Chinese cultural aspect. This paper has two key limitations; 1) the model proposed in this paper is conceptual and has not been thoroughly validated. Validation could be to carry out via an exploratory study including inter-views and focus groups with the designers, developers and marketers of Chinese social media plat-forms such as Tencent and Sina . This type of study would help us to understand the motivations for the creation of features within each platform. In addition, interviews with users of these platforms would help to determine whether or not these features help engender the cultural attributes discussed in the model. 2) In this paper we focus exclusively on the concept of collectivism, however in doing so we may overlook other important val-ues in the Chinese culture such as the concept of Harmony (Wei & Li, --- Introduction The market for digital financial services is moving strongly, resulting from cost-reduction ambitions of the financial service providers. Like in other industries that have developed mass-customized customer interactions and product offerings, Digital Investment Services are expected to follow suit and offer an excellent domain to test our views. For example ING Group, one of the leading banks in Europe, has clearly identified the multior omni-channel approach as part of their overall service concepts, and they are organizing themselves accordingly . The community of technology innovators to support these types of interactions is growing rapidly, as is illustrated by the many so called "FinTech" start-ups . For financial services with little complexity and limited need for customers to be adviced by a financial expert, many of these services have been developed and successfully implemented. However, Digital Investment Services are often restricted to the transactional part of the service and/or monitoring current positions through dashboards. The sales and advisory part would be a next challenge in the further digitization of financial services, but in our view requires a keen understanding of the psychology behind the sales process, in particular how the sales process is adjusted based on the customer's profile. If you ever have had interactions with sales representatives in your role as a customer, chances are that you can distinguish effective approaches that fit your needs from the hopeless attempts to push you to buy something. An effective sales representative is fast in recognizing the peculiarities of his potential customer and addresses these in his interaction. For instance, if the sales representative encounters a highly rational customer, he will deliver facts and refrains from the traditional "sales spiel". Is the customer uncertain about his desires, the sales representative will start by assisting the client and by identifying his primary decision criteria. If the client is highly sceptical, the sales representative's first objective should be to gain his trust. Or finally, if the customer wants to know everything there is to know about the product or service, the sales representative will need to show his professional expertise and deliver facts that matter to the customer. Experienced sales representatives not only master these different approaches, but more importantly, they have the skills to recognize when to use them by "reading" the customer in front of them. When we shift our attention to the digital environment and the sales processes there, all of these elements are present as well. Hence, digital sales channels must go beyond product representation and recommendation and interact in such a way with the customer that he feels well taken care of. These interactions do not necessarily need to be executed by humans, as insights from the field of artificial intelligence and in particular selflearning systems show . How such systems should operate is partly a technical matter, which is beyond the scope of this article. However, it is also a challenge from a business design perspective. We need to determine, which customer characteristics can help to determine if it is worthwhile engaging the customer, and if so, which process steps have to be adjusted and executed according to the customer profile. In this paper we propose a model that offers four dimensions to deliver individualized interactions in digital sales settings, using the example of Digital Investment Services. --- The OPTI Characteristics Model Based on insights from the behavioral finance literature , that studies the psychological aspects involved in making financial decisions, we have identified four different dimensions of a hypothetical customer profile. These foundations give us the conviction that it is possible in a digital setting to align the communication processes and interaction with the customer profile, similar to the sales representative and his empathy and human natural intelligence in our starting example. We refer to these dimensions as the "OPTI Characteristics" . Figure 1: The OPTI Characteristics as foundations for customized customer interactions The denotation of the respective customer specific characteristics within each of the four dimensions enables the construction of a customer specific and individual profile that forms the basis for a customized interaction: Objective, Prudence, Trustful and Interested. The next sections discuss these four characteristics in more detail, using the case example of an investment through a digital service channel. As such we present first ideas how the digital interaction for such an investment would change depending on differences in the characteristics in the customer profile. --- The "OBJECTIVE" Characteristic The dimension Objective captures the existence of rationality in the investment decisions of the customer. A maximum score in this dimension refers to a customer that does not allow any emotions to affect his decision and who has no cognitive dissonances . He is an analytic, who only cares for factual data, which he carefully weighs before reaching his decision. On the other extreme of the Objective scale, we find the customer who makes all the classical errors known from behavioral finance . Examples for these are cyclical investments and investments in primarily domestic stock, as they provide him with a higher sense of control, yet lead him to a poor diversification and 632 30 . Or he shows a clear level of overconfidence and is convinced he is smarter than the market . He is surprised, that after many transactions, he receives a smaller yield on his portfolio when compared to a passive investment on a market index . The construction of the interaction -especially for those customers who tend to make the classical investor mistakes -needs to capture these aspects, support them transparently and deliver a sustainable added value to the customer, without robbing him of the freedom to make the final decisions himself . An investor who prefers cyclical investments can be informed more actively and prominently that anti-cyclical investments may have some distinct advantages . Alternatively, he could be recommended to delegate more of his portfolio decisions to the system, for instance by offering a periodical rebalancing of the chosen asset allocation . In essence, all mechanisms could be applied that have become known and discussed under the term Nudging . This refers to the approach that psychological behavior patterns are structurally used to steer people towards a beneficiary path for them and/or society as a whole. --- The "PRUDENT" Characteristic The Prudent characteristic captures how careful and considerate a customer is regarding the conditions that influence a financial decision, or in other words, how well he knows the necessary facts and his own preferences . At the maximum of this scale we find the customer who has a complete overview of all his finances. Basically, he can articulate precisely, which investment goals he wants to achieve, while he is able to quantify his targets in relation to his risk appetite . Conversely, at the other side of the scale, customers have no or very limited insight in their financial situation. They have not yet considered which targets they want to achieve with the investment and are far from knowing which risks they are willing to take in doing so. These customers face a range of ambiguities and are feeling highly uncertain . For the interaction with customers, a correct measurement of this Prudent characteristic is very important, as customers with low prudence are quickly overwhelmed, especially in a digital setting. They are more likely to quit the interaction prematurely, especially since product-specific offers do not help them and they lack recognition that their personal circumstances are "understood" by the digital service . In our view, future successful Digital Investment Service providers will have the appropriate tools to reduce these ambiguities. Based on the customer type, different tools can be included in the interaction, for instance to first determine the monthly available capital for an investment. Subsequently, risks can be visualized in a graphically appealing way. This not only helps to identify the risk profile of the customer, but also provides him with more confidence in his ability to reach a sound decision, as he is structurally engaging in the relevant themes for his decision . For instance, he receives information how much money is needed for a meaningful retirement plan, the associated risks and benefits etcetera. This reduces the ambiguities and thus facilitates a decision . --- 2.3 The "TRUSTFUL" Characteristic The Trustful characteristic measures the fundamental trust in the digital offering. At the maximum point of the scale, customers trust their service provider and the tools and recommendations the provider delivers. They have no concerns about a lack of security or data privacy that would stop them from using the digital environment. However, if a customer does not trust the service provider, it will be difficult to envision any interaction, digital or otherwise, between them . Besides providing incomplete data to the tool, the untrusting customer may just want to test how the tool works, without completing the actual process and coming to an investment decision. The impact of this characteristic on the interaction is guided by the insight, that a lack of trust can be best addressed through personal contact . This means -if at allreverting to an off-line channel, or possibly a video-conference within the tool. Customers with a low score on Trustful should therefore not be asked to execute sensitive steps in the digital environment . For instance, the risk profile of a customer can be determined by attractive digital tools, which would be acceptable to these customers since they do not require sensitive personal data and do not result in financial consequences . The obvious advantage of a digital service is the size and scope of the available information as well as the determination of the customer preferences. Both elements would be difficult to achieve at a comparable level in a classical service conversation . Customers on the high end of the Trustful scale can be offered a fully digital interaction and they would likely experience this as added value and added flexibility, as they do not need to be bothered with scheduled meetings, travel time etc. Hybrid modes, where the representative and the customer are sitting together behind the same screen are getting more popular and show promising advantages for both service provider and customer . --- The "INTERESTED" Characteristic The Interested characteristic captures both the general interest of the customer in financial topics as well as his motivation to find a good answer to a specific question. On the extreme positive side of this scale, customers are continuously looking for comprehensive information and have the ambition to become knowledgeable on financial themes. They are willing to commit time, emotional energy and possibly monetary means to be engaged and to ensure the finances have been well taken care of . This usually results in a higher financial competence, as they already possess a lot of relevant information about the specific financial decision they are contemplating . The obvious counterpart on this scale is the customer who has absolutely no interest at all in financial themes and does not want to spend any effort on this theme. The customer with a high score on the Interested scale will shy away from a service provider who constructs and/or manages a portfolio without any explanations and arguments. This customers demand a clear understanding why the portfolio decisions have been proposed or taken. Offers that enable the client to identify thematic focal points, such as low carbon-emission investments, provide a good fit to this customer profile. They will value periodical updates beyond the yield development that include other developments in his field of interest . Conversely, the customer who is in "don't care" mode for all these matters should not be bothered with these themes, beyond the legal requirements the service provider has to comply with as part of his "customer care obligation". It would make him less certain or at the very least he would find it annoying and it would steer him away from his well-intended service provider . --- Conclusion and Outlook In this paper we focussed on Digital Investment Services and how they should aim for a level of individualization in the interaction process to fit the customer profile using digital and automated processes. This would not just deliver a custom fit from an investment portfolio perspective, but also achieve that the customer feels well taken care of during the entire interaction and service consumption. It would increase the customer engagement and identification with the product and provider, compared to current standardized digital solutions and interactions, but also the pseudo-individual interactions occurring in retail branches of financial institutions. In particular the characteristics Prudence and Trustful indicate, that already today there is the potential and the need for a combined multi-channel approach. For instance, the actions of the customer in the digital environment when providing information can be captured to provide input for the subsequent service process. associated translation to the customer profile. Also, the various technical and content components that would be needed to achieve the desired alignment of the customer interaction need to be identified and operationalized, including gaps where current technology does not yet offer solutions. This will be the focus of our next steps, in which we plan to develop such a profiling tool and implement it in a real-life Digital Investment Service. In summary, the OPTI Characteristics are expected to help in the identification of the various archetypical customer types. Knowing their different affinities or attitudes towards the use of digital services will enable the customization of not only the products and portfolio, but also the interaction with the customer, giving them the necessary comfort to use the digital channel if and when they like, possibly in addition to the traditional channel when the situation demands it. Understanding these characteristics helps to design the Digital Investment Services of the future. --- Introduction Mobile and wearable technologies have unique advantages within health and wellness. Wearables could be a way to help the young elderly to stay active longer and remain well. Even though wearable fitness trackers are not a new technology as such, there is evidence that they have not recently evolved to better meet the requirements of users . Smartphones are prevalent among the population, but present problems regarding fitness tracking such as problems with data entry and inaccuracy of data . Wearables can solve these problems and could thus be a better choice for sustained wellness . Current knowledge on wearables shows, however, that users easily abandon them after an initial use period. In a Gartner report it was found that the abandonment rate of smart watches is 29%, and 30% for fitness trackers in a study with more than 9500 participants. Gartner also found that wearable devices are not found useful enough and users easily get bored with them. The perceived value in relation to the price is not found to be compelling enough, especially in the over 45 years age group. Current wearables only take into account the physical dimension of wellness and they are traditionally targeted mainly at the working age population and already physically active consumers. We wanted to explore how adding a social dimension to wearable use would impact the wellness behaviour in the young elderly participants, and investigate attitudes towards wearables when introducing them to people not in the traditional target group of fitness wearables and without previous experience of wearables. We use the term young elderly to describe our target group of active 60-75 year olds The paper is organized in the following way: after this introductory section we present a literature review of wearables and wellness in section 2. In section 3 we discuss the study design and present the participants chosen for this study. In section 4 we present the results of the study and in section 5 we discuss the findings and the implications of the study. --- Literature review --- Wearables for wellness For a useful way to discuss wearable technologies for fitness and wellness, Ananthanarayan and Siek present a taxonomy consisting of goals and users, persuasion methods, and data presentation. An example of a relevant goal is motivating physical activity. Persuasion methods belong to either self-monitoring, social influence or fun interaction. Finally, they suggest that data presentation methods are especially important in wearable devices. Regarding social influence, the authors report studies where positive motivating effects were found, but the boundary conditions of successful social interaction in this context are not clear. In line with this, Schmidt et al. discuss fitness trackers from the viewpoint of sustaining motivation for using them. They suggest that current trackers are technically sufficient in their ability to capture exercise data, but they fail in supporting users' motivation due to the data not being connected to a clear personal fitness goal. In a small group study on teenage girls, Toscos et al. investigated the effect of forming virtual peer groups to support exercise motivation. In a post-trial questionnaire, the participants rated group performance to be the strongest method for motivating behaviour change. Engaging in virtual peer groups appears to transform exercise from a solitary self-monitoring activity to a shared experience. Fausset et al. report on a two-week trial where older adults were given fitness wearables to use within their everyday life. Despite initial enthusiasm, only three of eight participants reported continued intention to use the technology. Inaccurate data collection lead to lowered motivation and trust in the device. Uncomfortable design and a sense of wasting time when using the device were also problems. No users reported issues with the ease of use of the devices in the trial. Fritz et al. interviewed thirty wearable users who had of their own volition adopted the devices. The duration of use ranged from 3-54 months. The sample was slanted towards technology-related professions and early adopters. Results suggest that it is beneficial if the system allows support for social interaction. Fritz et al. found, in line with Fausset et al. , that the accuracy of exercise data was highly important for the users; "appropriate credit for activities is essential for encouraging physical activity" . In a 10-month in-the-wild study of an activity tracker smartphone app, Gouveia et al. report that only 14% of the participants continued use of the tracker after two weeks. All of the users quit before the ten-month period was over. They found initial adoption to be correlated to the stage of behaviour change; participants who had identified a need and were preparing for an exercise-related behaviour change exhibited the highest adoption rate. Participants who were already active or in the maintenance stage of their behaviour change were much less inclined to adopt the tracker. As high rates of abandonment seem to be the norm for activity trackers, Harrison et al. investigated barriers to use and users' workarounds to the barriers. Their participants reported main barriers to be related to inaccuracy, design and lack of social functionality. Interestingly, Harrison et al. note that most of these barriers were identified in research already ten years ago, suggesting that fitness wearables have not evolved significantly in this time period. Lazar et al. also investigate reasons to abandon wearables; they conclude central reasons to be irrelevant data, too cumbersome usage and the devices not matching the participants' conceptions of themselves. Preusse et al. suggest in a study on older adults' acceptance of activity trackers, that targeting barriers could increase their acceptance of wellness devices during the deployment-phase of adoption. Meyer et al. also investigate factors influencing the acceptance and usability of wearables. For a recent systematic review on wearable wellness support, please see Warraich . Discontinuation of use is a clear trend in most studies on fitness wearables. Different writers suggest that sustained use might not always be a necessary goal; if behaviour change is achieved and maintained, the tracker might no longer be needed. On the other hand, there is little evidence that behaviour change is retained in the long run after discontinued use of the wearable. Wearables could play a role in sustaining healthy behaviour also after the initial behaviour change. Users in many of the studies call for social functionality. Also frequently reported are difficulties with the accuracy and meaningfulness of the collected data. Most of the studies focus on working-age participants, but some specifically target older adults . --- Dimensions of wellness Wellness is a concept, which is often described to contain different dimensions. . In our research we use the six dimensions most frequently mentioned by wellness researchers . The dimensions are interrelated to some extent, Figure 1. Physical wellness is supported by the other dimensions of wellness, and vice versa. In this research we are especially interested in the physical and social dimension. Physical wellness is probably the most well-known dimension of wellness. The benefits of physical activities have been proven in many studies . Physical wellness generally refers to an individual´s physical health, physical activity level, nutrition, self-care, and vitality or longevity . Social wellness is understood as an "appraisal of one's circumstances and functioning in society", components of which are e.g. social contributionthe feeling that one is a valued, contributing and important member of society, and social integrationthe feeling of belonging to a community and having something in common with those within one's social sphere . Humans have an inbuilt need of social interaction, and deprivation of social interactions is known to be detrimental to health . Loneliness is a known risk factor for the elderly, associated with a heightened risk for depression , Alzheimer's disease , and coronary disease as well as an increased risk of mortality among men . We believe that supporting social interaction and consequently social wellness through technology is possible, but the research evidence is only emerging and still scarce . Part of our aim is to gain knowledge on how social interaction can be mediated through technology in order to maintain wellness. With social interaction we mean not only faceto-face interaction, but also e.g. interaction that can be same time / different place, different time / different place. Physical activities are known to be related to the social dimension. Social support is known to be a positive predictor for physical activities . Especially for women this relationship is an important aspect . --- Participants and study design This is an exploratory study aiming at gaining a holistic picture to guide further research. We utilize multiple research methods to gain rich data; we employ focus groups, individual interviews, a six-week trial of the target technology divided into three twoweek phases with planned interventions, and finally quantitative measurement of the participants' activity levels collected with the Physical Activity Scale for Elderly instrument. The PASE results are not reported in this study, as they did not help us understand the participants better. For the study we recruited five participants, three men and two women, all between the ages of 60-75. All participants were smartphone and computer users, three of the participants also used a tablet computer. None of the participants had experience of wearables. The participants were chosen through purposive sampling with a clear definition on the desired participant profiles. We wanted participants with smartphone experience, within the age range 60 to 75 years old and both male and female. Ellen, born 1940 has a master's degree in education and has worked in primary education as a language teacher until retirement at age 68. She is divorced and has a yearly income between 30 000 -40 000 euros. She uses a computer, a tablet and a smart phone. In her free time she goes to the gym, reads and does handicrafts. For the study we had access to the fitness bracelets Fitbit Charge and Polar Loop. Both bracelets offered similar functions: a pedometer, sleep monitoring, watch, and keeping track of reaching a daily activity goal. The Fitbit allowed forming groups of users who could follow each other's activity levels and send messages to each other. The Fitbit had the possibility of vibrating alarms. Two participants used a Polar Loop, the Fitbit Charge by the remaining three. We divided the study into three two-week long phases: Phase 1 The first phase of the study started in September 2015. Each of the participants was invited to the research institute individually for getting started with the study. The bracelets were set up at the institute together with the participants. The main functionalities were shown individually to the participants and possible questions were addressed. Participants were encouraged to be in touch if any questions or problems would arise. The pilot group was asked to wear the bracelet on their non-dominant hand. They were instructed to only take the bracelet off while showering/going to the sauna /swimming or while charging it. The activity bracelets synchronized automatically with the phones, throughout the day. After two weeks, a telephone interview was made. At the same time the participants received instructions for the following two week phase of the study, phase 2. The participants with the Fitbit charge activity tracker were connected with each other, so that they could follow each other's achievements on the Fitbit application. We wanted to test if this social aspect would have a motivational impact on the users. No manipulation was conducted with the Polar Loop users. After two weeks a telephone interview was again conducted. Also the participants received new instructions for the following two week phase of the study, phase 3. --- Phase 3 The Fitbit Charge users were promised a free lunch, if they could exceed their steps with 5% from the previous week. All of the three participants managed to do this within the given time-frame. Polar Loop users were not manipulated. At the end of phase 3, a phone interview was conducted. --- Findings --- Practical insights All the participants completed the six-week bracelet trial successfully and had an overall positive experience. There were some practical issues hampering the usage and usefulness of the bracelets however. One concern shared by all participants was that they like for the wearables to measure also other kind of exercise besides steps, such as cycling, swimming and stretching. Also incidental exercise, such as lifting things or working in the garden does not get recorded. The sleep monitoring was found useful, but not always accurate. At times, the bracelet seemed to record sleep, even if the user was awake. The design of the bracelets themselves received some criticism. The Fitbit was difficult to attach on the arm. The attachment is not secure; the bracelet falls off occasionally, even during the night. The Loop on the other hand was difficult to adjust to the right size; to cut the bracelet and get the pins in place. The Loop attachment was also not secure and would open occasionally by itself. On both bracelets, the text on the screen was easy to see. The information received from the bracelet was seen as enough. The participants lifted out the risk of getting too much information. Also the participants voiced that too many features might become confusing. An annoyance was that when charging the wearable, it shows as inactivity on the application. The participants felt using the bracelet to be motivating. They moved more and checked the steps regularly and made an extra effort to collect enough steps. The achievements during one day mattered more, than the overall weekly report, since the days are so different. --- General observations Even in this age group, people are not free from peer pressure. One member felt, that it is embarrassing to use a smartphone; many of her friends have not been using computers at work and thus have a skeptical attitude towards technology. This means that elderly taking into use new technology, such as a s fitness bracelet, might benefit from e.g. encouragement from people who matter to the person . Things that restrict or hinder the participants from exercising were discussed. The fear of walking alone and not wanting to travel too far in order to be able to exercise were mentioned. The participants were also encouraged to discuss things that might restrict their friends from exercising, in order to lower inhibitions or shame associated to not exercising. Different ailments were mentioned as an obstacle. Being lazy and being too comfortable at home on the sofa were brought forward, and on the other hand that it is difficult to start something new and take the first step. Other activities might restrict participating in physical exercise, such as devoting time to taking care of grandchildren. Being worried about the way one looks might be a restriction. Also there is a worry that gym personnel or personal trainers are not necessarily knowledgeable or interested in the exercise needs of the elderly. The focus group participants felt motivated to exercise due to the bracelets. One of the participants was not a frequent walker before the study, but reported finding the joy of being outside through the bracelet trial. The participants reported also other things which motivate them to be physically active. A dog was mentioned as a great motivator for getting outside, also alleviating the fear of walking alone mentioned by the women in the study. The feeling after exercising is motivating, as well as the physical effects of it, such as losing weight and noticing an increase in your flexibility. One of the themes of the concluding focus group session was different campaigns to promote exercise participation. The focus group participants found benefits in being a member of some social group and doing something together. But they also identified restrictions in this; you cannot walk as fast as you would like to and you have to decide together on a suitable day and time. Virtual campaigns, where the participants are not necessarily exercising at the same time or in the same place on the other hand were criticized for allowing participants to fake that you are doing something while you are not. The functions that the participants hoped for in a bracelet were a 'stop snoring'-alarm and reminders. They also hoped for alerts when the users' patterns change from the normal, such as sleeping more or less. Body temperature measurement was wished for, as well as possibility to share the data easily with others. The wearable needs to be durable and comfortable to wear in all activities, so it is not forgotten off the hand. It needs to endure swimming, sauna, dirt etc. They also hoped for a GPS function to increase their feeling of safety when moving outside. --- Introducing the social dimension Current research on fitness wearables indicates that they fail to engage users in the long run. Despite giving the user access to more accurate data on e.g. exercise and sleep than is possible through apps, but something seems to be missing. We wanted to investigate what, if any, impact including a social dimension would have. The participants in our focus group shared many common characteristics, but were not members of the same social network from before. Linking three of the participants together with the bracelet and smartphone app had some effects on their exercise behaviour. They reported experiencing positive peer pressure and elements of competition through seeing each other's achievements. They followed their peers actively and increased their own exercise in order stay ahead of the "competition" or "not be the worst". Also when we at phase 3 applied some external pressure through promising a reward for all participants who increased their step count with 5% or more, all respondents did reach the target, but they reported their main motivation behind it to be keeping abreast with the other participants rather than the reward. The participants also spontaneously started to send each other supportive messages. The virtual social group enabled the participants to have the feeling of being part of a social activity, without having to deal with the practicalities of actually exercising together and losing their autonomy and independence. --- Discussion Based on our experience, we believe that introducing functionality to the young elderly in a sequential manner, rather than all at once, might help overcome adoption-related challenges. An overload of functions is likely to happen when introducing a new device, which might cause confusion to such a degree that satisfaction is low and the will to continue using the device is impacted. The young elderly focus group had a clear interest in the wearable, even though they do not match the usually advertised target group. Introducing a social dimension to the wearable seemed beneficial as the young elderly quickly formed a both supportive and competitive relation. This is a novel finding, as 647 previous research has not highlighted the importance of building in support for the social dimension of wellness in wearables. The social connection formed through the device appeared to be value adding for the participants. The social dimension spurred on the participants to maintain or even increase their level of physical activity, which in itself is an important finding with implications for wellness service design. It seems to at least partially address the previously identified barrier of meaningless data, as giving a social context to the users' data made it more interesting. As a consequence of this, adding a social dimension would likely aid in lowering the abandonment rate of wellness wearables. The comparison to other users also had a direct impact on the decisions the users were making; the participants could see that their peers were ahead of them in steps and then decide to make their daily walk longer. We found it interesting that the competitiveness was so present and motivational also in this age group. It remains a challenge for future research to investigate whether it is prevalent in the young elderly, and whether it differs between cultures. The trialed devices allowed for social interaction, but we found the functions somewhat limited. With regard to the fact that the social dimension seems to be highly important for motivation, we suggest device manufacturers to put efforts into developing this dimension. For example, the pedometer data is rather one-dimensional and as such might not sustain interest for too long. Adding information about the users' average speed or length of average walks taken might be interesting for the social group. A social function that the participants hoped to see in future devices was the possibility to see where friends are located in order to join them for exercise. We did not continue to formally follow the participants after the two-month trial, but we have knowledge that at least two of the participants still use the device daily, eighteen months after the trial. This is in itself interesting, as in most studies such long-term use is not achieved. We assume this might be related both to the sequential introduction of functions and the role of the focus group administrator, but this needs to be investigated further. Limitations of the study at hand include the impossibility of replicating individual case studies and the fact that the results and findings might be different if the study participants would have had a different demographic profile, e.g. have less prior knowledge of technology. On the other hand, our study design enabled us to gain a very rich picture of the participants, which will be helpful in informing and designing future studies. To address the limitations of the current study we are continuing our research with a larger, more heterogenic sample and with different research designs . --- Introduction In the past, the predominant view on IT strategy was a functional-level view. IT strategy was treated subordinate to a deliberate business strategy and needed to be aligned with it Yet, any strategy needs a matching organizational design in order to be carried out. The organizational design may unleash organizational capabilities , which in turn can translate to a competitive advantagethe overall purpose of strategy . Any change in strategy requires a change of organizational design . Thus, organizations that pursue a DBS also need a matching organizational design that is different from "traditional designs" it summarizes the prior knowledge, the scope of the research question is relatively broad, the search process is comprehensive, the identified literature is of conceptual and empirical nature, the identified literature is selected via certain predefined selection criteria , due to the relatively young phenomenon of DBS, an appraisal for only high quality is not the focus synthesizing and analyzing the identified literature centers thematically around a given framework . A detailed and systematic search process is important to yield a rigorous, unbiased, objective, transparent and replicable review. Therefore, a review should provide explicit information on how the literature is identified, selected, assessed and synthesized. First, it should outline the research question, sources searched, search terms, search strategy and inclusion / exclusion criteria. Afterwards, the actual search is performed. The relevant literature is selected according to the chosen selection criteria and subsequently analyzed. Evidence is summarized and presented . The research questions, already presented in the introduction, is "What is the state of knowledge on organizational design in the context of digital business strategy". The initial keyword search for the topic relevant literature is conducted by drawing on 50 major IS journals and 16 IS conferences as proposed by Levy and Ellis . It is complemented by the Financial Times 50 list . In doing so, the scope of our search covers the dual aspects of DBS and organizational design for this study, i.e., management literature on the one hand and IS literature on the other hand. In the following, the three major steps to conduct this literature review are presented: keyword search, backward search and forward search : The keywords applied for searching within the journals and conference proceedings are "digit* business strateg*" OR "digit* strateg*", whereby asterisks are placed to cover any variation of the words. The keyword search is applied to peer-reviewed only and title, abstract and keywords fields . The selection for relevant articles takes places by reading the title, keyword, and abstract first . The criteria for judging the relevancy of the obtained articles is an explicit linkage to DBS and linkage to the organizational design framework . The next step is to perform a backward search, i.e., reviewing the citations of all relevant articles identified during the keyword search. Applying the same selection criteria for the backward search one obtains relevant prior articles that should be considered for this study. Finally, the last step is the forward search, which is the process of identifying relevant articles that build on the previously identified articles, also known as cited by. For this process, Web of Science and Google Scholar are used because --- Findings The following subsections present the findings of the identified literature on DBS and organizational design along the framework's components of strategy, structure, processes, rewards, and people. Whereby, the appendix includes a summarizing table "Table 2 Concept matrix of analyzed articles and organizational design components" and figure "Figure 1: Cumulative articles published on DBS and organizational design components". --- Strategy Following a DBS implicates establishing new capabilities, e.g., process-, customer and performance management . Specifically, organizations desire an increased agility and responsiveness, multi-channel ecosystem connectivity, visualization and governance of data and information. In order to obtain this, organizations need to invest in multiple IT-enabled efforts . In fact, Mithas, Tafti, and Mitchell show that under higher industry dynamics, organizational spending differs for DBS related activities and vice versa for industry growth and concentration. Technology related investments may allow organizations to solve ambidextrous strategies, like a DBS, because it often involves pursuing multiple goals at once e.g., by following revenue growth and cost reduction at the same time . However, Woodard, Ramasubbu, Tschang, and Sambamurthy show that organizations are path-dependent when it comes to designs of their existing digital artifacts. The authors refer to "design moves", resulting options/debt of past investments that enable/constrain strategic actions of organizations. Strategic paths can also be disrupted via a destabilization of self-reinforcing mechanisms resulting from digitalization . Though, DBS is not only about optimizing internal operations or responding to single competitors, it is also about the responsiveness and awareness of the whole competitive environment . This may open up new choices for digital business models, like Netflix, who first started with efficient delivery system of physical DVDs and later, due to digitization of media, the organization seized the opportunity and became the market leader for online media streaming . Therefore, IT does not just support strategic goals but increasingly becomes an enabler of strategic goals . As strategy originates from the decision makers understanding of environmental influences , for DBS, this is the case for pervasive digital technologies . Digital technologies are an integral part of DBS formulation . In line, the identified literature shows, that many DBS of organizations encompasses engaging in harnessing digital technologies to gain a competitive advantage and differentiation. This includes engaging in social media for various purposes. Organizations increasingly use social media such as wikis or blogs for internal and external communication and collaboration . Yet, social media is much more of just another customer touchpoint. Next to wearables, tracking customers via cookies or app permissions etc., social media is a valuable source of information. For example, combined with data analytics it yields customer insights and a better customer understanding . Analytics can provide meaningful insights and enable organizations to scale recommendations and offer products and services on a highly personalized level . Thus, the analysis of large data is often an integral part of DBS to e.g., become a more customer centric organization because "[…] the buyer, not the seller, determines which dimensions of value matter and how offers compare" . Other application fields of analytics within DBS also include the support for strategic and tactical decision-making and business processes . In sum, analytics of large datasets are a key under DBS and has the power to create a sustainable competitive advantage . Next to social media and analytics, cloud computing is also frequently mentioned within the identified articles. Yet, Goutas, Sutanto, and Aldarbesti highlight, that many organizations simply adopt it without having a clear DBS. In order to unleash the full potential of cloud computing, it not only has to fit to the existing processes and systems, but also has to be part of an overall DBS. DBS on cloud computing usually encompass the intention for optimization, innovation and/or disruption . Nevertheless, the overall focus should be the value creation to customers by e.g., increasing software security and customization. Only then, cloud computing enables DBS to transition to new, digital business models . Likewise, in a qualitative study Cowen, Johnston, and Vuke show, how cloud computing increasingly becomes an integral part of organizations DBS in a developing country. Their main findings indicate that via cloud solutions, organizations achieve a better return on capital, improved quality and efficiency, better customer relationship and innovation acceleration and it has a cultural impact. Finally, Ross, Beath, and Sebastian . Overall, " […] a strategic focus that directs their technology spending [on] social, mobile, analytics, cloud, and internet of things technologies" , is needed to foster new capabilities that make sense for DBS. --- Structure To implement a DBS successfully, organizations have to align their structure correspondingly. Literature shows, that there are several common practices for DBS. In general, Catlin et al. emphasize, that the governance and operating model need to fit to the organizations "digital maturity". Together with an increasing digital maturity a lot of the organizational functions become decentralized and embedded in business unit activities. Increasingly, organizations create units that consist of cross-functional teams e.g., of technology and operation for business lines, to achieve a better responsiveness . Others contributions highlight the launch of innovation labs detached from an organization . In sum, organizations need to decide how to integrate digital operations into their existing structures or separate it from the core business . Additionally, DBS needs to be communicated organization-wide by the senior management and managers at all levels across an organization should be enlisted in technology decisions. In so doing, Mithas and Lucas and Sia et al. point out, that the CEO, CIO and the senior management need to work tightly together to execute a DBS. For example, the "CIOs must engage their business counterparts to shape IT decisions and create buy-in for IT efforts" . Likewise, not all power over the DBS should be located at a single department, for example, at the marketing department, which might only lead to customers' attention shortly but will not provide sustainable value . Some organizations introduce a Chief Digital or Data Officer , a dedicated position within an organization who is in charge of the DBS. In this case, too, interactions and collaboration between the CDO and the other management is critical for DBS success. The CDO role, tasks, responsibilities and reporting structure need to be articulated clearlyparticularly with respect to the CIO as a neighbored manager . Especially, since it is known that a tight CIO-CEO reporting structure is beneficial for differentiation . Thus, the reporting structure needs to fit to the DBS of an organization. In sum, DBS affects the whole organizational structure along with the power over the DBS execution, which may vary from organization to organization . In line, Matt et al. come to the conclusion, that there is no distinct answer, who should be in charge of the DBS. --- Processes As introduced, the component processes refers to any connected activity that is linked with the information flow within and across the organization. The following paragraphs highlight the information flow within an organization, the information flow from the outside in and, from the inside out of an organization. First, the credo for DBS is "what can be digitized will be digitized" to cut costs and increase service quality. Therefore, digitization, optimization and standardization of processes are imperative to allow for e.g., straight-through processing or and rapid product configuration . As already mentioned for the component structures, teams from different departments or innovation labs are a common practice. The intention is to achieve a culture of experimentation, agility for innovation processes and an increase in the speed of product launches. This includes "test-and-learn" processes and allow failures as an example for new product development and as a part of the innovation process . It is increasingly encouraged that every employee can participate and give feedback . Additionally, social media is often used to internally or externally crowdsource ideas . Under DBS sophisticated customer service processes are gaining more and more importance to achieve customer orientation and customer response in order to answer changing customer demands. Setia, Venkatesh, and Joglekar exemplarily state that for "[…] the sophistication of customer service processes and goals of customer service performance, firms may customize their initiatives to build effective digital designs across customer service units". Second, nowadays organizations usually operate within whole business ecosystems and make use of shared products and platforms and processes become increasingly commoditized. Markus and Loebbecke introduced the term "commoditized processes", which are processes that are conducted in the same way, for example by using SAP or Salesforce. In contrast, standardized processes can still be customized individually e.g., an industry norm. Organizations that use commoditized processes do not necessarily have to interact in some way, but it can accelerate activities like partnering or outsourcing . Yoo et al. point out, that it can be a challenge for organizations to coordinate and manage distributed and dynamic processes of maintaining and designing IT infrastructures at a corporate level. Nevertheless, it is not a question of if but how to interface to customers, partners and suppliers because they are a critical source of innovation under DBS . More and more, organizations need to be able to integrate and process heterogenic internal and external information and knowledge resources. Being able to combine and store data from various databases can be used for different fields of application , such as a seamlessly omni-channel experience for customers or speed up the decision making process by using e.g. real-time business intelligence . In addition, it becomes increasingly important to not 660 30 only know the customer but also to process and lever relevant information e.g., via analytics as shown in the subsection strategy . This also requires integrating different sources of information such as new channels like apps, social media and webpages, not only with traditional offline channels but also with the inventory management system . Third, in today's world of ubiquitous information, stakeholder of an organization like their customers are empowered, well informed and want organizations to be transparent about their product quality, features, etc. in order to trust them . Therefore, organizations need to take care of the process, which and how information flows from the inside out. Granados and Gupta argue that transparency is a relevant part of DBS and organizations should selectively and strategically disclose information to their stakeholders. Nevertheless, Grover and Kohli debate, that organizations need to be cautious about exposing systems' software, process, and information, which might expose strategic intentions to competitors and thus potentially give away a competitive advantage. In line, Dewan, Freimer, and Jiang highlight that transparent information, such as stock and price information, could also be used by competitors and not only by customers. In sum, under DBS the information flow out of an organization can be described as a balancing act of giving away just the right information to stakeholders . --- Rewards The organizational design component rewards shows the fewest results in the literature. Only Catlin et al. emphasize that organizations need to reward a more risk-taking behavior, which should yield in a test-and-learn culture. However, the authors are not explicit on how this behavior is rewarded only that "digital spend [should be] measurable in terms of return on investment." . Similarly, when it comes to the specific person that are in charge of the DBS endeavor, their incentives should be directly linked to the target and progress of the DBS . --- People The role of digital talents is crucial for organizations that engage in DBS because new skillsets are required as digital technologies impact organizations at large . For example, it requires managers not only to think in terms of business or IT but with a deep understanding of DBS . Specifically, competencies and knowledge is required on how to synchronize IT and business strategy, IT governance, implement IT projects, and manage the organizational IT infrastructure in order to be successful in DBS . Leaders need to be open towards innovation and know how digital technologies and ubiquitous information affect their organization. This also includes an organization's ecosystem, which consist of their Limitations of this literature review exist because, for example, an organizational design perspective is adopted, which inhibits an in depth examination of DBS from an ecosystem perspectiveanother important aspect of DBS e.g., Pagani . Additionally, only literature is included that explicitly refers do digital strategy / digital business strategy and components of the framework. This contribution has practical and research implications likewise. The practical implications highlight the need for a suitable organizational design under DBS. In doing so, this review also shows practical audience, common organizational shifts for the components strategy, structures, processes, rewards and people. These design components are directly under the control of leaders and, therefore, organizations pursuing a DBS can draw from these insights and transfer them to their organizational context. Moreover, companies should reconsider existing portfolios of single DBS speedboat initiatives and treat them in a more holistic manner by orchestrating them. By doing so, the initiatives complement each other meaningfully and unleash their full potential. Common research implications for literature reviews are uncovering research gaps and pinpointing possible future research questions. Thus, a review typically can give guidance for future research . For strategy, future research directions encompass how and which single and formerly isolated digital technology solutions complement each other. Due to this, future research is emphasized to yield an integrative and holistic picture of digital technologies under DBS. In addition, mobile devices are getting smarter and mobile data traffic is increasing exponentially . Yet, their implications for DSB are still not fully examined and require future research. For the component structure, one can observe heterogeneous approaches of organizations. Therefore, an analysis of which structure may lead to superior organizational performance is emphasized. This may include reporting structures and distribution of power in general, new roles like the CDO, team settings like cross-functional teams etc. For the component processes, integrating and analyzing different sources of large amounts of information becomes increasingly important differentiator and a source of value. Yet research at the intersection of DBS and digital business infrastructure, i.e., how do incumbent firms build a digital business infrastructure, is still scarce. Another research gap is evident for the component rewards. Future research may look at how to harmonize individual behavior with DBS, including metric and measures. Finally, organizational design can influence not only organizational performance but also organizational culture . Organizational culture is an output of the "[...] cumulative design decisions that have been made in the past and of the leadership and management behaviors that result from those decisions." . This means leadership cannot directly influence organizational culture but indirectly via the organizational design. The impact of DBS on organizational performance has been proposed and examined in some recent contributions, e.g. . However, little is known on how culture changes or looks like under an organizational design for DBS. Therefore, future --- Introduction In the era of the Internet of things the information and communication technology is used to support everyday tasks of people . The number of different smart or magnetic stripe cards, keys and various other devices for personal identification, financial transactions, unlocking of doors, etc. has become unmanageable. When near field communication became available on mobile phones, some cards were offered as a mobile service. To increase security, most of the magnetic cards were equipped or replaced with radio frequency identification device microchip and NFC possibility. RFID microchips can be used for shopping, health care services, logistics, car industry and domestic usage. During the research on diverse types of personal identification, questions about a unified type of identification arose. People are no longer willing to operate with the diversity of identification cards and passwords needed to efficiently manage their professional and personal life. Recent studies have shown that the RFID technology is secure enough to be used for personal identification and some attempts were made to use RFID subcutaneous microchip implants . Body-implantable devices for non-medical purposes are emerging as a hot topic that has the potential to permeate throughout society . According to Graafstra , the attitude of consumers has changed from being unaware about the possible usage of RFID implants to general acceptance of RFID implants as a kind of jewellery. In recent years, people are becoming aware that the RFID-SM present a plausible future . Heffernan, Vetere & Chang even introduce a new concept called "insertables". Nevertheless, some researchers still explore the potential negative impact of enforced microchipping , while others look for highly positive effects of RFID implants. Namely, implantation of RFID microchips in tumours may provide a new method for cancer treatment . The literature review showed several attempts to research the readiness of RFID-SM adoption from the provider's viewpoint , while only a few of them dealt with the endusers . In addition, most of the studies are focused only on RFID-SM usage for the healthcare purposes. This research is a continuation of the research conducted in 2014 , when readiness of potential RFID-SM users to adopt the microchips in their everyday life was researched. There are two reasons of survey repetition and upgrade: • The attitudes towards technology acceptance change rapidly, so we wanted to compare the new results with the results from 2014, Basic TAM model proposes three positive relationships among constructs. Two of them were supported, while one was rejected. The positive effects of PU on BIU and positive effects of PEU on PU were supported. Hypothesis H5c regarding positive effect of PEU on BIU could not be supported. This is in accordance with the finding of the research from 2014, where this relationship has also not been confirmed. That result shows that ease of use is not an important predictor of BIU. If the respondents find the microchips useful, then they would implant them regardless their availability and handiness. The impacts of Age on BIU and of the Painful Procedure on HC are the strongest in the model. The variables PU and BIU have three significant predictors that can explain 51% and 58% of its total variance, respectively. HC have a negative effect on both PT and PU , where the impact is slightly stronger to the PT. PT has a positive impact on PU as well as direct effect on BIU . As expected, Age has a strong direct negative impact on BIU . --- Conclusion Since most of the research has studied the willingness to adopt RFID-SM technology from the viewpoint of providers , and only a few studies dealt with end-user willingness to adopt RFID-SM, we decided to research this gap in 2014. The research topic is rather delicate. There are ethical questions whether or not should we put something unnatural under our skin. Hundreds of deaf people with hearing implants will surely not reject interventions in their bodies to enable their hearing. The same goes for patients with cardiac pacemakers and diabetes patients. There are thousands of orthopaedic patients with different implants. In the first research, back in 2014, no statistically significant correlations between the attitude towards earrings, piercing and tattoos and willingness to use RFID-SM existed. Although we would expect that the people willing to puncture their skin just to change their appearance, would also be prone to RFID-SM if they find the advantages of such system inspiring. Most of the researched items showed a slightly more positive attitude towards the RFID-SM than two years ago. In addition, people are less concerned, since all items on Perceived Trust have higher average values. In addition, the recent results again showed that Perceived Ease of Use does not have a statistically significant influence on the Behaviour Intention to Use. The fact the implantation of RFID-SM is a painful procedure, positively influences the concept of Health Concerns. Although the Perceived Trust has slightly raised, Health Concerns are still evaluated as significant predictor of Perceived Trust and Perceived Usefulness. The result showed that the attitude towards the RFID-SM implantation is still negative. The respondents probably do not realize that most of the medical implants work the same way as an RFID-SM. According to the results, most of the issues on RFID-SM adoption perceived by the end users are slowly losing their importance. Due to different reasons, public has become more open to the possibility of using the RFID-SM for different purposes. Therefore, more studies on the safety of RFID-SM should be conducted. New, preferably less invasive ways to enable a unified personal identification should be proposed. This paper presents only the results of the survey conducted in Slovenia, therefore, our further research will include the results of the surveys gathered in other European countries to establish whether similarities in the attitudes toward RFID-SM adoption exists. A general extended TAM model for the intention to use the RFID-SM will be generated, where also an impact of privacy rights and privacy threats on Perceived Trust and indirectly on Behaviour Intention to Use will be examined. --- Introduction The use of Social Media has increased considerably within the last years. Today, social networks such as Facebook and Twitter report 1.8 billion respectively 320 million active users . Users of these networks not only share their opinions on products or companies or complain about products or services. They also share personal information that are potentially relevant for an interaction with companies . For companies, using information from these sources might be valuable since they originate directly from the customers them-selves. This development drives the necessity to automate the acquisition and pro-cessing of social data and to integrate it with Customer Relationship Management applications. This interconnection of Social Media on the one and CRM appli-cations on the other hand is referred to as Social CRM . This concept is a means to meet the personal agendas of a company's customers and therefore requires personalization based on additional cus-tomer information. As today's customers expect collaborative and personalized interactions with com-panies most businesses declare customer-orientation as a part of their business strategy . However, there are two different notions of customer-orientation, a seller and a buyer perspective, and this research adopts the latter, which refers to the customer and his respective benefits. This perspective is also named outside-in perspective and contrasts the in-side-out perspective . This paper suggests that context information are an adequate and promising means to satisfy this expectation and to understand the higherorder needs of a customer. Context is relevant to many interaction scenarios between providers and consumers and might lead to a new understanding of the customer, who actively influences and orchestrates the configuration of products and services across multiple providers . In addition, the current paper adopts the perspective of customer-dominant logic , an approach that places customers in the center of business activities and pursues an outside-in perspective. This requires that businesses understand their customers in terms of their respective situation that usually is not part of classical CRM applications. This paper argues that highly relevant information can be cap-tured from additional data sources, such as Social Media. To answer the research questions, two research methods are applied: First, a struc-tured literature review was conducted in order to clarify both the term customer con-text and its constituents and to finally derive a context model. Second, a mapping of the constituent context elements with Social Media data is provided. To achieve the research aim, the paper is structured as follows: The second chapter introduces the conceptual foundations, i.e. the CDL and Social CRM. Thereafter, chapter three pre-sents the literature review and derives the model as well its elements and finally de-scribes the matching. Chapter four discusses the findings and, finally, the paper con-cludes with a summary and the formulation of future research questions. --- Conceptual foundation --- Customer-dominant logic The term and concept of CDL originated from the fields of relationship marketing and service research . Compared to other approaches, such as the service-dominant logic , CDL is a perspective on business from a cus-tomer's viewpoint and therefore emphasizes how customers embed services in their lives rather than how businesses can provide services to custom-ers . CDL therefore answers the question "What can we offer to customers that they are willing to purchase and pay for?" instead of asking "How can we sell more of our existing offerings?" . In order to answer this question, businesses need to apply ade-quate methods to understand customers and their logic. The concept of CRM, which is a combination of customer-oriented strategies and technologies, aims at long-term profitable relationships and of-fers means to better understand customers. However, CRM systems offer an inside-out view on a customer, i.e. they create customer profiles that hold information about customers that are known to a company from past interactions. A complementing approach is the outside-in view as mentioned before which contributes information from the customers themselves and therefore complements classical customer profiles. This view might also con-tribute to a firm's competitive advantage as market requirements can be anticipated ahead of competitors . Hence, traditionally stored customer information is rather static and needs to be complemented by rather dynamic information . These initial considerations drive the need to enhance the concept of a CDL by proposing the application of a deeper understanding of the customer. --- Social Media and Social CRM Social Media can be defined as web-based internet applications that allow the crea-tion, access, and exchange of user-generated content . Kaplan and Haenlein propose a classification for Social Media which encompasses among others social networking sites and micro blogs . Facebook and Twitter are amongst the largest Social Media and contain millions of public postings each day. These channels represent platforms for the information exchange between customers and are therefore a valuable source of customer and context information. For example, a single tweet delivers up to 60 different attrib-utes that help in further enriching CRM data with information provided by customers themselves . The term Social CRM denotes a customer-oriented concept that integrates Social Media with CRM applications and thereby opens a broad spectrum of potential use cases in the area of marketing, sales and service . Among the examples are to derive knowledge on target customers and influ-encers or on product improvements as well as online customer interaction. It there-fore widens the understanding of classical CRM applications as it includes the out-side-in perspective on a customer. An important element of Social CRM is the inte-gration of unstructured data from the social web, such as product-or brand-based data and further context elements. This requires techniques for monitoring and ana-lyzing social content and integrating results into CRM processes. In this context, Reinhold and Alt proposed five task areas as elements of an integrated Social CRM. Here, Social Media Monitoring forms one of the components and aims at au-tomatically identifying business-relevant information. The related monitoring steps and their respective outcomes are described and further consolidated in literature . --- Elements of a customer context model for Social CRM --- Defining customer context The literature review followed the methodology suggested by vom Brocke et al. , which comprises the steps defining the review scope, conceptualizing the topic and the literature search itself. Starting with the first step, the scope of the literature review followed Cooper and focused on research outcomes and theories . It aimed at the integration of existing knowledge and was conceptually organized to cluster similar works. The perspective may be characterized as a neutral representation for both specialized scholars as well as practitioners as the target audience. The results are finally repre-sentative for the IS community as respective data sources were queried. After screening all publications, the relevant contributions to the understanding of customer context were selected . While analyzing the papers in detail it was found that they contribute to either a definition, the understanding of elements or a classification of the latter. The following table presents the resulting papers and indi-cates their main contribution. The results in the table show that solely one research paper provides besides a def-inition of context also dimensions and associated elements whereas most papers provide information on solely one of these aspects. Both context dimensions as well as models are sparsely described in current research as indicated above. Definitions of context are applicable to different spheres of life and are either comparatively broad or enumerative and therefore do not foster a com-mon understanding of the term. However, there are papers that consider the cus-tomer and his environment as relevant components of context which aligns with the customer-centered view of context within this paper. In addition and from a Social CRM perspective, context is conceived as additional information originating from the customer , which is called outside-in perspective in the follow-ing. It furthermore intends to supplement the existing inside-out view on a customer . Therefore, this research defines customer context as customercentered, dynamic and domain-independent infor-mation that might be used in different spheres of life and provide additional information about the customer and his environment. Given this definition, a further specification of context by defining its constituents is necessary and described in the following. --- Databases --- Structuring customer context In addition to the above-mentioned definitions of context, literature also provides a framework for structuring customer context respectively describes specific context elements. For this research, the schema of Nemoto et al. fits best as it is the only framework that suggests context dimensions, clusters context elements within these dimensions and aligns with the view on the customer and his environment. The other papers found mainly discuss definitions and elements and only a few mention related context dimensions. The resulting model summarizes context elements provided in the reviewed literature and is extended by examples for each element. It has to be considered that the given list of context elements is not exhaustive. However, the model differs the two before mentioned perspectives on context information, i.e. the customer and his environment. The characteristics of these information are furthermore distinguished into individual or global on the one and longterm or short-term validity on the other hand . With regard to a Social CRM system, individual context information belong to a specific customer whereas global information form the basis for describ-ing customer segments. Gathered With regard to customer profiles, the attributes in the model describe the before mentioned action, reaction, personal and potential data and enable businesses to complement or enrich their customer profiles. This serves as a basis for Social CRM processes such as for example customer segmentation and campaign management. Within a Social CRM the most relevant source of data are Social Media as they ena-ble businesses to get closer to the customer than ever before and pro-vide a rich set of data about customers and customer segments. Wearables, such as smart watches, are a second source of information. They deliver relevant user-centered information such as pulse rate, activity level, pedometer, altimeter, loca-tion, time, distance, or temperature. Especially health-related information from those devices are regarded as an addition to specific medical devices, such as heart rate monitors, which are a further source of information and may possess a higher accuracy of data capturing as they are calibrated and approved. --- Context elements from Social Media With regard to a Social CRM application, two principle methods of context infor-mation acquisition may be distinguished . The first method is a direct user input as a response to an input prompt. This may be the case when a customer inputs information himself, for example in order to search or configure a service offering . The second method is an indirect user input, which gathers data with or without a customer's knowledge. This may be the case when mobile applications automatically collect e.g. location data in order to offer relevant mobility services. This research focuses on the latter and assumes a conscious transfer of context information from a cus-tomer towards a company. In this setting, a customer is aware that certain data may be transferred. Capturing context from Social Media refers to the second method and may either be performed by using a social network's application programming interface or by using specific Social CRM applications or external service providers such as Google Fit . For example, using the Twitter API delivers the name of a user and the raw text of a tweet. Applications of Social Media Monitoring and Analytics on the other hand aggregate and interpret available context information and are able to create further information that were not available from the API. For example, based on a user's tweets SMA applications provide an overview about different topics a user is interested in and his attitude or sentiment towards these topics. Figure 2 summarizes both methods to capture con-text information from Social Media. The following table presents the results of a mapping between context elements from the model and available context information from the Twitter API. The matching refers to the indirect and mined method of capturing context in-formation and was conducted by reviewing all available attributes from the Twitter API and assigning them to a suitable context element in the model based on the attribute's description in the API. The table pre-sents directly available data elements, which are mainly related to the context di-mensions 2-4 . The contained information might be enriched by apply-ing e.g. SMA or Business Intelligence applications . However, especially for the first context dimension the derivation of information is necessary in order to obtain further in-sights. Based on the model and using the Twitter API, a software implementation could extract the given information and build a specific context model. By extracting fur-ther tweets from an individual, the model gradually completes. For example, the tweet text might reveal information on an individual's emotions, preferences as well as interests and thereby frame his "customer states". In addition, information such as coordinates and Finally, the user name, language and user description frame "customer attributes". --- Discussion Following Heinonen and Strandvik , the essential features of CDL are the business perspective, customer logic, offerings, value formation, and customer eco-systems. The results of this research contribute especially to the understanding of the customer logic and therefore improve the relevance of product or service offer-ings. Current research falls short in providing a common understanding of customer con-text with a structured collection of related context information and the instantiation with Social Media data. Therefore, this paper complements existing research by ad-dressing these aspects. As a first result and with respect to RQ1 this research pre-sents a definition of customer context in Social CRM settings and provides a concep-tual model to structure the concept and its constituents. As a second result and re-ferring to RQ2, the model is adapted with a non-exhaustive list of context elements found during a literature review. It builds on the results from multiple research disci-plines and therefore aims to be applicable to multiple spheres of live, e.g. mobility, communi-cation, and health. The paper then discusses several data sources of context infor-mation , focusing especially on Social Media as a rich data source. The pro-vided mapping shows that relevant context information are available within Social Media and relates them to the model. These results are discussed together with a CDL perspective on customer relation-ships. In CDL as a marketing perspective, customer logic is a concept describing a customer's activities, experiences, and goals . Each custom-er's logic is individual, can change and may be influenced or may change over time. Within a Social CRM, customer context is a spe-cific and structured enabler that helps businesses to understand this customer logic as it captures individual information, especially from Social Media, either by sensing or deriving context information. Customer context extends the often stressed 360° view on a customer by incorporating outside-in data with existing inside-out data and thereby puts the customer at the center of business activities. As a result, it is the basis to enable a cross-provider understanding of customers. This research provides the starting point for individualized, customercentered Social CRM processes based on the captured data from Social Media. The described context information might be used in Social CRM processes, such as the definition of personas, which represent specific needs, characteristics, or preferences of a target or target group or within a so called "social customer value dashboard", which contains weighted context ele-ments that calculate to a sum and provide information about the relevance of an offering for a target or target group. This briefly illustrates practical and exemplary application perspectives of the concept within a CDL strategy. Ultimately, these re-sults form the basis for businesses to answer the initially raised question "What can we offer to customers that they are willing to purchase and pay for?". --- Conclusions and outlook This research presents an analysis of current literature on customer context. It de-rives a definition of context, a model, context dimensions as well as specific context elements from literature in order to substantiate a common understanding of the concept for Social CRM. Thereafter, the paper describes a mapping of context ele-ments with Social Media data using Twitter as an example. As business environ-ments are increasingly competitive, the need to understand customers and their in-dividual logic is an inevitable success factor for them. Methods and sources for the collection of context information are discussed and it is postulated that especially Social Media deliver a large amount of data that may help to transform a company's inside-out perspective towards an outside-in perspective. However, the following considerations reflect on the limitations of this research and thereby formulate a short exemplary research agenda, which shall be addressed by future research. The aspects reflect on the application of the concept, the investiga-tion of benefits for both customers and businesses and the necessity to control the access to context information:  First, it is necessary to further research on the proposed model's applicability to service providers and extend the given list of context infor-mation. Furthermore, an application of the model to other application fields, such as medicine, shall be addressed and could be beneficial. With respect to the openEHR standard for Electronic Health Records possibly valuable context information could supple-ment clinical information such as basic information, medications list, thera-peutic precautions and the social situation. For example, using a case study approach could identify further context elements and application fields of rel-evance. ---  Second, further research also needs to answer the questions of how to mod-el and digitally represent context information. For example, XML notations and annotation models may be a suitable digital representation of context information to be exchanged be-tween application systems, such as Social CRM and recommender systems. ---  Third, research needs to address the resulting benefits that may arise from the incorporation of customer context into product or service offerings from both a company's and particularly from a custom-er's perspective. For example, a presumable selling potential could be based on a specific demand. ---  Finally and within such a customer-centered and data-based business strate-gy, privacy aspects are highly relevant and need to be considered by further research. The argumentation of this research is based on the assumption that publicly available data can be used within a business context but rising questions on privacy, data sovereignty, data usage, and data control still have to be answered to prevent a misuse of social data which entails latent risks e.g. for personal rights . With regard to the data control aspect, a proposed solution is a customer-owned "context app" which provides a central control mechanism to the user. For example, a cus-tomer could decide selectively, e.g. during a service configuration process, which additional context information he will provide in order to configure a service congenial to his need. With the rising use of Social Media on the one and the also rising demand of collaborative and personalized interactions with companies on the other hand, the latter need to apply methods to better understand their customers. Customer context is a promising means to achieve this aim as it helps to under-stand customers and their respective needs. It therefore helps to bring customers and companies closer together. --- Introduction The most used integrated software solutions in companies from almost all industries worldwide are Enterprise Resource Planning solutions. Number of ERP users is growing very fast and majority of employees are using ERP solutions daily at their work. Because this, on labour market is huge demand for students with knowledge of ERP solutions. In past few years, a lot of universities included topics from ERP solutions in their curriculums through different subjects such as: Accounting Information Systems, Enterprise Resource Planning, Information Systems etc. While number of ERP solution user is growing, a lot of research studies regarding ERP user adoptions/acceptance are emerging . The most used research models are : technology acceptance model , theory of reasoned action , theory of planned behaviour , innovation diffusion theory , stage model , technology-environment-organization ;and resource-based view . In this area, TAM is one of the most suitable and widely used model to study adoption in IS and therefore numerous IS researchers apply this method to ERP research. The key purpose of TAM is to provide a basis for tracing impact of external factors on internal beliefs , attitudes , intentions and actual use . Despite ERP acceptance by its users in companies has been researched by several authors, ERP acceptance by students within study programmes has not been researched so often. Our goal is to research external factors which influence student acceptance of ERP solutions. Our research model is based on TAM and include factors of original TAM but our research model modify external factors. We have included additional external factors which we think that will have impact on ERP acceptance: experience with computer, computer self-efficiency, personal innovativeness toward IT, computer anxiety, user manuals , system quality, social influence , training and education etc. The research approach is based on short interaction contact with ERP solution. The survey was conducted among group of students, who do not have any knowledge regarding ERP solutions before. After description of ERP solutions and literature review, research model is described in details and results of study are presented and discussed. --- ERP solutions ERP solution is usually referred to as a category of business-management software. Typically, this is a suite of integrated applications which an organization can use to collect, store, manage and interpret data from their daily business activities. ERP solutions provide an integrated and continuously updated view of core business processes using common database. ERP solutions track business resources-cash, raw materials, production capacity-and the status of business commitments: orders, purchase orders, and payroll. The applications that make up the system share data across various departments that provide the data . ERP facilitates information flow between all business functions and manages connections to outside stakeholders . Most ERP systems incorporate best practices which means the software reflects the vendor's interpretation of the most effective way to perform each business process . The organization Gartner Group first used the acronym ERP in the 1990s . ERP systems experienced rapid growth in the 1990s, because of the year 2000 problem and the introduction of the euro that disrupted legacy systems, many companies took the opportunity to replace their old systems with ERP . ERP systems initially focused on automating back office functions , while front office functions became integrated later, when the Internet simplified communicating with external parties. The ERP II was introduced in 2000 by the Gartner organization and describes webbased software that provides real-time access to ERP systems to employees and partners . Their role expands traditional ERP resource optimization and transaction processing and leverages information in the resources under its management to help the organizations collaborate with other organizations. ERP II solutions are typically used to enable collaborative initiatives such as supply chain management , customer relationship management , and business intelligence among business partner organizations through the use of various ebusiness technologies . Organization Gartner Group in year 2013 introduced the term "postmodern ERP" . According to Gartner's definition of the postmodern ERP strategy, legacy, monolithic and highly customized ERP suites, in which all parts are heavily dependable on each other, should sooner or later be replaced by a mixture of both cloud-based and on premise applications, which are more loosely coupled and can be easily exchanged if needed. Early ERP providers focused on large enterprises, smaller enterprises increasingly use ERP systems in last few years. The worldwide ERP market grew from 3.8% from 24.4B USD in 2012 to 25.4B USD in 2013. SAP is in market leadership position, follow by Oracle, Sage, Infor and Microsoft . ERP will remain basic software in the organisations. --- Literature review --- Technology Acceptance Model Several theoretical models have been used to investigate the determinants of acceptance and the use of new information technology , such as the theory of reasoned action , the theory of planned behaviour , the theory of the technology acceptance model , innovation diffusion theory , stage model , technology-environment-organization ; and resource-based view . Compared to competing models, TAM is believed to be more parsimonious, predicative, and robust , and so among the theoretical models is most widely used by IS/IT researchers and therefore numerous IS researchers apply this method to ERP research. TAM posits that two beliefs -perceived usefulness and perceived ease of use -are of primary relevance for computer acceptance behaviour . PU is defined as "the degree to which a person believes that using a particular system would enhance his or her job performance" . PEOU in contrast, refers to "the degree to which a person believes that using a particular system would be free of effort" . The two central hypotheses in TAM state that PU and PEOU positively influence an individual's attitude towards using a new technology , which in turn influences his or her behavioural intention to use it. Finally, intention is positively related to the actual use . TAM also predicts that PEOU influences PU, as Davis et al., put it, "effort saved due to the improved perceived ease of use may be redeployed, enabling a person to accomplish more work for the same effort". The key purpose of TAM is to provide a basis for tracing the impact of external factors on internal beliefs, attitudes, and intentions . Original TAM is presented in Figure 1 in grey rectangle. The original TAM is well established and tested and furthermore, a variety of extensions regarding external factors by examining the antecedents of PU and PEOU has been developed such as TAM 2 , UTAUT and TAM 3 . --- ERP solutions Even though TAM can be applied to a variety of technologies, the constructs of TAM need to be extended by customizing factors for specific information systems . Few studies, have investigated ERP user acceptance and usage utilizing TAM, and most of them investigate a small number of external factors They tested the impact of four cognitive constructors on AT and symbolic adoption. Nah et al., 2004. Their study evaluated the impact of one belief construct and its effect on the perceived technological value of an ERP solution leading to its use. Uzoka et al., 2008. They extended TAM to research the selection of ERP by organisations using factors: impact of system quality, information quality, service quality, and support quality as key determinants of cognitive response as well as which ERP solution to purchase/use. Calisir et al., 2009. They examined factors that affect users' BI to use an ERP solution based on potential ERP users at one manufacturing organisation. Scott & Walczak, 2009. They investigated students cognitive engagement, prior experience, computer anxiety, and organizational support as determinants of computer self-efficacy in the use of a multimedia ERP system's training tool Shih & Huang, 2009. Their study attempted to explain BI and AU through incorporated additional behavioural constructs: top management support, computer self-efficacy, and computer anxiety. They extended IT usage models to include the role of ERP's perceived work compatibility in users' ERP usage intention, usage, and performance in work settings. Youngberg et al., 2009. They researched impact of PEOU, result demonstrability, and subjective norm on PU and impact of it on usage behaviour. Lee et al., 2010. They examined factor organisational support on original TAM factors. Sternad et al., 2011. They Costa et al., 2016. They extended original TAM with factors top management support, training, and the system quality and research their impact on adoption and user satisfaction. Mayeh et al., 2016, They examined the effects of factors absorptive capacity , communication and trust through original TAM and intention to use ERP solution. Just two from above table researched students ERP acceptance through TAM model. But both authors used small numbers of external factors. Shivers-Blackwell and Charles also researched student readiness to use ERP technology through model TAM, but they researched ERP acceptance after students read an online newsletter provided by the ERP communication, education, and training team entitled "What is ERP". Participants were then solicited by their professors to complete the survey. So, they did not have practical experience with use of ERP solution. Their research shows that gender and perceived ERP benefits are related to students' readiness for change, and readiness for change is a significant predictor of students' attitude toward usage of the ERP system. Scott and Walczak examined cognitive engagement, prior experience, computer anxiety, and organizational support as determinants of computer self-efficacy in the use of a multimedia ERP system's training tool. They also examined the impact of computer self-efficacy on its acceptance. The sample consisted of 239 students taking an ERP course elective in the information systems undergraduate and graduate programs. --- Student ERP acceptance To examine ERP users' use of ERP systems, we need to extend the TAM. Synthesizing prior researches on TAM and researches on ERP systems, a conceptual model that represents the cumulative body of knowledge accumulated over the years from TAM and ERP research has been developed . --- Figure 1: Conceptual Model Our goal is to research student acceptance of ERP solutions while they are involved in ERP topics after short interaction with the systems and which external factors have impact on it. We are preparing conceptual model which will include factors of original TAM . Therefore, we use hypothesizes from original TAM : H1: Perceived ERP ease of use has positive and direct effect on perceived ERP usefulness . H2: Perceived ERP ease of use has positive and direct effect on attitude toward ERP system . H3: Perceived ERP usefulness has positive and direct effect on attitude toward ERP system . H4: Attitude toward ERP system has positive and direct effect on behaviour intention . Even though TAM can be applied to a variety of technologies, the constructs of TAM need to be extended by customizing factors for specific information systems. One problem with TAM research is that most researchers investigate small number of external factors. In case of ERP acceptance, several external factors may influence user acceptance. Thus, the conceptualisation of multiple, higher-order factors must be investigated to understand user behaviour. We expose in prior researches that external factors could be distributed among three groups of factors which are personal characteristics and information literacy , system and technological characteristics , and organizational-process characteristics . In these three groups, we are trying to capture many external factors which influence ERP user acceptance in operational phase. Since we research student acceptance of ERP solution we must adjust and add some other external factors. Personal characteristics and information literacy includes personality characteristics that can influence individuals' perceptions of ERP system acceptance and usage. Because goal of our research is to research student acceptance of ERP solutions we expose those factors which could have impact of their acceptance of course lectures and exercises regarding ERP solution. We expose several external factors in group PCIL which are: personal innovativeness toward IT , computer anxiety , computer self-efficiency and individual benefits . In contrast to most IT implementation research, the fact that ERP implementation research is focused on one technology has enabled the effect of specific technological characteristics to be examined. Surveying different research following external factors has been exposed in group of STC: system performance , user manuals , quality of ERP system and quality of information in ERP system . Organizational-process characteristics capture various social processes, mechanisms, and support organizations that guide individuals to facilitate the use of an ERP system. OPC includes social influence and training and education on ERP system . Therefore, it is hypothesized: H6: A group of external factors influence use of the ERP system through the conceptual factor personal characteristics and information literacy . H7: A group of external factors influence use of the ERP system through the conceptual factor system and technological characteristics . H8: A group of external factors influence use of the ERP system through the conceptual factor organizational-process characteristics . --- Research design and procedure The components of the proposed model are PU, PEOU, AT, BI and U, where PU and PEOU influenced by various external factors. The external factors are distributed among three second-order constructs which are: personal characteristics and information literacy , system and technological characteristics , and organizational process characteristics . Second-order factors are composed by specifying a latent variable which represents all the manifest variables of the underlying lower-order factors. PCIL includes: personal innovativeness toward IT, computer anxiety, computer self-efficiency and individual benefits. STC is composed of: system performance, user manuals , quality of ERP system and quality of information in ERP system. OPC includes: social influence and training and education on ERP system. Our conceptual model includes 15 first-order factors and 3 second-order factors. We already did researches regarding user acceptance of ERP solutions in organizations. The instrument was pilot tested with a group of 30 ERP users in one organization. Based on the results of the pilot testing, revisions and additions were made to the instrument. All the items of factors were measured on a 7-point Likert scale, ranging from 'strongly disagree' to 'strongly agree'; the scale was adopted from relevant prior research and adapted to relate to the context of student's ERP usage. Demographic information was collected as well. The survey was conducted among group of 121 students. The group included students who have course E-business . They do not have any knowledge regarding ERP solutions at the beginning of the course. Course includes 15 teaching hours lectures from ERP topics with focus on the business processes in Microsoft Dynamics NAV and 15 teaching hours exercises in computer lab where they have hands on training of some business processes in Microsoft Dynamics NAV . We are using version Microsoft Dynamics NAV 2016 . The survey was carried out after short interaction with NAV solution . We distributed paper version of questionnaire after 12 hours contact with ERP solution in the beginning of lecture and gave them half an hour to solve it. Students had 8 hour of lectures about ERP solutions, Microsoft Dynamics solutions and Microsoft Dynamics NAV, purchasing process in NAV and production process in NAV and 4 hours of computer lab exercises, where get familiar with navigation in NAV solution, purchasing process in NAV solution till then. 121 questionnaires were properly filled out by respondents and used for the purpose of analysis. Respondents were 38.8% male and 61.2% female. They have topics regarding Microsoft Dynamics NAV 2016 -4 hours per week: 2 hours lectures, 2 hours computer lab exercises and 0 individual work . The average age of students is 21.66 years. --- Analysis and results Demographic data were analysed by SPSS. All other empirical data were analysed PLS technique, using Smart PLS 3.2.1. Partial least squares approach can be employed to estimate the parameters of a hierarchical model and also allows the conceptualisation of higher-order factors through the repeated use of manifest variables . A higher-order factor can thus be created by specifying a latent variable which represents all the manifest variables of the underlying lower-order factors. We employed a PLS approach because of the relatively small number of samples of valid data and our desire to analyse second-order factors. Data was analysed in two stages involving a PLS technique using Smart PLS 3.2.1 . All measurement scales were examined for their psychometric properties prior to testing hypotheses . Results of measurement model were satisfactory . The hypothesis testing results utilize bootstrapping to test the statistical significance of each path coefficient using t-tests, as recommended by Chin . Results of this analysis are shown in Figure 2. Our research confirms results of original TAM. Perceived ERP ease of use has weak but significant effect on perceived ERP usefulness and strong significant effect on attitude toward using ERP system . Perceived ERP usefulness has strong significant effect on attitude toward using ERP system . Attitude toward using ERP system strongly influences on behaviour intention and behaviour intention strongly influences on actual use . Secondorder factors have significant positive effect on perceived usefulness and on perceived ease of use . PCIL has a strong positive effect ). OPC has a weak but significant effect on perceived ERP usefulness . STC has very strong positive effect on perceived ERP ease of use , and these findings provide empirical support for hypotheses H6, H7, and H8. --- Discussion Our results of original TAM model go with results of other researchers who research IT/IS acceptance . Both, perceived ERP usefulness and perceived ERP ease of use have strong positive effect on ERP usage, where relationship of perceived ERP ease of use is a little stronger. This is not consistent with Davis , Davis et al. and Simon and Paper who expose that perceived usefulness has stronger positive effect on IT/IS usage as perceived ease of use , while perceived ease of use has not so strong or even not statistical effect on IT/IS usage after some time of usage. On the other hand, results of some researches show stronger effect of perceived ease of use on attitude toward using ERP system then perceived ERP usefulness on attitude toward using ERP system . Because survey was carried out after short period of ERP solution learning it could be reason for that result. Some IT/IS researches show strong positive effect perceived ERP ease of use on perceived ERP usefulness , but this is not consistent with our study, where perceived ERP ease of use has weak positive effect on perceived ERP usefulness . Empirical findings on that relationship in the context of ERP are different, since some researches did not confirm a statistically significant relationship between two , while other researches confirmed a statistically significant positive relationship . Factor attitude toward using ERP system is vital in the TAM model and has very strong positive effect on behavioural intention and through it also indirect strong positive effect on actual use , which is consistent with other researches . The aim of this research was to identify external factors which influence student ERP usage after they were involved in ERP topics after short interaction with the systems. Based on the analytical results, we can see that it is possible to observe more external factors through second-order factors. The fact that ERP implementation research is focused on one solution has enabled the effect of specific technological characteristics to be examined. We have not found any research which has examined the effects of system and technology characteristics upon the ERP system's user acceptance . STC has strong impact on perceived ease of use through external factors system performance, quality of NAV system and quality of information in NAV system. Factor user manuals is not statistically significantit could be because students did not work alone and they did not use user manuals until then. Second order factor Personal characteristics and information literacy has through personal innovativeness toward IT and individual benefits greater impact on perceived usefulness than second order factor Organizational-process characteristics through social influence and training and education on ERP system. This means that for students are more important fact that they see individual benefits using NAV systems and that they like to use any computer tool/applications then social influence and training and education on ERP system. Furthermore individual benefits has stronger effect on perceived usefulness than personal innovativeness toward using software tools and applications . Factors computer anxiety and computer self-efficiency are not statistically significantthese students are students of higher class , who had several courses related to IT during the primary and secondary schools and also at the time of the study. Factor training and education of NAV has stronger effect on perceived usefulness than social influence who have influence on students' perception regarding NAV/ERP). --- Conclusion The aim of this research was to research which external factors have impact on students' acceptance of ERP within study programme, while they are exposed to ERP solution . We want to know how to motivate students to take seriously course E-business where we teach students ERP solution Microsoft Dynamics NAV. We exposed 10 external factors which have impact on student ERP acceptance. This work extended previous researches by incorporating groups of external factors, which have influence on students ERP acceptance. Studying the influence of more external factors on constructs not only contributes to the theory development, but also helps in designing teachers' curriculum. Our research shows that external factors personal innovativeness toward IT and individual benefits are very important personal factors which have impact on students ERP usage, while computer anxiety and computer self-efficiency are not important. It could be because students did not work alone and they did not use user manuals until then. Organisationalprocess factor training and education of ERP is more important than factor social influence who have influence on students' perception regarding NAV/ERP) and therefore we suggest to teachers put a lot effort to prepare excellent teaching materials and to try to explained students' ERP topics related content in an easy way. Scott and Walczak Understanding of ERP solutions is challenging for students, because they do not have practical experience of how ERP solutions is used in enterprises. Important systemtechnological factors are system performance, quality of NAV/ERP system and quality of information in NAV/ERP system, while factor user manuals is not important after short interaction with the system. The implications for researchers and practitioners include an extended version of TAM through second-order factors to improve the explanatory power of ERP usage. The technique for analysis of model was used. This study has certain limitations which may present the opportunity for further research. Since the respondents were limited to one group of students in Slovenia, this study should be extended to other counties. Further research is needed to explore the importance of presented external factors in different time frames as well as include additional external factors. Another limitation is also that research was conducted for one ERP solution -Microsoft Dynamics NAV, because of that the importance of external factors of different ERP solutions also could be explored . --- Introduction Hyper-turbulent environment and contemporary issues in incumbent businesses established the need for in-depth observations of companies' business models and their components. Elaborating on the absence of consensus on what a business model is or what it is not , we provide readers the insights from the most important areas within a business model research in the infant stage of business model topic and 6 years after Zott, Amit, and Massa identified some of the most visible clusters in business model research. Despite the discrepancies in its definition, business model is usually recognized as a set of resources through which transactions generate value for the company and its customers . Business models are necessary for capturing value and constructing organizations' capabilities . This vice versa relationship led Zott, Amit, and Massa to conclusion that business models enable a holistic perspective for observing organizations and their businesses. The assessment of business models, their usage and future trends is helpful, since it can provide us with the insights about the main topics in business and its associated theoretical traditions . Drawing on the on-going research, our paper provides bibliometric methods which can be used to identify the most influential keywords and future trends in field of business models. Since academic attention paid to business models has recently increased substantially a bibliometric analysis can provide a coherent map of contemporary business model research and assist both scholars and practitioners in innovating business models, along with recognizing the future trends in that area. Our aim is to identify the past conversations within business model literature and future avenues. Several excellent reviews of the field relied on the method of structured literature review to establish the state of the art in the field. Our contribution is to complement these reviews with bibliometric methods that use quantitative bibliographical data . In this way we can tap into the knowledge created by scholars in the field who expressed their opinion by citing specific articles and books. Such an investigation also forms an excellent basis to speculate on whether business model will survive as a term within strategic management and information systems literature as a distinct term to e.g. competitive advantage, strategy or digital transformation. --- Literature review Every organization employs a business model that encompasses how value is created, delivered and captured . An ample amount of research revealed that the consensus on what a utilization, development and structure of a business model has not been reached yet . That is why business model has been applied to different environments and utilized within a different context . Besides, phenomena such as the emergence of e-businesses and surge of technology innovations have influenced the development of business models. Business model is quite difficult to be depicted without a broader understanding of the environment in which organization operates. Despite that, some authors made an attempt to introduce business model through text and graphics in order to provide managers with a unique template for designing a winning business model. In spite of not having a universally applicable 'template', business model does depict "the content, structure, and stewardship of transactions that enable value creation in future business opportunities" . Teece ads data and other evidence into business model concept, since these two seem to support the value proposition for end-users. Finally, a line between strategy and business model was given by Casadesus-Masanell and Ricart , who identified a business model as a reflection of a firm's strategy. Additionally, business model not only resonates company's strategy but also links technological innovation to strategy . Innovation and technology are two facets of business models development, whereas only a scant amount of scholars have more or less successfully conceptualized business models' elements and relationships . According to Zott and colleagues an adequate business model is the one with value network encompassing both value creation and value capture, meaning to include all stakeholders and distribution channels along the entire supply chain of a certain organization. A company should not focus only on improving business model elements but to develop them in such a way that it will be able to continually change its existing or add a new business model as a response to unexpected changes . Unfortunately, managers usually respond by optimizing only each of the element of the current business model . This is insufficient, because the development of a new business model entails a paradigm shift, which requires an in-depth analysis of customers, competitors and partners . More importantly, the emphasis should be on articulation of business model and an evaluation "against the current state of the business ecosystem, and against how it might evolve" . The allure of business models is that they are based on observation and theorizing , making them a perfect template for running companies' businesses. Business model development is a long-term process that can 'shake' the markets or vice versa as seen when the emergence of information-communication technologies stroke the concept of a business model . In fact, authors have shown how difficult it is to create a winning business model, especially in the era of disrupting ICT innovations . In light of this, a great variety of business models became 'ICTenabled', since, after all, ICT provides organization with new channels for interacting 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES I. Župič, M. Budler & P. Trkman: Characterization of Business Model Research: Bibliometric Analysis and the Future Agenda with customers . Besides, there is yet a case to be made for sustainable business models , since sustainable business models are the ones interacting with and augmenting company's resources, partnerships and relations with customers . In regard to developing business models, we have seen an ample amount of companies possessing multiple business models in order to cope with different niches and preferences from end-users. Real-life business environment establish a need for using multiple business models ; however, doing this might be a double-edged sword . A great challenge to be addressed when companies try to utilize two different business models is that two business models will sooner or later interfere, causing conflicts. Two solutions were advised ; first, organization could physically separate both of the business models to avoid their interactions or, second, business models could be merged in order to exploit synergies. There has been a common misunderstanding on how to distinguish a strategy from a business models. Not only due to similarities between these two but also because of the strategic function embedded in business models . DaSilva and Trkman understand a strategy as a key determinant in the development of capabilities that enable future business models within an organization. Another distinction between strategy and a business model has been provided by ; authors claim that "every organization has some business model", whereas "not every organization has a strategy". As business models are seen as a source of competitive advantage, the interplay between the strategy and the business models gained its importance . Finally, there is a business model innovation defined as 'the discovery of a fundamentally different business model in an existing business' , or as a quest for finding a new template on which an organization could create and capture value not only for its customers but also for its stakeholders . Business model innovation can lead to organization achieving competitive advantage if the model is enough revolutionary and difficult for imitation by competitors . Incumbent businesses tend to elicit value from innovative ideas and disruptive technologies throughout their business models . Interestingly, the process can work vice versa, since business models are often shaped by modern technology and innovations . Business model or the development of business model can be seen as a stage between an idea growing from invention towards innovation , however, with an emphasis on business model ensuring that not only technology is engraved but also that the innovation is economically sound . --- Methodology We mapped the business models literature with bibliometric methods . These methods use the citation information in bibliographical databases to extract meaningful information about the structure of scientific fields. The quantitative information gathered from bibliometric analysis can be a useful complement to the traditional structured literature review. Specifically, we used the methods of citation analysis, bibliographic coupling and co-word analysis . Citation analysis measures the influence of specific documents or journals by measuring their citation frequencies. If certain article or journal is more cited it is assumed it had greater influence on the literature than its less cited counterparts. Bibliographic coupling uses the similarity of reference lists to establish connections among scientific publications. For example, if ten publications appear in both reference lists of two scientific papers, this means that these two papers are connected with coupling strength of ten. The stronger the coupling strength, the stronger the connecting link. When this information is gathered for all relevant publications in the scientific field of interest, clustering methods can be applied to delineate the structure of the field and identify the substreams of research. Co-word analysis, on the other hand, connects the word terms by their appearance in the same title or abstract. If two terms appear together multiple times this means that the connection link between them is stronger. Again, putting together this information for the whole scientific field gives us a clear thematic picture of the field's conversations. We searched Thomson Reuters Web of Science for "business model" in the topic of published articles in the time period 2010-2015. We selected this period because we wanted to analyse the current conversations and not the past literature. The search returned 1533 entries, which we further filtered for Business, Management and Economics categories. Of the remaining 598 articles we selected only document types of 'article', 'editorial material' and 'review' which left us with 580 entries. The abstracts of all 580 documents were read and rated by two authors. Criterion for inclusion in the sample was that business model was one of central themes of investigation in the research study. Articles that only passingly mentioned business model concept were excluded from the sample. After rating the articles independently the interrater agreement was 86.4%. The differences on the remaining 79 articles were reconciled by re-reading the abstracts by both raters together and reaching decision whether to include the contentious article. After this process 308 articles were left. --- Findings We have conducted three types of analyses of business model literature. First, the citation analysis shows the most important publications outlets for contemporary business model research, which journals consist the knowledge base of business model research and which documents are the most cited within the literature. Second, the bibliographic coupling followed by the application of network community finding algorithm provides the structure of contemporary business model research that is based on the quantitative citation data. Finally, the co-word analysis of most important keywords in abstracts and titles shows the topical domain of business model research. Eisenhardt's paper on building theories from case study research. This reflects the fact that the majority of the empirical articles on business models are based on qualitative case studies. Mangematin, 2013;Martins, Rindova, & Greenbaum, 2015) but also reviews of the field . --- Citation analysis Cluster 2 contains 19 articles. The vast majority of authors in this cluster are focusing on understanding the idea of a business model by identifying and explaining its meaning . Authors execute 'sensemaking' out of business models and try to make them context-dependent with regard to organizational strategy. A major question in this cluster is the distinction between business model and strategy . Additionally, the authors examine what is the role of business model when constituting strategies. In light of 'sensemaking', some of the authors have pursued their research to elucidating changing meaning of the business models, how the business model notion is changed due to the environment, and how to distinguish between various business models. Cluster 3 has 12 articles. It is predominantly strategy-based and the core of this cluster is represented by several publications of the 2010 Long Range Planning special issue on business models . Bibliometric Analysis and the Future Agenda 727 Cluster 4 is the smallest with 9 articles. The topics in this cluster are predominantly rooted in marketing themes. For example, the papers in this cluster explore the definition of markets as configurations , the usefulness of business models construct for service-based companies and the integration of products and services , solution business models and business models in project-based firms . --- Co-word analysis We visualized the text in abstracts and titles with co-word analysis. 6170 different terms are used in 308 abstracts. We selected top 133 terms with at least 10 appearances . We visualized 60% of the most relevant terms, resulting in 80 keywords. We further filtered out keywords that were research-related, like 'methodology', 'findings' and similar. We visualized remaining keywords with heat-map in Figure 2. Warmer areas represent more frequently used keywords and their proximity means that the terms are often used together. The area on the right shows papers emphasizing the importance of business model innovation, its meaning in change management and its role, especially in terms of enhancing organizations' performance, as emphasized by Casadesus-Masanell and Ricart . Furthermore, central cluster of keywords confirmed business model as the most important 'tool' for delivering value to customers; however, the value cannot be elicited from business model if organizations lack cutting-edge technology. In fact, not only technology but also various elements and capabilities play an important role when it comes to refining a business model . Another two clusters have pointed out that business model is redeemed as a system or a concept encircled around its focal element-product. --- Discussion In preliminary research we examined the 308 articles on business models published in the period 2010-2015. In further research we will also examine articles before 2010 and articles published in 2016. Business model topic has covered the emergence of ebusinesses and surge of technology innovations that influenced the vast majority of organizations. It can be discussed how much a business model is context-dependent, nevertheless, the future research should give us more information about business models' elements and the interplay between them. Further, by examining articles published in different periods thoroughly, we tend to investigate how the business model research has changed over time and, second, contemplate which future avenues are most likely to be addressed. The results of the citation analysis of the papers and the four identified clusters by bibliographic coupling jointly paint a coherent picture of the business model research. The disciplinary landscape spans from technological innovation through strategy to marketing. This is reflected in the journals that publish business model research, which also include practitioner outlets like Harvard Business Review. This makes the business model construct uniquely positioned to integrate the supply-and demand-side approaches to strategy . --- Conclusion We used bibliometric methods to examine state of the art of business model research. We identified the most influential documents in contemporary literature, divided the literature into four clusters and visualized its topical structure. Our analysis provides a useful tool for both veteran and new researchers who want to move the field forward. --- Limitations Bibliometric methods have several well-known limitations. First, it is not possible to determine based on solely citation data why certain document was cited. It could be because the citing author thought the cited reference was important foundation for their work, but it could be also to refute the claims in cited document or ritually cited because certain citations are expected in the specific scientific fields. Second, our analysis encompasses the most cited works and most used keywords. It is possible that some smaller research substreams were missed even though they could comprise an important but less cited niche. Finally, we have deliberately taken into account only categories "business", "economics", and "management" as we wanted to thoroughly examine the articles published in these mainstream areas. We tend to expand that in further research. --- Further research First, researchers could pursue the question why the 'conversations' of business models are usually happening only within a certain 'bundle' and what would be the implications of an interplay between these various sub-areas. Second, researchers could initiate follow-up studies on co-word analysis, evaluating whether a synergy between these sub-areas enabled the proliferation of incumbent business models . Finally, taking into consideration the results of our inquiry from the journals could lead researchers to a better understanding of the fields and industries interfering with the continuous development of business models. --- Introduction The Netherlands has a strong tradition of social housing for lower income groups. Within this tradition, housing associations are a major player something which dates back to the 1901 Housing Act. In the beginning, social housing was operated from the pillarization, the politico-denominational segregation. After World War II, the Dutch government managed and prescribed how, what and where to build. From the mid-1990s, the government withdrew itself and stimulated self-reliance . Today, the social housing system is failing, the decreasing support from society is a crucial threat to the future of the system . Therefore, innovation of the system, among other things by regaining commitment between the housing associations and their target population, is vital . A focus on core activities is, together with the first benchmark by Aedes in 2015 , the first step in the right direction. With rental incomes that are just sufficient to cover the expenses for management and maintenance, more efficient cooperation with maintenance companies can lead to more efficient maintenance processes and lower maintenance costs . It is believed by both scholars and practitioners that more efficient cooperation can be achieved through supply chain partnering and the effective use of information systems. Especially for housing associations, where the organisation of maintenance occurs in a complex environment. The very diverse property portfolio of housing associations is one of the complexing aspects. The portfolio's consists of recently completed new built houses, post-war dwellings and houses completed in the intervening period. Furthermore, they lack unity regarding construction quality, compliance with present living requirements, method of recording the construction and installation engineering information, and accessibility to and completeness of this information . Supply chain partnering has become a prominent phenomenon among academics and professionals working in the construction sector . Several benefits are ascribed to better coordinated cooperation between supply chain partners, including cost reduction, increase of quality, shorter execution times, and more opportunities for innovation and learning . And although information management is a prerequisite for successful implementation of SCP, there is little attention for the relation between the implementation of SCP and information management. Furthermore, most research on information management in construction focuses on building information modelling for new construction while benefits of BIM could also apply to maintenance. BIM use facilitates the integration of stakeholders thereby reducing fragmentation, improves knowledge management and communication, cooperation, decision-making, and performance of maintenance, and reduces maintenance costs . However, to fully benefit from BIM coordination of stakeholders and stakeholders' actions is required . Research on SCP also focuses mostly on new construction, which is surprising since new construction is still mostly about one-time projects while maintenance is an ongoing series of activities. It is the latter that generates opportunities for a more structural cooperation between supply chain partners and also a more structural coordination of activities, resources, and benefits and risks. This research addresses these opportunities and identifies the coordination mechanisms that help improve information management as well as the implementation of SCP. This research proposal has the following structure, hereafter the problem definition and formulated research question are discussed. Subsequently section three describes the research methodology while section four elaborates on the expected results. Future development of this research is discussed in section five. --- Problem definition Opportunities for implementation of SCP are particularly evident in the social housing sector in Northwest Europe, including the Netherlands. In Northwest Europe, the social housing sector is managed by professional property managers, who are capable of building professional partnerships with their contractors. In general, the housing sector is under increased financial pressure, which triggers social landlords to look for more efficient ways of working. According to the Housing Act 2015, Dutch housing associations must focus on building, renting out, and managing and maintaining social housing, and invest in the livability of the neighbourhood. The Housing Act 2015 also allows for commercial activities but only when commercial parties have no interest . This is executed within a framework of less subsidies ; various organisational structures; and a differentiated property portfolio. In addition, the internal business operations of Dutch housing associations are neither transparent nor efficient. An understanding of the activity-based costs is often imperfect , while the necessity to manage costs forces housing associations to develop structures of strategic stock management and a housing stock with sufficient flexibility to anticipate to future developments. In addition, the social rent that is actually paid to the housing association is often lower than the value of the housing services generated by the houses . The internal management of housing associations is often 736 30 . Potentially, about 80% of all housing associations could improve their processes regarding maintenance . Koolma & Allers also indicate there is ample room for efficiency gains in the Dutch housing association sector. In the current organisational structure of maintenance, housing associations still tend to do a lot of maintenance activities themselves. This is costing them a lot of time and money, therefore revenues from rent are just sufficient to cover management expenses . Both scholars and practice recommend that housing associations change their maintenance processes in order to lower the costs involved . This starts with changing the type of contract. Traditionally, parties rely on formal, dyadic contracts that specify each party's financial and other rights, responsibilities, and duties . And traditional approaches to maintenance lead to more management time, unnecessary costs, and poor maintenance decision-making . In addition, in construction projects, the relationship between firms typically last for the duration of the project , meaning that learning across and between projects to improve processes hardly ever occurs. Also, construction projects are often criticised because of the performance of contractors, with lower than expected performance in time, costs, quality, and satisfaction levels of clients . Kempton identified a significant problem with communication and a lack of coordination between the corporate goals of the development, management, and maintenance departments. This is illustrated by three employees of a medium sized Dutch housing association who point out that the new building projects department is an independent entity within the housing association. As a result, one of the key challenges is to have sufficient information available for maintenance work, such as specifications, information on previous maintenance work, a list of specialist professionals to conduct work, etc. . Information is often not available and available information is often not complete or up-to-date nor easily shared among supply chain members. Maintenance processes could be improved through improving coordination and information management processes. This is not provided by a dyadic contract since this type of contract neither provides a shared goal for all project partners, nor specifies the organisational or technological mechanisms to align information and knowledge flows between the project partners . A dyadic contract will more likely lead to fear of opportunism, to an experienced lack of trust in the beginning of the project, which in turn leads to more procedural coordination mechanisms to benefit project outcomes and to reduce project risks . Here, a transition towards integrative supply chain processes appears desirable, because maintenance projects require an approach with a clear and integral set of requirements, where all involved parties cooperate as a well-oiled team . Furthermore, transparency and an increase in efficiency are necessary for the legitimacy of housing associations in society . The idea of a shift from a fragmented into an integrative way of construction is also a generalised technological promise of building information modelling technologies . However, this does not provide a realistic conception of the complexity of the conditions of the implementation of BIM . According to Love et al. BIM technology in itself has no inherent value; having BIM technology in place will not necessarily provide benefits or create value for a housing association, benefits only arise from its effective use. This asks for coordination of stakeholders' actions . And learning to cooperate as partners is a social accomplishment, rather than a technical feature . Partnering must involve the production of new working practices at a local level . The implementation of BIM could help as it facilitates the integration of the roles of all stakeholders . In 2014 Nobakht stated in Cobouw, a daily magazine for construction professionals, that despite the changes and challenges housing associations are facing, structural innovations of the current business models were still omitted. He believes that the barrier for structural innovations lies in the originating small scale building sector, with a traditional way of thinking, a monoculture, and a lack of knowledge regarding strategic business problems . Construction clients appear to distrust their main contractors who, in turn, distrust their subcontractors and suppliers, and individual players have very little stake in the long-term success of, and therefore no commitment to resulting structure. . The core of the problem is that fragmentation is thought to be of interest to all involved parties although it leads to loss of information, misunderstandings, pointing at each other, sub-optimizations, and additional work . Although it is believed that supply chain integration must lead to improvement by developing a more stable environment , several barriers prevent this integration. The traditional fragmentation leads to resistance towards supply chain integration due to perceived extra costs, partners are unaccustomed to share knowledge across project phases and are unaware of potential benefits . Successful integration of the construction supply chain is possible. For instance through a multiparty contract which aligns financial interests and builds trust between supply chain partners in the beginning of the project; the contract aligns information and knowledge flow between the project partners by specifying organisational and technological mechanisms . Long term supply chain partnerships make it easier to be vulnerable and communicate freely and thus to establish common norms and good team practices, and are also positively associated with improved working practices and an increased level of trust . In high trust groups, coordination is more effective leading to greater efficiency and hence better performance . Coordination theory is relevant for improving the cooperation in supply chains , especially in combination with the concept of boundary objects . However, thus far this theory has not been applied to supply chains in the construction industry. Coordination theory has been defined by 738 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES D. Goedknegt: Information Management in Supply Chain Partnering: Improving Maintenance Processes in Dutch Housing Associations Malone and Crowston as "a body of principles about how activities can be coordinated, that is, how actors can work together harmoniously". Li and Wang distinguish two supply chain types, centralised and decentralised. They state that construction supply chains are decentralised supply chains, which are more difficult to coordinate because this requires a scheme to allocate the benefits of coordination throughout the supply chain to maintain the interest and participation of all dependent supply chain partners . For this agency theory "offers a unique, realistic, and empirically testable perspective on problems of cooperative effort" . It analyses the relationship that develops in an economic exchange when an individual concedes authority to another to act in his or her name . The exercise of coercive and legal power has a strong negative effect on collaborative behaviour, while rewards have a positive effect . The central goal of agency theory is to stop opportunistic behaviour in a situation where parties have different goals and the information supply is incomplete . Coordination theory and agency theory are complementary because where the latter theory presents a partial view of the world that ignores a good bit of the complexity of organisations , the former theory fills this gap by looking at the complexity of cooperation between organisations. Because supply chains are complex with many activities usually spread over multiple organisations and sometimes over lengthy time horizons, it is necessary to overlay a coordinated system . This coordinated system may include an explicit definition of processes, responsibilities, and structures aligned with overall objectives of the whole supply chain to bring together multiple functions and organisations . This implies that all these organisations and the people within the organisations have to face, and preferably employ, one of the four dialogical learning mechanisms of boundaries :  Identification, which is about coming to know what the diverse practices are about in relation to one another;  Coordination, which is about creating cooperative and routinized exchanges between practices;  Reflection, which is about expanding one's perspectives on the practices;  Transformation, which is about collaboration and co-development of practices. The results of this research are specifically aimed at realising recommendations for improving maintenance processes at Dutch housing associations by improving the collaboration of the supply chain processes. Based on the discussion as described above the results should provide an answer to the following main research question: --- Future Development The literature study is the rationale for subsequent future research. Although more scientific and practical research can be incorporated, this study has already shown that research regarding improving maintenance processes at Dutch housing associations is missing. Therefore, research will be executed through case studies at two Dutch housing associations currently implementing results-oriented maintenance processes. These case studies aim to reveal how the different constructs in our conceptual model help improve the information management, supply chain management and thus the maintenance processes. These results will then be tested via a qualitative survey with relevant stakeholders . This will contribute to the implementation of SCP in the construction industry. According to Van der Boon at Leertouwer many housing associations are still stuck in the previous century, steering at lowest cost based on Excel documents, sometimes even lacking the knowledge and skills to see the bigger picture . Van der Boon also stresses that although SCP is very relevant, construction is still an industry where phases are viewed as stand-alone, and learning across phases is still not common. When one phase is finished, information is not well nurtured, and cooperation and coordination are not common. Communication is key, and a change in culture is necessary. It is important to understand the role, responsibilities and processes of all actors. Wolf states that BIM, as a vehicle for improving the coordination of information of maintenance processes, can be used to change the current maintenance processes into processes based on sharing knowledge and information and empowering process stakeholders . --- Introduction Personalization has remained an increasingly intriguing concept among scholars . Through the digitization of everything , more and more information about user preferences is available for service providers . Rapidly evolving digital technology provides novel platforms and channels for service delivery , and consequently for personalization . In principle, personalization consists of two core components: 1) The understanding of user needs and 2) personalization of services based on those needs . In both these components, a wide variety of personalization technologies, such as recommendation systems are utilized. In other words, the purpose of personalization is to adapt standardized products or services to the individual user needs, and that personalization is carried out by the marketer on behalf of the user . The concept of personalization is often used interchangeably with another one-to-one marketing concept, customization, which on the contrary is user-led, and where the user proactively "personalizes" the service elements from the marketing mix, based on their own preferences . In this research, we follow the viewpoint from Sunikka and Bragge who view personalization as an umbrella term, including other closely related concepts like customization. Based on the aforementioned personalization principles, it can be argued that personalization is a service provider-led concept, where service provider decides the suitable services for an individual user, based on the information gathered. These viewpoints follow the value models of manufacturing , where the service provider personalizes the services for users, who then receive the services, for example in the forms of product recommendations. However, unlike manufacturing and tangible products, services, often intangible by their nature, are carried out in collaboration between actors . The service delivery may also involve more actors than service provider and the user only. Therefore, instead of emphasizing the distinction, where the marketer carries out personalization and the user receives the personalization, it is important to examine personalization from the different actors' viewpoints, as with services, the actors together construct the personalized service. --- Problem Definition Personalization has remained a puzzling concept among scholars for decades . The scholars in information systems , computer science, economics, services, and marketing have studied the concept through different lenses, with an aim to optimize services to the individualized user needs O. Korhonen: Personalization in Digital Services: Information Technology Supporting Service Personalization Process 751 emphasized, studied in the web context and examined from the perspective of a single software . That viewpoint has typically included two primary actors into the personalization process. 1) The service provider, who personalizes the service offerings, and 2) the user, who receives the personalized service offerings. This distinction follows the value models of manufacturing , where companies produce value and users consume that value . Companies try to understand users' needs, and to personalize the service offerings for those needs. In order to do so, different information technology solutions, such as personalization technologies are widely adopted. However, Service-Dominant Logic has challenged this thinking by proposing that markets have shifted from manufacturing and goods-dominance to services . Unlike tangible products, services can be defined as: "the application of specialized competences through deeds, processes, and performances for the benefit of another actor or the actor itself" . In other words, any act done intentionally for benefiting an actor can be considered as a service. Services are often intangible by their nature, but are occasionally supported by tangible products. In contrast to products though, the value in services is bound to knowledge and skills that are delivered in exchanges between actors. In my research plan, the aim is to examine personalization of digital services through S-D logic lens, and the role IT plays in the service personalization process. Unlike concrete products, intangible services can consist of multiple steps and phases, and often involve multiple actors in the service delivery process. That can be illustrated with a healthcare example, where the primary purpose of a healthcare company is not to sell tangible products to patients, but to serve the patients' needs collaboratively with by the patient. Furthermore, this service can be supported by tangible devices, like monitors for selfmeasurements, and involve multiple actors, such as medical doctor, patient, or the healthcare service provider that together construct the personalized service. The aim of my research is therefore to answer to the following questions:  How IT supported personalization can be viewed from the perspective of different actors taking part in the service delivery?  How and what support IT can provide for different actors in the service personalization process? --- Research Methodology My research will apply qualitative research methods, but also quantitative methods may be used to support the findings. The primary material for my research comes from two case studies , conducted in collaboration with two large service providers. The data from those case studies consists of service documentations and the interviews with the people who have been 752 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES O. Korhonen: Personalization in Digital Services: Information Technology Supporting Service Personalization Process designing the services under analysis. The data is collected and analyzed iteratively throughout the studies using qualitative data analysis approach , with an aim to interpret and construct understanding of the situation where the examined phenomenon takes place . For example, in the case study , two focus groups were conducted first, for getting an overview of the problem area. In the focus groups, more general and open-ended questions were discussed, with an aim to gain understanding of the unit of analysis . Second, the findings from the focus groups were used to formulate the themes for the semi-structured interviews, where the aim was to ask detailed questions from the key informants that were selected by selective sampling technique . In practice, those were the medical doctors that had been designing the examined care pathway. After the semi-structured interviews, the findings were categorized thematically and summarized into a table form. Third, a validating interview was conducted for validating the prior findings and to provide potentially complementary data. In the future, the plan is to utilize similar settings in another case study regarding to the service provider perspective. For the user perspective , user experiences will be collected using different types of interviews . That data can also be supported by quantitative data, in the forms of surveys that the service provider has already conducted with the service users. In addition to aforementioned case studies, other qualitative analysis methods are used in single papers, such as Nexus analysis to deepen the understanding on user experiences about motivation for exercising and Interaction analysis for studying service interaction between user and service clerk in a context of technology-mediated car rental service . --- Preliminary/Expected Results In overall, by covering the viewpoints of different actors, the aim of my research is to increase the understanding of value creation between different actors for personalized services in the framework of S-D logic and to examine the role of IT in the service personalization process. As a technology-emphasized concept, personalization is mostly studied using the G-D logic principles and with the value models of manufacturing. Due to the idea of market transformation to services, it is important to examine personalization 1) in the service context, 2) from the different actors' perspectives, and 3) to provide knowledge on the versatile role of IT in the service personalization process. Therefore the planned articles for examining the phenomenon are presented in the Table 1. Regarding to the preliminary findings, we have conducted an interpretive case study for examining IT support for personalization in the healthcare service context . In healthcare services, personalization is provided as a premise as individual conditions and needs vary between healthcare users (Berry and Bendapudi, --- In the next four sub-sections, we first assess the reliability and validity of the 25 construct indicators and the seven constructs included in the research model: use intention , perceived usefulness , perceived ease of use , optimism , innovativeness , discomfort , and insecurity . These assessments are based on a model that contains all the aforementioned constructs but does not yet contain any regression relationships between them. This is followed by the estimation of the actual research model and the examination of the potential age differences in the construct means and regression relationships. --- Indicator Reliability and Validity Indicator reliabilities and validities were evaluated by using the standardised loadings and residuals of the indicators, which are reported in Appendix B. In the typical case where each indicator loads on only one construct, it is commonly expected that the standardised loading of each indicator should be statistically significant and greater than or equal to 0.707 . This is equal to the standardised residual of each indicator being less than or equal to 0.5, meaning that at least half of the variance of each indicator is explained by the construct on which it loads. As can be seen, the two indicators that were furthest from meeting this criterion were DIS1 and INS4, which both had a standardised loading of less than 0.5. Thus, after assessing that there There is no such thing as a manual for a high-tech product or service that is written in plain language. --- INS1 People are too dependent on technology to do things for them. --- INS2 Too much technology distracts people to a point that is harmful. --- INS3 Technology lowers the quality of relationships by reducing personal interaction. INS4 I do not feel confident doing business with a place that can only be reached online. --- Note: The indicators of OPT, INN, DIS, and INS comprise the TRI 2.0 scale, which is copyrighted by A. Parasuraman and Rockbridge Associates, Inc., 2014. It may be duplicated only with a written permission from the authors. What is Digital Transformation? Strategy Bharadwaj, et.al. ; Matt, et.al. ; Mithas, et.al. ; Hansen & Sia ; Granados & Gupta ; Process Agarwal, et.al. ; Berman & Marshall ; Bharosa, et.al. ; Janowski ; Kreutzer ; Loebbecke & Picot ; Stieglitz & Brockmann ; Tamm, et.al. ; Wang, et.al. ; Hansen et.al. ; Business Model Henriette, et.al. ; Stieglitz & Brockmann ; Paradigm Shift Berman & Marshall ; Piccinini ; What are its Characteristics? Radical Liu et.al. ; Berman ; Berman & Marshall ; Westerman et.al. ; Disruptive Berman ; Berman & Marshall ; Granados & Gupta, ; HBR Analytics Services ; Fitzgerald, M. et.al. ; Evolutionary/continuous Loebbeck & Picot ; Janowski ; Wang et.al. ;Liu et.al. ; Complex Janowski ; Bharosa et.al. ; Matt et.al. ; Agarwal ; What are the Drivers of Digital Transformation? Digital Technologies Agarwal, et.al. ; Berman ; Bharadwaj, et.al. ; Bharosa, et.al. ; Janowski ; Kreutzer ; Luna-Reyes & Gil-Garcia ; Mithas, et.al. ; Lucas, et.al. ; Stieglitz & Brockmann ; Setia, et.al. ; Wang, et.al. ; Berman & Marshall ; Loebbecke & Picot ; Westerman et.al. ; Digital Capabilities Berman & Marshall ; Loebbecke & Picot ; Matt, et.al. ; Schuchmann & Seufert ; Tamm, et.al. ; Wang, et.al. ; Westerman et.al. ; Strategies Berman & Marshall ; Bharadwaj, et.al. ; Matt, et.al. ; Stieglitz & Brockmann ; Tamm, et.al. ; Mithas, et.al. ; Business Models Agarwal, et.al. ; Berman & Marshall ; Bharadwaj, et.al. ; Janowski ; Loebbecke & Picot ; Luna-Reyes & Gil-Garcia ; Matt, et.al. ; Mithas, et.al. ;Schuchmann & Seufert ; Tamm, et.al. ; Stieglitz & Brockmann ; Value Chain Agarwal, et.al. ; Berman & Marshall ; Bharosa, et.al. ; Janowski ; Stieglitz & Brockmann ; Tamm, et.al. ; Wang, et.al. ; What are the Key Impacts of Digital Transformation? Value Creation: Reshapes Realign Redefine Integrate Collaboration Matt, et.al. ; Mithas, et.al. ; Schuchmann & Seufert ; Berman ; Bharadwaj, et.al. ; Luna-Reyes & Gil-Garcia ; Stieglitz & Brockmann ; Johnson & Lederer ; Berman & Marshall ; Chen et.al ;Bharosa et.al. ; Wang, et.al. ; Agarwal, et.al. ;Buschmeyer et.al. ; Westerman et.al. ; Operational Efficiency: Optimize Processes, Omni Channel; Agility; Improved Decision Making Structural Change Bharadwaj, et.al. ; Luna-Reyes & Gil-Garcia ; Matt, et.al. ; Mithas, et.al. ;Schuchmann & Seufert ; Lucas, et.al. ; Setia ; Kreutzer ; Stieglitz & Brockmann ;Tamm et.al. ; Berman & Marshall ; Loebbeck & Picot ; Hansen & Sia ; Janowski ; Bharosa et.al. ; Wang et.al. ;Agarwal et.al. ; Berman & Marshall ; Chen et.al ;Westerman et.al. ; --- Create Competitive Advantage Bharadwaj, et.al. ; Lucas, et.al. ; Matt, et.al. ; Schuchmann & Seufert ; Kreutzer ; Stieglitz & Brockmann ; Chen et.al ;Westerman et.al. ; Improved Relationships: Enhance Bharadwaj, et.al. ; Luna-Reyes & Gil-Garcia ; Matt, et.al. ; Schuchmann & Seufert ; Bharosa et.al. ; Wang et.al. ; 30 TH BLED ECONFERENCE: DIGITAL TRANSFORMATION -FROM CONNECTING THINGS TO TRANSFORMING OUR LIVES R. Morakanyane Agarwal, et.al. ; Berman & Marshall ; Bharadwaj, et.al. ; Janowski ; Loebbecke & Picot ; Luna-Reyes & Gil-Garcia ; Matt, et.al. ; Mithas, et.al. ;Schuchmann & Seufert ; Tamm, et.al. ; Hansen et.al. ;Chen et.al ; Operational Processes Bharadwaj, et.al. ; Lucas, et.al. ; Luna-Reyes & Gil-Garcia ; Matt, et.al. ; Mithas, et.al. Female, Lagos, May 12, 2016). The expression as seen in price shows the engagement aspect of appraisal with the statement being attributed to another source which shows heteroglossic engagement. In product order, the statement "very poor" shows negative polarity as the next sentence is attitudinal, and further statement expressed heteroglossic engagement. Consumer service review depicts attitude as well as negative like product quality review. For delivery time, the reviewer express graduation with the word "wonderful" used and the review for shopping experience shows negativity and heteroglossic engagement aspect of appraisal. Under shipping, the statement is categorized as polarity reviews made under the return items, and store location is neutral. --- Online Community Benefits The authors deduced certain advantages for the mobile shoppers as evidenced from their Facebook page reviews under the headings of enlightenment, opportunity, involution and co-creation. Enlightenment: How To Make A Teddy Bear Out Of A Towel . Lovely. I will try to make one for my grandchildren. Practice makes perfect . Opportunity: Business opportunity! We are currently Leading an Expansion of a global fuel company and we are competing against the Trillions in Revenue … . Involution: DO NOT SHOP ON GMR!! Product Quality always totally different from description their coupon doesn't work either they still charge the same amount even after using the coupon...crap!!! Don't do it please! . Culture: This include language, cuisine, music, artefact and dressing. The cultural display shows the interplay of various culture represented on the platform due to ethnic diversity of Nigerian states. Co-creation: Limitations of our research stem from the specifics of the airport processes, which are mostly dependent on its size. Therefore the developed approach and artefact can be reliably expected to be applicable only to airports of similar size. Furthermore, the execution times specified by the airport experts are deterministic, i.e. fixed, making the model deterministic as well. Hermeneutics can help render the meaningful of a text , which has become obscured or 'distanced' in some way, thereby making it no longer immediately obvious . An obvious everyday example that does not interpretation is a STOP sign as it is either understood or not . When is Hermeneutics needed? Hermeneutics can provide a rich, detailed interpretation of peoples' experience and texts . Traces of data and metadata left in a network computing infrastructure are becoming computing history where Hermeneutics is needed to provide an interpretation of the data . Interpretive research can help IS researchers understand human thoughts and actions in social and organizational contexts; it has the potential to produce deep insights into IS phenomena including managing of IS and IS development . Hermeneutics was also discussed in the development of Information Engineering due to its powerful ability in interpreting users and the system. With new emerging technologies, human actions can be understood through the interpretation of data produced by the devices as they are used by people and patients for specific needs, specifically in healthcare. The data is becoming an extension of people and patients as traces of interaction between patients and medical professionals are TRANSFORMING OUR LIVES Z. Zekiria Sako, S. Adibi & N. Wickramasinghe Understanding New Emerging Technologies Through Hermeneutics. An Example from mHealth 529 information that is becoming an extension of them that requires a technique, like Hermeneutics, to be applied to understand the underlining messages hidden in the data. Similar future studies may incorporate mixed methods approach to strengthen the findings through triangulation of methods that would provide two different perspectives on data. --- Future Research Directions This research sets the foundation for examining the quality of health data in digital context. There are several areas that will require research to be done to continue delivering high quality healthcare services through mHealth technologies. One key area is the human behaviour when using the technology, especially when entering and transmitting the data. The first 12 weeks contained intensive face-to-face and eSupported coaching. After that, patient selfmanagement and eTools were key. After 50 weeks, attractiveness and feasibility of the intervention were perceived as high: recommendation 9,5 out of 10 and satisfaction 9,6 out of 10. TAM surveys showed high usefulness and feasibility. Acceptance and health behaviours were reinforced by the prolonged health results: Aerobic and strength capacity levels were improved at 50 weeks, plus Health Related Quality of Life . We draw three types of conclusions. First, patients' health literacy and quality of life improved strongly, which both supported healthy behaviours, even after 50 weeks. Second, regarding eHealth theory, iterative growth cycles are beneficial for long term adoption and e-relationships. In addition, most of the physicians indicated the need for the CPGs to be available on the intranet, next to the CDSS. To merge the different anti-clotting CPGs in a CDSS, the current overlap must be eliminated and the physicians need a guarantee that the state-ofthe-art versions will always be applied in the CDSS. Besides this, the CDSS needs to be available in the alignment of the current CPGs. This way, the CDSS will simplify the use of the CPGs but not replace them. From the collected and analyzed data gathered from the various CPG owners, we can conclude that the reactions towards the use of a CDSS are mostly positive. This enthusiasm shows that, despite the physician's doubts with regards to ease of use, they are open for the use of a CDSS and will be likely to adopt it, given the fact that most if not all challenges identified are overcome. Taking a look at our study, several limitations could be identified. One limitation is the available time that was planned for the focus group and the individual interviews. With more time we probably could have delved deeper into the experiences, problems, improvements and essential functionality of a CDSS as perceived by our interviewees in more focus groups. However, this was hard to negate as the physicians stated to have meager time to participate in this kind of research projects and are needed in the UMCU most of their time. We aimed to negate this partly by interviewing the individual participants as this allowed for further data collection and validation without utilizing focus groups which allow multiple stakeholders to be available on the same time and place. Furthermore, our sample composition and sample size are limited to eight stakeholders. While we believe this is appropriate at this stage of design of a CDSS in the context of the UMCU, future research should focus on the utilization of more quantitative research methods such as surveys, using larger sample sizes to increase the generalizability of the results. Also, future stages of development should medical informatics specialists, which excel in extensive testing on the subject-matter as well as the decision making process by a CDSS. In this study, we included a sample of eight stakeholders, which is, according to the guidelines of Dworkin , a valid amount of participants for a qualitative study. Therefore, an important note with regards to future research is that quantitative research methods are dependent on the actual implementation and adoption of the CDSS in practice. Hence, we encourage the UMCU to invest in further research projects to establish whether a CDSS contributes to the quality of healthcare. The impact of openness to experience was significant and impact of narcissism was borderline significant. The former had positive effect, the latter negative. But the model as a whole is not significant. Carlson and Wu suggest to exclude independent variables that are not significant. Parameter estimates for the reduced model are provided in Table 2. R2 is 0.051, R2adj is 0.036 and p-value is 0.034. Keeping only openness to experience in the model would worsen p-value to 0.085. A model with narcissism only would have a p-value of 0.093. The social hierarchy as a result of the high power distance in China leads to a strong respect for authority which is evident among Chinese daily practices . In a group orientated society, the social hierarchy and respect for authority of the interpersonal relations and the society is paramount. This cultural value has been largely involved with other cultural values in the discussion of interpersonal relationship in the Chinese context. Guanxi as a Chinese cultural value has been broadly discussed in the investigations of Chinese in-terpersonal relationships in business, society and organization . This attribute also is a key cultural factor that determines Chinese interpersonal behavior. To build up and maintain a good 'guanxi' helps to achieve positive group dynamics and strengthen social ties. Compared with other cultural values, the value of keqi tends to provide a guideline of practice in interpersonal relationships. 'keqi', refer to 'well-manner politeness' , which is a personal attribute as well as an embodiment of harmony in Chinese communication to keep a courteous dis-tance with an acquaintance. Chen argues that the keqi way of communication is the way to sustain the harmonious relationship. --- Research Methodology This paper is framed within the methodological stance of a case study which is useful for investigating contemporary phenomena and their context . The proposed model in this article is adapted from two existing models . This is the starting point of this research, this model centralizes the con-cept of collectivism and suggests a lens from which Chinese culture values can be understood in terms of specific cultural attributes of keqi, guanxi, and respect for authority. These three notions understand the collectivism from interpersonal relations, social hierarchy and harmonymaintenances. This model is designed to be used to provide an understanding of the cultural values inherent in the design of Chinese social media platform. The first step of the research process is presented in the next section, where the authors analyse existing features of WeChat alongside Chinese cultural values. This model can then be used to fur-ther explore the design of the WeChat application. Data will be collected through interviews with designers and developers of WeChat. We will employ a snowballing interview technique which is common in qualitative research . One of the key problems of snowball-ing as identified by Biernacki and Waldorf is finding participants and starting a referral chain. We can overcome this problem because one of the authors has personal connections to employees at Ten-cent . A social media platform is developed and eventually launched; it grows, and at some point will peter out unless it innovates . Aral et al. suggest that by thinking deeply about platform design platform designers have an op-portunity to consider add-on features and other forms of innovation to extend a platforms functionality and usability. In its relatively short history WeChat has been able to adapt and alter their life cycle through innovation. 2: concept matrix of analyzed articles and organizational design components"). --- Framework Organization design can be viewed as a chain of decisions and choices and collectively refers to the "process of configuring structures, processes, reward systems, and people practices to create an effective organization capable of achieving the [digital] business strategy" . Initially, it originates from Galbraith well-established organizational design framework that consists of the intertwined components of strategy, structures, processes, rewards and people. The following paragraph introduces each component briefly. The component strategy determines a company's course of action and can be understand as the cornerstone of the organizational design. It origins from the decision-makers' understanding of the various environmental influences such as new technologies, competitors, customers, suppliers etc. Essentially, it is the success formula to gain a competitive advantage and differentiation. Structure refers to the organizational chart and key roles. Some common types of organizational structures are functional, product, geographic, or customers-centric structures. It represents the possibilities of how to group different people together in an organization. Furthermore, it clarifies responsibilities, decision-making powers, and authorities. The component processes refers to any connected activity that is linked with the information flow within and across an organization. Processes dissolve collaboration barriers that may result from an organizations' structure. Well-designed processes ensure that e.g., the right people find each other to innovate a new product. Processes can determine mechanisms for collaboration and therefore how well units within and across organizations work together. Rewards have the purpose to harmonize the behavior and performance of individuals with the overall goals of an organization. It includes e.g., rewards based on measures or variable compensation. The component people contains practices like selecting, training, staffing and developing of people to gain desired capabilities and a mind-set to successfully execute the strategy. This may include e.g., competencies like interpersonal skills and decision making capabilities such as considering multiple points of view . TRANSFORMING OUR LIVES T. Weinrich: Reviewing Organizational Design Components for Digital Business Strategy 661 stakeholders like customers, alliances, employees, suppliers etc. Such an understanding is the foundation to lever digital resources and create value for an organization . In so doing, it may help an organization to preserve a competitive advantage or to gain new competencies and define a new competitive advantage . Nevertheless, managers need to be capable to communicate the DBS and their beliefs organization wide to create a common understanding . This is especially important because DBS affects the whole organization and any change may bring resistance to some degree . Digital talents can either be recruited externally or internally, by hiring people with the sufficient experience from academic institution or other organizations, mergers and acquisitions or training via dedicated digital training programs . --- Summary and Conclusion Overall, this literature review contributes to the body of DBS and organizational design. It sheds light on DBS and organizational design by specifically looking at the components of strategy, structure, processes, rewards and people . Considering strategy, it is evident, that digital technologies have to be an integral part of DBS. Yet, the majority of identified articles specializes on certain digital technologies under DBS and do not treat them in a holistic manner as frequently emphasized . Additionally, there is a strong focus on harnessing cloud computing, analytics and social media under DBS. Whereas, mobile technologies are underrepresented but not less important . In terms of structures, this piece of research points out that under DBS organizational functions become increasingly decentralized. It is also evident that the reporting structures and decision-making power shifts since DBS is an organization-wide endeavor and needs orchestration within and across the organization. However, how organizations achieve this is quite heterogeneous . Regarding the component processes, an increasing interfacing with the ecosystem, which includes customers, partners, suppliers and possibly competitors, is key. Organizations need to be capable to lever their ecosystem because it is a critical source of value creation by e.g., fostering innovation . Regarding the component rewards, this literature review found surprisingly little on harmonizing individual behavior with the overall goal of an organization. While literature mentions the importance of this aspect, only little information is given. Finally, the component people shows that to follow a DBS, digitally skilled employees and leaders are needed, which understand digital technologies, their strategic implications and know how to create business value from it. Overall, this literature review is able to show that in order to carry out a DBS, organization design requires a large shift. Yet, the presented organizational design components for DBS should not be treated mutually exclusive but as interrelating components, which need to be closely aligned to complement each other to be successful. . Similar to Chong, Liu, Luo & Keng-Boon , the basic Technology Acceptance Model was extended with three additional external variables which enabled us to include all of our research questions. Health Concerns were included in the model according to the results of previous studies on RFID adoption , Perceived Trust has similar to HC gained a lot of attention in the research community . Furthermore, age was included as a predictor variable of Behaviour Intention to Use since younger people are more prone to adopt new technologies . --- RFID microchip With the development of technology and robotic production, the capacity of microchip has multiplied while the size of it was minimised. The biggest challenge today is not the size of a microchip . The problem is the size of the antenna that should be at least 1mm long to get reliable results . Depending on power needed for operating, RFID microchips are categorised into three types: passive, active and semi-passive. While passive devices don't need any internal power, the active do and their life time depends on battery capacity, usually not longer than one year . Semi-passive devices present a combination of both other types. While data stored in a passive NFC RFID-SM microchip can be read with the help of electromagnetic field produced by a reader device, the sensor needs a power supply . To overcome this problem, the researchers are trying to develop rechargeable implanted batteries that produce electricity with the chemical reaction of body fluidsglucose bio-batteries . We can find the application of RFID microchip in manufacturing, supply chain management , logistic, automotive industry, livestock production , food production and public sector . RFID microchip is used in shops, passports, proximity cards, automated toll-payment transponders, ignition keys, contactless credit-cards, smart bracelets, smart finger rings, smart watches, etc. . In healthcare we can use RFID for resource management . There are also RFID systems for tracking patients and personnel . Besides, the high number of health care errors causing death can be reduced when using RFID system for monitoring patients . There were several attempts of using RFID-SM in vivo. The first human with active RFID-SM implant was Professor Kevin Warwick in 1998. He was able to programme doors to open and lights to switch on when he approaches the RFID reader. He removed the chip after nine days in order to avoid possible health complications due to the battery lifetime. In 2002 the Jacobs family members were implanted by Very chip . One of first recorded commercial use of RFID-SM was in 2004 in the Baja Beach Club in Barcelona, Spain, and Rotterdam . An RFID-SM with a unique code for identification of very important persons was used to enable electronic payment and access to VIP areas of the club. The name of the person was displayed publicly on screens upon their entrance to the club. In 2005, three employees of the U.S. Company Citywatcher.com were implanted with microchips for access control application. In the same year, the Very Chip was used for medical reasons to identify patients for the first time in the USA. Volunteers were chipped in hand or arm with local anaesthetics. The system was able to recognize 16 digit identification code to identify and gain an insight into patient medical record data . The author of the book RFID toys , Amal Graafstra's initial motivation to get a chip implant was for the convenience of eliminating keys . In 2013 first commercial company called Dangerous Things was established and started to sale the first RFID-SM for home use . The presented study considered the usage of the passive NFC RFID-SM of size 2mm x 12mm, similar to the glass-coated used for animals' identification. There are more than 5 million house pets with such chips, which enable identification of the pet's owner . --- Research approach --- Data collection The study about attitudes toward RFID-SM among Slovenians was performed from April to December 2016. The link to the web questionnaire was sent via email to members of researchers' social networks and it was posted on the faculty web page. --- Questionnaire and research hypotheses The research model includes all three basic concepts of TAM : Perceived Ease of Use , Perceived Usefulness , and Behaviour Intention to Use . The basic concepts are combined with two PU has seven items which are in accordance with items proposed by proposed by Davis in the original TAM model. Five of them were adopted from , and two additional items on storing information about organ donation and a general statement on saving lives in different medical conditions were added. PEU and PT items were adopted based on Davis and Smith , respectively. PT refers to an individual's trust that the state, banks and healthcare systems will be able to ensure the security and protection of gathered personal data. Items composing HC construct were prepared based on extensive literature review of medical research papers and they measure possible threats of RFID-SM usage. BIU reflects four different possible types of the RFID-SM usage as pointed out in the interviews. The exact items wording can be found in Table 1. AS noted above, each model component was measured by several items . The items of HC, PT, the last item of PU, and PEU were measured on a 5-point Likert-type scale of agreement; the first six items for PU were measured on a 5-point Likert-type scale of acceptability, while the items of BIU were measured as dichotomous variable . Research hypotheses are presented in Figure 1. We proposed ten hypotheses. Nine of them were adopted from the 2014 study, and one new was added. We assumed that perceived experience on implantation procedure has a positive impact on HC. The predicted relationships among concepts included in the model are presented with arrows, where a plus sign represents positive impact and a minus sign negative impact. --- Data analyses The proposed hypotheses in the research model were analysed with structural equation modelling . In this paper, presented results were obtained based on the analyses of 291 respondents, who provided at least partial responses on the variables included in the model . There is no general recommendation on minimal sample size required for SEM. Hair et al. suggested the sample size between 150 and 400, while Loehlin's rule of thumb suggests that the sample size should be at least 50 more than eight times the number of measured items in the model. Since our model consists of 25 measured variables, the minimal sample size should be 250, which indicates that the analysed sample size of 291 respondents is sufficient to achieve the statistical power necessary for SEM with three or more measured items per latent variable. To use all, also partial information obtained from the respondents, multiple imputations was used when analysing the data in order to improve the validity of the results . The research model was evaluated in two steps. First, measurement model was investigated, followed by the analyses of the structural model . To confirm, that the constructs are correctly defined, first data screening and confirmatory factor analysis was performed, followed by SEM. Our hypotheses assume several relationships between variables which could be analysed with several multiple regressions, but SEM was employed for its ability to analyse relationships between latent and observed variables simultaneously . Several statistics were calculated before SEM, and the detailed results are omitted due to limitation of the paper length. Here, we will only list the performed analyses to justify the corrections of the data analyses and results presented. To assess whether the data are approximately normal and therefore appropriate for CFA and SEM, the absolute values of skewness and kurtosis were calculated. The Cronbach's alpha coefficients were calculated for each of the five constructs in our research model to determine the extent of the internal reliability. The construct validity of each scale was assessed using CFA, and it was evaluated via the convergent validity and the discriminant validity. The convergent validity was examined based on three concepts : a) estimates of the standardized factor loadings which should exceed 0.5 , b) composite reliability for each latent variable which should exceed 0.7, and c) average variance extracted measuring the amount of the common variance between the indicators and their construct in relation to the amount of variance attributable to measurement error for each latent variable, which should exceed 0.5. In order to investigate the discriminant validity of the measurement model, the square root of AVE of each latent variable was compared to the correlations between the latent variables. In the final step, to evaluate the impact of proposed relationships among constructs in the research model, SEM was used. Since there are endogenous binary variables in the model, the robust weighted least squares mean and variance-adjusted estimation in the lavaan R-package was used . In order to assess the fit of the measurement model and the structural model, the overall fit was examined based on various sets of commonly-used fit indices: χ2/df which should be lower than 3 ; indices TLI and CFI which should be at least 0.9 in order to indicate adequate model fit . The root mean square error of approximation should be below 0.06 or at least below 0.08 as proposed by . Results of the SEM analyisis are presented in the Results section. The values of standardized path coefficients and corresponding z-values reflect the relationships among the latent variables in terms of the magnitude and statistical significance. For every endogenous latent variable the coefficient of determination is also calculated, which should be above 0.1 to confirm the predictive capability of the model. --- Findings and results --- Sample characteristics The sample consists of 59% of women and 41% of men. Among the respondents, 33% are in primary school, secondary school or at the university. More than half of the respondents are employed, 6% are unemployed, while 7% are retired. --- Descriptive statistics of the questionnaire items under study Table 1 presents descriptive statistics and standard deviation ) of 24 variables included in the research model. On average, respondents agree the most with the statement that subcutaneous microchips can integrate multiple functions at the same time . If we examine the four items of HC closely, we can see that respondents are worried due to treats of possible allergies , and an impact on the nervous system . On the other hand, they are less concerned due to possibility of microchip movements in their bodies and due to effects on emotional behaviour . Items of BIU were measured as dichotomous variables. In Table 1 the percentages of the respondents who positively answered on the individual question are presented. The highest proportion of the respondents would insert an RFID-SM for health care purposes and the smallest proportion of the respondents would have microchips for shopping and payment in a way that microchip would replace debit cards, credit cards, and profit cards. The means were calculated also for four components. Mean values are above 3 for three components: 3.08 for HC, 3.76 for PEU, and 3.46 for PU, which indicates that the overall response could be classified as positive. The mean of PT is equal to 2.71, which indicates that perceived trust on security issues provided by state, banks, and healthcare system is somehow low. --- Health Concerns Subcutaneous microchips can be threatening to my health because of the possibility of movement in my body. 2.97 1.187 Subcutaneous microchips may affect my emotional behaviour . 2.95 1.265 Subcutaneous microchips can be threatening to my health because of possible allergies. 3.27 1.196 Subcutaneous microchips can be threatening to my health because of their impact on the nervous system. 3.14 1.206 --- Perceived Trust ) The state will ensure the security and the protection of human rights . 2.57 1.271 Banks will provide security . 2.70 1.297 The healthcare system will provide security . --- 2.84 1.29 --- Perceived Usefulness Subcutaneous microchips could be used: for monitoring the health of the user, e.g. pulse or blood pressure. 3.60 1.127 for warning about potential health problems or complications . 3 --- Results of the SEM First, measurement model was evaluated. The item PEU3 on RFID-SM security protection was removed from the PEU construct, and consequently from the model, due to combination of its standard loading slightly above 0.5 and its variance which was twice as big as for other construct items. Standardized factor loadings for items in the model exceed a threshold of 0.5 for convergent validity, 19 of them exceed also stricter threshold of 0.7. The AVE for all five constructs reach and exceeds a threshold of 0.5 for convergent validity . In our measurement model, the obtained value of χ2/df = 1.465 is lower than 3, and both TLI = 0.89 and CFI = 0.90 are close to 0.9. The RMSEA is equal to 0.040, and the upper bound of RMSEA 90% confidence interval is lower than 0.06. According to the set of the calculated fit indices, it could be concluded that measurement model fits the sample data reasonably well. Therefore, the fit of the structural model could be evaluated. The goodness-of-fit of the SEM was evaluated with the same set of indices as for the measurement model. The results show that the model has a good fit: χ2/df = 2.154 , TLI = 0.88, CFI = 0.89, and RMSEA = 0.063 with its 90% confidence interval . --- Painful Procedure Implanting RFID-SM is a painful procedure. 2.89 1.167 Would you insert a subcutaneous microchip: --- Percentage of positive responses Behaviour Intention to Use for healthcare purposes ? 43% for identification purposes ? 28% for shopping and payment ? 20% for everyday home usage ? 23% if you were assured that GPS positioning and tracking were not possible? 29% The results of the structural model are presented with standardized path coefficients , which reflect the strength of the relationships among the latent variables . For every endogenous latent variable also the coefficient of determination is presented. The predictive capability of the model is satisfactory because all coefficients of determination are above 0.1. The smallest R2 is for HC and it is equal to 0.246, R2 for PT is 0.278, for PU is equal to 0.514, and the highest value of R2 is for BIU . Figure 2: The results for structural model --- Supported H5a: Perceived Ease of Use has positive impact on Perceived Trust. Supported H5b: Perceived Ease of Use has positive impact on Perceived Trust. Supported H5c: Perceived Ease of Use has positive impact on Behaviour Intention to Use. Not supported H6: Age has positive impact on Behaviour Intention to Use. Supported We can see from Figure 2 and The keyword search was performed on the databases of EBSCO, IEEE, and ScienceDirect in title , publication title , abstract , and keywords . The first search string was supplement-ed with the terms "consumer context" and "patient context" as the initial number of search results was low . Only reviewed contributions published since the year 2000 and such that are written in English language were considered in order to en-sure transparency of results on the one hand and currentness on the other hand. The number of search results for all three keywords and the named restrictions was 146 and formed the basis for a deeper analysis. Each publication was screened in the named fields and, if marked as relevant to the concept of customer context, the full-text was read to extract relevant items. Since it was found that context may either be related with application systems or their re-spective users , a further restriction was made towards the user per-spective. This view aligns with the CDL perspective as it helps businesses to under-stand customers and their individual, situation-based needs. Abstract ERP acceptance by its users in companies has been researched by several authors while ERP acceptance by students within study programmes has not been researched so often. For teachers should be important to know which factors have influence on student ERP acceptance. Our study researches student acceptance of ERP solutions while they are exposed to ERP solution and they are involved in ERP actual use. Our research is based on TAM which provides a basis for tracing impact of external factors on internal beliefs , attitudes , intentions and actual use. Research model includes additional external factors such as: experience with computer, computer self-efficiency, personal innovativeness toward IT, computer anxiety, user manuals , system quality, social influence , training and education etc. Research was conduct within a group of 121 students after short interaction with Microsoft Dynamics NAV ERP solution. Results show that most important external factors for student ERP acceptance are: individual benefits, training and education on ERP system and quality of ERP system. TRANSFORMING OUR LIVES . The chosen perspective for the objectives of the research is that of explanatory research since little is known about the research topic . This is combined with descriptive research in order to describe systematically the situation . The mode of enquiry perspective is that of a qualitative approach and therefore the form of case studies is chosen to retain a holistic and real-world perspective . A case study is interpretive and descriptive because it attempts to understand and portray results-oriented planned maintenance through the participants' interpretation of their context . The case study design is also chosen because the main research question is a 'how' question, the researcher has no control over actual behavioural events, and the degree of focus is on contemporary events . The research aims to discover which coordination mechanisms are used to align goals and objectives in the supply chain, to align decision-making by the supply chain partners, to share information within the supply chain, and to align cooperation in the supply chain. But also to discover whether the benefits of SCP improved project performance , reduced project costs , and reduced project risks are present in the cases. Further objectives are to investigate what ICT systems are used, the problems that occur in using the coordination mechanisms, and how these problems can be improved. This research consists of two cases. For these cases, a two-case case study design is chosen in order to describe and explain SCP in planned maintenance at Dutch housing associations. The findings from these cases are assessed in a wider context through a survey. Research results are published four times during the research. The first paper is a literature review, the second paper is based on the results of the first case study, the third paper is based on the results of the second case study, and the fourth paper is based on the survey results. The final thesis is composed based on the published papers . Figure 1: Research method The coordination processes of supply chain integration at Dutch housing associations are described through a literature study. This is supported by literature on coordination theory, agency theory, boundary crossing, and information management. Literature is found through desk research and snowballing using scientific databases such as Science Direct and scholar.google.com. Results of this literature review will be used in the case studies. Case study evidence may come from six sources: documents, archival records, interviews, direct observations, participant observations, and physical artefacts . And because in case study research it is important to use multiple sources of evidence , this research makes use of the following sources: documents, archival records, interviews, and direct observations. The researcher will not participate in the maintenance process, therefore participant observation is not used. The researcher remains "a passive observer, watching and listening to activities and drawings conclusions from this" . Also, physical artefacts are not used because processes are researched, not technical operations . Furthermore, two types of interviews will be used: prolonged case study interviews and survey interviews . The direct observations will contain observations of meetings and maintenance activities . Both case studies are organised to the same theory in order to strive for generalizable findings that go beyond the specific cases . This means that this research adopts the holistic multiple-case design and is a literal replication Yin . In all cases maintenance must be executed within a supply chain; within the supply chain all partners commit to predetermined results; maintenance is described by the housing association as technical performance demands; and the contractor assures both housing association and tenants that the technical performances are achieved. Results from both case studies will be validated through a survey amongst other Dutch housings associations and their maintenance contractors. The first object of study is a maintenance supply chain at a local Dutch housing association, founded in 1913. For this housing association, supply chain partnering is an important feature since 2011. They believe in the benefits of SCP and execute 80% of their maintenance work through SCP. In this case study, the main contractor is a new supply chain partner who has proven his reliability and skills in a small project. The following roles are included in the study: the project manager of the housing association, the foreman of the main contractor, the project manager of the most important subcontractor and the project manager of the supplier. It is important to point out that the project that is researched is the first of this particular main contractor. Aspects of study are the sub-questions as stated in section two. --- Expected results Based on our study of the literature, the following elements are a prerequisite for the improvement of the maintenance processes : supply chain partners have a joint understanding of the mutual dependencies between all supply chain partners; supply chain partners align their goals and objectives; supply chain partners agree on the coordination of decision-making; and supply chain partners agree on the exchange and availability of information and knowledge . The assumption is that by identifying and applying the coordination mechanisms , information management and supply chain partnering, and thus maintenance processes will improve. This will lead to all previously mentioned benefits . Preliminary case study observations show a difference in the approach to SCP. The property managers ambition is results-oriented cooperation with a permanent network of supply chain partners based on affordability, availability, and quality. He believes that data must be secured and available and knowledge must be assured, for example by using BIM. The project manager, however, does not talk about results-oriented cooperation but about performance oriented cooperation with responsible supply chain partners. He also draws up performance oriented contracts per project which contravenes to both the literature on trust and SCP and the housing association's own supply chain principles. The main contractor has aligned his goals with those of the housing association regarding the project, he puts the quality of living of the tenants during and after the maintenance activities first. Further research must give more insight into the actual cooperation process and its effects. CONNECTING THINGS TO TRANSFORMING OUR LIVES A. Pucihar, M. Kljajić Borštnar, C. Kittl, P. Ravesteijn, R. Clarke & R. Bons Personalization in Digital Services: Information Technology Supporting Service Personalization Process --- OLLI KORHONEN Abstract Personalization technologies are widely applied for providing appropriate products and services for individual users. Service providers utilize personalization technologies for understanding the individual user needs, and for personalizing their service offerings for those needs. That perspective follows the value models of manufacturing, wherein service provider personalizes the services for the user, and where the roles of service provider and user are distinct. However, propositions that markets have transformed to services, wherein services are co-created between actors, is not supporting the traditional personalization perspective properly. For example, healthcare services are not only personalized for the user, but in co-creation with the user. Therefore in my research proposal, the aim is to examine service personalization, and the role of IT in the service personalization process, from the perspectives of different actors. TRANSFORMING OUR LIVES O. Korhonen: Personalization in Digital Services: Information Technology Supporting Service Personalization Process 753 2007). As medical doctors are specialists in the healthcare domain, the services are typically personalized based on their professional knowledge for individual healthcare users, with support from IT and other tangible technology . In other words, IT is used as an artefact to provide the right information for the right person, in the right format . Therefore our study focused on examining the role of IT in the healthcare service personalization process. Our results from that study illustrate that personalization intertwines automatized support from IT with a more collaborative nature where service personalization occurs in co-creation and interaction between actors. Therefore, for illustrating our findings , we categorized different personalization types under three main categories, based on the automatization level provided by IT: 1) Coercive personalization is automatized and does not allow interpretation of the human actor, 2) Data display personalization is automatized, but interpreted manually by medical doctors, 3) Collaboration-based personalization is supported by automatization, but the emphasis is on interpretation and co-creation between actors. --- Future Development In the near future, we have plans to conduct another case study in collaboration with a large service provider . The aim is to examine both the user and service designer perspective and to provide insights how the personalized services are constructed in co-creation between these actors, and what is the role IT plays in the service co-creation. For the final paper , the aim is to draw an overview, a holistic framework regarding to service personalization. That framework covers the perspectives of different actors and presents the diverse role of IT in the service personalization process.

or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publisher.Univerzitetna knjižnica Maribor 659.23:004(082)(0.034.2) BLED eConference (30 ; 2017) Digital transformation, from connecting things to transforming our lives [Elektronski vir] : (conference proceedings) / 30th Bled eConference, (June 18 -21, 2017, Bled, Slovenia

introduction diabetes is a chronic disease that occurs when there is too much glucose in the blood because the body is not producing insulin or not using insulin properly as noted by the who diabetes is at epidemic proportions globally and needs to be addressed diabetes management involves a combination of both medical and nonmedical approaches with the overall goal for the patient to enjoy a life which is as normal as possible as there is no cure for diabetes diabetes must be regularly managed and monitored critical to this management regimen is the systematic monitoring of blood glucose levels however achieving this goal can be challenging because it requires effective lifestyle management as well as careful meticulous attention and monitoring by the patient and health professionals there is a need for identifying a simple and convenient noninvasive approach to monitoring blood glucose this forms the focus of this research background invasive semiinvasive and noninvasive solutions a key factor in the management of diabetes has been found to be the patients self blood glucose monitoring as a result of recent research general practice management of type 2 diabetes recommends smbg for patients with type 2 diabetes who are on insulin currently the dominant method to test blood glucose level is invasive it requires a blood glucose meter a lancet device with lancets and test strips further the patient must prick their finger with the lancet sometimes more than four times a day finger pricking in sbgm has been found to have several clinical and psychological disadvantages these are described below clinically there is a risk of skin infection and tissue damage repeated finger pricking associated with the depth and possible vibrations of the needle tip while penetrating the skin were found to cause soreness and damage the skin and in severe cases could lead to ulcer on their patient fingers therefore this sbgm practice can result in damage to the patient body site further sbgm using a finger prick glucometer is not practical for continuous monitoring of blood glucose as blood glucose levels of a patient change overtime possible occurrences of hyperglycaemia or hypoglycaemia between measurements may not be recorded thus the measurements may not truly reflect the patient blood glucose pattern 30 th bled econference digital transformation from connecting things to transforming our lives s adibi l nguyen a hamper f bodendorf n wickramasinghe a systematic approach to terahertzbased glucose monitoring 9 psychologically inconvenience and anxiety of constant performing finger pricking and extracting a drop of blood in patients daily lives and associated physical and emotional pain have always been troublesome in sbgm in a crosssectional questionnaire survey with 315 patients with diabetes in the uk about one third of general diabetes patients were found to have anxiety to finger pricking for sbgm positive correlations were found between anxiety due to finger pricking and avoidance of testing as well as between anxiety due to finger pricking and general anxiety in previous studies pain and discomfort were consistently found to cause a natural resistance to sbgm and subsequently result in a lack of adherence to this procedure anxiety due to the finger prick method and avoidance of testing were found across different ethnic groups and female patients were found to have greater anxiety to finger pricking sbgm the aforementioned disadvantages served to motivate the need for new approaches to sbgm they can be categorised into two groups the first group is to support for measuring blood glucose levels in a less painful manner wainstein et al used a coolsense device to reduce local pain sensation due to finger pricking they conducted an experiment with 177 adult patients with type 2 diabetes and concluded that the coolsense device significantly reduced subjective pain felt by the patients while maintaining the same level of clinical accuracy other studies suggest that instead of pricking fingers patients can prick other areas such as the forearm knee earlobe thigh and abdomen skin while pricking alternative body sites were commonly found to reduce pricking fingers to some extent it did not eliminate the pain completely disadvantages of pricking other body sites include lack of accuracy inconvenience and difficulty of pricking in public and technology switching costs to purchase new equipment for pricking and measurement the second group of approaches to sbgm is to developing semiinvasive and noninvasive technologies for blood measuring without needle pricks du et al propose a biosensor that can detect lowlevel glucose in saliva they conducted a study of ten healthy human subjects and conducted that the proposed biosensor can be seen as a potential alterative to sbgm using finger pricking the protocol of use is still rather complex consisting of nine steps requiring the patient to chew a sponge in hisher mouth to collect saliva and later squeeze the collected saliva into the device with a sensor thus is not easy to use more studies are required to investigate the accuracy of sensors in detecting low salivary glucose levels efficiency and practicality of the proposed approach zhang et al review current developments of noninvasive continuous sbgm methods using ocular glucose these authors review studies in ocular glucose monitoring using contact lensbased sensors and using nanostructured lensbased sensors they concluded that lens sensors have the potential to monitor a wide range of glucose levels quickly and accurately however there is a safety concern because boronic acid and concanavalin a may be released from 10 30 th bled econference digital transformation from connecting things to transforming our lives s adibi l nguyen a hamper f bodendorf n wickramasinghe a systematic approach to terahertzbased glucose monitoring the lens into the patient body nanostructured lensbased sensors have several advantages further studies are required to improve resolution and sensitivity of the lens and to determine physiologically relevance and baseline tear glucose concentration another review of current nanomaterialbased solutions using saliva sweat breath and tears as a medium for sbgm suggests that they are far from optimal further nanotechnology sensing devices need to be manufactured at a low cost to compete with established blood glucose meters one of the most recent advances in the area of semiinvasive glucose monitoring is abbotts freestyle libre system which is based on a body attached sensor and a smartphone loaded with the application this disposable body attached device is equipped with a thin and flexible fibre needle which is the only invasive part however the fibre is inserted only once and under the skin of the back of the arm the sensor can be used continually for 14 days without the need to be replaced the sensor captures glucose concentration information and once the smartphone that runs the required app scans the sensor the current and up to 8 hours of glucose levels are read and uploaded to the smartphone according to timothy et al the accuracy of the freestyle libre system as dependent function of a number of patientrelated factors has been found to be above 852 up to 14 days of testing overall studies in issues associated with sbgm using finger pricking devices and learnings from in current developments of new sbgm methods suggest the following key factors technology clinical accuracy clinical and safety interference with vision patient vision ease of use psychological effects and costs we develop table 1 to present the key aspects of problems and concerns identified in the extant literature relating to sbgm we conceptualise the problem in diabetes care management with the above factors therefore we propose an approach to solution development consisting of patients analytics to focus on the targeted patient cohort design science engaging patients in testing when its safe not early design to finally propose a new solution to address their concerns and ensuring appropriate monitoring of the care management plan once the specific thz approach is selected the methodological approach is to model the existing solutions and study the physical behaviour of terahertz technology when radiated onto the human skin and study the depth of penetration and the variations in the reflections this requires sophisticated thz lab equipment to run experiments on a test dummy which mimics the human skin and underlying soft tissues the results between the traditional needlebased sensing are then compared and the precision figures for the terahertzbased method are evaluated then the approach need to be finetuned and also other health issues are then considered proposed solution a design science research methodology will be used to operationalize this research this approach is particularly appropriate where improving an existing solution is desired andor there is a need for a new solution to address specific unsolved or unique aspects dsrm as a process model to carry out research is widely used in the information systems research to create new solutions or to improve existing ones dsrm process model consists of six process elements starting from identifying the problem and the motivation to conduct research and concluding with communicating the results and outcomes of the research table 2 maps the proposed project to dsrm process elements 30 th bled econference digital transformation from connecting things to transforming our lives s adibi l nguyen with the increased diabetes population and the disadvantages of conventional blood glucose tests the lack of a reliable and easy to use noninvasive technology to monitor blood glucose motivates this research definition of objectives of the solution the objectives can be qualitative or quantitative ie create or improve an artefact respectively based on knowledge of the state of the problem and current solutions if any and their efficacy the objective is to create and refine an artefact ie the sensors design and development creating the artefact including the desired functionality and its architecture based of knowledge of theory that can be used to bear in a solution this is usually an iterative process through several iterations the exact range for the frequency for the needed terahertz wave beam will be identified once the narrow range for the frequency for the terahertz wave is identified the cadcam programming will occur demonstration demonstrate the use of the artefact to solve the problem simulationbased this will be done in a lab using their simulation set up and mannequins clinical demonstration of the use of a new device to a sample of targeted patient population evaluation iterate back to better design the artefact if needed simulationbased as needed iterations will take place to fine tune the needed range for the terahertz wave projections clinical iterative evaluations to ensure that the prototype is truly tailored to meet clinical requirements for the targeted population communication publish and let the value of the solution talk about itself this will include conference publications journal publications and other presentation activities 30 th bled econference digital transformation from connecting things to transforming our lives s adibi l nguyen a hamper f bodendorf n wickramasinghe a systematic approach to terahertzbased glucose monitoring results and next steps based on our systematic review of the literature to date we have identified problems and concerns with the current methods for blood glucose monitoring as well as the need for a simple accurate noninvasive solution to it to address this void we have proffered a technology solution using sensor technology combined with a smart phone the next steps now include the design and development of the solutions coupled with establishment of proof of concept usability and fidelity this involves four key steps as follows phase1 this phase will involve the conducting of multidimensional analysis of provided data sets from a diabetic population the results will provide a clear picture of the current state reveal critical trends and important patterns regarding this population and assist to identify the patient sample it is anticipated that target patient cohorts and their demographics as well as geographic and clinical characteristics will be identified for the project to identify who would benefit most from the noninvasive smart solutions this phase aims to address the first dsrm process elements including problem identification and motivation and definition of objectives of the solution phase 2 phase 2 will include designing and developing the appropriate sensor technology the patented solution we have developed uses thz to identify blood sugar readings but this requires critical analysis to isolate the specific thz band inputs for this are derived from aspects of the data analytics performed in phase 1 above once this is done the required specifications for designing the sensors must be generated thus the results at the end of this phase include the design specification for the sensors to be used in the specific context so they are truly tailored to that context this phase aims to address the subsequent dsrm process elements including design and development simulationbased demonstration and associated simulationbased evaluation phase 3 phase 3 will focus on the design and development of the software solution necessary to develop the prototype to be used to measure blood glucose readings contemporaneously the health literacy issues will be examined and an appropriate education and coaching program will be developed for the targeted population this phase aims to continue the dsrm process element design and development phase 4 phase 4 involves establishment of proof of concept usability fidelity and functionality this will be conducted by running a field study on the selected patient population of 50 patients based on results from phase 1 it is anticipated that the filed study will involve and iterative process to ensure that the prototype is truly tailored to the selected populations needs and requirements in addition hba1c the standard diabetes marker will be tested at 3 month intervals over a 6 month time frame to assess success of the solution and changes to health literacy at these points will also be assessed this phase aims to address the dsrm process elements including clinical demonstration and clinical evaluation using the key aspects s adibi l nguyen a hamper f bodendorf n wickramasinghe a systematic approach to terahertzbased glucose monitoring 17 side effects and safety ease of use psychological effects and costs and relevant factors presented in table 1 as a result the list of factors will be refined to inform future implementations and evaluations the dsrm process element communication will take place through the whole project when findings from each phase become available discussion and conclusion concurrent and independent from the exponential rise of diabetes has been the rise of mobile and sensor technology the maturing and sophistication of these technologies has enabled them to be sued in many aspects of healthcare and wellness management the preceding has served to outline another potential area for the adoption of mobile and sensors namely to assist with a noninvasive approach for the monitoring and management of diabetes specifically we have identified an opportunity to use terahertz frequencies to detect blood glucose levels in individuals further we envisage designing and developing this solution by combining sensors with a mobile phone so that detection of blood glucose can not only be noninvasive but truly pervasive the implications for theory and practice are wide and far reaching from a theoretical perspective we combine two technology genres mobile and sensors to address a healthcare issuedetection of blood glucose levels using a design science research methodology this can lead to a better understanding and application of sensor technology in mobile technology scientifically backed roadmaps for including innovative sensors in mobile technology can support further dsrm based research in the field from the perspective of practice diabetes as noted by world health organization is global and at epidemic proportions with an estimated of 422 million adults living with diabetes in 2014 and 15 million deaths caused by diabetes in 2012 complications from diabetes can lead to other serious conditions such as heart attack stroke blindness kidney failure and lower limb amputation further the number of prediabetic individuals is also considerable monitoring and management is the only recognised strategy to maintaining appropriate blood glucose levels and thereby managing diabetes andor preventing a prediabetic becoming a diabetic given the problems and criticisms of finger pricking and other invasive approaches to sbgm the most prevalent approach to testing blood glucose using a noninvasive terahertz technology solution which we propose is very attractive to individuals by learning from glucose monitoring there is an opportunity to transfer the use of terahertz technology to test other blood values in a noninvasive way when such a solution is truly pervasive it becomes even more attractive thus we believe that the proffered solution will enable diabetic and prediabetic individuals to enjoy a better quality approach to monitoring and managing their blood glucose levels our future work will focus on establishing usability fidelity and acceptability of the proffered noninvasive pervasive solution introduction in the era of digitalisation music has become easier to create distribute and access than ever music recommender systems are meant to assist listeners in navigating through the myriad of available musical works and provide them with suggestions that would fit their preferences and needs this paper aims to present the most common techniques in music recommendation and how these affect the positions of nonsuperstar artists while previous research on mrs typically takes a technical perspective or focusses on the consumers the artists perspective has yet largely been neglected the phenomenon of superstars wherein relatively small numbers of people earn enormous amounts of money and dominate the activities in which they engage seems to be increasingly important in the modern world still the impact of mrs on nonsuperstar artists is particularly important as the vast majority of artists are nonsuperstar artists the economic situation of nonsuperstar artists is usually precarious and the technological and managerial skills required to manage and promote ones own business as an artist are usually not part of the typical educational paths of aspiring artists the importance of nonsuperstar artists is further underpinned by the long tail concept introduced by anderson a model that is specifically applicable to the music industry this model describes the economic tendency when there is a concentration of sales on the most popular items which form the head and then a long tail of less popular items that may fulfil niche demands of potential customers this model is considered the opposite of the hit model in industries where an item either becomes a hit or does not make any profit at all the implication is that it is more profitable to sell small amounts of the long tail of less popular items than large amounts of a small number of hits later empirical findings confirm this idea provided there are effective search and recommender systems available that enable users to access these longtail items easily at the same time mrs is an enabler to introduce niche items to a consumer who usually follows hits only in such a sophisticated manner so that this hitaffine user may start consuming longtail products as a result the employment of recommender systems in the longtailed online music market enables users to discover and access the work of nonsuperstar artists the paper is structured as follows section 2 provides a structured overview mrs and their functionality in section 3 we explore the influence of mrs on nonsuperstar artists by explaining the phenomenon of popularity bias the cold start problem and superstar economy section 4 provides details and results of a semistructured interview with an artist followed by the last section containing concluding remarks music recommender systems this section provides an overview of the structure of mrs its components and functionality and the most common techniques used typically recommender systems consist of three key components users items and useritemmatching processes this general structure also applies for mrs where users are the listeners and items are the music items the system collects relevant data about its users and applies mathematical models and diverse techniques to find and propose items which might be of interest for the listener to recommend items that most likely fit the listeners preferences the system needs to manage data about listeners and music items the system generates profiles for each of them and determines good matches by comparing these profiles in the following we discuss in detail the data and approaches associated with the three key components ie user item and matching user data in order to be able to make valid recommendations an mrs requires data about its users needs however getting such exact data is a costly process thus mrs rely on user modeling the system analyses its users data and generates profiles based on their differences to model music preferences and thus determine which music items might be of interest for the individuals typically the user modeling process consists of two subprocesses user profile modeling and user experience modeling user profile modeling is generally used to determine the position of the listener in comparison to others based on their features one of the approaches suggests dividing user profiles based on three major categories demographic geographic and psychographic further a number of attributes can be assigned to each category such as age gender country interests etc whereas user experience modeling is meant to approach the users with consideration of their music expertise level which further can be used to determine some of their expectations towards the mrs combining both approaches it is possible to predict some of the users demands and desires regarding music for instance it is possible to predict a users preferred ratio of new previously unknown vs popular already known music items she would like to listen to when engaging with a music platform some data can be obtained through observing listeners in their actions on the music platform such as listening patterns other data may be retrieved through input inquiries eg surveys to retrieve profile information 30 th bled econference digital transformation from connecting things to transforming our lives c bauer m kholodylo c strauss music recommender systems challenges and opportunities for nonsuperstar artists popularity bias one of the most problematic issues that affect the position of nonsuperstar artists is the socalled popularity bias in general the popularity bias phenomenon suggests that over time the most popular music items tend to get more and more attention while music items in the long tail get less and less attention in particular popularity bias is a significant problem when employing cf or contextbased filtering due to the nature of the integrated algorithms as concerns mrs this phenomenon manifests in several ways for instance cf uses listeners ratings to create recommendations this implies that popular music items receive generally more ratings than items of the long tail this in turn entails that an mrs recommends popular items more frequently than less frequently rated items this however reinforces the popularity of popular items and thus also increases their suggestion rates as a result items in the long tail receive less and less ratings and so the system recommends them less frequently for example fleder and hosanagar could show this effect in a simulation study they simulated an mrs based on cf where music items were recommended based on the results of previous recommendations across several different user groups the overall diversity of consumption by the end of the simulation was decreasing in other words the mrs was giving preference to more popular items over time in a similar way contextbased filtering uses data available about a musical works to derive recommendations since popular items are generally better promoted on media and are mentioned in more online sources overall more information is available about those items compared to items of nonsuperstar artists as a result an mrs employing contextbased filtering suggests popular and widely discussed items more frequently than items with less popularity and this gap grows over time the cold start problem closely related to the popularity bias is the socalled cold start problem which refers to the difficulty to get recognition in an early stage when a new user or new item enters a mrsdue to the lack of data related to the user or item when a listener just starts to use an mrs and has not submitted much information about herself or her preferences etc the mrs will only provide her with general recommendations similarly when new music items are introduced to a system they do not make it into the recommendation results because there is not enough data available about these items which would trigger the mrs suggestion in addition artists new to the market do not only have merely new music items in their portfolio there is also not much data available about them as artists entailed with less frequent discussion promotion etc as a result the chance that new artists items are 30 th bled econference digital transformation from connecting things to transforming our lives c bauer m kholodylo c strauss music recommender systems challenges and opportunities for nonsuperstar artists 27 recommended by an mrs are even less likely than that for new items of established artists superstar economy speculations in addition to research on the effects of and consequences inherent in the techniques an mrs employs some sources assume that mrs are biased towards popular tracks not only due to their design and the algorithms employed but on purpose as hit items generate larger profits than items of nonsuperstars for instance a marketing report by media insights decisions in action consulting concludes that the recording music industry is not at all oriented at longtail items according to this source one of the main reasons for it is that mrs do not only offer popularitybiased recommendations but also that music platforms get polluted with musical works that are created in bad quality on purpose with the aim to enhance the positions of the already popular music items such bad musical works sound similar to the bestselling songs but in comparison the listener would still prefer the more popular better song as a result the sum of sales for hit songs is higher than that for nonhits so music platforms are more motivated to sell more of popular music items this opinion is supported by findings of research investigating users music preferences show that users who prefer mainstream music are in general easier to satisfy with an mrs in contrast for instance levy and bosteels investigated whether the mrs employed by the lastfm platform is indeed biased towards more popular items as suggested in earlier literature they compared three different data sets the one of lastfm recommendation radio which recommends specific music to specific users based on their data the lastfm radio data set which plays music recommended to lastfm users in general and and a data set of the lastfm music streaming services as a whole which summarizes the information about what users are listening to while using lastfm the findings suggest that lastfm as one of the largest worldwide mrs is biased towards nonhits rather than towards hits in comparison to overall user listening experience and this bias is stronger for lastfm recommendation radio based on these results the authors conclude that realworld data can significantly differ from simulations and also state that not all mrs seem to be biased towards more popular artists 30 th bled econference digital transformation from connecting things to transforming our lives c bauer m kholodylo c strauss music recommender systems challenges and opportunities for nonsuperstar artists impacts of music recommender systems while the topic of popularity bias and the recommender system inadequacies seems to be one of the most broadly studied topics with regard to mrs research it seems that research has been limited on the existence and the reasons of these phenomena yet exploring the impact of these phenomena on different artist groups or differentiating in more detail within an artist group has not been investigated for instance as mentioned in a billboard article researchers and media tend to focus on disadvantages and flaws of mrs performances while neglecting the fact that the existence of the discussed phenomena may be a big advantage for a privileged group of artists for example in the old music business when music was either distributed on physical media andor promoted through live shows it was tremendously challenging for newcomers to the industry to get recognition if their music did not score to become an immediate hit now newcomers have the chance to slowly make their way up in industry by experimenting with the recommendation mechanisms and promoting their works accordingly the shift from the shorttail to the longtail model might not be as significant as in other entertainment industries such as films as books but it is still present and it continues growing this view is supported by the case we investigated and is presented in the following section 4 insights from a realworld case to gain some insights on how mrs impact nonsuperstar artists from their point of view we drew from the experience of an aspiring nonsuperstar music band using the internet as the main tool to promote their music approach several criteria motivated the selection of an interviewee to gain handson insights on challenges and opportunities for nonsuperstar artists recent release of an album experience with mrs use of internet as a main promotion tool newcomer on the market limited information about the artists available on the internet and professional attitude and aspiration based on these criteria we selected a ukrainian oriental metal band founded in july 2011 under the name parallax renamed in 2015 to ignea their first work alga was released in 2015 whereas they released their first fulllength album the sign of faith in 2017 this band was selected to provide insights on the topic of mrs from the artists point of view because since their debut in 2011 they mostly use internet to promote their work the interview indicates that the bands overall experience with them as a nonsuperstar artists is very positive for instances about 80 of their listeners and purchasers discovered the band through mrs recommendations furthermore achieving success on the platforms has led to mentions on the media overall our interviewee pointed out that mrs combined with the power of internet had helped the band to generate international audience instead of regional listeners currently the majority of their listeners is located in the united states the interviewee expressed her opinion that she thinks many artists fail on platforms with mrs due to the lack of knowledge andor effort that the artists put into managing their activities on such platforms trying to exploit mrs for their own ends she emphasized the importance of studying and understanding how such systems work and pointed out the lack of knowledge that artists seem to have about the tools available she said that those might not be aware of the tools and possibilities and do not sufficiently search for their opportunities the observation of the lack of managerial skills is backed up by research findings behaviour on the market partly resulting from such an educational deficit may lead to destruction of the economical basis of aspiring artists she believes that a good artist can reach success with the help of mrs she stated that her band will continue using mrs to promote their music in the future introduction some 720 years ago a book appeared in europe marvelling the travel in asia that marco polo started when he was seventeen and that ended when he came back to venice 24 years later although the book contains omissions and exaggerations it describes how a merchant perceived the wealth and great size of asian cities and it soon gained popularity in europe while inspiring other travellers to travel even further one of which was christopher columbus the purpose of this article is to describe an ongoing project for teaching professors to design a training program meant to transform any management students the same way a long journey to asia transformed a simple merchant into marco polo we define a study exchange program as a program in which students from a university study abroad at one of their institutions partner institutions since such programs might be hard to organize from an administrative point of view this article focuses on shortterm study abroad which lasts less than three months and exposes students to an intensive program that increases their understanding of other cultures communities and languages shortterm nonlanguagebased study abroad programs can have a positive impact on intercultural sensitivity moreover previous studies have already shown no statistically significant differences between the semesterlong group and the shortterm group a recent stream of literature has studied how shortterm study abroad enhance critical thinking among students which is defined here as the application of focused reflection and reasoned thought and how to prepare the predeparture sessions to properly prepare the students although the positive effects of a shortterm study abroad have been discussed in previous studies a major barrier for teaching professors is the cost to implement it in this study we wish to find a way to lower three components of such cost the effort required to obtain the economic resources needed to do the trip the effort required to prepare the students and the effort required to assess the acquisition of relevant competences in this paper we seek for a set of guidelines that reduce the effort required to organize a shortterm study abroad for a university course such goal seems to be best addressed by a design science methodology which seeks for utility rather than truth and will be instrumental to develop a framework of guidelines for teaching professors therefore our research question is how to reduce the cost of a shortterm study abroad aimed at increasing the critical thinking of management students the rest of the paper proceeds as it follows section 2 briefly assesses the state of the art with respect to relevant concepts needed to answer our research question section 3 describes our methodology and the proposed solution section 4 illustrates the 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students 35 preliminary results obtained section 5 concludes the paper by discussing its limitations and by highlighting possible directions for further investigation literature review in this section we introduce three concepts to address our research question apprenticeship as a way to gather resources for the trip massive online open course to standardize the content used to prepare the students information technology to collect information during the trip point out that the majority of study abroad programs are now shortterm and facultyled but it does not specifically address the issue of effort required for financing in this paper we suggest establishing partnerships with firms and have students do apprenticeship in the firms during the course in exchange of financial supports for the short term study abroad this approach is inspired by the finnish model of education to teach entrepreneurship the socalled team academy approach that has already influenced the way management courses are taught apprenticeship can be defined as a system of training a new generation of practitioners of a profession with onthejob training and some accompanying study with respect to internship apprenticeship is more structured and it requires a close collaboration between the firm and teaching professors if one assumes that management students are apprentices who do a project during a semester that includes a shortterm study abroad the predeparture sessions meant to enable students to perform critical thinking during the period abroad needs to be consequently adapted indeed existing literature has already offered a set of guidelines to increases the critical thinking of students by means of three sessions that addresses three relevant questions session 1 choosing my adventures session 2 whats my attitude and session 3 building my skills nonetheless the useful material offered by the authors need to be complemented with other resources that help students solving the problem of the firm in this sense one way to train students is to use a massive open online course which can be defined as an online course aimed at unlimited participation and open access via the web online companies such as coursera or edx offer courses from top universities that include videos and tests to assess knowledge acquisition although the real value of moocs is currently debated xmooc are a useful approach to assure that the training of students is in line with what is currently taught in other universities where x stands for extended meaning that the mooc complements a course done in class finally it should be taken into account that during a shortterm study abroad students do not have constant access to a personal computer or to internet access therefore it would be advisable to combine online tools that allows students from different classes to work together and paper templates to carry on and to fill in during the trip to assist 1 identify problem and motivate the overall need of international experience was brought by companies who hire our students after the completion of their university training the specific need of reducing the effort required to include this activity in the course was due to the limited resources available at the university 2 define objectives of the solution we looked for an existing solution to adapt our course of digital marketing once we found the model of we tried to extend it in order to allow quantitative analyses and benchmarks among groups of students 3 design and development we developed the course iteratively over three years each year we improved one of the three cost components the first year we introduced the notion of apprenticeship to lower the cost of financing the second year we complemented our courses with moocs and we started measuring skills acquisition with external surveys the third year we developed a travel guide with templates to fill after each visit 4 demonstration each year we tested the model by travelling with selected students of the course of digital marketing to the same location in order to allow comparison between different years 5 evaluation we assessed the effort required to organize the shortterm study abroad while measuring the satisfaction of students and companies 6 communication we waited until the third iteration to communicate the results of our model due to the complexity of the task at hand 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students 37 our framework the resulting model has four components that form the acronym polo two of which have been fully implemented for a course of digital marketing and two of which will be implemented in the next iteration a predeparture sessions we identified three main themes associated to the experience that students would have done abroad and that could be improved by digital marketing techniques tourism education and strategy consulting for firms according to there are three components of the themebased interdisciplinary approach which we adapted to our situation great questions in order to perform each experience students had to combine existing notions of information technology strategy market analysis and service design glocal awareness during each experience students had to report how they felt about being immerse in a foreign country and what changed with respect to the local context they were used to global awareness after each experience students were asked to propose ways to translate the skills learnt in a global context into the ecosystem of the firm they were working with moreover we had to take into account the interaction between the students and the firm that financed their trip since we did not want to personally attend the meetings between the students and the firm we decided to use a set of proxy measures we used two moocs from coursera and training material from google and facebook to prepare students to the topic of digital marketing students were asked to complete the course at home and to come to class prepared to discuss about how to implement the theory into their group project with the firm every month the students had to complete a set of quiz to monitor their mastery of theoretical concepts in order to measure retention of concepts we submitted the same quiz more than once hence the first month students would have to do quiz 1 the second month they would have to do quiz 1 and quiz 2 the third month they would have to do quiz 1 quiz 2 and quiz 3 and so on only the first quiz led to a summative evaluation the result of the other quizzes was known by the students but did not change the initial score that way we would monitor how many theoretical concepts were put into practice within each group and to perform risk analysis at the group level one month before the trip the firm had to do an intermediary evaluation and we checked if there were correlations between our risk analyses and the feedback of the firms b observation while being abroad according to there are three components of the cultural immersion a experience whenever possible students were advised to observe how locals were behaving with respect to each theme previously defined 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students b reflection at the end of each day students were brought to traditional monuments and restaurants to familiarize with the underlying culture of the city c application students had the opportunity to follow university courses and presentations done by international firms on the same topic in order to assess the increase in the critical thinking of the students a set of templates to fill were given the templates to fill in had the same structure for every theme analysis of the touchpoints between the student and the service link between the touchpoints and the concepts of digital marketing learnt in class observation of existing digital solutions used in the context and difference between theory and practice suggestions for improvement and explications of implementation c learning with another class this component of the framework is currently under development and it has not been tested yet in its final stage of development we envisage to create virtual teams composed by students from two universities in two different countries which will have to perform a joint task ie to attend the google online marketing challenge a groupware with project management functionalities such as liquidplanner will allow students from the two universities to talk before meeting during the shortterm study abroad then students will continue working together from two separate countries d ontological changes this component of the framework is currently under development and it has not been tested yet previous research has already shown that the different stages of the ucurve adjustment theory can be shortened by performing predeparture exposure to the host culture teaching techniques of anticipatory adjustments to the host culture and increasing the time spent with host country nationals accordingly teaching professors could link the quantitative results obtained during the predeparture sessions and the data collected during the trip in order to monitor if the honeymoon and the culture shock stages last too long and act accordingly for sake of simplicity we list here only two propositions derived from the ucurve adjustment theory students who spent little time to attend to models will report the lowest levels of perceived dissimilarity between the approach of the host country nationals and themselves at the beginning of the trip and students that have written more of new and appropriate behavior at the beginning of the trip will receive a greater positive reinforcement and will adjust quicker to the new culture preliminary test results in this section we illustrate the results of the most recent test the first two components of our model which was used with a class of 35 students of the course of digital marketing at the beginning of the academic year students were split into eight groups depending 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students 39 on their interests and skills the goal of each group project with the firm was the same to design and implement a digital strategy for the firm nonetheless each group project slightly changed over time depending on the stage of digital maturity of the firm or the resources available each group received theoretical classes once a week and had to meet the company once a month as part of their apprenticeship in the middle of the academic year a shortterm study abroad was meant to let students acquire international awareness by meeting multinational firms and by attending classes in another university accordingly the city of dublin was chosen since it hosts the headquarters for the europe middle east africa zone of facebook linkedin and twitter as well as hosting the headquarters of google ireland microsoft ireland and amazon ireland in the following paragraphs we illustrate how we monitored the interactions between the students and the firm during the predeparture sessions and between the students and their new environment during the observation phase abroad assessment of knowledge acquisition since we did not want to personally attend the meetings between the students and the firm we decided to use a set of proxy measures figure 1 illustrates how we monitored the firms each student did the quiz 01 three times over the course of one semester the quiz was composed of 40 questions directly taken from coursera and its score ranged from 010 to 1010 after each quiz we gathered all results of all students and then we extracted the median the maximum and the minimum for each group finally we assigned the groups to different risk clusters depending on their maximum and minimum 1 shows the classification that we used to monitor the groups if the maximum score was less than 710 we assumed that no one was in charge of the team and we assigned a 0 in the first column if there was a minimum score below 510 we assumed that there 40 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students was at least one slugger and we assigned a 0 in the second column usually teams started all at the best position during quiz 1 where most of the students had 1010 nonetheless over time students started forgetting what was not put into practice figure 1 different trajectories of the eight groups figure 1 shows that teams l1 and l2 managed to reduce the distance between the maximum score and the minimum score of the third quiz hence one can assume that they managed to involve the potential sluggers in the team instead teams f1 and f2 did not correct the distance between max and min but they managed to keep such distance steady between the quiz 2 and the quiz 3 team p1 and p2 could not control the amount of free riding in the team and eventually no one took the leadership interestingly enough these two teams did not have problems with the firm indeed by discussing with the firms we realized that the company took the role of the leader and the students decided to follow finally teams t1 and t2 increased the amount of free riding in the team over time and lost the degree of leadership these teams had issues in their midterm evaluation because the two firms did not take the lead preparation of the themebased interdisciplinary approach and cultural immersion table 2 illustrates an example of development of the theme strategy consulting students received a printed book with templates to complete such as the one shown in the example on day 1 students went to an irish university and conducted a case study under the supervision of a teaching professor in charge of the course of digital marketing 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students 41 at the hosting university on day 2 students went to visit the company analysed and where asked to perform reflective tasks to better understand the difference between theory and practice table 2 theme development across day 1 and day 2 case study guinness dates day 01 part 1 digital strategy of guinness analyze the amount of times the word guinness is searched on google ireland with respect to the word beer and world record part 2 marketing strategy of guinness storehouse read the hbr article the brand benefits of places like the guinness storehouse then link the keywords used by the reviews on tripadvisor to the seven principles part 3 your google ads to promote the website of guinness storehouse design a google ad to increase by 1000 the number of tickets sold online to tourists in the month of april to estimate the budget assume that the rate of ticket sold is 1 of the people clicking on the ad to comply with regulations on alcohol advertising make sure you do not sell alcohol to teenagers finally assume that every ticket sold online saves 3 chf to guinness with respect to a ticket sold on the building part 11 digital strategy of guinness why is the word «guinness » searched more than the word « beer » ………………………………………………………………………………………… … think about an example of how social marketing online allows guinness to promote its brand while respecting regulations on advertising of alcoholic beverages ………………………………………………………………………………………… … 30 th bled econference digital transformation from connecting things to transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students dynamics with the exception of the groups with the free riders where the leader became tired and one group in panic state which managed to rebound during the trip abroad this confirms our first proposition concerning the importance of the predeparture stage since one group has improved its relative performance during the trip we need additional information to confirm our proposition concerning the importance of positive reinforcement to teams which properly prepared before the trip and acquired new and appropriate behaviors in little time discussions and conclusions this article presents the preliminary results of an ongoing study to reduce the cost of a shortterm study abroad aimed at increasing the critical thinking of management students and to transform each of them into the marco polo of the 21st century we start by proposing to start by a project that implies apprenticeship in firms and that uses the time spent abroad in order to solve a problem of a company which could cover the travel expenses in return accordingly we have adapted existing templates for predeparture sessions of to include the notions required to solve the problem of the firm and we have devised a way to use moocs and standardized tests to monitor the work of the students finally we have extended the framework of to have the summative and formative evaluation under a quantitative form to allow benchmarks among students at its current stage this study has two major limitations the first one concerns the two missing dimensions of the polo framework which makes it hard to assess its validity as an overall the second shortcoming concerns the way reflective exercises are constrained by the templates to allow simple benchmarking nonetheless we believe that our preliminary results already offers two interesting contributions to previous knowledge if students work in teams the team dimensions should be taken into account and if students work with a sponsor the dynamic with the firm should be monitored to avoid the situation tired leader transforming our lives r bonazzi m poli n sarrasin polo a framework for shortterm studies abroad to enhance critical thinking amongst management students 45 in the future we intend to develop the two last components of our framework and to test it quantitatively on a larger scale in the beginning we shall limit our observation to two classes in two countries in order to better control for cultural effects indeed we intend to assess an additional proposition derived from black mendenhall concerning the sources of anticipatory adjustment such as training or previous international experience that increase attention and retention processes will in turn speed up the learning process of some students in order to properly assess the ontological change we also intend to try a version of the printed book with templates for students which constrain less their possibility to express themselves introduction open data is an increasingly topical concept which is rapidly growing in popularity amongst governmental organisations researchers the business community and other stakeholders open data has been defined as a philosophy or strategy that encourages mostly public organizations to release objective factual and nonpersonspecific data that are generated or collected through the delivery of public services to anyone with a possibility of further operation and integration without any copyright restrictions open data can be viewed as a key signifier of the evolving nature of the relationship between government and the citizen as the use of information technologies in government holds the promise of enhanced democracy and increasingly engaged citizen participation led by former us president barack obamas announcement in 2009 that his government would embark upon a transparency strategy that would see much greater levels of openness in government many governments around the world have since followed suit with increased emphasis on open data as a key component the potential benefits accrued are manifold these have been categorised by janssen et al as firstly political and social eg more transparency creation of trust in government more participation and selfempowerment of citizens etc secondly economic eg economic growth stimulation of innovation development of new products and services etc thirdly operational and technical eg counteracting cost associated with recollection and unnecessary duplication of data optimisation of the administration process improvement of public policies etc with the increased availability of open data intense pressure is being brought to bear on different public organisations to release government produced data there are myriad reasons for this including public spending cost reduction increased returns on public investment wealth generation service delivery and innovation the somewhat romantic view is that this will increase transparency and democratic accountability create trust in government and selfempower citizens while policymakers appear to believe that open data will be taken up and used by the public resulting in copious benefits this belies the fact that the focus of interest in the literature has been on technical and operationalisation issues and scant attention has been paid to usage theoretical contributions and the role of the citizen in this process this research will utilise the theory of value cocreation and develop a model that explains the factors that influence citizen engagement in the cocreation process we validate and expand on previous work by voorberg et al to create a theoretical model which we hope to validate through future research 30 th repositioning the role of the citizen the movement towards openness in government with open data as a key component has the potential to forever alter the relationship between the state and the citizen largely the participation mechanisms enacted over the last quarter of a century have been consultative in nature resulting in little influence over public policy these have taken the form of citizens assemblies referendums citizen juries public meetings and opinion polling these have been largely unsatisfactory in most cases and act as a supplement to traditional representative democracy rather than an alternative to representative democracy in addition dryzek has argued that since the 1990s democratic theory has taken a strong deliberative turn increasingly democratic legitimacy came to be seen in terms of the ability or opportunity to participate in effective deliberation on the part of those subject to collective decisions he further argues that democratisation takes place along three dimensions franchise scope and authenticity he states that authenticity is the degree to which participation and control are substantive as opposed to symbolic this search for dryzekian authenticity has come about as a result of declines in traditional forms of participation associated with representative democracy cocreation cocreation as a concept has evolved continuously since its antecedents appeared in the form of coproduction in the 1980s in the sphere of public administration the seminal papers produced added a solid foundation which was initially built on by prahalad and ramaswamy there has been a great deal of discussion in the academic literature concerning the issue of definitional differences relating to coproduction and cocreation voorberg et al found that when they compared the record definitions of coproduction and cocreation to a large degree both terms were defined analogously in addition they concluded that cocreation and coproduction have been used as interchangeable concepts while questioning the feasibility of conceptual clarity given the definitional murkiness of the cocreation concept and its interdisciplinary nature this research will draw from galvagno and dalli more broad definition of cocreation as a joint collaborative concurrent peerlike process of producing new value both materially and symbolically barriers to open data use from the citizen perspective in order to determine whether nontechnical barriers exist to open data use we reviewed the pertinent literature in the field we found that there is a lack of articles that examine ohemeng and ofosuadarkwa examined the ghana open data initiative from a demand side perspective which was initiated in 2012 with the primary aims of administrative efficiency and economic development they described the level of civil society involvement as abysmal and one the main nontechnical challenges has been the involvement of citizens in the process this is explained as a consequence of a skills deficit and a lack of awareness they further point out the necessity of balancing high and low technology approaches such as adopting a mobile government path shadbolt et al analysed the sociotechnical aspects of linked open government data from datagovuk they make clear that the makeup of the user interface is a crucial issue by explaining the ease with which ordinary citizens can access and query the data is a crucial factor for open government datas value huijboom and van den broek examined the open data strategies in five countries they found that one of the top barriers of open data policy was the issue of limited user friendliness they point out that technical experts of several countries stated that the existing databases should be converted into more userfriendly datasets to be of use for citizens and businesses this sample of case studies which address the user perspective endorse the idea that there is a dearth of studies investigating usage of open data from the citizen perspective they further point towards the existence of nontechnical and sociotechnical barriers the research model currently there is a dearth of literature examining theory contribution and development in the open data field furthermore as zuiderwijk et al point out little is known about what predictors affect the acceptance and use of open data to address this shortcoming this research paper will attempt to contribute to the advancement of theory by developing a research model that will explain intentionality to use open data to do so the authors adapted and extended previous research conducted by voorberg et al in the area of cocreation through a review of the pertinent literature we were able to validate the first three constructs identified by voorberg et al we further validated the risk aversion construct and added trust as a supplementary factor owing to a symbiotic relationship which exists between the two constructs finally we developed the construct of simplicity of task as the academic literature pointed towards its importance and necessity transforming our lives june 18 21 2017 it is our belief that these prominent factors in citizen cocreation represent moderating variables that have the potential to alter the relationship between the citizen and the outcome of open data usage this is visually represented below in figure 1 figure 1 research model conclusion and future work the next step of this ongoing research will be to design and conduct an exploratory crosssectional pilot survey with current open data users focusing on the individual as the unit of analysis to establish the strengths of our survey constructs this will be followed by a series of semistructured interviews with selected users it is hoped this will lead to validation of the constructs mentioned previously special attention will be paid to theory building and theoretical contribution following doty and glick theory must contain at least three principles to be defined as theory constructs must be identified relationships among these constructs must be specified and these relationships must be falsifiable opening up governmental data is riven with potential and pitfalls how this is managed by the state will determine the accrual of potential benefits for the private sector and society as a whole for understandable reasons previous and current research has focused on technical and operationalisation issues however if tangible benefits are to be realised greater attention needs to be paid to the end user the authors propose a research model from the perspective of the user by employing the theory of cocreation that will help in developing increased understanding of intentionality to use open data the contributions of this study are twofold firstly adapting and extending prominent factors in cocreation with a view to applying them to intentionality to use open data secondly the attempt to build theory in the area of open data which has been under investigated thus far background the proportion and socioeconomic relevance of ageing citizens is already high in most eu countries and there is growing political pressure to find tradeoffs between the costs and the substance of the care programs the young elderly age group represents 1823 of the population in most eu countries this is a large segment of the population that according to recent statistical estimates will be about 97 million eu citizens by 2020 for example this age group will represent 226 of the finnish population by 2020 and has already reached 17 million in sweden and 10 million in italy furthermore given their income level and accumulated wealth the young elderly represents very large and growing markets for digital wellness services especially in higher per capita income eu countries this demographic trend has clear economic and scientific implications the opportunities and challenges offered by the young elderly market in most eu countries is a market that so far mostly has been ignored by mobile service developers and providers offering progressive companies new areas for expansion across the eu and beyond it also provides fertile ground for collaborative research as it offers potential for researchers to work to find innovative solutions for large user groups testing and anticipating the benefits and impacts of deploying digital wellness services among the young elderly we have seen the need to build an industryresearch collaboration program to work out the means to build sustainable wellness routines for young elderly that would be progressive and innovative enough to get their interest be adaptive and useful enough for their individual needs to get adopted as part of daily routines and be flexible and meaningful enough for the users and their changing context so that wellness routines would become sustained and contribute over time to better health and quality years for the ageing population the program which has been worked out in both a national and a h2020 version is called digital wells and has the ambition to help form and support interventions in the daily routines of young elderly so that the interventions form wellness routines in turn these routines will help to preserve physical cognitive mental and social wellness for the young elderly and help to build the basis for healthier elderly years to make the interventions usable practical and sustainable a virtual coach vaidyahas been designed to ease and support the adoption of digital wellness services among the young elderly and to pave the way for some quickest possible gotomarket initiatives is a sanskrit word meaning physician pranabhisar vaidya the ones who protect lives by curing diseases and exhibits complete knowledge theoretically as well as practically introduction the society needs to have a strategy and priorities for the young elderly which areand need to bedifferent from the strategy and priorities for the senior age group a majority of the young elderly are healthy active and socially interactive and do not require much intervention or support from the health and social care systems of the society the logic behind working out digital wellness services for the young elderly is that improved health in this age group will significantly raise the probability for continued improved health in the senior age group for which illhealth among large numbers of citizens turns out to be very expensive we use wellness as the target concept as wellness will tackle different aspects of functional impairment the who defines wellness as the complete mental physical as well as social wellbeing of a person or groups of persons in achieving the best satisfying or fulfilling life and not merely the absence of disease or any form of infirmity there has been lively debate over the years about the dimensions of wellness ucr 12 has compiled the following seven dimensions  social wellness is the ability to relate to and connect with other people in our world  emotional wellness is the ability to understand ourselves and cope with the challenges life can bring  spiritual wellness is the ability to establish peace and harmony in our lives  environmental wellness is the ability to recognize our own responsibility for the quality of the air the water and the land that surrounds us  occupational wellness is the ability to get personal fulfilment from our jobs or our chosen career fields while still maintaining balance in our lives  intellectual wellness is the ability to open our minds to new ideas and experiences that can be applied to personal decisions group interaction and community betterment  physical wellness is the ability to maintain a healthy quality of life that allows us to get through our daily activities without undue fatigue or physical stress adams and els de la rey show the need for holistic wellness models and have tested this approach with a large empirical study here we will avoid any conceptual debate and use the following definition wellnessto be in sufficiently good shape of mind and body to be successful with all requirements of everyday routines the choice of wellness instead of health has the benefit that we are not dependent on access to health data that is strictly regulated in most eu countries with confidentiality and privacy limitations in this paper we will operate with wellness in two dimensions intellectual wellness and physical wellness there are of course challenges for introducing digital wellness services the first challenge is that common wisdom has it that young elderly do not have smartphones statistics now show that smartphones are becoming affordable general purpose instruments and will be even more so by the year 2020 recent statistics shows that the number of smartphones in finland was 6029 million in 2016 on an average finnish consumers had 20 apps installed on their smartphones of which 4 were paid a second challenge is the doubt that digital wellness services will be at all attractive to the young elderly this follows on a belief we have found in the market for mobile value services that elderly people will not learn how to use services on mobile phones there is no real use for mobile services in their daily routines advanced technology should be developed for young peopleand if elderly people use the services it will create the wrong brand image for the service developers we have now been running a research and development program for digital wellness services 201417 with support from two associations for elderly with more than 100 000 members our findings show that the mobile service market beliefs are misconceptions a third challenge is to work out empirically verifiable results on the intervention with digital wellness services valid theorybased results on how the design of digital wellness services will match the multiple wellness criteria and empirical verification on how digital wellness services will help reduce functional impairment there are several research methodologies available to meet this challenge here we will summarize the three methodologies we are using action research has been one of the key directions of service design and work with information systems for a couple of decades and would in our present case tackle problems with the development and implementation of digital artefacts the development work is often described as cocreative to find solutions that work and to not care too much about scientific precision design science is another possibility this is fundamentally a problem solving paradigm with roots in engineering and science and is working out designs in order to find ways to tackle realworld problems design science research is described as a paradigm in which a designer answers questions relevant to human problems via the creation of innovation artefacts that will contribute new knowledge the designs build on an understanding of what is needed to deal transforming our lives c carlsson p walden digital coaching to build sustainable wellness routines for young elderly 61 with the problems the design is both a process and a product and both can be validated and verified to be logically consistent and technically free of errors action design research found that design science is too technologically oriented and is not paying enough attention to the organisational or user context of the artefacts the adr works with digital artefacts that are ensembles shaped by the user context both when designed and developed and when used the adr deals with the dynamics and the complexity of the contextin our case the interventions to create wellness routines that are problems for engineeringinspired methods we use the adr in our research program the fourth challenge is the realisation that we cannot just create digital services and everything will then take care of itself this shows that we need to support the building of an infrastructure for design development implementation commercialisation and maintenance the approach that we propose is to build an ecosystem of service and infrastructure developers and providers and to support them with theory and methodology for agile business scrum processes the paper has been structured in the following way in section 1 we gave the background and in section 2 the key definitions and a summary of the methodology in section 3 we summarize results from a study of the acceptance and use of mobile apps and attitudes to wellness among young elderly on the åland islands in section 4 we introduce the principles of digital coaching and synergistic hybrid wellness solutions section 5 finally gives a summary and some conclusions as a basis for the continued work on wellness services young elderly on mobile apps and wellness we will start by addressing two of the challenges we identified in a recent project we cooperated with the association for elderly in the city of mariehamn and asked them to invite their young elderly to participate in a survey in the fall 2015 we collected 101 usable answers the proportion malefemale is 446545 831 of the respondents belong to the young elderlly and a further 149 are a bit older 653 are married and 149 are widowed 772 have a university or technicalcommercial degree 208 have a basic education in the sample 752 are retired and 238 are working fullor parttime or are carrying out voluntary work the most typical annual incomes before tax is 30 k€ 3040 k€ 4050 k€ and 50 k€ these profiles are typical for the åland islands and are representative for their group of young elderly here we will use these profiles as a snapshot of the young elderlywe will add to the profiles in the following to get a fuller description of the potential users of digital wellness services as we plan to run the digital wellness services over smartphones we need to find out how frequent they are in the sample we asked about the phones in use and found out that a majority use smartphones this was confirmed by the result that 729 of the respondents use mobile apps for navigation weather forecasting internet search etc we added to the profiles of the young elderly by asking how useful easy to use and valuable mobile apps are for them following davis and venkatesh et al structure of questions for the about 70 respondents that use mobile apps we found that the adoption of mobile apps scored high on a 5grade likert scale on several items  mobile apps are useful in my daily life 432  i will continue to use mobile apps 419  mobile apps help me to carry out my tasks faster 4 the results give us some insight to build on the young elderly use of smartphones is sufficient to launch digital wellness services the young elderly are confident users of mobile apps which is a prerequisite for getting the wellness services adopted this settles the first challenge and as mobile apps are digital services we can also claim that the second challenge is settled for the sample in the åland islands the research continues but so far we can stick to the proposal that digital wellness services could be developed and offered on smartphones for the young elderly then we moved on to get an understanding of what perceptions the young elderly have of two wellness dimensions physical and intellectual wellness a number of proposals scored high on a 6grade forced scale  intellectual challenges are important for my wellbeing 491  i get sufficient intellectual stimulation from my everyday life 461  my physical health has been good compared to people around me 438  my resistance to illness is good 424 30 th bled econference digital transformation from connecting things to transforming our lives c carlsson p walden digital coaching to build sustainable wellness routines for young elderly 63  the amount of information i have to process in my daily life is suitable for me 420  i expect my physical health to remain good 414  i expect my physical health to deteriorate with increasing age 394 the results we got show that the young elderly have clear perceptions of the two wellness dimensions thus it makes sense to develop digital wellness services in a next step we intend to cover also the emotional and social wellness dimensions then we need to find out if there are any characteristics that could single out the most promising potential users as we want to get good strong initial adoption of the wellness services our idea was that relations between socioeconomic characteristics attitudes toward the use of mobile applications and perceptions about wellness would help us to identify promising potential users details can be found in carlsson walden and carlsson carlsson we first run a factor analysis with 19 statements on mobile applications and 11 statements on wellness the results gave an indication for possible sum variables which were tested for reliability by calculating cronbachs alpha coefficients the target value was met for the constructed sum variables a nonparametric mannwhitney utest was run in order to explore possible differences between gender age highest level of education marital status current work status retired annual income and the level of experience of using mobile applications we found that there were significant differences in the positive attitudes to using mobile apps between the two age groups the younger age group was more positive the more educated group was experienced in using mobile apps the more educated group was socially active in using mobile apps the group with higher income gave more value to mobile apps males with higher income had a positive perception of physical wellness the group with a more active work status had a positive perception of their intellectual wellness we need of course to take some care with making conclusions from the collected data the sample of 101 respondents was not fully randomly selected and the survey was not fully reliable as we had no possibility to check the circumstances under which the questions were answered nevertheless the results are interesting as the young elderly have not been much studied in this way before the insight we gained from the åland island material relative to our overall vision to get young elderly interested in digital wellness services to get them to adopt them and to make the services part of their daily routines we should start with young elderly who are  digital coaching through digital fusion in early work with the young elderly we found that the interest in using digital wellness services on smartphones started to decrease after 23 months of continued use when the services were combined with activity bracelets the period of active use doubled to about 46 months these are early indicators and have something to do with the fact that there is a onetime cost for the activity bracelets this follows the pattern that if you have paid for a bracelet you keep up the wellness routines in order to get value for the money you have spent in an insight report it was found that 95 of applications on smartphones are abandoned within 1 month of download gartner found that the abandonment rate of smartwatches is 29 and 30 for fitness trackers in a study with more than 9500 participants in australia uk and the us this creates a dilemma for building wellness routines in order to get health effects among the young elderly the wellness routines need to be sustained for at least 35 years the ideal would be to keep them up for 1520 years ie well into senior years there is a need to build variety and advanced intelligent functionality into the digital wellness services a way to deal with this dilemma is coaching ie to make variety and innovative advanced functionality part of the digital wellness services which will keep the services interesting the material we worked out in section 2 already gave us some insight about the young elderly and this should be a starting point for giving the users individual advice and guidance on how to improve their wellness routines as a function of how advanced they are and what their goals and objectives are personal trainerscoaches have been proposed but will be too expensive we have worked out the functional requirements of the digital coach called vadiya  the coach builds on digital fusion fusion of heterogeneous data sets individual data groupcluster data big user group data from 100 applications and devices algorithms to build information from data sets fusion of sets of information with computational intelligence methods ontology to build knowledge from sets of information approximate reasoning and soft computing for knowledge fusion  coaching is built with data information and knowledge of different granularities context dependent individual wellness goals good practice  coaching is adaptive to national language cultural habits changes in legislation  vaidya coaching is continuous and is built to change dynamically should be maintained supported enhanced changed developed  vaidya is unobtrusive technology virtual coach on smart phone omnivore platform that will have 100 interface solutions for sensor data data from wearables new innovations transforming our lives c carlsson p walden digital coaching to build sustainable wellness routines for young elderly 67  vaidya builds on ideal wellness profiles that are worked out for individuals for groupsclusters of similar service users for countries with similar cultures and traditions etc deviations from the ideal profiles worked out with mcdm methods to offer recommendations of how to make optimal steps towards the ideal profiles a digital personal coach was proposed by schmidt et al to help fitness tracker users to personalize their training the coaching builds on partially observable markov processes and markov decision processes that use data from the fitness trackers when reported the coach was in first prototype development the implementation and use of markov processes may offer some challenges the digital fusion is needed as data will be multidimensional in each one of the four different wellness aspects some of the data can be collected with sensors other parts will need a gamification interface and support part of the data needs to be in real time part of it can be daily and weekly summaries we will need digital fusion to operate with heterogeneous data from different contexts and for different forms of wellness all of it should be presented in an understandable and tailorable form for young elderly users which is known as knowledge fusion the fusion methods and technology will add value to the digital wellness services  data fusion offers summary statistics from apps and devices goal attainment over days weeks months  information fusion produces trends deviations from trends targets and target revisions shows levels usually reached by similar service users  knowledge fusion compiles activities to combine add enhance information for advice support tailors enhanced activity programs an illustration of the differences between data information and knowledge in the wellness context was collected from a polar a360 activity bracelet and is shown in fig 1 in work with young elderly groups discussion quite often focused on wellness as a sum of different activities and it was pointed out that my best wellness is not achieved by maximizing my physical wellness but by finding some smart combination of intellectual physical and social wellness further study showed that wellness could be synergistic ie that combinations of different forms of wellness could be more than the sum of the individual wellness forms orienteering can produce synergistic wellness it offers cognitive and intellectual challenges in finding the optimal paths through the forest it is one of the physically most demanding sports the family of orienteers is closely knit also internationallyand promotes social wellness 30 th bled econference digital transformation from connecting things to transforming our lives c carlsson p walden digital coaching to build sustainable wellness routines for young elderly similar versions of synergistic wellness activities can be found among the young elderly concerts offer intellectual emotional and social wellness volunteer help and support of senior citizens offer physical emotional and social wellness singing in choirs offer emotional and social wellness and so on the digital coach vadiya should provide advice and support for synergistic wellness activities and for hybrids of wellness activities that work out innovative and sometimes unique combinations that would offer new challenges for the young elderly users there is of course the question of time for various activities and support for tradeoff between wellness activities ie how to get the best wellness value for time allocated to various activities figure 1 data information and knowledge fusion summary and conclusions we noted that the proportion and socioeconomic relevance of ageing citizens is high in most eu countries but that the young elderly has been ignored by the politicians worrying about the ageing population as they are too active and in too good shape to request any budgetfunded support from the society thus there are two cases of missed opportunities there is a potential market for digital services that represents 1823 of the population in most eu countries the young elderly are estimated to be 97 million by 2020 in the eu countries interventions that create sustainable wellness routines among the young elderly will reduce the probability for serious illness among the senior citizens we use wellness as the target conceptto be in sufficiently good shape of mind and body to be successful with all requirements of everyday routines in the study in the åland islands we could identify some first groups of supportive users of digital wellness services the first group is young elderly who are active in full timepart timevolunteer work and are experienced users of mobile apps and are 70 years the second group is young elderly who are experienced users of mobile apps and are more educated the third group is young elderly who are males with good physical health and an income 30 k€ per year the fourth group is young elderly who are more educated and find mobile apps good value for the price work with young elderly groups pointed to a dilemma interest for mobile and digital services tends to diminish rather quickly but wellness routines need to be sustained for at least 35 years to give positive health effects we proposed to introduce digital coaching as part of the digital wellness services to make the use of them sustained there is no doubt that much work remains to get wellness routines built and adopted by the young elderly introduction during the last few years there have been many changes for organisations on a global level nowadays through globalisation and the internet markets change quicker and organisations have a limited amount of time to adopt new trends or change their business models therefore the european commission states that innovation is critical in order to improve existing products services and processes or develop new ones that add value to an organization and increase europes competitiveness on a global economic level however besides innovation organizations are also focusing more and more on the efficiency and effectivity of their processes and therefore business process management is getting more attention bpm plays a vital role in addressing the priorities of current chief information officers because bpm is a key instrument in managing and improving organizational processes with information systems scientific studies that find that bpm maturity models support organizational performance are not new however recent research shows that bpm could also be an enabler to the innovation level of an organization what is not described in these studies is whether there is a difference in how bpm and innovation are related between different industries a relatively young industry such as it might be expected to be a lot more innovative compared to more traditional industries such as manufacturing therefore the objective of this study is to determine if such a difference exists the research question for this study is as follows what are the differences in the relation between bpm and innovation in a comparison between the it industry and the manufacturing industry this comparison is made in order to create a broader understanding as to whether and if so why the software industry is more innovative when compared to more traditional industries to be able to analyse this research question a quantitative study is performed based on data collected in three it companies and two manufacturing companies the remainder of this paper is organized as follows the next section will discuss the literature on the main constructs in our study followed by the research method in section 3 section 4 continues with the results and the paper concludes with the main findings in section 5 30 th bled econference digital transformation from connecting things to transforming our lives t cats p ravesteyn the relation between process management and innovation a comparison of the it and manufacturing industries 73 literature the theoretical framework of this study consists of three main constructs business process management maturity innovation value chain and innovation adoption in this section each of these constructs is discussed in more detail for the literature study google scholar and the databases of science direct springer and wiley online library are used in combination with the following keywords bpmm and innovation business process management and innovation innovation value chain innovation adoption innovation process management and innovation the papers that were found were accordingly analysed to determine the relevancy the findings are discussed below business process management maturity business process management is a management methodology that exists at different organizational levels on which processes are assessed stepwise with the goal to improve the capabilities of the organisation the maturity of bpm is studied by rosemann de bruin who created one of the first widely accepted bpmm models this model is multidimensional since it analyses different factors stages and contexts this is in line with vom brocke et al whom argue that most models in bpm have a onesizefitsall approach which causes problems that will not account for the situational contexts necessary to gain benefits furthermore vom brocke et al state that business process management supports an organization in their innovativeness rosemann de bruin based the factors of their model on bpm critical success factors which consist of independent and dependent variables the assumption is that the higher the score on these variables the higher the level of success in bpmm moreover they state that an individual organisation should translate process success into the most important bpmindependent success measures furthermore rosemann de bruin find that there is not a standardized toolkit for every organisation to put bpmm into practice fisher states that a onedimensional fivestage model for bpmm is not enough fishers model exists of two parts the first part is referred to as the five levers of change which are used to assess the capabilities of an organisation the second dimension also exists of five factors representing the five maturity stages of bpmm this dimension is used to measure the performance of the five levers of change fisher measures bpmm by using two different measure points in contrast the model of rosemann de bruin measures bpmm on three levels evidence is yet to be provided to see whether a multifactor model is superior when compared to a twofactor model finally fisher concludes that the advantages of using bpmm models for companies is that they will improve the efficiency 30 th bled econference digital transformation from connecting things to transforming our lives t cats p ravesteyn the relation between process management and innovation a comparison of the it and manufacturing industries and lower their costs which in turn could result in higher profits all these advantages combined provide companies a competitive advantage another bppm model is constructed by ravesteyn et al whom used the capability maturity model integrated as a foundation to establish seven maturity dimensions the cmmi model has also been used by rosemann and colleagues in their research as the bpmm model by ravesteyn et al is extensively used to research the relation to process performance this model is applied in the conceptual model of this study here performance is substituted with innovation in order to measure the level of bpm maturity within an organization ravesteyn et al used 37 items divided over the seven dimensions to measure the maturity level of the 37 bpm capabilities a likert scale from 1 5 is used innovation value chain hansen birkinshaw developed the innovation value chain framework their approach requires executives to have an endtoend view of the innovations in their companies their framework will also force executives to focus on the weakest links in the innovation process of the company the first phase is to generate ideas come up with new products or services either from within the company or outside the company convert ideas is the second phase at this stage the company has selected the ideas collected the funds and started the development of the product the third and final phase is to diffuse the developed product or service this means that the developed product or service concept is used in the organisation or launched in the market hansen birkinshaw state that when a manager wishes to use these three phases of the innovation value chain the manager has to focus on six critical tasks internal sourcing crossunit sourcing external sourcing selection development and company wide spread of the idea ganotakis loves state that the companys resources have a significant influence on the innovation process and on the growth of the company ganotakis loves find three main implications in their research first the innovation value chain makes it possible to identify the factors that enable a companys level for growth and productivity when compared to new technological based firms secondly companies which develop and market disruptive innovations show fast growth leading to better productivity and performance the third and last implication is that the innovation value chain makes it possible to identify the innovation behaviour focusing on the important role of r d which influences the success of innovation based on the studies by hansen birkinshaw and ganotakis love it can be concluded that the innovation value chain is a method that explains the process of innovation from generating ideas to converting ideas and subsequently its diffusion which leads to new business opportunities in order to generate new revenues 30 th bled econference digital transformation from connecting things to transforming our lives t cats p ravesteyn the relation between process management and innovation a comparison of the it and manufacturing industries 75 furthermore this approach also helps to draw the attention to an organisations strengths and weaknesses in the innovation process innovation adoption damanpour wischnevsky distinguish innovationgeneration from innovationadopting when organisations use innovation adoption the purpose is to change the organisation in such a way that it becomes more effective and develops a more competitive mind set in order to adapt more easily to new trends in the market in in an earlier study on the adoption of internet banking tan teo concluded that subjective norms lack a significant relationship with intentions perceived behavioural control and attitudinal factors can be used to predict the intentions they describe three factors which influence someones or an organizations intention to adopt a new product or service this is similar to the study by aljabri sohails in which it is concluded that the six factors together provide a solid measurement tool for innovation adoption conceptual model derived from the theory and concepts described in the literature study above the conceptual model for this research consists of three main constructs bpm maturity innovation value chain and innovation adoption for bpm maturity the framework has the seven dimensions with corresponding bpm capabilities from ravesteyn et al the capabilities are used as input in order to develop survey questions to measure each dimension the innovation construct in the conceptual model is split up into the two constructs innovation value chain and innovation adoption the innovation value chain is very focused on the analysis of how innovations come up whereas innovation adoption focuses on acceptance of the innovation by the final user or adoption of new innovations by the organization this codependency results in the assumption that both theories strengthen each other finally based on this reasoning the hypothesis is that there is a positive relation between the bpm maturity and innovation research method data collection for this study data is used that has been collected as part of a larger research project on bpm and innovation for this an online survey tool was used as this makes it very convenient for the respondents to answer the questions in their own time the data is collected across cultures and in different countries at seven companies three out of seven were located in the netherlands and the other companies were located in austria belgium china and ireland most of the companies are active in the software industry whereas the other companies are active in manufacturing or the finance sector the data was collected by a team of six researchers to ensure the data was collected in the same manner a coding manual was developed to ensure all collected data had the same definitions in total 200 completed surveys have been collected in all organisations the questionnaire the survey was constructed by using the structure of the conceptual model as explained above the conceptual model shows how many items are used for every dimension of bpmm and for the two innovation constructs the survey contained 50 questions on the main concepts 37 questions were divided over the seven dimensions to measure the level of bpm maturity and 13 questions addressed the innovation part for each statement a likert scale from 1 to 5 was used to indicate whether the participants strongly disagreed strongly agreed or stayed neutral in addition to that there were also some general questions concerning how knowledgeable the participants were regarding bpm how the respondents would define bpm and what position they had within their organisation validity of the research instrument to analyse the validity of the constructs a varimax method was used within the factor analysis which was developed by kaiser a rotation factor analysis is the most commonly used method in this type of analysis the results of the factor analysis showed that only six components were recognised for bpmm despite the fact that the bpmm construct consists of seven dimensions in the conceptual model the variable innovation showed three components and there were only two in the conceptual model based on this analysis it could be argued that the conceptual model could benefit from adjustments since not all components were recognised therefore a second analysis was performed the cronbach alpha was used to determine the reliability of separate components tavakol dennick suggest in their article that a cronbach alpha should be in the range of 070 to 095 however the recommended maximum value is 090 furthermore a low indication could be influenced by the number of questions asked for one item or poor interrelatedness between the items the results in table 1 showed that all dimensions have a value above the minimum of 070 and did not exceed the score of 090 which indicated that the results of the collected data were statically reliable analysis as cohen states that a ttest is widely used to compare means and that it also shows whether the difference between two elements is significant or not a ttest is conducted to compare the survey results of two sets of companies this is done by adding three variables in spss company name industry branch and bucket this last variable is used to define the groups three companies are labelled it and two were labelled old analysis results level of knowledge on bpm first the respondents were asked to assess their knowledge of bpm for this they could choose between four different levels out of 200 respondents 35 had little to no knowledge and practical experience with bpm 27 had some knowledge of bpm but no practical experience whereas 29 had some knowledge and limited practical experience with bpm only 10 of all the respondents had both knowledge and practical experience with bpm the percentages out of 200 respondents show that a small group of respondents was very experienced and is considered to have a high level of knowledge on bpm furthermore the category old shows a higher percentage in this level in comparison to it it must be noted that the majority of respondents either had no knowledge of bpm or a limited amount of knowledge and practical experience with bpm this might have influenced the results a comparison of it and manufacturing table 2 shows the mean scores for the bpm maturity dimensions between it and old the smallest difference between both groups is for measurement of process meaning that both groups use performance indicators that assess and check processes and use this to improve processes additionally bpm maturity dimensions process awareness process description and management of processes show that it has a higher maturity level in comparison to the companies in the old catagory from these results it can be concluded that group it is more aware of the impact that processes process descriptions and process owners have within their organisation and they incorporate this in their strategy the results also show that group old has a higher level of maturity in dimensions process improvements and process resources and knowledge this means that group old organizations try to improve their processes more often and also have a support system for process improvements in place group old also has more resources and employees with process knowledge finally the information technology dimension shows a large difference between the two groups this indicates that it companies make more use of information technology to design and carry out processes to produce realtime measurement information in comparison to the manufacturing companies in comparison to the findings described above the results of the ttest analysis only show a significant difference on information technology with 95 confidence interval of the difference 05224 table 4 shows all means of the innovation dimensions the results of the phases of the innovation value chain construct show that there is a small difference in regards to idea generation for both groups both groups tend to agree that their employees are good at creating ideas on their own but also across the organization furthermore the results show that group it has a higher mean on idea conversion whereas group old has a higher mean on idea diffusion from these results it might be concluded that group it tends to be better in selecting screening and funding ideas as well as turn ideas into a minimum viable product whereas group old tends to be better in getting new ideas out of the organisation the results of table 4 also show that group it has a higher mean on attitude to innovation and perceived behavioural control in comparison to group old this shows that group it agrees that the latest innovations benefit their organization and believe that it does not present any risk to their organization in addition group it also scores higher on perceived behavioural control which indicates that software organizations tend to use the latest innovations but also agree to have time money and resources to keep using these latest innovations furthermore based on the subsequent ttest only the difference on attitude to innovation and perceived behavioural control show significance between the two categories moreover the smallest difference between both groups is created by subjective norms within the innovation adoption construct which means that both groups use the latest innovation to stay competitive in the market on top of this customers also expect both groups to use the latest innovations as a result of the analysis described above it is possible to conclude that group it only differs on two dimensions of the conceptual model when compared to other companies this indicates that based on this analysis it companies tend to be more innovative than manufacturing companies for traditional organisations this is confirmed by rosemann and vom brocke et al who both suggest that bpm does not support the innovation process because it only provides methods and techniques which support the development of a structure to analyse an organisation conclusion main findings in this research the objective was to answer the question what are the differences in the relation between bpm and innovation in a comparison between the it industry and the manufacturing industry based on our analysis of the differences between it industry and manufacturing we find that these industries are very similar when it comes to the relation between bpm and innovation they only differ significantly on the bpm dimension information technology and the innovation adoption dimensions attitude to innovation and perceived behavioural control as tan teo concluded in their study on mobile banking adoption that perceived behavioural control and attitudinal factors are the key elements that can be used to predict the intention to adopt a new technology it might be concluded that the it industry is a step ahead of the manufacturing industry in terms of using information technology and are also able to adapted more quickly to new innovations that are beneficial to their organization this is something which is to be expected given the nature of it companies implications the it industry and manufacturing industry are surprisingly similar however based on this study we find that the manufacturing industry should put more effort towards adopting new technologies in order to be more innovative for example organizations can invest more in the latest technologies that could produce realtime measurement information in support of the daily business operations besides investing in new technologies it is also essential to invest in the knowledge of people in order to get the optimal performance out of the latest technologies limitations a limitation of this study is that data is collected across different industries but also from different countries within europe and china thus cultural differences could have influenced the answers as lee et al showed that different cultures have different perceptions therefore our scale for answering the statements could be interpreted differently additionally in this study a likert scale is used to measure all the dimensions of bpm and innovation based on the most wellknown scale from 1 to 5 however literature suggests that a fivepoint likert scale is a minimum but it is better to have a broader scale hinkin researched scale developments and within his review a majority of the researched studies used a fivepoint scale although the second biggest group used a sevenpoint scale according to these results the cultural influence on the likert scale and the scalesize are arguable and therefore seen as a limitation in this study furthermore in this study a ttest is conducted to investigated the significant differences based on the means between two constructs as there are also other techniques available to analyze the data this is also considered as a limitation recommendations for future research this study has gone some way towards enhancing the understanding of the relationship between bpm and innovation the conceptual model still needs some refinement because the factor analysis only recognised six out seven bpm dimensions and for innovation three instead of two dimensions moreover more research is required to improve the understanding of the relationship between bpm and innovation within and between different organizations and sectors as well as across cultures introduction this paper reports on experience gained during a research project the project involved the use of a new body of theory to critique the papers in a special issue of a leading ecommerce journal the resulting paper was submitted to the same journal and rejected the grounds were a combination of claimed lack of robustness of the research method and dismay about the fact that the special issue papers had been subjected to criticism i found both of these grounds bewildering the research method had been carefully prepared had been previously applied and the results published and it was i considered suitably documented moreover the suggestion that papers should not be subjected to criticism sounded to me like the antithesis of the scientific method to which the journal and the management disciplines generally claim to aspire i accordingly set out on a deeper study of metaquestions that were affecting the project what guidance is available in relation to secondary research whose raw data is published academic papers what particular approaches need to be adopted when the theorylens through which the observation is being performed arises from critical theory research what guidance exists for expressing the outcomes of research of this nature this papers objective was accordingly to enhance the publishability of the underlying research by grounding the content analysis technique more firmly in the research methods literature demonstrating the appropriateness of constructive criticism of published works and improving the expression of the results the paper is structured as follows brief explanations are provided of the underlying theory the special issue to which it was applied the research method adopted and key aspects of the review process a series of investigations is then outlined involving searches of relevant methods literatures this encompasses several variants of literature reviews and content analysis the nature of criticism is discussed and critical theory research reviewed it is concluded that two particular techniques provide the most useful guidance on how to approach a project of this nature the paper concludes by showing how the insights arising from the journey have enabled enhancements of the research method and of the manner in which the method and the findings are communicated to the reader researcher perspective the underlying research project adopted the particular theoretical lens of researcher perspective this was defined in clarke as the viewpoint from which phenomena are observed the papers postulated that in each research project at least one researcher perspective is adopted whether expressly or implicitly and whether consciously or unconsciously the researcher perspective influences the conception of the research and the formulation of the research questions and hence the research design the analysis and the results each particular perspective is specific not universal because the interpretation of phenomena depends on the perspective adopted the adoption of any single researcher perspective creates a considerable risk of drawing inappropriate conclusions is researchers generally adopt the perspective of a participant in an information system commonly the organisation that runs it or an organisation that is connected to it but sometimes the individuals who use it occasionally researchers may adopt the perspective of an external stakeholder or usee by which is meant a party who is affected by the is but is not a participant in it studies of several samples of refereed publications in the is literature have shown that a very large proportion of research adopts solely one particular perspectivethat of the system sponsor by that term is meant the organisation that develops implements or adapts a system process or intervention or for whose benefit the initiative is undertaken the theory advanced in clarke argues firstly that the singlemindedness of is researchers is frequently harmful to the interests of other stakeholders but secondly that the interests of system sponsors are also badlyserved by such singleperspective research higherquality research will be achieved through greater diversity in singleperspective research by dualperspective research and by multiperspective research the critique of the special issue the above theory relating to researcher perspective was applied to a special issue of the journal electronic markets on personal data markets which was published in volume 25 issue 2 a market is a context in which buyers and sellers discover one another and transact business and inherently involves at least two participants but usually considerably more participants and other stakeholders the digital surveillance economy that has emerged since c 2000 is a complex web of markets moreover it involves vastly more capture of consumer data than has ever previously been the case expropriation of that data for a wide variety of purposes by a wide variety of corporations and its application to 90 30 in order to investigate the researcher perspectives adopted in the papers in the special issue a research method was applied that had been developed and refined in several previous studies some of them reported in clarke the process specification used is in annex 1 one important aspect is the extraction of the research question in some papers this is explicit and in others implied but in some it needs to be inferred the most vital part of the study is the identification and interpretation of passages of text that disclose the perspective adopted by the researcher again this may be explicit but it is more commonly implicit and in many cases it has to be inferred in order to enable audit the process includes the recording of the key passages that led to the interpretations made and publication as supplementary materials of the process specification key passages codings and interpretations for each paper the paper was submitted to electronic markets in february 2016 went through two rounds of reviews and was rejected in january 2017 the primary grounds were the research article format is not appropriate legitimate or even warranted inadequate description of the research method used and overstated criticism each of these was a major surprise given that copious information was provided about the research method and critiquing of the existing state of theory is fundamental to any discipline that claims to be scientific it was plainly necessary for me to assume hostility on the part of reviewers step back and gather the information needed to convey to reviewers the appropriateness of the research method and of criticising prior published works this led to works on content analysis in its many forms and on the role of criticism in the is discipline related content analysis techniques a significant proportion of research involves the appraisal of content previously uttered by other people this section briefly reviews categories of research technique whose focus is adjacent to the topic addressed in this paper qualitative research techniques qualitative research techniques such as ethnography grounded theory and phenomenology involve the disciplined examination of content but content of a kind materially different to refereed papers the text may be generated in natural settings in contrived settings or in a mix of the two the issues arising with analysis of these kinds of content are very different from those associated with the analysis of carefullyconsidered formalised content in refereed articles informal literature reviews a context that is more closely related to the present purpose is the examination of substantial bodies of published research generally three broad categories of literature reviews can be distinguished firstly literature reviews are an integrative part of any research thesis secondly literature reviews can be an important type of publication in their own right however the most common form of literature review appears as a part of research publications as part of research articles literature reviews synthesize earlier relevant publications in order to establish the foundation of the contribution made by an article a succinct although rather negative description of the approach that was common until c 2000 is as follows traditional literature reviews commonly focus on the range and diversity of primary research using a selective opportunistic and discursive approach to identifying and interpreting relevant literature in traditional narrative reviews there is often no clear audit trail from primary research to the conclusions of the review and important research may be missing resulting in biased and misleading findings and leading to puzzling discrepancies between the findings of different reviews systematic literature reviews in 2002 the guest editors of an misq special issue expressly set out to drive improvements in literature review techniques in is their declared aim was to encourage more conceptual structuring of reviews in is webster watson the editorial is highlycited and appears to have had considerable impact on literature reviews published in the is field the conduct and presentation of literature reviews has subsequently been influenced by the evidencebased movement in the health care sector this adopts a structured approach to the task systematic reviews synthesise the findings of many different 92 30 it was subsequently argued within the is literature that a rigorous standardized methodology for conducting a systematic literature review was still needed within is and the authors proposed the 8step guide in figure 1 directlyrelevant content analysis techniques the focus in this paper is on the appraisal of published research papers in some cases the body of work is large for example many researchers have studied all articles in large subsets of papers the sampling frame is typically one or more journals most commonly the basket of 8 is journals in other cases the body of work whose content is analysed is smaller carefullyselected collections perhaps as small as a single article book or journal issue in order to understand approved practices in this field of research i adopted a twopronged approach firstly i searched out papers on the research technique the findings are outlined in this section in parallel i identified relevant exemplars extracts from 10 such papers are in annex 3 citing weber indulska et al offer this definition content analysis is the semantic analysis of a body of text to uncover the presence of strong concepts a critical aspect of content analysis is that it seeks to classify the text or specific aspects of the text into a manageable number of categories in hsieh shannon the following definition is adopted content analysis is the interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns the authors indicate a 7step process which they attribute to kaid as with any research technique all aspects need to be subject to quality controls krippendorff weber and stemler emphasise steps 35 in relation to the coding scheme and its application they highlight the importance of achieving reliability possible approaches include coding by individuals with strong experience in both the review of articles and the subjectmatter parallel coding by multiple individuals review of individuals coding by other parties and publication of both the source materials and the detailed coding scheets in order to enable audit by other parties content analysis techniques exhibit varying degrees of structure and rigour from impressionistic to systematic and they may involve qualitative andor quantitative assessment elements quantitative data may be on any of several scales nominal ordinal cardinal or ratio data collected on higherlevel scales especially on a ratio scale is able to be subjected to more powerful inferencing techniques qualitative data on the other hand may be gathered on a nominal scale or on an ordinal scale quantification generally involves measurement most fundamentally by countingwhich raises questions about the arbitrariness of boundaries and about configuration and calibration of the measuring instrument some research methods involve sleight of hand most commonly by making the largely unjustified assumption that likertscale data is not merely ordinal but is cardinal and even ratio many authors implicitly equate quantification with rigour and qualitative data with subjectivity they accordingly deprecate qualitative analysis or at least relegate it to pretheoretical research which by implication should be less common than research driven by strong theories the majority of authors spend only limited time considering the extent to which the assumptions and the processes underlying the act of quantification may be arbitrary or themselves subjective positivism embodies an implicit assumption that computational analysis necessarily leads to deep truth the assumption needs to be tested in each particular circumstance yet such testing is seldom evident a positivist approach to categorising content analysis along a continuum of quantification distinguishes narrative reviews descriptive reviews vote counting and metaanalysis king king hes categorisation is helpful but it involves a switch from largely textual sourcematerials in the first three categories to wholly quantitative sourcematerials in the fourth more usefully still three approaches are distinguished by hsieh shannon these are examined in the following subsections conventional content analysis emergent coding in this approach coding categories are derived directly from the text data the approach is effective when used to describe a phenomenon particularly when existing theory or research literature on a phenomenon is limited in such preliminary research it is normal to allow the categories and names for categories to flow from the data hsieh shannon suggests that only selected text is examined and that the context may not be welldefined the external validity of conclusions arising from this approach may therefore be limited they conclude that the technique is more suited to concept development and modelbuilding than to theory development depending on the degree of generality of the conclusions claimed by the author full disclosure of the text selection coding and inferencing procedures may be merely desirable or vital directed content analysis a priori coding in this case analysis starts with a theory or relevant research findings to help focus the research question and as guidance for establishing and defining initial codes segments of the text that are relevant to the research question are identified and then coded to the extent that the declared or inferred content of the text does not fit well to the predefined categories there may be a need to consider possible revisions of the coding scheme or even of the theory on which the research design was based it may be feasible to draw inferences based on counts of the occurrences of categories andor on the intensity of the statements in the text such as the confidence inherent in the authors choice of language as with any theorydriven research the evidence extracted from the text may have a selffulfillingprophecy quality about it ie there is an inevitable tendency to find more evidence in support of a theory than in conflict with it and contextual factors may be overlooked in order to enable auditability it is important that not only the analysis be published but also the raw material and the coding scheme summative content analysis this involves counting and comparisons usually of keywords or content followed by the interpretation of the underlying context the first step is to explore usage by identifying and quantifying certain words or content in text with the purpose of understanding the contextual use of the words or content because of the complexity and variability of language use and the ambiguity of a large proportion of words and phrases a naive approach to counting words is problematic at the very least a startingset of terms needs to be established and justified a thesaurus of synonyms and perhaps antonyms and qualifiers is needed allowance must be made for both manifest or literal meanings on the one hand and latent implied or interpreted meanings on the other counts may be made not only of the occurrences of terms but also of the mode of usage the degree of analytical rigour that quantification can actually deliver depends a great deal on a number of factors critical among them are • the text selection • the express judgements and implicit assumptions underlying the choice of terms that are analysed • the sophistication and comprehensiveness of the thesaurus applied and • the significance imputed to each term quantitative computational content analysis a decade later it is useful to break out a fourth approach from hsieh shannons third category this approach obviates manual coding by performing the coding programmatically this enables much larger volumes of text to be analysed the coding scheme may be defined manually cf directed content analysis a priori coding however some techniques involve purely computational approaches to establishing the categories cf machineintelligent emergent coding the processing depends however on prior data selection data scrubbing and dataformatting in addition interpretation of the results involves at least some degree of human activity in indulska et al a distinction is made between • conceptual analysis in which text material is examined for the presence frequency and centrality of concepts which can represent words phrases or more complex definitions and • relational analysis which tabulates not only the frequency of concepts in the body of text but also the cooccurrence of concepts thereby examining how given that the big data analytics movement is highly fashionable vast volumes of data are available and there is a comfort factor involved in officebased work much of which is automated it would appear reasonable to anticipate that quantitative computational content analysis techniques will be a growtharea in the coming few yearsat least until their limitations are better appreciated clarke content analysis within the is discipline content analysis is accepted as a research technique within the is discipline but its use has been somewhat limited for example in a survey of the papers published in six leading is journals during the 1990s mingers found that the use of content analysis as a research technique was evident in only four of the journals and even in those four in only 13 of all papers published during that time in february 2017 of the nearly 15000 refereed papers indexed in the ais electronic library 13 had the term content analysis in the title and 69 in the abstract annex 3 presents 10 instances which together provide an indication of the range of applications and approaches a total of 770 papers of the 15000 contained the termc 5 this is however subject to overinclusiveness it is also subject to underinclusiveness in recentlypublished papers the most common forms of text that have been subjected to content analysis appear to be social media and other message content with other categories including newspaper articles and corporations letters to shareholders the literature relating to the above four categories of content analysis provides a considerable amount of information relevant to the current project however there is a dimension of the project that is not addressed by these techniques and guidance needed to be sought elsewhere the role of criticism in research the previous sections have considered the analysis of content the other area in which further insight was sought relates to the purpose for which the analysis is undertaken in some cases the purpose of undertaking content analysis may be simply exposition that is to say the identification extraction and summarisation of content without any significant degree of evaluation there are benefits in undertaking content analysis in a positive frame of mind assuming that all that has to be done is to present existing information in brief and readilyaccessible form alternatively the researcher can bring a questioning and even sceptical attitude to the work is it reasonable to for example assume that all relevant published literature is of high quality that the measurement instruments and research techniques have always been good wellunderstood by researchers and appropriately applied that there have been no material changes in the relevant phenomena that there have been no material changes in the intellectual contexts within which research is undertaken criticism is the analysis of the merits and faults of a work the word can be applied to the process or the product there are also common usages of the term criticism in a pejorative sense implying that the critic is finding fault is being destructive rather than constructive and is failing to propose improvements to sustain the merits and overcome the faults the term critique is sometimes substituted in an endeavour to avoid the negative impressions to indicate that the work is systematic and to bring focus to bear on the contribution being made by both the criticism and the work that is being subjected to it criticism plays a vital role in scientific process the conventional popperian position is that the criterion for recognising a scientific theory is that it deals in statements that are empirically falsifiable and that progress depends on scrutiny of theories and attempts to demonstrate falsity of theoretical statements the scientific tradition passes on a critical attitude towards its theories the theories are passed on not as dogmas but rather with the challenge to discuss them and improve upon them however senior members of a discipline commonly behave in ways that are not consistent with the popperian position this might be explained by the postulates of normal science which view the vast majority of research work as being conducted within a paradigm and subject to its conventions in more practical terms the problem may arise because senior members of any discipline have strong psychic investment in the status quo andnomatter how cogent and important the argument 100 30 two examples are commonly cited within the is discipline as suggesting that conservativism is important and criticism is unwelcome in a section on the tone to be adopted in a literature review webster watson to make assertions about a population without providing sufficient detail about the individual instances invites reviewers to dismiss the analysis as being methodologically unsound it is in any case essential to progress in the discipline that each of us be prepared to accept criticism the advice continued do not fall into the trap of being overly critical if a research stream has a common error that must be rectified in future research you will need to point this out in order to move the field forward in general though be fault tolerant recognize that knowledge is accumulated slowly in a piecemeal fashion and that we all make compromises in our research even when writing a review article here the authors expression failed to distinguish between the two senses of the word critical the authors intention appears to me to have been to warn against overly critical expression on the other hand it is an obligation of researchers to think critically and to apply their critical faculties i submit that it would be inappropriate for readers of the article to interpret the quotation as valuing politeness among researchers more highly than scientific insight and progress in the second example a senior journal editor providing advice on how to get published in top journals wrote that the authors contributions should be stated as gaps or new perspectives and not as a fundamental challenge to the thinking of previous researchers to reframe papers should be in apposition the positioning of things side by side or close together rather than in opposition straub this is machiavellian advice in the positive or at least amoral sense of if the prince wishes to be published in top journals then unfortunately it is alltooeasily interpreted as expressing a moral judgement that criticism is a bad thing the inferences that i draw from the above analysis are as follows • criticism of previouslypublished ideas is vital to progress • criticism encounters strong opposition from a disciplines gatekeepers relevantly in the form of journal editors and reviewers design research is concerned with constructing an artefact variously of a technological or an intellectual nature both positivism and interpretivism on the other hand are concerned with description and understanding of phenomena sometimes the focus is on natural phenomena but frequently the interest is in natural phenomena have been subjected to an intervention importantly for the present project however both positivism and interpretivism involve strenuous avoidance of moral judgements and of having an agenda critical theory research on the other hand recognises the effects of power and the tendency of some stakeholders interests to dominate those of other stakeholders it brings to light the restrictive and alienating conditions of the status quo and expressly sets out to eliminate the causes of alienation and domination the original theoretical work on researcher perspective on which my current paper is based is appropriately framed within a critical theory research design the paper whose rejection stimulated these notes on the other hand uses content analysis to apply that theory to a set of papers in a new and potentially very important research domain the notions discussed in this section are therefore of general relevance to the establishment of a satisfactory content analysis research design but do not directly address the issues that i am confronting the recognition and critiquing of ideological assumptions although the references discussed above are of relevance to the problem they fell short of the need two particular sources appeared to provide an appropriate foundation for content analysis of the kind that my research project undertakes one is an approach to in boell cecezkecmanovic it is argued that a constructively loose and iterative process is needed to avoid undue constraints and unlock insight and creativity highly structured approaches downplay the importance of reading and dialogical interaction between the literature and the researcher continuing interpretation and questioning critical assessment and imagination argument development and writingall highly intellectual and creative activities seeking originality rather than replicability maclure 2005 hart 1998 the authors propose hermeneutic philosophy as a theoretical foundation and a methodological approach for studying literature reviews as inherently interpretive processes in which a reader engages in ever exp a nding and deepening understanding of a relevant body of literature hermeneutics does not assume that correct or ultimate understanding can be achieved but instead is interested in the process of developing understanding the framework reproduced in figure 2 comprises two intertwined cycles a search and acquisition circle and a wider analysis and interpretation circle the authors perceive the mapping and classification of literature as being a creative process that builds on a deeper understanding of the body of literature achieved through analytical reading this process may lead to new questions and identify new relevant publications to be included in the body of knowledge the approach embodies questioning and critical assessment of previous research and analysis of connections and disconnections explicit or hidden contradictions and missing explanations and thereby the identification or construction of white spots or gaps a critical assessment of the body of literature demonstrates that literature is incomplete that certain aspectsphenomena are overlooked that research results are inconclusive or contradictory and that knowledge related to the targeted problem is in some ways inadequate alvesson and s an dberg 2011 critical assessment in other words not only reveals but also and more importantly challenges the horizon of possible critical discourse analysis wall et al proposes an approach to content analysis that the authors refer to as critical discourse analysis their startingpoint is that the information systems discipline is subject to ideological hegemony they see this as being harmful and they argue that review papers can challenge ideological assumptions by critically assessing takenforgranted assumptions they explain the idea of ideological hegemony as being the conscious or unconscious domination of the thought patterns and worldviews of a discipline or subdiscipline that become ingrained in the epistemological beliefs and theoretical assumptions embedded in scientific discourse in academic literature a hegemony may manifest as common framing of research topics and research questions the domination of theories and research methods that carry similar assumptions common beliefs about what constitutes the acceptable application of research methods and common beliefs about how research results should be interpreted by ideology we mean those aspects of a worldview that are often taken for granted and that disadvantage some and advantage others ideologies are not falsehoods in an empirical sense but are a constitutive part of researchers and research communities worldview that are removed from scrutiny thus ideologies can be harmful to individuals who are disadvantaged or marginalized by them and they can be problematic to scientific research because they represent blind spots wall et al proposes that a critical review method based on habermasian strains of critical discourse analysis can overcome the limitations of working only within ideological assumptions cda examines more than just a communicative utterance foucauldian analysis also examines the context in which an utterance was uttered by assessing power relationships between actors and the structures and processes that guide behavior and constrain the development of knowledge the process involves the assessment of violations of four validity claims 1 the communications comprehensibility by which the authors mean technical and linguistic clarity of communication 2 the communications truthfulness which refers to the propositional content of communication as represented by complete arguments and unbiased assertions the hermeneutic approach to literature review and the cda approach to content analysis overlaid on the prior literature enable the design of a content analysis research method with the desired attributes that research method has a good fit with theory developed using critical theory research it prioritises depth of insight over narrow positivist quantification it encourages the analyst to focus on key validity claims and the hidden assumptions within the text under study it forces the researcher to confront and to take into account their own ideology and agenda it pushes the researcher in the direction of critique for the purposes of theory construction or reconstruction rather than criticism for its own sake application of the research findings the preceding sections provide a basis for adapting the research method for my research project the most significant implications for my work reflected in annex 2 were as follows  it is necessary to convey more clearly that researcher perspective theory is a product of critical theory research that it has a focus on the power structures that lie behind accepted interpretations that it takes a value position that it demonstrates that certain aspectsphenomena are overlooked and that it sets out to challenge ideological assumptions by critically assessing takenforgranted assumptions and that it is accordingly necessary for the content analysis to identify the elements of existing works that reflect the existing power structures  the iterative nature of boell cecezkecmanovic s hermeneutic approach for conducting literature reviews provides a clear explanation of the need for repetitive loops and introspective questioning by the researcher about their analysis and interpretation of the works this is reflected in step 7 of the revised process in annex 2  the distinction between preliminary orientational reading and deep analytical reading can be used to explain how confidence is gained in the appropriateness of the selection coding and interpretation of passages in each work this is reflected in steps 1 and 3 of the revised process in annex 2  the research method needs to be expressly described as directed content analysis using a priori coding as described by hsieh shannon however greater efforts may be needed to introduce some quantification such as frequency analysis and tabular graphical or pictorial presentations in order to upgrade from a narrative content analysis to descriptive content analysis this is reflected generally and particularly in step 6 of the revised process in annex 2  greater efforts may be needed to convey the means whereby reliability is achieved in selection coding and interpretation activities in line with krippendorff weber care is needed to avoid attributing intent on the part of authors whose papers are criticised and instead the analysis should assume that hegemonic participation is unconscious this is reflected in step 7 of the revised process in annex 2 conclusions this paper has reported on the results of a study of metaquestions affecting a content analysis project a range of guidance has been located and summarised in relation to secondary research whose raw data is published academic papers the role of criticism in is research has been clarified the particular challenge has been confronted of how to perform content analysis when the theorylens through which the observation is being performed arises from critical theory research the primary purpose of the work has been fulfilled in that the process specification for the analysis of the relevant papers has been adapted in order to better reflect existing theory relating to content analysis of published works particularly in a critical theory context further a set of changes to the research method section has been identified which have implications for the interpretation of the papers and the expression of the critique in addition guidance has been assembled on how to and how not to commuicate the results this paper has implications for is researchers generally much of the material that has been summarised applies to all content analysis of published papers nomatter whether the research approach adopted is positivist interpretivist design science or critical theory a small qualification is appropriate in that the majority of the material relates to research that goes beyond mere exposition of existing literature and is at least modestly questioning about that literatures quality andor continuing relevance this paper goes further however in that it contains guidance in relation to constructive criticism of existing works i contend that is will become increasingly static and its outputs will be decreasingly valuable if it values politeness to authors too highly and puts too little emphasis on constructive criticism of existing literature the method adopted includes proposals about how a researcher can detect and avoid excessively sharp expression focus the discussion on the message avoid shooting the original messenger and in turn avoid being shot themselves introduction in recent years organisations have realigned their information and communications technology strategic objectives to provisioning andor sourcing lower cost flexible resilient supply and delivery options as a means of responding to the impacts of globalisation and the associated cost pressures cloud computing represents an innovative technological advancement which appears to offer a solution to these aforementioned objectives subsequently incumbent organisations are undergoing cloudbased digital transformation journeys in order to reap the multitude of anecdotal business and strategic benefits in order for organisations to perform effectively in a digitized and networked economy an understanding of the role and relevance of strategy is necessary for effective competitive behaviour the role of ict in developing effective strategies has been well documented strategic ict can not only support and shape strategy but can also be pivotal in determining commercial viability and represent a source of competitive advantage when used in innovative ways however the concept of ictenabled strategy formulation is relatively ambiguous for instance ward opines that the knowledge we have developed over the past 30 years about information systems strategies appears to have had little impact in some organisations even though they invest hundreds of millions of pounds in new information systems and digital technology every year this is evidenced by a global survey conducted by mckinsey of 807 executives which revealed that while they acknowledged the strategic importance of digital technologies to their business goes beyond cutting costs they were also dissatisfied with its effectiveness pertaining to enabling overall strategic objectives in the context of cloud computing strategy can be defined as a set of decisions required to create and deploy a networkbased information service delivery strategy that results in both cost savings and organisational agility however the current state of art pertaining to cloudbased digital transformation strategies that might be appropriate for ict service providers is relatively ambiguous as ict service providers begin to formulate their cloud strategies they need to understand the inherent capabilities that are afforded by cloud computing… which can help them gain a competitive advantage by creating opportunities for cost advantage and organisational agility having a comprehensive understanding of cloudbased digital transformation is critical to forming a cloud strategy that will unlock business value worth orders of magnitude more than the costs ict are strategic insofar as they successfully implemented and are also used to realise strategic intent transitioning to provisioning cloud services the authors identified that as a result of the emergence of disruptive cloudbased digital transformation the strategy formation process encompasses a collective experimental learning process revolving around a number of alternative strategic intentions ranging from incremental evolution and transformation to complete replacement of the existing business model currently there is a dearth of research relating to how cloudbased digital transformation impacts ict service providers strategies consequently research relating to how these concepts develop interact and harmonise is also underdeveloped this is pertinent now as the cloud computing paradigm has reached a level of maturity which lays the foundation for is researchers to investigate how ict service providers have moulded and sustained their cloudbased digital transformation arrangments in order to ensure the longterm business viability and sustainability of the cloud computing paradigm further research is required to elucidate exemplars of successful and unsuccessful ict service provider digital transformation arrangements thus the objective of this research is to explore how cloudbased digital transformation impacts ict service providers strategies the remainder of the paper is structured as follows the next section builds the theoretical foundation for the study then we elucidate our research method next the findings are presented and discussed finally we conclude with implications for theory and practice theoretical underpining cloudbased digital transformation digital transformation is concerned with the changes digital technologies can bring about in a companys business model which result in changed products or organisational structures or automation of processes the long journey towards digital transformation is often fraught with complexity and ambiguity for incumbent ict firms this is compounded by the fact that the transformation of mature business models to digitalbased business models encompasses potential nuanced legacy liabilities and issues this is prominently evidenced by ict service provider stalwarts such as dell intel ibm and hewlett packard whose struggles pertaining to how to best leverage the benefits of cloudbased digital transformation have been well documented frequently these organisations are operating in unchartered digital waters and as a consequence lack the strategic clarity pertaining to what steps they need to consider prior to and during their digital transformation journey 2011 cloud computing enables ict service providers to virtualise their computational resources and concurrently provision them via a service orchestration process typically in the form of softwareasaservice platformasaservice or infrastructureasaservice while there is anectotal evidence which highlights the transformative business and strategic value afforded by cloud computing for ict service providers our understanding of how these organisations can develop digtal transformation strategies that effectively align with the value propositions inherent to cloud computing technologies is still limited bounding the concept of strategy in order for is researchers to have a comprehensive understanding of an organisations ict strategy it is useful to understand the evolution of their intended and realised strategies mintzberg and waters propose a widely cited comprehensive categorization for strategy which identifies intended realised deliberate unrealised and emergent strategy as constituting key components of the strategy formulation process this categorization of strategy is suitable for investigating the peculiarities of modern emerging ict and thus provides a backdrop for this study to better explore the strategy formulation process of ict service providers intended strategy represents the organisations official strategy and realised strategy which reflects the outcomes of decisions undertaken by the organisation stakeholders which may manifest from deliberate emergent and unrealised strategies deliberate strategy is defined simply as realised as intended emergent strategy as patterns or consistencies realised despite or in the absence of intentions and finally unrealised strategy as intentions that are unsuccessful in its consequences we selected the aforementioned seminal categorisation as a basis for conceptualising the concept of strategy for the following reasons first no single strategy can be a panacea for an organisation and that the most optimal strategic variables alter due to certain conditions and factors given the rapidly evolving nature of the cloud computing paradigm and the subsequent dynamic nature of cloudbased digital transformation the categorization is well suited for delineating the strategy formulation process and chronicling how ict service providers have arrived at their current realised strategy second in the context of cloudbased digital transformation the categorisation enables the identification of problematic issues and emerging patterns of events and behaviours which may have resulted in ict service providers deviating from their intended strategy third the categorisation enables business strategy to be viewed in a nondescriptive manner being conceived in terms of how companies actually decide and act not how they should decide and act in the next section we delineate the research method operationalised in order to elucidate our research objective methodology this papers research objective is to explore how cloudbased digital transformation impacts ict service providers strategies due to the dearth of empirical research pertaining to examining the relationships of the focal phenomena under scrutiny our study is exploratory thus a multimethod comparative case study research design was selected for the study the research sampling approach was directed by evolving theoretical concepts whereby we identified organisations and people from which we expected to elicit the majority of insights into the phenomena of interest for instance this study encompasses an analysis of both large and small and medium enterprise ict service provider firms the large business model mature ict ventures represent organisations that have significantly longer tenure as ict service providers that are currently transitioning from precloud to cloudbased business models the sme bornonthecloud ict ventures represent organisations who do not possess the requisite existing maturity or tenure of precloud business models these firms business models originated on the cloud data collection took place between january 2015 and august 2015 using semistructured interviewing based on a common protocol across 15 ict service provider organisations following the standard practice of using senior management as data sources we chose a senior manager from each targeted organisation interviews lasted between 70 and 120 minutes the interviews were conducted until theme exhaustiveness was reached which manifested when similar themes were being identified and no new themes emerged all interviews were transcribed proof read and annotated and then coded using nvivo 10 in order to improve the credibility of the data and provide cross and complementary perspectives on emerging elements secondary evidence in the form of archival documents and published materials sourced from the ict service providers websites were collated and analysed while the study did not undertake a grounded theory approach in analysing the data the researcher used an analytical hierarchical data analysis process adopted from ritchie spencer and oconnor incorporating open and axial coding techniques based on the recommendations of strauss and corbin findings in this section we report the empirical results obtained during the analysis of the semistructured interviews archival documentation and published materials it was evident from the study that cloudbased digital transformation not only have a dynamic and turbulent impact on ict service providers strategies but also have a cogent collective impact in terms of agility and competitive positioning the strategies for ict service providers encompassed short and longterm objectives such as cogent market impact increasing return on investment enhanced agility reinvestment of capital and reducing capex and opex for example study participants in levatte and sigmathen systems described how their strategy is focused on broadening their cloud geographic footprint and growing their customer base in order to increase revenues while the ceo at fieldzuite explained that their primary strategy is about increasing revenues through repeat customers all ict service providers confirmed that their cloudbased business model have significantly impacted the realisation of their companys strategic objectives which has been largely the cumulative result of a combination of deliberate emergent and unrealised strategy in terms of deliberate strategy all ict service providers identified that their main objective for operationalising cloud influenced business models was mainly for agility reasons for instance the cto at inno described how their cloud strategy was focused on enhancing the agility of the organisation stating that the new religion is cloud and we are all about agility and devops principals our objective is to develop new or improved services faster than we did in the past all new offerings must be agile and be able to be provisioned at low cost this cto further elucidated that our new strategy is that we are going to become a saas organisation and get out of the hardware business the ceo at braavos pointed out that their cloudbased business models foster agile and cost effective operations which are currently enabling our strategic objectives of becoming a market leader as a cloud integration service provider while the cto at zeta2k described how their cloud enabled business model has allowed us to be very agile and nimble in order to provide a service to a large number of users very quickly thus facilitating strategic objectives similarly the cto in fieldzuite explained that their business model has had a significant collective impact on the companys strategic objectives by not only enabling them to compete with larger ict service providers but also to deliver their cloud services with greater efficiency to multiple global locations around the world moreover the cto in mobcon elucidated on two examples of the cloud business model impact on their strategic objectives first he described how cloud computing facilitates enhanced efficiency and faster innovation in terms of supporting accelerated cycles of development for example cloud computing enables the early deployment of demonstration environments that would otherwise require substantial capital expenditure as a precursor to a full business case second mobcons strategic partnering with amazon web services facilitated stability in their business model components thus minimising strategybusiness model misalignment issues which may have manifested because of the disruptive nature of cloud computing technology the cto in sandstemtech added the cloud has enabled us to be more responsive we have sales pitch for a large airline next week and cloud computing has enabled us to create an enterprise demo environment for them in a matter of hours the traditional method we would have utilised three years ago would have taken weeks in order to create the same infrastructure for the demo environment strategic acquisitions were also identified as deliberate strategy by all large ict service providers for example the cto in sigmathen systems explained it was a deliberate strategic decision to acquire an established managed hosting in acd prior to this acquisition the company were losing customers to public cloud offerings in order to streamline the onboarding process for cloud customers the company also acquired an independent software vendor startup company who specialised in subscription billing the cto in inno also pointed out that their decision to acquire an established cloud provider such as cees was pivotal to their cloud success stating that innos acquisition of cees in 2013 accelerated its cloud computing strategy overnight we can now use the cees infrastructure and platform to rapidly deploy existing software services as saas partnerships were also identified as an example of deliberate strategy by ict service providers both the interviewees in lys and vclazz confirmed that it was a deliberate decision for their organisations to operate as value added resellers in order to avail of the economies of scale provided by their large ict service provider partner all ict service providers confirmed that their emergent strategy manifested from cloud enabled accelerated rate of business growth and incidences of unrealised strategy for instance the cto in vclazz opined as a result of the exponential rate of growth we have experienced provisioning cloud services we have successfully transitioned from the enduser market to the channel markets similarly the ceo in yet3 pointed out that the companys current realised strategy has manifested as a result of emergent strategy based on their accelerated growth in niche global target markets in relation to unrealised strategy iaas was provided as an example by ict service providers for example the cto in inno explained how prior to acquiring cees their efforts to build their own iaas proved vexatious further describing how it really was a painful process trying to develop our own bespoke iaas it didnt have the scale of aws rackspace and azure it failed simply as there wasnt a big enough pool of resources for all the customer requirements we had we did not invest in it aggressively enough and were far too conservative about investing in it the cto in mobcon described how the company were initially going to build their own cloud infrastructure however mobcon decided to partner with aws a partnership that enabled the company to accelerate its move to provide cloud services to its existing customers the study identified that the dynamic and recursive nature of ict service providers strategy formulation business model experimentation organisational learning and subsequent adaptation when attempting to explore disruptive andor innovative cloud business models figure 2 below depicts the process model we have developed to reflect this recursive process all ict service providers confirmed that their cloud strategy formulation and review decisions were largely managementled with changes being dictated by business model component performance for example the cto at zeta2k surmised our organisations strategy is managementled and informed by business model performance strategic roadmaps whitepapers analyst research reports and customer communities feedback while the cto at inno explained how they have a committee of fourteen people responsible for developing corporate strategy for the companys four divisions however on the contrary the ceo at yet3 described how their strategy is more leadershipled which is facilitated by the flat structure of the organisation the ceo elucidated while the advisory board help the company to see the forest from the trees we have employees in israel vietnam and japan who can influence strategic decisions without ever having met the ceo or the advisory board as they know more about the lay of the land than we do the ceo asserted that the ability of their globally distributed employees to provide strategic insight on their national landscapes has been a cornerstone of the companys continued success figure 2 the relationships among strategy formulation business model experimentation and organisational adaptation when exploring an emerging disruptive andor innovative business model in an effort to maximise the realisation of their strategic intent all ict service providers are engaging in business model experimentation and iteration for example the cloud manager at levatte described how they are experimenting and iterating their business model constructs at varying levels within the organisation the cto in inno also explained how their organisation was utilizing a bespoke component business modelling technique for formalising and reviewing their product business models the cbm technique breaks an enterprise down into its constituent segments and enables inno to take the aforementioned areas and break them down and identify elements which bring business value to the company the outcomes of this organisational adaptation served as an input for reevaluating the strategic intent of the organisations 0ur analysis complements and extends existing research in particular khanagha et al on the one hand it confirms the dynamic nature of ict service providers strategic intent in response to disruptive cloudbased digital transformation and also identifies the salient roles of adaptation business model experimentation and the resulting accruement of new knowledge however on the other hand contrary to their findings that presented structural adaptation as a precursor to business model experimentation our findings indicate that business model experimentation and iteration and the subsequent derived organisational learning serve as salient inputs to ict service providers evaluating whether the level of organisational adaptation required to pursue their strategic intent is feasible this would suggest that ict service providers are operationalizing a cautionary and evolutionary approach prior to committing substantial finances and resources to restructuring their organisation in order to realise their strategic intent in the next section we conclude with implications for research and practice introduction the decision whether or not to discharge a patient is one of the most frequent and complex decisions of clinicians it involves a multidisciplinary team and careful evaluation of several medical and nonmedical factors to determine the best time to send a patient home according to armitage the discharge of medical patients consists often not of a single event but of a lengthy process of negotiation involving professional staff patients and their relatives thus a variety of stakeholders and influencing factors are to be considered in this decision while the implications and requirements of effective discharge planning have been analysed in various studies the specific time of patient discharge that leads to the best outcome has not yet been considered in detail finding the optimal time of discharge can lead to fewer unnecessary readmissions enable cost reductions and therefore allow for a better allocation of resources within the hospital therefore this study focuses on the influencing factors that can determine the optimal time of patient discharge both from a qualitative and cost perspective for this purpose involved stakeholders as well as medical and nonmedical criteria that are considered in the discharge decision have to be identified to specify the best outcome from a qualitative view readmission rates are used as a comparative value from a cost perspective we utilize patient length of stay as the comparative indicator for the time of patient discharge as this represents a common cost factor over time hospital reimbursements are based on case rates according to socalled diagnosisrelated groups for each drg a cost weight is set by the department of health that determines the reimbursement rate for the hospital for each episode within that drg to allow for different types of stay and moderate financial risk the case mix model has been adapted to include cost weights for shorter or extended hospital stays in victoria a weighted inlier equivalent separation is used where the drg cost weight is adjusted for time spent in the hospital thus the length of stay highly influences a hospitals reimbursement rates figure 1 displays the development of costs and reimbursements over time the cost curve includes all costs incurred for procedures accommodation and maintenance costs we assume that the curve flattens with increasing time as costintensive procedures occur in the beginning and accommodation costs in the later stages of the stay a balance of revenues and costs ie the breakevenpoint for a drg is assumed at the determined average length of stay for a single drg as a result the shading to the left represents the profit zone for each additional day the patient is hospitalized in the hospital the hospital suffers losses the actual cost curve is hospitalindividual and can therefore deviate for each episode for a hospital it would therefore seem most profitable to discharge a patient as soon as possible within the inlier range however if the patient is readmitted to the hospital for a related cause of the preceding episode reimbursements can be suspended for the readmitted episode or other penalties might occur studies have shown that the length of stay has a potential impact on the quality of care and thus the potential risk of readmission of a patient while some argue a longer length of stay to be beneficial other studies show a negative effect with a longer length of stay on outcomes and risk of readmission or even suggest lower readmission rates with a shorter length of stay thus it is vital to determine the point of patient discharge that also considers the lowest risk of readmission to reach this goal the process of patient discharge and the involved stakeholders have to be known figure 1 correlation between patient length of stay and costs the purpose of this study is to determine the decision makers and criteria that are relevant in the patient discharge process for this purpose focus group interviews are held in an australian hospital group in victoria based on the results of these interviews propositions about the patient discharge decision and its implications are derived from the qualitative results in a subsequent study these results will be further developed into hypotheses and tested with episode data collected at the respective hospital group this paper is structured as follows the related work section briefly describes relevant stakeholders and decision criteria that have been previously identified for the patient discharge process while a lot of studies suggest qualitative approaches to determine these criteria we propose a mixedmethods approach to quantify the influences on patient length of stay and the patient discharge respectively section three afterwards describes our proposed method and the research design subsequently we present the results of the qualitative study and based on that derive propositions on factors influencing patient length of stay finally the limitations of this study as well as future research opportunities are discussed related work the following section describes the results of our literature analysis concerning decision makers and decision criteria in the patient discharge process the results form the basis for our qualitative analysis by supporting the selection of our focus group participants as well informing the development of our semistructured interview guidelines decision makers while the final decision to discharge a patient resides with the primary physician other groups have been shown to influence the time of discharge from the hospital according to armitage relatives play a vital part in the discharge negotiation where both a shorter or a longer stay than necessary could be requested depending on their personal situation their environment after discharge or their general wellbeing a patient can also act as an influencer in the discharge decision from the hospital personnel perspective nurses tend to give suggestions and actively participate in the evaluation of a patients wellbeing as they are the closest caregiver to the patient in the hospital setting they can sometimes better determine a patients status and have a deeper understanding of a patients personal situation than the treating physician finally the treating physician as well as other consulting doctors primarily evaluate the clinical factors they provide the final discharge decision with respect to the input of other stakeholders clinical guidelines or other underlying conditions such as ethical considerations decision criteria a literature review conducted by harun et al identified 17 studies analysing the patient discharge process to determine influencing factors in this context they found several medical and nonmedical influences on discharge decision making through either prospective or retrospective studies literature shows that mostly qualitative studies are conducted to identify impacts and behaviours of patient discharge thus the results solely rely on subjective opinions of the interviewees the factors identified in these studies can be assigned into two major categories measurable and nonmeasurable factors table 1 while nonmeasurable items can only be gathered and interpreted through qualitative methods measurable information can be collected and used to quantitatively test their impact on the patient discharge decision and their outcomes this way quantitative factors can be used for decision support to complement qualitative factors such as ethics and intuition the decision criteria as suggest in this study form the basis for our focus group interview guideline we thereby especially focus on the measurable factors to initially derive proposition and testable hypotheses in a next step method this paper presents the first part of a mixed methods approach either concurrently or sequentially to understand a phenomenon of interest this study is conducted sequentially ie the results of the qualitative study in this paper will be evaluated with a quantitative analysis afterward the aim of this study is to derive propositions on the impacts and implications of time of patient discharge thus in a first step focus groups are conducted at an australian hospital group to determine decision makers and criteria for patient discharge and the relevance of readmissions in this context figure 2 shows the proposed approach as well as the areas under study figure 2 mixed methods approach study population we held three focus groups with 4 participants each consisting of 7 men and 5 women thus 12 participants in total each session was facilitated by a moderator and lasted about one to two hours according to krueger focus groups should follow five key criteria first of all small groups of people are assembled usually ranging between five to eight people however socalled minifocus groups with four to six people are becoming increasingly popular as they provide a more comfortable environment for participants and allow every person to be able to participate furthermore the select participants should possess certain common characteristics to be suitable for the topic under discussion in our study the homogenous environment of an australian hospital group is selected as the main criterion in group member selection the groups consisted of medical and nonmedical personnel from various departments such as the icu research clinical audits quality management and the emergency department the focus of these focus groups on the one hand was the determination of stakeholders and decision makers as well as their concerns and criteria for the time of patient discharge on the other hand we addressed the topic of the risk of readmission and how readmissions are detected and handled in the hospital next the goal of focus groups is to collect qualitative data to gain different insights and opinions across groups that can subsequently be compared and contrasted finally this method utilizes a focused discussion to get a range of opinions about a something like an issue behaviour a semistructured interview guideline was prepared and reviewed to ensure consistency throughout all focus groups yet allow for some flexibility within the specified topics for this purpose focus group questions were developed by the research team according to three main areas decision makers and criteria risk of readmission  decision makers and factors influencing the time of patient discharge  factors influencing the risk of readmissions  information availability the aim of the focus groups was thereby to identify the issues behaviours and needs for patient discharge with regards to the risk of readmission and the available information in that process results in the following section we describe the results of our focus group interviews according to our three main areas we identify decision makers and influencing factors on the patient discharge decision as well as the impact of the risk of readmission to specify we utilize the patient length of stay as the comparative indicator for the time of patient discharge decision makers the results of the focus group support the results from our literature analysis but give a deeper understanding of the discharge negotiation requests from family members and patients to stay longer are taken into consideration in accordance with medical necessity and availability of resources family members or patients often push for a longer stay … the requests are taken into consideration but it requires a conversation about the medical necessity patients and family often ask to stay longer since its a private hospital that can sometimes be arranged depending on the available beds according to one interviewee this especially happens with readmission cases stating that if theyre nervous especially if the patient already had multiple readmissions they want to be on the safe side similar to the results from literature the focus groups agreed that usually nurses make the suggestions for discharge when they feel that the patient is well enough but that in the end the consulting physician has the final say and makes the decision when the patient is discharged in case a patient stayed at multiple wards or saw multiple doctors they will make a decision together depending on the ward a patient is treated at there can be specific people in charge that lead the decision in icu one interviewee stated that the decision to discharge … is made by the intensive care specialist in conjunction with the treatment team so the physician surgeon etc the physician will determine if the patient has been stable for a certain time if the blood tests are if not normal at least trending in the right direction in the special case of private hospitals as in the case under study insurance can also play a role in the sense that if the patient runs out of insurance then the patient is transferred to a public hospital influencing factors on time of patient discharge within all groups the type and severity of the diagnosis were concluded as the most prominent factor one person stated that the time of discharge depends on how what they come in with and how frail the patients are and why they needed the medical care in the first place similar others referred to this as the complexity of admission or proposed that the best time of patient discharge mainly depends on what heshe comes in with our first proposition that is derived from our interviews therefore suggests a significant difference within the durations of patient visits p1 there are significant differences in patient length of stay between different diagnoses going further not only the type of diagnosis but also the severity of the condition and frailty of the patient were mentioned as relevant factors therefore we further propose to differentiate time of patient discharge and length of stay within diagnoses groups p2 there are significant differences in patient length of stay within diagnoses groups depending on the disease severity influencing factors on risk of readmission next our interviews show a varying perception of the benefits and threats of a later time of patient discharge while some participants argued that a shorter length of stay is more beneficial for patients some interviewees propose that they tend to keep critical patients for longer to make sure a patient is healthy enough to leave one participant stated the more critical a patient is the longer the required period of normality before they are discharged thus the time of patient discharge shouldnt be both too early or too late leading to our following proposition p3 the length of stay has a significant impact on the risk of readmission furthermore the interviews show that this applies even more to certain patient groups especially for chronic diseases especially patients with chronic diseases are often frequent flyers in the hospital for example renal failure diabetes airways disease cardiac disease … these patients make up 80 of medical activity and cost we therefore conclude the following propositions p4a there are significant differences in risk of readmission between different diagnoses p4b there are significant differences in risk of readmission between within diagnoses groups depending on the disease severity figure 4 displays the theoretical model of the derived propositions visualizing the relationships between diagnosis disease severity the length of stay and risk of readmission figure 3 theoretical model of influencing factors on length of stay and risk of readmission information availability the third part of the focus group interviews focused on the type and amount of available data that is required in the discharge process in general one interviewee stated the discharge decision requires input about the objective medical factors as well as subjective factors ie intangible information that cannot be measured these subjective factors are usually determined by the physiologist the availability of information can also negatively impact the length of stay ie lead to a delayed time of patient discharge … having the data available sooner or digitally may or may not improve the decision of patient discharge but it could improve the efficiency of discharge because a delayed discharge is bad for the patient and the hospitals a delayed discharge can increase the risk of hospital infections and can result in penalties for the hospital if the length of stay is continuously too long across multiple episodes besides increasing efficiency through digitized data the advances of more complex data analysis and visualization were discussed within one of the focus groups it wouldnt be enough to digitize the information but to combine the information and use more complex information to show doctors more sophisticated overviews of risk etc in that sense los diagnosis disease severity individual data points might not be critical but in combination they might show relevant information to the clinician as one physician stated the complexity of data outpaces the availability of clinicians to digest the information within this discussion the application of business analytics or machine learning methods was proposed as helpful to counteract this complexity an intuitive visualization is thereby key to filter out the relevant information its important to quantify and visualize the results from such analyses eg likelihood of deterioration especially information concerning the potential risk is not yet assessed in detail even though unnecessary readmissions could be avoided with this knowledge the information of risk assessment of a patient is collected but not really used if that information was visualized properly that would be very helpful risk of readmission this information could be both helpful for treatment of individual patients as well as on a more organizational level for this purpose aggregated data for each drg group or specialty could be displayed to improve hospital coordination and management on an individual level the risk for each patient could support clinicians to determine the best time of patient discharge discussion in this study we identify decision makers and influencing factors in the patient discharge process and for risk of readmission and shortly discuss the potential of data analytics and visualization in the healthcare context as the first part of a mixed method study we develop semistructured focus groups interviews that are carried out at a notforprofit tertiary australian hospital group the results of the interviews show similar findings as our initial literature review considering decision makers and criteria in patient discharge but give a deeper understanding of the discharge negotiation the analysis of these focus groups results in five propositions on the influencing factors on length of stay and risk of readmission in private hospitals our aim is to further develop these propositions into a testable model and derive hypotheses on the relationships between these influencing factors for this purpose we will collect data on patient episodes at the case hospital to further specify our proposed theoretical framework in a followup study by following a mixed methods approach the qualitative results of the focus group interviews can be further supported by quantitative evidence and therefore strengthen our initial results thus the identified stakeholders involved in the patient discharge decision can be supported during this process by utilizing datadriven insights to find the optimal time of patient discharge the results of the focus groups also show a high interest and applicability of data analytics in the healthcare context to enable faster and more evidencebased decision making this study aims at providing a deeper understanding into the patient discharge process and gives suggestions on how the use of data analytics could support this process in the future from a research perspective the quantification of influencing factors on patient the results of this study have to be considered under certain limitations first the participants of the focus group were selected from a single hospital group to provide generalizable results further studies have to be conducted at different sites second the propositions developed in this paper are not yet quantitatively evaluated and are based on the authors interpretation of the qualitative results this restriction will be approached in a followup study using patient episode data at the hospital under study introduction in the new era of technologyenabled competition many organizations have to deal with disrupting technologies emerging new competitors challenging itbased innovative models in many industries digital transformation is a key enabler of future success or survival by better connecting digitally with consumers partners by improving internal efficiency through improved process by facilitating deeper insight and business intelligence and by providing enhanced products and services the increasing use of integrating digital technologies has a transforming impact on companies and on how their businesses work the depth of changes is dependent on digital maturity digitally lessmatured businesses have limited opportunities by concentrating on solving discrete business problems using individual digital technologies digitally most matured organizations develop digital strategy based complex innovations to transform the business digital business is a complex approach influencing all aspect of operations provides several benefits like improved transparency and control of operations extension of it based systems data collection and analysis increased integration of business applications transforms analogue process to streamlined and efficient digital ones typical organizations have internal efficiency and operational focus while the digitally matured organizations the priorities are automation of processes distant control and execution of procedures and automation of human activities pressures for digital transformation are also present in hungary survey results digital transformation in hungary research results confirmed that the investigated organisations consider digital business transformation as a key issue the research also points out that there are many uncertainties on the way towards digitization organizations cannot foresee the challenges and opportunities and only some of them marked out clearly their digital business strategy or even just a few implemented digital transformation projects most of the companies are not so enthusiastic about the risk related to the introduction of innovative digital solutions so digital strategy in a crossfunctional strategy that address all functions and processes of an organization the role of it strategy is to fulfil the requirements of the digital strategy that is interpreted as a business strategy digital strategy our research showed that almost half of the surveyed organizations include digital transformation issues into their organizational strategy while a little more than a quarter of the organizations include digital transformation questions into their it strategy moreover 10 of the organizational have an independent digital transformation strategy and 15 of the organizations have no digital strategy at all the results partly follow the insights of bharadwaj el al as most organizations integrate digital questions into their strategy but there is still a huge number of organisations which still believe the role of it in these questions moreover if we analyse how the business and it strategy is related to each other we can realise where strategic alignment of business and it could be accomplished higher share of business integrated digital transformation is present and there is no independent digital transformation strategy at all companies developing it strategy as a derivative of the business strategy are less interested in digital transformation some of them have an independent digital strategy and the it units influence on digital strategies is weaker companies having integrated business and it strategic planning are more active in digital transformation and they tend to involve digital innovation to their existing planning activities based on these results an adequately aligned it strategy can be a catalyst of digital strategies innovation process the origin of new ideas even though there is the willingness and implementation capacity solutions are needed that meet external and internal requirements therefore methods and approaches of ideageneration and collection in companies are key issues based on the survey results ideacollecting activities of companies are somewhat stronger than the medium in average but there are various levels of emphases on the different sources of innovative ideas the two most important area mentioned are the external and internal related ideas there is no significant difference between the importance of these sources companies put much less emphases on systematic exploration of the operations collection and evaluation of data related to operations in addition to these feedback sources the statistically analysed data and focused customer and employee data collection process monitoring problem detection may be the best basis for organizations to identify the improvement opportunities of activities processes customer experience although placed backward in the survey outside opinions can be also a valuable source of innovation planning and implementation recently many ceos generally understand the strategic opportunities and threats of digital transformation and developed a vision or even a strategy for their companies to initiate changes on the other hand most organizations have only insufficient skills and knowledge in digital business which can be a major impediment of executing the digital strategy digital transformation has become the major facilitator of business success it provides new approaches to optimise processes improve data analysis and extend customer relationships although technology can be mentioned as a key enabler of recent business innovations it is generally accepted that strategy is the key driver in the digital arena the digital business transformation can bring significant changes in the life of organizations but it means also significant risks this dichotomy can be observed in most of the companies despite the importance of digital transformation for many organizations organizational readiness is a key factor in the assessment of risks while the domestic entities reported the strategic importance of the issue they evaluated their own preparedness to a much lower level organizations estimated their technological knowledge and skills necessary for digital transformation just slightly higher than the medium level 2017 just as cultural and organizational issues from this perspective the situation is promising but the key aspects of the implementation capabilities are just slightly better than medium culture of innovation is not the strongest feature of many organizations so the hungarian results are also not surprising in this sense we can understand the riskavoidant behaviour of the organizations since taking a risky step requires preparation and knowledge • employees should have it knowledge and digital skills and organizations should consequently develop these skills • the organizations should consciously monitor and evaluate technology trends innovative solutions should be piloted • companies should set up a group with welldefined goals roles and responsibilities to implement digital transformation according to the results of weill and aral high it savviness is originated from five characteristics of successful organizations amongst them companywide it skills and management involvement our results showed that companies recognized the strategic importance of the digital transformation but the implementation related competencies should be developed further analysed companies evaluated their ability to give quick response to the fast environmental changes at lower than medium level so the implementation capability should be significantly improved most of the leading service providers reported in a survey that they are still in the early stages of their transformation program the overall observation of our survey was somehow similar but in hungary many companies are just in an experimental phase complaining about many issueslack of experiences lack of skills etc figure 5 there is the will for digital transformation the role of it in digital initiatives in 2016 digital transformation primarily occurred in cloud and mobile platforms but companies improved their communication technologies and great attention was paid to the integration of social media solutions the transformation does not only mean the introduction of it solutions but also requires the change of organizational operations or the transformation of processes even with the introduction of radical new solutions our results are similar to other surveys where the most widespread disruptive technologies are the cloud mobility and collaboration while the popularity of data related initiatives were much less frequently mentioned in hungary than on international level 296 302 the organizations in our research think that it knowledge is necessary to the digital business transformation in all areasthe difference may be in the extent not surprisingly the leader of the list is the it area but more importantly the responders evaluated the existence of digital knowledge in most areas higher than medium whats more the business respondents evaluated digital knowledge in marketing finance accounting and logistics more important compared to respondents from it while it knowledge necessary for the business transformation is required from it professionals by organizations the role of it seems to be more supporting to address security issues the implementation capacity architecture design interestingly participation in innovative projects pushed to the end of the listbut it is worth noting that even this category is stronger than medium it seems that it and it leaders have to manage an interesting situation their knowledge is essential to the successful implementation of digital business transformation but our research showed that in the making of ideas or innovation business areas do not rely on them business areas often go their own way and involve it areas latersometimes too late as evidence we have seen that most organizations consider the digital transformation strategy distinct from it strategy and they put the emphasis on business issues such as how will my business processes change what can be used from an existing digital toolbox 8 since the use of cloud services is increasingly widespread in hungary it can happen easily that business areas decide to use it services without involving the it then of course they need integration standardization and raise security issues this leads it to lose control and the opportunity of proactiveness conclusion our research results showed that the hungarian companies have a positive attitude towards the digital transformation concept the general level of awareness is high among the analysed topics we discovered some general patterns another important area to be developed is speed if it is not capable of quick changes or supply fast solutions business areas can take over control introduction although the banking industry is a traditional and conservative industry it has to follow the required changes of digital transformation although the banking industry is heavily dependent on technological solutions this change is not encoded in the genes of the banks moreover identifying possible digital developments is harder than the banks think the goal of our research was to analyse to identify customer challenges of hungarian retail banks to develop and to test digital ideas to address these challenges for this research we were collaborating with seven hungarian banks and analysed both online and offline customer challenges the goal of this paper is to overview the related concept in the literature and present the results of this research related concepts the goal of this chapter is to analyse the current challenges of digital transformation presenting the challenges of the banking industry and analysing how customer centric digital innovations can be delivered the challenge of digital transformation digital developments were traditionally dedicated to the responsibility of it departments although the alignment between business and it goals was a neverending discussion of both practitioners and researchers kahre et al 2017 the leading role of organizational it was not really questioned and outsourcing of it services usually arose mostly in operational issues by now the exclusivity of developing new it services and delivering digital innovations has loosened mainly because of the following reasons  as digitization reached business departments the requirement of it knowledge and it savvy employees became vital of organizational success therefore business leaders and employees had to acquire digital skills so it departments knowledge monopoly is under demystification  as softwareasaservice solutions especially cloudbased solutions became more and more accepted business units have the opportunity access it services without involving their it departments moreover introducing a new it service into business operations via the saas model takes less time than the traditional implementation projects  not only the speed of implementing new services is an issue but also the quality of new services as it solutions like infrastructure or access to internet became the transaction cost of choosing or changing saas services decreased therefore organizations can select innovative saas solutions with lower costs and lower risks as carr urged its time to rethink it management therefore bharadwaj et al claim that business units lead the way of digitization and digital business strategies are separated from traditional it strategies as digital strategies address crossfunctional business objectives and changing business processes by utilizing it resources digital strategy is treated as business strategy itself digitization challenges of the banking sector digital technologies have been entering the banking industry for years and the banking industry and banking operations and highly dependent on the it services shaikh and karjaluoto originates automated retail banking services into the mid1960s because of the requirement of processing the huge number of creditcard related electronic transactions since then digital solutions are not uncommon in the financial sector atms in the late 1960s and 1970s telephone banking and pos solutions since 1980s online banking and even mobile banking since late 1990s motivations of digitization was faster and cheaper customer service despite of these efforts and digital achievements banking services still seem to be lagged behind general digital technology trends and behind the digitization of other sectors especially commerce the situation is more challenging for the banks as their customers take their financial services from different service providers easy to access internetbased services make this situation even worse using saas services on the internet provides low transaction costs for trialling selecting or changing alternate service providers moreover ygeneration and technologysavvy customers demand and appreciate digital services and these segments are ready to change for a better digital customer experience beside the changing customer behaviour banks have to face new challenges  as new entrants fintech companies offer digital financial services in several niches fintech companies act as startups frame a very specific customer challenge and offer very specific solutions one fintech service probably will not endanger banks or the banking sector but together they target small but very profitable slices of the banks value chains surprisingly banks didnt start to address this challenge yet although this hybrid financial model seems to stick in the market and questions the role of banks in the following years  technology companies also enter to the market of financial services as financial services became an integrated segment of their value offerings alibaba google apple samsung etc provide more and more financial services which are technologically advanced and moreover they can target their existing user base  since the financial crisis started in 2008 government and industrial regulations became stricter and require banks to apply and report these requirements these compliance issues require additional investments in technological solutions and makes their service offerings less flexible and sometimes less user friendly customer centric digital innovations as customer behaviour is changing it is not enough simply to offer new digital services or just to copy the existing services of the competition even before the age of digitization customer experience questions were highly important and loyalty of banking customers was related to perceived value service quality service attributes satisfaction image and trust digital services are expected easy to use comfortable natural but moreover the solutions should service the need of the customers fintech companies and digital innovators not simply digitalize or automate existing processes but adequately understand customer challenges or new requirements in which customer experience has a vital role the need of a bettergrounded design of products and services started by herbert simon as defining the role of design as the transformation of existing conditions into preferred ones because of the nature of a general design thinking approach it is able to be a basis of digital innovations inspired by the overview of different design thinking approaches by gioia and based on the collection of dam and siang of the interaction design foundation and processing additional widespread models a general design thinking process includes the following steps the goal of our research was to explore and identify customer challenges in retail banking to achieve this goal 7 hungarian banks joined to the project of which total balance sheet altogether represents 68 of the hungarian banking industry nature of the research exploring digital banking possibilities the research was considered explorative we wanted deeper insight than the traditional surveys and case studies therefore we decided to select design thinking approach among the qualitative research methods the design thinking approach can provide a deeper understanding of customercentric challenges than traditional surveys or case studies through deeper involvement of observation the design thinking approach also help to identify and evaluate as many challenges as possible and ideate as many solutions as possible for the basis of the applied methodology the 5 steps approach of ideo and riverdale was selected because we have limited time and limited resources we had to adapt the methodology to fit into these frames to achieve our goal we used the following additional sources to construct our research methodology  the book of knapp et al presents the methodology that google uses for rapid prototyping of their ideas although we applied different phases and steps this book helped a lot how to organize the week this approach the agile project blocks also inspired the name of our methodology  although we heavily relied on the design thinking for educators methodology we used parts of additional design thinking approaches brown ambrose and harris stickdorn mootee kumar cosovan and horváth  to enhance creativity we used additional creative techniques during workshops based on the works of sibbet gray et al michalko zichermann and cunningham and vogel based on these resources we created the one week sprint format that consists of the following steps and content during the research each team was dedicated to a selected bank coordination of the teams and methodological assistance were provided by two leading researchers in the role of design thinking coaches the research team invested more the 1000 working hours during the 5 days to explore and analyse customer challenges and provide viable ideas for the banks in the discovery phase the main goal was to identify as many challenges as possible while in the interpretation phase the teams prioritised these challenged and reduced them into a few for further work in the ideation phase the teams brainstormed a huge number of ideas but during experimentation only a few viable were selected and tested and the successfully tested and iterated ideas got only the final phase in the last phase the surviving few ideas were developed further costs benefits risks were analysed and a project timeline was added following this methodology project teams delivered their research findings at the end of the 5th day concentrating on the main problems and main solutions after the one week sprint all the identified challenges and possible solutions were collected and analysed further by the coaches this paper presents these aggregated results transforming our lives june 18 21 2017 research findings our main findings can be grouped to three main areas  the changing role of branches  online mobile and phonebased services  products and services in each problem area we present the identified customer challenges based on our observation then we present the possible solutions identified by the project teams although each project team was dedicated to a specific bank customer challenges and problems overlapped of the different banks the changing role of branches customers articulated their most problems related to branches in discovery phase as we investigated the area of branches in interpretation phase it appeared that no one loves to go to bank branches especially not the younger generation the traditional functionality of bank branches was to serve as the central point of customer relations however for customers visiting the branch may be only a drag or worse it can mean frustration for them from the banks side the reducing number of customer visits should motivate branches to take advantage of these rare opportunities improve customer relationships and trying to sell new products and services using their personal presence from the customers side the branch visits are considered as a task with no significant added value so they would like to do it as fast as possible and they consider all the things that prevent this as annoyance to manage these problems nowadays it is considered natural to direct all possible administrative tasks to appropriate online channels the question remains what to do with the bank branch where customers do not want to appear in person and how to convince customers to choose the closest relationship personal appearance the question is complicated because of the heterogeneous composition of the banks customers and there is no solution that would be appropriate for everyone there are customers who prefers personal presence in their sensitive banking affairs and the customer experience should be ensured for them as well suggestions made up during ideation phase and tested in experimentation phase • enrich waiting time waiting is typically a lost time both for customers and for banks it is worth to make this time more meaningful and provide an opportunity for interaction with the bank through personal assistants or electronic solutions what is required for an agent to visit community offices appearing elsewhere daybyday as a mobile branch clerk to arrange matters after all the branch is not necessarily the physical space but the place where the issues can be arranged one full project proposal from the evolution phase was dealing with how to reduce waiting time and to understand the intentions of customers if the waiting time may be longer than a few minutes the customers should not draw a line number instead a tablet serves as a personalized caller through this device the authentication of the customer and identification of the customers preferences can be easily done the customer can get familiar with the bank offers and even express their interest in banking products the customer needs can be assessed in the form of tablet games it is important that in these cases the bank can identify the real customer needs and offer those products only that meet the real needs even in a personal administration rather than products typically offered to all customers if the customer needs can be identified in advance or detect lack of interest the personal administration will be targeted so it can be faster online mobile and phonebased services empowering customers to manage their issues in an online channel seems to be an obvious solution to most of the problems outlined in the previous section arranging issues online reduces the need of personal contact which may ease the customers life and lower operating costs for the banks themselves at the same time managing issues outside the branch leads to challenges that would have been easy to handle in the branch itself such as inadequate supply of information lack of consultation and the functional limitations of the different platforms regarding the nonbranch channels the most frequently expressed counterargument is the issue of security whether the data of the customer will be stolen what can ensure the customer that they are communicating with the bank itself what can guarantee the  provide adequate professional support to online channels in the back office of online and mobile applications there are no clerks because of these channels nature but if the customer gets stuck or has questions it would help them a lot if there is an opportunity to redirect to a more personal channel online chat video call call centre in addition because the customer has been authenticated online no other authentication should be performed again during the transition to the new channel this solution can reduce the number of lost cases  the customer should be a partner in security issues even though the issue of bank security belongs to the banks a significant proportion of fraud attempts are targeting customers credulity to prevent this banks should improve customers security awareness and manage their business transparently in evolution phase teams were making project plans to solutions which were targeting existing mobile applications without meaningful functionality or to a augmented reality branch where customers can manage their issues in the wellknown environment of their own branch with professional clerks as avatars using internetbased telephony products and services regarding to administration in branches the interviewed and examined customers highlighted in discovery phase the lack of transparency in the bureaucracy of banking and that there is a lot of paperwork with all issues the loan and investment administration turned out to be the most effected with the problem that the rules and the processes laid down by banks are too complex complicated and incomprehensive for customers customers typically get information from these rules and processes from clerks during the administration and sometimes different clerks give different information to them for the same issue that is a common customer complaint that the rules seem to be articulated in a way that the customer may not understand or do not want to understand them banks must meet several legal requirements and a significant part of these apply on the cooperation with customers so the banks have no other option than to enforce the rules applicable to customers this make the rules and the banking operations for customersbut often also for the clerks difficult to understand and what is even worse following the legislative changes the rules and processes are frequently changing as well because of the above mentioned the customers regardless of the intention of the banks can feel that they are at the mercy of these institutions from the banks side ensuring customer experience is becoming more challenging and this can lead to churn of customers this is one of the most important findings from interpretation phase the extent banking services can be customized or personalized which is also part of the customer experience many customers have indicated that there are only a few options of banking services available and they cannot find those services that meet their own sometimes not so unique needs therefore if they can find appropriate services in another bank they consider the possibility of switching banks from evolution phase a project plan visioning an online bank where personalized advertisements can be seen based on the data gathered from the chronologic and personal data from the customer is important to mention conclusion although most bank realized the importance of digitization customer centric approaches are quite new in the hungarian banking sector development is not only a technological question but also a methodological one in our research we demonstrated a useful rapid very focused approach of explore customer challenges but for a successful project we required a good and prepared team members the two coaches were able to provide adequate methodological support the findings of the project were discussed with the participated banks given them better insights of customercentric approaches through defining the demand but additional challenges also pressurise banks to develop their systems eidas compliance psd2 challenge gdpr regulation it is a limitation of this research that its focusing only on customer related challenges that mainly visible in front office services but for hungarian banks they have the opportunity to apply matured solutions and technologies what is still innovative on the hungarian market that is already tried out on other market and we can know the success and failure stories therefore it is important to benchmark the international market even before deciding on it is a strategic choice of the incumbent banks how to manage their relationship to fintech companies they can be considered as competitors as possible partners to work with but we have also seen a hungarian bank that itself developed a fintech incubator program fintech companies are considered either partners or competitors but they definitely increase the competition in the sector and support the digitization efforts generally the applied research identified several customer challenges and offered also several possible digital solutions although the project teams couldnt finish complete detailed readytoship products they made rapid progress generated and designed a huge number of ideas and they tested if they are headed in the right direction in future researches we would like to expand the size of the research the used oneweekspring approach should be expanded with additional surveys to validate the findings and to generalize the results introduction the development of information communication technologies brought various opportunities and prospects for small and medium enterprises very often smes are described as slower adopters of innovative information communication technology solutions in comparison to large companies which have capacity and possibilities to develop and adopt the latest ictbased innovations such situation is caused by the lack of knowledge strategic forecast and finances facing such situation smes tend to use information communication technology solutions which can be provided by third parties and third parties take care of the solutions such solutions might be provided on various platforms which offer new opportunities for smes recently a growing discussion about platforms their development and their business models has been observed these discussions as well as related research address how platform business models might be developed and how successful platform business models are run however smes usually act as users of the platforms in order to fulfil their needs and gain an advantage in the market the success of the company is determined by defining and implementing the business model that allows understanding the key aspects of the success in order to sustain longterm advantages smes should innovate their business models in response to the changing market conditions ie find new ways to expand their value propositions find new markets and segments use of platforms provides various options for smes according to researchers companies need to consider platforms such as google facebook amazon apple our research aims to contribute to understanding how smes use platform possibilities to innovate business models and how these decisions are made smes make strategic decision to deploy various platforms as they provide different opportunities eg google and apple help to reach customers facebook to develop relations amazon to use more effective services the research presented in the paper aims to understand how smes evaluate platform possibilities how the needed functionality of the platform is selected how smes change the business model and how smes assess the success of business model change the four platforms in particular become important partners in business to consumer markets as gafa takes about 55 percent of user digital life the phenomenon when new companies appear online by using only the infrastructure of gafa are also observed in this paper we contribute to the research body by analysing the use of google and facebook products for business model innovation among lithuanian smes business implications of digital platforms the term platform has been attracting the attention of practitioners and researchers in the last decade the term became so popular that practitioners and researchers started using a new term platform economy initially the term platform was defined as digital infrastructure on which different applications can be run or allowing for a finite and clearly defined set of uses techopedia suggests the following definition a platform is a group of technologies that are used as a base upon which other applications processes or technologies are developed this approach is clearly related to the technical point of view as key characteristics of platform refer to hardwaresoftware aspect and clearly defined set of action such definition addresses google or facebook platforms at the beginning of their activities as google served as search engine allowing users to find information while facebook served as communication tool providing an attractive and simple way to socialise however due to the development of technologies and more active role of platforms in the digital economy the new term platform company appeared the term aimed to describe company offering a platform or several platforms aiming to provide marketplaces distribution of media content andor coordination of activities this definition demonstrated managerial approach emphasising functionality which platforms were offering as a key value proposition ballon even suggested the term platformisation referring to new societal trend when companies are developing and offering platforms and new platformbased business models appear platform phenomenon became popular and new term platform economy appeared according to kenney and zysman platform economy is one in which tools and frameworks based upon the power of the internet will frame and channel our economic and social lives authors identify four essential elements that ensure the functioning of platform economy infrastructure training and skills social protection and regulatory transition the growing importance of platforms was also addressed during world economic forum 2016 by outlining the importance of platforms for companies and organisations naming disruption of economic activities lower market entrance barriers and in some cases changes to the logic of value creation capture and transfer to market as companies face new challenges in adopting platforms these challenges mainly refer to functionalities platforms offer companies using platforms can dedicate more focus for business development and business differentiation as platforms act mainly as facilitators companies need to understand how to adopt platforms in their daily activities and how to measure the value platforms bring to their business the growing number of platforms also indicates the differences between the platforms some platforms are oriented to reach consumers some facilitate communication and provide services some facilitate trade in many cases platforms act as facilitators enabling companies to enhance value proposition and optimise their activities but the value for both parties are created through orchestration platforms also might be described as frameworks that permit collaboratorsusers peers providersto undertake a range of activities often creating de facto standards forming entire ecosystems for value creation and capture gawer and henderson suggested an approach to defining a product as a platform according to gawer and henderson a product is a platform when it is one component or a subsystem of an evolving technological system when it is functionally interdependent with most of the other components in the system and when enduser demand is for the overall system so that there is no demand for components when they are isolated from the overall system platforms might be described by several important components despite growing popularity business model research area attracts academic exploration as according to teece this area resides somewhere between economics and business strategy and more elaborated research is needed the related area is business model innovation which according to spieth et al remains a slippery construct to study within our research context it is considered that platforms bring new opportunities for value creation and capture and companies need to rethink their business model logic this refers to business model innovation concept which can be defined as changes in business logic that are new to the firm yet not necessarily new to the world and have to result in observable changes in the practices of a bm a research framework there are many approaches to business model analysis one of the most popular approaches widely accepted by practitioners is business model canvas this approach defines key components of the business model value proposition customer segments channels customer relations key activities key resources and key partners as a consequence decisions regarding these components result in revenue streams and cost structure in our research we decided to address two important platforms namely facebook and google facebook is easily identified as a platform and companies might obtain various services through onestop shop approach google situation is different as google offers several different services and use of these services causes some confusion for smes smes are interested in using such products as adwords increasing their position in google search listing use a google drive the comparison between traditional business versus opportunities of facebook and google platforms for business model innovation is presented in table 1 platform adoption is strongly driven by the spread of ict and many new startups adopt platforms for the benefits platforms are offering considering such situation many entrepreneurial smes also move towards platform adoption as this should give them the opportunity to run the business more efficiently research method an analysis of several cases of lithuanian smes using facebook or google in their activities was carried out no distinction was made if smes use a platform by themselves or are they supported by business consultants we believe that even if smes use consultant services they understand benefits of platforms well enough as smes invest in the utilisation of the platform we tried to identify smes using facebook or google platform in many cases we found it complicated as smes tend to use both of them but we identified cases there one platform is key platform and use of the second platform is limited and therefore the role of the specific platform is more expressed interviews were carried out with sme representatives that are most knowledgeable about the use of a given platform within their organisation additionally an observation of actual use of a platform was carried out where possible the company is developing its toy brand ačiū pačiū and expects that in future the brand toys will become the main product of the company and there will be no need to take orders for other sewing services empirical findings for online marketing the company uses an eshop ecatalogue and facebook page they also plan to start using the instagram account the company also writes articles but rarely the primary reason to start using facebook was the fact that facebook was the cheapest and easiest to use way to reach the target customers of the business at the beginning of the business it was important that the means used would allow reaching customers without larger investments the other important reason was the responsiveness of the customers as it is significantly easier to communicate with them here and now it was noticed by the company that customers nowadays find it simpler and more convenient to write a facebook message than to write an email that was important to the company as they want to be accessible to customers have personal communication with them and to have the opportunity to offer personalised products facebook provided a platform enabling that kind of communication compared to other social media platforms activity on facebook achieves the highest engagement from followers key features of the facebook used by the company are the facebook page of the brand instant messaging function paid advertising options facebook page is administered by an external agency while the company itself maintains the content how platform affects business model innovation first of all use of facebook enables the company to reach its target customers in fact company representative claims that if not facebook i do not know how else we would have reached the customers at that moment when we needed that facebook enabled the company to reach new customers as well the company was targeting people from lithuania however they soon discovered getting orders from abroad as well facebook is also used as a source for modifying the product namely the core of the value proposition personalised and customised products are offered to customers based on personal communications with them via facebook messenger also the company uses feedback from their facebook community to make decisions regarding the products the latter option is rarely used however the communication with the community on facebook helped the company to understand that customers prefer simple products and designs whenever we placed a more unusual or interesting offer and expected people to prefer it they would surprise us by choosing more simple and basic option that helped us to provide more relevant products to our customers facebook page is used as one of the main channels to raise awareness of the products by introducing and promoting novelties advertising possibilities are used for this eg every post is boosted for few days by targeting target customers of the brand as mentioned it is also the main channel to communicate with customers therefore to provide postsales support as well facebook is also a crucial platform for maintaining relationships with customers the messenger is used for personal service to chat with customers answer their questions to find out their requests and preferences community relations are also maintained on facebook page of the brand case 2 use of google platform the company transer was identified as sme case with the use of google platform for business model innovation interview was carried out with one of coowners of the company the company transer offers translation services for technical text the company is sme and have five persons directly involved in company activities there is an extensive partner network as the company hires different interpreters for specific tasks the company revenues reach about 100k euro per year in the last three years and according to company ceo revenues are stabilised there is no specific reason why google platform was selected but the decision is based on a variety of information available in newspapers and journals about google benefits for business the first attempt to use google platform was in 2010 trying to reach a larger number of customers via ppc advertising however this initiative was not successful for several reasons first of all the company lacked knowledge and the second attempt to use google products was much more successful this time it was decided to use google drive and google documents in order to save costs and make internal operations more efficient according to the company owner the ability to use documentation in a more comfortable way was the reason to start i use two separate computersone in the office and another one at home typically in a rush i forget the documents and it means i cannot access them because documents are on another computer by using google drivedocuments i can access all documents from any computer the next step in using google platforms was to use google documents on various cooperation tasks as we realised we can all use the same document we started using this solution for implementing some activities after successful use of google documents the company decided to replace crm system with google documents the attempt was made to share information through google documents with partnersinterpreters but it was not successful interpreters preferred to call or send email but not use online documents how platform affects business model innovation the company used google platform for several business model innovations but only one of attempts was successful the first attempt was to reach new segments and new customers using google adwords but the lack of knowledge did not result in a desirable outcome the attempt to use adwords lasted just for several months second attempt related to the optimisation of internal operations and affected key resources and key activities the google platform improved internal operations and became part of company infrastructure as a consequence the company decreased costs around 500 euro per year those are not significant savings but company ceo considers them as important ones discussion from the theoretical research assumptions were made on the contribution of facebook and google platforms on business model innovations based on interviews with sme representatives we might state that the impact of facebook is easily recognised and valued by smes as facebook acts as onestopshop it is more complicated to determine the impact of google products from smes perspective as google offers various services which might be used by different departments facebook platform is perceived as a marketing tool mainly and in the case of google only some features are related to the from case studies we observe that platforms are used for reaching target segments in the case of facebook this associated with a typical feature of modern brand and company successfully maintains its presence on facebook from the perspective of google platform adwords were used to reach target segment however the company did not manage to do it appropriately as lacked skills to use adwords we also find out that companies can successfully use facebook platform as communication tool allowing to customise value propositions facebook messenger plays a major role in getting information about small details of a product therefore facebook messenger plays an important role in building customer relations we also observed that platforms might act as one of the main channels ensuring information flow and communication between company and target segment as google platform offers features targeted towards various activities of companies these features are used to make companies performance more efficient we observed a case then google documents are used for operation coordination and customer relationship management so the impact of google platform on key activities is significant none of the companies referred to platforms as partners but it is evident that both platforms play an important role as partners in activities of companies conclusion platforms play a greater role in smes activities as they give new opportunities for smes to innovate in the context of a business model smes typically approach the four main platforms google apple facebook and amazon some platforms act as onestopshop offering different functionalities some platforms offer features that are distributed platforms can bring opportunities for innovation in all business model components none of the companies recognised platforms becoming important partners but platforms role as key partners was observed introduction optimal healthcare access quality and value have become global priorities for healthcare domains to combat the exponentially increasing costs of healthcare services information systems information technology have been promoted as a critical enabler to achieving these priorities presently we are witnessing a staggering range of isit applications in healthcare that have promised to deliver higher quality and safety with greater value however the data supporting these claims is often lacking or poorly supported advocates in particular point to the potential reduction in medication errors as a critical advantage these singular advantages do not reflect the enterprise viewpoint that is so needed further the debate about the difference isit solutions can make to healthcare quality efficiency and safety has only intensified in the light of these complex circumstances there is a critical need for a framework to evaluate the business value of isit in healthcare previous research has discussed examining the business value in healthcare it by leveraging four groups of isit according to their business these groups classify isit into infrastructural transactional informational and strategic domains sociotechnical aspects with healthcare projects are also important to consider thus they are mapped in previous work with the different layers of healthcare delivery including healthcare ecosystem system structure delivery operations and clinical practices this research evaluates the developed model of the business value of it in healthcare this model was designed to help evaluate the business value of it in healthcare the model itself takes technical and sociotechnical perspectives in mind the former is presented by the work of weill and broadbent which classifies it investments into four categories based on their business objectives while the latter is presented by the work of rouse and cortese which classifies various healthcare delivery activities into four levels namely healthcare ecosystem system structure delivery operations and clinical practices specifically three clinical it systems at both private and public healthcare settings in australia were evaluated the first system is an american made computerized physician order entry system the second is an australian made nursing documentation system while the third is an australian made incident reporting system the selection of these systems was based on their characteristics as they address the needs of different stakeholders ie the nd system helps streamline the methods and settings a multiple case study approach was adopted as this enables contrasting results for predictable reasons to enhance the generalisation to other case studies two case studies were used in this study the selected cases were chosen based on 1 the volume of it investments they both made during the last 5 years 2 their nature to help identify any differences could result as a result of differences in care delivery models and 3 having vast ranges of clinical specialties the first is abc hospital a victorian public hospital established in 2000 and provides care for more than 750000 people abc hospital has been providing around one million episodes of patient care each year through the efforts of about 10000 staff abc hospital provides a comprehensive range of clinical services and highquality acute subacute and palliative care mental health drug and alcohol services and residential care community health and statewide specialist services to people and communities that are diverse in culture age socioeconomic status population and healthcare needs the second case study is xyz hospital which is a private hospital and counted as one of the largest notforprofit private healthcare groups in australia with seven sites and two rehabilitation centres xyz hospital has invested more in isit during the last few years than in the past and hence was one of the reasons they were chosen to be included in this study according to the chief financial officer approximately 30 of the capital budget during the last five year was set aside for it investments in business infrastructure and clinical systems three clinical it systems were examined the nd irs and the cpoe systems the nd system was studied within abc and xyz hospitals while the irs and cpoe systems were studied solely within xyz hospital prior to conducting the data collection all ethics approvals had been acquired from both hospitals for the nd system two sources of data were used survey 1 data collected from abc hospital and semistructured interviews at xyz hospital first the survey was distributed pre and post implementation of the nd system and consisted of six sections the survey used the unified theory of technology acceptance and use of technology as the studied nd system is a new system utaut was used as a technology acceptance model to uncover intentions of users regarding the use of a new system inclusion criteria for the survey was 1 being a nurse 2 worked for more than 5 years in similar settings and 3 willingness to participate in the survey the survey used the lens of utaut and was validated using extensive discussions with academics and experts in the healthcare domain required changes were made accordingly this method is widely used to measure the different aspect of interaction between human resources and health isit see for example due to the nature of nurses duties and to our intention to gain instant understanding of how the nurses found the investigated system a hard copy of the survey was prepared and provided to nurses at the completion of their shift those who met the criteria across two sites at abc hospital were 39 in site a and 48 in site b with response rates of 60 and 70 respectively due to the complexity of the cpoe and irs systems and given they both were new during the data collection phase 23 semistructured interviews were conducted for healthcare better understanding of the possible business value of these systems from these interviews specific themes emerged with critical information and insights from three major groups of professionals in the healthcare industry executives clinicians and it personnel selecting the participants was based on their role andor affiliation with the group as well as their level of interaction with isit investments and projects the first protocol for the interviews was reviewed by conducting three pilot interviews with medical and it experts this phase resulted in a shorter and more focused protocol three questions were deleted as they had been designed to ask about systems that never existed in the case study and two questions were added to explore insights from clinical it experts ie clinical people who are it savvy after modifying the interview protocols the main interviews took place all of the interviews were audio recorded with full permissions from interviewees professionally transcribed verified and then qualitatively analysed using qsr nvivo 10 software data collected from these interviews were analysed also to understand the business value of the studied systems these interviews were also used as a primary source of data about the cpoe and irs systems results data analysis was initiated by mapping the three systems using the business value of it in healthcare model based on the their functionalities the studied systems were classified as informational it which provides information for managing and controlling the firm as well as supporting decision making communication and control these systems though have other components from the it portfolio as table 2 depicts for example the cpoe system is informational in nature as it helps produce and share information on treatment plans and medication scheduling however it has a transactional component which enables data entryinput like identification progress notes medication scheduling discharge checklist and treatment plans in addition it utilises the it infrastructure like internet intranet workstations servers and databases the cpoe system the cpoe system specialized in oncology care has three modules focused on radiation medical and surgical oncology care at xyz hospital the radiation and medical modules have been implemented while the surgical module has not yet been acquired the aim of implementing this system is to replace the manual patients scheduling with an electronic means on a quest to improving the integration of the cancer care process and eliminating prescription errors the radiation module was implemented in xyz hospital two years ago while the medical module has been recently acquired globally the system has been in use in the market for 1015 years while in the australian market it is been in use for 7 years investigating the impact of this system showed that cpoe systems have high potential to optimize both patient outcomes and healthcare efficiency by better aligning with care standards and protocols since the introduction of this system theres been a significant reduction in errors because we prescribe according to the protocol these protocols are quite common and human error in prescribing is common it has enhanced legibility all that sort of stuff as one interviewee descried for the financial performance a number of interviewees expected that the system would enhance the financial performance by receiving more referrals from independent oncologists but this is subject to complex agreements that have to be reached between the hospital and the vmos and that is beyond the scope of this paper 32 the nd system the nd system has been envisaged by the developers to replace the paperbased nursing documentation applications in hospital acute wards in both private and public hospitals the objective of this system is to eliminate time assigned for nonmedical duties and allocate more time for patients care this is facilitated by putting smart terminals at patients bedsides creating more direct interaction between nurses and patients providing these smart terminals directly at the bedside should facilitate higher levels of collaboration between ward nurses and other healthcare professionals according to the systems designers results revealed from the utaut survey at abc hospital showed that this system increased the time for patient assessment from 52 to 91 of the total time spent by a nurse during a regular ward visit this was achieved by reducing the time consumed for nursing documentation from 157 to 64 not only did the care time increase but also the level of transparency as patients could witness more details about their care provision and an extra 481 of nursing activities were performed at the bedside compared to the process before introducing the nd system the system helped increase patients safety by having a onestopshop for patient records as one interviewee described on the other side a number of interviewees did not see a direct translation between longer care time and better care one interviewee noted that it is much more complex than just taking some aspects of the role away and even with this new system i think that even with our new technology that were testing now nurses find other things to do as another interviewee explained the scope of the system is limited to ward and nursing station this does not allow the system to cover the endtoend process of healthcare provision as one interviewee noted in their concerns in addition the nd system has demonstrated high potential to increase the healthcare efficiency by reducing the time dedicated for paper records and following patients information and records the nature of the system allows for a higher number of processes to happen ever than before as one interviewee noted which has direct impacts on the efficiency of healthcare delivery through prompts and real time documentation also this system seemed to have some impacts on the clinical decision making process with all patient data available in the ward in one electronic pool ie the nd system nurses can make clinical decisions or recommendations quicker and based on more evidence than the paper records as agreed to by the interviewees the results show that the system may have indirect impacts on the financial performance of the facilities this is by enhancing the reputation of the hospital through their use of stateoftheart systems that are visible to the patients a number of interviewees noted that this system has what was termed face value as a private hospital reputation is a fundamental part of the business as one interviewee described thus if patients feel that even just on face value that the nurses are not scribbling on a piece of paper but actually theyve got an it system that provides confidence in the organization other aspects of enhancing the financial performance by using this system included better resource allocation as the time spent by nurses to perform documentation duties is reduced nurses are expected to capable to provide care to higher number of patients the irs system this system is used across almost all of victoria and beyond in large parts of australia as well for capturing abnormal clinical incidents it serves two purposes documentation of an incident at the time it occurs to support the classification via an inbuilt algorithm into how serious the incident is and standardizing the information thats being captured through validation fields distribution of that information to where it needs to be and then to drive it through into a larger data set of all clinical incidents to support more detailed analysis this reporting system is webbased and enables all stakeholders to report different levels of incidents irrespective of their criticality along with capturing clinical or nonclinical incidents the irs enables sharing information with different levels of management and employees without any delay as one of the closet administrators of this system explains thats about people anywhere in the organization reporting clinical or incidents of any sort that a staff or patient thats dependent upon an it system having someone locally there are some benefits in terms of information provision this system is relatively inexpensive simple intuitive and easy to use as a majority of the interviewees agreed during our discussions these features make this system very popular in the australian healthcare context xyz hospital purchased this system a few years ago to address an obvious gap in the information flow regarding incidents across the hospital as a number of interviewees agreed without irs we will have no capacity to know or no realistic capacity to know what things are going wrong with our patients and therefore the ability to monitor them to improve them and to attract that improvement using this system has created a cultural shift towards reporting in the group as one interviewee notes weve got numbers of things that happened at the time we implemented it weve seen the cultural shift towards reporting so increased numbers of incidents being reported not occurring because we dont know what occurred then weve seen the severity of those events go down in the time weve used it then the frequency of things happening goes down while we have other indicators implying that reporting is still up this shift in turn has other impacts on the overall performance of the group a number of the interviewees emphasized that the use of irs is associated with increased patient safety healthcare delivery efficiency as well as reduced cost of healthcare provision if were not having patients stay longer because something went wrong then its more efficient if a patient comes to have a heart operation and then falls over and breaks their leg then they stay for another week have another operation all of which we potentially are not paid for so theres a cost imposed so there are real benefits discussion this study analyses the business value of it in three specific healthcare contexts this was done by using the business value of it in healthcare model which builds upon the it portfolio model and the enterprise of healthcare delivery model the results suggest that looking at isit solutions based on their business objectives helps identify which it systems in the healthcare industry may help create more business value for the studied hospitals informational it was shown to be the most relevant category for the healthcare context this is consistent with the findings of weill and broadbent that informational it is important to facilitate seamless information flow between different stakeholders this is particularly crucial for healthcare providers as clinical decision making is a sophisticated process and most of the time it requires inputs from different craft groups thus finding an electronic platform that provides dashboard capabilities to nurses and other physicians is prudent for todays and tomorrows healthcare the results from the interviews showed that information sharing that is facilitated through the use of the systems evaluated in this study irs nd and cpoe has positive impacts on patients outcomes efficiency of operations and the overall performance of the studied hospitals the cpoe system shows a potential to increase both patient outcomes and healthcare efficiency by facilitating smoother cancer care delivery and reducing drug prescription errors the private public nature of hospital did not have any visible impacts on patient outcomes and healthcare efficiency as the core business is the same between private and public hospitals ie patient care private hospitals seem to build upon brand and face value elements to attract more patients by introducing stateoftheart systems the use of these system was not the first factor the patients took into consideration when making the decision on where to receive the care they need however the adoption of such systems attracted patients given everything else in the care delivery was the same with the studied hospitals on the other side the results show that embedding isit into various healthcare delivery operations in the studied hospitals has introduced a significant change to both care givers and patients in addition given the cpoe is internationally developed the results from the interviews showed that it still needs some domestication to better attend to the uses requirements similarly the nd system was still under development during the data collection phase which resulted in a number of technical problems and thus frustrated the nurses no downsides were reported with the use of the irs system conclusion correctly and completely identifying the business value of it in healthcare contexts remains a challenging task to address this three clinical systems were examined to better understand how information technology can facilitate the generation of business value in healthcare the bvit model was constructed to map the studied systems and to understand what role privatepublic classification can play in the context of the two tier australian healthcare system all of the systems had direct and indirect impacts on generating business value the bvit model was found to be helpful to investigate the business value of a vast range of clinical it systems the next stage of research will study the cpoe system in australian public hospitals as the systems are implemented given that the australian healthcare system supports both public and private healthcare delivery models and the model in this study was shown to be as relevant in both spheres this provides strong support for the applicability of this model in other healthcare contexts namely uk or us where as discussed earlier the healthcare systems tend to be essentially public and private respectively in general investigating the business value of it in healthcare is a challenging undertaking due to the complexity and uniqueness of the healthcare industry unlike other industries such as finance retail and manufacturing various nonmonetized aspects need to be taken into consideration with evaluating the business value of it in healthcare this study has implications for both theory and practice for theory it significantly describes the development of a systematic and rigorous framework to enable and facilitate the establishment of business value of it in healthcare and also to value the it solutions in healthcare irrespective of the public or private nature of healthcare system being studied for practice it provides a systematic approach that can be applied to any healthcare context irrespective of the underlying healthcare system to facilitate a fuller and deeper identification of the actual business value of it in a specific healthcare context notes 1 for ethical and commercialisation considerations the reference is available upon request introduction digital transformation provides opportunities also for startups and early stage companies to innovate products and new ways of doing business where new product development takes radical technologypush disruptive change process as its starting point for new competitive products an evolutionary view about marketpull incremental effects on operations and products is provided by business modelling these alternative views have been under debate on innovation in corporations moreover studies on micro small and medium sized organizations survival provide growing evidence that entrepreneurial passion and originality can indeed compensate limited resources this intrinsic motivation and aspiration of abstract nature ie effectuationis expected to help smes in business model innovation bmi the effectual view supplements the above rational causal theories of marketpull with incremental adjustments and technology push of radical disruptive change but are there links between npd bmi and effectuation to performance in the reallife of smes for this purpose we synthesize a framework for inquiry to find out the elements of failure survival and performance in select case smes we first discuss npd and its connection to bmi then we present effectual reasoning and bricolage and how they are related with bmi third building on the previous discussion we compose a framework for analyzing innovation activities strategic intent and performance of smes with five selected sme cases finally we discuss our findings innovation performance of smes and directions for further research to confirm our tentative results lessons from innovating new products general finding in npd literature is that radically new products built on novel technology fail often mature slow and are accepted on the market gradually over time due to tardiness of diffusion and negative attitudes towards new technology but if such a product offers clear advantage in comparison with competing products the success rates are improved significantly new technology becomes even more attractive in the light of the findings that on unfulfilled markets novel products tend to sustain longer than products built on minor developments or product line extensions spending big on new product r d works in increasing the number of new successful products highquality development teams consisting of dynamic motivated experienced and talented developers improves the odds of success further especially if the management provides direct support or introduces systematic methodology for npd furthermore speed of npd has become increasingly important due to continuous reduction in the product lifecycle time and increased competition due to global technological progression rapid npd prototyping and testing increases likelihood of success as iterations help in discovering errors and provide flexibility and better understanding of the product potential on the market early as an indication of this sarja raised scalability visibility and timing as additional factors important to the success on digital products business landscape as trying to build innovations only on internal technologypush is unlikely to succeed companies are encouraged instead to focus on their customers needs already during the development of the product this also helps to prepare unfulfilled productmarkets for innovation the same applies if the novel technology and market analysis are used in combination during npdprocess beyond regular interviews with customers and endusers careful examination of alternative technologies products and markets during the development by product developers with end users further enhances the likelihood of success interestingly while the most growth potential in markets is attributed to smes smes often are limited in capabilities of the above npd success factors thus creating npd capability is the first requirement smes must fulfil noke and hughes for instance show how smes employed strategies that combine their internal capabilities while minimising their internal weaknesses by partnering and outsourcing their study thus highlights that it is essential for smes to get involved in external npd partner networks to kickstart the change process and to gear up for superior productmarket innovating capability we conclude that npd literature separates technologypush and marketpull as drivers of innovation because customer involvement is to help in incremental innovation involving customers may be detrimental to radical innovation the reasoning is that when a firm focuses on existing customers it may not recognize opportunities that arise in emerging markets or customers being offered disruptive solutions by innovators in the light of the above it is claimed that the process driven by technologypush leads often to radical innovations whereas market pull is more often served with incremental innovations to the user needs however recent research argue that the two forces are complementary and necessary in npd therefore building successful new products on new technology is lucrative because of the potential upside benefitsfast adoption long lifetime low competition however most of the means for successful new product launch do not depend on the technical skills only but on the capabilities of the product development teams systematic management support ample resources combined with the knowledge and skilled iterative probing realization and shaping of the market technology and needs business model innovation effectiveness business model innovation means notable changes in the logic how an organization creates delivers and captures value foss and saebi sum mainstream bmi outcomes and research directions by analyzing 150 peerreviewed scholarly articles on bmi published between 2000 and 2015 their analysis reveal external and internal antecedents that drive the bmi with expected outcomes this process is moderated by macro firm or microlevel variables and emergers as cognitive structures 1 the structures can either respond to exogenous technological and regulatory changes or operate as a learning process of iterative analysis and experimentation in response to changes in the environment we see these as fine tuning the previous view on the npd incremental adjustment of internal resources yet as evidence suggests new business models have often been the source and not the outcome of industry change companies on traditional industries have been able to generate supernormal profits by designing new business models in the presence of major technological progress or in the absence of regulatory limitations these new business models have boosted largescale disruptive industry change reaching far beyond reacting to changes in business environment or developing new products it is about being active in innovating and implementing radically new ways of doing business by the management bmi drivers of smes mostly differ from those of previously mentioned industrychanges a typical hightech startup or growth venture builds its future on one product to the global market furthermore we do not know too well what facilitates bmi in entrepreneurial firms and how are these drivers and obstacles different from incumbents a recent empirical study reports that 37 of smes in europe are involved in bm innovation but only 15 of them are familiar with mainstream bm methods like canvas stof visor or bm cube diverse tools are used but their use is limited in scope and sophistication compared to methodbased bmtoolsets more than 50 of the smes use consultants for bmi which may explain the unexpectedly high penetration of bm among the studied smes to conclude despite the lack of sophistication bmi is about to become mainstream in smes leveraging their bmi capabilities and capacity but does our contemporary bmi research capture the unique features of smes transforming our lives j heikkilä m heikkilä innovation in micro small and medium sized enterprises new product development business model innovation and effectuation 201 effectuation bricolage and entrepreneurial survival whereas bmi and npd literature is mostly focused on causal approaches on developing business towards given goal the entrepreneurial literature emphasizes the effectual side of businesses which is considered as the inverse of causal causal rationality starts with a predetermined goal and a given set of means and seeks to identify the optimal such as fastest cheapest or most efficient alternative to achieve the given goal the effectuation process is highly subjective starting from the capabilities and resources of the entrepreneur and takes this set of means as given and focus on selecting between possible effects that can be created with that set of means figure 1 causal and effectual reasoning sarasvathy proposes four aspects that differentiate causal and effectual reasoning she builds on her conceptual study and on her empirical enquiry on serial entrepreneurs effectuation entrepreneurs have been shown to have high tolerance for ambiguity whereas causation models aim to maximise the potential returns by selecting optimal strategies the effectuation predetermines how much loss is affordable and focuses on experimenting with as many strategies as possible with the given limited means causation models such as porter emphasise detailed competitive analyses effectuation emphasises strategic alliances and precommitments from stakeholders as way to reduce uncertainty and to create barriers of entry present business modelling requires extensive partnering from the very beginning for developing new products and viable services causation models are appropriate when eg knowledge or expertise of a specific new technology preexists effectuation is better for exploiting contingencies that arise unexpectedly over time this is where also recent bmi studies have paid attention to defines a marketassumed to exist independent of the entrepreneur as the universe of all possible customers an effectuating entrepreneur would define her market as a community of people willing and able to commit enough resources and talent to sustain her enterprises survival and creates the market by bringing together enough stakeholders who buy into her idea bmi researchers have identified the tendency of entrepreneurs to seek familiarity in business models and the challenges they face when confronted with unfamiliar concepts later research show that effectuation may play a role in search of bmi effectiveness eg sosna et al suggest that initial bm design takes form on the ownermanagers cognition and sensemaking and in the early phases of npd and bmi processes may be characterized by effectuation behavior effectuation is closely related with bricolage the term was coined by weick in organizational studies later adopted baker and nelson and ciborra in information systems field bricolage means good understanding of the resources at hand innovative good enough use of combinations of resources at hand to problems or opportunities and active selfcorrecting trialanderror make dobehaviour for example stenholm and renko suggest that the entrepreneurs passionate about developing their firms and inventing new solutions are more likely to engage in bricolage this involves creative manipulation of existing or available resources such as materials and financial resources to solve a problem at hand or to create new opportunities furthermore bricolage is a form of effectual reasoning of an entrepreneur to avoid the hazards embedded in the critical early stages of a new firm they conclude that passion for inventing and developing enhances entrepreneurs make do behavior and consequently indirectly increases the chances for entrepreneurial survival this is an addition to more rationalistic success factors by npd and bmi literature however there is mixed evidence on the effectiveness of bricolage for example in ciborras early study on a multinational hightech company bricolage helped it to adapt but simultaneously constrained its effectiveness to summarize many of the earlier justified criticism towards business planning business modelling and bmi has been alleviated in recent bmi techniques sarasvathys original effectuating entrepreneur resembles recent lean startup ideologies their main argument is that it is rational to bricolage and iterate because it eventually leads through an unpredictable groping process to rational goal lean startup emphasizes also effective and measurable outcomes like bmi does therefore effectuation and bricolage should be explicitly embedded in innovation effectiveness evaluation at smes summarizes the concepts of this paper and spans the framework of inquiry it links three potential drivers with three methods for innovating these are in turn accompanied with three market strategies eventually the decisions and steps taken are expected to influence performance which can range from failure to survival and success innovation drivers technology push technical evolution triggers or enables new ways of doing business as much as it does create new products often the starting point is basic scientific research or applied research and development in organisations these proceed through design and development into a product that can be manufactured effectively and economically and then sold on the market radical breakthroughs are more likely to be achieved through technology push market pull refers to the need for a new product or a solution to a problem which comes from the market these needs might be perceived by an entrepreneur for instance through market research which assesses what needs exist how far they are met by existing products and how the needs might be met more effectively by means of a new or improved innovation market pull more often leads to incremental innovations effectuation highly subjective approach where innovation starts from the capabilities and resources of the entrepreneur implementation npd product idea passes through a series of stages from ideation through design manufacturing and market introduction recent research suggests that technology push and market pull are complementary and necessary for npd bmi organization finance customer service and technology are main components of the bm change in one or several of these may result in business model innovation bricolage utilising the combinations of resources at hand to act on problems or opportunities selfcorrecting trialanderror make do behaviour market strategy highend strategy incremental improvements to the current products on markets lowend strategy provide a simple or low price solution offering good value for money new markets serve customers who were not previously served by existing incumbents performance failure the businessinnovation fails for instance the product is redrawn from the markets or business is in solvency or bankrupt survive the businessentrepreneur is hanging on or at high burn rate avoiding failure but not profitable success the business is clearly profitable research methodology and case selection we use multiple case study approach to analyse bmi effectiveness in five smes multiple cases serve as repetitions extensions and contrasts to the emerging theory and the researcher develops an understanding of why certain conditions did or did not occur and then offers interpretations data was collected by the authors of this paper and the other consortium partners in a multinational eufunded project the research collection follows a case study protocol which forms the basis for data gathering and case data repository this makes the data well structured and suitable for cross case analysis the protocol is available on request from the authors using subjective sampling we selected five sme cases with different performance outcomes under these outcomes we can first detect whether the drivers implementation approaches or market strategies are different for outcomes and then pursue explanations to the differing outcomes with the synthesized framework the cases are listed in table 1 in the appendix we describe and analyze the cases in more detail atelier started as selfemployed artist 12 years ago the entrepreneur was devoted to creating handicraft products by combining raw materials in novel ways despite the innovative products the production does not scale up visibility is hard to get and timing depends on fashion rather than on ateliers action the atelier had a store where she sells her products to tourists or locals looking for a birthday gift etc she also imitated the competitors by being present in facebook and in online store in 2015 she switched from a selfemployed person to an independent entrepreneur then she could hire a person to run the store and administrative matters unfortunately the sales could not to cover increasing costs the business was closed one year after she became an entrepreneur with company status and consequent legal obligations but already the same year she started experimenting with a new business idea related to remote life style coaching which she marketed in her facebook the case is typical case driven by effectuated entrepreneur and bricolage analysis everyone deserves plants is an sme initially established by a designer who had the vision to create a beautiful consumer product for cultivation of herbs inhouse with partner networksuch as researchers specialized in greenhouse cultivation the microsized startup company developed and recently patented worldwide its unique itcontrolled led light and growth system in parallel with npd they started using bmi tools to design and revise their business model and value proposition analyze the potential markets and to create user profiles this way they dared to abandon a fancy and fashionable mobile app for the users but their analyses proved that there were no markets for remote control feature the product is competing with other highend consumer products because there have not been direct competing products to increase its sales the company refocused its sales channel strategy from design shops to highend malls and warehouses in four years of operation the size of the company has been growing from four to 13 people thanks to its awarded and patented product the sme is attractive to the investors to raise capital but it has not been able to reach the planned turnover targets and is making loss scaling up the production is possible but the market is still emergingit seems the visibility of the product and timing of market entry are not optimal case c fresh natural air started from the idea of the founder who suffered from poor indoor air quality he wanted to improve the air quality by bringing part of nature inside ie living plants he started to build a green wall with a fellow university student who had both practical and theoretical knowledge on purifying water with ecological means the first prototypes were put together of plastic and vent duct tape simultaneously they were designing business models using bm canvas the challenge was to make the product look good and the plants flourish so they developed a remote sensing system with embedded sensors to measure the status of the green wall and its environment this data is analyzed automatically in a cloud software the adjustments to the plants growth parameters are fed back to the green wall at customers premises yet the system needs regular manual maintenance imitating benchmark companies from other industry sectors the sme decided to bundle allgreen wall remote control and maintenanceinto one service which it leases to btob customers right timing is hard despite the good visibility because the maintenance does not scale up well initially the target was new market entry but later they refocused on clean tech markets and have an alliance with a large air conditioning incumbent firm which could help in securing maintenance services in selected cities the personnel of the company has increased from 3 to 60 in five years it is making loss but has doubled its turnover for the last two years thanks to its iterative bmi and npd the sme is seen attractive by the investors event management service case d was established in 2007 by two cofounders they worked in hotel and travel business and found managing events a constant struggle with reservations cancellations detailed horeca 2 arrangements etc they were looking to find a service or product to help in this task but to their surprise they could not find neither affordable services nor suitable products so they started developing one for themselves in true npd sense in parallel they made a market survey that confirmed the existence of a niche market for automating of the event arrangement and management in businesses and public sector organizations the initial inhouse backoffice version was further developed to a webbased saas service for event management the market survey made them also known to the potential customers and their revised product got a flying start from the beginning the aim was to provide affordable service to cut costs of arranging events on the current market but they could also reach new customers that were not served by the existing incumbents nowadays the awarded service is available worldwide and runs constantly through npd iterations which ensures compatibility with customers information systems their initial timing was good product gained good visibility through the market survey the current implementation of the platform scales up well case d has grown during the last four electronic medicine dispenser case e established in 2003 is a hightech company with technologypush approach its innovative new dispenser service was expected to have pull from the market in addition to its main value proposition of providing improved dispensation safety and quality of medication to the patients it could promise cost savings to the hospitals and nursing homes the company is experienced in npd but in this case they used also bmi tools to support the process business modelling revealed that the envisioned product was not lucrative enough for one of the key partners in terms of business therefore case e decided to discontinue the development and instead focus its npd bmi efforts onto more potentially profitable and feasible products even though the dispenser service failed first companys partners eventually implemented a derivative design and brought it to market with smes major incumbent partner which is a visible actor with a credible reputation on the market sme is employing around 120 persons and runs profit their present implementation of the service scales up well and was synchronized on time with the incumbents product launch to gain momentum to us case e appeared least driven by effectuation but rather relying on npd combined with customer and partner network based bmi findings and conclusions researchers have observed that business model schemas are complex structural representations of the underlying activity systems as such they are also difficult to ideate from scratch due to the challenges of working out at once all the attributes and interrelationships comprising a complex system this means that ideation anchors to a known way of developing new products elements of a business model or available resources when met by changing circumstances this all is expected to depend on entrepreneurial effectuation therefore we expanded the concept of bmi with elements of npd effectuation and bricolage of entrepreneurs our framework also can depict the market strategies with profitability and sustainability we used the framework to analyze five case smes most of the case companies are awarded thanks to their innovative productservice andor business models too the case companies were established around 1015 years ago one of them filed in bankruptcy two are surviving along investors funding rounds and two companies are going strong most profitable business model has a scalable product that meets directly a customer need outside the customers core business bmi plays a minor role because the business has hit a sunspot from the beginning and is able to keep that position due to constant product updates in close development cooperation with their customer the other successful case innovated an idea which could scaleup by cooperating with its partners however they could not convince all partners to commit to the service at the first place even though the market was there the launch did not appear profitable according to business modelling bmi helped the company first to put the market entry on halt and then to reconfigure the fundamental idea with more powerful partners and reschedule the launch fast business modelling iteration seemed to be a key to successful adjustment to the market needs improving visibility and timing in addition to its originally good scalability survival cases business models both have a physical fancy product with extended itbased features and lucrative stories but their business models need constant revisions due to the bottlenecks in expanding to new markets with logistic linguistic and product related complications fast iteration is a necessity but contracting subcontracting and building the physical operations on various markets takes a time and a lot of entrepreneurial effectuation but the problems with scalability and timing persist finally the failure had highend sustaining product strategy improving the quality of the existing product and service by formalizing business however the sme did not survive on the market with that approach because it was accruing extra costs and losing entrepreneurial agility all the cases follow different paths of evolution and market strategies and in all survivor cases the takeoff has taken years even with the most successful of the selected case it hit a bullseye niche with npd thanks to its effective indirect premarketing for the clientele and has been able to maintain that position by iteratively cocreating integrated new features without losing its core product simplicity the need for bmi is marginal it is a textbook example of successful npd the companies that could create a viable business model can implement product and bmi very differently it seems that innovative physical hightech products take a long time to develop to a mature profitable business even though entrepreneurs know and iterate their business model regularly on the other hand the most profitable of the pack case d has a business that is virtual by nature builds on platforms and scales up to thousands of users by selfservice and has high demand in a niche market it shares some similarities with case e which used to develop a portfolio of new products at constant rate but later to direct their development efforts according to bm analyses towards most potential business prospects their business modelling thus articulated the product and business roadmaps in a way that they could be put aside for a while and rampedup in short notice as the opportunity emerged the cases show how effectuation has a strong influence in the initial stages of the innovation typically the idea for the business came from the life or work experiences of the founder what is remarkable in most surviving cases is that the companiesentrepreneurs learned to broaden their business thinking with bmi the initial mindset is productcentric many times with altruistic mindset of improving the lives of the people or their environment typically after the rounds of bmi they can improve timing and visibility of their products better to the needs of the markets however the problem of scalability with physical products remain finally in sme context the value of bmi is in iteration and as the means to identify and react upon exogenous changes the idea of combining npd bmi and entrepreneurial effectuation by bricolage seems to reflect the reality in the case companies mostly well it is also worth noting that bmi improves the entrepreneurs product and business development skills and helps to time innovations entry to the market bricolage the first prototypes were created of duct tape and some plastic boxes ndp the founders created the product first for internal use then offered it to markets bmi market analysis showed the lack of products on the market market strategy high end highquality unique products low end the introduction the term educational technology is defined as the study and ethical practice of facilitating learning and improving performance by creating using and managing appropriate technological processes and resources elearning webbased learning online learning and itbased learning are just a few examples for technological processes and resources based on information technology however it is a constantly evolving sector influencing many areas of all our lives thus education is changing since it allows for many new possibilities especially in combination with the playful approach to learning playful learning often also called edutainment is a recent trend in academic education which focuses on the handson practice of learning instead of on the sitandlisten approach spanning between free play and guided play in the digital economy there is a huge demand for skilled it workers not only in the it departments but across entire organizations this demand can be satisfied by a broad introduction of students to the digital world and further education in it skills early on additionally in todays society it has become a standard for students to have constant access to the internet and the immediate onthespot knowledge provision opportunities that are provided by it students use digital means to learn communicate access knowledge and for other professional application a case study involving undergraduate students in slovenia stated that 375 of the students reported to use the web frequently in more than half of their courses and 50 even stated that they always use web resources this trend in students behaviour can be observed growing rapidly in 2002 a case study involving 2054 students at 27 institutions of higher education across the united stated stated that 73 of respondents claimed to use the internet more than the library while only 9 said they use the library more than the internet for information searching thus our nowadays educational systems are facing both students with highly developed digital skills and the necessity to evolve the digital skills of students in order to support selfregulated personalized learning itbased learning approaches gain momentum in our digital economy as countless numbers of software projects for computers as well as for smartphones are realized with the goal to educate students on different topics the importance of digital mediums as a form of education is increasing and many academic researchers such as mcgonigal prensky gee fabricatore and pivec and moretti put increasing effort into the exploration and validation of teaching techniques using the playful approach as a core concept many of these playful approaches use handson and selfregulated or personalized learning as a medium to transfer knowledge to students and the usage of the selfregulatory processes has shown strong correlations with high academic achievement in all kinds of fields of education are widespread although the majority of them supplies no scientific results concerning a structure on how to implement such a playful teaching model thus this paper aims to fill this gap and hence to answer the following research question what would be a best practice for programming lessons by using a playful approach fullan asserted that the moral purpose of education is to equip students with the skills that enable them to be productive citizens when they finish their studies thus in the age of the digital economy improving the digital skills should be one of the topics students ought to learn in school trilling and fadel called education in information media and technology skills vital for the 21st century job market differentiating between the traditional education subjects and upcoming subjects such as information transformation and coding skills which are much needed in todays economy as the structure of a teaching approach is always to some level dependent on the subject and because of the dire state of the computer science education throughout europe we focus on the area of computer science with the special topic of learning how to program as a framework in which the structure is developed however the structure is easily transferrable to other school subjects as the core composition stays the same next to the success factors identified for teaching with a playful approach in heininger prifti seifert utesch and krcmar other factors also need to be taken into account concerning a successful implementation of a study course examples are the relevant curriculum and specific environment factors of the respective school or university the development of the structure will manipulate certain environmental factors as well as provide opportunities for the students to become motivated interact in class and engage with the content of the curriculum on a deeper level than in a traditional course in which the lecturer just transfers knowledge by lecturing the overall goal is to promote continuous passion and motivation to look beyond the box and to become interested in programming the ideal outcome would manifest in students wanting to code even if there is no extrinsic reason to such as good grades in school or any other rewards from the outside the development of the curricular structure and the structure of implementation targets this endeavor state of the art driven by rapidly advancing information technology many academic researchers have lately delved into the topic of different approaches to education the benefits and theoretical as well as practical outcomes of playful approaches in education have been 218 30 at high school universities and even at an us air force academy however scientifically developed and afterwards validated structures for implementation are rare and often not documented only simionescu and marian present a proposal for a change of paradigm based on a playful approach in course structures for efficient student evaluation in a previous research paper the success factors concerning the playful teaching approach were discussed and evaluated by conducting a literature review of the current state of the art with this contribution we aim at answering our research question by using these success factors as the theoretic part of the basis for our structure table 1 shows the five key success factors influencing the outcome of such an endeavor motivation integration and involvement in class the audiencecentred focus giving feedback and enhancing interaction and the fluent integration of the educational content into the gameplay the basic reason why people do anything the variation of individual differences the attitude behaviour and study practices integration and involvement selfinvolvement and active participation by students the shift from the passive recipient to an active integrated partner adaption to the audience specification of the target audience the adaption to the curriculum and environment the game shall be easy to understand and to play interaction and feedback formal as well as informal the individual response to the students difficulties the examination of different ideas and multiple perspectives integration of educational content into gameplay finding an application of the curriculum inside of a gameplay the balance of gameplay and educational content in a game method curriculum decision making is generally an iterative and lengthy process carried out by a broad range of participants and influenced by a wide variety of stakeholders cho noted on the same subject that the implementation of curricula is not an event but a longer change process following biggs and tang there are three levels of learning outcomes at major institutionsat the institutional level at the degree programme level and at the course level as we concentrate on the curriculum of a school our focus is on the course level learning outcome while the degree programme level is less distinctive furthermore we limit the computer science curriculum to the subject of learning how to program in order to be able to provide a clear and comprehensive structure van den akker and voogt noted that the curriculum should offer materials which provide concrete and illustrative elaborations of the general program as well as a framework for broad categories biggs and tang further remarked the importance and analysed the intended learning outcome for the student as it defines the goals of the curriculum based on this outcomebased learning concept by biggs and tang we will describe the current state of computer science curricula and point out some major design decisions for our curriculum in this chapter linking to a school curriculum many countries have adjusted their curriculum in the last years adapting to the changes of the digital economy which requires new skills however specific curricula are often set at state or city level not at national level an example outside of europe is new york city where a computer science course will be a graduation requirement by 2018 in europe many countries have begun to adjust their curricula as well but major changes are still awaited by both the industry and the academia austria for example requires a mandatory course devoted solely to computer science only in grade 9 teaching students about software hardware operating systems and data privacy slovenia offers a mandatory computer science course in grade 10 while offering elective courses in the grades 79 and 1113 teaching students about processing data computer networks and programming as well as algorithmic thinking and problem solving however in 2016 mori and lokar criticized the outdated slovenian computer science curriculum dating back to 1998 with minor updates in 2008 as well as the short duration of the mandatory course of only one year in germany the education system is mainly the responsibility of the federal states in 2012 only two out of sixteen german federal states had mandatory computer science courses free state of saxony in grades 7 and 8 and free state of bavaria in the grades 6 to 12 including topics such as introduction to software and hardware terminology basic concepts of information technology computer networks algorithms and data modelling however the curricula for the different types of schools in germany respective in each individual state are often vastly different and some of them do not teach about computer science at all in 2015 a survey with 1002 german parents stated that the majority considered the childrens preparation by the schools for the digital job market bad 5 even considered it very bad while only 32 considered it good and 3 considered it very good overall the changes in the emphasis lies on students learning to independently break a problem down into smaller parts and create advanced pieces of software the modulation of problems is explained with the use of procedures functions giving parameters and multiple usage of blocks of code knowledge about array data structures as well as objects of predefined classes are part of the curriculum as well the overall goal is to teach students about complex structures like loops and functions to give them the ability to differentiate between the use of procedural structures and functions object oriented programming is the last part of the computer science curriculum of the vocational schools in bavaria students ought to gain insight to how coding and handling objects work their ability to generate a solution creating functions based on problem is in focus the curriculum for objectoriented programming contains knowledge about classes and objects their attributes and methods as well as class instantiation the focus lies on the definition of classes and calling functions and attributes of the instances as well as handling the transfer of parameters this includes calling functionality in other functions as well as setting optional return values the goal is to teach students about well and systematically designed structures of classes and functionality to ensure their ability to solve complex problems and give them the tools to code on their own in the future at this point of our contribution we deem it important to note that the curriculum of vocational schools in bavaria will be changed in the near futurecomputer science will soon not be a mandatory subject anymore at all but rather a voluntary subject in grade 12 and 13 the content of the voluntary subject will also consist of multiple optional topics from which only a few can be taught as the course will probably not have the required length in order to cover all of them thoroughly choosing the programming language python the focus of an introduction to programming in secondary schools lies on giving insights into writing software and understanding the basics of programming the usage of languages developed for children which are based on graphical draganddrop handling seems to be missing the point in this endeavor choosing a programming language for beginners means not only considering technical aspects for instance run time efficiency memory consumption and reliability but must be evaluated even more concerning the difficulty of learning the language without prior coding experience furthermore there is the possibility of teaching an industry relevant language like java python and c or a language specifically designed to introduce programming to beginners in a case study ivanović budimac radovanović and savić note that the choice of programming language does indeed not affect the success of students in the course they also note that the main goal of the introductory programming course is to teach students essential programming concepts in order to develop their ability to think and solve problems by algorithms and to acquire newother programming languages and techniques efficiently this allows students to change to other differently structured programming languages later on if desired the language should have a simple syntax provide easy io handling as well as output formatting use meaningful keywords and give immediate feedback python offers many advantages concerning grammar and writing of code time wasting matters of style are avoided and indentation not only structures the code grammatically but also visually helps beginners to easily understand which block of code belongs to which functionality another advantage of python is its compactness and that unfamiliar code in python is usually easy to read choosing python as a programming language affects the curriculum concerning the time which must be allocated for specific concepts within the language as an example python is a language that most people consider easy to learn though it still finds use in big software companies like google python where we can c where we must and in games like eve online battlefield mount blade or civilization iv thus we consider python as an industryrelevant language unlike other languages proposed for teaching to novices python is not just a teaching language it is a language that is suitable for developing realworld applications an important goal of the python developers is making python fun to use as also can be noticed by the origin of its name while focusing on code readability extensibility and clear error message handling focusing on gaining insight into what it is really like to code and at the same time considering the shallow learning curve of python leaves us at the conclusion that python is a good start for beginners without prior coding experience results in order to clarify the developed structure we divide the topic into its three major components in this chapter first we will present the organization of the lectures which consist of four parts plan do check and act secondly we will draw up a timeline of the progress of the lessons tackling the curriculum apportionment and the general concept of introducing students to new knowledge in the last part of this chapter we will introduce the educational content the means of the playful approach and the main design principles for an educational game organization of the lectures the lecture optimally is held by an experienced teacher with previous experience in the playful teaching approach as well as extensive knowledge in computer science and coding computers with the preinstalled software are provided by the school but the students should still be encouraged to bring their own laptops in order to be able to take notes and to code in their own environment as they would back home on their own every school student should play and code independently in the first five minutes of each unit the teacher repeats the knowledge learned in the last unit combined with an outlook to what students are required to learn in the current unit and how it is connected to previous knowledge as the students will have progressed at different speeds and hence be at different levels of knowledge the repetition is based on their remarks and input the underlying idea is to not set a common learning goal for the students for each unit but to clear up eventual difficulties with previous contents the students themselves set interim learning goals during the course of each unit the teacher helps and coaches the students if needed the teacher does not need to approach students but let them work independently in order to give them the freedom to solve problems on their own the aim behind this endeavor is fostering their motivation selfvalue and to increase their confidence in their own skills a solution for a problem should not merely be offered by the teacher but be worked towards together the last five minutes of the units are for a short repetition of the current content in order to gather more information on the difficulties the students experienced and how they felt about the learning process while playing the game the students should use the time for selfreflection the teacher provides handouts for each stage of the game to give the students something tangible to study and base their learning effort on before the exam in order to keep track of the school students progress homework will be assigned to the students to ensure quality one of the underlying concepts of this approach is the plandocheckact cycle 1 of w deming as illustrated in figure 1 showing the general lesson structure the students will receive instant feedback on their code by the game the teacher should help if difficulties come up and the students cannot solve a problem based on the feedback of the game or do not understand the error messages by observing the students play the teacher will also be able to identify complications in the gameplay or during the execution of coding tasks lesson structure the length of each lesson is 45 minutes as it is custom in the german school system the time planned for computer science and more specifically to teach how to program are six lessons spread over the course of six weeks in the bavarian technical upper vocational schools the course is mandatory for the students most of which have no prior experience in coding in this chapter we explain the specific content of each lesson whenever possible concepts should be introduced completely and at once as an exception some concepts are initially introduced in a limited fashion and then revisited in a later topic for full coverage the lesson structure introduces the students to different concepts and knowledge about coding with a gradually advancing learning curve the content is structured to build on previous knowledge learned in earlier units and allows for a start without any prior coding experience the lesson structure is adapted to the curriculum set by the bavarian education ministry and the predefined situational and environmental circumstances in the school the course is divided into six individual units which are presented in the following and summarized in table 2 st unit students are introduced to coding and its use in our daily lives the educational game will be implemented and its controls will be explained beginning with small pieces of code the school student gains knowledge on how to handle the idle python gui editor to be able to solve tasks and experiment at home on his own basic knowledge about assignment of values to variables mathematical operators and output as well as basic data types including integers floats and strings nd unit the students learn about boolean values and conditional structures to give software the ability to react on different types of input the students learn basic commands to handle arrays and to calculate with boolean operators the goal is to deepen the knowledge about dealing with different types of output and data while introducing branching structures manipulation of arrays and decision structures based on boolean variables or by analyzing the input complete this chapter rd unit the third lesson will give a deeper understanding and further foster the ability to handle more complex data structures more commands in order to handle arrays are given such as sorting reversing inserting indexing and popping elements in arrays this will be combined with handling the forloop functionality iterating over arrays and building decision structures to connect the new knowledge to the 2nd unit are at the core of this repetition by connecting previously learned knowledge with complex tasks discover and close gaps in knowledge deepen the comprehension of the content th unit in this unit the students learn about repetitive use of code using methods and classes methods are introduced in a functional coding style and afterwards connected to classes classes will be used as a way to describe objects in a compact way and give functionality to them in order to change their attributes based on input and parameters as well as handling the interaction between classes examples of their use will be given and students are expected to add functionality and attributes to an existing class before creating a class on their own th unit this unit focuses on knowledge about classes while introducing new features involving multiple instances and parameter transfer as well as optional return values furthermore the whileoperator in connection with boolean operators and values will be introduced the emphasis of this unit lies on good systematic design of software to ensure readability and transparency of the code th unit the last unit holds no more additional new knowledge but means to give students the tools to code on their own in the future it combines previous knowledge of the first six units the students are given complex tasks in order to recognize potential in coding the goal of the unit is to discover knowledge gaps in order to help students repeat or deepen specific units in order to achieve full understanding of given code game features and educational content an educational video game is being developed with the single goal of connecting the curriculum with a game that is interesting and fun to play and simultaneously puts learning into perspective and gives incentive to learn more the students will be able to see that their own learning environment was created by using the same knowledge they will have at the end of the course furthermore by creating an educational game for learning how to code in a gameplay setting which resembles widely used and popular interactive development environments could incite the motivation selfesteem and knowledge in students to carry on coding on their own necessary features in an educational game can easily be derived by approaches to satisfy the success factors for the pla motivation integration and involvement in class the audiencecentred focus giving feedback and enhancing interaction and the fluent integration of the educational content into the gameplay main design principles for an educational game can also be derived from the iterative processes of conducting case studies by other authors and evolving and improving an educational game interaction and iteration of those interactions adaptive and personalized feedback clear winning criterion and no or few opportunities to cheat the game those criteria have been confirmed by another often cited study of educational games proposing practical steps for designing educational games a good game is easy to learn but hard to master meaning the handling of the basic game is easy but to be good at it becomes more and more difficult the further you advance the playful approach motivates the students to become more interested in their own education and willingly sacrifice time for it the game achieves this by students having to work for their knowledge by beating the game defeating numerous enemies and mastering obstacles a basic rule of good gameplay is to provide the player always with clear shortterm goals in an educational game this may mean partly beating enemies collecting coins and jumping over obstacles but also means solving coding tasks to advance in the gameplay beating enemies and collecting coins may obviously not have a direct impact on the students learning success but very well can create the joy and motivation to keep on playing and thus to keep on learning examples of collectibles for the sake of their own can be found in numerous games coins in the mario series spraying graffiti in gta san andreas or visiting viewpoints in the assassins creed series players often do not try to find all collectibles for the purpose of getting a reward but for the sheer pleasure of the treasure hunt after all games are supposed to be fun and not purely work conclusion based on former research concerning the success factors for teaching with a pla we were able to develop a lesson structure which shows the structures used for a playful approach to teaching the content is based on the curriculum for technology classes of the bavarian technical upper vocational schools as well as bavarian school norms however it can be transferred to other types of schools and curricula as well by customizing the proposed structure to fit different circumstances such as timeframe of a lesson length of course programming language and previous skill level of students the lesson plan can be especially useful to be implemented in different german vocational schools but also in other cultures as the structures core is based on outcomebased learning which was analysed and evaluated by biggs and tang and is used worldwide as a framework for good teaching and assessment the curriculum was adapted to python and its specific language constructs the development of an educational game as an exemplary playful learning approach would be based on the structure created and paired with the educational content of the curriculum the educational game as an electronic learning platform brings together practice teachers scholars and students in one environment we chose python as the favourable programming language based on its compactness and intuitiveness which makes it easy to learn and to use for beginners whenever possible concepts are introduced completely and at once as an exception some concepts are introduced in a limited fashion and later revisited for full coverage a professional teacher who is experienced in the topic of computer science optimally accompanies the lecture five minutes in the beginning as well as at the end of each lesson are used to repeat the knowledge of the last lesson respectively to recap the knowledge learned in the current lesson the use of an educational game as shown in this paper and the implementation of a playful teaching approach in a case study at a bavarian upper vocational school will be part of the research in the future in order to validate the lesson structure these merging technologies represent a considerable problem for standardisation they will require cooperation between standardisation entities with very different cultures from equally different backgrounds and used to very different technology life cycles while this is a general problem this paper aims to contribute to an answer to the question how well the ess is likely to fare in this increasingly important and complex environment is it futureproof and if it isntwhat needs to be done to change that the remainder of the paper is organised as follows in sect 2 a swot analysis is used to discuss the ess the resulting policy issues are addressed in sect 3 finally sect 4 presents a rudimentary roadmap and outlines some future steps that the ess might consider taking to overcome these issues the european standardisation system a swot analysis the swot analysis of the ess aimed at the identification and analysis of the major standardisationrelated issues in general and in the field of smart infrastructure and applications in particular tables 1 and2 show the outcome the tables show that both strengths and weaknesses of the ess result from it being a wellestablished longstanding system on the one hand good relations with policy makers and their international counterparts together with timehonoured processes have made cen and cenelec major players in many fields and entities to be reckoned with in addition a contradictionfree set of standards is a major asset yet such systems tend to become selfcomplacent for example until very recently the ess largely ignored the importance of private standards consortia in the ict sector a fairly recent european regulation eu 2012 certainly points in the right direction on this and several other aspects but it still remains to be seen how things will develop in practice specifically it is still unclear how the call for both greater speed and more inclusiveness can be answered in practice that said greater speed is not a desirable feature perse in particular supposedly longlived technologies like eg communication infrastructures may well benefit from a longer more thorough and less errorprone process that involves all stakeholders inclusiveness would be of special importance for smart applications where many stakeholders will be involved that are typically absent form normal ict standardisation moreover it remains an open issue how the contradictionfree system is to be maintained in the face of the likely wealth of consortium standards eventually used and referenced from the swot analysis it also would seem that there is a real risk of international marginalisation of at least cen and cenelec in the fields of smart infrastructure and particularly applications this is primarily due to • overly strong european focus if this focus leads to inadequate international links the situation will become worrisome this will hold especially if it occurs in a field where global standards are a sinequanon • limited activities on smart applications limitations materialise in two ways most notably cenelec focuses the majority of its activities on transposing iec standards into european ones secondly with the exception of its the smart aspects of applications have largely been ignored so far foci if any are on the underlying communication side the latter is all the more surprising as one of the ess strengths is its close link to policy making this could be exploited through new european standards setting activities that focus on the upper layers of smart applications here the associated governance aspects imply the needs for such close links between standardisation government and policy making unfortunately some of the perhaps less obvious issues that may nevertheless have potentially considerable longterm ramifications do not get the attention they deserve these include primarily the link between r i and standards setting and the education about standardisation a weak link to research may imply that important findings never make it into the standardisation process and that accordingly standards will be developed that do not take into account the stateoftheart as a result such standards will either not be taken up by the market or be very soon superseded by others inadequate education about standardisation may in the medium to long term lead to poorly equipped european standardisers in the international arena policy issues this section looks at some of the issues the ess faces or is likely to face in the near future this includes some general ones as well as a number of aspects that relate specifically to the standardisation of smart infrastructures and applications general european standardisation issues european standardisation still needs to deal with a number of issues that were identified already many years ago and have been discussed ever since but in several cases without a satisfactory outcome these include the need for speed in standards but speed is not a value in itself if it supports the timely production of a standard speed will be beneficial otherwise it may stand in the way of quality and completeness accordingly the popular unqualified focus on speed needs to be questioned in addition achieving both speed and inclusiveness is next to impossiblethe larger the number of interested parties around the table the longer it will take to reach consensus a casebycase balance needs to be struck speed must not be the overriding issue when it comes to eg standards for security and privacy in smart applications and inclusiveness must not be the showstopper for standardisation of eg interfaces to peripheral devices that is the necessary and desirable levels of inclusiveness and speed vary between standards see also eg sherif 2003 the link between r i and standardisation is another longstanding issue which also links to education about standardisation the european commissions recent joint initiative on standardisation ec 2016a is but the latest attempt to overcome the barriers that still exist between standardisation innovation and education and the respective communities its eventual outcome remains to be seen in any case without a closer integration of these domains neither policy makers nor industry will be able to reap the full benefits standards and standardisation offer close links between policy making and standardisation exist in the eu this is a bit of a doubleedged sword though on the one hand some standards are not so voluntary anymore if the producer does not manufacture in conformity with these harmonised european standards he has an obligation to prove that his products conform to the essential requirements ceu 1985 30 th bled econference digital transormation from connecting things to transforming our lives k jakobs emerging smart technologies and the european standardisation system 237 on the other hand these links may well be beneficial when it comes to the standardisation of smart applications where regulatory aspects may well play a role european smart applicationinfrastructure standardisation from a standardisation perspective the development over time in both the application areas and the infrastructural technologies show considerable similarities in all cases the complexity of the respective web of ssos has increased dramatically over the past 20 years as has the number of relevant entities within individual ssos the most notable proliferation of such entities could be observed for the past five to seven years with the exceptions of its and mobile communication where the development was more homogeneous and far less pronounced peaks occurred around 2005 and in the late 2000s respectively jakobs 2017 another similarity lies in the fact that in all cases but one the establishment of formal sdos predate those of consortia by decades overall it would seem that up to now consortia play a less important role in the development of smart applications and iotrelated technologies than they do eg in the mobile communication sector ict systems span the globe and by definition the associated standards need to be global as well the task of regional standards then is to introduce regional specifics into international standards while maintaining global interoperability alternatively some such regional specifics may find their way into international standards however both cases require dedicated regional standardisation activities against this background a look at the developments in europe yields a somewhat ambivalent picture on the bright side etsis activities on smart applications and particularly smart infrastructure through its smartm2m tc and its partnership projects are well positioned in the global context however the focus is on rather more lowlevel wireless telecommunication services on the other hand the eight cen technical committees identified as being active in the field of smart technologies in cencenelec 2016 focus almost exclusively on metering and do not really link to ict the iot or cpss the one exception is centc 294 however as the name suggests the focus here as well is on the communication system perhaps more notable cen has long been playing a prominent role in the its sector also covering more applicationoriented services apart from that however cen and cenelec seem to have adopted a laggard role with cenelec largely focussing on the transposition of international standards according to the rolling plan for ict standardisation ec 2016b cenelec works out methods for safe and secure communication protocols for wired and wireless industrial automation applications in the field of smart manufacturing ec 2016b yet this work as well has so far moastly been limited to the adoption of iec standards given the pioneering role that europe in general and germany in particular play in this field 30 th bled econference digital transformation from connecting things to transforming our lives k jakobs emerging smart technologies and the european standardisation system it seems a bit strange that such a leadership position should not be translated into indigenous european standards that could eventually be adopted by iso or iec in fact the apparent reluctance to play a more active role in smart manufacturing standardisation is also at odds with ec 2016a this document highlights europes long standing leadership in factory automation and that standardisation has an important role to play in helping european industry to secure this leadership the esos coordination groups on the smart grid smart meters and smart and sustainable cities and communities respectively have so far been more policy advisory entities rather than actually active in standards setting with respect to the iot cencenelecs standardisation activities are limited to the field of automatic identification and data capture where a newly formed wg addresses iot related issues in this context the lack of any approach towards truly multidisciplinary standardisation is worrying it is also surprising since the european commission has identified the need for such an approach in ec 2016b the document calls for multidisciplinary standardisation in several application areas including smart grid and smart cities given the almost frantic activities that are going on at the international level this seemingly rather restrained european approach appears a bit odd in fact it is in stark contrast to the recommendations made already in prose 2011 while these recommendations relate to the field of embedded systems they are equally valid for the standardisation of the iot and smart applications the relevant ones read recognise the need to value standardisation and to take leadership of standardisation recognise the need to cooperate on standardisation across competitive boundaries and to reconcile and manage the differences that presently inhibit such cooperation invest in the efforts required to bring about standardisation allowing staff the time and support to bring about longterm benefits invest in people and rtd in order to feed the technology pipeline that provides the basis for standardisation the above recommendations should be applied at least to those sectors where europe has assumedor aims to assumea leadership position technologically andor in standardisation specifically this holds for the its sector where cen has been leading the way for a number of years now likewise existing strengths in smart manufacturing should be exploited in the standardisation arena this section aims to deepen these insights by identifying actions potentially to be taken by the esos to meet external challenges fig 1 shows the underlying framework in an environment characterised by uncertainties a roadmap offers a visual representation of alternative paths towards a strategic goal or a vision here the overall goal is a global standardisation environment within which the esos play a central role in the standardisation of a smart communication infrastructure and smart applications to this end a number of external influences have been extracted from a literature review a survey8 and the swot analysis they are depicted in fig 2 along with the associated actions to be taken to adequately address them and to eventually make the vision a reality it would appear that two already ongoing trendsstrong asianchinese participation in standards setting for smart applications and infrastructure and the need for truly interoperable implementations may well imply a further reduction of the esos international importance the same holds for the possible trend towards allip networks this is hardly going to happen anytime soon but may well be expected in the medium term the same holds for a wider deployment of cpss and of smart applications given the current fragmented standardisation landscape and the infancy of the associated standards setting activities these developments are a unlikely to be aligned and b likely to deploy proprietary technology however this may increase the need for interoperability and thus for international standards this in turn would represent an opportunity for the esos if they managed to position themselves as relevant players in the meantime figure 2 a very rough roadmap for smart standardisation fig 2 shows that the esos do not always play the role they could play in the standardisation arena for smart infrastructureapplications the swot analysis revealed a number of issues that need to be addressed these issues fall into three categories • limited relevant activities this has two dimensions for one not all relevant technical areas are covered by the esos moreover especially cenelec frequently limits its activities to the transposition of iec standards into european ones • inadequate international interconnectedness while very good links exist to the esos respective international counterparts the same may not be said for private international standards consortia • process aspects this refers to limited links to relevant research activities to the equally limited activities in standards education to the disregard of implementation aspects and to the lack of multidisciplinary standardisation these weaknesses will be discussed in the following limited relevant activities of the esos a number of gaps in the esos standards setting activities may be identified in the realm of smart infrastructureapplications for one with the exception of etsis smartm2m group hardly any activities are to be found this comes as a bit of a surprise since both cen and cenelec have been venturing into the field of communication systems and for the smart grid moreover a smart infrastructure is the basis for all smart applications similarly the activities relating to smart cities are in their infancy at best given the necessary tight integration of standards activities on smart applications on the one hand and a smart infrastructure on the other it would seem that joint eso activities in the smart realm are called for how exactly such joint activities may look like would have to be discussed joint cencenelec entities have already been established an extension of this concept to also include etsi should be considered this would on the one hand strengthen the expertise on the communication side and support multidisciplinary and integrated standardisation on the other along similar lines do the virtually nonexisting global standardisation activities for cpss represent an opportunity for europe research in this field has been going on for quite a while now in europe this accumulated knowhow could be used as basis for european standardisation activities also eg through a tc managed jointly by all esos the other issue relates to the fact that in many cases cenelecs main activity seems to be the transposition of iec standards for example in the field of smart manufacturing almost all but ten standards passed by clc tc65x originated from the iec it certainly makes sense not to unnecessary duplicate any work however the thought of cenelec standards solely being based on iec documents for both its and the smart grid is a bit worrying after all there are european specifics most notably in the highly regulated field of the smart grid specific european boundary conditions may also be assumed for eg smart cities a higher level of autonomy in these fields is called for inadequate international interconnectedness the focus of both cen and cenelec is clearly on europe this is not a bad thing perse for an eso nevertheless cen and cenelec together have so far established links with only four international organisations that are of some relevance for the standardisation of smart infrastructure and applications it may be assumed that this isolation also contributes to the fact that regional standards bodies importance in the field is seen as either limited to the identification of specific regional requirements and the associated adaptation of global standards or is questioned altogether jakobs wehrle 2017 as a first step links to relevant noneuropean players should quickly be established through formal cooperation and coordination mechanisms process aspects a number of rather diverse aspects fall under this heading for one the need for education about standardisation has been highlighted by several sources 2016a has commenced after initial difficulties its outcome remains to be seen moreover links between standardisation and research innovation need to be improved this issue has also been on the agenda for quite a while now both the interest interest 2007 and more recently the bridgit project bridgit 2014 made a number of similar recommendations on how to bridge the gap between standardisation and r i in unison they highlight the need to increase awareness on both sides and to mutually promote and educate likewise incentives need to be offered to researchers to spend resources on standardisation activities this should be of relevance for research funding organisations for the esos this would include adapted or new processes that are more researchfriendly ie shortlived cencenelec workshops and etsis industry specification groups are certainly steps in the right direction however their usefulness is limited by the fact that no mechanism exists to feed their output into the standardisation process proper taking the various recommendations made by the two projects on board would definitely help improve the situation not unlike their international counterparts both cen and cenelec stay clear off any implementation aspects the situation for etsi is slightly different their plugtests represent at least a step towards taking implementation issues into account in any case 30 th bled econference digital transormation from connecting things to transforming our lives k jakobs emerging smart technologies and the european standardisation system 243 the success of ssos like the ietf and the w3c may to no small part be attributed to the fact that they consider implementations and proven interoperability as part of their respective standardisation process it seems highly unlikely that cen and cenelec will change their stance on implementations nevertheless at least for the ict sector steps ought to be taken to provide the market with what it needsinteroperability perhaps a new entity that develops andor certifies interoperable implementations might be a way forward the lack of multidisciplinary standardisation is another issue the need for such a new way of setting standards for the field of smart infrastructure and applications has been corroborated by survey respondents in jakobs wehrle 2017 a standards setting platform jointly managed by the esos has already been suggested above such a platform would have the potential to kill two birds with one stone on the one hand it would help improve the level of the esos involvement in the international standardisation of smart infrastructure and smart applications as the european expertise from the different relevant fields would likely be concentrated on this platform it would also contribute to the goal of multidisciplinary standardisation a third bird would be the fact that such a major hub of standardisation in the smart field could also attract other ssos to enter into cooperation agreements such a platform would allow experts from different backgrounds and from several ssos to meet and to address inherently multidisciplinary standardisation problems introduction hardly a day passes without reports of largescale attacks against it infrastructures launched by internal and external perpetrators these attacks frequently result in the unintentional disclosure of confidential information and proprietary data previous research on the economic impact of it security breaches on affected firms focuses on realized unsolicited disclosure of information and proprietary data however we argue that it is equally likely that stock markets punish firms for creating the mere possibility of a data theft this is because of a diminished trust in the firms capabilities to protect sensitive data with adversarial effects on future sales and thus its stock price which resembles the discounted value of expected future dividends thus within this study we examine the overall research question of the impact of potential it security breaches on stock prices we draw on information boundary theory to investigate our research question specifically we study the impact of the heartbleed vulnerability within the widely used cryptographic library openssl on the value of 4147 publicly traded firms openssl is used to secure connections in computer networks and was enabled on approximately twothirds of all webservers worldwide when heartbleed was publicly announced examples of affected services include facebook instagram google search gmail youtube yahoo search yahoo mail and dropbox our exploratory findings reveal a timedelayed response of stock markets to potential it security breaches as well as a discrimination among firms operating in different industries the remaining portion of this paper is structured as follows section two provides background on related research privacy theory as well as our research model section three provides information on our research methodology section four presents the results of our study and discusses its implications section five concludes the study background and research model research on realized it security breaches as summarized in table 1 previous research can be largely divided into the impact of data security breach announcements on firms and vulnerability disclosures on software vendors 30 th first results regarding the overall impact of security data breach announcements are mixed while some authors find negative cumulative average abnormal returns of publicly traded firms stock prices ranging from 058 to 317 over shorthorizon event windows below 10 days others dont for example numerous studies find limited evidence of overall abnormal price effects but strong evidence for discrimination among firm and event characteristics campbell et al finds no evidence for an overall effect but strong and statistically significant support for negative effects of security breaches that involve unauthorized access to confidential data exemplary for evidence of discrimination among the type of firms are hovav and darcy who find a statistically negative caar of internetcentered firms only and ettredge and richardson who find a negative caar of internetcentric firms second software vendors that created vulnerable products were negatively affected and experienced a caar of 063 associated with the announcement of a vulnerability within their products and services in summary previous research focuses on the impact of realized it security breaches however little research exists on the question whether stock markets punish firms for creating the mere potential to breach their it security heartbleed vulnerability on april 7th 2014 the existence of heartbleed a vulnerability within the cryptographic library openssl was publicly announced heartbleed is the result of an improper implementation of the heartbeat extension research model to study potential it security breaches the concept of privacy is considered to be of undisputed importance to societies of modern economies and has been studied for centuries however grasping the concept of privacy is cumbersome because of its manifold definitions acquisti et al notes that attempts of precise definitions of privacy oftentimes remain ambiguous changing with the perspective of the observer a view that is shared by introna and pouloudi nevertheless in a landmark paper called the right to privacy published in 1890 by warren and brandeis the authors reasoned that the concept of privacy gradually evolved over time to the right to be let alone this view is still reflected by modern definitions with the notion of privacy as freedom from the judgment of others acquisti et al defines a privacy incident roughly as a failure of mechanisms designed to protect personal information of customers partners or employees from threats of technical managerial organizational or human nature the heartbleed vulnerability thus represents an it security related privacy incident ibt is the result of a research program to investigate the impact of monitoring and surveillance technology on the perceived privacy of workers xu et al describes ibt as an explanatory framework that allows for studying social impacts of information disclosures ibt states that people possess unique physical or virtual informational spaces these spaces are limited by clearly defined boundaries attempts of external entities to cross these boundaries might be perceived as an intrusion into the informational space the extent of this perception is dependent on situational and personal conditions according to stanton and stam ibt represents the synthesis of three separate constructs first the communications boundary management theory second the group value approach to organizational justice third a general expectancy valence framework for privacy protection ibt is comparable to attempts of moor the case of openssl heartbleed 249 reasoning that the unifying feature of privacy incidents is the violation of certain expectations about how data will be handled xu et al show that ibt can be applied in an information privacy context to describe the formation of an individuals privacy concerns table 2 distinguishes two groups of firms by the overall news the public announcement of heartbleed conveyed to firm stakeholders group a includes firms that were protecting their webserver by a vulnerable version of openssl allowing for the exploitation of heartbleed group b covers firms that were protecting their webserver with an unaffected ssltls solution research hypotheses set h1 deals with the overall impact of potential it security breaches within group a and b and is based on ibt we hypothesize that firms within group a experience a reduction in shareholders equity value approximated by freefloat stock prices at the time of the public announcement of the heartbleed vulnerability primarily because we assume that the announcement induced a reassessment of firm stakeholders regarding the risk of unwanted information disclosure this reassessment may result in a change in outcome from an acceptableto an unacceptable risk as suggested by the ibt this outcome is primarily driven by an increased perception of privacy intrusion induced by heartbleed in other words stakeholders experienced negative news and responded with a decreased willingness to provide confidential information which ultimately decreases business opportunity of affected firms this reduced ability to conduct business will decrease future revenues and ultimately the amount of dividends a firm is able to pay out ceteris paribus and assuming that stock prices are primarily determined by the present value of expected future dividend payments this results in a decrease in stock value the resulting research hypothesis in which negative stock market reactions refer to falling share prices is explicitly stated as h1a negative stock market reaction in group a around the public disclosure of potential it security breaches additionally we hypothesize that group b firms experienced a positive effect on shareholders equity valuations at the time of potential it security breach announcements especially because the knowledge that the firm was not affected by heartbleed despite being protected by ssltlsmay lead to a positive outcome of the reassessment of the risk of unwanted information disclosure this in turn attracts new 250 30 the case of openssl heartbleed business opportunities through stakeholders which previously assessed the risk as unacceptable furthermore it is likely that stakeholders of group a switched to group b after assessing the risk of group a firms as unacceptable which again results in an increased ability of group b firms to conduct business thus and under the same assumptions regarding the effect on future dividend payments introduced in the last paragraph this should result in an increase in the stock price of group b firms h1b positive stock market reaction in group b around the public disclosure of potential it security breaches ibt states that people construct personal informational spaces within boundaries thatamong other thingsdepend on the nature of information in question we assume that firms in different industries process different types of information of which some are considered of greater importance than others to the overall riskevaluation process of firm stakeholders for example firms in the communications or financial services industry may process more confidential information than firms in the materials sector thus we hypothesize that there are industry specific differences in the outcome of the reassessment of the risk of unwanted information disclosure which in combination with the reasoning of the last section yields the second set of hypotheses h2a existence of industry specific differences in negative stock market reaction of firms within group a around the public disclosure of potential it security breaches h2b existence of industry specific differences in positive stock market reaction of firms within group b around the public disclosure of potential it security breaches methodology event study design event studies are commonly used to examine the effect of specific events on the value of firms while mackinlay broadly defines event studies as using financial market data to measure the impact of a specific event on the value of a firm others developed a more narrow understanding and note that event studies examine the behavior of firms stock prices around corporate events in event studies the timeline is divided into the estimation window the event window and the post event window returns are indexed in event time t where t0 represents the event date returns prior the event date are typically indexed with negative integers relative to the event date at its core event studies assess the effect of an event on the performance of a security in the event window by subtracting the expected return of a security from actual observed returns to get abnormal returns and subsequently the case of openssl heartbleed 251 aggregating these over time andor securities thus the estimated abnormal return it of a given security i at time t can be written as 𝐴𝑅 ̂𝑖𝑡 𝑅 𝑖𝑡 𝐸 where rit represents the actual observed expost return and e the exante normal return with xit as the conditioning information of the normal return model two predominant normal return estimation models are the constant mean return model and the market model in which xit is the market return that is the same for each security i but changes with t the market model rit αiβi rmtξit linearly relates the return rit of a security i at time t to the return rmt of market portfolio m at time t with disturbance term ξit that exhibits an expected value of zero and variance σ 2 parameters of the market model are the intercept αi and the slope βi of security i which can be empirically determined by means of ols regression using estimation window data the abnormal return it of security i at time t within the event window using the market model can then be estimated as 𝐴𝑅 ̂𝑖𝑡 𝑅 𝑖𝑡 𝛼 ̂𝑖 𝛽 ̂𝑖𝑅 𝑚𝑡 where α iand ̂ are ols estimators of the market model event studies typically deal with more than one security and event windows that span over multiple days abnormal returns are therefore aggregated to draw overall inferences of the events impact on returns which can be done across time across securities and both across security and time the cumulative average abnormal return of n securities over a timeperiod within the event window spanning from ta to b can be written as 𝐶𝐴𝐴𝑅 ̂ 1 𝑛 ∑ ∑ 𝐴𝑅 ̂𝑖𝑡 𝑏 𝑡𝑎 𝑛 𝑖1 empirical research indicates that stock prices are not normally distributed this is typically addressed by using nonparametric tests when analysing abnormal returns of a single day however problems arise when nonparametric tests are applied over multiple days on a car basis thus kolari and pynnonen the case of openssl heartbleed event day clustering additionally grank often has good or higher empirical power when compared to highly popular parametric tests such as the ordinary ttest or bmp ttest this holds true for event windows of any given length therefore we rely on grank in the following economeric design table 3 summarizes the econometric design of each event study designed to put research hypotheses sets h1 and h2 to test and are repeated for good and bad news firms the event of interest is the public announcement of the heartbleed vulnerability within the cryptographic library openssl on april 7th 2014 the market model with daily close prices was chosen for estimating the normal returns first because gains from more sophisticated multifactor models such as capm and apt based as famafrench3factor over statistical models are limited second the market model is slightly less affected by crosssectional return correlation in the presence of eventdate clustering than the famafrench3factormodel the estimation window length to estimate the regression coefficient is 200 trading days which roughly equals the mean of 52 papers including event studies in is research originally compiled by konchitchki and oleary three different event window lengths covering 3 13 and 23 days respectively are applied the shorthorizon event window of three days complies with the econometric reasoning of superiority of shorthorizon event windows by konchitchki and oleary the mediumand longhorizon event windows are designed to capture potential information leakage prior to the event and delayed stock market reaction and act as a robustness check overall impact hypotheses set h1 is concerned with the overall impact of potential it security breaches on stock prices of publicly traded firms table 5 presents empirical results by providing caars and results of twotailed nondirectional grankt tests over short medium and longhorizon event windows the null hypothesis tested by the tgrank test statistic states that there is no mean effect while the alternative is that there is a mean effect the case of openssl heartbleed 257 in the latter two cases at the 10 and 5 level however figure 2 reveals that firms in the group b performed better relative to firms in group a industry specific differences h2a predicts the existence of industry specific differences in negative stock market reaction of firms within group a around public disclosure of potential it security breaches results presented in table 6 seem to support this prediction most industry specific caars in the shorthorizon event window are of no statistical significance according to the twotailed grankt test however firms operating in the consumer discretionary and health care industry experienced caars of 143 and 259 which are significant at the 10 and 5 level respectively interestingly when looking at the results of the mediumhorizon event window the statistical significance of the effect on firms in the consumer discretionary sector vanishes instead the caar of 49 of firms in the communication sector becomes statistically significant at the 1 level in addition the effect on the health care industry becomes significant at the 1 level with a caar of 655 in the longhorizon event window eight out of ten industries experienced an effect of statistical significance at the 10 level ranging from caars of 947 to 44 h2b predicts the existence of industry specific differences in positive stock market reaction of firms within group b around public disclosure of potential it security breaches table 6 indicates that there is little support for this prediction in the shorthorizon event window as only the caar of 140 in the consumer discretionary sector is of statistical significance additionally there is little support for the predicted positive effect as the vast majority of industry specific caars is negative in the mediumhorizon event window three industries experienced a significant effect with caars ranging from 314 over 391 to 882 in the longhorizon event window these negative effects increases even more in addition the negative effects within the consumer discretionary and financials sectors are statistical significance 1997 first regarding the efficient markets assumption we assumed that people are both able to find and make sense of publicly available information while easy to find it is possible that firm stakeholders were unable to make sense of it due to the technical sophistication of the heartbleed vulnerability thus even if large investors were aware of the problem they may have concluded that other stakeholders were not and assumed no reevaluation of the risk of unintentional disclosure of private information would take place second event anticipation is unlikely as search query data of google and wikipedia revealed no interest in heartbleed prior its public disclosure third it is not possible to control for confounding events when analyzing a sample of 4147 firms however effects are likely to be wiped out due to the large sample size and are especially unlikely in the shorthorizon event window where the economic calendar provided by econoday reveals no event window contaminating news typical additional issues of event studies are the sample size the identification of outliers the length and justification of the event window and further explanation of abnormal returns because of the large data sample explicitly defined outlier return thresholds theoretically justified event windows and research hypotheses these should not pose a significant issue next to these limitations future confirmatory studies must examine comparable large scale it security issues where a multitude of firms are affected conclusion and outlook this paper provides empirical evidence on the global impact of potential it security breaches on stock markets thereby it enhances the understanding of the full economic impact of information privacy measures by shedding light on previously neglected hidden costs by drawing on ibt research hypotheses are developed and put to test by means of multiple large scale event studies covering 4147 firms headquartered in 43 countries first our exploratory study indicates that stock markets react with a time delay to potential it security breaches second we provide evidence for a discrimination of firms operating in different industries therefore this work extends the understanding of consequences of jeopardized it security by adding a previously neglected hidden cost component to information privacy considerations future scientific research in this field could investigate additional determinants of the discrimination of stock markets between potential and actual it security breaches introduction the emergence of new technologies has changed the nature of work since the early 1980s in two ways firstly the ongoing transformation has an impact on work relations and lead to an increase in nonstandard work arrangements secondly even within standard work relations the organization of work is undergoing a significant change resulting in new ways of collaborating with stakeholder groups inside and outside of organizations although the changed nature of work relations is the driver for the phenomena coworking the focus of this paper is not on the rise of the freelance or gig economy but on the question how traditional organizations deal with the new work scenario coworking and how they integrate it in the portfolio of existing ones it is thereby of particular interest in which ways their usage scenarios are different from the ones of freelancers and microbusinesses and how the collision of the two entities in these third places could be beneficial for both since coworking is a rather new phenomenon it is not yet elaborately discussed in the academic literature this is even more the case for coworking from a companys perspective where only few articles exist eg ross ressia who look at coworking as an alternative for homebased telework in the public and private sector the focus of this article is however not on the potential for replacing a work scenario but on adding it to existing ones the changing nature of work remote work scenarios are not new it was the first oil crises in 1973 that helped telework and telecommuting to its triumph however todays highly mobile and connected digital nomads have little in common with these early teleworkers who completed work outside of the office in an isolated manner supported by stationary computers fixed telephones and fax machines the emergence of mobile devices cloud computing as well as social software is drastically transforming the way in which companies conduct work and organize collaboration today work is no longer tied to a time or place which makes the assignment of all employees to a fixed space obsolete science to rethink existing models and assumptions the focus of this article is however not on new forms of employmentwhich have beyond doubt been the catalyst of the whole coworking movementbut the question which value proposition coworking offers from the perspective of established firms while working alone together is one of the main promises for freelancers and microbusiness coworking spaces only represent an alternative work scenario for established firms at least in a shortterm view the relevant question from their standpoint is therefore how these third places will complement the existing work scenariosin contrast to freelancers and microbusinesses who chose coworking as primary work location these user groups have been subject to various studies in the last decade the key question to expand the existing studies on coworking is therefore what is it for whom as this definition focuses strongly on ideologic goals the definition has limited validity from a companys perspective based on the accurate overview of the most important aspects of coworking provided by bouncken and reuschl the following own definition shall be used in this article the emergence of coworking coworking spaces are neutral places where affiliated and unaffiliated professionals work side by side or in collaboration the spaces are used by individuals teams or other crossorganizational groups during a specific project phase or for an unlimited period in addition to other work scenarios or exclusively the most significant difference between coworking as envisaged by freelancers and microbusinesses in the early years and companies who only started developing interest recently is the community aspect whereas participating in an active diverse community is for most companies an important benefit it is not an exclusion criterion as the present field experiment suggests coworking also offers attractive opportunities from a boundary management perspective where the benefit of individual flexibility is more important than mingling with others and fostering accelerated serendipity coworking is far more than a hype as a look at the growth rate since 2005 confirms according to deskmag both the number of coworking spaces and members continue to grow rapidly by the end of 2016 11 300 coworking spaces and 835 000 coworking members were counted worldwide thereof 70 in switzerland where the experiment took place not included in these numbers are coworking spaces and seats offered by companiesit can be expected that the number of corporate powered workspaces will also rapidly increase as can for example be seen in research methodology this research was undertaken with two main goals the first was to understand the value proposition that coworking offers from the perspective of companies who operate corporate offices but are interested in alternative work scenarios in addition to the existing ones the second was to identify different usage scenarios and based on these to derive insights how companies can integrate this new work scenario in the existing ones research was done in an exploratory way as both the subject coworking and in particular the perspective of established companies is relatively new in the academic literature and not all relevant aspects are yet discovered indepth semistructured qualitative research interviews were conducted this methodology was chosen as the focus was on understanding the new scenario from the point of view of the participants of the field experiment study participants the basis for this study is a field experiment in which voluntary participants of two swiss ict companies 9 from the smaller and 16 from the bigger one took place during 4 months the 25 volunteers were asked to try out coworking no specifications were made regarding the expected frequency of usage the combination with existing work scenarios or the visited coworking spaces they could choose from over 100 coworking locations within switzerland 8 the participants were informed about the project via social intranet email facetoface discussions with their managers and an optional kickoff event as all participants volunteered the group was very heterogenous and consisted of members from different teams and with different job profiles most of them were in marketing or sales roles all participants came from a company and team culture where it was normal and accepted that work was also done outside of the corporate office or the clients facility except for two participants all were employed with a fulltime contract they varied quite strongly in their degree of mobilityabout half of them still had their personal desk the others worked with a shared desk concept with or without a clearly assigned home base some of them had already been in coworking spaces but no participant was experienced with coworking as the boundaries between mobile knowledge workers and more stationary knowledge workers are blurring no further distinction regarding degree of mobility was made during the four months field experiment a few interventions were made as the utilization of the coworking spaces was on a very low level from the beginning the interviews were done at the end of the experiment data collection the study is a qualitative inquiry based on semistructured interviews with 25 participants of a coworking field experiment the interviews were mostly done in person in meeting rooms provided by the respective employer a few were done via skype prior to the interview the interviewer briefly explained the most relevant facts about the field experiment and the focus of the study this information was already provided in written beforehand in the process of recruiting the voluntary participants the interviews were audio recorded and transcribed they ranged in length from 40 to 65 minutes and were conducted in german or english the interview protocol was openended with the goal to get a detailed understanding of the persons work disposition as well as of their experiences with the new work scenario coworking data analyses data analyses was done based on the exploratory grounded approach chosen as methodology for this study the audio recordings of the interviews were transcribed imported in to atlasti and coded in an open way based on the first interviews the interview guidance was slightly adapted however after 15 interviews a certain saturation could be remarked where no new themes related to the core focus came up the usage scenarios personae and recommendations were done based on the interviews and an extensive literature research on coworking and new work scenarios from the perspective of companies findings the findings are presented as follows first the insights into factors that were analysed by means of the semistructured interviews are presented in the form of a general evaluation it is then followed by the identified benefits and obstacles of coworking from the perspective of companies which is derived from the interviews in combination with literature research general evaluation  utilization the most surprising finding of the coworking experiment was the low utilization figures on average the participants went 29 times in the coworking spaces within the four months and spent 36 hours per visit there it can be expected that the utilization would have been on an even lower level without the interventions which reminded the participant of the project whether the low utilization was based on the short experiment duration the low eagerness to experiment or the schedules of the participants which did not allow for more time spend in coworking spaces was not inquired  perception of the experiment despite the low utilization the general feedback of the participants towards the project was throughout positive most of them interpreted the pilot project as a sign that their employer not only tolerated working outside of the office but also invested in new ways of working  individual productivity a small majority stated that they were more productive in the corporate office compared to the coworking spaces it is noteworthy that most of the participants who said they were most productive in the coworking space do not like to work from home it might be interesting to do further research on the question in which ways the personal boundary management strategies and the individual coworking use cases are interlinked since all participants used the coworking spaces for individual work and not for team collaboration only the individual productivity could be observed the results of the study might be different if whole teams use coworking space  individual creativity the participants rated the corporate office followed by the home office as the location where they were most creative coworking only ranked as third given that coworking spaces are often referred to as creative hubs at least from the perspective of freelancers and microbusinesses it was surprising to see that the corporate workers did not choose them as preferred location for creative work nonetheless mentioned a small majority when asked that they had gained new impulses in the coworking spaces be it by meeting new people or stumbling across new ideas some interviewees attributed the lower creativity to the fact that they did not have whiteboards flipcharts or other or other visualization tools available in the coworking space or they did not want to transport them after use to continue working with them  use of technology all interviewees stated that they used the same communication and collaboration technologies as they use in the corporate office at home or when working mobile what was different was the amount of time they spent in calls compared to the corporate office a lot of participant went to the coworking spaces especially to make calls or to conduct virtual meetingsthis was in particular the case when they were traveling the whole day and tried to use time inbetween external meetings in a productive and way this usage scenario coworking as a filler for productivity conflicts with the original purpose and focus of most coworking spaces which is to bring people together and not to foster undisturbed work and retreat besides the disturbance by noise or the fear of disturbing others when doing a call in the open space zone the participants raised concerns regarding data privacy and protection  online and offline community management belonging to an active community is one of the main reasons for freelancers and microbusinesses to engage in coworking one aspect of the interview was therefore whether this element was also looked for by the participants of the experiment when asked about contacts with other coworkers in the space the majority reported that they were hardly any exchanges with others although most of them did not actively look for new encounters they saw in networking and informal exchanges with new contacts a big advantage of coworking compared to other work scenarios some interviewees mentioned that they would plan their coworking journey differently in the future eg having lunch with the community participating in local events or blocking time for informal discussions instead of spending the whole day in virtual meetings or working rigidly through their task lists most participants were in contact with the coworking host for the checkin procedure however they did not notice any community management measures such as an active introduction to other members professional coworking chains such as wework offer also a virtual community management platform which is mainly used to communicate with the members or to facilitate the exchange between the members the project team in charge of the field experiment set up a group on the enterprise social platform yammer which could be accessed by employees of both participating companies the goal of using an enterprise social network was to facilitate the project coordination between the project leads and the participants but also to enable networking amongst the participants for example to coordinate physical meetings in the coworking spaces despite the users familiarity with enterprise social networking the group did not attract any interest from the participants and was not used except by the project leads to share background information about the experiment in the beginning benefits and obstacles the following table aims at summarizing the gained insights by listing the most important benefits of coworking as well as the perceived obstacles from the point of view of obstacles of coworking relevance mitigation possibility of retreat the interviewees were missing separate spaces for calls and virtual meetings because of their spatial separation from internal and external stakeholders this is an obvious need however it showed at the same time that most of them did not adapt their behaviour and work schedule to the new space concept during the observed phase despite the positive attitude towards the new work scenario a lot of interviewees mentioned their fear of increased coordination efforts within the team and the organization some of them mentioned that complexity was already high because one fraction of the team was always traveling or working from home this concern raised the question whether the reduced face time for formal and informal interactions within the organization would not lead to a decrease of team productivity connectedness and identification with the organization the introduction of new work formats should be well accompanied by corresponding measures and team discussions team chats and enterprise social platforms can support the coordination equipment of space and workplaces whereas about half of the experiment participants expected to have the same equipment available in the coworking space as in the corporate office the other half was indifferent most appreciated the variety and used what was there coworking spaces should actively communicate about their equipment to facilitate the selection of the right space other important success factors mentioned by many interviewees as important requirements were the network quality and ease of access a simple booking and billing process for the coworking hours consumed the geographical location and the proximity to public transportation as well as good quality of coffee as these factors do not differ from the needs of freelancers and microbusinesses they were not in the focus of the study coworking personae based on the interviews and literature research the study author tried to identify different poles of usage and expectations and grouped them into different personae the goal of the personae is not to identify a distinct behavior but to visualize the different needs which in turn allows to build different coworking journeys the personae might also be 274 30 helpful when it comes to discussing different situational preferences and spatial needs in the corporate office a similar attempt to classify the different users was done by bilandzic foth who distinguish in their studies about coworking in libraries between those who use coworkingspaces mainly because of the offered infrastructure learners who use coworkingspaces to acquire knowledge and have an exchange with peers and socializers who search for recognition and acknowledgement figure 3 coworking personae as figure 3 shows the interviewees diverged most regarding the two following axes  connectedness are coworking spaces primarily used to get access to a community or to dissociate from the teamoffice or familyhome  disposition are coworking spaces primarily used to get inspiration from the different space and community or with the goal to increase of efficiency eg bridging time between meetings discussion the duration of the observed experiment was a rather short period when it comes to analyzing the acceptance and embedding of this new work scenario into existing ones it is above all too short to observe the changed behavior based on new interpretations of coworking which in turn will also lead to new interpretations of the corporate office home office and mobile work orlikowskis practice lens addresses changes in technology use over time where users may deliberately or inadvertently use it in ways not anticipated by the developers these new interpretations lead to new work practices and as these work practices change interpretations of the technologys function change too it would therefore be interesting to observe and discuss theses multiple interpretations and associated changes in work practices over a addressing these different expectations and perceptions and dealing with the multiple interpretations over time as mentioned is an important management aspectwhen companies want to benefit from new work practices they also need to assume responsibility for the organizational learning process one concrete example is to address whether it makes sense to go to a coworking space when the agenda is fully booked with calls and virtual meetings the measured utilization figures are also an interesting point of discussion whether they were so low because the pilot duration was too short or because the participants schedules did not allow much time for experimentation or if they preferred working from home or on the road instead of discovering new scenarios is unclear the conclusion that they were not interested in coworking or that it offers no value to companies falls short also with regard to the very positive reactions they expressed in the interviews conclusion the biggest consensus amongst all study participant was reached with the question whether they would like to trade in their corporate office for coworking none of the interviewees opted for this scenario most of them mentioned the importance of their office as center of gravity andor identification part of this reaction can be explained that they were scattered to over 100 locations and participated as individuals not as teams in the pilot project one element which came out clearly in the study is that networking serendipitous encounters and informal knowledge exchange with other members do not come for free in coworking spacesit needs concrete measures if these benefits are the main motivation for companies to invest in coworking these findings are in line with other research eg parrino who showed in two case studies that colocation does not automatically lead to interactions and knowledge exchange between individuals both the focus of the coworking space as well as the policies that promote interactions amongst members are decisive factors that determine whether interaction and knowledge exchange takes place similar findings are presented by spinuzzi who differentiates between good neighbours and good partners depending on whether people just work side by side on their own projects or collaborate in a more intense way the interviews also highlighted the relevance of the work and leadership culture for the successful adoption of new work scenarios introduction during the past years individuals and healthcare sector have become increasingly interested in measuring and promoting various aspects of wellness and health by using different technological solutions although different technological solutions for personal wellness have been around for quite a while the whole business field of wellness technology is still at a relatively unmature stage and rapidly growing there is a wide variety of products ranging from exercise and wellness applications to activity trackers and versatile sport watches in the market and completely new solutions are released constantly typical to these devices is that they can be used for selftracking purposes the findings of miyamoto et al suggest that tracking wellness related data alone may result in heightened awareness of daily activity but it may not be adequate to sustain the use of wellness technologies which often have low retention rates wang et al found that a wellness application is more effective the more frequently it is used and more effective when used over a longer period of time compared to shortterm use such reports and findings demonstrate the growing need for studying the usage of these technologies regardless of the business field it is essential to understand as much as possible about the target audience studying consumers motives and habits is important to deepen the understanding about their desires and needs there exists a wide variety of user characteristics within the wellness technology users and different target groups have different set of requirements as wellness technologies are ever more used there is a growing need to deepen the understanding on their users and thus it is important to research them to gain new understanding on this matter the purpose of this study is to deepen the understanding of how people use and perceive wellness technology in their everyday lives besides the many aspects regarding wellness technology use itself the focus of the study is also on how wellness technology gamification is perceived and whether it motivates people in their wellness related activities third point of interest is how people think integrating wellness technologies into their lives is seen by other people and how these thoughts might influence their wellness technology usage in general the main research questions studied in this paper are 1 what kinds of feelings do wellness technologies and their use wake among their users 2 how do people experience gamification with wellness technology and how does technology support gamifying 3 how do people perceive other peoples views on their wellness technology usage and gamification the term wellness technology is used as an overall term for different kinds of technological health wellness and sports related solutions that people use in their the results of this study can help the wellness technology providers in deepening their understanding on wellness technology usage and in providing solutions that are better welcomed by their target audiences the findings may also assist people working in the healthcare sector in implementing different wellness technologies for health and wellness related purposes the paper comprises of six sections introduction theoretical background methodology results conclusion and finally the limitations and future research section theoretical background motivation and wellness technology the actions and behaviours of individuals are influenced by observations on how other people act according to banduras social cognitive theory observational learning and social experience play an important role in peoples personality development and in the development of their selfefficacy selfefficacy refers to ones own belief in ones own capability to do a task which in turn affects their motivation to attempt that task people with high selfefficacy feel a task more attainable and less difficult and trust their abilities to perform it whereas people with low selfefficacy might perceive a task as too difficult and may be less motivated to perform it according to ryan and deci motivation can be divided into intrinsic and extrinsic motivation intrinsically motivated people perform activities such as exercising just because of the pleasure of doing it whereas more extrinsically motivated people do the activity because they see it as a tool of gaining something else they are interested in such as competition prizes from a race or acceptance from their peers a person who does not have any motivation to perform a task is considered amotivated there has been a substantial interest in the role of wellness technology to motivate people to be more physically active or to adhere to physical activity guidelines as this research finding suggests that the main motivation for the increase has to be based on personal and intrinsic motivation and it can be strengthened with technology the reasons why different kinds of wellness technologies are acquired seem to vary previous research has shown that the usage intentions of different solutions can be driven by both utilitarian or hedonic perceptions gamification and exercise motivation gamification refers to the use of game elements in nongame contexts the common purpose of gamification is to motivate users to behave in desired ways by making the user experience more playful and enjoyable implementing gamification has become very popular in various different contexts as the utilization of gamification has grown it has become a subject of growing interest in academic research as well kari et al proposed recently that a division should be made between the process of gamification and the experience of gamification kari et al define the process of gamification as using a set of activities with the aim to implement game elements to nongame context and the experience of gamification as a use experience in nongame context that the user perceives as gameful commonly the process of gamification aims to create an experience of gamification for the user yet the experience of gamification can also arise from nongamified features in this study the focus regarding gamification is especially on the experience of gamification gamification can be an efficient approach to influence user behaviour and use of an application it can also have a positive impact on motivation in general but differences occur between different solutions elements and also between individuals in the context of wellness technology these individual differences can be traced to such personal characteristics as attitudes towards sports technology exercise habits and competitiveness different people also experience gamification in different ways overall the experience of gamification can influence a users exercise motivation positively a recent study shows that the relevance of gamification in wellness domain will continue increasing methodology this study followed a qualitative approach it can be defined as a diary study based on phenomenographic approach phenomenography is a research method originally developed by ference marton phenomenographic studies are usually based on textual data eg transcribed interviews essays or diaries in the research setting of this study user diaries were selected as data collection methods diary study was selected as the method because its ability to provide more authentic information on humantechnology relationships and technology use in situ as the socalled presentation effects are diminished the voluntary participants for this study were recruited from a list of participants from an earlier study they had expressed to be available to participate in research related to sports and wellness technology the goal was to get 15 to 20 participants for the study to recruit the participants during late 2015 invitation email to participate in the study was sent out to 50 potential participants out of which 35 replied out of those 35 who replied 22 signed up for the study no restrictions were placed regarding the participants as the goal was to reach varying kinds of participants however all the participants were from finland the participants were asked to keep a diary of their wellness related technology usage and perceptions for six weeks they were also asked to provide basic demographic information on a separate sheet all the participants received an information letter in which the central termswellness technology and gamificationwere explained the participants were also given instructions regarding keeping the diary they were especially asked to focus on three different aspects in their diaries and write down opinions thoughts feelings experiences and perceived effects regarding 1 wellness technologies and their use 2 wellness technology and gamification and 3 perceptions on other peoples views on ones own wellness technology use and gamification they could choose how to keep the diary themselves all the participants wrote it electronically the participants were not given any strict time limits regarding when the sixweek period should take place the return dates of the diaries ranged from december 2015 to february 2016 after the sixweek period the diaries were returned electronically to one of the authors out of the 22 participants four dropped out during the study as a result diaries were received from 18 participants this can be considered to be an adequate amount for this qualitative study to analyse the data thematic analysis was used this analysis method is often used especially when researching matters of common everyday life since it provides practical answers to the research problems it is also the most widely used analysis method of qualitative research and enables organizing and describing the data with rich detail the actual data analysis was guided by braun and clarke following their suggestion the guidelines were adjusted to fit the research subject and the data thematic analysis was used to identify analyse and report patterns within the collected data the analysis started with familiarizing oneself with the data and marking all the interesting features of it the data was then divided into three different themes for each individual the themes were as follow 1 wellness technology use and perceptions in everyday life 2 wellness technology and the experience of gamification and 3 perceptions on other peoples views regarding ones own wellness technology usage and gamification after this all three themes were separately studied by examining all the participants answers under that particular theme and searching for similarities and differences these were then reviewed in relation to the data the analysis also aimed at interpreting specific aspects and exceptions of the investigated matter finally the report was produced as braun and clarke propose the analysis process was a recursive and nonlinear as it moved back and forth between the different phases of analysis results in total the study had 18 participants four of the participants were male and 12 were female the age of the participants ranged from 18 to 70 and the average age was 396 years more detailed description of the sample can be found from the appendix wellness technology use the wellness technologies used by the participants varied from activity trackers and heart rate monitors to smart scales and step counters as well as different mobile applications related to wellness and physical activity few also reported the usage of exergamesdigital games requiring aerobic physical effort from the player or other gamified applications the most common reason for acquiring a device or an application was to get more accurate data on personal exercising or health data that is not only based on own feelings gps features were also considered as important by many participants most participants liked how they were able to get varying and interesting data with the help of wellness technology many were using the technology to control their exertion level during physical activity either by checking that they were not training with too high intensity or that they were training with intensity high enough wellness technologies were also considered to have motivational elements since they provided a reliable tool for setting goals most of the participants reported that wellness technologies had positively affected their motivation by enabling them to see and compare their own exercise data seeing longerterm improvement regarding exercise some participants reported they were intrinsically motivated to exercise and for some of them using wellness technology did not bring any extra motivation some participants reported wellness technology being able to increase their motivation during their more active exercise periods however when they feel less physically active using wellness technology and seeing your own data could actually decrease exercise motivation respectively some reported that when things are going well the information from the technology makes one happy but when things are going badly the information from the technology can be annoying for some participants wellness technology also had some educational effects such as learning more about training intensity calorie consumption and heart rate levels and being able to better compare objective data to subjective feelings this kind of learningeffect could also lead to discontinuance in using the technology as it was felt that the technology could not provide any new or interesting information some participants raised the question about the reliability of wellness technology they highlighted the fact that their devices sometimes do not work properly participants found this annoying since they would rather focus on their own performance during the exercise than thinking whether their device works at that moment some participants also emphasised that people should not always blindly trust the information received from wellness technology since the information is never completely individualised for them some participants were also reluctant to value wellness technology data and its accuracy over their own feelings some were commenting that why can exercise be considered hard only then if the result is proven by a sport watch the most common negative remark about wellness technology was related to technical problems that occur during exercise for some this might even bring the feeling that the exercise has gone to waste if the heart rate monitoring stops working during exercise i want to throw the device into a rubbish bin another case when technology might bring negative feelings is when people forget to take it along to their exercises or when some wellness application does not work on a specific device some participants considered sport watches to be so big in size that they did not want to use them during any other time than while exercising which limited their usefulness in tracking other everyday wellness related activities such as sleep or general activity while some participants felt it was easy to wear wellness technology devices others felt wearing them was uncomfortable and sometimes even pointless for example when transforming our lives t kari e kettunen p moilanen l frank wellness technology use in everyday life a diary study their training focus was on strength training instead of aerobic training in other words the willingness to use technology was also partly associated with the conducted activity or sport few participants reported that keeping a log of their own exercises was hard work with or without the help of wellness technology some also emphasised the fact that some wellness technology devices and applications are too difficult to use for one participant tracking exercises created too much stress about exercising and therefore woke the need to stop using all devices several participants associated wellness or sports technology use with hard and intensive training with set goals they did not consider themselves as athletes and therefore did not see why they would need to use or how they would benefit from using wellness technologies some of them were afraid that adding new technologies to their exercise routines would take some of the fun away by making it more goal oriented and strict subsequently decreasing the intrinsic motivation to be physically active the study also included four participants from the young elderly age group ie 6075 years of age studying the young elderly age group is deemed important as they are a growing and a very large group of individuals with a rising need for different digital wellness solutions bearing in mind that the study only had four participants from this category the data supports this notion by carlsson and carlsson as all the young elderly participants were using some sort of technology to support personal wellness however among the young elderly the polarisation was quite apparent at its simplest the technology used by two participants was restricted to just a blood pressure meter or an electronic scale whereas the other two were using sports computers with their various features and electronic training diaries interestingly only one saw age as any kind of limitation regarding the use of these technologies wellness technology and the experience of gamification almost all participants who were using wellness technology reported they were comparing their own previous health and exercise related results to their current ones to keep track of their development and fitness level this data was often received from a sport or wellness technology device some participants reported they compared their old and new data also to see how their technique had developed this kind of comparison also seemed to wake experience of gamification however when it comes to sharing data in social media or comparing own data with other peoples data the situation was different most participants felt their exercise data is personal few participants compared any of their data with family members data or to other peoples data that can be seen for example in some web service only those participants who did some level of competitive sports more constantly compared their results or data with their training partners considering this it seemed that the experience of gamification rather comes from comparing own data with own data than comparing own data with data from others an exception to this seems to be different voluntary physical activity when participants explicitly reported about the type of gamifying they do they also most often referred to comparing their own results with their own exercise history and data with the help of some technology some participants set a goal to reach enough daily activity to walk or run the same route with a faster pace than before or to be able to maintain a lower heart rate than in previous runs strength training was also reported to be something where the gamified aim is to reach the next level more competitive exercisers reported gamifying by comparing their own training and race results to previous ones or trying to improve their own scores in competitions or lap times during training some participants reported to challenge themselves by tracking their weight on a regular basis one participant reported using a gamified application to drink enough water overall different technologies were regularly mentioned to support these gamified activities considering the motivational effect many participants reported that this kind of gamifying brought extra motivation one participant described that the activity tracker reminds a tamagotchi with the need to feed it and keep eye on it on a regular basis few participants were also using gamified applications or doing geocaching which as an activity is all about integrating technology into exercise by adding extra gamified elements into regular hiking walking or running session for these participants having the gamification element made them venture further and visit different places exergaming was also mentioned as a one form of exercise among the young elderly the participants reports were similar most commonly the experience of gamification came from comparing own current data with own previous dataoften with the help of some technology this was also considered motivating and an enjoyable means to support reaching personal goals one also mentioned occasionally playing exergames it seemed that some people also engage in a sort of selfgamification which can be defined as a desirebased action to gamify some recurring activities or bodily functions pursuing the experience of gamification by selfgamification could begin as nontechnical but later on some technology was implemented to support the gamifying perceptions on other peoples views of wellness technology use most of the participants neither shared their wellness related data with other people nor felt the need to tell anybody that they were tracking their wellness some felt exercising was their own personal thing and no one elses business and some were reluctant to show their results to anybody because they felt other people exercise more and have better results some believed that no one would be interested in whether or not they track their wellness or exercise because it is considered so normal these days some had the 288 30 perception that many others usually view tracking as too difficult or time consuming and therefore not worth doing some reported that other people had asked them about their use of the device they were wearing some participants were even a little bit ashamed of their exercising and results one participant was worried to be seen as too oldfashioned if anybody knew about the habit of doing exercise with an exercise video another participant reported to be sure other people would consider geocaching to be a too childish hobby some applications also seem to have a negative image and people were not eager to admit they were using such application one such example was a calorietracking application which was associated as a tool for overweight people one participant felt embarrassed to wear a sport watch due to feeling concerned to be seen as an athlete by others even though being just a regular exerciser in badminton it can be embarrassing to wear a sport watch since my opponent is better than i am it makes me feel i take this too seriously i try to start my watch in a way that is as unnoticeable as possible the perceptions were similar among the young elderly if anything they seemed to feel even more strongly about not wanting to share their own personal data with other people they also believed that their friends would not be interested in their own data respectively they reported to be very uninterested in the data of their friends even though there were more negative perceptions regarding other peoples views on personal wellness technology use a few participants reported they felt proud and got extra motivation when other people saw them doing something different and positive such as running or using a wellness technology conclusion the purpose of this study was to deepen the understanding of how people use and perceive wellness technologies in their everyday lives the focus was also on related gamification and perceptions regarding other peoples views a qualitative diary study based on phenomenographic approach was conducted the study included diaries from 18 participants who kept diaries for six weeks regarding their wellness technology usage and related issues the most common reason for acquiring a wellness technology was to get more accurate and objective data motivational effect was also an important factor behind acquiring one based on the data it seems that the use of wellness technologies can positively influence wellness motivation for some a mere buying of a device brings additional motivation but for the majority being able to follow personal progress by receiving objective data and that way comparing own results to previous results is the key motivational factor this implies that it would be worthy for the designers and the parties aiming to increase in general wellness technologies can help people to learn more about the level of physical activity and training effects regarding the finding that a learningeffect could lead to discontinuance in using the technology it demonstrates that even if the user would stop using the technology it does not necessarily mean that the technology or its use would have been a failure but instead a success in a way of being able to teach the user the things he or she wanted to know this was an interesting new finding and something to consider for example when investigating the retention or use continuance with these technologies and also is in general the biggest concerns the users seem to have are related to the situations where the device stops working during an exercise or for some reason does not record the entire exercise session properly for some this may even be a reason to stop exercising therefore to achieve longerterm motivation for some people it would be better to use devices and applications they are already familiar with both users and those promoting wellness should acknowledge this another concern was related to wearing a wellness device such as a sport watch whereas some described wearing one to be perfectly easy and normal some reported not feeling comfortable wearing one outside exercising or sometimes not even when exercising this obviously limits their usefulness in tracking other daily wellness related activities thus these devices should be designed as ubiquitous and as easytowear as possible also acknowledging the look of the device and the different user groups regarding gamification the most common type of gamifying seems to be comparing personal results or data with previous personal datausually with the help of some technology this kind of comparison also seemed to wake experience of gamification which in turn was reported to influence motivation positively it also seems that some people engage in selfgamification which we define as a desirebased action to gamify some recurring activities or bodily functions interestingly pursuing the experience of gamification by selfgamification can begin as nontechnical but later on be supported by the use of some technologies in general including a gamification element to wellness related activities seems to bring extra challenge motivation or even make the activity as more enjoyable thus people struggling with their wellness motivation could try selfgamification or some gamified technological wellness solutions the designers should undertake the process of gamification for example implement their devices and application with gamified features the societal parties working with wellness promotion might be able to increase the effectiveness of their interventions with gamification with the exception of more competitive individuals most participants did not feel the need to share their training data with other people since the information was generally considered personal some were also concerned how other people view their wellness technology use this implies that the marketers of these solutions could benefit from 290 30 making it seem that the use of these devices is common and socially acceptable among their target audiences regarding the young elderly experiences of gamification were similar with people of other ages compared to others they felt more strongly about the personality of their own data and felt it to be uninteresting to others regarding the usage in general there seemed to exist polarisation among the participants these findings support the call made by carlsson and carlsson about the need and importance of studying the habits and experiences that the young elderly have with digital wellness solutions this study provides interesting insights into peoples everyday use of wellness technologies the results assist the scholars and wellness technology providers in deepening their understanding on wellness technology usage the developers can utilize the findings in providing and marketing solutions that are better welcomed by their target audiences the findings may also assist people working in the healthcare sector in implementing different wellness technologies for health and wellness related purposes limitations and future research there are few limitations to the study that should be noted first studies concerning wellness and exercise behaviour at some level have been known to include the challenge that research subjects may intentionally report their behaviours as more positively than in reality thus biasing the responses however the participants of this study were emphasized that the wellness and exercise behaviour itself are not relevant regarding the study but rather the experiences and perceptions regarding wellness technologies and their use the intention of this was to minimize the possibility that participating in the study would lead the participants to intentionally change their behaviour second the study was based on the diaries from 18 participants although providing a great amount of information the amount of data should be considered when assessing the results of the study especially so in regards with the young elderly as there were only four of them one should also consider the femaledominance in the sample third the level of detail in reporting in the diaries varied between the participants despite these limitations this study provides some highly valuable new insights into the subject future research could collect diary data from a longer time period and focus on possible behaviour changes regarding wellness behaviour and the usage of wellness technologies future research could also repeat similar research with particular focus on some specific user group for example the young elderly or athletes overall the whole area of wellness technology usage continues to be an important topic of research activity trackers and other wearable devices have been found to bring a variety of benefits for their users for example hagströmer oja and sjöström found that objectively obtained estimates of physical activity yielded different activity patterns and lower values compared to those that were obtained by selfreports this shows that wearable devices often provide more accurate data compared to selfperception and therefore serve as more reliable information source when planning and executing health behaviour change programs kari et al found that using a mobile exercise application can enhance the awareness of personal physical activity and motivate towards being more physically active moreover activity trackers could have even more potential in increasing the amount of physical activity as suggested by kari et al yet it seems that the perceived increase in wellbeing would require a long enough use period for the user to notably perceive any changes a mere tracking of wellness related data may result in increased awareness of daily activity but may not be sufficient to maintain the use of wellness technologies the use of wellness related technology is also more effective the more frequently it is used the intention to use such devices is mostly based on utilitarian reasons but also hedonic perceptions play a role obrien et al evaluated the utility and feasibility of activity trackers among older adults and found that most users experienced positive outcomes they also suggested that activity trackers could be useful in improving older adults health by monitoring and promoting physical activity as the popularity of activity trackers is growing tremendously there is an increasing need to conduct more research on their use these kinds of investigations enable a deeper understanding of the influences activity trackers have on peoples behaviour much of the prior research has concentrated on the feasibility of individual solutions rather than the human aspects such as psychological and social variables for companies producing wearable devices or using the devices with their clients sustained consumer engagement has been named as one of the key challenges to achieve sustained consumer the aim of the study was to investigate how using an activity tracker can influence participants physical activity behaviour and motivation it was not the aim of the study to encourage participants to increase or change their exercise behaviour in some way rather it was to investigate how the activity tracker influences their exercise behaviour the main research questions of the study are 1 do activity trackers influence fitness centre members gym attendance and overall physical activity level 2 do activity trackers influence the fitness centre members awareness of their physical activity and health related issues 3 do activity trackers have a different influence on members with different lengths of membership history or personal trainer members the activity tracker used in this study was the polar loop by polar electro finland the group using an activity tracker is referred to as the loop group the study includes 100 fitness centre members divided into a test group and a control group both groups were also divided into three subgroups old new and personal trainer members considering the claimed benefits and the rising popularity of wearable activity trackers the results of this study can benefit several stakeholders the new knowledge it provides can have theoretical implications for scholars as it increases our understanding on the usage of these devices the study can also provide practical implications for exercisers manufacturers fitness centres and those working with physical activity promotion theoretical framework motivation and physical activity motivation can be divided into intrinsic and extrinsic motivation selfdetermination theory is a major component in the discussion of intrinsic and extrinsic motivation and physical activity selfdetermination consists of three psychological needs autonomy competence and relatedness autonomy refers to the need to be selfinitiating in the regulation of personal behaviour competence represents a persons need to interact effectively within their environment and relatedness reflects the persons need to feel connected to other people the feeling of these needs can separate or together facilitate intrinsic motivation the most common motives for getting involved with physical activity and exercise are extrinsic factors such as improved health improved fitness or weight loss however although extrinsic motives act as catalysts the focus can often change between initial adaptation and subsequent adherence this change also applies to the change in the level of selfdetermination from nonselfdetermination to limited to moderate and finally to full selfdetermination this study included participants who had different membership periods old members were defined of having been going to the gym for more than 9 months and new members had been going to the gym for less than 2 weeks therefore it can be assumed that old and new participant groups might have different levels of selfdetermination and differences in their types of motivation goal setting techniques have been used extensively to enhance motivation and adherence and to improve performance studies conducted in exercise settings showed that 99 of participants set multiple personally motivating goals for their exercise participation these goals were perceived as influencing actual exercise behaviour and helped people acknowledge what exercise behaviour is needed in order to meet their goals goal setting also helps people maintain their exercise program and keep up motivation to maintain their level of activity goal setting can therefore be seen as a way to maximize effectiveness in reaching exercise and physical activity objectives the most effective goals in exercise settings tend to be flexible goals that people have set for themselves according to abraham and michie there are various behaviour change techniques all of which have different positive aspects the key is to find the right technique to apply in the correct setting and with the target group techniques promoting specific goal setting selfmonitoring of behaviour review of goals and performance feedback are considered to be effective health behaviour change interventions tend to be more effective if they are firmly connected with a health behaviour change theory participants were not asked to set any specific goals for themselves however polar loop users were asked to set their activity tracker to a setting that best fit their everyday life this affected the daily activity goal provided by the tracker even though loop group members were not asked to try to meet the daily activity goals the activity tracker can still be seen as a goal setter by giving people a target for how physically active they should be according to their set activity level transtheoretical model of health behaviour change most health related behaviour change programs have concentrated on negative behaviours such as alcohol consumption smoking or obesity rather than focusing on increasing positive behaviour such as physical activity and exercise the transtheoretical model has been applied to many health behaviour programs in this study the transtheoretical model was used as a theoretical background for designing the questionnaire participants selfevaluated their current stage in becoming more physically active before and after the 10week test period however it is important to remember that 10weeks is a short time to make any real changes between the stages and therefore the results concerning behavioural change should be interpreted with caution according to banduras social cognitive theory there are different reasons why people might need outside help in order to better reach their set goal firstly people might have lost their means to reach their desired outcome secondly they might think that a third person is more capable of facilitating the achievement toward the desired outcome finally people may want to give control over to somebody else because they want to shift the responsibility of the direct control in an exercise and physical activity setting the use of proxy agent often a personal trainer helps a person to manage environment and task demands as well as gives extra help in regulating and controlling exercise behaviour developing new skills and helping in lifestyle management having a proxy agent also provides a person social support which increases positive outcomes this can lead to greater likelihood of experiencing full involvement focus and enjoyment methodology study design and data collection the study follows a quantitative experimental design the study was carried out among members of a fitness centre located in finland the study consisted of two main groups the test group and the control group the loop group members were given polar loop activity trackers and h7 heart rate sensors in the beginning of the test period whereas the control group did not receive these devices after the study the loop group got to keep their devices and the control group were also given loops as a reward for participating the two main groups were further divided into three subgroups old members new members and personal trainer members participants were recruited via the fitness centres email newsletter all club members were allowed to apply for the study and the first 100 suitable candidates were selected and randomly split into the loop group or control group both groups had the same number of male and female participants from the 50 participants in the loop group 25 were old 13 were new and 12 were pt the loop group was asked to create a polar flow account which made the training observable for research purposes data was also collected from the fitness centres visitor database which recorded all the fitness centre visits participants did during the 10week test period in addition a questionnaire concerning the members perceptions regarding their own health and fitness and the possible changes the 10week test period had on them was collected from the participants before and after the test period the questions were identical both times the questionnaire included questions regarding current physical activity sleeping time daily sitting time and awareness regarding their own overall wellbeing the participants could also give feedback regarding their experiences during the study period after the study ended in the results section the experiences concerning loop are reported the full questionnaire is available from the authors by request in total three different data sets were used 1 one obtained from polar flow service which showed weekly activity goals based on the activity level set on the device and how well these goals were achieved 2 one obtained from the fitness centres visitor database which was used to compare the loop group and the control group as well as their subgroups to see whether there were differences in physical activity measured by gym visits 3 one obtained by the preand poststudy questionnaires which was used to investigate the changes in the perceptions of the participants data analysis the quantitative data from polar flow and the visitor database was analysed with ibm spss statistics 21 the data from the questionnaires was transformed into numeric data and also entered to spss for further analysis means age range and frequencies were computed in order to obtain the basic information of the test group this was followed by next the analyses concentrated on the first measurement which related to gym visit activity an independent sample ttest was done in order to test differences between the loop group and control group here the independent variable was the group and the dependant variable was the number of average weekly fitness centre visits within the 10week period the same test was also done to compare the subgroups between the loop and control group when testing differences within the loop group or control group the test method was oneway anova the same method oneway anova was also used in measurements concentrated on loop group weekly activity percentages and their development here the independent variable was the subgroup and the dependent variable was the weekly average activity percentage within the 10week test period the last phase of the spss analyses was done by using repeated measures manova to test for differences before and after the 10week period among groups results the tests of normality were conducted to investigate normality for the main variables average gym visits and average activity percentages the normality tests were done after dividing the data into different subgroups results for the kolmogorovsmirnov test for normality indicated that average gym visits were normally distributed within old subgroup due to the smaller sample sizes for other subgroups the results from the shapirowilk test were more appropriate these tests indicated normal distribution in all subgroups gym visits and activity percentages regarding the amount of gym visits ttest was done in order to investigate differences between the loop group and control group no statistically significant difference was found but it can be seen that the average visit amount for the 10week test period was higher with the loop group compared to the control group new members gym visits it was the opposite within both pt and new the loop group average gym visits were higher than in the control group 100 measurement means a user has achieved that goal it is also possible to exceed the weekly goal and have a measurement higher than 100 no statistically significant differences were found between loop subgroups in weekly activity percentages similar to gym visits all loop groups experienced a slight decrease in weekly activity percentages during the test period however the decrease was larger with gym visits when comparing different loop subgroups the decrease in activity percentages was strongest within old whereas within pt and new groups the decrease was almost nonexistent figure 2 loop group activity percentage and gym visit trends pearson correlation test revealed that gym visits and activity percentages were positively correlated questions that participants answered based on their own subjective feelings there were no statistically significant differences in the results of the questionnaires but some trends were seen participants were asked how active they perceived being before and after the 10week test period the overall trend was that participants felt they were more physically active after the test period the only subgroup that perceived a decrease was the loop group old after subjectively estimating their own physical activity level the participants rated their own satisfaction related to their activity level satisfaction levels of all groups increased after the test period with the exception of the loop old group which experienced a decrease in their level of satisfaction one question measured how satisfied the participants were with their sleeping time and whether they thought it was sufficient results showed that all loop group subgroups experienced an increase the result was opposite in the control group this indicates that loop usage increased the loop group participants awareness of their own sleeping and perhaps also persuaded them to sleep more one question concerned the daily sitting time and whether participants thought they sit too much during the day the loop group experienced small increases in all subgroups except the new group in the control group participants were more certain after the test period that they do not sit too much during the day one of the questions concerned participants awareness of own state of wellbeing the results show loop group participants had an increase in their perceived awareness during the test period the results of the control group show a small decrease in their perceived awareness one question was based on the transtheoretical model measuring the participants progress toward a more physically active lifestyle during the test period the loop group experienced a small positive increase and after the test period they perceived to have a more physically active lifestyle than before the results were the same with the control group old subgroup but otherwise the control group experienced a it should be noted that ten weeks is a relatively short time period to make significant changes or even take a step between levels so these findings should be considered with caution figure 8 perceived state of transformation feedback most of the feedback related to the polar loop was that participants had learned more about their own wellbeing no matter what their initial starting point was some participants mentioned that loop had changed their awareness and perceptions of their sleeping time sitting time and overall physical activity some critical comments were related to polar loop functions and how the activity tracker was not suitable with the participants own existing devices a few comments were also related to the pressure that the loop and goal setting had created whereas some people felt it was positive and motivating others first experienced it negatively but eventually learned to cope with it only one participant quit using loop in the beginning of the test period because they felt too much pressure to reach the set goal every day conclusion the purpose of this research was to study the role of an activity tracker in influencing fitness centre members motivation and awareness regarding their own health and physical activity the study followed a quantitative experimental design and included 100 fitness centre members divided into test and control groups although the investigation revealed no statistically significant differences between different groups some interesting findings can be reported on average participants with a polar loop visited the gym more often than those without though the difference was not statistically significant there was a small decrease in gym visits and activity trends during the 10week test period in both main groups and in all sub groups thus it can be assumed that an activity tracker alone might not be enough to sustain motivation to visit the gym or to be physically active but can bring some benefits regarding the transformation towards a more physically active lifestyle the difference between loop and control groups was not statistically significant on a sub group level the differences were also not statistically significant but the results suggest that for new fitness centre members an activity tracker could provide some tools for achieving intrinsic motivation which is important when trying to maintain a more physically active lifestyle in the longterm the results also suggest that there might be a reciprocal benefit where a personal trainer can use the extra information provided by the device to plan the training while the user can utilize the personal trainers knowledge to better understand the data overall it can be concluded that an activity tracker may not significantly influence fitness centre members gym attendance and overall physical activity levels but might make them more aware of their health and physical activity which is needed in building long lasting motivation considering the high number of fitness centre members who volunteered for the study it is probable that the polar loop worked as an extrinsic source of motivation previous studies have shown that exercise applications may increase exercise level and health outcomes leading to increased level of selfefficacy based on some of the participants feedback it was appreciated that polar loop offered a tool for personalized goal setting and also provided the participants with personalized information providing personalized feedback and increasing awareness about health related issues the activity tracker may have increased the participants level of perceived competence which is one element in enhancing intrinsic motivation thus in order to help turn the motivation more intrinsic an activity tracker should provide personalized information and offer a tool for personalized goal setting regarding the awareness of personal health and physical activity on average both main groups claimed to be more physically active at the end of the study period this subjective feeling does not match the fitness centre data which showed that participants in all groups went to the gym less often in the latter part of the study period loop group members also seemed to be less active at the end of 10week period based on the loop activity percentages the satisfaction towards ones own physical activity level followed the development of perceived activity level these findings support the ones by adams et al that there can be some biases in selfreports of physical activity the finding that the loop group were more concerned about their daily sitting time at the end of the test period suggests that the information the loop provided made them more aware and more concerned about their daily sitting time thus activity trackers could be used to educate users about their sitting or other inactivity habits the results also suggest that an activity tracker might increase a persons perceived awareness of their own state of wellbeing whereas the loop group perceived an increase in their awareness the control group perceived a decrease a similar result was found regarding the perceived sleep amount as the loop group reported being more satisfied with their amount of sleep while the control group reported a decrease in satisfaction overall it can be concluded that there are several influences an activity tracker has on ones awareness of personal physical activity and wellness related behaviour however given the contradiction between perceived and measured physical activity levels the influence can be both positive and negative electronic monitoring of daily physical activity can offer tremendous opportunities for people to independently improve their health and wellbeing however it is important for the stakeholders working in related fields to acknowledge that the key is not to just implement a device but to find out how the electronic devices are able to deliver useful information that is also motivating and easy to understand for diverse populations limitations and future research this study has some limitations the first limitation concerns the sample size which could have been higher even though the sample size is large enough for conducting the statistical analyses and can present the situation among the members of the particular fitness centre it somewhat limits the generalizability to activity tracker users in general the second limitation concerns the length of the study a 10week period is not necessarily long enough to facilitate changes in awareness or gym visit habits particularly as according to the transtheoretical model of change it might take several months to generate changes in habit formation one potentially interesting avenue of future research would be to do a similar study with a larger number of participants which would provide better statistical representation of the target population this study could also be done by having a longer study period which would give more reliable results and allow to the transtheoretical model assessment tools to track changes a follow up questionnaire and measurements could also be done in order to see how the training motivation has developed after end of the study period similar study could also be conducted in different fitness centres future studies could also include gamification as a motivation driver as well and examine it more deeply as it seems that its relevance in this domain will continue increasing introduction conceptually crowdsourcing is not a new concept at all it is simply the process of calling upon the general public the crowdto contribute by whatever method appropriate to solving a business problem in the 1700s the alkali prize was established to solicit from the general public a less expensive method of producing sodium carbonate and in the 1800s the oxford english dictionary asked the general public for new words which might be added to the dictionary successful examples of crowdsourcing can be found throughout history but the exponential growth of the concept did not begin until the internet gave quick and easy access to the crowdand particularly the enabling characteristics of web 20 although the concept is nothing new the term crowdsourcing was coined as recently as 2006 when it appeared in a seminal article the rise of crowdsourcing initially howe only described the phenomenon without providing a succinct definition after the crowd had some time to explore and discuss the concept howe proposed a formal definition crowdsourcing is the act of taking a job traditionally performed by a designated agent and outsourcing it to an undefined generally large group of people in the form of an open call capability and awareness are the two most important factors in crowdsourcing first the internet provides the capability of reaching and communicating with the crowdthe general public to which the open call is placed second public awareness of the concept of customersourcing as a new business tool as awareness quickly lead to popularity a wide variety of subcategories arose each with varying purposes and characteristics for example  crowdfunding  cloud labor  crowdvoting  crowdsearching  crowdsolving  crowdsourcing  crowdreviews  customersourcing as a subcategory of crowdsourcing customersourcing is the focus of this article as first described by crane kitchens in particular the focus will be on the intrinsic motivation which individuals have for participating in customersourcing activities rise of customersourcing many traditional business processes have been altered with advancement of the internet and ebusiness customersourcing is one such example it can be described as a modification from the traditional value chain and supply chain models as described here supply chain model the supply chain model is traditionally depicted as a chain of business entities one leading to the next in a linear fashion the supplier leads to the firm which leads to the distributor to the retailer and finally to the customer this represents the flow of goods from raw materials to finished product as depicted in figure 1 supply chain model figure 1 supply chain model value chain model the value chain model depicts the primary activities and support activities occur within a business unit the activities included in the traditional value chain are depicted in figure 2 value chain activities figure 2 value chain activities the effect of the internet and disintermediation has in many cases caused the elimination of the middleman thus by eliminating the distributor and retailer from the supply chain model and by inserting the value chain model in place of the manufacturerservice provider the resulting new model depicts the customer a business in the realm of ecommerce all of the traditional functions of the supply chain continue to exist but the individual firms have been disintermediated the result is fewer middlemen perhaps reduced to a single entity providing the services of the entire supply chain this single firm is then collecting the resources from suppliers performing some operation on the material to produce a product or service and supplying the end product to the customer in the case of crowdsourcing the suppliers may actually be the crowd the resources generated from the crowdsuppliers could conceivably be anything recalling a few of the various subcategories of crowdsourcing reveals the wide variety of customersourced resources available to a firm  customersourcing customersourcing is a unique category of crowdsourcing in which the customers are also serving in the model as the suppliers the resources which are being provided by the suppliers are actually coming from the customers themselves perhaps the easiest resource to supply in an ecommerce model would be data there are many examples of situations where data is supplied to a firm in which the firm processes the date in some way and provides it back to the customers examples of customersourcing abound in the most pure form of customersourcing the customersuppliers are a closed group all customers are suppliers and there are no suppliers who are not customers a popular example of this situation is found in onlinedating sites in this situation the potential customer is required to create an account and upload certain data describing themselves before they are allowed to download any information about other people who might be potential dates thus the customer is forced to first become a supplier before they may become a consumer of the onlinedating sites services there are other situations where the customersuppliers are not necessarily an exclusive group customers might be potential suppliers or suppliers might have an interest in improving the output but may never choose to consume the resulting output themselves the social networking industry is built on this concept facebook for example is the largest social networking site in the world with 11 billion unique monthly visitors they allow anyone to browse a limited portion of their content to see more content a potential customer is required to create an account and befriend other customers this model is depicted in figure 4 customersourcing model motivation the financial aspect of customersourcing has been explored by kitchens crane in which the customersupplier participants were found to fall into 3 broad categories those with net income those who broke even and those who experienced a net outflow the prospects of breaking even let alone volunteering to knowingly experience a net financial outflow gave rise to the question of motivation specifically why do the customersuppliers participate in an endeavour in which they know they will experience no financial benefit or will result in a net financial loss in addition if these situations harbour ulterior incentives then perhaps the prospect of financial gain is not the only incentive in the net income category it has been shown that the motivation for individuals engaged in crowdsourcing can be a mix of intrinsic and extrinsic factors intrinsic motivation traditionally intrinsic and extrinsic motivation were thought to be mutually exclusive categories of motivation the more contemporary view is that these exist as to distinct types of motivation which create a continuum while multiple motivators may exist simultaneously the strength of each motivator may vary from person to person and from task to task while financial incentive is one possible motivator on the extrinsic end of the motivation continuum it may not be the only motivator on the other end of the continuum intrinsic motivation can be categorized into sixteen basic desires the sixteen categories of intrinsic motivation are  acceptance the need for approval  curiosity the need to learn  eating the need for food  family the need to raise children  honor the need to be loyal to the traditional values of ones clanethnic group  idealism the need for social justice  independence the need for individuality  order the need for organized stable predictable environments  physical activity the need for exercise  power the need for influence of will  romance the need for sex and for beauty  saving the need to collect  social contact the need for friends  social status the need for social standingimportance  tranquillity the need to be safe  vengeance the need to strike back and to compete crowdsourcing and intrinsic motivation using these categories it is possible to classify the major motivators for each of the main crowdsourcing subcategories crowdfunding for example is where the crowd provides financial resources for anything from business startups to studyabroad trips for students crowdfunding could provide multiple forms of intrinsic motivators selecting from the list of 16 intrinsic motivators those that most likely apply to crowdfunding are  honor such as the satisfaction of supporting a family member studying abroad  curiosity the opportunity to learn more about a new invention possibly even being one of the first to own a prototype  idealism the opportunity to aid in correcting social justice by supporting an underdog  saving the chance to add to a collection in exchange for a financial contribution  social status the chance to be a major investor in a promising startup business the classification of forms of crowdsourcing into the 16 forms of intrinsic motivation can be performed for every category customersourcing and intrinsic motivation focusing specifically on the customersourcing form of crowdsourcing it is easy to imagine how each customersourcing site might embody a specific set of intrinsic motivators even within the same industry specific sites may have differing sets of motivators for example within the social media industry two of the leading sites are conclusions identification and classification of intrinsic motivation for crowdsourcing and more specifically customersourcing websites is not an activity without consequence websites need users in particular customersourcing web sites are vitally dependant on their customers as users in order to receive some form of supply for their value chain yet some of these sites have no extrinsic benefit to the usersfinancial or otherwise studying these intrinsic factors is vitally important site developers need to identify the motivators and create web sites which support and enhance the users intrinsic motivators the ultimate goal when a site relies on users for some of its value chain items is for an increased number of users with increased frequency of visits further research should seek to quantify the most important motivators which result in increased users and increased frequency of use introduction data analytics is already applied in many industries the educational domain however has only recently started using data to improve its processes analytical activities aimed at improving education at a microlevel of educational institutes is called learning analytics the measurement collection analysis and reporting of data about learners and their contexts for purposes of understanding and optimizing learning and the environment in which it occurs common research objectives include modelling student behavior in virtual learning environments and prediction of performance the learning analytics process comprises four steps 1 learners generate data 2 these data are captured collected and stored 3 analysis and visualization of the data and 4 the design and use of datadriven pedagogical interventions the process is a cycle as the effects of the interventions can again be measured analyzed visualized et cetera see figure 1 the remaining of this paper is structured as follows first the background of learning analytics processes and our experiment will be provided we then elaborate on the primarily findings of the experiment conducted thus far finally future work will be described background higher educational institutes implementing learning analytics processes face several difficulties eg changing existing information systems by implementing a learning records store and customizing data streams managing the increase in workload for teachers and making sure all activities are in compliance with privacy legislation greller drachsler provide a generic learning analytics framework with six critical dimensions to consider whilst setting up learning analytics services see figure 2 figure 2 learning analytics framework in order to help dutch higher educational institutes overcome the aforementioned difficulties surfnet set up the learning analytics experiment the experiment provides all instruments itarchitecture data standard algorithmsrequired to answer five predefined pedagogic questions these questions are sourced from previous research aimed at identifying questions relevant for dutch educators setting up the tool is relatively easy as the only necessarily activities involve putting tracking codes on the pages and learning materials in the virtual learning environment since the codes can easily be copypasted only basic computer skills are required once placed the codes allow data to be stored in a learning records store from which the data can be analyzed and visualized in a dashboard see figure 3 for the learning analytics architecture and figure 4 for the resulting dashboard as seen with a teachers account teachers can see the anonymized activities of all learners in the experiment learners have their individual dashboard and can view their own activities to ease compliance with dutch privacy laws students must optin to allow their data being captured and analyzed research objectives and method the objective of this study is to research to what extent it is possible to perform learning analytics activities in the case organizations virtual learning environment and what barriers are encountered when doing so and to research in what way pedagogical interventions can be designed and performed during the course by teachers based on the visualizations in the learning analytics dashboard we do this by answering the following research questions 1 what issues are encountered when implementing an experimental learning analytics tool in the case organizations virtual learning environment 2 in what way can the visualizations in the learning analytics teacher dashboard be used to design and perform timely pedagogical interventions we use the framework of greller drachsler after the first phase of the experiment all involved teachers and researchers from surfnet evaluated the process and outcomes during a focus group based on open observations all experiences worth pointing out by the participants were discussed and notated as all teachers involved encountered the same issues consensus was reached fast this led to the description of the preliminary results as shown in the next section preliminary results the first round of the experiment resulted in several experiences and insights in this section we will elaborate on the most pressing results first an overview of encountered issues is provided these are then categorized according to the dimensions of the learning analytics framework technical issues although it is relatively easy to set up the tracking at the virtual learning environment some technical issues arose during the experiment it became clear that not all activities were tracked root cause for this anomaly were the necessity to optin for the experiment students who optedin only provided permission to capture data from the specific device they used to subscribe this results in incomplete datasets and renders extensive data implementing an experimental learning analytics tool 329 analysis useless the causing issue has been resolved so this problem will not appear in the second round of the experiment another encountered technical issue relates to the surfconext connection between the case organizations virtual learning environment and the surfnet learning analytics dashboard with surfconext it is possible for students to log in the learning analytics dashboard by using their own institutional username and password this saves the need to create a new account to establish the connection the institutional surfconext contact person must login his administrator account and provide permission to do so at the beginning of the experiment however the connection was not allowed until only a few hours before the start of the courses this almost led to cancellation of the experiment as the researchers did not want to confuse students with nonworking dashboards and connections this experience shows the need for institutionalbroad support and cooperation in order to make learning analytics work selfselection bias students need to optin for the experiment allowing their data being captured and analyzed of the 234 business engineering students who enrolled in the course 89 optedin only 38 similar proportions were found at the other institute after the final exam of the course the difference between the final grade of the students who participated in the experiment and those who did not were calculated using spss participants scored an average grade of 51 and nonparticipants an average grade of 43 an independent ttest shows there is a significant difference between the two groups and students who participated in the experiment scored on average better than those who did not as no interventions were initiated based on the information in the dashboard it is suspected that selfselection takes place future initiatives involving voluntary participation must account for this effect need for more data in order to perform effective interventions rich data is required in our experience the current data is too poor to use for interventions the lack of sufficient data can partly be traced back to the teachers who put too few tracking codes on their course page of the virtual learning environment as one of the involved teachers puts it next time i will track everything every page every article and every video the experiment also relied on data from the virtual learning environment only this provides only one side of the story anecdotal observations of students using the online materials showed that they sometimes jointly sit together at a single computer to work on assignments having the system only registering one student similarly interaction between these students cannot be measured this way in our experiment data from other resources was not aggregated with the data in the learning records store for example the virtual learning environment provides students the possibility to take quizzes quiz data however are yet not stored and processed in the records store in order to design and perform effective interventions these data must be aggregated in future experiments problem categorization based on learning analytics framework in order to analyze which dimensions of the learning analytics framework are causing problems during the implementation of the tool we mapped the identified issues to the frameworksee table 2 this shows that four out of six dimensions faced difficulties so even though an almost plugandplay tool is provided implementing it is a nontrivial endeavor future work the experiment will be continued in the fall of 2017 at the institute for engineering and design two courses will implement the learning analytics tool in their course design one of the courses is taught to fulltime students the other one to parttime students this provides the opportunity to explore behavioral differences between participants of the two programs furthermore to date no interventions were performed based on the data analysis and visualizations in the experiment learning analytics research in general often focuses on data collection management or how data will help to improve education but designing effective pedagogical interventions becomes a critical element now we have demonstrated the tool can be implemented in the case organizations virtual introduction being physically active is not only beneficial for an individual but also for the society modern world health problems like obesity have become common and people are facing difficulties in maintaining physical activity in their everyday lives which emphasizes the possibility of encouraging more active lifestyles by changing individual exercise habits thus it is evident that people should be encouraged and motivated to maintain their mobility behavior in recent years a number of mobile devices and applications that aim at supporting people in their athletic endeavors and other physical activities have emerged and these applications with various tracking features encourage people to exercise more these exercise applications provide opportunities for personalized health services which make use of digital data in proactive and personalized ways in this study we examine the use of narratives in motivating users to engage in physical activity we collected data using participatory observation a focusgroup and semistructured interviews after which we analyzed users reasons and motivations for exercising and use of the exercising application applying a nexus analysis approach with nexus analysis the aim is to deepen the understanding of the qualitative data collected the concept of user experience is widely applied in the fields of humancomputer interaction and interaction design and it is used for collecting subjective experiences comprising the interaction between people and products by analyzing these experiences we search for techniques for personalizing narratives our research increases the understanding of narratives as a motivational strategy and their impact on individuals motivation related work as modern life has increasingly been intertwined with digital technology leisure activities are an important arena that have seen a lot of digitalization in recent years for example sports and overall wellbeing are topics receiving increased interest from research as well as from industry for this reason both software developers and the general audience should be aware of the various ways of and the approaches to how people may be are being and will be influenced through the design of computer systems the hci community has strived to promote wellbeing by developing applications and technologies that monitor and track users activities this has mainly been through use of theoretical frameworks derived from persuasion and social psychological theories which make use of behavioral components like regular feedback and reminders to users in their physical activities a related concept gamification the application of game design elements in nongame contexts has also become prevalent gamification can have a positive impact in health and wellbeing and there have been increasing interests in using game principles in nongame contexts to make a challenging activity such as exercising more enjoyable and integrated into the users daily lives one basic element in gaming are narratives in gaming narratives are used to structure games into logical series unlike traditional narratives in movies for example which are linear and fixed in games players interact with the narratives and the structure of the narratives is typically nonlinear among the motivations for exercise is usually a discrepancy between the desired and actual lifestyle and technology is used to support people towards a lifestyle they would like to lead motivation is an essential feature in exercising as it highlights individual differences in behaviors when engaging in exercise using exercise applications is a complex mix of motivation towards exercising satisfaction towards the application external pressure and actual effect of the usage of the application in this study we consider both intrinsic and extrinsic motivation intrinsic motivation refers to exercising for internal reasons like fun and pleasure extrinsic motivation emphasizes the role of external factors in motivating behavior for example exercising because of the expectation of a reward recently motivational factors for exercising have been studied for example in the context of young adults doing physical activity capel et al found that goal achievement staying healthy and social aspects were the key motivational factors for adolescents more sustainable motivational factors have been studied by fritz et al where the authors interviewed users that had been using persuasive technology devices constantly for at least three months the authors found that routinized usage integration to daily life numerical feedback and awareness of the value provided were the key factors that motivated users towards a more sustainable use of technology research methodology the research method applied in this study is nexus analysis a research strategy that uses discourse analysis and other methods wellsuited for studying complex social action in nexus analysis each social action is thought to be mediated by the interaction order among participants in a particular environment the historical bodyprevious knowledge experience attitudes and assumptions that the participants bring into the action and the discourses in place that is the discourses that are associated with or embedded in the scene of the action in this study the concepts of historical body and interaction order are used in our analysis study context the artefact under examination is zombies run zombies run is an exercise application that is available for mobile devices through google play and apples app store it is a running game with zombies as a survival story is meant to be an immersive adventure and the game takes the player into a postzombieapocalypse world the idea is to be outdoors as the application is storybased and at certain intervals during the story one is instructed to do certain things users can pick a mission before they start their run or follow a predefined series of missions culminating in an entire season the unique characteristics related to apocalyptic narratives make the game as a good example of a gamificationbased application the application includes gamification elements such as rewards distance challenges points as well as supplies to be collected during the runs runs can be synced online and progress can be shared in various social media outlets like facebook zombies run initially started as a premium service but recently launched a freemium versionthe basic application is free but additional services and storylines that can improve the user experience come at a fee data collection and analysis six participants were recruited for this study all participants were female postgraduate students we were interested in studying the users motivational factors for exercising usage of the application and to examine the role of narratives in motivating exercise according to their level of familiarity with the application participants were categorized into two groups experienced and inexperienced and were assigned aliases that will be used henceforth to represent them inexperienced users had minimal or no prior experience with the application whereas experienced users had been using the application for at least 2 months multiple qualitative data collection methods were used for achieving methodological triangulation data was collected using three different methods 1 a focus group which was video recorded 2 semistructured interviews and 3 participant observations where participants were asked to think aloud and also video recorded during exercise data collection occurred between september and november 2015 and recruitment was mainly done using snowball sampling the focus group had 3 participants one inexperienced user abbey and two experienced users becky and carla the focus group consisted of openended questions starting from basic questions related to participants motivations for exercise and covering exercising habits role of technology in exercising hindrances towards exercise and their experiences of zombies run following the focus group participant observation while using the application and three semistructured interviews each lasting 4060 minutes were conducted interviews consisted of similar questions to those in the focus group and the aim of recording was to capture users authentic feelings and user experiences when using the application interviews were transcribed and the data was analyzed using nvivo11 software data analysis process was twofold first we identified and categorized general discourses regarding motivations for exercising and the role of narratives in exercising second the concepts of interaction order and historical body were applied in order to understand the motivations and the role of narratives more clearly results generally all participants had positive thoughts about exercising but some of them pointed out the need for extra motivation which could be provided for example by exercise applications historical body historical body refers to an individuals background experiences beliefs and practices which may influence their view of and interactions with different media abbey debbie and ellen had not used the application prior to the study whereas becky carla and felicia had two of three experienced users participated in the focus group and one in a semistructured interview abbey regularly went to the gym went jogging and also walked reason to use the application debbie was video recorded while jogging and participated in a semistructured interview she stated that she was physically active and exercised regularly but at times finding time to exercise was a problem debbie also occasionally used activity tracking applications ellen participated in a semistructured interview she used to exercise in various ways but the frequency had been decreasing due to tight time schedules and difficulties in starting to exercise again becky participated in a focus group she had been using the application for about half a year and prior to that she hardly exercised the main reason for using the application was because it was different and she needed something interesting to get her to exercise regularly the role of narratives was very important in her decision to purchase the application as can be seen in the following quote i bought it because it is geeky and fun and it sounded more interesting than other running apps carla had been using the application for a longer period of time she enjoyed the zombie genre and liked listening to the narratives prior to using the application she was not very active and she stated that the application helped her to improve her exercise habits the narratives and preset goals motivated her to exercise more because she saw preset goals as challenges that had to be completed which she was incrementally able to do as illustrated by the comments below the 5k which i tried first is perfect for anyone who has not been running but wants to start you start with really small steps and in the first parts you just run for 30 seconds or something it really improved my running a lot i would say within six months in the beginning i would run for five kilometers and after six months i could run twenty so there is a big difference felicia participated in a semistructured interview she stated that she was physically active but finds it difficult to be consistent her motivation to exercise was related to wellbeing as exercising made her feel more energetic felicia mostly exercised alone because she wanted to focus on only that when doing it the quote below illustrates this i like exercising alone for example if i go to gym i try to go there as late or as early as i can so that there is no one else also when running i prefer to run alone interaction order interaction order is about how relationships and technical affordances affect peoples interaction the interaction order entails studying how mediated actions occur whether alone in groups the time what precedes or triggers an activity and so on the different kinds of interactions that can take place are supported or encouraged by different designfeature implementations and these in turn control or limit users actions other than supporting the primary intent which is jogging in zombies run there are gamelike features where users collect various supplies that help protect from a zombie attack and can be used to rebuild ones virtual town users can also share information about their exercises via social media channels or via runkeeper that offers more social features than zombies run abbey felt that the narratives in the missions were a distraction and they could be shorter although the narrative and gamelike features are what initially attracted her to the application becky felt that they were not an integral part of the running experience after using the application for a while carla and felicia also stated that the narratives could be improved on by making them shorter or by reducing the time in between stories there are long pauses in the stories when running that make it difficult to continually concentrate on a mission because ones focus is every now and then shifted away from a particular mission carla needed a distraction from the narratives because of the long pauses and according to abbey the option of listening to music during the breaks in the mission was even more of a distraction as one had to switch between two states of mindthe joy provided by the music and the concentration needed in the mission abbey and carla also felt that social features were not important for enhancing their experience of or engagement with the application becky on the other hand felt that social elements were important and a key feature needed to give her that extra motivation to exercise for ellen a lack of actual interactivity in the stories negatively affected her experience with the application all the participants felt that the virtual rewards did not add any value or interactivity to a mission and the running experience would have been the same with or without them debbie and ellen felt that it would have been much better if collecting or winning something in the mission would have been linked to a physical activity for example in order to win a firstaidkit one had to either increase their speed or do jumping jacks that were directly linked to the item collected personalization of narratives nexus analytic concepts of historical body and interaction order enabled us to study narratives as a motivational feature instead of a generic narrative narrative adaptation is one method for personalized gaming personalized narratives are related to interactive storytelling where the game content is personalized according to user preferences we thus agree with göbel et al that it is not feasible to create a narrative for each individual user therefore based on our analysis we propose three different narrative personalization techniques in the form of use cases personalizing narratives for goal achievement this technique proposes that narratives are personalized based on users goals once the user sets a personal goal narratives are personalized to support the achievement of that goal by monitoring users the system identifies that achieving a personal goal requires a longer run for example and by personalizing the narrative the system systematically persuades users to achieve their goals the following quotes present some of the user goals you have a certain goal for every exercise you do and that gives structure to your exercise i think that is one of the most motivating things for me to have a certain specific goal as for me i think what i find motivating about running is the improving getting faster going further that is one motivation losing a little weight …i have run for twentyfive minutes this week even though last week i could only run for fifteen minutes the number of kilometers i have been running is more related to personal goals not that much of the goals set by the system personal goals between users vary some try to lose weight whereas some want to improve in running the following use case illustrates this narrative personalization technique a while back ellen was an active young woman but recently she has been demotivated and her husband constantly reminds her about her new years promise to exercise more previous sports applications supported her goal settings but this application also provides narratives tailored to her goals her goal is to lose weight and increase the distance she can run after one month has passed ellen is not likely to achieve her goals therefore the application adjusts the narratives to last for 60 instead of 40 minutes goal setting is supported on many sports applications but personalizing narratives to certain goals set by users is not that common once users set their goals the system personalizes a narrative by either lengthening or shortening an episode to support the achievement of those goals personalizing gamification level of narratives this technique proposes that gamification level is personalized some users preferred to passively listen to the narratives without game elements whereas others would have liked more playful elements in the narratives whether it was related to goal achievement building a virtual base or the integration of narratives into their surroundings application did not succeed in motivating me because it was not actually interactive at all i was expecting some interactivity related to achieving my goals in the game base can be improved but improving that base has no effect on the missions or how the story goes on because i wanted to experience something i started to play the storyline like when i heard that bandages or whatever were picked i started to pick some leaves fallen from the trees by personalizing gamification level system could provide more gamification elements tasks for users to complete for building the base or provide sub missions that are integrated to certain locations and surroundings of the user the following use case illustrates this technique debbie has heard about zombies run from her friend carla carla persuades her to try the applications and upon installing it she is asked to set her location and level of gamification after a while zombies are chasing her as she collects virtual bandages concurrently in the narrative there are facts integrated to springfield where zombies have captured the town hall to rescue the town hall she has to run intensively to the hall in order to expel the zombies debbie does this and the she is rewarded by getting an extra town hall badge that can be used in her virtual base also personalizing genre or intensity of narratives this technique proposes that the narrative genre is personalized based on users preferences some users were willing to have more intense storylines whereas others preferred milder ones the following quotes present the ideas of genre based personalization you should have different storylines for other people as well i could never imagine my mom going running with the zombies there could be some adjusting in the storylines you could for instance exclude the zombies or choose a different kind of narrative as zombies are the selling point in the application excluding the theme fully may not be appropriate however letting users personalize the intensitygenre of a storyline from scary to light could attract a wider audience to the narratives the following use case illustrates this technique felicia is a true zombie freak who has been organizing annual zombie parades in her local area she was an early adopter of the application and now she is listening to the narratives again but with a new scarymode on as she jogs the zombies are ultraaggressive and she loves it this is something she wants to show to her sister as her sister abbey tries the scarymode she does not like it and quits right away she blames felicia for even suggesting her to try that felicia calms her sister down and lets her know that the intensity can be adjusted switching it from scary to light she persuades abbey to try the application again abbey decides to go for a jog and instead of an avalanche of zombies just a few zombies appear and some of them are even having a vegetarian picnic in the park she enjoys the mode and agrees that it provides a joyful experience personalizing narratives for different genres can consist of different levels of storylines some can be scary and involve personalization based on the difficulty level where the run could end up with game over if ultraaggressive zombies catch the user vice versa on the lighter storylines zombies are not aggressive at all concluding remarks technology plays an important role in motivating people to exercise and pervasive devices like smartphones can provide an accessible and personalized platform for applications supporting regular physical exercises in this study the focus was on investigating the use of narratives as a motivational feature findings related to motivations and the role of technology are first discussed and this is then followed by the use of narratives all participants exercised and had positive thoughts towards exercising although their intentions to use exercise applications varied ahtinen et al found that motivation to use exercise applications required both simultaneously enjoying to exercise and satisfaction with the application in our study not all participants were satisfied with the applications features and its technical stability which negatively influenced their intentions to use the application in future staying healthy socializing and achieving certain goals are key factors that motivate young adults to be active social sharing was found not to be a key motivator which is consistent with findings in ahtinen et al as most of the participants did not want tofeel the need to share their exercise logs with other people or on online social platforms the participants were primarily motivated to exercise for health reasons and even though some did not exercise consistently they considered exercise to be an important part of their overall wellbeing all participants found goal setting and data tracking as good motivators for exercise some users preferred setting goals themselves and others used the systemset goals the systemset goals were considered by some to be challenging whereas others felt that these goals did not match their own personal goals gamification improves attitudes and enhances exercise and the gamification elements supporting goal setting and monitoring were appreciated by all participants a recurring observation was that the gamified elements should better support the monitoring of preset or personalized goals ie to better merge narrative elements of the application with individuals goals and their tracking combining personalization strategies with persuasive systems rather than offering generic solutions has potential for better outcomes and can enhance users experiences and achievement of their goals however support for personalization is still at a low level within these systems personalizing narratives for each user may not be technically feasible but as users motivations vary personalization should be supported in our study three narrative personalization techniques were proposed to support users motivation for physical activity the present study had a limited number of participants with relatively homogenous backgrounds user experiences were collected using a focus group participatory observation and semistructured interviews our intention was not to focus on women only but with snowball sampling we ended up with such a homogenous user group furthermore at the time we conducted the study women were the most willing participants and not all of them were available to participate in all the data collection phases nevertheless this provided us an opportunity to combine several qualitative data collection methods and get detailed qualitative data but sets limitations for the generalizability of the results as it was limited to a small group of finnish users gender age and cultural differences were also not considered in this study and therefore the findings cannot be assumed to be widely applicable to different contexts with different application and users results may differ nonetheless the study highlights the importance of tailoring and personalization and presents ideas on how this can be done for different user groups in summary technology for supporting motivation towards healthier lifestyles has remained a key topic in the fields of hci and computer science development and evaluation of exercise applications with various features have been studied comprehensively this study qualitatively analyzed the role of narratives to motivate people to exercise by using a nexus analytic approach the focus was on user experiences related to an exercise application that utilized narratives to motivate users our study revealed that features like tracking and goal orientation did motivate users to exercise and so did narratives however their usage in wellbeing technology is still in its infancy personalization techniques have been used for setting personalized goals or objectives but in narratives these techniques are not widely studied in this study we have proposed three techniques for personalizing narratives introduction the current study analysed how earlier studies have approached and presented serious games in healthcare the term serious game or applied game is used to classify a game in which its main purpose is something other than pure entertainment this group includes several subgroups including edutainment advergaming edumarket games political games and training and simulation games to educate train advertise and influence people games can work as motivators or to help change players behaviour healthcare services are looking for new functions to empower their customers sg in healthcare can provide methods for maintaining and developing health in different age groups the goal can be to provide a new kind of model for selfhelp or rehabilitation play and entertainment can be effective foundations for serious interventions in healthcare nevertheless there is a need for more research studies that show a causal link between playing video games and health outcomes we wanted to understand how sg are seen by researchers the main research question was how are serious games in healthcare perceived and approached in the literature to get the answer three supplementary questions were presented  which journals include papers on serious games in healthcare  what are the most investigated areas of serious games in the health sector and how have these changed over time  what research type and methods are most frequently applied a method of systematic mapping was selected for getting a broad overview of the chosen area systematic mapping study is a proper method to reveal whether there is research evidence on a topic and to provide any indication of the quantity of evidence the guidelines provided by petersen et al petersen vakkalanka and kuzniarz and kitchenham budgen and brereton were applied existing criteria on research approaches given by wieringa maiden and roland were utilised in the evaluation this paper presents a systematic mapping study of sg in healthcare and is organised into four major sections background and related work on sg research approach mapping results and conclusions background and related work the concept of serious games was introduced in the 1970s when it referred to an activity among two or more independent decisionmakers seeking objectives in a limited context in that time sg were focused on educational functions the concept involves a digital game whose main purpose is something other than pure entertainment and is designed to be used in training education and healthcare zyda games that engage the user and contribute to the achievement of a defined purpose other than pure entertainment fullerton described a digital game as a system in which the whole is greater than the sum of its parts a digital game creates a structured conflict and provides an entertaining process for players to resolve that conflict game design combines psychological aspects with mechanical and artistic aspects game designers empathise with players and their main task is to ensure that the game will be entertaining juul defined video game as a game played using computer power and a video display that can be a computer cell phone or console game video games not only can tell stories but also allow players to live them figure 1 illustrates aspects of sg design the challenges presented to players and the actions players are permitted to take both to overcome those challenges and to perform other enjoyable activities in the game world the healthcare sector has strong interests in using new technologies related to health sg in the health sector can be divided into gamebased education of health professionals and improving therapeutic outcomes of patients todays increasing challenges with aging populations and chronic diseases suggest that serious games in healthcare may be one strategy to help with survival health games can be classified also by their main purpose type of players and the stage of disease of patients the stages of disease of patients include stage of susceptibility presymptomatic stage stage of clinical disease or stage of recovery or disability as divided by wattanasoontorn hernandez and sbert who indicated three main purposes for health games 1 games that are designed originally for entertainment and in which a health purpose comes secondary but can be found in the games figure 2 illustrates these classifications figure 2 classification of sg in healthcare there are many different stakeholders in the healthgame market such as hospitals clinics privatepractice physicians government corporations other organizations and individual consumers social security systems and healthcare providers differ significantly among different countries and on a global scale with each market area having its own methods to facilitate a healthy lifestyle significant changes should be expected for example in medical simulations serious games and mobile serious games and an increased need for seriousgame analysis is already present supporting players motivations and enhancing behavioural changes are essential in healthgame design design includes using game elements such as surprise and simulation to engage players and enable immersion on the other hand developing a health game requires a multidisciplinary team to work together successfully it is important to define both the target group and main objective then design a game accordingly using sound gamedesign principles in collaboration with health professionals and involving patients as early as possible braad folkerts and jonker describe the healthgame design process as a gamebased intervention process their humancentred design method consists of four phases analysis design development and evaluation like braad et al friess kolas andknoch and deen et al use similar processes in sg development in the health sector they all include strong research and analysis phases at the beginning and involving different stakeholders is essential iterative development processes or the use of prototyping are among their development methods the gamedevelopment process then ends usually with usergroup testing and evaluation or validation phases in the design of sg in health games the target group should be considered during the development process a multidisciplinary team is necessary to develop a successful and effective health game and professional knowledge is an essential part of the development process research approach to get an overview of sg in healthcare studies the guidelines for a systematic mapping process were followed this chapter describes the chosen research method and how it was applied overview of systematic mapping study a standard systematic literature review is usually conducted over a specific research question that can be answered by empirical research a mapping study on the other hand aims to provide an overview of a topic area through multiple research questions mapping questions are about what we know with respect to a specified topic the results of a systematic mapping presented as a visual summary the map help determine in which areas to conduct a conventional systematic literature review a systematic mapping process figure 3 systematic mapping process mapping questions often are formulated around what we know with respect to a specified topic and include questions regarding venues research methods and trends the search is conducted in relevant databases for all papers in the research field and as recommended by kitchenham and brereton the use of ieee and acm as well as two indexing databases is sufficient a search string is defined based on the research questions the third step in the systematic mapping process is the screening of papers inclusion and exclusion criteria are needed to find relevant papers that answer the research questions inclusion and exclusion criteria can be related to the relevance of the topic of the article venue of publication period considered requirements for evaluation and restrictions with respect to language the selection of papers is performed on titles and abstracts thereby building a classification scheme first then later reading is extended to introductions and conclusions for classifying the type of research kitchenham et al and petersen et al recommended using a classification system developed by wieringa et al with six categories 1 validation research which concerns evaluating novel techniques not yet deployed in industry 2 evaluation research which concerns evaluating industrial practices 3 solution proposals which discuss new or revised techniques 4 philosophical papers which structure the field in new ways such as taxonomies 5 opinion papers 6 experience papers which discuss how someone did something in practice in the dataextraction phase relevant articles are sorted into a scheme such as an excel spreadsheet the mapping process ends with a presentation on the frequencies of publications for each category using maps for visualization research questions to get a broad overview on how serious games in healthcare are perceived and approached in the literature the following supplementary questions were asked  rq1 which journals include papers on serious games in healthcare  rq2 what are the most investigated areas of serious games in the health sector and how have these changed over time  rq3 what research types and methods are most frequently applied the objective of rq1 was to identify the forums of discussion the objective of rq2 was to discover trends in research and possible gaps the objective of rq3 was to determine the methods of research used search and screening of papers to get a broad overview of the research area searches were first conducted on these scientific databases ieee acm scopus web of science and google scholar at the second stage the database of web of science was left out of the process due to technical problems with remote access the following inclusion criteria were applied to titles in the screening of papers  topic of study focuses on serious games in healthcare  studies are in the field of software engineering or information systems the following exclusion criteria were applied to titles in the screening of papers this yielded a total of 479 papers of which 71 were found to be duplicates leading to a final total of 408 papers  keywording and study selection the basic information in papers such as authors titles years published source titles abstracts digital object identifiers and links were exported into an excel spreadsheet this table was used in keywording to find the classification scheme as follows abstracts from acm ieee and scopus search results were downloaded as text from the excel spreadsheet to tagcrowd to create an overview of used keywords in the filteredout abstracts these keywords are presented in figure 4 to visualise the volumes of used words in the abstracts the classification schemes were formed based on the chosen keywords and included research articles from these keywords and connecting the information with research questions the following classification schemes were formed 1 source title 2 aimtarget and focus year using keywords such as behaviour change cognitive educationlearning rehabilitation therapy exergaming designdevelopment userpatient interaction persuasive usability 3 the frequencies of keywords or index terms of serious games in healthcare are presented in this order acm ieee and scopus in figure 4 data extraction and mapping process to answer research questions the data was sorted on an excel spreadsheet with basic identification information from papers such as identification number authors titles years published source titles dois and links the classification schemes were added aimtarget and focus research type and research method since the search results totaled up to 408 papers it was decided that rq1 and partly rq2 would be based on the whole body of articles on the other hand to be able to answer rq2 and rq3 required reading through papers and gathering needed information in classification schemes it was decided that this would be done in publications that have 10 or more papers in each source publication restricting the upper limit of read papers to 112 each of these papers was read to find the above information which was added to the spreadsheet at this phase 18 papers were considered to be not fully in the realm of health games and thus were excluded and 11 were not available as full text which brought the number of papers down to 83 if information was not available on the abstract or the paper was not accessible in full text it was excluded at this point papers were arranged in ascending order by publication time the analysis of the results focused on presenting the frequencies of publications for each category the quality of the sample of studies selected in the inclusionexclusion process generalizability of the results of the mapping and reliability of the conclusions drawn in relation to the data collected were identified as possible threats to the validity of the research analysis and interpretation this chapter is structured with the help of the assisting research questions venues of publication to find out which journals include papers on sg in healthcare the distribution of papers in different publications is visualised in figure 5 and the publications that have 10 or more papers in each publication are listed in table 3 the papers were published in 163 different publications which indicates quite a vast distribution over different sectors 93 publications included only one paper in this area topics and frequency of publication to analyse the annual distribution of sg articles in healthcare the annual distribution was calculated between the years 2005 and 2016 some of the papers were published in 2017 but those were excluded due to the scheduling of the study figure 6 shows the number of papers over the years and the trend has been increasing until 2014 according to a content analysis of 83 papers the most investigated areas of serious games in the healthcare sector regarding games aims are presented in figure 7 the five top subjects of serious games were  education  exergaming  cognitive rehabilitation  psychology and  rehabilitation figure 7 number of papers according to aimtarget of the serious game most of the papers focus on describing design and development of a serious game the next most popular focus areas were usercentred design and participatory design this is presented in figure 8 one way to categorise the most investigated areas of health care was to analyse the target group of developed games as illustrated in figure 9 the targeted demographic groups of most serious games in these papers were children the elderly and patients of certain diseases research types and methods to analyse the research type and methods the papers were categorised according to the research types in the classification system by wieringa et al none of the analysed papers were considered opinion or experience research 55 of them were categorised as solution research 19 philosophical 15 validation and 11 evaluation research which is presented in figure 10 conclusions the purpose of the study was to analyse how sg in healthcare are perceived and approached in the literature to solve the research problem systematic literature mapping was applied in the study a total of 408 studies from 20052016 were found and after screening and exclusion 83 studies were analysed the results of this systematic mapping could be used to identify gap areas in research of sg in healthcare although the concept of serious games is from the 1970s we found out that there were just a few publications who wrote about the phenomenon before 2009 the number of publications increased until 2014 after which there was a gap in 2015 then the number increased again in 2016 most of the analysed papers came from conferences the most popular forum of discussion was the ieee segah conference with the lecture notes in computer science coming in second since the development of sg in healthcare is multidisciplinary some of these papers were published in medical journals and thus were not included in this study wattanasoontorn et al classified health games by their main purpose types of players and patients stage of disease the biggest target groups of sg described in this mapping study were children the elderly and patients with certain diseases in the analysed studies the main purpose and type of player were easily found but none used classifications for stages of disease in educational games the players were 1 healthy people of a certain group children adolescents the elderly etc 2 patients with certain diseases or 3 students and professionals in a certain medical area considering the focus and methods of research the most common approach was to describe design or development of sg by using a case study most of these were considered solution proposals as defined by wieringa et al thereby discussing new or revised techniques the focus of most studies was in using usercentred participatory and collaborative design models this supports prior research involving different stakeholders in sg development also there were some literature reviews that were deemed to be philosophical papers structuring the research field in new ways kato brought up the need for validation of sg in healthcare but it was not seen as a topic in many papers one rct and a controlled experiment were found as well as a couple of intervention studies few papers covered guidelines for assessment of sg many described prototypes of sg were tested with focus groups but there were no further studies found there were just a few papers focusing generally on sg design or providing guidelines for sg developers in healthcare even though there were plenty of cases described the study unearthed new knowledge on the topic of how serious games in healthcare are perceived and approached in the literature the results provide a foundation for deeper analysis of the use of sg in the health sector and suggest that the next focus will be on developing general guidelines for sg developers in healthcare focusing on validation of sg and research of sg maturity models to improve level of development the study points to future avenues of research integrating both the gaming industry and healthcare professionals there are limitations to the study of research mapping and further studies should be conducted to validate and further extend the knowledge of sg in healthcare introduction commercial and industrial sources in the us produced three times the co2 emissions of residential sources in 2010 while the buildings sector also consumes 20 of the total delivered energy worldwide at the same time the commercial sector features the fastestgrowing energy demand with its consumption projected to grow by an average of 16 per year until 2040 more importantly buildings account for 3045 of the global energy demand with commercial buildings and primarily office and university buildings classified amongst those presenting the highest energy consumption and savings potential therefore it is important to increase our efforts towards energy conservation in commercial buildings and workplace environments towards addressing the worldwide recognised issue of energy wastage albeit the documented effect of public buildings on energy consumption only a limited body of research focuses on employees energy consumption behaviour which can certainly play a significant role in the buildings energy footprint aiming to contribute to this research path we are participating in an h2020 eu project that develops a platform which utilizes internet of things enabled smart meters smart plugs and lowcost sensors to monitor energy use and simultaneously wastage per work device area and employee the ultimate goal of this research project is to use the accurate energy consumption data collected from the interconnected devicesthings in order to transform the employees energy usage behavior gamification the use of game design elements in nongame contexts has been identified as an instrument that when appropriately utilised could lead to employees energy behaviour change it can support companies to change behaviours increase and sustain employee engagement and productivity furthermore the active use of gamification for the improvement of business processes results in amplified workers positive psychology and strengthens positive emotions engagement relationships the sense of meaning as well as accomplishment thus we were inspired to build in the course of the project a gamification application that receives input from the iotenabled platform and provides realtime recommendations to employees in three participating pilot sites motivating and educating them to adopt a more green behavior to design an effective gamification app that the employees will adopt and use we had to consider two important factors during the apps user requirements analysis employee personal profiles needs and preferences as well as workplace contextual characteristics we first performed onsite visits to identify the contextual characteristics of the three different workplace environments that participate in the project then we conducted a series of semistructured interviews with representative employees to formulate a more holistic view of the three sites special requirements our primary focus was on collecting useful insight towards the design of a gamified app that matches the needs and preferences of its endusers as well as serves the contextual limitations and opportunities of the pilot workplaces in the next sections of the paper we begin by reviewing related work presented in the literature discuss our observations through the site surveys as well as our findings through interviews with employees and conclude with our future research plans related work energy consumption in workplaces energy in public buildings is mostly consumed through space heating and cooling systemstypically the largest energy consumption sources both in the eu and the us lights refrigerators computers and other equipment additionally occupant behaviour is an important factor in the consumption of energy in buildings as it can add or save onethird to a buildings designed energy performance however unlike private households users at workplaces have by default no direct financial incentive to minimize energy use within their office workspace therefore motivations as well as incentive structures for users in organizational settings are different as no personal monetary gains are normally expected from a change in behaviours hence more altruistic motives like supporting the organization in energy and monetary savings contributing to environmental protection or complying with expectations from colleagues and superiors can be leveraged to engage in energy saving behaviour at the workplace studies in energy consumption behaviours emerged with the oil crisis of the 1970s from a wide range of disciplinary perspectives specifically the findings of a metaanalysis of 156 published informationbased energy conservation experiments encouraged us to explore the occupants energy behaviour in public buildings nonmonetary informationbased strategies can lead to an average reduction in electricity consumption by 74 monetary incentives in contrast lead to a relative increase in energy usage rather than inducing conservation energy conservation through behavioural change should be considered alongside efforts to reduce energy consumption through technological improvements overall a limited number of studies exist regarding energy conservation in a work environment compared to household contexts very few studies have also investigated employee energyrelated behaviours none of which involving interorganisational comparisons gamification for energy efficiency purposes the basic and most wellknown gamification elements are points badges and leaderboardsa useful starting point for gamification effortsbut a number of additional game elements exist functions but in interaction with each other they can have varying and complex motivational effects the mda framework is widely used to categorise gamification elements α commonly stated objective behind using gamification is to encourage behaviour change in the form of increased participation improved performance or greater compliance at the same time gamification in a work environment can focus on business processes or outcomes involving participants or players both from outside andor inside a firm to improve employee satisfaction when organizational goals are aligned with participants goals organizations can achieve their goals as a consequence of players achieving their goals and employees can become fully engaged with new company initiatives furthermore since gamification often involves storing and processing personal potentially sensitive data this could lead to transparent employees within company boundaries and at the same time inappropriate extrinsic incentives might crowd out intrinsic motivation workplace gamification also needs to apply to longterm apart from initiativespecific objectives in a corporate setting players have also tend to be more invested in intragroup than in intergroup competition gamification might also contradict with some personality types and cultural norms highlighting the importance of designing gamified applications to match their potential users profile by assessing their respective characteristics as well as preferred game mechanics more specifically various studies have suggested gamification as a means for motivating energy efficient behaviour grossberg et al conducted a thorough review of gamified energy efficiency initiatives concluding that saving energy is highly rewarding in itself and the greatest achievement a gamified app could aim for is to outline this fact to its users furthermore they note that energy savings in the range of 36 have been reported on a number of studies featuring the application of gamification to reduce energy consumption with an achievable possible savings of more than 10 inspired by the forementioned information we decided to conduct a thorough observation of the three targeted workplaces as well as a detailed exploration of the characteristics and preferences of our prospective gamified app participants our ultimate goal was to ensure that we will design and develop an effective gamified app that motivates employees towards a more energyconscious behaviour identifying context and user requirements physical observation of the workplaces the gamified app will be deployed and pilottested in three different workplacesparticipating in the forementioned eufunded projectthat are located in different european countries the first workplace is a public office in athens greece which provides it support to the facilities of its home organisation both locally as well as in external temperature and humidity conditions affect energy consumption while around 40 of electricity consumption is due to air conditioning as heating is provided by natural gas consumption smart meters are installed for monitoring the energy consumption per category of use but no specific strategy for reducing energyconsumption has been set the third workplace is a public museum at the old city of luxembourg it comprises of 4 buildings containing the exhibition rooms and 25 administrative offices there are 100 employees in the museum 40 of which administrative staff lights are always on in the exhibition area and visitor restrooms during the museums visiting hours there are very few automated light switches and although the daylight prevails in the museum rooms many lights are kept on for security reasons the largest part of energy consumption is due to lighting and the climate system in the exhibition rooms which ensures the museum exhibits are secure and properly preserved heating in the administrative offices is controlled per office where there is no airconditioning employees cannot alter the climate or lighting conditions in the largest part of the facilities and museum visitors cannot act on the climate controls or any other energy consumption actuator at a first glance only the lift usage of visitors may alter their contribution to energy consumption in the museum overall through the physical observation process a number of common as well as contradictory significant characteristics of the three pilot workplaces were highlighted the museum is different to both the other workplaces in that it hosts a very large number of visitors per year whereas close to no visitors are expected in the other two sites at the same time the climate and lighting conditions in most of the areas of the museum are very specific and therefore lights and climate control cannot be used in a gamified app for these areas furthermore it consists of four whole buildings as opposed to a single floor office space the only area of the museum that resembles the other two workplaces is the employees backend office area a special distinctive feature of the museum is that its visitors could conserve energy by opting to use the stairs instead of the elevator regarding the office spaces in all three sites a lot of similarities exist in the possible targeted behaviours pcs monitors and printers can be switched off more often as well as lights when not needed common area equipmentkettles coffee makers toasters and microwave ovens depending on their availability on each sitecan also be user interviews method and results we performed indepth semistructured interviews with a representative sample of employees per workplace as a small amount of interviews can produce data capable of addressing a set research goal selected with careful sampling and a thorough collection technique furthermore following the theoretical saturation rule of qualitative research we sampled until no new information or insight was produced 26 employeesalso exceeding ten cases in consistence with the suggested valid range of case sampling our intention was to gain a first understanding of the employees habits needs and preferences regarding energy consumption and gamified apps we conducted a discussion starting from specific questions but the order of questions was changing according to the order of the subjects discussed we intended to elicit mostly spontaneous answers and we encouraged the participants to add their remarks in the end of the conversation as they saw fit moreover all information collected during the interviews was content analyzed and coded by three independent coders into categories pertaining to the present research a number of categories were decided upon ahead of time while other categories were identified based on the employees responses in the case of disagreement on the classification of any particular statement the disagreements were resolved upon joint discussion table 2 includes the questions used to stimulate the conservation respectively table 3 based on the interview results we can deduce a number of suggestions regarding the differences and characteristics that a gamified application towards energy conservation should respect first of all the varying roles of the participants in the three sites seem to affect their daily duties as well as their opportunities to act upon specific energy for example some need to print a lot of documents according to their duties while others not at all at the same time the employees in the exhibition area of the museum for example do not have access to many energy saving actions in general secondly working in a shared space presents further challenges towards designing a gamified app as the individual actions of the participants also affect their colleagues and therefore a level of cooperation towards common goals in the game may be preferable in these situations comfort levels are a parameter that also needs to be addressed as the actions of the participants in a game should not impede on the personal comfort of their colleagues or lead to tension and disagreements we should also take into account that some of the participants feel colderhotter than their colleagues and this issue should not preferably be exacerbated by an app interestingly when asked whether personal or collective actions have an impact on energy conservation at their respective workplaces the participants were somewhat equally divided indicating that the game should provide opportunities for both personal and collective actions to be acted upon the necessity of interviewing the prospective participants of a gamified app towards energy conservation was also demonstrated by the fact that different cases where energy is wasted are unanimously identified by the participants in the three different sites at the public office monitors and printers left on standby upon leaving at the energy agency lights and appliances left on afterhours and at the museum heating printers and elevators as per the main problems that employees identified at their respective workplace regarding energy consuming devices employees at the public office suggested that air conditioner temperature is not always set optimally lights are left on after operating hours or used when ambient light suffices screens and printers are left on standby mode when leaving and windows opened with the air conditioner on at the energy agency the air conditioner temperature may be very low during summer all lights are left on even when a few people are present in commonly used areasor when ample natural light suffices screens and printers are left on when unused excessive printing is reported coffee makers are often left on afterhours windows are opened with the air conditioner on and the elevator is overly used by the employees that avoid using stairs instead at the museum employees have no control over air conditioning lights or opening windows in the exhibition areas due to restrictions screens printers pcs and monitors are often left on standby mode and elevators could probably be used less all these actions can be targeted through a gamified app according to the specific needs of each site towards attaining the optimum behavioural effect on energy conservation as only some of the prospective participants in two of the three sites consider saving energy at work their own personal responsibility the ones that do could be selected as leaders in a teamplay scenario so that they can provide positive role models for their fellow team mates furthermore since both personal and collective actions are considered to have an impact on energy conservation by some of the participants a gamified app towards that end should instigate both individual as well as collective actions this is further supported by the fact that on all sites the majority of the participants prefer a collaborative game with team competition while the minority a competitive game featuring solo play the same stands for collective vs competitive goals an additional interesting finding is also that varying percentages of employees in the three sites believe that a reward is deserved for being energyefficient at the workplace as well as that the existence of even small rewards is motivating towards the same target therefore a gamified app would be more efficient through the inclusion of tangible rewards only for a percentage of employees depending upon the general trend on each site as well as their availability by employers the app could also selectively include these extrinsic means of motivation to adhere to each specific situation finally as only about half of the participants on all sites play games in general a gamified app featuring only basic game elements and not an overly complex narrative or gameplay could be more universally accepted as well as effective towards behavioural change through the interviewing process the participants also provided some additional interesting insight regarding what we should consider when designing a gamified app towards energy conservation at their workplace the most prominent suggestions were  every single small action is important but in the end only collective actions will have a really deep impact  we have to conserve energy responsibly for our future and because we want to do it not to collect rewards  if we combine all the small consumptions they may add up to a considerable amount of energy saving the information of how much each device consumes in standby mode should be provided to the users  in view of the great differences between the tasks of the museums staff i do not see any possibility for competitive games a collective goal can be more interesting  the game should have specific rules and a clear target  any awards should be divided between users based on their contribution in the game  the gamified system should not make people feel guilty about their energy consumption conclusion a body of research exists regarding energy conservation in public buildings due to their large share in energy consumption worldwide the use of ict has also been featured in a number of studies aimed at energy conservation in public buildings however the effect of such solutions is limited by the building occupants intentions to follow specific energy consumption behaviour gamification has been introduced in various contexts to instigate behavioural change including energy conservation initiatives where it has been utilised as a means to affect occupant behaviour the results from the relative studies have been mixed as well as difficult to compare due to the vast differences in both the actors and contexts characteristics aiming to amend this issue we have followed a structured process involving two steps onsite visits to prospective pilot sites as well unstructured interviews with a representative sample of the participants in future gamified apps aimed at energy conservation we have provided the questionnaire used in the interviewing process so that it can be used in future similar studies through our analysis we have discovered a number of contextual differences between the pilot sites as well as in the prospective participants available suggested and preferred actions towards energy conservation at their respective workplaces at the same time we have also gathered insight regarding the game related preferences of our participants in our field of application by combining all this information we can design a gamified application to better match both our future participants context as well as preferences leading to an overall bettersuited solution to a betterdefined problem therefore we expect the effectiveness of our resulting application to be enhanced compared to cases where neither the context nor the preferences of the prospective participants of a gamified app have been analysed in advance based on our findings we have identified the main elements that affect the design of a gamified application towards energy conservation in the three workplaces surveyed employee roles and daily routines existing limitations towards specific behaviours within the workplace the layout in the workplace existing employees comfort levels and different opportunities to conserve energy in each workplace affect the accessibility as well as impact of specific energy saving actions that can be included in a gamified app as per the app design itself in our pilot sites both personal and collective actions individual and team play should be considered whilesince only a few of the employees play gamesa basic game play could be more effective in energy behaviour change apart from its merits our study also bears some limitations first of all we have investigated our prospective participants by interviewing a sample of employees therefore our findings would be better grounded if we were given the opportunity to interview all of the employees at the sites we visited in addition we conducted the onsite visits only once in each site whereas a longitudinal study could provide more accurate results as well as additional insight not currently recorded finally and more importantly we expect that the validity as well as usefulness of the methodology we propose would be significantly enhanced by a practical application of our findings in an actual gamified energy conservation experiment that would be conducted in our surveyed pilot sites we aim to proceed towards this direction through our research in the future introduction recent statistics show that consumers are more committed to electronic commerce than ever the prediction is that 464 of all internet users worldwide will purchase products online in 2017 the growing interest in ecommerce also means that varying consumer emotions are likely involved before during and after online shopping encounters emotions are important during these encounters as alongside trust they attempt to moderate the relationship quality between the consumer and the service provider of online services new technologies can enhance the shopping experience but longlasting evidence shows that online users are individuals with unique characteristics and emotions almost two decades ago scholars indicated that affective and emotional dimensions truly matter as part of the consumer decisionmaking process onand offline emotions differ from similar concepts such as sensations and feelings and emotions are also initiated by some particular objects or events real or imagined and they tend to motivate particular kinds of behavior in this paper the focus is on eemotions which are seen as emotional states of a consumer that are somehow apparent and visible in an online environment consequently consumer eemotions matter at multiple levels of the service relationship including preand postconsumption stages thanks to the development of technology and the expansion of social networking environments the online environment has changed drastically in recent years making especially postconsumption behaviors more public for example electronic wordofmouth has a significant role in consumer emotion buildup and affects other consumers preconsumption stages the current development has led to the situation in which communication is also more dynamic and active than ever before active interaction between consumers stakeholders and organizations is part of the socalled engagement process additionally online users engage with various objects such as brands products and virtual brand communities these engagement processes are often accompanied by different emotions and behaviors that thus play a central role in ecommerce as well as in stakeholder relations in general although literature reviews of online shopping motives and intentions as well as of the adoption of computermediated services exist there is an emerging need to generalize the current state of the research related to consumer emotions in the context of online shopping as technology and consumer behavior are changing management must understand this development and identify possible consumers and customers pain points currently the research related to eemotions and ecommerce this study responds to this need and is implemented as an integrative literature review this paper is a preliminary attempt to gather the research literature related to consumer eemotions in the context of online shopping and the current state of the research across various disciplinesinformation technology psychology communication and marketingwas synthesized and analyzed by gathering previous articles published in peerreviewed journals the goal in this paper is to classify the literature related to the topic and through review and synthesis introduce the key findings this paper is organized as follows first the process of the integrative literature review is introduced second the relevant literature gathered during the process is assembled and the results introduced third the results are combined and the synthesis and analysis of the literature review are presented the key findings in the literature are addressed finally the validity and reliability of the study are discussed and suggestions for future research are provided methodology integrative literature review this study utilized the integrative literature review method integrative literature reviews balance between less structured descriptive literature reviews and more structured systematic literature reviews this method is a form of research that reviews critiques and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated although this study was integrative it followed finks model of systematic literature review consistently to add more validity and reliability the first step in fink model is to select the research questions this step is critical because the research questions aim the researcher in the decisionmaking process and address what kind of articles should be included this study answers the following research questions 1 according to previous literature what kind of research and studies have been put into practice related to consumer emotions in online shopping 2 according to the literature analyzed in this study what are the recent key findings related to consumer emotions in ecommerce the second step was selecting the databases from which to look for literature in this study the goal was to cover interdisciplinary literature related to emotions in ecommerce across the following disciplines information technology psychology communication and marketing the following bibliographic databases were utilized abiinform complete business source elite computer and information systems abstracts emerald insights proquest psychology journals and psycarticles 30 th bled econference digital transformation from connecting things to transforming our lives m lievonen consumer emotions and ecommerce a literature review after the databases were selected search terms were chosen search terms should frame the topic enough so the appropriate literature can be found however the framing should not be too tight the search terms were defined based on the research questions the literature searches were conducted in february 2017 advanced or multifield searches were used in the databases and the following search terms were applied in order to find relevant literature emotion and online and shop or ecommerce the search terms were restricted to be present in the key words or subject terms the author also applied the limitation of the search to peerreviewed content if this option was applicable in the databases in the advanced search options the proquest and ebsco databases offered this option and the emerald and american psychological association databases did not offer this option in the advanced search the input of the search terms in the databases gave the following results abiinform complete 73 results business source elite 13 results computer and information systems abstracts 73 results emerald insights 251 results proquest psychology journals 73 results and psycarticles 1 result as can be seen from the search results all proquest databases offered the same amount of literature the results were also similar in content so the three proquest databases were treated as one entity during the review process according to fink the preliminary literature searches usually give many results therefore it is important to screen for articles with certain criteria to find the relevant articles after the searches were conducted in the databases the practical screen and methodological quality screen was applied by executing following inclusion criteria peerreviewed journal articles published since 2006 and studies related to emotions in the context of ecommerce or online shopping the following research designs and content were excluded from the review literature reviews and conference proceedings the review was conducted in two stages in the first stage the headings and abstracts of the studies were read through this the most likely relevant literature to include in the final review was found as jesson et al suggested in the second stage the literature was scanned more thoroughly at this stage it was also important to analyze research designs findings and conclusions of the studies before deciding what literature should be included for the final review the articles in the review are shown in table 1 in the next section after the literature for the final review was apparent it was time to synthesize the results these conclusions are introduced in a more specific manner in the following sections where the content of the review is interpreted and analyzed the key findings of the studies are also reviewed more thoroughly in later parts of this paper results of the literature review after a careful scan of the available literature 66 peerreviewed articles were included in the final review studies that had interfaces with consumer emotions in the context of ecommerce were included this was evaluated through keywords and how at the same time the studies focused on the topic in a recognizable way in the research design andor findings articles that did not match the criteria or did not cover the topic clearly enough were excluded from the review the literature consisted of studies covering information technology psychology communication andor marketing the articles were classified into four groups studies related to website design characteristics or atmosphere and how they generally affect consumer emotions and behavior studies related to preconsumption emotions and predictors of consumers online shopping intentions and activities such as the effects of online user reviews studies related to consumer emotions during actual online shopping encounters for example decision making in purchase situations and studies related to consumer postconsumption emotions and behavior such as repurchase intention and commitment to ewom in general recent studies focused on consumer eemotions during all stages of the relationship this result supports the assumption that eemotions are not just restricted to the purchase or buying situation in fact consumer emotions and behaviors are under scrutiny in multiple situations people eagerly read reviews and participate in public discussion before making a purchase decision and even after the consumption stage there is a possibility that the experience turns either good or bad consumers possibly continue the service relationship disengage with the service provider or even engage in ewom after ecommerce encounters analysis of the key findings in the reviewed articles the literature was analyzed in the four groups the idea was to explore and compare the key findings within the groups and draw conclusions based on these findings the literature is presented in table 1 in addition the most relevant and synthesized key findings of the studies of each group and the authors are introduced as can be seen in table 1 the studies indicated that the research in eemotions is diverse and versatile moreover the perspectives in these articles were broad and interdisciplinary the studies explored consumer online emotions behaviors and their relations to ecommerce at multiple levels from prepurchase to postconsumption stages next this paper takes a closer look on the key findings presented in table 1 website design effects on consumer emotions according to the key findings in the articles in group 1 the website characteristics design and atmosphere usually have a major influence on consumers emotions as well as on behavior first cultural differences exist in emotional responses and perceptions in online shopping environments emotions are crucial in the perception stage of the atmospheric and characteristic cues of websites and affect consumers attitude toward the site level of involvement and purchase intention studies show a website that uses images of humans instead of generic cues stimulates higher levels of positive emotions and enjoyment music and colors used on these sites also have an effect on the emotional responses of potential customers and users product presentation and store layout are also important as they are emotionally valid characteristics and part of a pleasant shopping experience interestingly emotional trust has a role in influencing consumers purchase intention and cognitive and emotional responses play a key role in communication through the websites in addition website patronage intention is affected by pleasure arousal entertainment and esthetic experiences consumers receive preconsumption emotions according to the key findings in the articles in group 2 preconsumption emotions and expectations of certain ecommerce services are usually influenced by the information available online the information is often available through user reviews and through public discussion on social media and discussion forums however information overload has a negative effect on consumer emotions and thus affects purchase intention shortor longterm price drops significantly affect how consumers respond in public product reviews if online user reviews are inconsistent cognitive trust and emotional trust are affected as zhang et al claimed emotional trust most likely affects purchase intention anxious or enthusiastic online reviews are considered more helpful than angry reviews the amount of review manipulation also matters if there is proof that the potential ecommerce retailer has had severe trust violations in the past reconciliation efforts are meaningful when consumers ruminate on their potential options strategies for repairing trust are effective in building a positive mood which in turn is an important mediator in rebuilding consumer trust additionally positive emotions mediate the relationship between personalization and purchase intentions and the consumers experience affects these intentions as well however the reconciliation tactics should be moderate as consumers are affected by the tactics used moreover the severity of the trust violation also affects consumer perceptions how these efforts are documented and presented publicly is also important consumers seek this information and they evaluate the firms reputation so that they can be certain and trust the online shop they are going to use to create an emotional attachment to browsing and increase purchase intention online retailers should focus on consumer pleasure and community relationships hedonic choice options are also important as they are more strongly related to positive emotions and pleasurable experiences than utilitarian online shopping options even though hedonic performance expectancies are not always positively related to usage intentions cognitive and emotional responses as well as the interaction play a key role in communication through websites this also indicates how tempting the websites look to potential customers and how easy the sites are to use consumer emotions during actual online shopping encounters according to the key findings in the articles in group 3 emotional and rational routes as well as eservice quality influence consumers during the online shopping process not only highquality website design but also consumers product involvement elicits positive emotions during these encounters emotions encompass pleasure arousal and dominance and they precede cognition moreover a linear relationship exists between the level of interactivity provided by an online store and pleasure pleasure increases the likelihood of purchasing during the ecommerce encounters and at the same time consumers previous emotional experiences can affect their behavior in these circumstances using human brands and utilizing enhanced perceptions of human connections and the formation of emotional bonds could provide a competitive advantage for online retailers incidental moods tend to increase process impulsivity in online shopping decisions differences in users emotional experiences on ecommerce 30 th bled econference digital transformation from connecting things to transforming our lives m lievonen consumer emotions and ecommerce a literature review 395 websites are primarily embodied in subjective emotional ratings and eye movements mixed emotions are likely to lead to consumers leaving the stores a common issue for ecommerce retailers is that customers are not ready to proceed through checkout procedures for example emotions can have a significant impact on the decision to give personal information that is necessary to complete a purchase on a website the consumers online shopping cart might already be filled with various products but especially firsttime customers might be suspicious trust and distrust coexist in online ecommerce relationships and can result in ambivalence when they have high attitudinal values represented in emotions beliefs or behaviors use of the principles of web usability guidelines and trust indicators will improve consumers emotion about adopting ecommerce and increase the likelihood that consumers complete the checkout process the purchase encounter must be as reliable as possible because perceived risk in ecommerce has a significant negative effect on consumers satisfaction hedonic values and aspects are important for online store users hedonic values increase online impulse buying tendencies interestingly consumers who are under stress have a higher impulse buying tendency as well high or low hedonistic emotional commitment seems to be important to the perception of the usefulness of an online store for utilitarian products therefore it is important to offer a highquality web design interface and move toward enhancing consumers product involvement as they are also crucial for eliciting positive consumer emotions postpurchase emotions according to the key findings in the group 4 articles the postconsumption or postpurchase stages are crucial for ecommerce retailers customers and consumers tend to expect that after the purchase has been successfully executed the service relationship will continue ordered products are received on time and the product qualities are as expected positive emotions increase postsatisfaction which positively affects postpurchase intentions as well emotional stability moderates the relationship between the perceived usefulness of a website and satisfaction in online shopping emotions felt after visiting a website positively influence consumers perceptions of the website atmospherics that in turn influence a set of behavioral variables ending with intention to purchase again for example transaction cost advantage preview and trust significantly and positively affect satisfaction which in turn influences repurchase intention moreover satisfaction and perceived usefulness of the website contribute to individual online shopping continuance intention interestingly shopping habit increases the influence 30 th bled econference digital transformation from connecting things to transforming our lives m lievonen consumer emotions and ecommerce a literature review of emotional evaluation on continuance while at the same time habit weakens the impact of rational evaluation on continuance intention online shoppers excitement leads to positive wordofmouth and increases the intent to return moreover online service quality has a positive effect on satisfaction while also influencing directly and indirectly through satisfaction consumers behavioral intentions site revisit wordofmouth communication and repeat purchases although electronic wom has a positive direct effect on consumers intention to repurchase quantity has a negative influence thus it is necessary to monitor the tone of consumers public discussion during the postpurchase stage if service failures have occurred the switching intentions of consumers who are affected by negative emotions become stronger when the failures are controllable factors that could be managed and prevented however if consumers are treated in an appropriate way after the failure the studies show that distributive justice increases positive emotions and decreases negative ones furthermore negative emotions also affect repurchase intention in addition procedural justice such as received fairness from the company enhances satisfaction especially after the consumer has complained and the company seeks service recovery conclusions this study was a preliminary attempt to group and analyze peerreviewed journal articles related to consumer emotions in the context of ecommerce the author aimed at contributing to academia and practice and introduced four groups of the current state of consumer eemotions research in the context of online shopping groups 1 and 2 included studies on the effects of website design on emotions and studies on prepurchase emotions groups 3 and 4 included studies on actual online shopping encounters and their effects on emotions as well as studies on postpurchase emotions and behavior in addition the author synthesized and analyzed the key findings of the reviewed studies by recognizing the emerging need and timely challenge of understanding online users and their emotions better the goal of this paper was to increase the knowledge of the topic and the paper brought up new perspectives by combining the previous research findings according to the analysis consumer emotions are present at various stages of the ecommerce relationship for example website design and characteristics affect consumer emotions which in turn mediate site involvement in the preconsumption stage emotions initiate the purchase intention and during actual online shopping encounters positive emotions and trust increase the likelihood of purchases postconsumption emotions are also interesting as they mediate the behavioral responses of the consumer such as wordofmouth and intention to return to the web store 30 th bled econference digital transformation from connecting things to transforming our lives m lievonen consumer emotions and ecommerce a literature review 397 as a preliminary attempt this study has several limitations most noticeably the search terms and databases used in the process affected the availability of the reviewable literature using different search criteria and databases could naturally provide alternative results and guide the indications to alternative directions than presented in this paper however using similar search terms should be possible in almost any academic database and give similar results from a research method perspective an integrative literature review has advantages and disadvantages the most recognizable difference between this study and systematic reviews was the analysis systematic reviews aim at offering a systematic descriptive review analysis or even perform a metaanalysis while the goal of this paper was simply to combine the current state of the research in a condensed form and reconstitute the current knowledge by utilizing conceptual grouping the author also wanted to synthesize the results and analyze the key findings with flexibility in mind to add something new to the topic as baumeister and leary suggested reviews that were conducted too systematically and mechanically might lack essential details additionally integrative literature reviews do not have to differ much from systematic reviews if they follow a clear pattern and utilize a structured methodological grasp the author accomplished this by implementing finks systematic method diversely during the review process these actions also added credibility and validity to the study this mixed approach was also flexible as the literature related to the topic was fragmented across various fields and disciplines finally yet importantly the authors goal was to follow torraco who implied that an integrative literature review has an important role in stimulating future research on the topic as the tendency of positive and negative consumer eemotions in ecommerce is still somewhat unclear the author suggests that future studies should answer the following research questions what usually causes positive emotions in the context of ecommerce when customers are motivated and intend to buy from an online store what emotions are present when consumers have negative ecommerce experiences what prevents consumers from buying from an online store introduction in several prior studies technology readiness has been found to significantly influence the acceptance and use of information systems typically individuals who rank higher in terms of tr have been found to be more apt adopters of is in contrast to those whose ranking is lower however in spite of this central role tr has gained relatively little attention in is research for example little is known about how tr varies in terms of different demographic variables and how these demographic variables moderate the effects of tr on is acceptance and use as well as its main antecedents in this study we aim to address this gap in prior research by examining the aforementioned issues in the case of one highly important demographic variable age age is a demographic variable that has been of high interest in several prior studies on is acceptance and use for example in the wellknown and widely used unified theory of acceptance and use of technology by venkatesh et al as well as its extension utaut2 by venkatesh thong and xu age is hypothesised to act as an important moderator for the effects of various antecedent constructs on is acceptance and use however no studies that we are aware of have examined age as a moderator for the effects of tr on is acceptance and use as well as its main antecedents we conduct our examination in the case context of online electricity services offered by electric suppliers which allow their customers for example to manage their electricity contracts and track their electricity consumption over the internet such services have become increasingly common in the recent years and offer an ideal case context for the current study because they are often used by individuals with a widely varying age range the only main exceptions are typically the very youngest and the very oldest individuals who either still live at their childhood home or live in some sort of communal accommodation such as a student apartment or a retirement home as a theoretical framework for conceptualising and operationalising is acceptance and use its main antecedents as well as tr we utilise the technology acceptance model by davis and the technology readiness index by parasuraman which have also been integrated together in several prior studies this paper is structured as follows after this brief introductory section the theoretical foundation of the paper is discussed in section 2 after this the methodology and results of the study are reported in sections 3 and 4 the results are discussed in more detail in section 5 concentrating especially on the implications for the socalled young elderly segment consisting of individuals aged 6075 years finally section 6 considers the limitations of the study and some potential paths of future research tam by davis is an adaptation of the theory of reasoned action by fishbein andazjen to the is context which posits that the acceptance and use of a particular system can be best predicted by the use intention towards it use intention in turn is hypothesised to be predicted by two main antecedents associated with the perceived system characteristics perceived usefulness which has traditionally been defined as the degree to which a person believes that using a particular system would enhance his or her job performance and perceived ease of use which has traditionally been defined as the degree to which a person believes that using a particular system would be free of effort the more useful and easier to use a particular system is perceived to be the higher should be the intention to use it in addition perceived ease of use is hypothesised to act as a predictor of perceived usefulness so that systems that are perceived as easier to use should also be perceived as more useful these hypotheses are illustrated in figure 1 although tam was originally developed to explain and predict is acceptance and use only in the organisational context it has since been applied also outside it to promote its applicability to other contexts numerous extensions to the original tam have been suggested such as tam2 and tam3 as well as the aforementioned utaut and utaut2 in this study we utilise only the original tam as our theoretical framework for conceptualising and operationalising is acceptance and use as well as its main antecedents because we consider it highly applicable to our current case context of online electricity services which can be characterised as utilitarian selfservice technologies thus their use intention is likely to be influenced mostly by the usefulness and ease of use aspects included in the original tam rather than for example the more hedonic social and resource related aspects added to it in extensions like utaut and utaut2 however like many prior is studies we omit the empirical examination of the linkage between use intention and actual use because this would have required a longitudinal rather than a crosssectional study setting which was not possible due to practical reasons as a theoretical framework for tr we utilise tri by parasuraman which defines tr as peoples propensity to embrace and use new technologies to accomplish goals in home life and at work and postulates it to comprise of four coexisting dimensions defined as follows  optimism a positive view of technology and a belief that it offers people increased control flexibility and efficiency in their lives  innovativeness a tendency to be a technology pioneer and thought leader  discomfort a perceived lack of control over technology and a feeling of being overwhelmed by it  insecurity distrust of technology stemming from scepticism about its ability to work properly and concerns about its potential harmful consequences of these four dimensions optimism and innovativeness are hypothesised to increase tr whereas discomfort and insecurity are hypothesised to decrease it tam and tri have also been integrated together in several prior studies for example in their technology readiness and acceptance model lin shih and sher examined the effects of the aggregate tri construct on tam constructs whereas the studies by walczuch lemmink and streukens as well as godoe and johansen concentrated on effects of the four composite tri constructs hypothesising optimism and innovativeness to have a positive effect on pu and peou and discomfort and insecurity to have a negative effect on them in this study we follow this latter approach by examining the individual effects of the four composite tri constructs on not only pu and peou but also use intention because in the study by lin and chang tr has been found to affect use intention not only indirectly through pu and peou but also directly this research model is illustrated in figure 2 methodology to examine the potential age differences in tr and its effects on is acceptance and use we conducted a selfadministered online survey targeted at finnish consumers between december 2015 and january 2016 due to the case context of the study the survey was promoted via the online channels of two electric suppliers as well as via the internal communication channels of our university and several discussion forums to raise the response rate also several gift cards with a total worth of 356 € were raffled among the respondents in the survey questionnaire the 9 items measuring the three tam constructs of perceived usefulness perceived ease of use and use intention were adapted from davis as well as davis bagozzi and warshaw whereas the 16 items measuring the four tri constructs of optimism innovativeness discomfort and insecurity were adapted from the tri 20 scale by parasuraman and colby the exact wording of each item translated from finnish to english is presented in appendix a all the items were measured on a fivepoint likert scale ranging from 1 to 5 more information about mplus can be found in its users guide and technical appendices as the model estimator we used the mlr option of mplus which stands for maximum likelihood estimator robust to nonnormal data the missing values in the construct indicators were handled by using the fiml option of mplus which stands for full information maximum likelihood and uses all the available data in the model estimation the potential age differences in the construct means and regression relationships were examined by dividing the sample into three age groups with an approximately equal age range and using multiple group analysis results the conducted online survey was completed by a total of 1370 respondents however to promote the quality of data 194 of them were excluded from the final sample in two phases first we excluded 124 respondents who had not reported being customers of any electric supplier and thus were not likely to be able to give reliable assessments on the online electricity services offered by the companies to their customers second we also excluded an additional 70 respondents who had reported missing values in all the items measuring the three tam constructs this resulted in a final sample size of 1176 respondents to be used in the model estimations descriptive statistics of this sample are reported in table 1 all in all the gender and age distributions of the sample corresponded quite well with those of the adult finnish population at the end of 2015 which are reported in the final column of would be no adverse effects on the content validity of the two constructs that they were measuring we decided to eliminate them and to reestimate the model in the reestimated model all the indicators now met the criterion or at least were very close to meeting it meaning that the reestimated model could be considered to exhibit satisfactory indicator reliability and validity construct reliability and validity construct reliabilities were evaluated by using the composite reliabilities of the constructs with which it is commonly expected that each construct should have a cr greater than or equal to 07 in order for it to exhibit satisfactory reliability the cr of each construct is reported in the first column of table 2 as can be seen all the constructs met this criterion in turn construct validities were evaluated by examining the convergent and discriminant validity of the constructs which were evaluated by using the two criteria proposed by fornell and larcker they are both based on the average variance extracted of the constructs which refers to the average proportion of variance that a construct explains in its indicators in order to exhibit satisfactory convergent validity the first criterion requires that each construct should have an ave greater than or equal to 05 meaning that on average each construct should explain at least half of the variance in its indicators the ave of each construct is reported in the second column of table 2 as can be seen all the constructs except for dis and ins met this criterion however they this correlation was expected due to the hypothesised effect of peou on pu in tam and thus does not warrant the elimination of either of the constructs estimation results figure 3 presents the standardised estimation results of the research model which was able to explain 564 of the variance in int 793 of the variance in pu and 312 of the variance in peou the effects between the three tam constructs followed the hypotheses of tam with the exception that peou was actually found to have a negative although a very weak and statistically not significant effect on int in contrast the effect of peou on pu as well as the effect of pu on int were both found as positive and statistically significant this also caused the total effect of peou on int which takes into account both the direct and indirect effects to be positive and statistically significant opt on int to be 0316 all these effects were statistically significant the second tri construct inn was found to have positive effects on int and peou but surprisingly a negative effect on pu causing the total effect of inn on int to be 0179 in this case as well all these effects were statistically significant the third tri construct dis was found to have a negative effect on peou but surprisingly positive effects on both int and pu although these two latter effects were weaker than the former one they were all statistically significant however they caused the total effect of dis on int to be only 0051 which was statistically not significant finally the fourth tri construct ins was found to have negative effects on both int and pu but surprisingly a positive effect on peou which was the only one of these effects that was statistically significant however the total effect of ins on int was only 0036 which was statistically not significant the goodnessoffit statistics of the model are reported in the topright corner of figure 3 as can be seen the χ2 test of model fit rejected the null hypothesis of the model fitting the data however instead of actual misfit this may have been caused by the tendency of the test to underestimate the fit especially in the case of large samples and more complex models for this reason also four alternative fit indices were used to evaluate the fit the comparative fit index the tuckerlewis index the root mean square error of approximation and the standardised root mean square residual their values clearly fulfilled the commonly accepted cutoff criteria meaning that the model could be considered to exhibit a good fit with the data age differences in construct means and regression relationships in order to examine the potential age differences in the construct means and regression relationships we first divided the sample into the age groups of under 40 years 4059 years and 60 years or over and then tested whether a sufficient level of measurement invariance existed across the groups to allow meaningful comparisons between them at the minimum the comparison of the regression coefficients requires the existence of configural and metric invariance whereas the comparison of the construct means requires the existence of configural metric and scalar invariance the testing followed the method formalised by steenkamp and baumgartner in which increasingly strict constraints on parameter equality are added across the groups and the fit of the resulting constrained model is compared to the fit of the unconstrained model as the main test criterion we used the χ2 test of difference corrected with the satorrabentler scaling correction factor due to the use of the mlr estimator however because the χ2 test of difference suffers from a similar sensitivity to sample size and model complexity as the χ2 test of model fit also the changes in the four aforementioned fit indices were considered as suggested by steenkamp and baumgartner the results of the tests are reported in table 3 as can be seen the fit of this full configural invariance model remained approximately as good as the fit of the model without the group separation thus the hypothesis on full configural invariance was accepted second metric invariance was tested by constraining also the indicator loadings equal across the groups and comparing the fit of this full metric invariance model to the fit of the previous full configural invariance model as can be seen the χ2 test suggested no statistically significant deterioration in the model fit 42862 p 0095 which was supported by the four fit indices as well thus also the hypothesis on full metric invariance was accepted third full scalar invariance was tested by constraining also the indicator intercepts equal across the groups and comparing the fit of this full scalar invariance model to the fit of the previous full metric invariance model as can be seen in this case the χ2 test suggested a statistically significant deterioration in the model fit 192894 p 0001 which was supported by the four fit indices as well thus the hypothesis on full scalar invariance was rejected as a result of this we tested for partial scalar invariance by relaxing the added constraints concerning the equality of indicator intercepts one by one based on the highest modification indices of the model and comparing the fit of these the results of the comparisons of the construct means are reported in table 4 the first and the second columns list the differences in the construct means of the age groups of 4059 years and 60 years or over in comparison to the age group of under 40 years as well as their statistical significance whereas the third column lists the differences in the construct means of the age group of 60 years or over in comparison to the age group of 4059 years as well as their statistical significance all the reported differences are unstandardised in order to ease their interpretation as can be seen of the four tri constructs statistically significant differences were found in case of all the constructs except for ins finally we tested for the invariance of the regression relationships by constraining also the regression coefficients equal across the groups and comparing the fit of this full path invariance model to the fit of the previous partial scalar invariance model as can be seen from table 3 the χ2 test suggested no statistically significant deterioration in the model fit 37993 p 0150 which was supported by the four fit indices as well although there was a significant increase in the value of srmr thus the hypothesis on full path invariance was accepted meaning that there were no statistically significant differences in the effects of the tri constructs on the tam constructs or on the effects of pu and peou on int as well as peou on pu across the groups discussion and conclusions in summary the findings of this study on the potential age differences in tr and its effects on is acceptance and use suggest several differences in the tri constructs of optimism innovation and discomfort but no differences in the effects of any of the tri constructs on the tam constructs of pu peou and int all in all the effects of the tri constructs on the tam constructs were found to be in line with those found in prior studies which have also suggested optimism and innovation having the strongest effects on pu and peou whereas the effects of discomfort and insecurity have typically been weaker and often statistically not significant from a theoretical perspective the findings of the study promote the understanding on the effects of tr on is acceptance and use by considering also the vital role of various demographic variables like age this promoted understanding can be utilised for example to better explain and predict the potential differences in the antecedents of is acceptance and use as well as in is acceptance and use itself between various user segments respectively from a practical perspective the findings of the study can be utilised by is developers and marketers to promote the acceptance and use of the newly introduced systems and services especially in user segments that have traditionally been found more challenging in terms of is adoption one example of such a segment is the socalled young elderly segment which consists of individuals aged 6075 years and has often been overlooked for example in the development and marketing of digital services in spite of its vast market potential this segment can be considered as practically equivalent to the age group of 60 years or over in this study because although this age group contained also individuals that were older than 75 years about 95 of the individuals in it were aged 75 years or younger thus if we use the age group of 60 years or over as its proxy the findings of the study suggest that the young elderly segment is characterised by a slightly lower level of technology optimism in comparison to the individuals aged under 40 years and also a considerably higher level of technology discomfort especially in comparison to the individuals aged under 40 years but also in comparison to individuals aged 4059 years in addition the young elderly segment seems to be characterised by a lower level technology innovativeness in comparison to individuals aged 4059 years thus in spite of being on par with the younger individuals in terms of technology insecurity this all suggests that individuals in the young elderly segment have a somewhat lower level of tr in comparison to younger individuals which should be taken into account if one wants to maximise the acceptance and use of the newly introduced systems and services in this user segment of the aforementioned differences the most important ones are obviously the differences concerning technology optimism and innovation because these two tri constructs were the ones that were found having a statistically significant total effect on the intention to use is when considering both the direct and indirect effects on it consequently when developing and marketing new systems and services to the young elderly segment special attention should be paid to making them as easily approachable as possible for also people who are typically not at the forefront of adopting new technological innovations as well as to highlighting the benefits that the usage of these new systems and services can bring to their everyday lives the strategies that aim at doing this may include for example marketing and advertising campaigns as well as various technological solutions such as the usage of tutorials which lower the threshold to trial the systems and services and make their overall learning curve less steep the implementation of such strategies is likely to result in two synergetic advantages first in the short term they are likely advance the adoption of the systems and services amongst the users in the young elderly segment with a lower level of tr second in the long term through this adoption they are also likely to advance the level of tr in the whole young elderly segment especially if the use experiences of the adopted systems and services are positive and they are able to fulfil the user expectations towards them limitations and future research this study can be seen to have three main limitations first the study was conducted by analysing the survey data collected from only finnish consumers which obviously limits the generalisability of its findings to other countries and cultures second the study was conducted in the case context of online electricity services which poses limitations on the generalisability of its findings concerning the effects of the tri constructs on the tam constructs but not on the generalisability of its findings concerning the mean differences in the tri constructs themselves since their measurement was conducted independently of the case context in question finally the third main limitation of the study stems from the selection of tam as the theoretical framework for conceptualising and operationalising is acceptance and use as well as its main antecedents which obviously omits the antecedents that have been added to the original tam in its subsequent extensions such as utaut and utaut2 however as already stated in section 2 we consider this selection welljustified because of the utilitarian case context of the current study future studies should aim to address the aforementioned limitations by replicating the study also in other countries and cultures as well as in the case context of other types of is the selection of the case context should also be reflected in the selection of the theoretical framework for conceptualising and operationalising is acceptance and use as well as its main antecedents in addition to age we also encourage future studies to concentrate on examining the potential differences in terms of other interesting and important demographic variables such as gender and income it is likely that i will use the eservices in the following year pu1 using the eservices to manage my electricity affairs would be convenient pu2 using the eservices would make it easier for me to manage my electricity affairs pu3 i would find the eservices useful in managing my electricity affairs peou1 i would find the eservices easy to use peou2 my interaction with the eservices would be clear and understandable peou3 learning to use the eservices would be easy for me opt1 new introduction internet with its promise for lowering the cost potential for increasing the quality of services and efficiency enabled a rapid development for ebusiness nevertheless the possibility that anyone can have a web page with almost no investment has presented a huge opportunity for creating and advertising business online the promise of reaching a global market no matter neither the size nor location of the organization seems to raise the hope of many companies therefore in the last few decades almost every company has been trying to leave some presence in the world wide web mostly due to the promise of no matter how small you are there is a whole world for you the globalization of markets was believed to supplant the multinational commercial and corporations the future was in offering the same things in the same way everywhere since the global corporations should operate as if the whole world is a single entity technological progress made this future even more real nowadays ecommerce is having a larger share of commerce in more and more regions yet the promise of internet and the possibility to reach the whole world was not equally successful for all in the digital era there are again some global organizations dominating the world while contrary there are several market leaders in local markets that are completely unknown outside their local region the same applies to the providers of different online platforms offering vouchers tourism services auctions and web browsers or social media as well despite having global online platform providers like groupon airbnb ebay google and facebook there are several local online providers in different regions more than successfully facing with the global well known competitors within their regional borders the purpose of the research is thus to examine the factors that influence the success of local online platforms the aim is to identify the reasons why some local online platform providers that have been market leaders failed while other local providers remained successful or even a market leader in a local environment despite the existence of global wellknown providers this researchinprogress paper will present a research program together with the methodological steps that will be performed in our research therefore the paper is divided into two main parts firstly a short literature review is presented followed by the methodology and a research plan finally some concluding remarks and future research possibilities are outlined digitalization the digitization initiative began decades ago however it has become more prevalent in the last years and will certainly have an important effect in the next decades it is becoming the most significant technological trend with global consequences since it is affecting individuals organizations communities and entire regions it is believed that digital transformation will change business processes customer experience and the entire business models due to the more and more information available for individuals and organizations and therefore enables to perform activities even more efficiently it was even claimed decades ago that business models from the industrial age were not suitable anymore to deal with the forthcoming challenges of the information age the same may be valid today where past business models are not suitable to deal with the challenges of the digital transformation era moreover innovative business models were namely claimed to be one of the most important reasons for the success of several organizations tightly connected to the online business like amazon microsoft or ebay however is it merely about the innovative business models are innovative models enough to penetrate to global market or to become a global leader digitization is spreading out in almost all industries sectors and therefore it is anticipated that there will be even more online competition in a global market hence the question about important factors needed for local companies to survive in a digital world becomes more important as ever before local versus global providers the debate about local and global providers has its roots in the glocalization concept it has been denoted as a mixture of globalization and localization balancing the universal of globalization and the particular of localization ideas of glocalization are mainly associated with the international contexts however glocalization can be also related to the understanding of cultural differences within regional and national boundaries several key areas were distinguished in relation to when and how different cultures access information or use the technologies including literacy linguistic difference physical environment cultural norms and technological infrastructure all these areas and specifics should be considered when launching new web services or online platform in local market even in japan the second strongest provider is with 40 share much above the global average while google with its 57 much below the average at the moment there is an increasing pressure on global services providers to grow along with the needs of their customers in order to offer classier range of services both in terms of extent and geographic coverage research program we decided to delve into this issue with a research program that will identify and validate the factors that influence the likelihood of the success of a local online platform and build a framework for successful deployment of local online platforms when competing with global online platforms different research methods will be used in several steps the first step of our research will be a focus group by which we will be able to clearly define the outline of our further research the focus groups are restricted to early exploratory stages of research they offer an insight to the discussed topic the focus group will consist the second step will be based on the literature review and results from focus groups we will conduct a delphi study with the goal to identify the factors for success of local online platform providers when competing with global online platform providers delphi study is a group iterative method that uses controlled opinion feedback group of respondents it can be used in management disciplines to shape a group consensus of relative importance of issues by using a ranking system it can also be used as a method for concept or framework development the delphi study will include two separate groups one group will be practitioners from the field of online platforms while the other group will be the expertsresearchers this split panel approach is advocated because of the ability to create a joint reality shared by both groups the number of steps in the delphi study will depend on how fast the consensus will be reached while some authors suggest that a certain percentage of participants in the study need to reach consensus other authors suggest a more qualitative approach to estimate when consensus is reached the delphi study will be designed based on the principles presented in after identifying the factors for success of local online platform providers we will conduct several indepth case studies of local online platforms case studies are used in research which is still in the process of understanding detection and characterization the case studies will be used to verify the identified factors for success of local online platforms by analysing real companies conclusion the companies that are offering local online platforms often have to compete with global online platform providers the purpose of the research is to identify and examine the factors that influence the success of local online platforms when competing with global online platforms contrary the research will also ease the understanding when creating local online platforms has no potential our research will include several steps that will help us rigorously identify the factors and verify them introduction the advent of information and digital technologies the time characterized by use of information and communication technologies as well as mushrooming of new digital technologies their adoption and use presents a new form of transformation digital transformation in business organizations this form of organizational transformation which is technologyenabled is concerned with the use of information and digital technologies to impact different aspects of the organization for example organizations adopt emerging technologies such as social media mobile technologies internet of things cloud technologies big data analytics etc to enhance their daily operations as a result these technologies transform the way business entities operate creating value and bringing different experiences to various stakeholders involved several studies have been carried out to demonstrate how organizations and industries have adopted digital technologies as well as demonstrating their transformational impacts an mit sloan management review research report revealed that 78 of executives and managers across various industries believed achieving digital transformation would be critical to their organizations another study by harvard business review analytics services revealed that 50 of business and technology leaders said their organizations were already missing out on new technologyenabled business opportunities berman argues that the key transformational opportunities are creating new business models improving operational processes and enhancing customer experiences bharadwaj etal reflect on digital transformation era as a time for organizations to rethink the role of it strategy from that of a functional level strategy to one that integrates it strategy and business strategy all these indicate how organizations are increasingly being involved in digital transformation in fact in todays digital era digital transformation has become an everyday agenda item in business boardrooms as a result of this the digital transformation phenomenon has created new research interest across different disciplines although substantial amounts of work is ongoing in this area this study reveals that research carried out in this regard is still at a nascent stage there are indications of an immature literature landscape coupled with a limited understanding of the phenomenon the few literature review papers on digital transformation that were encountered during our search while some researchers associate digital transformation with business models and strategy others view digital transformation as a paradigm or as a process in light of this we argue for the extension of literature that describes and articulates the phenomenon of digital transformation what it is how it behaves what drives it what impacts it creates as well as where the impacts are felt we believe that a solid foundation for this phenomenon is required to this end a systematic literature review is carried out and a concept centric matrix is developed drawing on this matrix a more inclusive and general definition is constructed the selection of keywords in this comprehensive definition of digital transformation is explained and avenues for further research are also highlighted methodology a scholarly literature search was performed with the aim of retrieving credible peer reviewed and academic research articles in this area 3 articles retrieved were scrutinized to extract similar traits and patterns that build up towards the phenomenon where variables such as description of what is characteristics drivers impacts and transformed areas were identified as constructs to the fundamental conceptualization of the phenomenon the concept centric matrix process was adopted to synthesize the retrieved articles this process was carried out within the period of march to october 2016 using gass etal s 4 phase approach to literature analysis table 1 below illustrates the approach and how it was utilized in this review the literature search yielded many articles criteria from the screening processes were applied to narrow the search and set the final inclusion and exclusion criteria for searches that yielded many results the search was sorted according to relevance and only first 10 results were considered on analysing the metadata articles that did not meet the criteria set were excluded while there was a deliberate focus on articles published in the basket of 8 articles from other peer reviewed sources and academic conferences were also considered articles included in the final selection were then downloaded and perused in more detail analysis revealed that some of the articles retrieved stated the definition of digital transformation also giving different descriptors such as characteristics drivers impacts and transformed areas while others gave a perspective approach of what digital 2 summaries the type of articles downloaded defining each type the number of articles in each type that provided the definition of digital transformation as well as the total number of articles downloaded for each type digital transformation the current situation an indepth analysis of the articles was carried out to determine how authors describe digital transformation in this process retrieved articles were used to identify the definition characteristics drivers impacts and the transformed areas as articulated by the authors a concept centric matrix was developed to capture the different variables for each construct as they are identified table 3 is an illustration of the concept centric matrix developed from analysing these articles a further indepth analysis of both concept centric matrix and the current definitions revealed that there are significant differences regarding how digital transformation is conceptualised nevertheless a common pattern has been identified in the structure of digital transformation definition which suggests how the keywords and variables have been used to describe the concept to qualify and refine this pattern an iterative process was carried out several times alternating different variables and keywords in order to attain a more precise yet general structure of the definition after several iterations we propose a pattern that suggests that digital transformation is … something with certain characteristics that is driven by something to create certain impacts on certain aspects of the organization using the proposed definition structure we illustrate the inconsistencies in the literature of this phenomenon using both concept centric matrix and current definitions in order to reconcile these differences and square this circle we draw upon these tables to construct an inclusive and general digital transformation definition characteristics of digital transformation the literature assessed views characteristics of digital transformation as behavioural traits displayed by this phenomenon different authors used adjectives to describe these traits perhaps because of the long term impacts digital transformation have on business organizations from the analysis only a few of the articles described the digital transformation phenomenon in terms of its behavioural characteristics however notwithstanding the few descriptions these characteristics could not be ignored because they serve a purpose of putting into perspective the extent of the impact that is created during the transformation whether the impact is small or large gradual or abrupt etc in this instance the analysed literature characterizes the behaviour of digital transformation as radical disruptive evolutionary continuous and complex we propose that for a more inclusive and comprehensible description digital transformation displays more of an evolutionary trait drivers of digital transformation drivers of digital transformation are attributes that influence and enable the process of digital transformation to take place although insufficient the existing literature identified attributes such as digital capabilities and maturity digital technologies strategies business models etc as factors that drive the digital transformation agenda in organizations ezeokoli etal notices that several studies have articulated digital transformation drivers as profitability and new revenue growth customer satisfaction increased operational efficiency convenience and the same highquality technical standard increase business agility increased employee productivity and competitive advantage while it was also observed that in some instance there was an overlap between digital transformation drivers and impacts caution was exercised to separate the two such that drivers remain attributes that influence and enable while impacts are emerging benefits realised from the process of digital transformation however while it is arguable which attribute would be possessing more digital drive we argue that digital technologies play a vital role in the digital transformation process we believe the capabilities that these technologies possess coupled by other factors such as culture strategy and digitally savvy human capital is what enables the digital transformation process kane etal argue that simply using digital technologies to drive the digital transformation process is not enough and that it also uses digital capabilities strategies culture and talent development impacts of digital transformation digital transformation impacts are the effects that business organizations experience as a result of the transformation process while analysed literature has not classified these impacts we categorize these impacts into customerfocused and organizationfocussed categories customer focused are the effects that impact customers and organizationfocussed impact the organization itself we further argue that these impacts can have a positive or negative effect on both the customer and the organization different studies have used different verbs to describe actions that digital transformation has on organizations however we believe the ultimate impact that organizations want to leverage on digital transformation is value creationto both the organization and customers 30 transformed areas different authors identify different areas which are impacted during the digital transformation process westerman etal alludes that digital transformation takes places in three key areas of the firm customer experience operational processes and business models suggesting that the effects of digital transformation in business organizations are felt in these three key areas while westerman etal allege that these three key areas are what business leaders focus the enterprises transformation efforts towards from an orchestrating the organization lens it is established that not all key elements that ensure a perfect organizational orchestration have been included for instance bouee argue that employees should not be left out in the digital transformation journey other researchers including matt etal bharadwaj etal etc demonstrate how digital transformation impacts organizational structure while piccinini loebbeck picot etc allude that digital transformation impacts relationships in determining the transformed areas we however argue that as the benefits of digital transformation are to be felt by both the organization and the customers it is important to ensure that the transformed areas considered for the general description of digital transformation should be inclusive of both organization and customer we therefore propose that westerman etal s three key transformed areas are more general and inclusive of both the organization and customer the process was repeated several times alternating different keywords and variables to ensure rigor and relevance in the proposed definition it is after iterating several times that the definition below was proposed digital transformation is an evolutionary process that leverages digital capabilities and technologies to enable business models operational processes and customer experiences to create value towards a more comprehensive understanding of digital transformation this section discusses the concepts used in our proposed definition and further describes the meaning of each concept table 6 gives a simple definition of each of these concepts and subsequently a justification is provided of why each concept was selected for inclusion in the definition liu etal 2011 bharosa etal 2013 while digital transformation was referred to as a radical change more than as an evolutionary process we believe an evolutionary process is a more inclusive term that captures the fact that digital transformation evolves with time and whenever this evolution takes place the impacts bring about a radical change to the organization also digital technologies as key drivers of digital transformation are in their nature evolving while earlier forms of digital transformation entailed the introduction of computer based systems and automation of processes present day digital transformation is more concerned with adoption and use of emerging technologies which are in their nature evolving drivers of digital transformation digital capabilities specifies that in order to thrive in a digital transformation journey organizations require particular skill set mindset and culture that is digital we argue that relevant skill set and culture digital capabilities should be incorporated with digital technologies to achieve the best digital transformation results the second key driver identified in our definition digital technologies indicates that at the foundation of all digital transformation efforts are digital technologies for technology enabled organizational transformation to take place technology based systems are at the core of the effort digital technologies create opportunities that organizations leverage these opportunities have the potential to transform certain aspects of the organization especially business models operational processes and customer experiences as a result the organization benefits from impacts of this transformation impacts of digital transformation value creation is identified as the key impact brought about by digital transformation this value is realized by both the organization and its transforming our lives key transformed areas of digital transformation business models operational processes customer experiences are acknowledged as the key transformed areas of digital transformation initiatives focusing transformation on these 3 key areas naturally engages transformation in other aspects of the organization thus enabling the transformation impacts to be felt across the organization for example transforming operational processes within the organization has the potential to create an impact in other aspects of the organization such as improving efficiency costs saving for both the organization and the customer resulting in value creation conclusion this study has highlighted the lack of a unified and overarching definition of digital transformation as well as inconsistencies in the existing literature in order to address this gap a systematic literature review was carried out in order to conceptualize this phenomenon a concept centric matrix was used to describe the phenomenon in terms of what it is its characteristics its drivers impacts and the transformed areas inconsistencies in the definition are also identified and a new and more inclusive definition of digital transformation is constructed and explained other gaps that have been identified during the literature review process include insufficient literature on transformational effects of digital technologies on different aspects of the firm and as well as specific to industries while digital transformation involves the use of digital capabilities and technologies to impact different aspects of the organization in order to create value it is also important to understand specifically how different types of digital technologies paired with capabilities impact particular aspects of the organization moreover it is important to understand the nature of the value that is created through this transformation such research would have significant impact on both theory and practice introduction in nigeria studies have shown social medias influence in different sectors such as education health promotion security issues political participation fink kopecky bos and thomas described how certain aspects of an online population can be characterized however there is a paucity of research in the context of social commerce which is the focus of this study nigeria has a potential for social media and mobile commerce as the facebook users in nigeria increased to 16000000 which account for 84 of its population this datum makes nigeria one of the leading facebook users in africa also nigeria is advancing in mobile commerce and its ultraconnected population is impacting the revenue of the mobile commerce merchants averagely nigerians are online once every hour and 20 use the internet at least ten times a day mobile commerce is growing with innovative addon feature that is influencing the existing value networks and turning around the global economy one of the leading appurtenances of mobile commerce is social media the union of mobile commerce and social media is multifarious and involves different actors such as online retailers customers service and content providers and regulators across various business sectors mobile commerce entails mobile devices social media and mobile applications kaplan and haenlein classified social media into six groups such as social networking sites virtual social worlds blogs collaborative projects content communities and virtual game worlds in 2009 the estimation of facebook active users reached 175 million but according to the facebook active users realtime counts on the internet in february 2017 the users number has soared to 18 billion in the space of eight years between 2009 and 2017 there was an increase of 16 billion facebook active users this is more than the population of many countries in the world for example china whose population is now 13 billion this implies justifications of fusing mobile commerce with social media because of its capability to hold a large online community the sudden surge of facebook active users is an interesting insight for mobile commerce vendors to capitalize on for customers engagement sales conversation and profit making some authors have impacted the body of knowledge in the context of mobile commerce in nigeria and social media as a separate research domain discovered a gap in social media data collection and analysis and came up with a computational model that combined the strength of topic and sentiment classification to draw out consumer perception on important subjects in social media on the other hand kaplan and haenlein endeavoured to clarify the notion about the real meaning of social media in comparison with close concepts like web 20 and user generated content and apprise the companies that wish to adopt social media with the major points of advice despite the contribution of recent studies there is still need for more academic impact in the research stream of social commerce the different researches that focused on the topics relating to the union of mobile commerce and social media are rare and statistical reputation in the developing country such as nigeria actuate further study of mobile social commerce studies have fused social media and mobile commerce this study seeks to use hybrid approach that combines different methodology and data analysis techniques we used netnography a form of online participantobservational technique the study also employed sentiment analysis for mobile commerce facebook followers opinions sentiments evaluations appraisals attitudes and emotions towards entities such as products and services this paper is guided by a general objective to analyse the interwovenness of mobile commerce and social media with these specific objectives to state the importance of social media in online shopping to analyse online facebook reviews sentiment and examine customer service to develop an explanatory theory that associates mobile commerce with social media theoretical framework appraisal theory claims that people evaluate the personal meaning of an exciting event or events before emotional responses are generated the appraisal theory of emotion has been used to examine the relationships between appraisals consumption emotions and postconsumption behaviors the form and emergence of emotions depend on cognitive appraisal process which are their byproducts bloom said the theory of appraisal shift sentiments classification further and considers the assessment expression as a basic grammatical unit by which an opinion is expressed opinion are classified in previous studies mainly to their polarity as positive negative or neutral besides which appraisal expressions covers additional attributes of opinions that extend the core description of the expressed opinion the basic attributes attitude which are engagement and graduation are complementary with polarityorientation the identified attributes of appraisal theory are orientation it recognizes if a term is positive or negative some studies refer to this attribute as polarity in contrast the polarity attribute represents the fact that a sentimental term can be unmarked or marked that means that the term orientation can be influenced by an expression that negates the meaning of the phrase or a sentence if a term contains such a negation it is labelled as marked according to šimko and korenek the main advantage of using the appraisal theory in sentiment classification is that it helps to take a look deeper inside the mind of authors who wrote texts and find out their real meaning using linguistic and psychological analysis of their texts transforming our lives june 18 21 2017 methodology the growth of technology most especially in the area of social media is aiding the researchers to adopt different research methodology this paper seeks to use a hybrid approach that combines different methodology and data analysis techniques such as entity and aspectlevel sentiment manual techniques data mining text mining and netnography to overcome some of the problems that existing researchers had identified concerning sentiment analysis of social media in their studies some of the authors have identified the problem of using slangs disjointed words incomplete phrase or sentence and buzz words that lack proper understanding and meaning kozinets defined netnography as a form of ethnographic research adopting the participantobservational approach and taking online interactions as its fieldwork netnography preponderates tourism research stream but kozinets recommends netnography methodology to researchers that work with social media and other online platforms the study followed fivestage outlines mapped out by kozinets to extract data from electronic commerce facebook online community as a participantobserver we planned the data collection the extraction and the coding to get insight from the data one of the authors represented himself on the ecommerce facebook online community as an observer and we extracted the data with ncapture a browser plugin that allows us to capture the data of ecommerce product and service reviewers we opted for transforming our lives june 18 21 2017 sentiment data analysis the emergence of the social media has turned things around in mobile commerce in social media retailers can only measure their return on investment through advertisement in form of sales but to appraise the soldout products and services rendered to the customers is a bit challenging through online reviews and posts on social media like facebook it is easy for online community members to learn from one another state their experience express their opinion and synchronise cultures we adopted five steps process posited for sentiment analysis from the work of nikumbh nikumbh and gaikwad we skipped data collection and text preparation postulated by nikumbh et al because we had earlier used netnography approach but we used nvivo with manual techniques for sentiment detection sentiment classification and output presentation we exported data extracted with ncapture to the nvivo which consists 15790 general merchants retailers reviews 1559 specialty retailers reviews and only 256 agency retailers reviews all together for 33 electronic merchants in nigeria we had 17605 facebook reviews we used the word query to analyse the most frequent one thousand words the result gave us a clue to the keywords that are necessary for coding to discover emerging themes from the data we also performed word frequency clustering analysis for the general merchant retailers specialty retailers and agency retailers we performed jaccard similarity coefficient analysis between positive and negative review of facebook online community reviews for ecommerce products and services we performed jaccard statistic test with nvivo 11 plus to compare the similarity and diversity of positive and negative online community sample if the sets data result would be 100 similar it means the closer to 100 signify the intensity of the similarity and in comparison 80 will be more similar than 70 nvivo generates jaccards coefficient result of 0038961 based on 7235 positive and 1783 negative references we multiplied the result by 100 and it gives us 4 the word similarity of positive and negative reviews is 4 to get the dissimilarity of the positive and negative review we subtract the jaccard index from 100 the jaccard distance between the positive and negative reviews is 96 facebook online community engagement rate the tables below show the mobile commerce engagement rate on facebook online community in nigeria as shown in the tables 1 2 and 3 above the engagement rate is calculated by taking the total ptat and divide by the total number of likes surveys show that to have success on facebook an engagement rate greater than 7 should be met as revealed by facebook likealyzer tool in the gmr categorization it shows that only two of the mobile commerce successfully engaged their customers with 8036 and 1287 respectively all the specialty retailers sampled shows very low engagement with their clients while two of the retail agencies sampled indicated that they recorded success in engaging their customers at 1777 and 789 this result reveals that generally most of the merchants and vendors do not actually engage their customers it is very important to note that it is not sufficient to have many likes but to have many ptat as well many likes and low ptat yields a very low engagement rate as seen for example in shoprite jumia and konga recording a high or low ptat and a corresponding number of likes will yield a very high engagement rate as evidenced in katadeals payporte and jiji it is not enough to have millions of likes on the facebook platforms of mobile commerce while ptat is very low as it is crucial for a successful engagement rate with customers our results based on sentiments detection from the reviews on the ecommerce merchant social media platform are classified under four headings these are views on products and services online discussion merchants response and online community benefits these classifications identified the attributes of appraisal which include attitude graduation engagement and polarity all these constructs are interlinking in the expressed opinions of consumers on products or services product and service sentiment the analysis starts by investigating polarity which is useful for determining the overall sentiment orientation or bias of a document or person towards an object or services consumers shared their views on products such as electronics computers mobile phones clothing and food items we extracted the reviews of product and services from the facebook page of mobile commerce platforms the excerpts below depict the mind of the reviewers positive i love gmr i like ra stores negative gmr is selling products that are of low standard inferior and low quality because i bought a 32inch sharp tv and after two weeks the tv couldnt power on neutral i have never had any issues with gmr… people have been talking about gmr but i never patronize them lagos november 20 2016 i enjoyed the lenovo tab i bought from them just that it doesnt have flash so painful the above quotes from the online shoppers depict their experience and show their positive negative neutral and polarity comments on products and services rendered to them by the general merchant retailers and retails agency online discussion the most discussed topic that generated contributions from consumers on the ecommerce platforms as identified are price product order customer services delivery time product quality shopping experience shipping return items store location this is evidenced in figure 2 above the excerpts below express the mind of the reviewers price how can your price of shipping be more than the goods or items being bought…if you keep going like this it will get to a stage where no one will buy anything from gmr product order very poor you place an order and never get a response if a large company like amazon with millions of daily orders can easily manage them why cant… customer services the attitude of your rep ao is appalling enlightenment as a benefit brings about passing knowledge about something to others this is shown in the statements made by the reviewers under enlightenment teaching others how to do new things customers advertises exchange ideas and present business opportunities for other customers alike merchants response the merchant response is very important for whatever brand to communicate engage the customers or consumers and redeem the image or solve issues relating to patronage and many more some of the excerpts below are from merchant responses to comments on their products and services so sorry for this experience sadly the item delivered is the item ordered since the seal has been broken well be unable to retrieve the item an agent has been assigned to contact you regarding this thank you were delighted to receive your feedback and are super glad that you enjoyed our service thank you for your kind words vo quite appreciated please spread the word and we welcome referrals… the first response given above represent the attitude and the information passed as evident in the merchant comment reveals that the terms and condition of the agency is not known by the consumers as alluded to in the comment the other responses received encouraging feedbacks about their product and services and they appreciated them going by the reviews generally the rate of reply of the merchant to the reviewers is slow as there are complaints about response rate it seems there is no personnel designated to answer the queries of customers conclusion and implication despite the prevalence of ecommerce mobile commerce and social media as an interwoven study in diver disciplines it is noted that few scholars in the field of electronic marketing have fully explored the connectedness of mobile commerce and social media for customers service improvement this study applies the hybrid technique to sort out social commerce customers reviews appraise the quality of the extracted data and identify the opinion that transpired between online retailing merchants and online customers the unicity of this study lies in the accessibility of large dataset of online multiculturalism douse with emotion although this study is an overture of social commerce in the context of developing countries such as nigeria we are able to gain insight into the sentiment of online shopping due to this development it is viewed that this study will set a pace for online shopping customer engagement through social media in electronic marketing it makes this study one of the foremost in this study demonstrated the importance of social media in ecommerce in a new way by identifying the benefits of online community reviews and exhibited reviewers emotions though our findings were based on facebook data generated from 2014 to 2017 the result reflects how online shopping experiences ensued emotion in facebook commerce reviews the study reveals the intensity of positive negative neutral and polarity sentiments this study furthermore emphasized the explanatory power of theory for the union of mobile commerce and social media the appraisal theory used for the pairing of mobile commerce and social media explain how attitude and graduation connect engagement in the context of products and services review the equilibrium of mobile commerce and facebook social media stands to improve customer service some managerial implications were offered as it advocates the significance of social media in mobile commerce to the electronic marketing practitioners due to its vastness many online consumers have turned facebook into their second home and it will be easy for the mobile commerce merchants to reach them for feedback in realtime the study also emphasizes the importance of facebook followers and clarify the differences between the facebook likes and ptat as the determinant of customers online engagement the engagement rate is one of the useful metrics for merchants that uses facebook online reviews this study is not without limitations and its explanation should be treaded carefully it is a common argument that social media data validity is not a cleancut but recommends heterogeneous facebook users and generalized result as a standard for online data validity rife et al testify to the viability of facebook data over traditional samples demographic data is hard to extract but we limit the quotes to the reviewers that make their name sex domicile available on their facebook page there were more positive reviews than the negative the neutral and polarity were scanty another limitation was that the sample represents general merchants retailing specialty retailing and agency retailing and only 33 of the mobile commerce retailers were available for this study according to fink et al social media is a viable means of getting enriching social and cultural data for studying the developing nations future studies should endeavour to examine online reviews of social media such as twitter instagram google and pinterest regarding mobile commerce as a comparative study introduction deal sites also referred to as group buying websites are a well established trend in online commerce to get a better price by volume discount original idea behind a deal site is to group consumers together forcing the merchants to offer wholesale prices to these groups merchants sell products and services at significantly reduced prices usually 40 off or more on the condition that a minimum number of buyers would make the purchase when the minimum number of orders is reached the deal becomes activated and all the customers that signed up for the deal become eligible to purchase if the minimum number of orders is not reached within agreed time period usually 1 7 days then the deal is cancelled group buying promotions can generate a large number of sales in a short period of time thanks to the viral nature of this promotion often promoted on social networking sites merchants sales can be boosted by the order of hundreds to thousands of orders in a single dayweek because deal sites take up to 40 of the price the merchant is only making slight margin sometimes even sustaining shortterm loss for the following reasons cash flow boost payments for vouchers are processed within short period after the deal is closed so the merchant receives a quick boost in cash flow effective advertising daily deals promoted by group buying websites are fairly inexpensive and they are much more effective at generating real sales rather than just increasing brand awareness new customers deal sites are able to attract new clients by offering large discounts that get the firsttime customer in the door although retention of such price sensitive clients can be problem groupon is possibly the most wellknown deal site from a business model perspective it can be classified as affinity club roundup buyers buying club and trade show thirdparty marketplace in the framework compiled by taran et al in spite of groupon being the so wellknown groupbuying is not the main nor the mandatory feature of deal sites slevomatcz is the clear leader among czech deal sites it offers the widest range of experiential services such as adrenalin and cultural events gastronomy and weekend stays slevomat stopped selling fashion goods they focus on services with higher value especially with the advent of shopping via mobile phone the portal also provides assurance to its customers since in the competitive market it is crucial to guarantee satisfaction literature review to the best of authors knowledge impact of personality traits on gift giving specifically linked to deal sites has not been investigated yet the literature search has brought only couple of journal articles and a few conference papers investigating gift giving in general personality trait can be defined as habitual patterns of behavior thought and emotion traits are relatively stable over time differ across individuals and influence behavior traits are in contrast to states which are more transitory dispositions agreeableness is a personality trait manifesting itself mainly in such behavioral characteristics that are generally perceived as kind cooperative sympathetic warm andor considerate narcissism could be defined as the pursuit of gratification from vanity or egotistic admiration there is a published study of relational signaling over recipient preferences in their gift choices which point out that givers balance their goal to please recipients with gifts that match recipient references against their own goal to signal relational closeness with gifts that demonstrate their knowledge of the recipient close givers divergence from the giftregistry is not the result of their altruistic search for a better gift but is a strategic effort to express relational signals it occurs only when givers will receive attribution for their choice same authors in 2013 also point out that gift giving creates giver identity threat as a function of social closeness they established that gift giving in which individuals may make product choices that run counter to their own identities in order to fulfil the desires of the intended recipient purchasing an identitycontrary gift for a close friend who is an integral part of the self can itself cause an identity threat to the giver who subsequently engage in behaviors that reestablish his identity such as indicating greater identity affiliation with the threatened identity and greater likelihood to purchase identityexpressive products the role of narcissism selfesteem and gift giving was discussed by in their exploratory study that identifies romantic giftgiving motivations and examined these motivations in relations to the two personality constructs a factor analysis found three motivations for romantic gift giving intrinsic maintenance and power motivation when selfesteem age and sex were controlled narcissism was positively related to maintenance motivation in the past and maintenance and power motivation in the future selfesteem was negatively related to power motivation in the past and maintenance motivation in the future controlling for narcissism age and sex an exploration of influences on attitudes to giving and receiving gifts reports the results of a study that examined the influence of organisational level and education on attitudes towards giving and receiving gifts in exchange for preferential treatment in three cultural groups analysis of the data using hierarchical regression revealed that after controlling for age gender cultural background business sector and years of service respondents organizational level and education positively influence attitudes to accepting gifts while only education influences attitudes to giving gifts contributions to giftgiving theory from an identitystripping context measured by the identitybased motivation model to examine gift giving within the identitystripping context of nazi concentration camps as reported in the memoirs of holocaust survivors is a bit extreme example of giftgiving oriented scientific paper by exploring gift giving in this crisisladen context authors demonstrate the fundamental role gifts can play in reestablishing personal and social identities and provide insights into the motivations for giving that go beyond the existing paradigms that emphasize social exchange economic exchange or agapic giving the role of adolescents gift giving in managing their impressions among their peers examines adolescents gift giving using a qualitative methodology based on impression management theory giftgiving motives and the characteristics of the chosen gifts indicated that adolescents use gift giving instrumentally to manage and protect their impressions among their peers the research provides evidence regarding different types of gifts such as joint neutral and twofold gifts while research on selfgift consumer behavior has shown evidence of the importance of this behavior in western cultures there is no understanding of selfgift giving in collectivist cultures tynan et al used personal interviews to establish the existence of selfgifting in china and further to compare motivations for and the emotions associated with it their findings indicate that selfgifting is less selforiented for the chinese than for the british gittell and tebaldi found that charitable giving by households in the united states is significant they estimate that private giving represents more than 2 of total gross domestic product and is a significant factor in funding the nonprofit sector their research adds detailed data and analysis supporting and supplementing research that identifies personal income capital gains religious group affiliation age volunteerism and educational attainment as the main factors affecting household giving the aim of our paper based on the identified gap in the literature is to analyze impact of gender age and personality traits on purchasing coupons from deal sites as gifts the rest of the paper is organized in the following way in the next section there is a description what data were collected and how and how they were analyzed in the following section results of the analysis are presented the last section offers conclusions data and methodology the data was collected in december 2016 to january 2017 using an online questionnaire respondents were 264 university students from the czech republic of which 140 respondents indicated that they use deal sites and 124 do not the analysis of use versus nonuse of deal sites from this data set was published in surveyxact was used for the questionnaire unlike qualtrics it does not allow to showhide questions based on answers to questions on the same page therefore the questionnaire was split into two pages and questions for deal sites users appeared on the second page seven respondents stopped after the first page and one respondent provided random high numbers as answers for multiple openended questions hence this row was excluded from the analysis so the effective sample size is 132 on the second page of the online questionnaire there was a question regarding the number of coupons purchased on deal sites as gifts the distribution of the answer is provided in figure 1 since the distribution of the number of gifts is rightskewed ordinal logistic regression is used for the analysis spss software was used for the analysis personality traits were measured using rammstedt and johns big five inventory10 ie a shortened 10item version of the big five inventory questionnaire developed by john and srivastava and translated to czech by hřebíčková et al the instruction was to rate how well do the following statements describe your personality with statements i see myself as someone who on a 15 likert scale where 1 meant strongly disagree and 5 stood for strongly agree extraversion was calculated as an average of the 1st and the 6th answer agreeableness as an average of the 2nd and the 7th answer conscientiousness as an average of the 3rd and the 8th answer neuroticism as an average of the 4th and the 9th answer and openness to experience as an average of the 5th and the 10th answer the researchers are aware of the new version of big five inventory big five inventory2 with 60 items and of 30item short and 15item extra short versions but there is no validated translation available yet narcissism was measured right after big five inventory10 using the same instruction with the statement is of narcissistic nature the statement was adapted from the single item narcissism scale developed and validated by konrath meier and bushman they recommend sins for online studies the questions related trust issues have been summarized in an article trust innovation prosperity the questionnaire contained additional questions which were not used in the analysis presented in this paper the impact of age was significant impact of agreeableness and of narcissism were borderline significant all of them have positive effectolder agreeable and narcissist people are more likely to use coupons as a gift conclusion purchasing coupons from deal sites and then using them as gifts is significantly influenced by age age could be mediated through several variables eg somewhat older people lived longer so they gave gifts for a longer period somewhat older may have a better income somewhat older people may have a better overview what is available on deal sites that their friends could enjoy in light of the literature mentioned previously our research is filling the gap in understanding how the coupons are used in giftgiving mode and which personal traits can be traced to such behavior as for implications for marketers there would be problematic recommendation either to focus coupon campaigns on older clientele with narcissistic inclinations or controversy focus on the customers who are empathetic and altruistic rammstedt and john mentioned that the twoitem measure of agreeableness does not have as good properties as measures of the remaining four of big five inventory traits therefore in the future research it may be worth to add a third item namely is considerate and kind to almost everyone it could possibly improve significance of agreeableness now that there is an indication of impact of narcissism on purchasing coupons as gifts it is justifiable in future research to use more items to measure narcissism such as narcissistic personality inventory which is probably the most widely used measure of the narcissism and contains 40 forcedchoice items if a longer instrument is to be chosen such as fivefactor narcissism inventory which contains 148 items it may be advisable to select only certain factors introduction governments and healthcare organizations in many countries are looking for ways to transform traditional healthcare services and to develop new services within a digital format there is strong impetus for this development from legislation and government target setting to increase service availability and to deliver those services cost effectively for healthcare organizations with limited resources the everincreasing demand for healthcare services and the complexity of customer situations present huge challenges digitization offers new possibilities in meeting these challenges as more active empowered customers interact with healthcare professionals requiring the redesign of service processes digitization of health care services is typically discussed from a technological medical science or customer perspective and the role of the service provider is less widely studied the present study aims to enhance understanding of how service providers can address issues of service process change through digitization for value cocreation the service provider must consider certain risks and seek to enhance identified benefits which are dynamic rather than static making the development of digital services more complex risks in the health care service process are often linked to issues of quality which in this sector relates to the fundamental need for security and high standards of care in digital format risks of quality failure or variation can be said to diminish as the service is standardized and variation can be controlled digitization entails a technological approach to customer and service issues but the managerial dimension must also be considered the present study contributes to the discussion on digitized healthcare services by highlighting the need for standardization of work processes the dario value cocreation model of digitized services described here is derived from prahalad and ramaswamys value cocreation building blocks the key development is the models focus on service processes implemented through standardized work providing opportunities for value cocreation literature review healthcare service systems are transforming rapidly to become more customerfocused shifting from value proposals to systems of value cocreation this shift is strongly supported by the changing role of the customer and significant technological developments offering opportunities for secure and collaborative value cocreation for health care professionals the challenge is to integrate digital healthcare services with the overall service process and operations which inevitably become standardized through digitization value cocreation according to servicedominant logic both customer and service provider become resource integrators in value cocreation servicedominant logic further designates the customer as the focal actor in defining value the customers perception of value relates not only to value as service outcome but also as experience or valueinuse in a healthcare context value is generally understood as the outcome of the service process but the customer experience during the treatment process and the value cocreated during the process is seen to be of even greater relevance irrespective of the final outcome the changing role of the customer also changes expectations about how healthcare services are delivered requiring a shift of mindset in service development digitization brings the customer into focus and the digital service process offers mechanisms supporting value cocreation in a knowledgeintensive sector such as healthcare the service provider is especially well positioned to influence the process of cocreating value with the customer through professional expertise and knowledge as well as interaction value cocreation involves processes in which the service provider and the customer operate independently in their respective domains the nature and existence of these independent processes is of course arguable as according to grönroos et al value is always cocreated only in direct interactionin other words there has to be simultaneous interaction between the stakeholders in value cocreation however as well as value related to the service providercustomer interaction there is also value derived from or related to the service process that is actually cocreated among stakeholders other than service provider and customer these independent domains include processes that for the service provider involve cocreation opportunities planning and implementation and metrics connected to implementation for this reason the service provider can exert significant influence on the creation of customer value by providing opportunities for value cocreation digitized services provide opportunities for mutual benefits with joint targets set for the entire process according to the principles of value cocreation the dialogue between customer and service provider itself becomes an ongoing element of the digitized service process further digitization increases potential availability of the service as well as better customer access by departing from the traditional direct appointments approach in addition riskbenefit evaluation is considered a further building block of value cocreation and can be utilized to analyse the impact of digitization on the service shared information is one element that enhances the service system by creating opportunities for value cocreation digitization creates these opportunities by establishing a platform for sharing information so introducing transparency to the service process in healthcare settings transparency is closely linked to shared information and to the related concept of shareddecision making based on shared information that the service provider contributes to and facilitates the customer is empowered to participate actively in shareddecision making however transparency does not necessarily deliver value for the customer unless the digital service process is properly integrated into the practical operations through which concrete value cocreation opportunities emerge the digital service process requires a new way of operating and a different approach on the part of the service provider it is therefore necessary to properly define the new processes and to integrate the digital service portal into the service process and operations to ensure that professionals do not act sporadically on the basis that it is just a gadget or a tool given that transparency can be seen to relate to information and to operations which differ in certain respects the present study proposes a modification of the dart model in the form of dario a new value cocreation model as described in figure 1 below dario operationalizes the concept of transparency into information and operations as two distinct features introduced by digitization for value cocreation and the development of digitized services the models key contribution is the focus on service operations through customer activities within the portal and the professionals standard work as opportunities for value cocreation as indicated operations are an essential contributor to value cocreation as both customer and service provider use the digital service portal offering opportunities for value cocreation for the service provider operations represent an organizational aspect of value cocreation as processes and practices need to be integrated with digital processes to operationalize the service many ehealth services fail because insufficient attention is paid to actual implementation of the service based on the value cocreation definition of the customer as the focal valuedefining actor operations must be valuedrivenin other words digital service processes must be developed in close cooperation with the customer enabling work processes to be successfully integrated however developing digital solutions customer needs and changing capabilities require that development is a continuous process including reevaluation of processes following actual implementation operations as standardized service processes the present study views the service providers operations as an opportunity for value cocreation and as an element of that value cocreation digitization of healthcare services requires effective implementation so that the service provider or the professional can integrate the digital service portal with operations enabling value to be cocreated if implementation of the digital service portal is not given due consideration but is instead seen as something that just happens implementation may fail or fall short of its full potential for service delivery due to a lack of proper planning here implementation means successful integration of the digital service with the overall service process to ensure seamless care professionals who must learn new ways of interacting with the customer do not always receive sufficient support to ensure successful implementation and the consequences for professionals work must be carefully considered and planned in the development phase of the digital service portal many healthcare organizations have made huge advances in their operations through standardized procedures and defined targets based on the lean method lean is based on continuous improvement and a focus on people both customers and personnel lean essentially means following the customers path through the service process and monitoring that process through the customers eyes to become a customercentered service organization following the customer path through the service process and developing and planning the new process contribute to more successful implementation of the digital service lean philosophy takes the customer as the starting point for the organizations operations and processes understanding the customers actions and path through the service process are the key objectives for lean value stream mapping value stream mapping as a lean tool starts from the customer at the threshold of the service process and follows on through operations multiple interaction points and subprocesses that the customer encounters taking the customer as starting point in the planning of the digital service process is closely analogous to the founding premises of value cocreation for the service provider this means keeping the customer in view when developing service processes and operations or work processes it follows that planning for implementation of the digital service should consider the professional work processes with which use of the digital service portal must be integrated risks in the health care service process are often associated with issues of quality the requirement for quality reflects the requirement for security and high standards of care and treatment in the digital service format the risks of quality variation or failure arguably diminish as the service is standardized enabling variation to be controlled by the very nature of the technology digitization necessitates definition of work processes and operations further according to lean philosophy the operations defined in the digital service format help to reduce the risks of quality failure or variation as the service process becomes standardized and variations can be controlled the concept of standard work refers to how professionals perform operations in a unified and similar way standard work looks to create a consensus in the practice of procedures and operations to reduce any variation among practicing professionals reduced variation of treatment increases the consistency of quality of operations and outcomes standard work is very often misunderstood as excluding the possibility of interpretation and the use of professional expertise however this is not the objective on the contrary standard work reduces wasted time and effort in the service process and so releases the professionals time and expertise to make a more meaningful contribution to the service process digitization of processes can too easily be regarded as a threat to professionals work and more emphasis should be placed on how a standardized work process facilitates nonroutine work requiring advanced expertise and knowledge methodology the study is based on single case data gathered from a large healthcare organization using the qualitative methods of thematic and focus group interviews the single case study facilitates exploration of an industry embarking on a new approach to value creation and implementing processes for value cocreation opportunities through digitization it is also appropriate when studying a new phenomenon under unusual or complex circumstances the material obtained through the interviews was further enriched by observations within the organization while participating in two seminars and workshops on digitizing healthcare and its services the organization in question identified mental health and weight control digital services development groups from which the interviewees were drawn participants in the thematic interviews were selected by means of snowball sampling with each interviewee identifying the next interviews continued until the information gathered became repetitive and no longer added to the information from previous interviewees there were two focus group interviews involving mixed combination of people who were active participants in the development of these digital healthcare services in total 26 people participated in the individual or group interviews the observations in seminars and workshops consisted of several discussions and workshop tasks with multiple health care professionals who were interested in or participating in digitization of healthcare services the personal thematic interviews were taperecorded and the group interviews were videorecorded with participants permission the recorded material was typed grouped and organized utilizing the guiding thematic issues for the purposes of analysis the material casts light on the attitudes of the organization and its professionals toward digitization and on understandings and measures concerning the need to define internal processes to meet the challenge at the customer interface for value cocreation findings the case organization has several ongoing projects developing digitized healthcare service portals very often implementation of these services would not progress or even seem to fade away because of deficits in service process integration planning poor understanding of the implications for work procedures and low managerial commitment to implementation this lack of managerial commitment owed to uncertainty about the the development groups comprised voluntary participants ensuring their motivation and commitment to developing the services however voluntary participation also means that management commitment may be low while some development groups proceed well and people are committed there are others whose work lack management commitment and the lack of sufficient organizational participation resulting in poor planning and potential failure of implementation this is a journey toward understanding what this could mean for us based on the interview findings it seems obvious that careful planning of digital service processes is fundamental for successful implementation enabling value cocreation you have to plan changes in the way of working before implementation there are now ongoing efforts to formalize the development work based on a strategic approach to which services to digitize how to proceed with planning and whom to involve in development however there is an evident lack of experience within the organization in defining services service processes roles and work descriptions which is rather resource bound for ict supporting this development work with less support from the management or from the human resources organization we proceed with the lean plandocheckact of continuous improvement with small steps in the development work the organization utilizes lean methods for digital service development involving both personnel and customers services are planned and developed on the basis of a customer forum of customer experience expertsthat is real customers for the services to be digitized for the professionals defining the service process for digitization introduces the concept of standard work which assures quality and reduces waste in the process such as missing or lost information which are also essential features of digitization the planning of digital treatment paths is an iterative process and courage is required in order to learn through an iterative process we learn from our experiences and utilize that in subsequent services results improve each time and enhance the functioning of the digital service process however training for new work processes remains secondary in terms of planning although its importance for the successful implementation of the services has been recognized discussion theoretical and managerial contributions the study findings can be discussed in terms of the dario model which links transparency to information and operations as indicated in figure 1 this more precisely captures what the service provider must consider for successful value cocreation in digital services the dario model contributes to the discussion of digitization of healthcare services which requires new crossdisciplinary inputs the findings have several managerial implications the service provider who has a huge impact on value cocreation opportunities must also be a resource integratorthat is they must be able to integrate the digital service into the overall service along with defined work processes and standard work this highlights the importance of developing digital services through close interaction between customers and professionals the development of digital services is based on voluntary involvement by the participants in the development groups however from a managerial perspective this voluntary participation fails to deliver the necessary understanding of the digitized service process to the organization and of the related workload to management the findings suggest that a lack of clear targets for implementation including voluntary participation in the development work hinders integration of resources which further slows the implementation process and increases the risk of low adaptation both of these effects undermine achievement of the ultimate targets of increasing service availability and cost effectiveness in the delivery of healthcare services based on these findings there is an imminent need for systematic involvement of management in the development processes and in defining targets for implementation in terms of number of users and timespan for integrating the digital service within the overall service the mental therapy service offers a huge range of possibilities to proceed with the customer there seems to exist uncertainty of and lack of a common description for the proceedings how to combine the digital mental therapy service with sufficient amount of empathy and presence with the weight control house these are services for various combinations of conditions like anorexia or severe obesity with linkages to mental therapy services as often there is a connection with these issues during the interviews or in the focus group interviews there was less remarks on the implications to work processes or operations in general concerning the mental therapy services or weight control house services however as digitization changes these work processes and service operations tremendously there emerges a need to redefine work processes or the work algorithms behind the service process guide how the service proceeds but these do not define operations or how the professional integrates the digital service portal into the service process leans standard work introduces a coercive formula to follow a defined work process in the digital service portal these findings suggest that the organization still lacks the necessary systematic planning for implementation of the service portals of mental therapy or weight control with defined standardized work processes and training for the professionals for integration with the overall service processes this suggests a need for systematic involvement of management in defining implementation training and standardized work in order to gain commitment and ensure successful implementation and value cocreation opportunities within the service process limitations and directions for future research the study has several limitations the first of these relates to the theorybuilding process an approach combining value cocreation and lean standard work through operations may seem risky as there is no readily available theoretical precedent and the model can therefore be considered limited in this regard nevertheless the idea of combining value cocreation and lean offers multiple possibilities for future research second the focus here is on single professionals and their standard work multiprofessional teams were not considered because of practical constraints this limitation invites more thorough and separate research on standard work in multiprofessional teams in the context of digital healthcare services third there was no possibility of studying customer operations within the digital service portal for practical reasons of permissions and the need to focus on the professionals however customer use of the digital service portal represents an interesting and fruitful area for further research introduction the ever increasing global competition leads industrial companies to engender organisational changes and drive innovations a new generation of information technology can contribute to the transformation of the shop floor on the one hand by advancing the automation of manufacturing processes and on the other hand by putting shop floor workers and their skills more in the focus however so far manufacturing companies have been slow in taking advantage of the possibilities offered by the current wave of digitalization yet we know little about the information needs and possible benefits of it for the manufacturing sector therefore the goal and main contribution of our study is to identify describe and explore current challenges that companies are facing due to emerging sociotechnical trends in the manufacturing sector for this context we define a digital challenge as the combination of 1 the identification of the problem situation 2 the implementation of a sociotechnical solution to address the problem and 3 the continuous transformation of the existing work practices we start this paper by presenting emerging sociotechnical trends that are currently engendering changes in manufacturing we start by discussing technology as catalyser of this transformation process and then discuss its impact on individuals and the organisation in chapter 3 we explain how the close collaboration with six industrial companies in a european project for more than two years has allowed us to identify and then further specify four digital challenges those are 1 digitally augmented human work 2 workercentric knowledge sharing 3 selflearning manufacturing workplaces and 4 insitu mobile learning next we illustrate each digital challenge with an example of a company from the project for each case we describe the problem situation and then the proposed solutions to overcome problems being faced by each that have been implemented or are currently implemented thus drawing on the insights from these companies we demonstrate how the manufacturing industry can leverage challenges they are experiencing beyond practical relevance this conceptualisation of the current situation as digital challenges for manufacturing companies helps building the basis for a better theoretical understanding of the changing nature of it on the shop floor in chapter 5 we discuss how to take a step forward by proposing sociotechnical solutions for the workers in response to these digital challenges to support their work practices and increase job satisfaction in the following we present sociotechnical trends that emerge in the context of manufacturing in order to identify these trends we thoroughly reviewed the latest literature the public media as well scientific publications we categorize the trends into three pillars as summarized in figure 1 and discuss them in the following sections technology which is the basis for this transformation and catalyses the other changes on individual and organisational levels figure 1 emerging sociotechnical trends in the manufacturing sector technology new technological developments can serve as drivers for change on organizational and individual levels the following recent technological trends have the potential to substantially affect the workers situation on the shop floor and also the organisation of manufacturing environments the webbased linking of machines sensors computers and also humans is rapidly moving towards the idea of the connected factory the benefits of the socalled internet of things technologies include reduced down time increased quality and less waste as well as greater visibility of the manufacturing floor this connectivity enables companies to leverage the value of their plant floor information and promises an increase in productivity improved utilization of assets and better decisionmaking whereas recent technical advances in interoperability have resulted in higher maturity of product and process models companies still face the task of building coherent services when the individual components are technically different and managed by different units iot technologies allow devices to communicate automatically and enable companies to monitor collect process and analyse huge amounts of data which may lead to more precision and the chance to get deep insights into manufacturing processes measuring and monitoring realtime data from across the factory leads to rapidly growing data sets that are increasingly gathered by cheap and numerous sources and often so large or complex that traditional data processing applications are inadequate to deal with in this context the term big data was coined to capture business value and meet the demands of smart manufacturing companies need to be able to manage these large data sets and extract meaning out of them this large quantity of data leads to new questions and solutions concerning especially the analysis search sharing updating and visualization advanced analytics in the form of predictive analytics user behaviour analytics or certain other methods that extract value from data are needed to cope with this great amount of data it offers possibilities to make extensive use of analytical tools often capable of providing diverse reporting on any device anytime these tools are able to deliver data about companies productivity and security as well as supporting decisions according to product configurations service bundles and pricing options the utilization of metrics is evolving at a rapid pace and will become even more pervasive in the future danson et al state that industrialized analytics is increasingly influencing business strategy and commanding substantial investment and connecting analytics capabilities is crucial for manufacturing companies individual level as with any new way of working or even more general of doing individuals need to learn and adopt it get used to it and in the best case benefit from it striving towards a smart factory may have an enormous impact on work practices on the shop floor employees face changed processes they need to handle new technologies and accomplish different tasks as one out of three trends for the future of manufacturing the world economic forum therefore identified the focus on the workforces skills with the spreading and growing importance of technology in the manufacturing sector the need to be able to acquire new skills to get the work done properly increases individuals are not only facing changes of technologies but as a consequence also the increasing complexity providing workers with information where and when it is needed and more generally speaking supporting the employees in their daily work promises significant benefits as a consequence shop floor workers are expected to solve occurring problems as fast as possible and to constantly improve their workrelated knowledge and skills people who were not born into the digital world have learnt to use different kinds of technology at some stage in their adult lives and are likely to experience some difficulties in accepting technology related changes at work conversely the digital natives have grown up with diverse it the entering of digital natives into the workplace might mark a paradigm shift the way people process information fundamentally differs and depends from how and when they grew up thinking patterns have changed and it is very likely that even their brains have physically changed it could be shown that this implies an ease with which digital natives learn to make use of unfamiliar technologies they need however to be provided with the opportunity to use them for meaningful purposes in order to remain competitive companies need to take this into account another perspective on the same phenomenon is that some employees may be faced with fears about whether digital natives and smart machines will soon take over their jobs however humans with the most diverse skills and competencies as well as with valuable experience have always added value to manufacturing processes and this is likely to continue there is a variety of possible ways in which people and machines will work alongside each other of course some will build implement maintain and operate upcoming technologies others will be in roles that machines cant perform well such as those involving high levels of experience intuition creativity or empathy therefore manufacturing companies should not overvalue digital skills at the expense of traditional skills instead they are advised to recognize and promote experience and handicraft talent too focusing on all different kinds of skills is a great challenge but it may create advantages for manufacturers and also positively impact workers employment and incomes when facing this challenge appropriately it is important to rethink and develop group specific learning arrangements and individual work place designs organizations will need to examine knowledgeintensive processes and determine which tasks can best be performed by machines and which by humans early training and supporting employees to prepare for a collaborative future with smart machines is essential organisational level the exponential growth of data and the convergence of different affordable technologies are transforming organizations key infrastructures are underlying considerable changes that play a vital role in securing competitive positions in the manufacturing industry anytime retrieval monitoring and operating of technology infrastructures even over huge physical distances enables simultaneous control and coordination of complex technological processes consequently a shift can be observed away from centrally controlled processes towards decentralized distributed structures and processes as a result todays strategies value chains and business models will come under increasing pressure companies need to decide whether to react on emergent demands or to proactively contribute to a transitions design or they can choose between an incremental change versus a radical change in each case an appropriate change management is crucial the prevailing view of it strategy has mostly been that it is a functionallevel strategy that must be aligned with a companys business strategy the business infrastructure has become digital though with increased interconnections among products processes and services the arrival of iot cyberphysical systems and others allows everything to be networked in order to create a smart environment where people and machines communicate with each other naturally this has led to fundamentally transforming not only business processes products and services but also business strategies accordingly the role of it strategy has to be rethought from that of an aligned but subordinated functionallevel strategy to one that reflects a fusion between it and business strategy key themes to guide this are the scope the scale and the speed of digital business strategy as well as the sources of future value creation and capture in digital business strategy when addressing a change in strategy its success strongly depends on a firms ability to evolve its corporate culture thereby companies are advised not only to take advantage of emerging technologies but also critically to embrace the new business strategies that those technologies drive enterprises must focus on enabling people to accomplish more with technology they will have to create a new corporate culture that looks at technology as the way to enable people to constantly adapt and learn continually create new solutions drive relentless change and disrupt the status quo in times where the focus is locked on technology it is important in fact to place people first thus it is the task of managers to promote an organizational climate that supports decentralized and selfresponsible use of information assets for this many leaders are likely required to develop new skills resulting in training recommendations for supervisors who have a prominent position in digital workflows the rise of the generation of digital natives as stated above brings a new kind of employee not only with different attitudes towards technology but also with different outlooks aspirations and expectations regarding their employer their workplaces and about how work should be organized it appears that preferences are shifting towards aspects such as connectivity information or entertainment the push towards new forms of working challenges organizations on the one hand it is important to thoroughly plan and execute the change on the other hand there is strong competition between manufacturers for new employees a successful employer branding would create sustainable competitive advantages with the right engagement research design this study is a part of the international research project facts4workers the objective of facts4workers is to create attractive and intelligent work places in a factory of the future therefore we initially studied how practices on the shop floor can be supported through humancentred it solutions a deep understanding of workers individual practices has been our basis to deliver suggestions for sociotechnical solutions that support smarter work guiding through the process of exploring smart factory solutions we identified four digital challenges together with our six industrial partners from the manufacturing domain the identification was done in the constitutional phase of the project by conducting a focus group with all six companies the intense collaboration with the companies over a span of more than two years allowed us to deepen our understanding and to further explore the four specific digital challenges further field studies at each of the six companies enabled us to collect data from more than 60 interviews various observations as well as at least one further focus group at each partner for further information about first phases of the data collection please refer to and this has all contributed to describe their individual challenges in more detail digital challenges for manufacturing companies the role of knowledge in manufacturing companies has grown over the last century and innovations and technologies have changed it radically a number of times currently the focus has drifted towards knowledgeintensive and humancentred manufacturing currently and in the future human workers have an important role in manufacturing environments as they are capable of complementing modern technology and performing knowledgeintensive work tasks more effectively compared to solely technical approaches however this also will require more knowledge management skills from the workers and manufacturing environments the data gathered from six companies allowed us to identify four digital challenges 1 digitally augmented human work 2 workercentric knowledge sharing 3 selflearning manufacturing workplaces and 4 insitu mobile learning these fall into different facets of knowledge management while for example predictive manufacturing focuses stronger on the technological aspects of knowledge aspiration humancentred manufacturing rather focuses on the social aspects beyond identifying the digital challenges we illustrate all of them with a case vignette eachthat gives insights into the situation at the industrial partners production environments figure 2 digital challenges for manufacturing companies digitally augmented human work human shop floor workers deal with information that is increasingly more complex and transforming combined from multiple sources and types augmenting human work with digital technologies means to provide them with an immediate and personalized provision of information at the shopfloorlevel which can be interacted according to their needs roles preferences and constraints our research reveals that one common request of many assembly and manufacturing workers is to have a better awareness of the process status in order to have a more conscious decision making process and increase their responsiveness to process breakdownchange to date in many companies the operators need to actively seek the required information and select the correct information from a large number of data sources to carry out their tasks thus the main idea of the challenge is to create a personal information feed for a specific worker that could support his activity and empower him to become a smart worker with more autonomy and problemsolving capabilities the solution should provide also the appropriate tools not just see the correct data but also to analyse them in the smartest and personalised way not only the access to data has to be personal but also the analysis should be developed and selected in order to provide an understanding of the process that will be profitable for the specific worker hidria rotomatika is a slovenian automotive tier1 supplier that produces electric stators and rotors for automotive use we observed operators of the machining departments who deal with turning and milling machines a preliminary analysis of the workers needs has highlighted how some operations could be timeconsuming and require the acquisition of paperbased data or knowledge from an experienced colleague these data must be processed manually in order to obtain a smooth process especially machine setup processes and measurements of each part could be very complex and timeconsuming this challenge addresses the core issue of providing natural interfaces that allow workers to interact and access knowledge effectively when performing their regular tasks the challenge is to enable the workers to utilize big data analytics fuelled by automated electronic measurements to make decisions more effectively when calibrating production equipment better access to information and analytics would allow to cut production times while increasing product quality and reducing waste due to making betterinformed decisions and detecting patterns and trends in product deviations for the worker being able to benefit fully from information generated by machines and previous decisions could reduce frustration and help retaining a productive flow of work in the proposed solution the workers automatically receive all relevant information in a digital format and obtain a fit solution to fix the problem directly at their current work station moreover the operators acquire more autonomy due to the implementation of a trend analysis of the process which usually means the degradation of some components or machines in this case the operator becomes a leader of a proactive analysis phase for the machine maintenance that is actually carried out using a traditional reactive approach by the maintenance team this allows the operator to gain more autonomy and take charge of advanced tasks that are beneficial both for the process and its satisfaction workercentric knowledge sharing workercentric knowledge sharing means the utilization of workergenerated content and peer sharing about best practices problem solving and ideas to fuel organizational learning and even workerdriven innovation this includes not only equipping workers with appropriate tools but also with specific use cases for utilizing these tools empowering workers to share their knowledge transparently with others reduces the risk of productivity bottlenecks eg through redundant work and improves the pace and depth of onthejob learning at the same time the worker feels more valued more socially connected to the work community and better motivated thyssenkrupp steel europe is an international provider of flat steel we observed the practices of the mobile maintenance team in the areas of airconditioning technology and electricity the occurrence of a fault is reported via phone email or fax rough information on the type of fault and system is then passed onto the mobile maintenance employee in paper form frequently neither local information of the production site in which the disruption is located nor particular safety instructions are provided the necessary knowledge is usually acquired through the accompaniment of an experienced colleague or through systematic trial and error despite a structural knowledge transfer since approximately 3000 different types of systems must be serviced and possibly debugged employees rarely possess all the relevant information tools and spare parts to solve a specific problem without a considerable communication effort or multiple journeys the direct communication in the process of fault elimination is currently supported by mobile phones without access to mobile data the paperbased asynchronous information exchange between the employees who are involved in the fault process often leads to delays or redundant work furthermore at the site of the disruption there is often a lack of knowledge that other employees could deliver in this case the opportunities to directly communicate with other colleagues eg to exchange pictures and documents are missing due to the abovementioned mobility and the numerous and varied challenges which the maintenance personnel faces it is important that the workers are provided with the necessary information in a bundled contextual and mobile way this will be realized through the implementation of a mobile employeecentred knowledge management system that places the maintenance staff at the centre of attention the solution can provide necessary information on maintenance in two ways 1 contextspecific information on all systems can be called up by the employee through a mobile information system 2 access to colleagues practical knowledge can be realized through a chat function with the possibility of exchanging images and videos these two components support the maintenance employee on his way becoming a smart worker who has access to all necessary knowledge through this form of knowledge networking the communication between colleagues can be increased practical knowledge exchanged and the process of eliminating faults thereby designed in a more efficient way due to the accessibility of relevant information unnecessary journeys can be avoided and the certainty in the employees actions increased selflearning manufacturing workplaces selflearning manufacturing workplaces support workers discovering and sharing knowledge during manufacturing enhancing their competencies and worker satisfaction however the manufacturing knowledge and information is currently often scattered across a plethora of information silos without a centralized platform to connect combine analyse and organize the information according to the present needs of the shopfloor worker mastering the complexity of data and information requires sophisticated semantic and data mining technologies to discover the relationships between different sources allowing intelligent search and exploration with the implementation of advanced it solutions iot technologies and sufficient knowledge management procedures new possibilities for leveraging the manufacturing knowledge arise one such concrete advance is the creation of a selflearning manufacturing workplace utilizing detailed and consistent data from manufacturing operations enterprises are able to implement eg predictive maintenance and machineassisted decision making for calibrations that allow reducing unplanned process disruptions and maintaining a smooth workflow case vignette 3 hidria technology centre is a slovenian company which designs and manufactures a wide spectrum of partially or fully automated assembly lines ranging from simple conveyer belt designs to fully automated lines these complex and automated manufacturing lines incorporate lots of fault conditions the loss in efficiency is due to either timeconsuming setup and maintenance activities or lacking supplies in such cases the line comes to a halt or produces parts that have not been specified the increase of operating time and the reduction of maintenance time of the assembly lines are therefore in the focus the main worker needs in this case are derived from one of the customers sites hidria dieseltek plant which produces glowplugs and pressure sensors one of the challenges in this case is that operators at the shop floor cannot predict upcoming problems or breakdowns but instead they work mainly on tasks related to reactive maintenance thus supporting tools for shifting operators workloads towards more predictive maintenance tasks are desired further operators have to react quickly to resolve problems during manufacturing the team of operators aim to directly fix small problems like the replacement of defective parts with larger defaults or more complex problems the internal maintenance team helps to bring the production up to speed again as quickly as possible thus in this case it is aimed at better supporting the problemsolving activities of the line operators by a new integrated knowledge base of the production line fault analysis in addition the solution finding to a problembreakdown is highly dependent on the experience of the worker and this knowledge is important to be shared also to less experienced workers for enhancing peerlearning at workplaces the information and knowledge of manufacturing processes technologies and solutions is currently scattered across the factory without a centralised platform to store share and analyse the information according to the present needs of the worker at the shop floor a proposed selflearning approach will monitor a combination of human process and machine parameters and supports humanmachine interaction the solution offers 1 a reactive 2 predictive and 3 proactive decision support to shop floor workers reoccurrence of problems will be minimized by storing and sorting the problems systematically and combining them with user generated solutions into the machine bookthereby enabling selflearning workplaces the solutions to a specific problem can also be rated by the workers in addition an employee can generate new solutions in forms of comments videos or pictures as a conclusion selflearning manufacturing workplaces are able to increase the workers autonomy and competence by providing them the knowledge required for carrying out specific tasks insitu mobile learning the increasingly needed flexibility of workers leads them to perform a wider range of tasks and share more responsibilities in manufacturing this causes the pervasive need of overall onthejob knowledge available at the right time in the right place furthermore knowledge is subject to continuous change as work practices evolve and requirements change so far declarative and often abstract generic knowledge is acquired offthejob and it appears that this gap can be bridged by mobile learning in the right context workers need contextaware learning in reallife situations for continued education and training since insitu learning is relatively new to manufacturing environments the challenge includes finding the optimal way to utilize contextual and realtime machinegenerated data and to design and deliver the learning service so that it is effective efficient and widely accepted case vignette 4 schaeffler is a large german automotive supplier the studied plant recently changed the former functional shop floor organization towards a new value stream design along with these organizational changes came changes to the role of the individual worker formally deeply specialized personnel now works in diversified areas requiring a variety of skills and knowledge however expert knowledge is still needed to solve tough problems currently there are three steps for competence development within the company formal trainings for learning factual knowledge mentoring for the transfer of expert knowledge and the learning directly on the shop floor within real working contexts right at the machines in these settings several problems surface the knowledge transferred in formal trainings is not directly related to specific workplace requirements mentoring defines the learning content and its recipients only through specific circumstances learning directly on the machine is difficult as the complexity of the problem often requires an expert onsite which induces a resource problem as a solution a mobile learning approach enables the company to detach knowledge transfer from formal contexts and enables the learner to consume the knowledge when needed four core components allow individual context specific learning and therefore facilitate a sustainable learning arrangement 1 the learning system includes a sensory interface to the workplace sensing the machine state as well as the operator 2 an automatic evaluation of the incoming sensory data provides contextand situationsensitive problemsolving and learning content in case of an unknown or currently unresolvable problem expert assistance is necessary 3 in such cases the expert would be included into the situation virtually first using audiovideo tele cooperation 4 with the usage of wearable augmented reality devices such as data glasses the learning context becomes completely immersed into the work place and the current work situation as the worker has both hands free true parallel working and learning is possible with the introduction of appropriate learning systems the transaction costs for identifying and consuming necessary information can be reduced also the breakthroughs in mobile device technologies over the past years now allow the design of innovative learning arrangements whereby the boundaries between working and learning will disappear in the future discussion in the last years technical infrastructures have become more and more sophisticated with large bandwidth networks affordable software solutions and large storing capacities notwithstanding as we have shown in this paper a number of sociotechnical trends lead manufacturing companies to change the way they work one of these changes includes designing peoplecentred workspaces that pay more attention to their employees and put them into the centre of their efforts creating an environment that contributes to more efficiency and increasing workplace satisfaction requires more than just implementing appropriate technical solutions as technology matures the focus of it development can shift from a largely technical perspective to a more holistic sociotechnical perspective rather than focusing on centralized computer systems and treating the worker as an entity not yet replaced by machines the humanistic view focuses on humanhuman interactions where it serve as tools to deliver support for specific tasks when we acknowledge that the human worker keeps a preferred role in future manufacturing systems through the everrising demand in complexity knowledge work and decision making the humanistic perspective might be the only sustainable point of view to take taking this view it also seams easier to design for basic human needs as autonomy relatedness and competence as well as variety in the first place as these can be formulated as core objectives enabling a humanistic design approach advances in technology and organizational themes as well as changes in the society are important input variables that stimulate the creative process of designing future work environments although called digital challenges they have one common theme keeping the worker in the loop with appropriate information moreover the digital challenges aim to extend the natural sensory reach and information processing capabilities of an individual human worker the field of interaction eg vision touch or hearing and further aim to strengthen knowledge absorption capabilities of individuals and knowledge distribution within communities conclusion we started this paper with an overview of emerging sociotechnical trends in manufacturing that coalesce to establish new ways of work in smart factories technological advancements in terms of iot big data and others drive organisational change in a manner not previously seen organisations must simultaneously incorporate and leverage the increasing shifts in technologies whilst maintaining a corporate culture that facilitates the most efficient and effective work force consequently employees on the shop floor are expected to adjust their work practices to take into account the changing technologies and increasing complexity drawing on the detailed insights from six manufacturing companies that we gathered as part of a european project aiming to create attractive and intelligent work places in a factory of the future we demonstrate how the manufacturing industry can leverage challenges they are experiencing with this conceptualisation of the current situation as digital challenges for manufacturing companies we contribute to a better theoretical understanding of the changing nature of it on the shop floor the four illustrated digital challenges span a wide range and are capable of supporting different facets of the knowledge practices in manufacturing companies taking into account different knowledge management facets helps to better understand and meet the needs and requirements as expressed by prospective users moving them in the focus of the implementation efforts we have observed that workers expect new digital solutions to draw on what they already are familiar with from their private lives eg designing commenting searching or networking functionalities in the style of wellknown internet platforms in this context ict seems to play more and more the role of a hygiene factor that supports the workers in an invisible way this implies that the pure existence of a new solution is not in itself able to give increased satisfaction or lead to higher motivation however dissatisfaction often results from its absence or inadequate design this calls for more research that contributes to creating workercentric factory solutions of the future introduction international airports are operating in a competitive environment the requirements of low cost airlines and prevalence of costcutting measures in aviation is forcing airports to optimise their operations and reduce costs while still offering efficient and high quality airline and passenger services efficiency quality and costs are conflicting criteria presenting airports with a difficult optimisation problem to improve efficiency and reduce costs an airport can optimize the availability ie schedule of resources used for passenger and airplane services however airports are complex logistics systems and the analysis and optimization of processes can be a tedious and timeconsuming task airport processes have their own specifics since they can be interleaved and can therefore not be analysed separately since they are also subject to frequent changes they cannot be modelled with an exact mathematical approach a wide range of scheduling problems can be found in the airports and elsewhere in the airline industry scheduling problems in these environments do not have straightforward solutions their complexity varies according to the number of constraints addressed typical scheduling problems in the airport domain are aircraft scheduling ground crew scheduling disruption management aircraft landing sequence scheduling or personnel training scheduling particularly in the domain of personnel scheduling the most popular type of scheduling problem is the aircraft crew scheduling while the problem of ground crew has mainly been neglected nevertheless if an airline wishes to produce a high quality service for their passengers the ground crew is as important as the aircraft crew the aim of our research was to produce a viable approach to solve ground crew scheduling problem at the airport the contribution of our research is an it artefact used to automate workforce scheduling and shift generation at a small international airport the system produces floating shifts adjusted to variation of workforce requirements throughout the day in a fraction of the time needed for manual schedule preparation and allows dynamic rescheduling in case of unforeseen events or disruptions in order to achieve optimal workforce deployment we needed to minimize the criteria of personnel costs and aircraft delay costs prevalent methodology for this purpose is discrete event simulation methodology which is well suited for welldefined processes the dynamics of airport operations however requires a certain level of adaptability and the modelling of adaptable business process requires a flexible methodology such as abm in this research we addressed the problem of ground crew scheduling in a more efficient and innovative way a similar solution for a small airport in need of an adaptable system this paper presents the development of a novel hybrid desabm simulation model of regional airports ground crew operations which will be used for schedule verification and optimization specifically for the optimization of workforce quantity present in work groups covering specific types of tasks during the working day at the airport the simulation model can be used to support the scheduling process in international airport of similar size literature review since 19 of delays in air traffic are caused by airport operations these operations cannot be neglected diverse approaches and simulation studies have been presented in the literature as discussed in bazargan to efficiently cover the aircraft maintenance operations aircraft were classified according to the stopover time based on the length of stopover the entire maintenance program with exact numbers of technicians and daily shifts are proposed kleinman hill ilenda have used stochastic methods to calculate the delay costs in air traffic attempts were even made to influence the schedule of aircraft landings in order to balance the workload of ground staff boysen fliedner have tried to adapt the landing schedule in order to efficiently schedule the ground crew in general most of the research in the area of airport operations is focused on optimization of airport surface operations in some cases divided into passengerrelated tasks and aircraftrelated tasks most of the solutions for ground crew scheduling are focused on only one work group herbers covers some aspects of ground staff planning with proposed procedures for requirement planning some of the solutions are limited to fixed shifts and static demands while others use mathematical models not appropriate for complex systems in general the approaches to shift planning and crew assembly often use assumptions with strongly limited validity or deal with simplified problems thus limiting wider practical applicability methodology design science research design science research is a process of creating new knowledge through design of novel and innovative artefacts and analysis of their performance with reflection to enable improvement and understand the behaviour of aspects of information systems according to hevner march park ram design science research in is addresses the so called wicked problem characterized by unstable requirements and constraints complex interaction between subcomponents inherent flexibility to change design processes dependence on human cognitive and social abilities considering all these characteristics we concluded that the problem of ground crew scheduling matches the description given similar to other design science research our objective is to develop a technologybased solution to a relevant problem of personnel scheduling hevner introduces the three design science research cycles in a design research project the relevance cycle the rigor cycle and the design cycle the research process model as presented in vaishnavi kuechler consists of awareness of the problem suggestion development evaluation and conclusion these steps and cycles together with the design science research checklist were used as a guideline to develop the artefact our main research question that we have sought to answer was  how can the addition of abm components to a des airport ground crew model be used to improve the model in terms of adaptability and comprehensibility modelling and simulation a part of the it artefact development phase was the development of a simulation model for validation and optimization of heuristic scheduling algorithms according to borshchev three different types of simulation methods can be applied to a given problem based on the abstraction level of the model system dynamics discrete event simulation or agent based modelling can be used to map the real world problem to the model most of the simulation solutions for ground crew scheduling at the airport are based on des method although this approach has historically had a significant success in scheduling process optimization the addition of abm based components can add more flexibility to a simulation model using abm we can model the movement of individual crewmembers who can make their own decisions about the performance of the tasks assigned to them according to a predefined set of rules most of real events are much easier to model using agents therefore the model is more realistic and flexible than the des model nevertheless both models enable monitoring of resource utilization and other important statistics according to siebers macal garnett buxton pidd abm is a better choice for dynamic process modelling since descriptive models of decision making processes can be included in the model whereas des models are more appropriate for the normative approach although abm can be considerably more difficult to develop than sd and des models it allows the spatial or geospatial aspect to be included in the behaviour of an individual agent proposed research design in our research we combined the design science research project with the simulation modelling approach at the beginning of the research the identification of opportunities and problems in the actual ground crew scheduling environment took place afterwards the criteria were set to enable evaluation of the efficiency of the proposed artefact semi structured interviews were conducted with scheduling experts for each service group with the goal of identifying the tasks and scheduling criteria in this paper the second major iteration of the relevance cycle is presented outputs from the experimental and fieldtesting were used to improve the artefact in the rigor cycle an exhaustive literature and related work study in the knowledge base was conducted to ensure the presented solution is not only a routine design based on the application of known design process and artefacts since the combination of des and abm has not been previously used to solve the ground crew scheduling problem our contribution can be seen as an improvement in the final phase our artefact came in a form of an instantiation in the following section we present the development of our artefact following the steps proposed by vaishnavi kuechler the problem is defined and the model suggestions are given the model is then developed and evaluated with proper conclusions given in the phase of development simulation modelling techniques were used to achieve the given goals the problem definition the aim of this step is to generate problem awareness the modelled airport is a regional hub located in the southeast europe with over 30000 flights and over 1400000 passengers per year the airport has a single 3300 m long runway equipped with cat iiib instrument landing system a 23 m wide taxiway and 25 independent parking positions airports aerodrome reference code is 4e the terminal capacity is 500 passengers per hour with 13 checkin counters and 2 baggage claim conveyors the total area of the airport is 320 hectares the airport was selected for the design research project due to similar size and organization to other regional airports and the established r d relationship with the faculty ground crew scheduling problem at the considered airport and therefore also the operation of the simulation model is confined with the arrival and departure of the aircraft ie tasks can only be performed on aircraft present at the airport the tasks are performed in a predefined time sequence according to several criteria the execution times specified by the airport scheduling experts are deterministic ie fixed making the model deterministic as well the execution times are determined from experience and represent the maximum expected task duration until the proposed it artefact based solution was introduced management at the airport used spreadsheets to manually generate schedules based on their knowledge and prior experiences adhoc solutions and schedule changes due to frequent disruptions of the aircraft timetable required a lot of effort and were too slow to allow a timely but optimal response in addition the workforce requirements in peak and offpeak times were not properly addressed and have been only partially solved with the employment of part time workers interviews with manual scheduling experts eg crew managers were conducted to extract the decision criteria and heuristic rules for scheduling all the criteria identified were stored in the flight information system enabling a smooth transition to the algorithm based scheduling the identified scheduling criteria were as follows  type of stopover  flight type  aircraft type  carrier  destination ground crew operations the scheduling criteria presented in previous section were used to define tasks which have to be performed for the arriving and departing aircraft the tasks of the ground crew are performed by crewmembers with appropriate skills an individual crewmember can have one or more skill groups defined each skill group incorporates several different tasks therefore crewmembers in this skill group are able to perform all the given tasks in their skill group some tasks are simple and can be performed by almost any skill group while others require specific knowledge or other skills and can therefore be performed only by certain skill groups with the workforce requirements calculated shifts have to be defined several rules are given to define a start time and the duration of the shift maximum and minimum duration allowed start times number of shifts an employee can be scheduled to during one workday the availability and schedule of resources used also have to be defined during one shift each skill group performs only one type of a task in general tasks are divided into three main groups a aircraft supply b passenger service and c technical service figures 1 and 2 describe the process of passenger service for the arrival and departure of a scheduled passenger flight the passenger service department included six different operational tasks which were mapped to skill groups with the same name listed in figure 1 most of the skill groups required two persons to be assigned to the skill group the two exceptions are the skill groups lost luggage referee at the arrival and sales desk referee at the departure where according to the requirements two workers should be assigned to the task the required number of individual workers in specific task group is as it can be seen from figure 1 and 2 most of the tasks overlap and must be performed simultaneously the tasks that require a strict sequence are the tasks of guidance and transfer in figure 2 which cannot be stared before the checkin task is finished the sales desk in this particular case is opened three hours prior to the departure of the aircraft and stays opened one hour after the departure the arrival services are mostly completed long before the departure of an aircraft however they affect the availability of ground crew groups and equipment our work in the relevance cycle has so far resulted in two versions of heuristic workforce requirement scheduling algorithms and a shift construction algorithm the algorithm for generation of floating shifts and assignment of individuals to shifts is described in the shifts are generated according to the generated workforce requirements and shift length demands in order to automate the validation of algorithmgenerated schedules and shorten the algorithm tuningverification cycle we have developed a simulation model of airport operations used which combines des and abm the model development is described in the following chapters selection of modelling methodology different simulation methodologies can be used in airport scheduling while the most frequently used discrete event simulation has been used to simulate airport situations for decades agent based modelling has only recently gained attention of the researches in the area of airport scheduling according to piera eroles ramos fernandez robayna des has proved to be efficient in the case of airport ground crew scheduling problem abm has been used in various cases from optimization of the air transportation system to airport capacity prediction due to efficient usage of des and abm combination in other personnel scheduling domains we can expect that the combination of both methods can also add significant value in the case of airport ground crew scheduling while the des methodology is efficient to represent the flow of agents and diverse resources in the case of airport ground crew scheduling abm components allow us to model the activities and the communications between crew groups their supervisors and aircraft management in detail using this methodology we can lower the level of abstraction and enable a comprehensive insight on the ground crew problem making it clear and presentation friendly when presenting it to the airport management in addition to the advantages of the des where the resource utilization and time agent spends for individual activities can be addressed and optimized the abm allows the spatial insight on agents with detailed ground movements and estimation of time needed for the movements from one site to another according to clausen ground crew tasks can be divided into passengerrelated tasks and aircraftrelated tasks where the latter include maintenance cargo baggage loading cleaning catering towing and operations while some personnel scheduling problems are not constrained with the availability of equipment ground crew uses several different types of equipment within their tasks in addition skills of personnel have to be considered only few tasks performed by ground scheduling crew are plain with no sequences and dependencies defined several overlapping tasks have been identified while other tasks are interconnected due to these attributes the ground crew scheduling problem gains complexity number of constraints and variations of schedules mathematical models used to resolve the personnel scheduling problem in advanced scheduling tools could be used at the level of individual work group but due to interconnectivity of tasks and resources in a case of ground crew other techniques need to be employed since high level scheduling solutions can be too costly for small airports many of them still use solutions which combine manual scheduling with basic spreadsheets or similar basic tools model development since most generalpurpose modelling tools are limited to a single methodology the combination of des and abm methodologies within a system model generally required the utilization and integration of several generalpurpose modelling tools or the development of proprietary code for the implementation of the abm model however the anylogic tool allows the use of all three simulation methods and from version 7 it also enables the usage of agents in des and abm model allowing easier combinations of both methods to be implemented in one simulation model borshchev emphasizes the possibility of a des servers and entities to be implemented as agents and use of agents to introduce intercomponent messaging into the model the latter approach is used in the presented case des and abm models are linked via passing a message between aircraft and work group agents where aircraft traffic model is presented as a des model and ground crew work model is presented as abm model model data the simulation model generates arrivals and departures of aircraft based on the flight schedule data transferred from the fis into internal anylogic database table 1 shows an example of parameters stored in the database assembled from the fis dd1 defines the date of the flight fltnoa and fltnod describe the aircrafts arrival and departure code the type of traffic is defined in column trftyp sta and std show the time of arrival or departure and routea and routed designate the arrival or departure airport and actyp defines the type of aircraft aircraft traffic simulation model the level of abstraction and autonomy has to be identified prior to the development of the simulation model according to available data we have identified the des as the most appropriate method to model the aircraft traffic simulation model for the purpose of personnel scheduling only arrivals and departments of the flights are important in our simulation model further on the model was upgraded to the abm elements where the movement of an element on the surface is easier to implement the arrivals and departures constitute of several discrete tasks that involve ground crew members delay elements are used to model a simple delay in the process in our case the delay elements include the state of arrival or departure services depending on the to make the model more transparent a physical layout of the airport was used and paths of the aircrafts were added to the model due to focus on workgroup tasks and client specifications taxiing and parking logistics were not modelled and are excluded from the model statistics the aircraft traffic model consists of two submodels the arrivals submodel and the departures submodel the separation was a logical sequence of the airport business rules and inability to track individual aircraft in fis after the arrival the arrivals submodel uses the arrival schedule from the fis to generate the aircrafts aircraft taxi to the gates already waits on the apron for an assignment the submodel of arrivals ends with an element of parking or exit point from the system while the model of departures assumes the aircraft is present at the airport and available to start the tasks when needed the departure tasks start times are based on the departure times given in the fis schedule the modelled departure times depend on the execution of tasks and should not be delayed when scheduling constraints are defined properly in the departures submodel an aircraft first has to move to the gates where it is serviced with the delay modelled with servicedept element afterwards the aircraft moves to the runway the queues were modelled to enable the simulation of an aircraft waiting until a taxiway or a gate or a parking area is available the fis data is gathered in the elements arrivals and depts linked to a local database with arrival and departure schedule and service requirements for each flight the service requirements are assigned to every aircraft at the moment of its entry in the model according to the ideal heuristic requirements where the availability of workforce is not an issue the service task parameters are contained in the messages generated by aircraft agents and sent to the relevant ground crew work group agents work group agents maintain an internal queue of tasks which are executed according to the fifo rule and specified service start time since anylogic models all des entities as agents the addition of the message feature to the des aircraft traffic model was straightforward ground crew model due to relatively rigid process modelling in des methodology which hinder the modelling of dynamic aspects of ground crew operation the decision was made to incorporate abm to allow dynamic ground crew process modelling while preserving the required level of abstraction abm has allowed us to model the dynamic aspects of ground crew operations with better analogies with the actual processes making the model more comprehensible abm allows us to model the entities and processes in a way that is closer to reality ie the ground service work groups have the role of service stations however they travel to the aircraft and not vice versa the sequence of services depends on the availability of service work groups and the place of an aircraft within a service work groups internal queue and perhaps most important an aircraft can be serviced by several work groups simultaneously each work group agent has an internal state chart model of its task process as shown in figure 4 the initial state is waiting and here the agent waits for a service request message from an aircraft with service requirements specifications these requests are added to the internal queue and processed according to the fifo rule if an agent is in the waiting the work group agent moves to the aircraft and begins the requested service and performs until specified end time after the servicing is complete the work group agent sends a message to the aircraft and proceeds to the next aircraft in its internal queue or returns to the waiting area evaluation the fis serves as a database for the ground crew scheduling providing an accurate source of data about arrivals and departures at the airport the start end and work requirements of tasks which have to be performed at an aircraft are determined by the attributes of the aircraft to be serviced the availability of workers is determined by the workforce requirements schedule the schedule is generated and optimized by the heuristic algorithm by combining the schedule of optimized workforce numbers and ideal requirements of a flight we can verify the effects of a generated workforce requirements schedule in practice and foresee the potential flight delay costs workforce requirements generated by the heuristic method described are used to vary the availability of workers during the simulation run workers are modelled as resources and arranged into work groups each work group performs only one type of task a work group is then modelled as an agent flight delays in the simulation results are mainly caused by the occupancy of personnel with other tasks therefore the discrepancy between ideal and modelled workforce requirements exists delays in the presented model are calculated for departures delays are measured by comparing the scheduled departure time as recorded in the fis and the departure time as recorded by the simulation model the modelled delays are however exaggerated because the start times of tasks are not yet optimised and the start of a task is delayed unless all required workers are available further development of the model will include the execution of tasks with a reduced number of workers and longer execution time and the execution of tasks at earliest opportunity and should model flight delays more accurately conclusion although managing disruptions of airport ground processes is a complex task suitable personnel and equipment scheduling solutions are vital for efficient operation of an airport as a system international airports face a constant challenge to coordinate all the departments efficiently perform all operations needed and provide an excellent service to the passengers airport ground crew scheduling system does not have a straightforward or mathematical solution which could easily be implemented the complexity of the problem and the necessity to solve it is not only an attribute of large airports in our research no appropriate solution or algorithm to solve the ground crew scheduling problem in a small international airport was found therefore a research was conducted to develop and evaluate an artefact to solve the ground crew scheduling problem in a small international airport two versions of heuristics were developed in this artefact to implement an efficient scheduling algorithm the algorithm for generation of floating shifts and assignment of individuals to shifts is described in previous publication further on a simulation model was built to verify the proposed algorithm and enable further optimization of the processes the simulation model presented used two simulation methodologies des and abm this combination provides us with an efficient and realistic model which is used to simulate the results of the developed scheduling algorithm according to the design science research checklist all questions were answered during the presented phases we were able to answer our main research question how can the addition of abm components to a des airport ground crew model be used to improve the model in terms of adaptability and comprehensibility using a suitable tool we can combine the abm and des methodologies within a single model since abm modelling requires more effort and produces a more complex model it should be limited to the modelling of system elements that are by nature dynamic and cannot be suitable modelled using des methodology such an approach improves model comprehensibility introduction the information technology innovation continuum is creating new and innovative solutions for different industries particularly the healthcare industry is witnessing a new era of innovation as new emerging technologies such as mobile health is being adopted to assist in fighting and managing diseases at both global and individual levels to deliver better health management platforms the technology is delivering innovative solutions through mobile devices that facilitate a number of initiatives that include but not limited to health call centres treatment compliance appointment reminders mobile telemedicine and patient monitoring these innovative solutions can empower people and patients to be proactive in managing their health through selfmanagement as selfmanagement can prove critical in reducing healthcare costs while delivering optimal healthcare services the empowerment of patients to selfmanage is through the delivery of information that allow them to understand their medical conditions and it is through the devices as the devices act as a getaway for accessing healthcare services through the exchange of data and information the exchange of data is through secure data transfer mechanisms between patients and healthcare professionals the data contains valuable information and it is primary driver for the treatment of diseases and empower of individuals to selfmanage their health the technologies are new to the health domain and require a wellestablished research method to understand how they operate specifically the it solution that is delivering healthcare services to people and patients although todays modern data analytics platforms are extracting new insights from such technologies to create business value and answer some of the business questions yet from a scientific perspective it can be challenging a way to approach the analysis of secondary data from new emerging technologies can be accomplished through hermeneutics hermeneutics has long been applied in studies where the textsartefacts are distant from its original authors the application of hermeneutics in new emerging technologies is to gain a window through interpretation into the phenomena lived by the patients interacting with healthcare professionals for the management of diseases while using any of the technologies the essence of interpretation in such cases is to understand how the technology is operating the quality of the primary driver of the technology being data and the integrity of the information based on the data the purpose of this study is to understand what data accuracy is discover the sources of data inaccuracy in health data and the impact inaccurate data has on the integrity of the information while determining the most appropriate machine learning algorithm that can detect inaccurate data the accuracy of the data is understood through interpretation and it is done through hermeneutics and thematic analysis literature review this section of the paper introduces hermeneutics with a background around hermeneutics in the information systems domain and an example from a current research in progress where hermeneutics is used for analysing secondary data based on an mhealth solution for diabetes hermeneutics the term hermeneutics is a modified transliteration of the greek verb hermeneuein a term that means to express aloud to explain or interpret and to translate as explained by kennedy schmidt and it is a technique derived from the interpretive paradigm it is also known as the process for making a meaning hermeneutics was thought to have originated as the study of the interpretation of the bible and has been applied in the interpretation of previous work of authors who studied the bible historically in ancient greek it was believed that hermes the mythological messenger god was equipped with language and understanding that enabled him to interpret the messages from the gods and deliver them to the mortals this mythological example illustrates the process for interpreting messages and communicating them with people the four key terms of language understanding interpretation and communication from the example are key to hermeneutics in research the researcher must be equipped with the language of the subject understudy understand the messages has a method to interpret the texts to effectively communicate the results from the study to the audiences although equipped with language and understanding the interpretation can become an issue when interpretation becomes an issue it is an issue of unintelligibility and it occurs when a person does not understand an artefact that he or she came across and it is known as rebelling against successive smooth understanding in research unintelligibility can occur when the researcher accesses secondary artefacts that are distant from their original authors and has no access to the language that would enable an understanding of the artefacts the objective of using hermeneutics in research is to interpret texts that would allow an understanding of phenomena peoples actions and behaviour to address questions that fall under the interpretive paradigm is research can be classified as interpretive if it is assumed that our knowledge of reality is gained only through social constructions such as language consciousness shared meanings documents tools and other artefacts interpreting texts through hermeneutics is not an easy task and requires an indepth understanding of hermeneutics and the interpretation process the problem with interpretation is that it is a twofold problem the first problem is avoiding projecting ones own viewpoint on the text and blur the interpretation of the texts as ones preconceived ideas may influence the interpretation the second problem is the need to successfully communicate to a variety of audiences however ones own perceptions and experiences in a subjective cultural and historical as referred to as the lifeworld can be included in the interpretation of the texts in the is domain hermeneutics has had a dominant role in the interpretation of information technology is related studies and the results are quite interesting as they provide a fresh view of the it systems the widelyknown paper of klein myers set out principles in conducting hermeneutics in is robert wendy and lucas for hermeneutics and meaning making in is boydens and van hooland using hermeneutics in quality of empirical databases and acker toward a hermeneutics of data are a few examples where hermeneutics is key ingredient to the study they all seek to make meaning of the study and providing guidance in finding a meaning to the study 30 th bled econference digital transformation from connecting things to transforming our lives z zekiria sako s adibi n wickramasinghe understanding new emerging technologies through hermeneutics an example from mhealth captured and exchanged to achieve a desired state of wellbeing yet while the data has served its purpose it contains valuable information that can help in different scenarios from the technological side of the solution it sheds light on how the technology functions how the underlying data quality help achieve the desired health outcome and what exactly does the data contain that enables this transaction while mhealth being a new technology where prototype solutions have been developed and commercially available studies in the actual quality of data is not looked at thoroughly as the technology is still in its early stages the following section will elaborate on how hermeneutics is applied to study the emerging technology of mhealth with specific focus on data quality hermeneutics in a case study research of mhealth the preceding section has defined hermeneutics and its application in is studies this section illustrates with an example the process of applying hermeneutics in the study of a new emerging technology used for health and disease management the illustrated example in this paper is from a current research study the objective of conducting the study is to evaluate data accuracy and information integrity in mhealth solutions identify how data inaccuracy can occur test different machine learning algorithms and evaluate the accuracy of the algorithms in detecting inaccurate data the selected case study is mhealth for diabetes with the case being patients data the selection of the case study was based on the research question in which it posed as following how can machine learning be applied in mhealth solutions to address data accuracy and information integrity the research question aligns with the study objectives as it is broken into sections starting by which type of machine learning how it can be applied in mhealth what defines data accuracy and information integrity the selection of the case study was based on the research question as it is one that conforms to yins criteria for selecting case study as the form of question is how requires no control of behavioural events and focuses on contemporary events with using case study the data is secondary deidentified data of people with diabetes and there was no control of behaviour when the data was produced and it presented a contemporary event the two sources of data present both structured and unstructured cases of data the first dataset is of patients with diabetes who have glucose measured through both a device and recorded on paper the second dataset is extracted from hospital admission records where diabetes was either a factor in admission or was recorded during the admission these two datasets assist in addressing the research question by using the interpretive paradigm as it allows for the reconstruction of understanding of the social world both the hermeneutics method used in this study is adapted from kim using the 3 layers consisting of text translation and interpretation layer the 3 layers separate the text into layers where each has its own purpose and that allow for the data to be analysed using hermeneutics the text layer is all the textdata in the study and it is the first layer of hermeneutics the text starts with the actual datasets the datasets are reviewed to form an understanding of what the datasets contain the format theyre in and all the properties of the data including data dictionaries once reviewed the data is then aligned with codes from the literature review that cover data quality information integrity and machine learning to simulate the process of disease management for patients with diabetes the data is mapped against the omaha client care plan that segments the data into problem classification scheme intervention scheme and problem rating scale for outcomes the simulation helps in understanding the role of each instance of data in disease management after the data is examined and mapped against omaha system the data is then divided into training and testing data and that is to test different machine learning algorithms these parts form the text layer as they are mainly text and are yet to bring a meaning that would assist in addressing the research question the text is translated using thematic analysis the second layer is the translation layer where thematic analysis is applied to generate themes that can extract meaning from the text the thematic analysis is adapted from braun and clarke boyatzis explains thematic analysis as a process for encoding qualitative information the text in this study is secondary data one where theres no access to the patients or the medical professionals and they are open for research the state of the data does not have a meaning and is therefore stateless data to understand what the text is thematic analysis look for patterns in information that at minimum describe and organize possible observations while at maximum interpret aspect of the phenomenon the interpretation of the data occurs at the third layer of kims model the interpretation layer is interpreting the themes to form an understanding about the phenomenon the interpretation method is adapted from taylor francis and hegney and it starts with turning to the nature of the lived experiences that is accessing people who would tell about the phenomenon understudy the lived experience comes from investigating the experience as it has been lived rather than conceptualizing it by accessing data or people who have an experience related to the research question that is real and has occurred combining the three layers with the thematic and hermeneutics analysis is to divide the sections with clear and concise objectives that would allow for hermeneutics technique findings the purpose of hermeneutics is to derive understanding from the text under study as explained by phyl carol the adoption of hermeneutics in this research has moved the study from analysing electronic data to understanding the meaning of accuracy and how it occurs in a technology based solution such as mhealth the data was first measured and evaluated against a set of criteria derived from the definitions of data quality that were based on world health organization data quality standards and definitions of information integrity from the literature review to date the study has found that accuracy occurs at multiple levels with each instance of accuracy intended for specific use the first level of accuracy occurs at the validation layer where data is simply validated as either accurate or inaccurate based on the input the model of this validation measures the input against type of data and whether they fit the range this form of validation ensure that the data passes its basic test of meeting the minimum level of accuracy before it is passed on to the next level of validation this made the classification algorithm an appropriate machine learning algorithm that could be applied to filter through the data and test the validity of the data before it is processed modern electronic forms apply a simple rule based validation where data is tested at the time it is entered and no learning is taken into consideration when the next set of data is entered machine learning powerful capability the second level of data accuracy examines the properties of the data although the data might have passed its first instance of validation yet the properties might still not be appropriate for its intended purpose such as timely medical reminders currency and completeness of readings of a patient or symptoms achieving this level of accuracy can be accomplished through the prediction algorithm that can predict future datasets based on the existing and historical data this allows for the current values to be crossexamined against what the algorithm have predicted and raise an alert if major discrepancies in the data is detected through the algorithm figure 3 levels of data accuracy in a digital health context the third level of accuracy occurs at the behavioural level where the human behaviour based on the data is analysed to understand the meaningfulness or the usefulness of the data and its intended use this includes decision based behaviour or health outcomes that can detect if a treatment is being adhered to as planned or if theres a gap in the intervention program for the specific disease behavioural accuracy is reflected through the decisions that are being made which can be mapped through decision trees or neural network algorithms that can simulate a persons decision making process that would 528 30 th bled econference digital transformation from connecting things to transforming our lives z zekiria sako s adibi n wickramasinghe understanding new emerging technologies through hermeneutics an example from mhealth allow the medical professional to understand the thinking behind patients decisions this satisfies the collection of the data in an mhealth scenario and in the absence of a medical professional when the data is entered by the patients while still at an early stage of analysis these findings are a result of hermeneutics where the technique has shifted the focus from simply crossexamining the data against certain definitions to understanding the meaning of accuracy in an mhealth context limitations a key drawback for this study is the datasets the data was not obtained from an actual mhealth solution as the mhealth solutions are still in early development stages however the use of the algorithms against data like the ones produced by mhealth solution particularly one designed for chronic diseases such as diabetes make the results more appealing and relevant to technologies the results do not only consider the accuracy of the data but highlight some key areas of where data accuracy might be influenced by behaviour of patients and users of mhealth technologies discussion and conclusion emerging technologies can hold valuable data that require beyond traditional analytics platforms for the analysis of data from a scientific perspective hermeneutics has had a role in previous is studies and has provide to provide a fresh perspective of is systems the new technologies are changing the way patients seek advice from medical professionals manage their disease and delivering healthcare services through the platform this change can have many undiscovered unexplored phenomenon attached to the technologies that are yet to be studied the role of hermeneutics in this study is to assist in the interpretation of the data through a welldesigned process that extracts meaningful information from the themes generated by the data the study is of qualitative nature and not quantitative as it seeks to understand the data and particularly application of machine learning in mhealth to understand what the data means and how machine learning can be applied thematic analysis and hermeneutics provide rich and detailed coded information with techniques to extract information that provide insights about data and how information is produced the data is of quantitative nature and the study focuses on understanding a single instance of mhealth designed to assist in a case of chronic disease it does not aim to statistically evaluate the instances of accurate or inaccurate datasets in a mhealth transaction but instead its objective is understanding in detail the cause of inaccurate data is studies have become richer in information and hermeneutics has found its place in is domain as an interpretive technique that seek and explore a deep powerful meaning of a phenomena the mhealth technology is capturing peoples actions and health introduction mobile games have become a booming branch of gaming industry over the past years this is mainly due to new smartphones with better displays faster internet connections much higher computing power than before and easy and powerful app delivery platforms with monetization abilities globally in 2016 mobile game industry brings in revenue of 369 billion yearly and is expected to grow to 474 billion by 2018 as the number of games increases so does the competition to get visibility and share of the players interests and on the other hand to keep the players to play the game they have started once keeping players engaged in the mobile game is referred to as player retention in particularly in the freetoplay mobile games player retention is important to the games business model freetoplay games are freely available to the player but they typically contain mechanisms that include inapp purchasing in the game where virtual currency can be bought with real money such purchases offered to players are usually virtual items that bring benefits modifications or personalizations to the game world other ways games monetize on their players are for instance selling advertisements players watch ads in order to proceed or gain advances in the game getting the player to spend money one way or the other is vital to the freetoplay games and in order to retain the players new ways to get them to returning to the game are needed games developed or published by the same gaming house are looking for ways beyond traditional advertising to get the player to stay inside their gaming business at the same time game industry aims to grow beyond the boundaries of the industry to other fields of entertainment at the same time cryptocurrencies virtual currencies loyalty programs etc are reaching new areas of digital business the traditional view of economy is being splintered and new ways of payment and currencies are coming every year loyalty programs are frontrunners in a trend where ability to spend points is extending rapidly and the loyalty points are more and more becoming a currency in traditional sense cryptocurrencies like bitcoin approach this from another direction where the currency is well controlled by rules but the places where to spend the cryptocurrency are still limited spending is often done by first exchanging the cryptocurrency to more traditional vehicle of credit like euros or dollars and then are spent especially in cases where anonymity of the transaction is not crucial cheah point out that bitcoin and other cryptocurrencies often behave as an asset and not like a currency as it is subject to lots of speculative actions and the value is changing rapidly this upheaval in economy and influx of new currencies are affecting the gaming industry as well where games are usually considered as islands where ingame economy is affected only by game mechanics and influx of resources created by players buying virtual items and purchasing power with traditional currencies in this research we investigate the possibilities to design a common market for crossgame purchases that can be used in several freetoplay mobile games the motivation transforming our lives e siira e annanperä o simola s heinonen j ylikantola j järvinen designing and implementing common market for crossgame purchases between mobile games 533 for this is to have stronger gamer crosspollination between games and to crosspromote and advertise other games in better targeted ways for players using the common market platform the players could also buy virtual items to other games creating more interest for them to stay within the boundaries of the common market the designed common market would connect the games on game mechanic level through the crossgame purchasing and subsequently creating an exchange rate between game currencies instead of using ingame currencies only in one game economy the target is to expand this thinking to link game economies loosely together to clarify the scope of the research there is no single currency in games and the designed platform does not allow virtual currencies to be exchanged directly it means that for instance gems in game x cannot be exchanged to gold in game z however what the platform would allow to do is to spend gems in game x to purchase virtual items in game z the publisher of game z in this situation dictates the selection what is available to be bought the common market approach does not have to stop only to games but there will be also a possibility to add nongame items to the common market for example coupons to web stores etc could be bought ingame as well our research question are 1 how the crossgame purchasing between mobile games could be designed and implemented and 2 what kind of limitations can be identified regarding game economies game design and implementation in our research we study singleplayer games that are free to play mobile games but our findings may extend further in chapter 2 we introduce the related research on how virtual currencies and game economies have been studied in chapter 3 the methodology for the research is delineated and the use case for the single market crossgame purchasing is described in more detail in chapter 4 the implementation of the system is described and in chapter 5 the findings based on the design concept are discussed finally in chapter 6 we offer conclusion of the study related research no comparable system for crossgame purchasing between mobile games has been found in our investigation of the preexisting systems therefore we have studied game economy and virtual currencies as both are important part of the creation of the common market lehdonvirta yamaguchi notes that traditional economics do not consider ingame currencies as real but in his research the virtual currencies in games do have enough same characteristics than governmentissued currencies so ingame currencies may be considered as real currencies at least in some games for example no one is going to buy a monopoly hotel with a real money but may buy a virtual item in a mmorpg thus an exchange rate is formed between virtual game currency and traditional money sasson has studied freetoplay mobile games and noted how the most successful ones have two currencies used in the same game he names these currency concepts as a hard currency which is more closely related to the real money the players are using to the game and soft currency which is more virtual currency soft currency is what players earn in the game by playing it and hard currency needs to be bought with real money or the player needs to earn it somehow which is not directly linked to game flow if only one currency is used it limits the users spending abilities as monetisation of the game requires the single currency to be hard to obtain and players may not be able to continue without spending real money into the game balancing game economy is important as source of currencies need to be in line with the ability to spend the currency both soft and hard currency needs to be of value to the user sasson shows that if the currencies are a bit scarce when comparing to the players want to continue the player is more likely to buy some aid to the game with real money cryptocurrencies have entered the mainstream of currencies after the launch of bitcoin in 2009 they have no physical manifestation but work only in digital environment from the cryptocurrencies especially the bitcoin has gathered trust around it to make it a currency which can be used in many places it excels in use cases of anonymous digital transactions where traditional currencies are heavily tracked and have slow and cumbersome processes to transfer money from person a to person b bitcoin and other cryptocurrencies altcoins are based on the blockchain technology which is a public distributed ledger with a mechanism for arriving to consensus between all nodes cryptocurrencies are very flexible to design and configure due to the flexibility there has been several implementations for different use cases but very few has gathered enough popularity around it to make it as a workable currency sharp and sharp define loyalty programs as structured marketing efforts which reward and therefore encourage loyalty behaviour one trend in loyalty programs is to expand the industries participating in the loyalty program this is especially true in airline industry this adds value for the customer and make program more attractive to join loyalty programs are inherently virtual currencies with restricted abilities to use them buchinger et al studied four different cases of virtual currencies in loyalty programs and defined how they are different in terms of what they are achieving generating and spending currencies are two pillars of the currency behaviour for example bitcoins are created by mining them which means performing difficult 30 th bled econference digital transformation from connecting things to transforming our lives e siira e annanperä o simola s heinonen j ylikantola j järvinen designing and implementing common market for crossgame purchases between mobile games 535 mathematical puzzles to ensure the transaction coherence in the system in loyalty schemes the company creates from thin air the currency which is promised some value in the loyalty scheme network the value might change and perhaps the currency has an expiration date cryptocurrencies are indestructible in a sense that the coin does not leave the system in transaction the ownership is changed in loyalty schemes the value of the credit is nullified after the purchase as it has no intrinsic value bitcoin and other cryptocurrencies have brought an interesting discussion about the fundamentals of currencies themselves mallard et al argue that the bitcoin has a distributed currency model without any issuing organisation there is only an original ruleset which has been updated along the evolution of the bitcoin the trust is based on the rules and if everything is running normally there is no party which can change the rules on their own traditional currencies like euros and us dollars have a centralized organisation which is responsible of the issuing the currency due to history the ability to issue currency is detached from the daily politicians and central banks have been created central banks are deemed the trustworthy organisations which should behave predictably and not be intimidated by politics and quick gains research method and context the aim of this study was to design an implementable solution for crossgame purchasing that would make possible to use earned currency in one game to buy virtual items in another game the possibilities for earning currency was either to play certain games or import exercise data from wearable sensors no matter how the currency was earned it could be used to make purchases in other games belonging to the system the additional goal of the currency was that it could be used to gain discounts for purchases made in selected web stores or brickandmortar stores this aim was deemed specific to the needs of the project companies and it was anticipated that the solution for the virtual currency system would have to be tailormade to the companies in the project the existing virtual currency systems reviewed above were not seen fitting to the purpose therefore we adopted case study research methodology case studies are commonly used in software engineering field to study practical phenomenon in a real life context here research needs were first to understand the requirements of the multigame virtual currency system and then design a working system to purchase virtual items between games and interaction with real life contexts in later stage the system will be tested in the real life context due to the complex nature of the studied system this research presents first the vision of the planned crossgame purchasing the real world complexity determines the limitations of the study where we first present the created vision of the crossgame purchasing before considering the reallife use in our study we also consider the challenges of building such system in reallife and therefore the tradeoffs that can be anticipated at this stage of the study the selected case under investigation in hailing form a research project where companies identified the need for the multigame currency with options to collect and use it also in real world the case study comprises of two gaming companies fingersoft has made and produced mobile games since 2012 and has several games out at the moment these games are freetoplay games and the company has approximately 100 million monthly active users globally fitness village is a new gaming company focused on developing their first game that targets gamification of exercise including exercise related virtual game play and exercise data imported from wearable exercise sensors in the centre of interest of the participating companies is to design and implement an entire service platform which imports real world exercises from sensors and exports the data to selected mobile games as virtual currency through conversion rate this currency could be used to buy virtual items from other games this exercise data part of the research is not studied in this paper only what happens after the exercise has been changed to an ingame currency on the other hand most freetoplay game also have their own internal point or currency systems as the enabler for in app purchases this currency works in isolation within the game and is often too specific to the game logic in question to be transferred to other games as such meaning that some type of point or currency conversion is needed for crossgame purchases as well the overall vision is to have a socalled common market for crossgame purchasing that combines all the elements together and allows expansion by adding new games and web stores or retailers to the system ultimately this would enable the creation of a functional and powerful digital ecosystem on the top of the technical solution for the companies in the digital ecosystem this will give excellent opportunities to monetize their business in various ways starting from the existing means in mobile games industry to also giving an unique selling points for businesses in other domains to market their services and products for the mobile gamers and exercise oriented customers it is envisioned that this way the players will be more engaged to stay in the gaming ecosystem since they receive tangible rewards from the time and effort they use on playing and thus improving the game retention a vision of the common marketplace with virtual currency earning use possibilities is shown in figure 1 it is understood that the realization of the full service platform and virtual system would require a type of banking solution that would keep track of transactions in a secure way yet the companies aim not to build too heavy and complicated system that would not allow scalability and would be too complex to maintain next the first working design to be build is constructed and the next steps and foreseen challenges elaborated on results the implemented case presented in this paper is only the first part of the research to design and implement the above presented vision as a whole although there are two selected games in this case that are part of the interconnected system the design is still done by taking account that it could serve several games in future and the games can be different kinds of freetoplay mobile games one selected game is an established game and the other is a game is to be released during year 2017 both games do have their own currency systems but there 538 30 th bled econference digital transformation from connecting things to transforming our lives e siira e annanperä o simola s heinonen j ylikantola j järvinen designing and implementing common market for crossgame purchases between mobile games is a possibility to buy ingame products from another game by using a currency from that game in this case the possibility to buy virtual items is unidirectional where products in game a can be bought from game b implementation does not yet cover the buying the products to other direction because in the more established game the user interface part is not yet able to provide this both games have dualcurrency model similar to what sasson described the currency used to buy virtual products from another game is a hard currency which is more difficult to obtain than the soft currency making the virtual product more valuable and rare the publisher of the game a uses the marketplace platform to put products available for purchase and prices them in the currency which is used in the game a the marketplace has an exchange rate table which tells how much game b currency is worth in game a currency this exchange rate is determined when new games or entities are entered to the system concurrently other limitations are determined like from which games can the virtual item be bought how many of the items can be bought in certain amount of time or how much of currency can be used for this for example no more than two times per day can the purchases be made per player the single virtual item can have its limitations as well for example one item may be bought five times or just one time in the figure 2 is described the highlevel architecture of the common market in the centre is the combination of marketplace and bank marketplace is responsible for keeping count of virtual items that are available for purchase and which of the items has been sold to which player sellers can add edit or remove the items or check how their items have been sold the marketplace will offer the list of purchasable virtual items for the games bank is responsible for the transactions between the games and keeps track what assets are located where and how they are being paid in addition the bank has abilities to roll back the transactions if the customer is unhappy and demands his resources back or some technical error has occurred and the purchase did not succeed perfectly the bank accounts do not store value they only exist to track the transferred resources and receipt is created from it the value is afterwards nullified the reason for this is that the philosophical approach of the bank is not to mimic a traditional bank but provide platform for assets to be exchanged between the games both games are benefitting from the exchange from other means than keeping the ingame resources of the other game thus the ingame resource may be nullified after use the similarity to a real bank extends to the reliability and robustness of the system the system needs to be able to detect in vast majority of cases if the transaction was complete and the virtual product bought was actually delivered in some cases the delivery may be delayed due to problems in networks or servers but in our case the limit for delivery is 24 hours and if the product has not been delivered during that time it is reimbursed for the customer when designing the bank entity there was a design choice to be made on how to implement the bank entity and the transactions in this implementation the bank is controlled by one actor but one choice could have been to create more independent platform by utilising blockchain technology which would offer higher scalability and possibly more trustworthiness for other game publishers to join the common market as well in the end the closed and controlled system was decided to be the implementation as that is more in line with the business plan marketplace platform is for game publisher and third party web stores to control what they have available to be sold in games for example game a publisher can put pink running shoes for sale and value it at in game a currency for example in gems the item may have some ingame abilities or be just aesthetical upgrade visibilities to different demographics and games has been under discussion but not yet implemented in figure 3 in games there is a shopping module which is common for all games that are implementing the common market for crossgame purchasing when player navigates to the ingame shop the game asks for a web page which is created and populated in the marketplace but the visual style can be set by cascading style sheet in the game a default page without modifications can be used as well but how games are showing the list and how it is navigated to can be up to the game in question when an item has been bought for a game from another game it is checked and deployed when game is launched and then user is informed that the item has arrived and it references the other game as a source the product is deployed only once after that it is the responsibility of the game to track identity management in the common market is important as it should not encourage sharing resources between players but it should encourage one player to play multiple of games how the identity is shared between games and how they are linked through the bank entity has multiple possible solutions and it has to be taken account how the chosen solution affects the user experience and privacy the platform does not need to know who the user is but it needs to know that the player playing game a and game b is the same person the reason for this is that even if it would be valuable to know who the player really is it cannot be a requirement it is identity providers responsibility to know who the player really is apple and google are dominating the mobile game distribution by their appstore and google play markets both are taking their cut from the purchases made in games by 30 th bled econference digital transformation from connecting things to transforming our lives e siira e annanperä o simola s heinonen j ylikantola j järvinen designing and implementing common market for crossgame purchases between mobile games 541 real traditional money the companies are closely guarding their share of the profits the crossgame purchasing needs to be created in a way that it conforms to the rules set of apple and google especially this needs to be in line in cases where the games and identities are ranging from one ecosystem to another in crossgame purchasing there is no money moving between games and the virtual items available must be exclusive for the common market discussion according to our research the common market for crossgame purchasing is a novel solution for higher player retention and advertisement of other games for players the advertisement part is more subtle than stateofthe art advertisement videos we see now in mobile games for them the crossgame purchasing is offering value as they are getting something out of it implementation is now only between two games and it is likely that the concept would need more games to make impact and be more meaningful for the players however as a proofofconcept it shows that the concept can be implemented and it has some merit for future research is left the analysis of the impact and how the players are reacting to this concept some potential issues have been identified during the design of the common market first of all the crossgame purchase might affect the game balance in unhealthy way if the items bought from another game are disrupting the player path this balancing of purchasable items is noted also in oh and ruys research for korean games for example buying too powerful item too early in the game might derail the whole game and take out the feel of accomplishment from the player aestheticonly items without game effect are easier to add from the game design point of view but they might leave a subset of players uninterested about the purchase implementing the crossgame purchase to a game needs to be part of the game design and designers should weigh what they want from it and how it might affect the game another point is the effect of the crossgame purchase to the game where the buying was initiated when a player is pondering whether he or she should use resources in game a to purchase something to game b the player faces a dilemma where he or she needs to think if the resources used would help more in game a than in game b making the player to compare the games and the willingness of progressing in either of the games might lead to feelbad moments which should be avoided hardearned currency in game a is valuable for the player and squandering it to a wrong item might hurt the player desire to play the game further this dilemma of putting the games against each other in terms of resource usage needs to be researched in future more thoroughly to see how it should be solved in more elegant and user friendly way another point for discussion and further research is the data ownership in games the currency earned by a player in one game and used in another can be tricky from data authorization point of view in cases where games a and b are developed by companies 542 30 th bled econference digital transformation from connecting things to transforming our lives e siira e annanperä o simola s heinonen j ylikantola j järvinen designing and implementing common market for crossgame purchases between mobile games that are not in a formal business relationship since the currency in game a is owned by the player the marketplace platform is required to request access to the currency from the player him or herself only after player has granted access to his or her game a currency it can be utilized in game b by the same player via the marketplace platform it is anticipated that this dilemma can be solved using a standard oauth mechanism but this will be in the scope for further implementations of the system conclusions in this research we studied a novel concept of how common market for crossgame purchasing could be designed and implemented stateoftheart mobile games have dual currency system which provide us the possibility to build on top of that any kind of connection between different mobile games is not in mainstream today in our research the connection is based on ability to buy virtual items from other games by using ingame currency the motivation for this to game publishers is to increase player retention in games and use the system to advertise other games incentive for the player to take part of this instead of watching periodic advertisement videos he or she gets value by installing new games and playing more the implementation connects two games and makes it possible to do crossgame purchases to one direction in future the connection should be bidirectional and possibly new games are added the crossgame purchasing needs a marketplace entity and a bank entity the marketplace entity will manage the items available in games and provide ui for sellers and buyers to interact with the system the bank entitys responsibility is to monitor how resources are moving between games and additionally it has the right and the ability to roll back faulty purchases there are open questions on how the players like the functionality to buy items from other games or even discount coupons from web stores in chapter 5 we brought up some open issues and future research directions which we have encountered during this work introduction our western lifestyle plays a large role in the onset and progression of dm2 type 2 diabetes mellitus several lifestyle interventions improved outcomes in type 2 diabetes patients on insulin therapy most notably lower blood sugar and lower medication needs however these are often costly highly controlled interventions moreover the longer term sustainability of behaviour changes is limited the question is can we do this on a more doityourself and esupported basis this would have two advantages first since behaviour improvements are implemented within patients lives it improves the chances of sustained health behaviour second it is cheaper since 2010 the health coach program has been used to improve lifestyle and metabolic outcomes patients via esupport improved selfmanagement and rapidly improved health behaviours to promote rapid health results a hintc intervention of 12 weeks was developed for this patient population plus lightweight esupport and mostly selfmanagement in weeks 13 50 the intervention combines improving health literacy with active behaviour change support this paper discusses follow up results and design lessons after 50 weeks as part of a larger biomedical study an important goal of the biomedical pilot study was to promote long term healthy lifestyle adoption in senior dm2 patients even in wellfacilitated settings a majority of interventions lack sustained health effects after 6 months moreover in ehealth initiatives there is always the risk of falling victim to the ehealth law of attrition meaning that 90 of users are often already lost within a few usage instances in this study population there were additional challenges due to their low average ictand health literacy this exploratory design analysis formulates design lessons based on 50 weeks follow up we focus on feasibility and attractiveness of the hintc esupported lifestyle intervention plus on formulating design lessons given the desire to develop costeffective long term ehealth support relationships with these types of patient groups a focus is on long term erelationship support lessons medical results will be discussed in another paper as part of the design analysis we address efficacy of the service mix deployed in esupported lifestyle interventions we combine the 50week results from our measurements with a design analysis based on an evaluation framework of requirements for ictenabled healthy lifestyle interventions theory the esupported lifestyle program combines coach sessions with electronic dashboarding and selfmanagement hybrid programs have been indicated to be attractive for some time finding the right mix between offline and online contacts is an ongoing design research challenge in summary a hybrid or multichannel service mix is recommended combining electronic and facetoface interactions still there are many design challenges given the multitude of options for a more extensive discussion see simons key functionalities to increase health motivations and behaviours in this esupported lifestyle program are  daily logging of insulin and blood sugar levels for close progress monitoring of the health coaches physicians and participants themselves  close cooperation with physicians for rapid medication adjustments initially plus medical monitoringcoaching in the following weeks  a personal online health dashboard with graphs of progress towards adherence targets on the various health behaviours  automated feedback on lifestyle aspects where positive scores have been achieved  coaching by a health coach generating online reports on progress towards adherence targets in the personal dashboard  the coaching sessions can be flexibly planned based on convenience and participant preference during inclinic visits or phone based from home  options to ask questions to the coach via messaging within the dashboard or via email  online schedule indicating upcoming events group sessions individual coach sessions physical measurements surveys it was theorized and tested elsewhere that the design challenge of persuasive technology for health is not just located in the ict design but also in the design of the overall service scape including health effects and coach relationship it should generate positive mutually reinforcing service experiences across communication channels and activate long term health motivation andbehaviours in order to deliver long term health results this is reflected in the following design evaluation framework for health improvement ict solutions see figure 1 methods study design intervention this is a nonrandomized one arm pilot intervention study of 12 weeks septnov 2015 plus effect measurement at 50 weeks follow up approved by the leiden university medical center ethics board the biomedical results will be addressed in a separate paper the study participants were 11 insulindependent diabetes mellitus type2 patients patients were volunteers and provided written informed consent prior to the study they were recruited by lumc from the larger leiden area in the netherlands they were 8 men and 3 women ages 3970 years with widely varying levels of education and of comorbidity challenges regarding design of individual training schedules were posed by all the physical constraints in this group 7 had significant movement restraints 5 had neuropathy and 7 had cardiovascular disease on average they had been a type 2 diabetes patient for more than 10 years and they were motivated for trying lifestyle improvements health literacy health behaviors health outcomes quality of life and wellbeing ict value adding quality of motivators triggers experiences simplicity familiar interfaces ease of use embedded in and enhancing coach relation coaching performance promoting health actions supporting selfefficacy activating intrinsic motivation health effectiveness venkatesh 2000 were used at weeks 4 and 12 to assess intervention feasibility and attractiveness in this study tam is only used qualitatively as a tool for user evaluation not to make technology acceptance calculations or predictions for this purpose its eight dependent variables provided us with ample user evaluation insights compared to the four dependent variables of utaut furthermore user satisfaction evaluations were user plus the rand sf8 health related quality of life survey besides a standardised sitstand test is used to assess strength as an umbrella overarching the personalized coaching per participant the general lifestyle advice follows the guidelines of the harvard epidemiology and nutrition group for nutrition and physical activity with specific modifications for diabetics the guidelines are to increase intake of vegetables and low sugar fruits to choose whole grains instead of refined grains to limit sugar and other high glycaemic load foods to have one daily serving of nuts andor legumes to limit intake of red meat and processed meat to limit intake of trans and animal fats and to have no more than 2 or 1 alcoholic beveragesday physical exercise guidelines are at least 60 minday moderate intensity activity and at least 3x30 minweek intensive activity which was also supported with group training sessions at the lumc location three times per week stress management guidelines are relaxation exercises for 10 minday results we discuss several types of results we address answers to the first research question what are the 50weeksfollowup feasibility and attractiveness of the hintc esupported lifestyle coaching program including the positive feedback provided by the improvements in quality of life and physiology and to answer the second research question we analyse efficacy of the service mix deployed in esupported lifestyle interventions following the framework of figure 1 from theory first regarding attractiveness and feasibility satisfaction and recommendation were not only high after 4 weeks and 12 weeks but also after 50 weeks 96 and 95 out of 10 respectively this is in contrast with usual patterns where the initial enthusiasm of the first weeks wanes after 3 months regarding health related quality of life as measured with the rand sf8 an interesting pattern emerged over the 50week period as illustrated in figure 2 experienced mental health seems to peak at week 4 this coincides with the large positive surprise that the patients experience in the first 4 weeks fast improvements in fitness quality of life medication selfefficacy health literacy fun and group support plus a hope for a better future in the following period between weeks 4 and 12 there is a continued building up of strength and fitness losing weight building patternshabits and gaining longer term selfefficacy after 12 weeks group training stops and patients are much more on their own patterns diverge with some continuing to improve further whereas others decline second some of the physiological improvements of the first 12 weeks were sustained at 50 weeks average 8 weight loss roughly 20 lower fasting glucose and 65 lower insulin medication clearly the results in the first 12 weeks helped motivate patients and provided positive feedback that they were on the right track the tam user evaluation at weeks 12 and 50 shows three main patterns first these patients were relatively positive at 12 weeks and 50 weeks about all tam constructs aspects that scored particularly high were usefulness and the support offered by the multidisciplinary health team second some patients were not ictliterate and clearly had trouble with etools like the health quiz of foodexercise logging see simons for a more extensive discussion on their differences in ict adoption which became apparent in the first 12 weeks third we observed that over the course of roughly weeks 12 to 50 attention of participants shifted also visible in their tam scores after initial attention on tools and start up challenges attention later shifted to health literacy plus sustaining healthy food and exercise patterns in hindsight participants started appreciating the intensive start menu and start workshop more the exercise support continued to be highly valued plus sustaining healthy patterns in weeks 12 to 50 was top of mind see the high scores for these elements in tam constructs 8 and 9 on the level of social support and maintaining a healthy lifestyle focus the group spontaneously organized monthly meetings together outside of the hospital setting the final set of study results regard research question 2 analyses to enable lessons for long term ehealth relationship building as a basis we use an efficacy evaluation of the hybrid esupport mix deployed at 50 weeks follow up ictilliterate health quiz and food logging being complex for some fit with coach processes etools integral part of coach processes and effectiveness much motivation support still from the coaches less from tools table 2 contains several lessons first looking at health effectiveness we see mixed results biologically there are large positive effects for all 11 participants even at 50 weeks even despite the large health education and psychology differences within the group however regarding health literacy and selfmanagement competence the large differences that were observed at the start became increasingly pronounced during the 50 weeks follow up this relates to the second column coaching performance promoting health actions and intrinsic motivation worked relatively well but with those patients that have less selfmanagement skills it is hard to maintain coaching effectiveness in the 12 to 50 weeks period third regarding ict value adding it was good that there was a variety of etools given the large differences in the patient group regarding ict literacy and preferences the simple mail based tool for sugarinsulin monitoring was highly valued by all and for the multidisciplinary coach team the etools were very useful for progress monitoring and proactive coaching see section 51 design lessons and implications for practice for further reflection and improvement ideas on etools design lessons and implications for practice several lessons can be learned from this study in relation to the intensive healthy lifestyle approach and in relation to the suitability of hybrid ehealth support plus we will address options for improvement third opinions varied regarding the suitability of most of the etools provided in the short term of the first few weeks virtually all tools were used by virtually all patients after several weeks usage patterns diverged two factors appeared important in determining adoption and use of these tools availability of time plus ict literacy because he liked this form of explicit monitoring two other participants continued using the health quiz throughout the 50 weeks several others continued reading week tips and other health content during the 50 weeks follow up clearly user preferences for the various esupport tools differed fourth the exception to this varied etool adoption pattern was the simple daily mail reminder tool for sugarinsulin inputs also described in simons this tool was used daily again by the patient group in weeks 48 50 to assemble user pattern data we think that the combination of high simplicity with high usefulness was the key to its high adoption the tool was an important basis for the coaching from the multidisciplinary support team in conclusion esupport was not only useful for the patients but especially for the care givers providing them with much more extensive views on the users fifth besides etool support the group effects and the multidisciplinary support team were highly valued the patient group arranged several social events together during the weeks 12 50 period and every 6 weeks there was a 1hour gathering at the hospital again with the support team the hospital team meeting was valued socially but also for health literacy and practical support these group effects fostered high levels of interpersonal commitment which is important for long term relationships and something that is more challenging to achieve with etools finally if we look at future improvement suggestions several innovation opportunities emerge first in the coaches professional opinion strength and endurance improvements could have been significantly larger with more effective training thus in the next diabetes lifestyle project better training equipment will be used second the training progress feedback loop will be used more with a mail based selfmanagement monitoring tool similar to our sugarinsulin tool so that even after completion of the group training period together the coaches can continue monitoring and guiding patients better on their exercise progress third regarding building long term erelationships it would not be correct to label the phase of 12 to 50 weeks as maintenance patients are continuously renewing their patterns experiences and lessons all in relation to health literacy and health competence better support is needed for these renewed learning processes within long term support relationships there clearly are patient needs for continued learning growth and discovery hence more functionality will have to be developed to stimulate online effective search interactionand questionanswer behaviours of patients both in relation to health literacy questions as well as in relation to health routines goals and competencies implications for theory as stated before for several of the patients in this group their learning styles were highly noncognitive an understanding of health cause and effect seemed to have less impact than experiencing cause and effect daily feedback loops between behaviours and sugar values were useful in this regard for this group learning is not very much about explicit awareness intentions goals behaviour and maintenance plans as postulated in models like hapa and ichange this appears to resemble mental models of impulse purchasing in marketing first acting then experiencing and opinion forming next the term maintenance seems a missqualifier for the longer term phase of health behaviours observed here what we observed was closer to processes of iterative circles continuous renewal reinterpretation and discovery these processes of course include pitfalls for those who have fragile health literacy the latter group easily tend to fall prey to misbeliefs and misadvise from others around them thus finding effective and efficient formats for continued coaching is very valuable for long term support as part of long term erelationships with patients finally four of the eleven participants simply disliked using ict for either reading checking mail or inputting data still the overallattractiveness of the intervention was rated high because of a the large benefits and b the extensive practitionerand group support thus the ehealth law of attrition transforming our lives was bypassed partly thanks to benefits in the context of the ict plus some cognitive dissonance may have worked to our advantage if something is a challenge then people may appreciate their own achievements and results more this appears to have helped increase motivation for ictadoption as well as the extensive lifestyle improvements especially in the longer run their increased selfappreciation and selfefficacy appears to have helped conclusion summarizing from this study we can conclude a few key points this preliminary analysis has several limitations first this is only a pilot study with 11 participants second the 50week data analyses are not complete yet more biometric and behaviour data analyses still need to be done third regarding external validity these study results may only apply to motivated individuals who volunteer for lifestyle training fourth it can be argued that tam is not the only suitable instrument for evaluating technology adoption for example utaut is also viable however utaut was developed and validated in organisation contexts where functional aspects of information systems adoption are relatively important in consumer contexts items regarding attitude towards use are relevant as well and those are part of tam still on the positive side our results prove relatively robust across the 11 participants even though they are diverse in background and this pilot provided an opportunity for design analysis regarding the hybrid service mix deployed and opportunities for long term erelationship building introduction in this paper we study a mobile application for supporting anaphylaxis patients the app was proposed by a team from the department for allergology at the university medical center utrecht a large academic teaching hospital in the netherlands the app will be developed in collaboration with physicians and patient groups supporting anaphylaxis patients anaphylaxis is a type of immediate allergic reaction categorized as type 1 hypersensitivity further defined as an acute systemic reaction caused by mast cellmediator release which is potentially life threatening anaphylaxis may be caused by a number of triggers also called anaphylaxis agents such as foods medication insect bites or contact with latex anaphylactic reactions cause symptoms which may be lifethreatening and require an emergency response the proposed app is intended to support anaphylaxis patients and their caregivers by providing stepbystep assistance in the case of an anaphylactic reaction exposure to allergens that cause anaphylactic reactions may occur via ingestion inhalation injection or direct contact anaphylaxis manifests itself through symptoms such as flushing and itchiness of the skin difficulty breathing swelling of the mouth or eyes or an abnormal heart rate an anaphylactic reaction is usually treated by administering a dose of epinephrine intramuscularly into the thigh using an autoinjector after which the patient should be admitted to a hospital for further treatment and observation the exact prevalence of anaphylaxis is difficult to establish as people may develop sensitivities to allergens at different points in life or may be unaware of sensitivities to allergens they have not yet been exposed to different studies indicate a 05 to 2 prevalence in the worlds population a 121 to 1504 prevalence and a 16 to 77 prevalence in the us population data provided in the apps proposal indicates the prevalence of diagnosed food allergy in the netherlands at 12 in adults and 13 in children with 90 carrying emergency medication for insect bites the prevalence is 13 among the dutch population the morbidity and mortality of anaphylaxis are believed to be underestimated due to limited data on its incidence evidence points towards an increase in anaphylaxis prevalence which may be attributed to changes in diet and medicine use besides the physical symptoms anaphylaxis is shown to have a societal impact by leading to a decreased quality of life and limiting of social activities for children as well as proneness to school absence and decreased participation in the labour market for adolescents several patient groups aim to support anaphylaxis patients by providing information on the internet examples are the national foundation of food allergy in this study aims to determine the critical success factors for the adoption of the proposed anaphylaxis app to achieve this we conducted a mixed method approach containing a literature review a domain expert interview and a patient survey the research question addressed in this paper is defined as follows rq what are critical success factors for user acceptance of an app to support patients suffering from severe allergic reactions the remainder of this paper is organized as follows first we provide information with regards to the anaphylaxis app that will be developed by umcu analyze similar apps and identify success factors for the adoption of such apps in literature in the background and related work section this is followed by the research method in section three in section four the results of the mixed method approach are presented lastly in section five we reflect on the results and applied research methods in the discussion conclude upon our study and propose possible directions for future research background and related work in this section the anaphylaxis app will be presented and compared to existing applications additionally the literature with regards to critical success factors is explored and discussed upon the anaphylaxis app the anaphylaxis app studied in this paper was proposed by a team at the department of allergy at the umcu the proposal entails a request for funding which will be needed to start the development of the app for android and ios currently no actual app or prototype exists development of the app will be performed by the medical apps cocreation center also known as mac³ mac³ provides centralized services for the development testing and research of medical apps the author of the proposal was interviewed in order to gather background information on the app the team at umcu collaborates with the national foundation for food allergy the dutch anaphylaxis network and the domain group for eczema which is a part of the dutch society of dermatology and venereology these contacts are used to establish requirements for the app and to foster its acceptance in the medical community the purpose of the app is to provide a better alternative compared to the leaflets that are usually given to patients by physicians alongside anaphylaxis medication such leaflets provide information on emergency procedures but are not always carried by the patient the app should improve the availability of this information by residing on the 564 30 the information provided will be personalized depending on the type of reaction the severity of the reaction and the medication the patient uses information on reactions caused by other less common triggers is not explicitly included but may be covered by the available information on treating reactions caused by food or insect bites besides providing assistance in the case of an allergic reaction the app will provide background information on allergic reactions to be consulted at any time while similar apps already exist in countries such as the uk and australia an app geared towards the dutch market that is endorsed by patient organizations and contains validated medical information and instructions is not yet available countryspecific apps are also needed because of differences in medications available per country related appsgames the current offering of anaphylaxisrelated apps was studied in order to explore similarities and differences compared to the proposed app apps were collected by performing the search query anaphylaxis and allergy on the google play store and the apple app store including related apps for any identified app that resulted from our search the apps and their characteristics features and ratings are compared in table 1 30 target market most apps provide similar functionalities some being more extensive than others such functionalities may include general information about anaphylaxis and allergies instructions for emergency procedures and the use of autoinjectors medication expiration reminders and interactive maps for finding nearby medical facilities all apps found are aimed at anaphylaxis patients or caregivers as evidenced by the available data on the number of installations there does not appear to be one particularly popular anaphylaxis app install base data is only available on the google play store and not on the apple app store in terms of ratings and evaluations of the app no information was found originating from independent sources some of the compared apps are free to use while others require a small fee apps such as the one made by coventry university are intended for a more general audience of anaphylaxis patients while the jext app developed by alkabelló is to be used specifically by patients using jextbranded autoinjectors the former app is also the only app found that is endorsed by a local patient organization namely the uk anaphylaxis campaign critical success factors the current body of knowledge on critical success factors in the context of this study consists of research on both allergy management in general and anaphylaxis management the available literature which consisted of nine relevant papers is presented in three main categories preventative information providing assistance and mobile healthcare preventative information mobile technology is used in several ways to support patients suffering from allergies or anaphylaxis one of these ways is providing preventative information by enabling patients to scan food items or medications through the use of barcode or nfc technology a general study into smartphones and barcode scanning by eichler luke describes a prototype developed by deutsche telekom laboratories called allergy warner which provides an alert message when scanning barcodes of food products in the supermarket the app will contain a personalized allergy profile which looks for matching ingredients in the scanned products eicher luke argue that modern smartphones can quickly and easily scan and recognize multiple types of barcodes making them suitable for this purpose a similar study by gassner vollmer prehn fiedler ssmoller concludes that reliable information about food products is difficult to obtain because of different interests of stakeholders in the food value chain a mobile app that provides such information would fill a gap in the market ottenhof provides a proof of concept for a devicebased solution that allows customers in supermarkets to scan product packages for allergy information however ottenhof concludes that a lack of information provided by manufacturers proves to be an obstacle stierman found that scanning product packages make it easier for patients to retrieve allergen information patients were more likely to buy products they were unfamiliar with thanks to a scanning solution a study by möller diewald roalter kranz evaluated an application called mobimed which allows users to scan medicines in different ways either through text search barcode scanning visual search or near field communication this app could then be used to warn patients for medicines that would put them at risk of allergic reactions extracting information through nfc was found to be the fastest and most preferable method because the user does not need to search for and scan a barcode however the integration of nfc technology in smartphones and packaging is not yet widespread ottenhof found that nfc technology provides the best matching capabilities because of its high storage capacity and the possibility to tag products on an item level rather than by product type while this information is easily extracted by modern smartphones the implementation of rfidnfc on packaging is a backend that provides additional information would be needed problems could occur when the composition of one type of product with the same barcode changes over time when looking at the current literature on providing preventative allergy information to patients we can conclude that there are still some improvements that can be made to cater to patients in terms of retrieving the information a universal fast and costeffective method needs to be found to provide contextual information about physical products on a smartphone additionally manufacturers of medicines and food products need to provide allergen information that is easily accessible for consumers providing assistance a series of works by hernandez et al describes a personal mobile health device and the associated app used to alert emergency services automatically when an autoinjector is administered to a patient the solution called pervalaxis uses an accelerometer connected to an autoinjector to detect its usage which is signaled wirelessly to a smartphone using bluetooth emergency services can be contacted automatically through the phone in a later study pervalaxis was further validated by involving patients a pilot study was performed after which the patient sample was increased over time use case diagrams were used to test usability and determine important success factors for the solution these success factors are reported to be adrenaline injectors expiry alerts an emergency support button and adrenaline injection sensing limitations identified for this solution were the reliability of the mobile phone transmission and the accuracy of the injection sensor other works suggest that instructions for providing assistance to patients should be segmented towards different user groups this may be done based on the age of the patient and the number of years of experience they have with their illness further personalization of the app could be of use here mobile healthcare obiodu studied the top 500 medical apps in the android market and concluded that the majority of apps are designed for healthcare professionals while it is plausible that most endusers are patients rather than healthcare professionals one significant problem is that it is often unknown whether medical apps intended for patients provide information that is validated by medical professionals in practice it is found that medical professionals are often not involved in the development process of medical apps or that there is a lack of validated sources available in the app beyond this there are no obvious signs to distinguish medically validated apps from apps that have not been validated such as an international mark of quality when an app does not offer a diagnosis treatment or cure it cannot be classed as a medical device and will not be subject to the thorough scrutiny of such medical devices however the general information or advice provided by such a medical app may still cause harm to the patient an increasing number of apps published and the lack of an international safeguard for monitoring medical apps undermines patient safety critical success factors the literature contains 9 relevant contributions with regards to csfs applicable in our study the csfs of the app can be defined as follows 1 the information is contextaware through scanning of physical objects 2 the information is easy to retrieve 3 the information improves the users understanding of the subject when looking at the ability of the app to provide assistance in the event of an allergic reaction and general characteristics of mobile healthcare the following success factors were identified 4 the app should provide advice that is validated by medical professionals 5 the app should provide advice that is tailored to the users medicines 6 the app should provide advice that is tailored to the characteristics of the user such as age or level of experience in table 2 the critical success factors are linked to the papers from the literature review in the header row the six csfs identified earlier are transformed into keywords ✓ ✓ research method interview in this section we describe the setup deployment and the evaluation of the interview with a domain expert who is a representative and the founder of the dutch anaphylaxis network known as nan in dutch the nan informs and provides support to patients while also keeping in touch with stakeholders such as food producers on current issues surrounding allergies as the interview is semistructured of nature the following topics are discussed 1 the current necessity of an app 2 existing knowledge on mobile applications concerning allergy or anaphylactic patients 3 critical success factors concerning user acceptance of an app 4 additional comments or advice with regards to csfs the domain expert was first invited to provide his own insight into possible csfs and then asked to evaluate the csfs identified during the literature review this was done in order not to create a possible bias by first presenting our findings derived from literature survey following the literature review and domain expert interview a survey was conducted among a sample of patients in order to gather further data on csfs as described in section one the proposed app is aimed at the dutch market with a prevalence of diagnosed food allergy at 12 in adults and 13 in children with 90 carrying emergency medication for insect bites the prevalence is 13 among the dutch population as indicated by the proposal of the app all patients in the netherlands who may be at risk for anaphylactic shock are included in the scope of the survey the survey was designed to first establish basic information about the patient such as their age and the number of years of experience they have with anaphylaxis the patient was also asked if they are familiar with smartphones including the total years of use and a selfassessed competency rating a number of possible functionalities for the app were presented to the participants for which they could indicate their desire for such a functionality in an anaphylaxis app on a likert scale these functionalities were adopted and where needed adapted from results of the literature review and domain expert interview an openended question provided respondents the possibility to provide additional functionalities the ratings given for the functionalities were then used to determine the most valuable functionalities and therefore csfs for the adoption of the app another set of questions adopted from the system usability scale and technology acceptance model determined which usability factors were deemed most important by patients such as the clarity of the presented information and the interactivity of the app finally the respondents were asked to rate the likeliness of using an anaphylaxis app on a scale of 1 to 10 results in this section the results of the interview and the patient survey are presented domain expert interview the domain expert was positive about the concept of an anaphylaxis app there is a necessity for such a solution in the domain with regard to replacing paper leaflets an app may be useful but only until the patient has familiarized himself with the information after this the app will need additional functionalities to engage and support the patient such as training users to identify and avoid possible anaphylactic triggers the domain expert identified the following csfs for the adoption of an anaphylaxis app 1 the app should focus on including avoidance strategies for potential anaphylactic triggers 2 the app should include gamification such as a quiz used to test knowledge on allergens and emergency procedures both for the patient caregivers as well as friends or family 3 the app should focus on different user groups since the information needs of each group can differ adolescents may more easily ignore food warnings for example making it necessary to address them in a different way 4 the app should be interactive rather than just providing static content 5 the app should be free earlier research by the domain expert concluded that paidfor apps lead to low adoption rates among patients patient survey contacting patients directly through umcu proved to be difficult and timeconsuming due to the clearance procedures involved the decision was therefore made to deploy the survey on the website of the nan with help of the domain expert interviewed earlier the nan receives about 500 unique visitors per day on their website the survey was featured on the front page for a period of 6 days between from the 21st up until the 26th of june 2014 patients could voluntarily and anonymously fill out the survey on the website 276 respondents filled out the survey the sample consists out of 167 male and 797 female respondents with an average age of 4096 years our respondents have an average of 981 years of experience with anaphylaxis 931 of respondents indicate owning a smartphone with a 46 percent share android is the most used mobile operating system closely followed by ios at 391 the remaining share goes to other or unknown operating systems and blackberry the average number of years respondents have been using a smartphone is 395 years they rate their own competency in the use of mobile phones with a 775 on a scale of 1 to 10 the desirability of an app to support anaphylaxis patients is rated with an average of 834 on a scale of 1 to 10 while the probability of the respondents using such an app is rated with an 875 the three most compelling app features indicated by respondents are the clarity of the information the medical validation of the information and the availability of information regarding emergency procedures with average scores of 668 662 and 648 on a scale of 1 to 7 respectively the aspect rated as least important are the presence of an element of play a quiz to test allergy knowledge and interactivity of the app with average scores of 2 the openended question in the survey asking patients for other desirable functionalities yielded many results the functionalities provided were categorized by similarity 22 respondents indicated the desire for a functionality that helps to translate allergens and emergency instructions into another language for when the patient is traveling 12 respondents wish for an alarm button that can quickly contact emergency services and other predefined contacts and another 12 respondents wish for a newsfeed containing updates on medication or treatments conclusion discussion the research questions addressed in this paper was defined as follows what are the critical success factors for user acceptance of an app to support patients suffering from allergies to answer this research question we looked at the results of the analysis of the in literature a number of studies were found concerning food allergies in general and specific measures for anaphylaxis the studies on food allergies noted the possibility to scan food packaging as a critical success factor for user adoption in their specific context the studies related specifically to anaphylaxis such as the study concerned with automatically detecting the activation of an adrenaline injector through a bluetooth accelerometer were more concerned with the validity of the information provided by the accompanying app however the umcu has already indicated that such features will not be included in the app at this time the factors that remain based on literature are that the app should contain medically validated information be easy to use and improve the users understanding of the subject and be sensitive to different user groups the proposed app will adhere to these factors the domain expert indicated a number of new factors mainly relating to the interactivity of the app and having certain quiz or gamification elements that test the knowledge and train them to avoid allergens another factor mentioned was that the app should be free in order to boost user adoption patients surveyed agreed with this although they did not appear to be very enthusiastic about gamification or quizzes once more new factors were introduced after the patient survey such as the ability to translate allergens and procedure information providing a newsfeed and a list of predefined emergency contacts the factors for the medical validation of the information and the availability of clear emergency procedures were also rated highly by patients another interesting factor is that patients indicated they would overall be very likely to use such an app in relation to all of the features that were established in this study the proposed anaphylaxis app appears to be relatively limited in features however the team at umcu has indicated that the proposed app should be simple and straightforward to use the decision was made not to include features such as scanning of objects or giving extensive information on types of food that contain allergens even though the app does not contain all functionalities that may be seen as critical success factors the app may still prove to be of added value for patients when its functionalities are fit for purpose the simplicity of the app will also contribute to the clarity of the information which was another success factor an effectiveness study will have to reveal the actual usefulness of the app for patients the current body of knowledge related specifically to anaphylaxis apps is rather small and anaphylaxis apps are a relative niche market within the medical app landscape making it difficult to predict the effects the csfs will have on actual user adoption beyond this we recommend the team at umcu looks into the possible expansion of the app in the future in order to include some of the features that were indicated as being desirable for patients moreover our results also indicate a selection of lower rated functionalities for the app for example the functionality that was rated lowest in our results was the functionality regarding the addition of a challenging game element while we believe that our survey was conducted with the aim to gather data from the appropriate user groups some of the respondents indicated to be a parent or caregiver this is usually the case with younger children there could be a difference between how a sample drawn solely from patient groups versus our sample rate the functionalities presented in a survey currently our results are difficult to link with the existing body of knowledge as no uniform opinion exists on the importance of csfs and related functionalities besides the methods used in this study further validation should be performed using other patient organizations medical professionals domain experts and patients in this study we were only able to contact one medical professional and one representative of a patient organization therefore the results of the survey could be affected by the input from the results of the interview which were derived from one subjectmatter expert the generalizability of our results could be improved by involving more subjectmatter experts from different perspectives in addition to the dutch market the development team could also get into contact with other international organizations who have previously developed similar apps in order to find out more about their lessons learned all in all we believe that the current potential success of the app lies in the fact that it is being developed by medical professionals in collaboration with patient organizations which is a highly regarded success factor in addition the app will be available for free and is targeted towards the dutch market where no such app currently exists the information given about emergency procedures may indeed prove to be a useful replacement to paper leaflets once doctors start prescribing the app alongside anaphylaxis medications from a theoretical perspective our study provides an overview of csfs and the importance of those csfs in the context of a substantial dutch sample geared towards the development of an app to manage anaphylaxis from a practical perspective our results provide direct evidence and directions for development and help in the prioritization of the development of functionalities in similar apps introduction medical protocols are used by physicians as guidelines to perform a diagnosis and subsequently a treatment that fits that diagnosis these protocols also referred to as clinical practice guidelines are defined and maintained by medical organizations such as hospitals but also by national or international governing medical institutions a cpg may offer specific instructions on which diagnostic or screening tests to use how to provide medical or surgical services the duration that patients should stay in a hospital or regarding other details of clinical practice these cpgs may contain overlapping content between different medical specialties to help to determine the right decision for an accurate diagnosis despite the redundancy it is possible to implement the different protocols into one clinical decision support system a cdss can be described as the provision of the knowledge of clinical experts in combination with patientrelated information in an information system medical knowledge and patientrelated information combined are filtered and presented at the times necessary these actions are performed to improve patient care by providing an accurate decision on what medicine and corresponding treatment to adhere to essentially cpgs are an accumulation of rules with regards to diagnostics medication and treatments thus these rules can be programmed in a cdss this research paper will explore how the existing anticlotting cpgs at the university medical centre utrecht can be embedded into a knowledge model to be implemented in a cdss to support decision making a similar study by ozel bilge zayim cengiz focused on the development and evaluation of a webbased cdss that supports intensive care unit providers in making decisions more efficient and effective this particular study states that the aim of the study was to develop a supportive webbased system which was constructed in line with the needs and preferences of intensive care physicians and evaluate its efficiency effectiveness and usability in contrast to this study the challenge addressed in this paper is the development of a cdss containing eight cpgs each from different specialties at the umcu currently when the diagnostic medicine and treatment variables have to be determined for a patient all involved specialties have to discuss the best course of action based on their specific cpg to ensure that medical professionals with different specialties and backgrounds follow decisionmaking processes in a consistent manner it is important that the different cpgs are combined a successful implementation of cpgs into a cdss will provide stakeholders in medical processes with the ability to systematically make decisions in an effective manner without the need to discuss medicine and treatment variables with each specialism furthermore the utilization of a cdss for decision making could result in a reduced error margin as the decisions supported can be 30 th bled econference digital transformation from connecting things to transforming our lives k smit p koornneef j nysingh m van zwienen m berkhout p ravesteyn transforming clinical practice guideline usage through the use of a clinical decision support system an explorative study at the university medical centre utrecht 579 evaluated appropriately the evaluation of the output is important as it enables the cdss to learn to provide more accurate decisionsupport to ground our goal to develop a cdss for the determination of anticlotting medicine and treatment the following research question is formulated rq how can the available anticlotting cpgs of the umcu be combined into a cdss with the aim to support decision making and increase adoption of the cdss the remainder of this paper is organized as follows in section two the background and related work with regards to cpgs and cdsss will be explored next the research method is presented in section three this is followed by section four in which the data collection and analysis are described finally in section five the results of our study are presented and in section six we draw conclusions from our results followed by a discussion with regards to the research study conducted after which we provide directions for future research background and related work in literature several definitions for a cpg exist in our study the following extensively cited definition from field lohr will be used systematically developed statements to assist practitioner decisions about appropriate healthcare for specific clinical circumstances since cpgs are developed and implemented in the clinical practice it has shown a lot of potential for the improvement of the quality of the healthcare the combination of scientific literature and evidence with insights from clinical experts form the basis for a cpg usually published by national medical governing bodies for example the dutch college of general practitioners or the american institute of medicine and are further specialized and instantiated per hospital based on this recommendations are developed on specific clinical subjects for example a clinical subject is given a score based on the insights from the clinical experts the height of the total score determines what treatment is supposed to be given the recommendation according to the score is always backed by scientific literature these recommendations provide professionals working in healthcare guidance whom in some cases dont have the expertise required to effectively andor efficiently determine medicine and treatment for a patient a couple of proven benefits that cpgs realize in the clinical domain are 1 decision making on appropriate care for patients 2 promote education and improvement of care processes 3 reduce unwanted variation in the delivery of health care and 4 help contain costs most of these positive attributes are similar with the benefits from cdsss however the utilization of cpgs also poses stakeholders with challenges like how to maintain cpgs so that stateoftheart knowledge is guaranteed and how to ensure the validity of its contents implementation of cpgs for a cpg to be effectively utilized it needs a successful implementation multiple studies show that in some cases after the dissemination of the cpgs there is a lack of usage in the clinical practice a part of the problem is the lack of behavior change by the physicians this is mostly caused by a lack of agreement with cpgs itself the lack of agreement can be based on specific factors for example a lack of confidence in the author or it can be based on the lack of agreement in general other identified reasons for a failing implementation of cpgs can be the wrong distribution of the cpgs although these are serious concerns for the adoption and utilization of cpgs two studies show that in the netherlands a high acceptance and feasibility level is achieved for the development and implementation of cpgs although cpgs help stakeholders in the diagnosis and treatment of diseases another challenge exists most cpgs are printed on paper which limits practical clinical use this is one of the reasons that clinical decision support systems are developed the combination of the knowledge of clinical experts with patientrelated information is filtered and presented by a cdss when it is required there are different sorts of cdss archetypes according to power those are 1 modeldriven 2 datadriven 3 communicationdriven 4 documentdriven and 5 knowledgebased cdsss clinical decision support systems knowledgebased systems are used most and proved most efficient in the cdsss setting knowledgebased systems hold knowledge about a domain in the domain this knowledge is the understanding of the problems and skills for solving these problems knowledgebased systems mostly use ontologies for structuring the knowledge in this paper we use ontologies that refer to an engineering artifact as formulated by the popular work of these are constituted by a specific vocabulary used to describe a certain reality plus a set of explicit assumptions regarding the intended meaning of the vocabulary words this set of assumptions has usually the form of a firstorder logical theory where vocabulary words appear as unary of binary predicate names respectively called concepts and relations some of the benefits that cdsss provide are 1 providing knowledge to medical professionals at appropriate time and manner 2 facilitating an efficient and effective decision making 3 reducing preventable medical errors 4 improving the overall quality of healthcare for patients and 5 serving as a didactic tool for critical learning for medical students several studies have proven that cdsss improve the clinical practice and practitioner performance by respectively 64 and 68 a recent implementation of a webbased cdss in an intensive care unit in turkey shows that the cdss significantly contributed in the accuracy of the decisionmaking by the physicians although the time for making decisions wasnt reduced this study did show that user satisfaction and usability were high in two test scenarios 150 questions were posed in the first scenario the participants needed to answer these questions without the support of a cdss in the second scenario the cdss supported the decisionmaking by the participants without the support of a cdss 24 of the answers were correct with the support of a cdss the number of correct answers increased significantly to 832 finally the study states that there is a great need for research and development of cdsss especially in the intensive care unit since the icu produces large volumes of data since the clinical environment is always developing and changing the knowledge in cdsss requires a high level of modifiability and maintainability however when changes are made in cpgs it is hard to implement these in the cdss this is because it requires both the expertise of the clinical domain as well as the informatics domain a possible solution for the problem is simplifying the manner in which knowledge can be modified within cdsss this particular functionality is referred to as knowledge editing if this functionality is simplified in a way that requires less expertise in the informatics domain adoption of the change process by clinical experts increases as it becomes more easy to modify the cdss knowledge based on changes in cpgs for example this can be achieved with the visualization of the knowledge in schematic plans such as an eventbased decision tree study design to construct a cdss and assess the value of the knowledge in the cdss a threephase research design has been implemented the first phase comprised the analysis of eight anticlotting cpgs followed by the construction of the actual knowledge in the cdss the second phase consisted of the validation of the content of the knowledge in the cdss by a group of medical stakeholders at the umcu the third phase comprised the refinement based on the feedback that was received from the medical stakeholders which was followed by another round of validation but in an individual setting with the additional goal to evaluate the utilization of cpgs through a dss an important factor in determining the appropriate research method to validate the cdss is the maturity of the research field in literature we identified several developments and trends regarding the use of dss in a medical context however the research field of cpg usage through a dss in the dutch context to the knowledge of the authors is still nascent according to edmondson mcmanus fields should be on identifying new constructs and establishing relationships between identified constructs therefore the construction of the consolidated anticlotting cpg will be performed using a round of secondary data collection and analysis consisting of documents regarding the eight anticlotting cpgs available at the umcu as our goal is to validate the cdss and to explore the challenges related to the adoption of a cdss at the umcu a wide range of possible ideas or solutions should be explored from different stakeholders an adequate research method needs to be used to explore a broad range of possible ideas andor solutions from a complex issue and combine them into one view when a lack of empirical evidence exists in this light groupbased research techniques are adequate examples of group based techniques are focus groups delphi studies brainstorming and the nominal group technique the main characteristic that differentiates these types of groupbased research techniques from each other is the use of facetoface versus nonfacetoface approaches both approaches have advantages and disadvantages for example in facetoface meetings provision of immediate feedback is possible however facetoface meetings have restrictions with regard to the number of participants and the possible existence of group or peer pressure to ground our research results and to eliminate the disadvantages we combined the facetoface and nonfacetoface technique by means of applying a focus group as well as individual semistructured interviews data collection analysis data for this study is collected over a period of two months between november 2016 and december 2016 through 1 secondary data analysis 2 one round of validation utilizing a focus group session and 3 one round of validation utilizing individual semistructured interviews see also figure 1 all three methods of data collection and analysis are further discussed in the remainder of this section modeling of umcu cpgs in the first phase the eight cpgs of umcu had to be collected and transformed into ontologies to understand the process of a medical examination and to be able to model them in the cdss pilot at the umcu one challenge was that the team of researchers consisting out of three researchers with experience in knowledge modeling and three researchers with experience in the field of cdsss quickly came to the conclusion that the cpgs are predominantly textual documents that rarely visualize the process the cpgs included in this study were 1 bridging vitamin k antagonists 2 direct oral anticoagulants 3 heparininduced thrombocytopenia 4 unfractionated herapine use 5 start vitamine k antagonists 6 profylaxe venous thromboembolism 7 venous thromboembolism and 8 nerve and neuraxial blockade with anticoagulant the process of transformation of the cpgs into ontologies was conducted as a cyclic approach first the researchers with experience in knowledge modeling analyzed the secondary data and modeled the ontologies to be implemented these ontologies were then submitted for review by the cdss researchers this process was repeated five times before the final cdss pilot for validation in the focus group was established in order create the cdss eight cpgs were developed into a model this model links ontologies collected from the cpgs in the pilot of the cdss to make sure that the modeling of the cpgs was performed adequately the researchers started with the analysis and modeling of only one ontology which was then validated by the cdss researchers when the first cpg was modeled and found valid the knowledge modeling researchers started with the development of all cpgs involved and repeated the internal validation 584 30 process with the cdss researchers based on the developed ontologies the researchers had to analyze which of the ontologies was characterized by the highest uniqueness as the analysis resulted in overlapping rules and content in the included cpgs based on the analysis of the created ontologies the hemorrhage risk ontology was found most unique and therefore the largest contributor to the determination of anticlotting medicine and treatment for this reason we selected the hemorrhage risk ontology to serve as a basis for the creation of the bridging ontology which contained all decision knowledge from all ontologies to determine anticlotting medicine and treatment at the umcu the ontologies were built using the decision support system of beinformed a supplier of dss the output of the modeling phase was used to prepare and structure the validation of the ontology by means of the focus group session focus group validation subsequently to the modeling of the knowledge into the cdss the focus group session was prepared and conducted in december 2016 the session had a duration of one and a half hour in total before a focus group is conducted first a number of key design concepts need to be considered 1 the goal of the focus group 2 the selection of participants 3 the number of participants 4 the selection of the facilitator 5 the information recording facilities and 6 the protocol of the focus group the goal of the focus group was to validate the anticlotting cdss based on this we selected eight participants the selection was done in collaboration with the umcu the selection consisted of five specialized physicians from which each one was responsible for one or more of the cpgs included furthermore two pharmacists and one laboratory expert were involved the focus group was chaired by an experienced facilitator one of the cdss research team members additionally one knowledge modeling research member was present to take notes as the contents of the bridging ontology are confidential the focus group meeting could not be captured via audio or video lastly the protocol of the focus group was based on the cpgs modeled which were presented onebyone during the focus group session this protocol provided each participant the opportunity to provide feedback per cpg the results from the focus groups were also utilized to get an impression of the attitude of stakeholders and challenges for stakeholders with regards to the use of a cdss and develop a list of topics to address in the individual interviews these particular questions were not posed during the focus group as it would allow for peer pressure amongst the participants thus would be more appropriate during the semistructured validation interviews after the focus group session was finished the researchers continued to refine the cdss for example by changing the sequence of questions posed by the cdss and the formulation of the questions after this the third phase of this study was conducted comprising the semistructured interviews with the same five physicians that participated in the focus group session in phase two the main goal of the interviews was to validate the refined cdss based on the feedback provided in the focus group validation session furthermore based on the input of the participants in the focus group session we managed to develop the following set of four topics that were discussed with each interviewee  experiences with regards to the current use of cpgs  improvements with regards to the current use of cpgs  problems that are anticipated with regards to the use of a cdss  significant features that should be included into the cdss to promote adoption as stated in subsection 42 each of the interviewed physicians was responsible for one or multiple cpgs furthermore none of the participants had knowledge on what their coworkers had answered the individual interviews were audiotaped and transcribed within 48 hours the interview data was analyzed by linking and categorizing answers from the physicians if several responses matched they were labeled by the researcher on perceived advantages and disadvantages with regards to working with a cdss this was then crosschecked by other researchers from the research team to ensure coding accuracy this approach resulted in patterns with regards to the four topics that were addressed in the interviews results in this section the results of the three phases executed in this study are reported first we present the results of the modeling phase where we collected analyzed and transformed the cpgs into ontologies to be implemented into the cdss this is followed by the results of the validation focus group session in which we validated the first version of the cdss and used to prepare the semistructured interviews lastly the results of the interviews are presented that comprise the validation of the refined cdss as well as an exploration of the experiences problems improvements and significant functionalities with regards to cpgs and cdsss modeling phase the first and most complex cpg was transformed in an understandable way to model in the cdss on top of those ontologies is a proven method to model medical knowledge the hemorrhage risk showed to be the most important factor in determining which treatment should be started and therefore the first ontology the research team started with when the hemorrhage risk is known a treatment could be prescribed the ontologies modeled that comprised the vitamin k antagonist bridging cpg were as follows 1 specialism type 2 treatment type 3 action at anticlotting treatment 4 indications 5 anticlotting treatment periopera 6 thromboembolic complication risk factor 7 hemorrhage risk and 8 cha2ds2vasc risk factor see for an example figure 2 as stated above the determination is mostly depended on the level of hemorrhage risk ie whenever a type of surgical intervention depicts a certain risk level which triggers a certain treatment none of the other questions about other indications are posed in the final model the surgical interventions were categorized in the different kinds of medical specialism this resulted in a better overview in the first version of the cdss first the medical specialism was posed before showing the surgical interventions as soon as the model behind the first version could make a decision based on the different ontologies included the cdss would stop posing questions with regards to possible indications and provides a treatment as a suggestion figure 2 example highlevel excerpt from the vitamin k antagonist bridging cpg focus group the first version of the cdss was presented to the hemorrhage risk commission consisting of the hemorrhagerelated cpg owners of the umcu at this presentation the bridging cpg was shown in the cdss the participants expressed mixed feelings about the first version although it was predominantly positive feedback most of the positive feedback concerned the modeldriven method of the cdss the participants acknowledged that this was a powerful method to overcome the complexity of the cpg a large amount of feedback with regards to the cdss was provided by the participants and noted by one of the researchers this feedback comprised errors in the contents of the model the feedback was used to refine the cdss after the focus group session another topic that was addressed during the focus group meeting was the possibility to store decisions made by physicians it became clear that the focus group saw this as an opportunity to improve the cpgs whenever a physician would execute the cdss and document his or her decision statistics could provide or suggest which cpg needs alternation after the presentation of the first version of the bridging cpg the focus group had some input for the actual functionality of the cdss a clear majority of the focus group participants addressed the need for an integration with the personal health records or at least an import of patient data from epd which also should eliminate the overlap between different cpgs one participant proclaimed that the cdss would result in cookbook medical care this argument is in conformance with the results of a study about physicians barriers for utilizing cpgs cookbook medical care was labeled as a bad attitude against the cpg showing a lack of agreement with guidelines in general semistructured interviews after the cdss was refined by the research team based on the feedback acquired in the focus group session in phase two the semistructured interviews were conducted with regards to the first goal the final design of the cdss was presented per interviewee all interviewees provided feedback as part of the validation of the cdss which was processed after the third phase of data collection and analysis the average duration of the interviews was one hour consisting of 40 minutes for the second round of validation of the cdss and 20 minutes for the additional topics on experiences problems improvements and essential functionality of the cdss with regards to the second goal four topics provided insights into the experiences and preferences of the physicians in using cpgs in a cdss in this subsection we report on 588 30 with regards to the first topic the attitude of the current use of the cpgs the majority claimed that the use of cpgs in the daily practice is an improvement of medical care this amplifies the conclusion that cpgs are found to be successful in the dutch clinical setting the majority thought the cpgs although improving medical care are indistinct they claimed this is a consequence of cpgs with a large amount of text also the majority confirmed that the current cpgs are not always stateoftheart when applied in practice some improvements the participants addressed in using cpgs are discoverability the amount of text and coverage the majority would like to see that the discoverability of the cpgs is improved the cpgs should be listed on the intranet but should also be stateoftheart when listed furthermore the majority stated that large amounts of text should be prevented in cpgs which aligns with the attitude of the use of cpgs the majority also mentioned the need for improvement with regards to the existing amount of overlap between cpgs overlap in cpgs is a factor that increases the difficulty in maintaining the cpgs because if one cpg changes other cpgs get outdated instantly next we asked what challenges the participants would find in using a cdss the majority fear that the implementation of a cdss will create a large dependency on it the interviewees stated that physicians do not want to be dependent on it too much whether this is because of earlier failures of dss or other itrelated influences remains unknown furthermore the majority doubt the cdss will be a userfriendly system lastly one particular property of a cdss was deemed indispensable by the majority of the interviewees linking to the cpgs that are available on the intranet such a construction will not replace how the cpg is used but merely simplify its use we believe that this preference is caused by the low amount of trust that the interviewees have in a cdss specifically with regards to their requirement of stateoftheart cpgs in the cdss which is not always safeguarded even in the current paper practices at the umcu discussion conclusion in this paper we aimed to find an answer to the following question how can the available anticlotting cpgs of the umcu be combined into a cdss with the aim to support decision making and increase adoption of the cdss in this question two subjects are of relevance 1 how to combine different anticlotting cpgs in a cdss and 2 what do the physicians need to increase the likelihood that they will adopt the cdss the data shown in section five shows that a majority of the physicians have uncertainties in the overlap of the various cpgs and the correctness when modifying versions more introduction deal sites in one form or another exist for over two decades they received a lot of publicity before groupons initial public offering according to a recent study cited by kotler et al digital coupons now outpace printed newspaper coupons 10 to 1 in other words use of deal sites is reasonably widespread for hackers to also link presumably leading to deal sites for infiltration to the best of authors knowledge nobody investigated impact of personality traits on phishing that is specifically linked to deal sites google scholar search for phishing personality traits yielded more than 2000 results of which the first 100 were checked there were two journal articles and a few conference papers investigating impact of personality traits on phishing in general pattinson et al discovered that from big five inventory personality traits higher extraversion and higher openness to experience led to better dealing with phishing emails they state that the findings are interesting because they appear to be counterintuitive since both of these personality traits should lead people to be more trusting of others which would mean treating some phishing emails as genuine but they do not cite any source that would support the link between any of the two personality traits and trust on the contrary our results indicate a link between some of the three remaining personality traits and trust or mistrust but extraversion and openness to experience were not linked to trust nor to mistrust though the findings were not published yet a more comprehensive study in a sense of using more variables than only personality traits was conducted by welk et al the impact of extraversion was significant but the sign was negative when only five personality traits were included in the model the sign was positive in the full model and the extraversion was not significant when only five personality traits and three trustdistrust variables were included the remaining results are unclear as the terms used to describe personality traits were anxiety reservation calmness and ability to keep emotions under control the two items measuring neuroticism are anxious easily upset and calm emotionally stable they seem to cover 3 of 4 remaining personality traits mentioned by welk et al the remaining term reservation looks like the second item to measure extraversion reserved quiet so even the findings for extraversion mentioned at the beginning of the paragraph possibly do not hold there were published a few conference papers on the topic the most relevantconsidering the research design and quality of description of source data including data collection is they tested impact of big five inventory 30 th bled econference digital transformation from connecting things to transforming our lives f sudzina a pavlicek propensity to click on suspicious links impact of gender of age and of personality traits 595 personality traits on susceptibility to phishing emails in two phases in the first phase none of the personality traits was significant in the second phase openness to experience was significant and extraversion was borderline significant but the direction of the impact is not clear from the published figures they provide se in the table 2 for these two personality traits not parameter estimates alseadoon i et al forgas et al users emotions impact their ability to detect deception the second most relevant conference paper is although they do not describe respondents nor what instrument was used to measure big five inventory personality traits they state that agreeableness and neuroticism influence whether a given information is received as either trusted or distrusted moreover they state that high neuroticism deteriorates decision performance under low openness and conscientiousness other conference papers were theoretical and some of them proposed also a model but they did not collect data nor tested the model the rest of the paper is organized in the following way in the next section there is a description of data collection and how they were analyzed in the following section results of the analysis are presented the last section offers conclusions data and methodology data were collected between december 2016 and january 2017 using an online questionnaire respondents were 264 university students from the czech republic of which 140 respondents indicated that they use deal sites and 124 do not surveyxact was used for the questionnaire unlike qualtrics it does not allow to showhide questions based on previous answers on the same page therefore the questionnaire was split into two pages and questions for deal sites users appeared on the second page seven respondents stopped after the first page so the effective sample size is 133 on the second page of the online questionnaire there was a question would you click on suspiciously advantageous offer if it led to a deal site and respondents were supposed to answer on a 15 likert scale where 1 meant certainly yes and 5 stood certainly not in other words a high number corresponds to positiveresponsible behavior is more responsible three of 133 respondents still stated that they would certainly click on the link while 20 stated that they certainly would not this is the dependent variable for the model presented later in the paper a generalized linear model was used spss software was used for the analysis a multivariate approach to testing was used parameter estimates tables from glm were provided in order to be able to see signs of parameter estimates the results should be equivalent to a multiple linear regression model estimates in case the dummy variable is set to 1 for male and to 0 for female r2 and r2adj are provided in order to be transparent about how much a model explains though it may be significant personality traits were measured using rammstedt johns big five inventory10 ie a 10item version of the big five inventory questionnaire developed by john srivastava and translated to czech by hřebíčková et al the study by used big five inventory44 alseadoon i et al has an active imagination on a 15 likert scale where 1 meant strongly disagree and 5 stood for strongly agree extraversion was calculated as an average of the 1st and the 6th answer agreeableness as an average of the 2nd and the 7th answer conscientiousness as an average of the 3rd and the 8th answer neuroticism as an average of the 4th and the 9th answer and openness to experience as an average of the 5th and the 10th answer authors are aware of the new version of big five inventory big five inventory2 with 60 items and of 30item short and 15item extra short versions but there is no validated translation available yet narcissism was measured right after big five inventory10 using the same instruction with the statement  is of narcissistic nature the statement was adapted from the single item narcissism scale developed and validated by konrath meier bushman they recommend sins for online studies the questionnaire contained additional questions which were not used in the analysis presented in this paper results the openness to experience had also a significant and positive impact in moreover the same impact had also extraversion in their study higgins et al linked openness to experience to iq in students this could possibly explain why they are less likely to click on suspiciously advantageous offers conclusion the openness to experience was found to be linked to iq in students this could explain more responsible behavior in addition to that it may be relevant to consider the extent of use deal sites it may be possible that people open to experience visit them more or purchase from them more ie they get involved with them more therefore they have a better understanding of them ie they are more smart and this could explain more responsible behavior now that there is an indication of impact of narcissism on purchasing coupons as gifts it is justifiable in future research to use more items to measure narcissism such as narcissistic personality inventory which is probably the most widely used measure of the narcissism and contains 40 forcedchoice items hypersensitive narcissism scale with 10 items or pathological narcissism inventory with has 52 items if a longer instrument is to be chosen such as fivefactor narcissism inventory which contains 148 items it may be advisable to select only certain factors the study was conducted in the czech republic where there were fraud cases coupons for services of nonexistent companies were sold on regular deal sites so findings are generalizable possibly only for markets with similar negative experience further research should establish whether the same findings hold also on markets with no reported fraud cases moreover university students as respondents are possibly more it literate and tech savvy than the general population therefore it is possible that they are more responsible when it comes to online behavior it is not clear whether it brings any limitation the findings presented or not if the current signaltonoise ratio uncovers relationships hard to spot in the whole population i introduction the impact of social media on various economic sectors has been widely noted in the literature to remain relevant in the competitive landscape of contemporary business marketers must remain active on different social media platforms consumers see the emergence of social media as an emancipatory platform migrating them from their previous perceived status as peripheral stakeholders to strategic partners whose inputs are critical for successful product and service innovation consequently the agglomeration into online communities of consumers sharing similar interests and values has witnessed phenomenal recent growth interestingly for about 80 of consumers who participate in online communities 74 of those communities are owned by large corporations and 77 of those corporations report that online communities have significantly improved their brand exposure awareness and credibility according to kang tang and fiore consumers participate in online communities for social psychological hedonic and monetary benefits the need to meet new people share ones feelings and access better product and service options are fundamental motivations for that participation for instance researchers have found that participation by professionals in online peer communities enhances research collaboration as a consequence both firmhosted and independently owned communities are increasing rapidly in number however online communities have also affected firms and individuals negatively through counterand alterbrand communities deceptive posting lurking and invasion of members privacy online travel communities have recently become a hot topic in the tourism literature because they unofficially occupy a boundary spanning role so influencing consumer interest in destinations as tourism is a hedonic experience that cannot be comprehended prior to consumption consumers rely on the advice and experiences of others concerning the best travel decisions a thorough search of the wider literature identified only one review study of online communities with none in the otc research on that basis the present systematic literature review has a number of objectives first to understand travelers motivations for participation in otc second to understand the consequences at both firm and individual level of otc participation third to understand the contexts and platforms through which otc interactivity is fostered and finally to provide a conceptual framework that will schematically encapsulate the activities of otcs against this backdrop the study contributes to the literature by providing a solid platform that integrates the fragmented studies in this research stream this represents a useful tool for subsequent studies as managers in tourism and destination marketing organizations will also find the concepts and arguments adduced here useful as levers to optimize the value of otcs for their firms the rest of the paper is structured as follows section 2 discusses the background to otcs section 3 describes the research background online travel communities otcs can be defined as groups of people trying to achieve goals with similar interests and interested in building relationships making transactions and engaging in fantasy governed by rules and using new information technology as the means development and acceptance of it means that tourism has undergone continuous transformation and otcs attract travelers through reviews and recommendations on platforms such as tripadvisor fodor qunar virtual tourist and lonely planet although better understanding is needed it is known that people join online communities for several reasons to share views on products to obtain valuable information and to create enhance and sustain social ties between online members in short consumers join otcs for psychological social and utilitarian reasons otcs offer travelers an opportunity to share their travel experiences and opinions by posting reviews these then serve as information references for other travelers providing valuable information about points of interest gastronomy weather forecasts news and safety bulletins however there is also a negative side to this increased information sharing within online communities as reported by wang et al biased noncredible or deceptive information can be very challenging for travelers seeking reliable advice a further problem is that a member of an otc may be a lurker someone who does not participate or contribute to any discussion but only reads and reaps the communitys ideas by becoming a part of that community additionally in their evaluation of technological modus operandi and social motivations for membership in 11 otcs dippelreiter et al found that although most of the communities are integrating new technologies some still lack integrative emerging technologies such as ssl encryption and hashed userid security features otcs also need to improve personalized ontrip services to members research methodology literature search and selection to conduct the literature search we first defined key terms for the study which included online tourism community virtual community in tourism tourist online community web 20 enabled community in tourism virtual space in tourism and social media community in tourism given the uniqueness of the present study and the need to capture as many relevant articles as possible we followed shaikh and karjaluotos results statistics of findings geographically the highest number of publications came from the usa followed by countries in the european bloc and then the east asian bloc most of the studies were published in 2016 while 2005 2008 and 2009 each returned the same number of publications with none in 2006 the most frequently used theory was the technology acceptance model however inspite of the extensions to tam2 and tam3 all but one study utilized the original tam other theories included social identity theory flow theory expectationconfirmation theory situational strength theory and interpersonal relationship theory and some studies used a combination of theories see table 1 a majority of studies adopted a hybrid model to characterize use of otcs integrating different variables to create a model figure 3 shows the percentage frequency of the various methodological approaches among the quantitative studies survey administration and retrieval were performed primarily through the different online communities and used structural equation modeling as the main analytical tool however some of these studies adopted a big data approach analyzing the credibility of reviews in tripadvisor and qunar while a few of the qualitative studies used facetoface structured interviews a majority adopted a netnographic approach netnography is a qualitative exploratory figure 3 methodologies used in the selected studies motivations for joining online travel communities psychological motivations user involvementthat is the degree of interest in a piece of technologyhas been studied across many information systems in otc wu xiao and wu examined the relationship between breadth and depth of involvement and members loyalty they argued that depth of involvement exposes the individual to other activities in the otc that increase flow experiences pleasure satisfaction and fun according to elliot li and choi members satisfaction increases site stickiness which also influences transaction intention however in evaluating customer purchase involvement and otc website design sanchezfranco and rondancataluña suggested that while otc website aesthetics and usability increase satisfaction these effects are moderated by purchase involvement and level of involvement influences members perceptions of the usefulness of otc websites another important psychological factor for otc membership is escapism as argued by lee and hyun social family or romantic loneliness drives peer identification in otcs in other words involvement in otc activities is primarily a means of overcoming loneliness members experience a sense of fulfilment and satisfaction when otc managers create additional platforms to enhance peer interaction through services like meeting a new companion through a certain travel product forming a virtual family based on a particular travel view and talking with a romantic partner about a certain travel product the conceptual framework in figure 4 summarizes motivations for participation the range of otc contexts interaction platforms and consequences social motivations selfexpression is an innate human attribute and participation in otcs is driven by the individuals desire for selfexpression for this reason members assign greater importance to the transmission of information than to its reception investigating the antecedents and moderators of members social satisfaction in otcs yang zhang and gallagher identified entertainment social interaction and reciprocity as predictors of satisfaction to enhance members interactivity then otc managers should incorporate entertaining features and activities that will maintain and strengthen members social ties whether online or offline luo and huang proposed that otc participation is driven by functional social psychological and recreational motives and that most people join online communities because of the social desire to make more friends these findings challenge vogt and fesenmaiers argument that functional needs are seen to be the most important influence on information search finally member reputation built through exotic profiles shared on members pages influences evaluations of similarity and community that often lead to bonding offline interaction and enduring relationships utilitarian motivations the utilitarian approach asserts that a morally correct action is one that provides the greatest benefits over harms for every individual chung and buhalis argued that of the three motivations for otc participation information acquisition most strongly influences participation and attitude toward the otc for this reason information such as best price service quality best destination and safety are the most common search criteria among travelers in some cases otcs offer specific utilitarian services that increase subscription to its membership for instance luo and huang reported that aside from sociopsychological motivations participation in couchsurfing otcs is driven by the utilitarian drive for recreation those who subscribe for couchsurfing believe that the community has specialists with the requisite skills to ensure that their recreational needs are met jeon jang and barrett suggested that utilitarian value and online trust mediate the relationship between website interactivity and repurchase intention conversely the importance of utilitarian motivation for otc participation was challenged by kang tang and fiore who contended that otc participation on facebook fan pages was largely driven by hedonic and sociopsychological benefits while functional and monetary benefits had no impact on participation contexts and interaction platforms our systematic review also revealed different platforms of interaction among community members these include chatrooms forums newsgroups blogs websites and review sites however the choice of platform depends on ones motive for participation for instance facebook fan page members are likely to visit facebook fan pages of restaurants when they gain sociopsychological and hedonic benefits from such visits to increase visit to their fan pages then restaurants should constantly upload content that appeals to the hedonic instincts such as games or live streaming videos of music and current events that will facilitate realtime interactions among members additionally members who use blogs and websites to share their experiences are motivated by communal feelings unlike the sense of selfrecognition that motivates the sharing of experiences on twitter it is also argued that the use of email as an interaction platform is fundamental for otc managers seeking to foster social friendly and romantic togetherness among community members email facilitates closeknit interactions where members can communicate freely about private issues in a way that may be more difficult on open platforms however to sustain otcs forums and chatrooms are also necessary where members freely share travel experiences that will assist others in making travel decisions in summary members see the otc as an attraction where they can learn from the experiences of other members reducing the time taken to search other sources for information about a destination consequences of online travel communities negative effects studies of online social relationships report negative effects such as extreme verbal inhibition and aggression bullying denigration privacy issues and lurking the present systematic review revealed both firmand individualrelated negative effects of otcs for instance cova and white suggested that firmrelated negative effects of otcs have led to the emergence of counterbrand communitiesa phenomenon of aggregation against a company that manages the brand and which leads to the creation of competing brands by members of the communityand alterbrand communitiesa phenomenon of aggregation around notforprofit projects that nevertheless creates a brand that can compete with the brands of certain companies members of these alien communities are former adherents of a brand who have moved away because of their frustration with the firm and float activities and programs parallel to the brand aimed at damaging its reputation in terms of individualrelated negative effects we also identified sociopsychological deviant behaviors that engender repulsive reactions from other members of the otc for instance complaints of bullying and posting of irrelevant topics and lurking are common in otcs as argued by ruizmafe tronch and sanzblas these negative emotions constitute psychological social and privacy risks and otc managers should incorporate technologies to curb any such deviant behaviors positive effects similarly positive effects of otc membership are observed at both firm and individual level including increased brand awareness functional brand image brand use and visit intention lee and hyun argued that trust is a fundamental driver of membership stickiness leading eventually to loyalty to promote loyalty managers should ensure navigation functionality security and privacy protection trust in the community also fosters a sense of belonging and sharing of emotions and experiences in most cases such relationships transfer to the offline world ending in some cases in strong bonds such as romantic affairs discussion the aim of the present study was to elucidate the motivations and consequences of otc participation through a systematic review of existing studies a thorough and rigorous literature search yielded 63 studies comprising journal articles conference papers and phd dissertations through otcs tourists assume the status of destination evangelists whose gospels about destinations are believed and trusted more than marketers messages both firmhosted and independent otcs promote a range of activities that engender agglomeration of membership to a critical mass which is seen as an antecedent of success for otcs interestingly the threat of otcs emanates from the question of brand ownership as the emergence of brand communities has shifted brands from private control to publicly socialized phenomena by taking an interest in and promoting the activities of otcs tourism firms serve a boundary spanning role with concomitant favorable effects on destination image and visit intention our review revealed three main motivations for participation in otcs psychological social and utilitarian psychologically participation in otcs is motivated by escapism those seeking travel advice from otcs do so as an escape from social family or romantic loneliness additionally as an individual stays longer in the otc they are more likely to continue increasing flow experience enjoyment and involvement as the social desire to forge ties and bond with others also influences otc participation interactivity is a key additionally arenasgaitan rondancataluna and ramirezcorrea argued that members assign greater importance to the transmission of information than to its reception as a platform for highlighting and maintaining social status finally information acquisition for best travel decisions product purchase and service quality evaluation represent utilitarian motives for participation in otcs as website interactivity is the cornerstone of members functional satisfaction contributions of the study our study contributes to existing knowledge in a number of ways first no previous literature review has focused on otcs studies of otcs have followed different trajectories with no coherent integration resulting in disparate and in most cases conflicting findings that resist meaningful interpretation by scholars and managers this systematic review provides a solid platform that integrates and aggregates these fragmented and disparate studies offering a useful tool for subsequent studies in this area second by identifying motivations for otc participation and its positive and negative consequences both at firm level and for individuals our study extends prior research on online communities additionally by explicating the interaction platforms and contexts of otcs and the arguments adduced herein this study offers destination managers levers for optimizing the value of otcs to their firm finally from our synthesis of prior studies and findings we conclude that online travel communities do indeed matter and that tourism and destination marketing organizations neglect their strategic importance at their own peril limitations of the study and future research direction one of the present studys limitations is that the data obtained were restricted by date future research might usefully increase the sample size by including relevant articles published before 2005 it is also acknowledged that additional factors beyond those investigated here also influence participation in online communities and further study should more fully investigate these other factors finally extraction and analysis was conducted manually here which may exclude relevant studies and automated extraction and analysis should be utilized in future research of this kind introduction while many social media platforms are created for worldwide consumption it is usually a significant challenge to develop these platforms for users from various cultural backgrounds this is increasingly important as the use of a social media platforms often reflects the cultural values of the user while there have been quite a few papers recently published that examine a usercentred approach ie how cultural contexts shape social media use there are fewer studies that examine the influence of cultural values on social media platform design a study by van belleghem highlights the differences in social media penetration between western european countries and others such as india and brazil together with gong l stump and g li they conclude that the differences in diffusion of social media across countries highlights the need for global emarketers to appreciate why people in a particular country may be more receptive to and prone to adopt online social media than people in other countries this paper attends to this research agenda by reflecting on the underlying cultural values that motivate the design of a chinese social media platform wechat the exploration of cultural values inherent in the design of social media platforms is motivated by aral dellarocas and godes and kane alavi labianca and borgatti both set of researchers present research frameworks and research agendas to encourage scholars to explore the impacts social media has on organisations and society features built into social media platforms either enable or constrain user behaviour while providing the building blocks to allow interactions of social processes the design of social media platforms is important to understand because they enable interactions of social processes and culture that affect the fabric of society in the current research in progress paper our goal is to explore the cultural values inherent in a chinese based social media platforms using wechat as an example while the idea that culture is entwined in the design of information systems and applications is not new kim triandis kâğitçibaşi choi yoon 1994triandis trafimow 2001 especially in the context of social media platforms in this paper we use this dimension as a starting point to explore the particular values inherent in chinese culture that are in turn reflected in the design of wechat to this end we begin by proposing a model which encapsulates one of the key chinese cultural values collectivismand then use this model to evaluate key features of the wechat application this paper serves as the first step of the research process by building the model and providing a preliminary implementation of it the paper is structured as follows firstly we examine wechat and chinese cultural values and present our proposed research model next we apply our proposed model to a social media platform called wechat finally we conclude with our limitations and suggestions for future work social media and wechat social media social media provides a platform for different social groups and communicate and exchange information sns is defined as a webbased software application that helps users to connect and socialize with friends family members business partners or other individuals features and functionality designed into social media affect how users interact coordinate and form relationship networks there are different types of social media platforms which provide businesses with many types of interactive communication methods social media text and instant messaging applications blogs wikis and other web forums are growing as a means of supporting additional often critical and accurate information within the public sphere social media provides a platform that allows users to communicate news and information to others as an alternative form of communication such as television radio and print wechat chinese use of social media is increasing faster than the rest of the world chinese consumers tend to consider products or services if they see them mentioned on a social media site because social media such as facebook youtube and twitter are blocked in china wechat is one that marketers could use to directly communicate with their chinese audience wechat is the most widely used social networking service in china and has become an important social media platform for computermediated communication chinese values in a social context traditionally speaking eastern cultures such as china are collectivistic they value family friends and their groups over self members of eastern cultures tend to have fewer closer and more enduring friendships than members of western cultures collectivism in asian societies is maintained through a general value placed on social obligations and commitments and familial ties while hofstede and trompenaars have their critics criticisms are mainly focused around the fact that that there is no such thing as a national cultural identity and that the cultural dimensions are formulated from a western perspective there is however many countries where the major cultural group is such a dominating factor that nationally cultural values do have a national cultural identity albeit with cultural subgroups within that national identity with regard to hofstede and trompenaars having a western viewpoint in the words of hampdenturner and trompenaars themselves social science methodology is not culture free there is no neutral point above culture from which to view the universe it follows that many different ways of viewing culture are legitimate we look beyond these critics and evaluate chinese values of collectivism in cultural dimensions which may bring valuable insights in terms of explaining behaviours in particular the designers perspective which has been largely overlooked subsequently this section is going to develop a framework that assembles chinese cultural attributes and centralising chinese collectivistic culture this is based primarily on hofstedes work this framework helps to explain the various interrelated cultural attributes that inherent in the design of chinese social media platform 1 within the context of application design we aim to have at least 5 interviews and will continue interviewing until saturation has been reached should more participants be available to triangulate the data collected from our interviews we will also consult documentary sources such as design specifications and screenshots of the wechat design all data will be collected in chinese and translated into english by the chinese speaking author data analysis will use thematic analysis to identify common themes and ideas emerging from the data preliminary results in this section we present preliminary results from our analysis of wechat features which are based on the chinese culture elements presented above and the proposed model in figure 1 this will help us formulate a basis for our interviews with designers and users of this platform in the next step of the research a feature that demonstrates the cultural attribute of respect for authority is the subscribe functionality which enables users to subscribe to a celebrity or to newsletters the owner of the account has the absolute right to choose and decide what comments to put on under the post in addition the creator of a chat group who assembles the group chat has the power to dissolve group whilst other chat group members can only join or exit the chat group the chinese cultural attribute of guanxi can include both the creation of new ties as well as the strengthening of existing ties with people this attribute is reflected in the features of shake and people nearby which spontaneously match people with strangers virtually through this feature wechat allows people to form instrumental ties with strangers in addition holmes balnaves and wang explore the recently introduced feature red packet this feature digitally imitates the chinese lunar new year tradition of hong bao where elders pass money to the young to encourage prosperity and provide good blessings the red bags themselves imply a range of expectations that do not need to be made explicit unlike the tradition of senior people giving to junior people the wechat feature encourages people to give money to anyone thus this feature is a way to strengthen or build up social tiesanother demonstration of guanxi and finally the nuanced design of moments within wechat emulates the concept of keqi for example while one can post images and links for all of their friends to see and comment on the comments are only visible if the commentators are friends with each other this features enables the appearance of wellmannered politeness by not allowing acquaintances to necessarily see each others comments the need for privacy which is encapsulated in the attribute of keqi is further seen in the ability of wechat users to restrict broadcasts to specific users the current design of wechat affords the practices of these three key cultural attributes respect for authority guanxi and keqi hsu emphasizes that chinese are social and psychologically dependent on others and have a strong group orientation therefore individualistic behaviour is regarded as an expense to others for example a number of wechat features such as go dutch and group buy further reflects this group orientation conclusion research on social media platform design presents interesting opportunities to examine how platform designers can structure and influence user interaction in particular ways this research can help shed light on crosscultural differences related to social media design and will be of great value to social platform designers who are pursuing a mobility strategy targeted to a global audience culture is often reflected by or perceived through shared practices in a community cultural differences influence communication behaviour and values asianbased social media tend to have tighter social relationships with their practices reflecting an indirect communication style and less open selfdisclosure whereas western based social media tend to have wider social networks with their practices reflecting a more direct communication style and bolder selfdisclosure while social media platforms like wechat have a potential to modernize elements of chinese culture they simultaneously act as a vehicle for the reinforcement of traditional chinese collectivist cultural values we have demonstrated in this paper how a particular social media platform wechat reflects the broader shared cultural values inherent in chinese society our findings do not imply that other cultures other than chinese are unsuited for using wechat as the application is now becoming popular outside of china however as it is developed in china there are chinese cultural values inherent in its design additionally many of its features are not available outside china a future part of our larger study will analyse and contrast social media designs from other cultures for example whatsapp and facebook in contrast to wechat and weibo however this paper only includes the chinese cultural aspect this paper has two key limitations 1 the model proposed in this paper is conceptual and has not been thoroughly validated validation could be to carry out via an exploratory study including interviews and focus groups with the designers developers and marketers of chinese social media platforms such as tencent and sina this type of study would help us to understand the motivations for the creation of features within each platform in addition interviews with users of these platforms would help to determine whether or not these features help engender the cultural attributes discussed in the model 2 in this paper we focus exclusively on the concept of collectivism however in doing so we may overlook other important values in the chinese culture such as the concept of harmony wei li introduction the market for digital financial services is moving strongly resulting from costreduction ambitions of the financial service providers like in other industries that have developed masscustomized customer interactions and product offerings digital investment services are expected to follow suit and offer an excellent domain to test our views for example ing group one of the leading banks in europe has clearly identified the multior omnichannel approach as part of their overall service concepts and they are organizing themselves accordingly the community of technology innovators to support these types of interactions is growing rapidly as is illustrated by the many so called fintech startups for financial services with little complexity and limited need for customers to be adviced by a financial expert many of these services have been developed and successfully implemented however digital investment services are often restricted to the transactional part of the service andor monitoring current positions through dashboards the sales and advisory part would be a next challenge in the further digitization of financial services but in our view requires a keen understanding of the psychology behind the sales process in particular how the sales process is adjusted based on the customers profile if you ever have had interactions with sales representatives in your role as a customer chances are that you can distinguish effective approaches that fit your needs from the hopeless attempts to push you to buy something an effective sales representative is fast in recognizing the peculiarities of his potential customer and addresses these in his interaction for instance if the sales representative encounters a highly rational customer he will deliver facts and refrains from the traditional sales spiel is the customer uncertain about his desires the sales representative will start by assisting the client and by identifying his primary decision criteria if the client is highly sceptical the sales representatives first objective should be to gain his trust or finally if the customer wants to know everything there is to know about the product or service the sales representative will need to show his professional expertise and deliver facts that matter to the customer experienced sales representatives not only master these different approaches but more importantly they have the skills to recognize when to use them by reading the customer in front of them when we shift our attention to the digital environment and the sales processes there all of these elements are present as well hence digital sales channels must go beyond product representation and recommendation and interact in such a way with the customer that he feels well taken care of these interactions do not necessarily need to be executed by humans as insights from the field of artificial intelligence and in particular selflearning systems show how such systems should operate is partly a technical matter which is beyond the scope of this article however it is also a challenge from a business design perspective we need to determine which customer characteristics can help to determine if it is worthwhile engaging the customer and if so which process steps have to be adjusted and executed according to the customer profile in this paper we propose a model that offers four dimensions to deliver individualized interactions in digital sales settings using the example of digital investment services the opti characteristics model based on insights from the behavioral finance literature that studies the psychological aspects involved in making financial decisions we have identified four different dimensions of a hypothetical customer profile these foundations give us the conviction that it is possible in a digital setting to align the communication processes and interaction with the customer profile similar to the sales representative and his empathy and human natural intelligence in our starting example we refer to these dimensions as the opti characteristics figure 1 the opti characteristics as foundations for customized customer interactions the denotation of the respective customer specific characteristics within each of the four dimensions enables the construction of a customer specific and individual profile that forms the basis for a customized interaction objective prudence trustful and interested the next sections discuss these four characteristics in more detail using the case example of an investment through a digital service channel as such we present first ideas how the digital interaction for such an investment would change depending on differences in the characteristics in the customer profile the objective characteristic the dimension objective captures the existence of rationality in the investment decisions of the customer a maximum score in this dimension refers to a customer that does not allow any emotions to affect his decision and who has no cognitive dissonances he is an analytic who only cares for factual data which he carefully weighs before reaching his decision on the other extreme of the objective scale we find the customer who makes all the classical errors known from behavioral finance examples for these are cyclical investments and investments in primarily domestic stock as they provide him with a higher sense of control yet lead him to a poor diversification and 632 30 or he shows a clear level of overconfidence and is convinced he is smarter than the market he is surprised that after many transactions he receives a smaller yield on his portfolio when compared to a passive investment on a market index the construction of the interaction especially for those customers who tend to make the classical investor mistakes needs to capture these aspects support them transparently and deliver a sustainable added value to the customer without robbing him of the freedom to make the final decisions himself an investor who prefers cyclical investments can be informed more actively and prominently that anticyclical investments may have some distinct advantages alternatively he could be recommended to delegate more of his portfolio decisions to the system for instance by offering a periodical rebalancing of the chosen asset allocation in essence all mechanisms could be applied that have become known and discussed under the term nudging this refers to the approach that psychological behavior patterns are structurally used to steer people towards a beneficiary path for them andor society as a whole the prudent characteristic the prudent characteristic captures how careful and considerate a customer is regarding the conditions that influence a financial decision or in other words how well he knows the necessary facts and his own preferences at the maximum of this scale we find the customer who has a complete overview of all his finances basically he can articulate precisely which investment goals he wants to achieve while he is able to quantify his targets in relation to his risk appetite conversely at the other side of the scale customers have no or very limited insight in their financial situation they have not yet considered which targets they want to achieve with the investment and are far from knowing which risks they are willing to take in doing so these customers face a range of ambiguities and are feeling highly uncertain for the interaction with customers a correct measurement of this prudent characteristic is very important as customers with low prudence are quickly overwhelmed especially in a digital setting they are more likely to quit the interaction prematurely especially since productspecific offers do not help them and they lack recognition that their personal circumstances are understood by the digital service in our view future successful digital investment service providers will have the appropriate tools to reduce these ambiguities based on the customer type different tools can be included in the interaction for instance to first determine the monthly available capital for an investment subsequently risks can be visualized in a graphically appealing way this not only helps to identify the risk profile of the customer but also provides him with more confidence in his ability to reach a sound decision as he is structurally engaging in the relevant themes for his decision for instance he receives information how much money is needed for a meaningful retirement plan the associated risks and benefits etcetera this reduces the ambiguities and thus facilitates a decision 23 the trustful characteristic the trustful characteristic measures the fundamental trust in the digital offering at the maximum point of the scale customers trust their service provider and the tools and recommendations the provider delivers they have no concerns about a lack of security or data privacy that would stop them from using the digital environment however if a customer does not trust the service provider it will be difficult to envision any interaction digital or otherwise between them besides providing incomplete data to the tool the untrusting customer may just want to test how the tool works without completing the actual process and coming to an investment decision the impact of this characteristic on the interaction is guided by the insight that a lack of trust can be best addressed through personal contact this means if at allreverting to an offline channel or possibly a videoconference within the tool customers with a low score on trustful should therefore not be asked to execute sensitive steps in the digital environment for instance the risk profile of a customer can be determined by attractive digital tools which would be acceptable to these customers since they do not require sensitive personal data and do not result in financial consequences the obvious advantage of a digital service is the size and scope of the available information as well as the determination of the customer preferences both elements would be difficult to achieve at a comparable level in a classical service conversation customers on the high end of the trustful scale can be offered a fully digital interaction and they would likely experience this as added value and added flexibility as they do not need to be bothered with scheduled meetings travel time etc hybrid modes where the representative and the customer are sitting together behind the same screen are getting more popular and show promising advantages for both service provider and customer the interested characteristic the interested characteristic captures both the general interest of the customer in financial topics as well as his motivation to find a good answer to a specific question on the extreme positive side of this scale customers are continuously looking for comprehensive information and have the ambition to become knowledgeable on financial themes they are willing to commit time emotional energy and possibly monetary means to be engaged and to ensure the finances have been well taken care of this usually results in a higher financial competence as they already possess a lot of relevant information about the specific financial decision they are contemplating the obvious counterpart on this scale is the customer who has absolutely no interest at all in financial themes and does not want to spend any effort on this theme the customer with a high score on the interested scale will shy away from a service provider who constructs andor manages a portfolio without any explanations and arguments this customers demand a clear understanding why the portfolio decisions have been proposed or taken offers that enable the client to identify thematic focal points such as low carbonemission investments provide a good fit to this customer profile they will value periodical updates beyond the yield development that include other developments in his field of interest conversely the customer who is in dont care mode for all these matters should not be bothered with these themes beyond the legal requirements the service provider has to comply with as part of his customer care obligation it would make him less certain or at the very least he would find it annoying and it would steer him away from his wellintended service provider conclusion and outlook in this paper we focussed on digital investment services and how they should aim for a level of individualization in the interaction process to fit the customer profile using digital and automated processes this would not just deliver a custom fit from an investment portfolio perspective but also achieve that the customer feels well taken care of during the entire interaction and service consumption it would increase the customer engagement and identification with the product and provider compared to current standardized digital solutions and interactions but also the pseudoindividual interactions occurring in retail branches of financial institutions in particular the characteristics prudence and trustful indicate that already today there is the potential and the need for a combined multichannel approach for instance the actions of the customer in the digital environment when providing information can be captured to provide input for the subsequent service process associated translation to the customer profile also the various technical and content components that would be needed to achieve the desired alignment of the customer interaction need to be identified and operationalized including gaps where current technology does not yet offer solutions this will be the focus of our next steps in which we plan to develop such a profiling tool and implement it in a reallife digital investment service in summary the opti characteristics are expected to help in the identification of the various archetypical customer types knowing their different affinities or attitudes towards the use of digital services will enable the customization of not only the products and portfolio but also the interaction with the customer giving them the necessary comfort to use the digital channel if and when they like possibly in addition to the traditional channel when the situation demands it understanding these characteristics helps to design the digital investment services of the future introduction mobile and wearable technologies have unique advantages within health and wellness wearables could be a way to help the young elderly to stay active longer and remain well even though wearable fitness trackers are not a new technology as such there is evidence that they have not recently evolved to better meet the requirements of users smartphones are prevalent among the population but present problems regarding fitness tracking such as problems with data entry and inaccuracy of data wearables can solve these problems and could thus be a better choice for sustained wellness current knowledge on wearables shows however that users easily abandon them after an initial use period in a gartner report it was found that the abandonment rate of smart watches is 29 and 30 for fitness trackers in a study with more than 9500 participants gartner also found that wearable devices are not found useful enough and users easily get bored with them the perceived value in relation to the price is not found to be compelling enough especially in the over 45 years age group current wearables only take into account the physical dimension of wellness and they are traditionally targeted mainly at the working age population and already physically active consumers we wanted to explore how adding a social dimension to wearable use would impact the wellness behaviour in the young elderly participants and investigate attitudes towards wearables when introducing them to people not in the traditional target group of fitness wearables and without previous experience of wearables we use the term young elderly to describe our target group of active 6075 year olds the paper is organized in the following way after this introductory section we present a literature review of wearables and wellness in section 2 in section 3 we discuss the study design and present the participants chosen for this study in section 4 we present the results of the study and in section 5 we discuss the findings and the implications of the study literature review wearables for wellness for a useful way to discuss wearable technologies for fitness and wellness ananthanarayan and siek present a taxonomy consisting of goals and users persuasion methods and data presentation an example of a relevant goal is motivating physical activity persuasion methods belong to either selfmonitoring social influence or fun interaction finally they suggest that data presentation methods are especially important in wearable devices regarding social influence the authors report studies where positive motivating effects were found but the boundary conditions of successful social interaction in this context are not clear in line with this schmidt et al discuss fitness trackers from the viewpoint of sustaining motivation for using them they suggest that current trackers are technically sufficient in their ability to capture exercise data but they fail in supporting users motivation due to the data not being connected to a clear personal fitness goal in a small group study on teenage girls toscos et al investigated the effect of forming virtual peer groups to support exercise motivation in a posttrial questionnaire the participants rated group performance to be the strongest method for motivating behaviour change engaging in virtual peer groups appears to transform exercise from a solitary selfmonitoring activity to a shared experience fausset et al report on a twoweek trial where older adults were given fitness wearables to use within their everyday life despite initial enthusiasm only three of eight participants reported continued intention to use the technology inaccurate data collection lead to lowered motivation and trust in the device uncomfortable design and a sense of wasting time when using the device were also problems no users reported issues with the ease of use of the devices in the trial fritz et al interviewed thirty wearable users who had of their own volition adopted the devices the duration of use ranged from 354 months the sample was slanted towards technologyrelated professions and early adopters results suggest that it is beneficial if the system allows support for social interaction fritz et al found in line with fausset et al that the accuracy of exercise data was highly important for the users appropriate credit for activities is essential for encouraging physical activity in a 10month inthewild study of an activity tracker smartphone app gouveia et al report that only 14 of the participants continued use of the tracker after two weeks all of the users quit before the tenmonth period was over they found initial adoption to be correlated to the stage of behaviour change participants who had identified a need and were preparing for an exerciserelated behaviour change exhibited the highest adoption rate participants who were already active or in the maintenance stage of their behaviour change were much less inclined to adopt the tracker as high rates of abandonment seem to be the norm for activity trackers harrison et al investigated barriers to use and users workarounds to the barriers their participants reported main barriers to be related to inaccuracy design and lack of social functionality interestingly harrison et al note that most of these barriers were identified in research already ten years ago suggesting that fitness wearables have not evolved significantly in this time period lazar et al also investigate reasons to abandon wearables they conclude central reasons to be irrelevant data too cumbersome usage and the devices not matching the participants conceptions of themselves preusse et al suggest in a study on older adults acceptance of activity trackers that targeting barriers could increase their acceptance of wellness devices during the deploymentphase of adoption meyer et al also investigate factors influencing the acceptance and usability of wearables for a recent systematic review on wearable wellness support please see warraich discontinuation of use is a clear trend in most studies on fitness wearables different writers suggest that sustained use might not always be a necessary goal if behaviour change is achieved and maintained the tracker might no longer be needed on the other hand there is little evidence that behaviour change is retained in the long run after discontinued use of the wearable wearables could play a role in sustaining healthy behaviour also after the initial behaviour change users in many of the studies call for social functionality also frequently reported are difficulties with the accuracy and meaningfulness of the collected data most of the studies focus on workingage participants but some specifically target older adults dimensions of wellness wellness is a concept which is often described to contain different dimensions in our research we use the six dimensions most frequently mentioned by wellness researchers the dimensions are interrelated to some extent figure 1 physical wellness is supported by the other dimensions of wellness and vice versa in this research we are especially interested in the physical and social dimension physical wellness is probably the most wellknown dimension of wellness the benefits of physical activities have been proven in many studies physical wellness generally refers to an individual´s physical health physical activity level nutrition selfcare and vitality or longevity social wellness is understood as an appraisal of ones circumstances and functioning in society components of which are eg social contributionthe feeling that one is a valued contributing and important member of society and social integrationthe feeling of belonging to a community and having something in common with those within ones social sphere humans have an inbuilt need of social interaction and deprivation of social interactions is known to be detrimental to health loneliness is a known risk factor for the elderly associated with a heightened risk for depression alzheimers disease and coronary disease as well as an increased risk of mortality among men we believe that supporting social interaction and consequently social wellness through technology is possible but the research evidence is only emerging and still scarce part of our aim is to gain knowledge on how social interaction can be mediated through technology in order to maintain wellness with social interaction we mean not only facetoface interaction but also eg interaction that can be same time different place different time different place physical activities are known to be related to the social dimension social support is known to be a positive predictor for physical activities especially for women this relationship is an important aspect participants and study design this is an exploratory study aiming at gaining a holistic picture to guide further research we utilize multiple research methods to gain rich data we employ focus groups individual interviews a sixweek trial of the target technology divided into three twoweek phases with planned interventions and finally quantitative measurement of the participants activity levels collected with the physical activity scale for elderly instrument the pase results are not reported in this study as they did not help us understand the participants better for the study we recruited five participants three men and two women all between the ages of 6075 all participants were smartphone and computer users three of the participants also used a tablet computer none of the participants had experience of wearables the participants were chosen through purposive sampling with a clear definition on the desired participant profiles we wanted participants with smartphone experience within the age range 60 to 75 years old and both male and female ellen born 1940 has a masters degree in education and has worked in primary education as a language teacher until retirement at age 68 she is divorced and has a yearly income between 30 000 40 000 euros she uses a computer a tablet and a smart phone in her free time she goes to the gym reads and does handicrafts for the study we had access to the fitness bracelets fitbit charge and polar loop both bracelets offered similar functions a pedometer sleep monitoring watch and keeping track of reaching a daily activity goal the fitbit allowed forming groups of users who could follow each others activity levels and send messages to each other the fitbit had the possibility of vibrating alarms two participants used a polar loop the fitbit charge by the remaining three we divided the study into three twoweek long phases phase 1 the first phase of the study started in september 2015 each of the participants was invited to the research institute individually for getting started with the study the bracelets were set up at the institute together with the participants the main functionalities were shown individually to the participants and possible questions were addressed participants were encouraged to be in touch if any questions or problems would arise the pilot group was asked to wear the bracelet on their nondominant hand they were instructed to only take the bracelet off while showeringgoing to the sauna swimming or while charging it the activity bracelets synchronized automatically with the phones throughout the day after two weeks a telephone interview was made at the same time the participants received instructions for the following two week phase of the study phase 2 the participants with the fitbit charge activity tracker were connected with each other so that they could follow each others achievements on the fitbit application we wanted to test if this social aspect would have a motivational impact on the users no manipulation was conducted with the polar loop users after two weeks a telephone interview was again conducted also the participants received new instructions for the following two week phase of the study phase 3 phase 3 the fitbit charge users were promised a free lunch if they could exceed their steps with 5 from the previous week all of the three participants managed to do this within the given timeframe polar loop users were not manipulated at the end of phase 3 a phone interview was conducted findings practical insights all the participants completed the sixweek bracelet trial successfully and had an overall positive experience there were some practical issues hampering the usage and usefulness of the bracelets however one concern shared by all participants was that they like for the wearables to measure also other kind of exercise besides steps such as cycling swimming and stretching also incidental exercise such as lifting things or working in the garden does not get recorded the sleep monitoring was found useful but not always accurate at times the bracelet seemed to record sleep even if the user was awake the design of the bracelets themselves received some criticism the fitbit was difficult to attach on the arm the attachment is not secure the bracelet falls off occasionally even during the night the loop on the other hand was difficult to adjust to the right size to cut the bracelet and get the pins in place the loop attachment was also not secure and would open occasionally by itself on both bracelets the text on the screen was easy to see the information received from the bracelet was seen as enough the participants lifted out the risk of getting too much information also the participants voiced that too many features might become confusing an annoyance was that when charging the wearable it shows as inactivity on the application the participants felt using the bracelet to be motivating they moved more and checked the steps regularly and made an extra effort to collect enough steps the achievements during one day mattered more than the overall weekly report since the days are so different general observations even in this age group people are not free from peer pressure one member felt that it is embarrassing to use a smartphone many of her friends have not been using computers at work and thus have a skeptical attitude towards technology this means that elderly taking into use new technology such as a s fitness bracelet might benefit from eg encouragement from people who matter to the person things that restrict or hinder the participants from exercising were discussed the fear of walking alone and not wanting to travel too far in order to be able to exercise were mentioned the participants were also encouraged to discuss things that might restrict their friends from exercising in order to lower inhibitions or shame associated to not exercising different ailments were mentioned as an obstacle being lazy and being too comfortable at home on the sofa were brought forward and on the other hand that it is difficult to start something new and take the first step other activities might restrict participating in physical exercise such as devoting time to taking care of grandchildren being worried about the way one looks might be a restriction also there is a worry that gym personnel or personal trainers are not necessarily knowledgeable or interested in the exercise needs of the elderly the focus group participants felt motivated to exercise due to the bracelets one of the participants was not a frequent walker before the study but reported finding the joy of being outside through the bracelet trial the participants reported also other things which motivate them to be physically active a dog was mentioned as a great motivator for getting outside also alleviating the fear of walking alone mentioned by the women in the study the feeling after exercising is motivating as well as the physical effects of it such as losing weight and noticing an increase in your flexibility one of the themes of the concluding focus group session was different campaigns to promote exercise participation the focus group participants found benefits in being a member of some social group and doing something together but they also identified restrictions in this you cannot walk as fast as you would like to and you have to decide together on a suitable day and time virtual campaigns where the participants are not necessarily exercising at the same time or in the same place on the other hand were criticized for allowing participants to fake that you are doing something while you are not the functions that the participants hoped for in a bracelet were a stop snoringalarm and reminders they also hoped for alerts when the users patterns change from the normal such as sleeping more or less body temperature measurement was wished for as well as possibility to share the data easily with others the wearable needs to be durable and comfortable to wear in all activities so it is not forgotten off the hand it needs to endure swimming sauna dirt etc they also hoped for a gps function to increase their feeling of safety when moving outside introducing the social dimension current research on fitness wearables indicates that they fail to engage users in the long run despite giving the user access to more accurate data on eg exercise and sleep than is possible through apps but something seems to be missing we wanted to investigate what if any impact including a social dimension would have the participants in our focus group shared many common characteristics but were not members of the same social network from before linking three of the participants together with the bracelet and smartphone app had some effects on their exercise behaviour they reported experiencing positive peer pressure and elements of competition through seeing each others achievements they followed their peers actively and increased their own exercise in order stay ahead of the competition or not be the worst also when we at phase 3 applied some external pressure through promising a reward for all participants who increased their step count with 5 or more all respondents did reach the target but they reported their main motivation behind it to be keeping abreast with the other participants rather than the reward the participants also spontaneously started to send each other supportive messages the virtual social group enabled the participants to have the feeling of being part of a social activity without having to deal with the practicalities of actually exercising together and losing their autonomy and independence discussion based on our experience we believe that introducing functionality to the young elderly in a sequential manner rather than all at once might help overcome adoptionrelated challenges an overload of functions is likely to happen when introducing a new device which might cause confusion to such a degree that satisfaction is low and the will to continue using the device is impacted the young elderly focus group had a clear interest in the wearable even though they do not match the usually advertised target group introducing a social dimension to the wearable seemed beneficial as the young elderly quickly formed a both supportive and competitive relation this is a novel finding as 647 previous research has not highlighted the importance of building in support for the social dimension of wellness in wearables the social connection formed through the device appeared to be value adding for the participants the social dimension spurred on the participants to maintain or even increase their level of physical activity which in itself is an important finding with implications for wellness service design it seems to at least partially address the previously identified barrier of meaningless data as giving a social context to the users data made it more interesting as a consequence of this adding a social dimension would likely aid in lowering the abandonment rate of wellness wearables the comparison to other users also had a direct impact on the decisions the users were making the participants could see that their peers were ahead of them in steps and then decide to make their daily walk longer we found it interesting that the competitiveness was so present and motivational also in this age group it remains a challenge for future research to investigate whether it is prevalent in the young elderly and whether it differs between cultures the trialed devices allowed for social interaction but we found the functions somewhat limited with regard to the fact that the social dimension seems to be highly important for motivation we suggest device manufacturers to put efforts into developing this dimension for example the pedometer data is rather onedimensional and as such might not sustain interest for too long adding information about the users average speed or length of average walks taken might be interesting for the social group a social function that the participants hoped to see in future devices was the possibility to see where friends are located in order to join them for exercise we did not continue to formally follow the participants after the twomonth trial but we have knowledge that at least two of the participants still use the device daily eighteen months after the trial this is in itself interesting as in most studies such longterm use is not achieved we assume this might be related both to the sequential introduction of functions and the role of the focus group administrator but this needs to be investigated further limitations of the study at hand include the impossibility of replicating individual case studies and the fact that the results and findings might be different if the study participants would have had a different demographic profile eg have less prior knowledge of technology on the other hand our study design enabled us to gain a very rich picture of the participants which will be helpful in informing and designing future studies to address the limitations of the current study we are continuing our research with a larger more heterogenic sample and with different research designs introduction in the past the predominant view on it strategy was a functionallevel view it strategy was treated subordinate to a deliberate business strategy and needed to be aligned with it yet any strategy needs a matching organizational design in order to be carried out the organizational design may unleash organizational capabilities which in turn can translate to a competitive advantagethe overall purpose of strategy any change in strategy requires a change of organizational design thus organizations that pursue a dbs also need a matching organizational design that is different from traditional designs it summarizes the prior knowledge the scope of the research question is relatively broad the search process is comprehensive the identified literature is of conceptual and empirical nature the identified literature is selected via certain predefined selection criteria due to the relatively young phenomenon of dbs an appraisal for only high quality is not the focus synthesizing and analyzing the identified literature centers thematically around a given framework a detailed and systematic search process is important to yield a rigorous unbiased objective transparent and replicable review therefore a review should provide explicit information on how the literature is identified selected assessed and synthesized first it should outline the research question sources searched search terms search strategy and inclusion exclusion criteria afterwards the actual search is performed the relevant literature is selected according to the chosen selection criteria and subsequently analyzed evidence is summarized and presented the research questions already presented in the introduction is what is the state of knowledge on organizational design in the context of digital business strategy the initial keyword search for the topic relevant literature is conducted by drawing on 50 major is journals and 16 is conferences as proposed by levy and ellis it is complemented by the financial times 50 list in doing so the scope of our search covers the dual aspects of dbs and organizational design for this study ie management literature on the one hand and is literature on the other hand in the following the three major steps to conduct this literature review are presented keyword search backward search and forward search the keywords applied for searching within the journals and conference proceedings are digit business strateg or digit strateg whereby asterisks are placed to cover any variation of the words the keyword search is applied to peerreviewed only and title abstract and keywords fields the selection for relevant articles takes places by reading the title keyword and abstract first the criteria for judging the relevancy of the obtained articles is an explicit linkage to dbs and linkage to the organizational design framework the next step is to perform a backward search ie reviewing the citations of all relevant articles identified during the keyword search applying the same selection criteria for the backward search one obtains relevant prior articles that should be considered for this study finally the last step is the forward search which is the process of identifying relevant articles that build on the previously identified articles also known as cited by for this process web of science and google scholar are used because findings the following subsections present the findings of the identified literature on dbs and organizational design along the frameworks components of strategy structure processes rewards and people whereby the appendix includes a summarizing table table 2 concept matrix of analyzed articles and organizational design components and figure figure 1 cumulative articles published on dbs and organizational design components strategy following a dbs implicates establishing new capabilities eg process customer and performance management specifically organizations desire an increased agility and responsiveness multichannel ecosystem connectivity visualization and governance of data and information in order to obtain this organizations need to invest in multiple itenabled efforts in fact mithas tafti and mitchell show that under higher industry dynamics organizational spending differs for dbs related activities and vice versa for industry growth and concentration technology related investments may allow organizations to solve ambidextrous strategies like a dbs because it often involves pursuing multiple goals at once eg by following revenue growth and cost reduction at the same time however woodard ramasubbu tschang and sambamurthy show that organizations are pathdependent when it comes to designs of their existing digital artifacts the authors refer to design moves resulting optionsdebt of past investments that enableconstrain strategic actions of organizations strategic paths can also be disrupted via a destabilization of selfreinforcing mechanisms resulting from digitalization though dbs is not only about optimizing internal operations or responding to single competitors it is also about the responsiveness and awareness of the whole competitive environment this may open up new choices for digital business models like netflix who first started with efficient delivery system of physical dvds and later due to digitization of media the organization seized the opportunity and became the market leader for online media streaming therefore it does not just support strategic goals but increasingly becomes an enabler of strategic goals as strategy originates from the decision makers understanding of environmental influences for dbs this is the case for pervasive digital technologies digital technologies are an integral part of dbs formulation in line the identified literature shows that many dbs of organizations encompasses engaging in harnessing digital technologies to gain a competitive advantage and differentiation this includes engaging in social media for various purposes organizations increasingly use social media such as wikis or blogs for internal and external communication and collaboration yet social media is much more of just another customer touchpoint next to wearables tracking customers via cookies or app permissions etc social media is a valuable source of information for example combined with data analytics it yields customer insights and a better customer understanding analytics can provide meaningful insights and enable organizations to scale recommendations and offer products and services on a highly personalized level thus the analysis of large data is often an integral part of dbs to eg become a more customer centric organization because … the buyer not the seller determines which dimensions of value matter and how offers compare other application fields of analytics within dbs also include the support for strategic and tactical decisionmaking and business processes in sum analytics of large datasets are a key under dbs and has the power to create a sustainable competitive advantage next to social media and analytics cloud computing is also frequently mentioned within the identified articles yet goutas sutanto and aldarbesti highlight that many organizations simply adopt it without having a clear dbs in order to unleash the full potential of cloud computing it not only has to fit to the existing processes and systems but also has to be part of an overall dbs dbs on cloud computing usually encompass the intention for optimization innovation andor disruption nevertheless the overall focus should be the value creation to customers by eg increasing software security and customization only then cloud computing enables dbs to transition to new digital business models likewise in a qualitative study cowen johnston and vuke show how cloud computing increasingly becomes an integral part of organizations dbs in a developing country their main findings indicate that via cloud solutions organizations achieve a better return on capital improved quality and efficiency better customer relationship and innovation acceleration and it has a cultural impact finally ross beath and sebastian overall … a strategic focus that directs their technology spending on social mobile analytics cloud and internet of things technologies is needed to foster new capabilities that make sense for dbs structure to implement a dbs successfully organizations have to align their structure correspondingly literature shows that there are several common practices for dbs in general catlin et al emphasize that the governance and operating model need to fit to the organizations digital maturity together with an increasing digital maturity a lot of the organizational functions become decentralized and embedded in business unit activities increasingly organizations create units that consist of crossfunctional teams eg of technology and operation for business lines to achieve a better responsiveness others contributions highlight the launch of innovation labs detached from an organization in sum organizations need to decide how to integrate digital operations into their existing structures or separate it from the core business additionally dbs needs to be communicated organizationwide by the senior management and managers at all levels across an organization should be enlisted in technology decisions in so doing mithas and lucas and sia et al point out that the ceo cio and the senior management need to work tightly together to execute a dbs for example the cios must engage their business counterparts to shape it decisions and create buyin for it efforts likewise not all power over the dbs should be located at a single department for example at the marketing department which might only lead to customers attention shortly but will not provide sustainable value some organizations introduce a chief digital or data officer a dedicated position within an organization who is in charge of the dbs in this case too interactions and collaboration between the cdo and the other management is critical for dbs success the cdo role tasks responsibilities and reporting structure need to be articulated clearlyparticularly with respect to the cio as a neighbored manager especially since it is known that a tight cioceo reporting structure is beneficial for differentiation thus the reporting structure needs to fit to the dbs of an organization in sum dbs affects the whole organizational structure along with the power over the dbs execution which may vary from organization to organization in line matt et al come to the conclusion that there is no distinct answer who should be in charge of the dbs processes as introduced the component processes refers to any connected activity that is linked with the information flow within and across the organization the following paragraphs highlight the information flow within an organization the information flow from the outside in and from the inside out of an organization first the credo for dbs is what can be digitized will be digitized to cut costs and increase service quality therefore digitization optimization and standardization of processes are imperative to allow for eg straightthrough processing or and rapid product configuration as already mentioned for the component structures teams from different departments or innovation labs are a common practice the intention is to achieve a culture of experimentation agility for innovation processes and an increase in the speed of product launches this includes testandlearn processes and allow failures as an example for new product development and as a part of the innovation process it is increasingly encouraged that every employee can participate and give feedback additionally social media is often used to internally or externally crowdsource ideas under dbs sophisticated customer service processes are gaining more and more importance to achieve customer orientation and customer response in order to answer changing customer demands setia venkatesh and joglekar exemplarily state that for … the sophistication of customer service processes and goals of customer service performance firms may customize their initiatives to build effective digital designs across customer service units second nowadays organizations usually operate within whole business ecosystems and make use of shared products and platforms and processes become increasingly commoditized markus and loebbecke introduced the term commoditized processes which are processes that are conducted in the same way for example by using sap or salesforce in contrast standardized processes can still be customized individually eg an industry norm organizations that use commoditized processes do not necessarily have to interact in some way but it can accelerate activities like partnering or outsourcing yoo et al point out that it can be a challenge for organizations to coordinate and manage distributed and dynamic processes of maintaining and designing it infrastructures at a corporate level nevertheless it is not a question of if but how to interface to customers partners and suppliers because they are a critical source of innovation under dbs more and more organizations need to be able to integrate and process heterogenic internal and external information and knowledge resources being able to combine and store data from various databases can be used for different fields of application such as a seamlessly omnichannel experience for customers or speed up the decision making process by using eg realtime business intelligence in addition it becomes increasingly important to not 660 30 only know the customer but also to process and lever relevant information eg via analytics as shown in the subsection strategy this also requires integrating different sources of information such as new channels like apps social media and webpages not only with traditional offline channels but also with the inventory management system third in todays world of ubiquitous information stakeholder of an organization like their customers are empowered well informed and want organizations to be transparent about their product quality features etc in order to trust them therefore organizations need to take care of the process which and how information flows from the inside out granados and gupta argue that transparency is a relevant part of dbs and organizations should selectively and strategically disclose information to their stakeholders nevertheless grover and kohli debate that organizations need to be cautious about exposing systems software process and information which might expose strategic intentions to competitors and thus potentially give away a competitive advantage in line dewan freimer and jiang highlight that transparent information such as stock and price information could also be used by competitors and not only by customers in sum under dbs the information flow out of an organization can be described as a balancing act of giving away just the right information to stakeholders rewards the organizational design component rewards shows the fewest results in the literature only catlin et al emphasize that organizations need to reward a more risktaking behavior which should yield in a testandlearn culture however the authors are not explicit on how this behavior is rewarded only that digital spend should be measurable in terms of return on investment similarly when it comes to the specific person that are in charge of the dbs endeavor their incentives should be directly linked to the target and progress of the dbs people the role of digital talents is crucial for organizations that engage in dbs because new skillsets are required as digital technologies impact organizations at large for example it requires managers not only to think in terms of business or it but with a deep understanding of dbs specifically competencies and knowledge is required on how to synchronize it and business strategy it governance implement it projects and manage the organizational it infrastructure in order to be successful in dbs leaders need to be open towards innovation and know how digital technologies and ubiquitous information affect their organization this also includes an organizations ecosystem which consist of their limitations of this literature review exist because for example an organizational design perspective is adopted which inhibits an in depth examination of dbs from an ecosystem perspectiveanother important aspect of dbs eg pagani additionally only literature is included that explicitly refers do digital strategy digital business strategy and components of the framework this contribution has practical and research implications likewise the practical implications highlight the need for a suitable organizational design under dbs in doing so this review also shows practical audience common organizational shifts for the components strategy structures processes rewards and people these design components are directly under the control of leaders and therefore organizations pursuing a dbs can draw from these insights and transfer them to their organizational context moreover companies should reconsider existing portfolios of single dbs speedboat initiatives and treat them in a more holistic manner by orchestrating them by doing so the initiatives complement each other meaningfully and unleash their full potential common research implications for literature reviews are uncovering research gaps and pinpointing possible future research questions thus a review typically can give guidance for future research for strategy future research directions encompass how and which single and formerly isolated digital technology solutions complement each other due to this future research is emphasized to yield an integrative and holistic picture of digital technologies under dbs in addition mobile devices are getting smarter and mobile data traffic is increasing exponentially yet their implications for dsb are still not fully examined and require future research for the component structure one can observe heterogeneous approaches of organizations therefore an analysis of which structure may lead to superior organizational performance is emphasized this may include reporting structures and distribution of power in general new roles like the cdo team settings like crossfunctional teams etc for the component processes integrating and analyzing different sources of large amounts of information becomes increasingly important differentiator and a source of value yet research at the intersection of dbs and digital business infrastructure ie how do incumbent firms build a digital business infrastructure is still scarce another research gap is evident for the component rewards future research may look at how to harmonize individual behavior with dbs including metric and measures finally organizational design can influence not only organizational performance but also organizational culture organizational culture is an output of the cumulative design decisions that have been made in the past and of the leadership and management behaviors that result from those decisions this means leadership cannot directly influence organizational culture but indirectly via the organizational design the impact of dbs on organizational performance has been proposed and examined in some recent contributions eg however little is known on how culture changes or looks like under an organizational design for dbs therefore future introduction in the era of the internet of things the information and communication technology is used to support everyday tasks of people the number of different smart or magnetic stripe cards keys and various other devices for personal identification financial transactions unlocking of doors etc has become unmanageable when near field communication became available on mobile phones some cards were offered as a mobile service to increase security most of the magnetic cards were equipped or replaced with radio frequency identification device microchip and nfc possibility rfid microchips can be used for shopping health care services logistics car industry and domestic usage during the research on diverse types of personal identification questions about a unified type of identification arose people are no longer willing to operate with the diversity of identification cards and passwords needed to efficiently manage their professional and personal life recent studies have shown that the rfid technology is secure enough to be used for personal identification and some attempts were made to use rfid subcutaneous microchip implants bodyimplantable devices for nonmedical purposes are emerging as a hot topic that has the potential to permeate throughout society according to graafstra the attitude of consumers has changed from being unaware about the possible usage of rfid implants to general acceptance of rfid implants as a kind of jewellery in recent years people are becoming aware that the rfidsm present a plausible future heffernan vetere chang even introduce a new concept called insertables nevertheless some researchers still explore the potential negative impact of enforced microchipping while others look for highly positive effects of rfid implants namely implantation of rfid microchips in tumours may provide a new method for cancer treatment the literature review showed several attempts to research the readiness of rfidsm adoption from the providers viewpoint while only a few of them dealt with the endusers in addition most of the studies are focused only on rfidsm usage for the healthcare purposes this research is a continuation of the research conducted in 2014 when readiness of potential rfidsm users to adopt the microchips in their everyday life was researched there are two reasons of survey repetition and upgrade • the attitudes towards technology acceptance change rapidly so we wanted to compare the new results with the results from 2014 basic tam model proposes three positive relationships among constructs two of them were supported while one was rejected the positive effects of pu on biu and positive effects of peu on pu were supported hypothesis h5c regarding positive effect of peu on biu could not be supported this is in accordance with the finding of the research from 2014 where this relationship has also not been confirmed that result shows that ease of use is not an important predictor of biu if the respondents find the microchips useful then they would implant them regardless their availability and handiness the impacts of age on biu and of the painful procedure on hc are the strongest in the model the variables pu and biu have three significant predictors that can explain 51 and 58 of its total variance respectively hc have a negative effect on both pt and pu where the impact is slightly stronger to the pt pt has a positive impact on pu as well as direct effect on biu as expected age has a strong direct negative impact on biu conclusion since most of the research has studied the willingness to adopt rfidsm technology from the viewpoint of providers and only a few studies dealt with enduser willingness to adopt rfidsm we decided to research this gap in 2014 the research topic is rather delicate there are ethical questions whether or not should we put something unnatural under our skin hundreds of deaf people with hearing implants will surely not reject interventions in their bodies to enable their hearing the same goes for patients with cardiac pacemakers and diabetes patients there are thousands of orthopaedic patients with different implants in the first research back in 2014 no statistically significant correlations between the attitude towards earrings piercing and tattoos and willingness to use rfidsm existed although we would expect that the people willing to puncture their skin just to change their appearance would also be prone to rfidsm if they find the advantages of such system inspiring most of the researched items showed a slightly more positive attitude towards the rfidsm than two years ago in addition people are less concerned since all items on perceived trust have higher average values in addition the recent results again showed that perceived ease of use does not have a statistically significant influence on the behaviour intention to use the fact the implantation of rfidsm is a painful procedure positively influences the concept of health concerns although the perceived trust has slightly raised health concerns are still evaluated as significant predictor of perceived trust and perceived usefulness the result showed that the attitude towards the rfidsm implantation is still negative the respondents probably do not realize that most of the medical implants work the same way as an rfidsm according to the results most of the issues on rfidsm adoption perceived by the end users are slowly losing their importance due to different reasons public has become more open to the possibility of using the rfidsm for different purposes therefore more studies on the safety of rfidsm should be conducted new preferably less invasive ways to enable a unified personal identification should be proposed this paper presents only the results of the survey conducted in slovenia therefore our further research will include the results of the surveys gathered in other european countries to establish whether similarities in the attitudes toward rfidsm adoption exists a general extended tam model for the intention to use the rfidsm will be generated where also an impact of privacy rights and privacy threats on perceived trust and indirectly on behaviour intention to use will be examined introduction the use of social media has increased considerably within the last years today social networks such as facebook and twitter report 18 billion respectively 320 million active users users of these networks not only share their opinions on products or companies or complain about products or services they also share personal information that are potentially relevant for an interaction with companies for companies using information from these sources might be valuable since they originate directly from the customers themselves this development drives the necessity to automate the acquisition and processing of social data and to integrate it with customer relationship management applications this interconnection of social media on the one and crm applications on the other hand is referred to as social crm this concept is a means to meet the personal agendas of a companys customers and therefore requires personalization based on additional customer information as todays customers expect collaborative and personalized interactions with companies most businesses declare customerorientation as a part of their business strategy however there are two different notions of customerorientation a seller and a buyer perspective and this research adopts the latter which refers to the customer and his respective benefits this perspective is also named outsidein perspective and contrasts the insideout perspective this paper suggests that context information are an adequate and promising means to satisfy this expectation and to understand the higherorder needs of a customer context is relevant to many interaction scenarios between providers and consumers and might lead to a new understanding of the customer who actively influences and orchestrates the configuration of products and services across multiple providers in addition the current paper adopts the perspective of customerdominant logic an approach that places customers in the center of business activities and pursues an outsidein perspective this requires that businesses understand their customers in terms of their respective situation that usually is not part of classical crm applications this paper argues that highly relevant information can be captured from additional data sources such as social media to answer the research questions two research methods are applied first a structured literature review was conducted in order to clarify both the term customer context and its constituents and to finally derive a context model second a mapping of the constituent context elements with social media data is provided to achieve the research aim the paper is structured as follows the second chapter introduces the conceptual foundations ie the cdl and social crm thereafter chapter three presents the literature review and derives the model as well its elements and finally describes the matching chapter four discusses the findings and finally the paper concludes with a summary and the formulation of future research questions conceptual foundation customerdominant logic the term and concept of cdl originated from the fields of relationship marketing and service research compared to other approaches such as the servicedominant logic cdl is a perspective on business from a customers viewpoint and therefore emphasizes how customers embed services in their lives rather than how businesses can provide services to customers cdl therefore answers the question what can we offer to customers that they are willing to purchase and pay for instead of asking how can we sell more of our existing offerings in order to answer this question businesses need to apply adequate methods to understand customers and their logic the concept of crm which is a combination of customeroriented strategies and technologies aims at longterm profitable relationships and offers means to better understand customers however crm systems offer an insideout view on a customer ie they create customer profiles that hold information about customers that are known to a company from past interactions a complementing approach is the outsidein view as mentioned before which contributes information from the customers themselves and therefore complements classical customer profiles this view might also contribute to a firms competitive advantage as market requirements can be anticipated ahead of competitors hence traditionally stored customer information is rather static and needs to be complemented by rather dynamic information these initial considerations drive the need to enhance the concept of a cdl by proposing the application of a deeper understanding of the customer social media and social crm social media can be defined as webbased internet applications that allow the creation access and exchange of usergenerated content kaplan and haenlein propose a classification for social media which encompasses among others social networking sites and micro blogs facebook and twitter are amongst the largest social media and contain millions of public postings each day these channels represent platforms for the information exchange between customers and are therefore a valuable source of customer and context information for example a single tweet delivers up to 60 different attributes that help in further enriching crm data with information provided by customers themselves the term social crm denotes a customeroriented concept that integrates social media with crm applications and thereby opens a broad spectrum of potential use cases in the area of marketing sales and service among the examples are to derive knowledge on target customers and influencers or on product improvements as well as online customer interaction it therefore widens the understanding of classical crm applications as it includes the outsidein perspective on a customer an important element of social crm is the integration of unstructured data from the social web such as productor brandbased data and further context elements this requires techniques for monitoring and analyzing social content and integrating results into crm processes in this context reinhold and alt proposed five task areas as elements of an integrated social crm here social media monitoring forms one of the components and aims at automatically identifying businessrelevant information the related monitoring steps and their respective outcomes are described and further consolidated in literature elements of a customer context model for social crm defining customer context the literature review followed the methodology suggested by vom brocke et al which comprises the steps defining the review scope conceptualizing the topic and the literature search itself starting with the first step the scope of the literature review followed cooper and focused on research outcomes and theories it aimed at the integration of existing knowledge and was conceptually organized to cluster similar works the perspective may be characterized as a neutral representation for both specialized scholars as well as practitioners as the target audience the results are finally representative for the is community as respective data sources were queried after screening all publications the relevant contributions to the understanding of customer context were selected while analyzing the papers in detail it was found that they contribute to either a definition the understanding of elements or a classification of the latter the following table presents the resulting papers and indicates their main contribution the results in the table show that solely one research paper provides besides a definition of context also dimensions and associated elements whereas most papers provide information on solely one of these aspects both context dimensions as well as models are sparsely described in current research as indicated above definitions of context are applicable to different spheres of life and are either comparatively broad or enumerative and therefore do not foster a common understanding of the term however there are papers that consider the customer and his environment as relevant components of context which aligns with the customercentered view of context within this paper in addition and from a social crm perspective context is conceived as additional information originating from the customer which is called outsidein perspective in the following it furthermore intends to supplement the existing insideout view on a customer therefore this research defines customer context as customercentered dynamic and domainindependent information that might be used in different spheres of life and provide additional information about the customer and his environment given this definition a further specification of context by defining its constituents is necessary and described in the following databases structuring customer context in addition to the abovementioned definitions of context literature also provides a framework for structuring customer context respectively describes specific context elements for this research the schema of nemoto et al fits best as it is the only framework that suggests context dimensions clusters context elements within these dimensions and aligns with the view on the customer and his environment the other papers found mainly discuss definitions and elements and only a few mention related context dimensions the resulting model summarizes context elements provided in the reviewed literature and is extended by examples for each element it has to be considered that the given list of context elements is not exhaustive however the model differs the two before mentioned perspectives on context information ie the customer and his environment the characteristics of these information are furthermore distinguished into individual or global on the one and longterm or shortterm validity on the other hand with regard to a social crm system individual context information belong to a specific customer whereas global information form the basis for describing customer segments gathered with regard to customer profiles the attributes in the model describe the before mentioned action reaction personal and potential data and enable businesses to complement or enrich their customer profiles this serves as a basis for social crm processes such as for example customer segmentation and campaign management within a social crm the most relevant source of data are social media as they enable businesses to get closer to the customer than ever before and provide a rich set of data about customers and customer segments wearables such as smart watches are a second source of information they deliver relevant usercentered information such as pulse rate activity level pedometer altimeter location time distance or temperature especially healthrelated information from those devices are regarded as an addition to specific medical devices such as heart rate monitors which are a further source of information and may possess a higher accuracy of data capturing as they are calibrated and approved context elements from social media with regard to a social crm application two principle methods of context information acquisition may be distinguished the first method is a direct user input as a response to an input prompt this may be the case when a customer inputs information himself for example in order to search or configure a service offering the second method is an indirect user input which gathers data with or without a customers knowledge this may be the case when mobile applications automatically collect eg location data in order to offer relevant mobility services this research focuses on the latter and assumes a conscious transfer of context information from a customer towards a company in this setting a customer is aware that certain data may be transferred capturing context from social media refers to the second method and may either be performed by using a social networks application programming interface or by using specific social crm applications or external service providers such as google fit for example using the twitter api delivers the name of a user and the raw text of a tweet applications of social media monitoring and analytics on the other hand aggregate and interpret available context information and are able to create further information that were not available from the api for example based on a users tweets sma applications provide an overview about different topics a user is interested in and his attitude or sentiment towards these topics figure 2 summarizes both methods to capture context information from social media the following table presents the results of a mapping between context elements from the model and available context information from the twitter api the matching refers to the indirect and mined method of capturing context information and was conducted by reviewing all available attributes from the twitter api and assigning them to a suitable context element in the model based on the attributes description in the api the table presents directly available data elements which are mainly related to the context dimensions 24 the contained information might be enriched by applying eg sma or business intelligence applications however especially for the first context dimension the derivation of information is necessary in order to obtain further insights based on the model and using the twitter api a software implementation could extract the given information and build a specific context model by extracting further tweets from an individual the model gradually completes for example the tweet text might reveal information on an individuals emotions preferences as well as interests and thereby frame his customer states in addition information such as coordinates and finally the user name language and user description frame customer attributes discussion following heinonen and strandvik the essential features of cdl are the business perspective customer logic offerings value formation and customer ecosystems the results of this research contribute especially to the understanding of the customer logic and therefore improve the relevance of product or service offerings current research falls short in providing a common understanding of customer context with a structured collection of related context information and the instantiation with social media data therefore this paper complements existing research by addressing these aspects as a first result and with respect to rq1 this research presents a definition of customer context in social crm settings and provides a conceptual model to structure the concept and its constituents as a second result and referring to rq2 the model is adapted with a nonexhaustive list of context elements found during a literature review it builds on the results from multiple research disciplines and therefore aims to be applicable to multiple spheres of live eg mobility communication and health the paper then discusses several data sources of context information focusing especially on social media as a rich data source the provided mapping shows that relevant context information are available within social media and relates them to the model these results are discussed together with a cdl perspective on customer relationships in cdl as a marketing perspective customer logic is a concept describing a customers activities experiences and goals each customers logic is individual can change and may be influenced or may change over time within a social crm customer context is a specific and structured enabler that helps businesses to understand this customer logic as it captures individual information especially from social media either by sensing or deriving context information customer context extends the often stressed 360° view on a customer by incorporating outsidein data with existing insideout data and thereby puts the customer at the center of business activities as a result it is the basis to enable a crossprovider understanding of customers this research provides the starting point for individualized customercentered social crm processes based on the captured data from social media the described context information might be used in social crm processes such as the definition of personas which represent specific needs characteristics or preferences of a target or target group or within a so called social customer value dashboard which contains weighted context elements that calculate to a sum and provide information about the relevance of an offering for a target or target group this briefly illustrates practical and exemplary application perspectives of the concept within a cdl strategy ultimately these results form the basis for businesses to answer the initially raised question what can we offer to customers that they are willing to purchase and pay for conclusions and outlook this research presents an analysis of current literature on customer context it derives a definition of context a model context dimensions as well as specific context elements from literature in order to substantiate a common understanding of the concept for social crm thereafter the paper describes a mapping of context elements with social media data using twitter as an example as business environments are increasingly competitive the need to understand customers and their individual logic is an inevitable success factor for them methods and sources for the collection of context information are discussed and it is postulated that especially social media deliver a large amount of data that may help to transform a companys insideout perspective towards an outsidein perspective however the following considerations reflect on the limitations of this research and thereby formulate a short exemplary research agenda which shall be addressed by future research the aspects reflect on the application of the concept the investigation of benefits for both customers and businesses and the necessity to control the access to context information  first it is necessary to further research on the proposed models applicability to service providers and extend the given list of context information furthermore an application of the model to other application fields such as medicine shall be addressed and could be beneficial with respect to the openehr standard for electronic health records possibly valuable context information could supplement clinical information such as basic information medications list therapeutic precautions and the social situation for example using a case study approach could identify further context elements and application fields of relevance  second further research also needs to answer the questions of how to model and digitally represent context information for example xml notations and annotation models may be a suitable digital representation of context information to be exchanged between application systems such as social crm and recommender systems  third research needs to address the resulting benefits that may arise from the incorporation of customer context into product or service offerings from both a companys and particularly from a customers perspective for example a presumable selling potential could be based on a specific demand  finally and within such a customercentered and databased business strategy privacy aspects are highly relevant and need to be considered by further research the argumentation of this research is based on the assumption that publicly available data can be used within a business context but rising questions on privacy data sovereignty data usage and data control still have to be answered to prevent a misuse of social data which entails latent risks eg for personal rights with regard to the data control aspect a proposed solution is a customerowned context app which provides a central control mechanism to the user for example a customer could decide selectively eg during a service configuration process which additional context information he will provide in order to configure a service congenial to his need with the rising use of social media on the one and the also rising demand of collaborative and personalized interactions with companies on the other hand the latter need to apply methods to better understand their customers customer context is a promising means to achieve this aim as it helps to understand customers and their respective needs it therefore helps to bring customers and companies closer together introduction the most used integrated software solutions in companies from almost all industries worldwide are enterprise resource planning solutions number of erp users is growing very fast and majority of employees are using erp solutions daily at their work because this on labour market is huge demand for students with knowledge of erp solutions in past few years a lot of universities included topics from erp solutions in their curriculums through different subjects such as accounting information systems enterprise resource planning information systems etc while number of erp solution user is growing a lot of research studies regarding erp user adoptionsacceptance are emerging the most used research models are technology acceptance model theory of reasoned action theory of planned behaviour innovation diffusion theory stage model technologyenvironmentorganization and resourcebased view in this area tam is one of the most suitable and widely used model to study adoption in is and therefore numerous is researchers apply this method to erp research the key purpose of tam is to provide a basis for tracing impact of external factors on internal beliefs attitudes intentions and actual use despite erp acceptance by its users in companies has been researched by several authors erp acceptance by students within study programmes has not been researched so often our goal is to research external factors which influence student acceptance of erp solutions our research model is based on tam and include factors of original tam but our research model modify external factors we have included additional external factors which we think that will have impact on erp acceptance experience with computer computer selfefficiency personal innovativeness toward it computer anxiety user manuals system quality social influence training and education etc the research approach is based on short interaction contact with erp solution the survey was conducted among group of students who do not have any knowledge regarding erp solutions before after description of erp solutions and literature review research model is described in details and results of study are presented and discussed erp solutions erp solution is usually referred to as a category of businessmanagement software typically this is a suite of integrated applications which an organization can use to collect store manage and interpret data from their daily business activities erp solutions provide an integrated and continuously updated view of core business processes using common database erp solutions track business resourcescash raw materials production capacityand the status of business commitments orders purchase orders and payroll the applications that make up the system share data across various departments that provide the data erp facilitates information flow between all business functions and manages connections to outside stakeholders most erp systems incorporate best practices which means the software reflects the vendors interpretation of the most effective way to perform each business process the organization gartner group first used the acronym erp in the 1990s erp systems experienced rapid growth in the 1990s because of the year 2000 problem and the introduction of the euro that disrupted legacy systems many companies took the opportunity to replace their old systems with erp erp systems initially focused on automating back office functions while front office functions became integrated later when the internet simplified communicating with external parties the erp ii was introduced in 2000 by the gartner organization and describes webbased software that provides realtime access to erp systems to employees and partners their role expands traditional erp resource optimization and transaction processing and leverages information in the resources under its management to help the organizations collaborate with other organizations erp ii solutions are typically used to enable collaborative initiatives such as supply chain management customer relationship management and business intelligence among business partner organizations through the use of various ebusiness technologies organization gartner group in year 2013 introduced the term postmodern erp according to gartners definition of the postmodern erp strategy legacy monolithic and highly customized erp suites in which all parts are heavily dependable on each other should sooner or later be replaced by a mixture of both cloudbased and on premise applications which are more loosely coupled and can be easily exchanged if needed early erp providers focused on large enterprises smaller enterprises increasingly use erp systems in last few years the worldwide erp market grew from 38 from 244b usd in 2012 to 254b usd in 2013 sap is in market leadership position follow by oracle sage infor and microsoft erp will remain basic software in the organisations literature review technology acceptance model several theoretical models have been used to investigate the determinants of acceptance and the use of new information technology such as the theory of reasoned action the theory of planned behaviour the theory of the technology acceptance model innovation diffusion theory stage model technologyenvironmentorganization and resourcebased view compared to competing models tam is believed to be more parsimonious predicative and robust and so among the theoretical models is most widely used by isit researchers and therefore numerous is researchers apply this method to erp research tam posits that two beliefs perceived usefulness and perceived ease of use are of primary relevance for computer acceptance behaviour pu is defined as the degree to which a person believes that using a particular system would enhance his or her job performance peou in contrast refers to the degree to which a person believes that using a particular system would be free of effort the two central hypotheses in tam state that pu and peou positively influence an individuals attitude towards using a new technology which in turn influences his or her behavioural intention to use it finally intention is positively related to the actual use tam also predicts that peou influences pu as davis et al put it effort saved due to the improved perceived ease of use may be redeployed enabling a person to accomplish more work for the same effort the key purpose of tam is to provide a basis for tracing the impact of external factors on internal beliefs attitudes and intentions original tam is presented in figure 1 in grey rectangle the original tam is well established and tested and furthermore a variety of extensions regarding external factors by examining the antecedents of pu and peou has been developed such as tam 2 utaut and tam 3 erp solutions even though tam can be applied to a variety of technologies the constructs of tam need to be extended by customizing factors for specific information systems few studies have investigated erp user acceptance and usage utilizing tam and most of them investigate a small number of external factors they tested the impact of four cognitive constructors on at and symbolic adoption nah et al 2004 their study evaluated the impact of one belief construct and its effect on the perceived technological value of an erp solution leading to its use uzoka et al 2008 they extended tam to research the selection of erp by organisations using factors impact of system quality information quality service quality and support quality as key determinants of cognitive response as well as which erp solution to purchaseuse calisir et al 2009 they examined factors that affect users bi to use an erp solution based on potential erp users at one manufacturing organisation scott walczak 2009 they investigated students cognitive engagement prior experience computer anxiety and organizational support as determinants of computer selfefficacy in the use of a multimedia erp systems training tool shih huang 2009 their study attempted to explain bi and au through incorporated additional behavioural constructs top management support computer selfefficacy and computer anxiety they extended it usage models to include the role of erps perceived work compatibility in users erp usage intention usage and performance in work settings youngberg et al 2009 they researched impact of peou result demonstrability and subjective norm on pu and impact of it on usage behaviour lee et al 2010 they examined factor organisational support on original tam factors sternad et al 2011 they costa et al 2016 they extended original tam with factors top management support training and the system quality and research their impact on adoption and user satisfaction mayeh et al 2016 they examined the effects of factors absorptive capacity communication and trust through original tam and intention to use erp solution just two from above table researched students erp acceptance through tam model but both authors used small numbers of external factors shiversblackwell and charles also researched student readiness to use erp technology through model tam but they researched erp acceptance after students read an online newsletter provided by the erp communication education and training team entitled what is erp participants were then solicited by their professors to complete the survey so they did not have practical experience with use of erp solution their research shows that gender and perceived erp benefits are related to students readiness for change and readiness for change is a significant predictor of students attitude toward usage of the erp system scott and walczak examined cognitive engagement prior experience computer anxiety and organizational support as determinants of computer selfefficacy in the use of a multimedia erp systems training tool they also examined the impact of computer selfefficacy on its acceptance the sample consisted of 239 students taking an erp course elective in the information systems undergraduate and graduate programs student erp acceptance to examine erp users use of erp systems we need to extend the tam synthesizing prior researches on tam and researches on erp systems a conceptual model that represents the cumulative body of knowledge accumulated over the years from tam and erp research has been developed figure 1 conceptual model our goal is to research student acceptance of erp solutions while they are involved in erp topics after short interaction with the systems and which external factors have impact on it we are preparing conceptual model which will include factors of original tam therefore we use hypothesizes from original tam h1 perceived erp ease of use has positive and direct effect on perceived erp usefulness h2 perceived erp ease of use has positive and direct effect on attitude toward erp system h3 perceived erp usefulness has positive and direct effect on attitude toward erp system h4 attitude toward erp system has positive and direct effect on behaviour intention even though tam can be applied to a variety of technologies the constructs of tam need to be extended by customizing factors for specific information systems one problem with tam research is that most researchers investigate small number of external factors in case of erp acceptance several external factors may influence user acceptance thus the conceptualisation of multiple higherorder factors must be investigated to understand user behaviour we expose in prior researches that external factors could be distributed among three groups of factors which are personal characteristics and information literacy system and technological characteristics and organizationalprocess characteristics in these three groups we are trying to capture many external factors which influence erp user acceptance in operational phase since we research student acceptance of erp solution we must adjust and add some other external factors personal characteristics and information literacy includes personality characteristics that can influence individuals perceptions of erp system acceptance and usage because goal of our research is to research student acceptance of erp solutions we expose those factors which could have impact of their acceptance of course lectures and exercises regarding erp solution we expose several external factors in group pcil which are personal innovativeness toward it computer anxiety computer selfefficiency and individual benefits in contrast to most it implementation research the fact that erp implementation research is focused on one technology has enabled the effect of specific technological characteristics to be examined surveying different research following external factors has been exposed in group of stc system performance user manuals quality of erp system and quality of information in erp system organizationalprocess characteristics capture various social processes mechanisms and support organizations that guide individuals to facilitate the use of an erp system opc includes social influence and training and education on erp system therefore it is hypothesized h6 a group of external factors influence use of the erp system through the conceptual factor personal characteristics and information literacy h7 a group of external factors influence use of the erp system through the conceptual factor system and technological characteristics h8 a group of external factors influence use of the erp system through the conceptual factor organizationalprocess characteristics research design and procedure the components of the proposed model are pu peou at bi and u where pu and peou influenced by various external factors the external factors are distributed among three secondorder constructs which are personal characteristics and information literacy system and technological characteristics and organizational process characteristics secondorder factors are composed by specifying a latent variable which represents all the manifest variables of the underlying lowerorder factors pcil includes personal innovativeness toward it computer anxiety computer selfefficiency and individual benefits stc is composed of system performance user manuals quality of erp system and quality of information in erp system opc includes social influence and training and education on erp system our conceptual model includes 15 firstorder factors and 3 secondorder factors we already did researches regarding user acceptance of erp solutions in organizations the instrument was pilot tested with a group of 30 erp users in one organization based on the results of the pilot testing revisions and additions were made to the instrument all the items of factors were measured on a 7point likert scale ranging from strongly disagree to strongly agree the scale was adopted from relevant prior research and adapted to relate to the context of students erp usage demographic information was collected as well the survey was conducted among group of 121 students the group included students who have course ebusiness they do not have any knowledge regarding erp solutions at the beginning of the course course includes 15 teaching hours lectures from erp topics with focus on the business processes in microsoft dynamics nav and 15 teaching hours exercises in computer lab where they have hands on training of some business processes in microsoft dynamics nav we are using version microsoft dynamics nav 2016 the survey was carried out after short interaction with nav solution we distributed paper version of questionnaire after 12 hours contact with erp solution in the beginning of lecture and gave them half an hour to solve it students had 8 hour of lectures about erp solutions microsoft dynamics solutions and microsoft dynamics nav purchasing process in nav and production process in nav and 4 hours of computer lab exercises where get familiar with navigation in nav solution purchasing process in nav solution till then 121 questionnaires were properly filled out by respondents and used for the purpose of analysis respondents were 388 male and 612 female they have topics regarding microsoft dynamics nav 2016 4 hours per week 2 hours lectures 2 hours computer lab exercises and 0 individual work the average age of students is 2166 years analysis and results demographic data were analysed by spss all other empirical data were analysed pls technique using smart pls 321 partial least squares approach can be employed to estimate the parameters of a hierarchical model and also allows the conceptualisation of higherorder factors through the repeated use of manifest variables a higherorder factor can thus be created by specifying a latent variable which represents all the manifest variables of the underlying lowerorder factors we employed a pls approach because of the relatively small number of samples of valid data and our desire to analyse secondorder factors data was analysed in two stages involving a pls technique using smart pls 321 all measurement scales were examined for their psychometric properties prior to testing hypotheses results of measurement model were satisfactory the hypothesis testing results utilize bootstrapping to test the statistical significance of each path coefficient using ttests as recommended by chin results of this analysis are shown in figure 2 our research confirms results of original tam perceived erp ease of use has weak but significant effect on perceived erp usefulness and strong significant effect on attitude toward using erp system perceived erp usefulness has strong significant effect on attitude toward using erp system attitude toward using erp system strongly influences on behaviour intention and behaviour intention strongly influences on actual use secondorder factors have significant positive effect on perceived usefulness and on perceived ease of use pcil has a strong positive effect opc has a weak but significant effect on perceived erp usefulness stc has very strong positive effect on perceived erp ease of use and these findings provide empirical support for hypotheses h6 h7 and h8 discussion our results of original tam model go with results of other researchers who research itis acceptance both perceived erp usefulness and perceived erp ease of use have strong positive effect on erp usage where relationship of perceived erp ease of use is a little stronger this is not consistent with davis davis et al and simon and paper who expose that perceived usefulness has stronger positive effect on itis usage as perceived ease of use while perceived ease of use has not so strong or even not statistical effect on itis usage after some time of usage on the other hand results of some researches show stronger effect of perceived ease of use on attitude toward using erp system then perceived erp usefulness on attitude toward using erp system because survey was carried out after short period of erp solution learning it could be reason for that result some itis researches show strong positive effect perceived erp ease of use on perceived erp usefulness but this is not consistent with our study where perceived erp ease of use has weak positive effect on perceived erp usefulness empirical findings on that relationship in the context of erp are different since some researches did not confirm a statistically significant relationship between two while other researches confirmed a statistically significant positive relationship factor attitude toward using erp system is vital in the tam model and has very strong positive effect on behavioural intention and through it also indirect strong positive effect on actual use which is consistent with other researches the aim of this research was to identify external factors which influence student erp usage after they were involved in erp topics after short interaction with the systems based on the analytical results we can see that it is possible to observe more external factors through secondorder factors the fact that erp implementation research is focused on one solution has enabled the effect of specific technological characteristics to be examined we have not found any research which has examined the effects of system and technology characteristics upon the erp systems user acceptance stc has strong impact on perceived ease of use through external factors system performance quality of nav system and quality of information in nav system factor user manuals is not statistically significantit could be because students did not work alone and they did not use user manuals until then second order factor personal characteristics and information literacy has through personal innovativeness toward it and individual benefits greater impact on perceived usefulness than second order factor organizationalprocess characteristics through social influence and training and education on erp system this means that for students are more important fact that they see individual benefits using nav systems and that they like to use any computer toolapplications then social influence and training and education on erp system furthermore individual benefits has stronger effect on perceived usefulness than personal innovativeness toward using software tools and applications factors computer anxiety and computer selfefficiency are not statistically significantthese students are students of higher class who had several courses related to it during the primary and secondary schools and also at the time of the study factor training and education of nav has stronger effect on perceived usefulness than social influence who have influence on students perception regarding naverp conclusion the aim of this research was to research which external factors have impact on students acceptance of erp within study programme while they are exposed to erp solution we want to know how to motivate students to take seriously course ebusiness where we teach students erp solution microsoft dynamics nav we exposed 10 external factors which have impact on student erp acceptance this work extended previous researches by incorporating groups of external factors which have influence on students erp acceptance studying the influence of more external factors on constructs not only contributes to the theory development but also helps in designing teachers curriculum our research shows that external factors personal innovativeness toward it and individual benefits are very important personal factors which have impact on students erp usage while computer anxiety and computer selfefficiency are not important it could be because students did not work alone and they did not use user manuals until then organisationalprocess factor training and education of erp is more important than factor social influence who have influence on students perception regarding naverp and therefore we suggest to teachers put a lot effort to prepare excellent teaching materials and to try to explained students erp topics related content in an easy way scott and walczak understanding of erp solutions is challenging for students because they do not have practical experience of how erp solutions is used in enterprises important systemtechnological factors are system performance quality of naverp system and quality of information in naverp system while factor user manuals is not important after short interaction with the system the implications for researchers and practitioners include an extended version of tam through secondorder factors to improve the explanatory power of erp usage the technique for analysis of model was used this study has certain limitations which may present the opportunity for further research since the respondents were limited to one group of students in slovenia this study should be extended to other counties further research is needed to explore the importance of presented external factors in different time frames as well as include additional external factors another limitation is also that research was conducted for one erp solution microsoft dynamics nav because of that the importance of external factors of different erp solutions also could be explored introduction hyperturbulent environment and contemporary issues in incumbent businesses established the need for indepth observations of companies business models and their components elaborating on the absence of consensus on what a business model is or what it is not we provide readers the insights from the most important areas within a business model research in the infant stage of business model topic and 6 years after zott amit and massa identified some of the most visible clusters in business model research despite the discrepancies in its definition business model is usually recognized as a set of resources through which transactions generate value for the company and its customers business models are necessary for capturing value and constructing organizations capabilities this vice versa relationship led zott amit and massa to conclusion that business models enable a holistic perspective for observing organizations and their businesses the assessment of business models their usage and future trends is helpful since it can provide us with the insights about the main topics in business and its associated theoretical traditions drawing on the ongoing research our paper provides bibliometric methods which can be used to identify the most influential keywords and future trends in field of business models since academic attention paid to business models has recently increased substantially a bibliometric analysis can provide a coherent map of contemporary business model research and assist both scholars and practitioners in innovating business models along with recognizing the future trends in that area our aim is to identify the past conversations within business model literature and future avenues several excellent reviews of the field relied on the method of structured literature review to establish the state of the art in the field our contribution is to complement these reviews with bibliometric methods that use quantitative bibliographical data in this way we can tap into the knowledge created by scholars in the field who expressed their opinion by citing specific articles and books such an investigation also forms an excellent basis to speculate on whether business model will survive as a term within strategic management and information systems literature as a distinct term to eg competitive advantage strategy or digital transformation literature review every organization employs a business model that encompasses how value is created delivered and captured an ample amount of research revealed that the consensus on what a utilization development and structure of a business model has not been reached yet that is why business model has been applied to different environments and utilized within a different context besides phenomena such as the emergence of ebusinesses and surge of technology innovations have influenced the development of business models business model is quite difficult to be depicted without a broader understanding of the environment in which organization operates despite that some authors made an attempt to introduce business model through text and graphics in order to provide managers with a unique template for designing a winning business model in spite of not having a universally applicable template business model does depict the content structure and stewardship of transactions that enable value creation in future business opportunities teece ads data and other evidence into business model concept since these two seem to support the value proposition for endusers finally a line between strategy and business model was given by casadesusmasanell and ricart who identified a business model as a reflection of a firms strategy additionally business model not only resonates companys strategy but also links technological innovation to strategy innovation and technology are two facets of business models development whereas only a scant amount of scholars have more or less successfully conceptualized business models elements and relationships according to zott and colleagues an adequate business model is the one with value network encompassing both value creation and value capture meaning to include all stakeholders and distribution channels along the entire supply chain of a certain organization a company should not focus only on improving business model elements but to develop them in such a way that it will be able to continually change its existing or add a new business model as a response to unexpected changes unfortunately managers usually respond by optimizing only each of the element of the current business model this is insufficient because the development of a new business model entails a paradigm shift which requires an indepth analysis of customers competitors and partners more importantly the emphasis should be on articulation of business model and an evaluation against the current state of the business ecosystem and against how it might evolve the allure of business models is that they are based on observation and theorizing making them a perfect template for running companies businesses business model development is a longterm process that can shake the markets or vice versa as seen when the emergence of informationcommunication technologies stroke the concept of a business model in fact authors have shown how difficult it is to create a winning business model especially in the era of disrupting ict innovations in light of this a great variety of business models became ictenabled since after all ict provides organization with new channels for interacting 30 th bled econference digital transformation from connecting things to transforming our lives i župič m budler p trkman characterization of business model research bibliometric analysis and the future agenda with customers besides there is yet a case to be made for sustainable business models since sustainable business models are the ones interacting with and augmenting companys resources partnerships and relations with customers in regard to developing business models we have seen an ample amount of companies possessing multiple business models in order to cope with different niches and preferences from endusers reallife business environment establish a need for using multiple business models however doing this might be a doubleedged sword a great challenge to be addressed when companies try to utilize two different business models is that two business models will sooner or later interfere causing conflicts two solutions were advised first organization could physically separate both of the business models to avoid their interactions or second business models could be merged in order to exploit synergies there has been a common misunderstanding on how to distinguish a strategy from a business models not only due to similarities between these two but also because of the strategic function embedded in business models dasilva and trkman understand a strategy as a key determinant in the development of capabilities that enable future business models within an organization another distinction between strategy and a business model has been provided by authors claim that every organization has some business model whereas not every organization has a strategy as business models are seen as a source of competitive advantage the interplay between the strategy and the business models gained its importance finally there is a business model innovation defined as the discovery of a fundamentally different business model in an existing business or as a quest for finding a new template on which an organization could create and capture value not only for its customers but also for its stakeholders business model innovation can lead to organization achieving competitive advantage if the model is enough revolutionary and difficult for imitation by competitors incumbent businesses tend to elicit value from innovative ideas and disruptive technologies throughout their business models interestingly the process can work vice versa since business models are often shaped by modern technology and innovations business model or the development of business model can be seen as a stage between an idea growing from invention towards innovation however with an emphasis on business model ensuring that not only technology is engraved but also that the innovation is economically sound methodology we mapped the business models literature with bibliometric methods these methods use the citation information in bibliographical databases to extract meaningful information about the structure of scientific fields the quantitative information gathered from bibliometric analysis can be a useful complement to the traditional structured literature review specifically we used the methods of citation analysis bibliographic coupling and coword analysis citation analysis measures the influence of specific documents or journals by measuring their citation frequencies if certain article or journal is more cited it is assumed it had greater influence on the literature than its less cited counterparts bibliographic coupling uses the similarity of reference lists to establish connections among scientific publications for example if ten publications appear in both reference lists of two scientific papers this means that these two papers are connected with coupling strength of ten the stronger the coupling strength the stronger the connecting link when this information is gathered for all relevant publications in the scientific field of interest clustering methods can be applied to delineate the structure of the field and identify the substreams of research coword analysis on the other hand connects the word terms by their appearance in the same title or abstract if two terms appear together multiple times this means that the connection link between them is stronger again putting together this information for the whole scientific field gives us a clear thematic picture of the fields conversations we searched thomson reuters web of science for business model in the topic of published articles in the time period 20102015 we selected this period because we wanted to analyse the current conversations and not the past literature the search returned 1533 entries which we further filtered for business management and economics categories of the remaining 598 articles we selected only document types of article editorial material and review which left us with 580 entries the abstracts of all 580 documents were read and rated by two authors criterion for inclusion in the sample was that business model was one of central themes of investigation in the research study articles that only passingly mentioned business model concept were excluded from the sample after rating the articles independently the interrater agreement was 864 the differences on the remaining 79 articles were reconciled by rereading the abstracts by both raters together and reaching decision whether to include the contentious article after this process 308 articles were left findings we have conducted three types of analyses of business model literature first the citation analysis shows the most important publications outlets for contemporary business model research which journals consist the knowledge base of business model research and which documents are the most cited within the literature second the bibliographic coupling followed by the application of network community finding algorithm provides the structure of contemporary business model research that is based on the quantitative citation data finally the coword analysis of most important keywords in abstracts and titles shows the topical domain of business model research eisenhardts paper on building theories from case study research this reflects the fact that the majority of the empirical articles on business models are based on qualitative case studies mangematin 2013martins rindova greenbaum 2015 but also reviews of the field citation analysis cluster 2 contains 19 articles the vast majority of authors in this cluster are focusing on understanding the idea of a business model by identifying and explaining its meaning authors execute sensemaking out of business models and try to make them contextdependent with regard to organizational strategy a major question in this cluster is the distinction between business model and strategy additionally the authors examine what is the role of business model when constituting strategies in light of sensemaking some of the authors have pursued their research to elucidating changing meaning of the business models how the business model notion is changed due to the environment and how to distinguish between various business models cluster 3 has 12 articles it is predominantly strategybased and the core of this cluster is represented by several publications of the 2010 long range planning special issue on business models bibliometric analysis and the future agenda 727 cluster 4 is the smallest with 9 articles the topics in this cluster are predominantly rooted in marketing themes for example the papers in this cluster explore the definition of markets as configurations the usefulness of business models construct for servicebased companies and the integration of products and services solution business models and business models in projectbased firms coword analysis we visualized the text in abstracts and titles with coword analysis 6170 different terms are used in 308 abstracts we selected top 133 terms with at least 10 appearances we visualized 60 of the most relevant terms resulting in 80 keywords we further filtered out keywords that were researchrelated like methodology findings and similar we visualized remaining keywords with heatmap in figure 2 warmer areas represent more frequently used keywords and their proximity means that the terms are often used together the area on the right shows papers emphasizing the importance of business model innovation its meaning in change management and its role especially in terms of enhancing organizations performance as emphasized by casadesusmasanell and ricart furthermore central cluster of keywords confirmed business model as the most important tool for delivering value to customers however the value cannot be elicited from business model if organizations lack cuttingedge technology in fact not only technology but also various elements and capabilities play an important role when it comes to refining a business model another two clusters have pointed out that business model is redeemed as a system or a concept encircled around its focal elementproduct discussion in preliminary research we examined the 308 articles on business models published in the period 20102015 in further research we will also examine articles before 2010 and articles published in 2016 business model topic has covered the emergence of ebusinesses and surge of technology innovations that influenced the vast majority of organizations it can be discussed how much a business model is contextdependent nevertheless the future research should give us more information about business models elements and the interplay between them further by examining articles published in different periods thoroughly we tend to investigate how the business model research has changed over time and second contemplate which future avenues are most likely to be addressed the results of the citation analysis of the papers and the four identified clusters by bibliographic coupling jointly paint a coherent picture of the business model research the disciplinary landscape spans from technological innovation through strategy to marketing this is reflected in the journals that publish business model research which also include practitioner outlets like harvard business review this makes the business model construct uniquely positioned to integrate the supplyand demandside approaches to strategy conclusion we used bibliometric methods to examine state of the art of business model research we identified the most influential documents in contemporary literature divided the literature into four clusters and visualized its topical structure our analysis provides a useful tool for both veteran and new researchers who want to move the field forward limitations bibliometric methods have several wellknown limitations first it is not possible to determine based on solely citation data why certain document was cited it could be because the citing author thought the cited reference was important foundation for their work but it could be also to refute the claims in cited document or ritually cited because certain citations are expected in the specific scientific fields second our analysis encompasses the most cited works and most used keywords it is possible that some smaller research substreams were missed even though they could comprise an important but less cited niche finally we have deliberately taken into account only categories business economics and management as we wanted to thoroughly examine the articles published in these mainstream areas we tend to expand that in further research further research first researchers could pursue the question why the conversations of business models are usually happening only within a certain bundle and what would be the implications of an interplay between these various subareas second researchers could initiate followup studies on coword analysis evaluating whether a synergy between these subareas enabled the proliferation of incumbent business models finally taking into consideration the results of our inquiry from the journals could lead researchers to a better understanding of the fields and industries interfering with the continuous development of business models introduction the netherlands has a strong tradition of social housing for lower income groups within this tradition housing associations are a major player something which dates back to the 1901 housing act in the beginning social housing was operated from the pillarization the politicodenominational segregation after world war ii the dutch government managed and prescribed how what and where to build from the mid1990s the government withdrew itself and stimulated selfreliance today the social housing system is failing the decreasing support from society is a crucial threat to the future of the system therefore innovation of the system among other things by regaining commitment between the housing associations and their target population is vital a focus on core activities is together with the first benchmark by aedes in 2015 the first step in the right direction with rental incomes that are just sufficient to cover the expenses for management and maintenance more efficient cooperation with maintenance companies can lead to more efficient maintenance processes and lower maintenance costs it is believed by both scholars and practitioners that more efficient cooperation can be achieved through supply chain partnering and the effective use of information systems especially for housing associations where the organisation of maintenance occurs in a complex environment the very diverse property portfolio of housing associations is one of the complexing aspects the portfolios consists of recently completed new built houses postwar dwellings and houses completed in the intervening period furthermore they lack unity regarding construction quality compliance with present living requirements method of recording the construction and installation engineering information and accessibility to and completeness of this information supply chain partnering has become a prominent phenomenon among academics and professionals working in the construction sector several benefits are ascribed to better coordinated cooperation between supply chain partners including cost reduction increase of quality shorter execution times and more opportunities for innovation and learning and although information management is a prerequisite for successful implementation of scp there is little attention for the relation between the implementation of scp and information management furthermore most research on information management in construction focuses on building information modelling for new construction while benefits of bim could also apply to maintenance bim use facilitates the integration of stakeholders thereby reducing fragmentation improves knowledge management and communication cooperation decisionmaking and performance of maintenance and reduces maintenance costs however to fully benefit from bim coordination of stakeholders and stakeholders actions is required research on scp also focuses mostly on new construction which is surprising since new construction is still mostly about onetime projects while maintenance is an ongoing series of activities it is the latter that generates opportunities for a more structural cooperation between supply chain partners and also a more structural coordination of activities resources and benefits and risks this research addresses these opportunities and identifies the coordination mechanisms that help improve information management as well as the implementation of scp this research proposal has the following structure hereafter the problem definition and formulated research question are discussed subsequently section three describes the research methodology while section four elaborates on the expected results future development of this research is discussed in section five problem definition opportunities for implementation of scp are particularly evident in the social housing sector in northwest europe including the netherlands in northwest europe the social housing sector is managed by professional property managers who are capable of building professional partnerships with their contractors in general the housing sector is under increased financial pressure which triggers social landlords to look for more efficient ways of working according to the housing act 2015 dutch housing associations must focus on building renting out and managing and maintaining social housing and invest in the livability of the neighbourhood the housing act 2015 also allows for commercial activities but only when commercial parties have no interest this is executed within a framework of less subsidies various organisational structures and a differentiated property portfolio in addition the internal business operations of dutch housing associations are neither transparent nor efficient an understanding of the activitybased costs is often imperfect while the necessity to manage costs forces housing associations to develop structures of strategic stock management and a housing stock with sufficient flexibility to anticipate to future developments in addition the social rent that is actually paid to the housing association is often lower than the value of the housing services generated by the houses the internal management of housing associations is often 736 30 potentially about 80 of all housing associations could improve their processes regarding maintenance koolma allers also indicate there is ample room for efficiency gains in the dutch housing association sector in the current organisational structure of maintenance housing associations still tend to do a lot of maintenance activities themselves this is costing them a lot of time and money therefore revenues from rent are just sufficient to cover management expenses both scholars and practice recommend that housing associations change their maintenance processes in order to lower the costs involved this starts with changing the type of contract traditionally parties rely on formal dyadic contracts that specify each partys financial and other rights responsibilities and duties and traditional approaches to maintenance lead to more management time unnecessary costs and poor maintenance decisionmaking in addition in construction projects the relationship between firms typically last for the duration of the project meaning that learning across and between projects to improve processes hardly ever occurs also construction projects are often criticised because of the performance of contractors with lower than expected performance in time costs quality and satisfaction levels of clients kempton identified a significant problem with communication and a lack of coordination between the corporate goals of the development management and maintenance departments this is illustrated by three employees of a medium sized dutch housing association who point out that the new building projects department is an independent entity within the housing association as a result one of the key challenges is to have sufficient information available for maintenance work such as specifications information on previous maintenance work a list of specialist professionals to conduct work etc information is often not available and available information is often not complete or uptodate nor easily shared among supply chain members maintenance processes could be improved through improving coordination and information management processes this is not provided by a dyadic contract since this type of contract neither provides a shared goal for all project partners nor specifies the organisational or technological mechanisms to align information and knowledge flows between the project partners a dyadic contract will more likely lead to fear of opportunism to an experienced lack of trust in the beginning of the project which in turn leads to more procedural coordination mechanisms to benefit project outcomes and to reduce project risks here a transition towards integrative supply chain processes appears desirable because maintenance projects require an approach with a clear and integral set of requirements where all involved parties cooperate as a welloiled team furthermore transparency and an increase in efficiency are necessary for the legitimacy of housing associations in society the idea of a shift from a fragmented into an integrative way of construction is also a generalised technological promise of building information modelling technologies however this does not provide a realistic conception of the complexity of the conditions of the implementation of bim according to love et al bim technology in itself has no inherent value having bim technology in place will not necessarily provide benefits or create value for a housing association benefits only arise from its effective use this asks for coordination of stakeholders actions and learning to cooperate as partners is a social accomplishment rather than a technical feature partnering must involve the production of new working practices at a local level the implementation of bim could help as it facilitates the integration of the roles of all stakeholders in 2014 nobakht stated in cobouw a daily magazine for construction professionals that despite the changes and challenges housing associations are facing structural innovations of the current business models were still omitted he believes that the barrier for structural innovations lies in the originating small scale building sector with a traditional way of thinking a monoculture and a lack of knowledge regarding strategic business problems construction clients appear to distrust their main contractors who in turn distrust their subcontractors and suppliers and individual players have very little stake in the longterm success of and therefore no commitment to resulting structure the core of the problem is that fragmentation is thought to be of interest to all involved parties although it leads to loss of information misunderstandings pointing at each other suboptimizations and additional work although it is believed that supply chain integration must lead to improvement by developing a more stable environment several barriers prevent this integration the traditional fragmentation leads to resistance towards supply chain integration due to perceived extra costs partners are unaccustomed to share knowledge across project phases and are unaware of potential benefits successful integration of the construction supply chain is possible for instance through a multiparty contract which aligns financial interests and builds trust between supply chain partners in the beginning of the project the contract aligns information and knowledge flow between the project partners by specifying organisational and technological mechanisms long term supply chain partnerships make it easier to be vulnerable and communicate freely and thus to establish common norms and good team practices and are also positively associated with improved working practices and an increased level of trust in high trust groups coordination is more effective leading to greater efficiency and hence better performance coordination theory is relevant for improving the cooperation in supply chains especially in combination with the concept of boundary objects however thus far this theory has not been applied to supply chains in the construction industry coordination theory has been defined by 738 30 th bled econference digital transformation from connecting things to transforming our lives d goedknegt information management in supply chain partnering improving maintenance processes in dutch housing associations malone and crowston as a body of principles about how activities can be coordinated that is how actors can work together harmoniously li and wang distinguish two supply chain types centralised and decentralised they state that construction supply chains are decentralised supply chains which are more difficult to coordinate because this requires a scheme to allocate the benefits of coordination throughout the supply chain to maintain the interest and participation of all dependent supply chain partners for this agency theory offers a unique realistic and empirically testable perspective on problems of cooperative effort it analyses the relationship that develops in an economic exchange when an individual concedes authority to another to act in his or her name the exercise of coercive and legal power has a strong negative effect on collaborative behaviour while rewards have a positive effect the central goal of agency theory is to stop opportunistic behaviour in a situation where parties have different goals and the information supply is incomplete coordination theory and agency theory are complementary because where the latter theory presents a partial view of the world that ignores a good bit of the complexity of organisations the former theory fills this gap by looking at the complexity of cooperation between organisations because supply chains are complex with many activities usually spread over multiple organisations and sometimes over lengthy time horizons it is necessary to overlay a coordinated system this coordinated system may include an explicit definition of processes responsibilities and structures aligned with overall objectives of the whole supply chain to bring together multiple functions and organisations this implies that all these organisations and the people within the organisations have to face and preferably employ one of the four dialogical learning mechanisms of boundaries  identification which is about coming to know what the diverse practices are about in relation to one another  coordination which is about creating cooperative and routinized exchanges between practices  reflection which is about expanding ones perspectives on the practices  transformation which is about collaboration and codevelopment of practices the results of this research are specifically aimed at realising recommendations for improving maintenance processes at dutch housing associations by improving the collaboration of the supply chain processes based on the discussion as described above the results should provide an answer to the following main research question future development the literature study is the rationale for subsequent future research although more scientific and practical research can be incorporated this study has already shown that research regarding improving maintenance processes at dutch housing associations is missing therefore research will be executed through case studies at two dutch housing associations currently implementing resultsoriented maintenance processes these case studies aim to reveal how the different constructs in our conceptual model help improve the information management supply chain management and thus the maintenance processes these results will then be tested via a qualitative survey with relevant stakeholders this will contribute to the implementation of scp in the construction industry according to van der boon at leertouwer many housing associations are still stuck in the previous century steering at lowest cost based on excel documents sometimes even lacking the knowledge and skills to see the bigger picture van der boon also stresses that although scp is very relevant construction is still an industry where phases are viewed as standalone and learning across phases is still not common when one phase is finished information is not well nurtured and cooperation and coordination are not common communication is key and a change in culture is necessary it is important to understand the role responsibilities and processes of all actors wolf states that bim as a vehicle for improving the coordination of information of maintenance processes can be used to change the current maintenance processes into processes based on sharing knowledge and information and empowering process stakeholders introduction personalization has remained an increasingly intriguing concept among scholars through the digitization of everything more and more information about user preferences is available for service providers rapidly evolving digital technology provides novel platforms and channels for service delivery and consequently for personalization in principle personalization consists of two core components 1 the understanding of user needs and 2 personalization of services based on those needs in both these components a wide variety of personalization technologies such as recommendation systems are utilized in other words the purpose of personalization is to adapt standardized products or services to the individual user needs and that personalization is carried out by the marketer on behalf of the user the concept of personalization is often used interchangeably with another onetoone marketing concept customization which on the contrary is userled and where the user proactively personalizes the service elements from the marketing mix based on their own preferences in this research we follow the viewpoint from sunikka and bragge who view personalization as an umbrella term including other closely related concepts like customization based on the aforementioned personalization principles it can be argued that personalization is a service providerled concept where service provider decides the suitable services for an individual user based on the information gathered these viewpoints follow the value models of manufacturing where the service provider personalizes the services for users who then receive the services for example in the forms of product recommendations however unlike manufacturing and tangible products services often intangible by their nature are carried out in collaboration between actors the service delivery may also involve more actors than service provider and the user only therefore instead of emphasizing the distinction where the marketer carries out personalization and the user receives the personalization it is important to examine personalization from the different actors viewpoints as with services the actors together construct the personalized service problem definition personalization has remained a puzzling concept among scholars for decades the scholars in information systems computer science economics services and marketing have studied the concept through different lenses with an aim to optimize services to the individualized user needs o korhonen personalization in digital services information technology supporting service personalization process 751 emphasized studied in the web context and examined from the perspective of a single software that viewpoint has typically included two primary actors into the personalization process 1 the service provider who personalizes the service offerings and 2 the user who receives the personalized service offerings this distinction follows the value models of manufacturing where companies produce value and users consume that value companies try to understand users needs and to personalize the service offerings for those needs in order to do so different information technology solutions such as personalization technologies are widely adopted however servicedominant logic has challenged this thinking by proposing that markets have shifted from manufacturing and goodsdominance to services unlike tangible products services can be defined as the application of specialized competences through deeds processes and performances for the benefit of another actor or the actor itself in other words any act done intentionally for benefiting an actor can be considered as a service services are often intangible by their nature but are occasionally supported by tangible products in contrast to products though the value in services is bound to knowledge and skills that are delivered in exchanges between actors in my research plan the aim is to examine personalization of digital services through sd logic lens and the role it plays in the service personalization process unlike concrete products intangible services can consist of multiple steps and phases and often involve multiple actors in the service delivery process that can be illustrated with a healthcare example where the primary purpose of a healthcare company is not to sell tangible products to patients but to serve the patients needs collaboratively with by the patient furthermore this service can be supported by tangible devices like monitors for selfmeasurements and involve multiple actors such as medical doctor patient or the healthcare service provider that together construct the personalized service the aim of my research is therefore to answer to the following questions  how it supported personalization can be viewed from the perspective of different actors taking part in the service delivery  how and what support it can provide for different actors in the service personalization process research methodology my research will apply qualitative research methods but also quantitative methods may be used to support the findings the primary material for my research comes from two case studies conducted in collaboration with two large service providers the data from those case studies consists of service documentations and the interviews with the people who have been 752 30 th bled econference digital transformation from connecting things to transforming our lives o korhonen personalization in digital services information technology supporting service personalization process designing the services under analysis the data is collected and analyzed iteratively throughout the studies using qualitative data analysis approach with an aim to interpret and construct understanding of the situation where the examined phenomenon takes place for example in the case study two focus groups were conducted first for getting an overview of the problem area in the focus groups more general and openended questions were discussed with an aim to gain understanding of the unit of analysis second the findings from the focus groups were used to formulate the themes for the semistructured interviews where the aim was to ask detailed questions from the key informants that were selected by selective sampling technique in practice those were the medical doctors that had been designing the examined care pathway after the semistructured interviews the findings were categorized thematically and summarized into a table form third a validating interview was conducted for validating the prior findings and to provide potentially complementary data in the future the plan is to utilize similar settings in another case study regarding to the service provider perspective for the user perspective user experiences will be collected using different types of interviews that data can also be supported by quantitative data in the forms of surveys that the service provider has already conducted with the service users in addition to aforementioned case studies other qualitative analysis methods are used in single papers such as nexus analysis to deepen the understanding on user experiences about motivation for exercising and interaction analysis for studying service interaction between user and service clerk in a context of technologymediated car rental service preliminaryexpected results in overall by covering the viewpoints of different actors the aim of my research is to increase the understanding of value creation between different actors for personalized services in the framework of sd logic and to examine the role of it in the service personalization process as a technologyemphasized concept personalization is mostly studied using the gd logic principles and with the value models of manufacturing due to the idea of market transformation to services it is important to examine personalization 1 in the service context 2 from the different actors perspectives and 3 to provide knowledge on the versatile role of it in the service personalization process therefore the planned articles for examining the phenomenon are presented in the table 1 regarding to the preliminary findings we have conducted an interpretive case study for examining it support for personalization in the healthcare service context in healthcare services personalization is provided as a premise as individual conditions and needs vary between healthcare users berry and bendapudi in the next four subsections we first assess the reliability and validity of the 25 construct indicators and the seven constructs included in the research model use intention perceived usefulness perceived ease of use optimism innovativeness discomfort and insecurity these assessments are based on a model that contains all the aforementioned constructs but does not yet contain any regression relationships between them this is followed by the estimation of the actual research model and the examination of the potential age differences in the construct means and regression relationships indicator reliability and validity indicator reliabilities and validities were evaluated by using the standardised loadings and residuals of the indicators which are reported in appendix b in the typical case where each indicator loads on only one construct it is commonly expected that the standardised loading of each indicator should be statistically significant and greater than or equal to 0707 this is equal to the standardised residual of each indicator being less than or equal to 05 meaning that at least half of the variance of each indicator is explained by the construct on which it loads as can be seen the two indicators that were furthest from meeting this criterion were dis1 and ins4 which both had a standardised loading of less than 05 thus after assessing that there there is no such thing as a manual for a hightech product or service that is written in plain language ins1 people are too dependent on technology to do things for them ins2 too much technology distracts people to a point that is harmful ins3 technology lowers the quality of relationships by reducing personal interaction ins4 i do not feel confident doing business with a place that can only be reached online note the indicators of opt inn dis and ins comprise the tri 20 scale which is copyrighted by a parasuraman and rockbridge associates inc 2014 it may be duplicated only with a written permission from the authors what is digital transformation strategy bharadwaj etal matt etal mithas etal hansen sia granados gupta process agarwal etal berman marshall bharosa etal janowski kreutzer loebbecke picot stieglitz brockmann tamm etal wang etal hansen etal business model henriette etal stieglitz brockmann paradigm shift berman marshall piccinini what are its characteristics radical liu etal berman berman marshall westerman etal disruptive berman berman marshall granados gupta hbr analytics services fitzgerald m etal evolutionarycontinuous loebbeck picot janowski wang etal liu etal complex janowski bharosa etal matt etal agarwal what are the drivers of digital transformation digital technologies agarwal etal berman bharadwaj etal bharosa etal janowski kreutzer lunareyes gilgarcia mithas etal lucas etal stieglitz brockmann setia etal wang etal berman marshall loebbecke picot westerman etal digital capabilities berman marshall loebbecke picot matt etal schuchmann seufert tamm etal wang etal westerman etal strategies berman marshall bharadwaj etal matt etal stieglitz brockmann tamm etal mithas etal business models agarwal etal berman marshall bharadwaj etal janowski loebbecke picot lunareyes gilgarcia matt etal mithas etal schuchmann seufert tamm etal stieglitz brockmann value chain agarwal etal berman marshall bharosa etal janowski stieglitz brockmann tamm etal wang etal what are the key impacts of digital transformation value creation reshapes realign redefine integrate collaboration matt etal mithas etal schuchmann seufert berman bharadwaj etal lunareyes gilgarcia stieglitz brockmann johnson lederer berman marshall chen etal bharosa etal wang etal agarwal etal buschmeyer etal westerman etal operational efficiency optimize processes omni channel agility improved decision making structural change bharadwaj etal lunareyes gilgarcia matt etal mithas etal schuchmann seufert lucas etal setia kreutzer stieglitz brockmann tamm etal berman marshall loebbeck picot hansen sia janowski bharosa etal wang etal agarwal etal berman marshall chen etal westerman etal create competitive advantage bharadwaj etal lucas etal matt etal schuchmann seufert kreutzer stieglitz brockmann chen etal westerman etal improved relationships enhance bharadwaj etal lunareyes gilgarcia matt etal schuchmann seufert bharosa etal wang etal 30 th bled econference digital transformation from connecting things to transforming our lives r morakanyane agarwal etal berman marshall bharadwaj etal janowski loebbecke picot lunareyes gilgarcia matt etal mithas etal schuchmann seufert tamm etal hansen etal chen etal operational processes bharadwaj etal lucas etal lunareyes gilgarcia matt etal mithas etal female lagos may 12 2016 the expression as seen in price shows the engagement aspect of appraisal with the statement being attributed to another source which shows heteroglossic engagement in product order the statement very poor shows negative polarity as the next sentence is attitudinal and further statement expressed heteroglossic engagement consumer service review depicts attitude as well as negative like product quality review for delivery time the reviewer express graduation with the word wonderful used and the review for shopping experience shows negativity and heteroglossic engagement aspect of appraisal under shipping the statement is categorized as polarity reviews made under the return items and store location is neutral online community benefits the authors deduced certain advantages for the mobile shoppers as evidenced from their facebook page reviews under the headings of enlightenment opportunity involution and cocreation enlightenment how to make a teddy bear out of a towel lovely i will try to make one for my grandchildren practice makes perfect opportunity business opportunity we are currently leading an expansion of a global fuel company and we are competing against the trillions in revenue … involution do not shop on gmr product quality always totally different from description their coupon doesnt work either they still charge the same amount even after using the couponcrap dont do it please culture this include language cuisine music artefact and dressing the cultural display shows the interplay of various culture represented on the platform due to ethnic diversity of nigerian states cocreation limitations of our research stem from the specifics of the airport processes which are mostly dependent on its size therefore the developed approach and artefact can be reliably expected to be applicable only to airports of similar size furthermore the execution times specified by the airport experts are deterministic ie fixed making the model deterministic as well hermeneutics can help render the meaningful of a text which has become obscured or distanced in some way thereby making it no longer immediately obvious an obvious everyday example that does not interpretation is a stop sign as it is either understood or not when is hermeneutics needed hermeneutics can provide a rich detailed interpretation of peoples experience and texts traces of data and metadata left in a network computing infrastructure are becoming computing history where hermeneutics is needed to provide an interpretation of the data interpretive research can help is researchers understand human thoughts and actions in social and organizational contexts it has the potential to produce deep insights into is phenomena including managing of is and is development hermeneutics was also discussed in the development of information engineering due to its powerful ability in interpreting users and the system with new emerging technologies human actions can be understood through the interpretation of data produced by the devices as they are used by people and patients for specific needs specifically in healthcare the data is becoming an extension of people and patients as traces of interaction between patients and medical professionals are transforming our lives z zekiria sako s adibi n wickramasinghe understanding new emerging technologies through hermeneutics an example from mhealth 529 information that is becoming an extension of them that requires a technique like hermeneutics to be applied to understand the underlining messages hidden in the data similar future studies may incorporate mixed methods approach to strengthen the findings through triangulation of methods that would provide two different perspectives on data future research directions this research sets the foundation for examining the quality of health data in digital context there are several areas that will require research to be done to continue delivering high quality healthcare services through mhealth technologies one key area is the human behaviour when using the technology especially when entering and transmitting the data the first 12 weeks contained intensive facetoface and esupported coaching after that patient selfmanagement and etools were key after 50 weeks attractiveness and feasibility of the intervention were perceived as high recommendation 95 out of 10 and satisfaction 96 out of 10 tam surveys showed high usefulness and feasibility acceptance and health behaviours were reinforced by the prolonged health results aerobic and strength capacity levels were improved at 50 weeks plus health related quality of life we draw three types of conclusions first patients health literacy and quality of life improved strongly which both supported healthy behaviours even after 50 weeks second regarding ehealth theory iterative growth cycles are beneficial for long term adoption and erelationships in addition most of the physicians indicated the need for the cpgs to be available on the intranet next to the cdss to merge the different anticlotting cpgs in a cdss the current overlap must be eliminated and the physicians need a guarantee that the stateoftheart versions will always be applied in the cdss besides this the cdss needs to be available in the alignment of the current cpgs this way the cdss will simplify the use of the cpgs but not replace them from the collected and analyzed data gathered from the various cpg owners we can conclude that the reactions towards the use of a cdss are mostly positive this enthusiasm shows that despite the physicians doubts with regards to ease of use they are open for the use of a cdss and will be likely to adopt it given the fact that most if not all challenges identified are overcome taking a look at our study several limitations could be identified one limitation is the available time that was planned for the focus group and the individual interviews with more time we probably could have delved deeper into the experiences problems improvements and essential functionality of a cdss as perceived by our interviewees in more focus groups however this was hard to negate as the physicians stated to have meager time to participate in this kind of research projects and are needed in the umcu most of their time we aimed to negate this partly by interviewing the individual participants as this allowed for further data collection and validation without utilizing focus groups which allow multiple stakeholders to be available on the same time and place furthermore our sample composition and sample size are limited to eight stakeholders while we believe this is appropriate at this stage of design of a cdss in the context of the umcu future research should focus on the utilization of more quantitative research methods such as surveys using larger sample sizes to increase the generalizability of the results also future stages of development should medical informatics specialists which excel in extensive testing on the subjectmatter as well as the decision making process by a cdss in this study we included a sample of eight stakeholders which is according to the guidelines of dworkin a valid amount of participants for a qualitative study therefore an important note with regards to future research is that quantitative research methods are dependent on the actual implementation and adoption of the cdss in practice hence we encourage the umcu to invest in further research projects to establish whether a cdss contributes to the quality of healthcare the impact of openness to experience was significant and impact of narcissism was borderline significant the former had positive effect the latter negative but the model as a whole is not significant carlson and wu suggest to exclude independent variables that are not significant parameter estimates for the reduced model are provided in table 2 r2 is 0051 r2adj is 0036 and pvalue is 0034 keeping only openness to experience in the model would worsen pvalue to 0085 a model with narcissism only would have a pvalue of 0093 the social hierarchy as a result of the high power distance in china leads to a strong respect for authority which is evident among chinese daily practices in a group orientated society the social hierarchy and respect for authority of the interpersonal relations and the society is paramount this cultural value has been largely involved with other cultural values in the discussion of interpersonal relationship in the chinese context guanxi as a chinese cultural value has been broadly discussed in the investigations of chinese interpersonal relationships in business society and organization this attribute also is a key cultural factor that determines chinese interpersonal behavior to build up and maintain a good guanxi helps to achieve positive group dynamics and strengthen social ties compared with other cultural values the value of keqi tends to provide a guideline of practice in interpersonal relationships keqi refer to wellmanner politeness which is a personal attribute as well as an embodiment of harmony in chinese communication to keep a courteous distance with an acquaintance chen argues that the keqi way of communication is the way to sustain the harmonious relationship research methodology this paper is framed within the methodological stance of a case study which is useful for investigating contemporary phenomena and their context the proposed model in this article is adapted from two existing models this is the starting point of this research this model centralizes the concept of collectivism and suggests a lens from which chinese culture values can be understood in terms of specific cultural attributes of keqi guanxi and respect for authority these three notions understand the collectivism from interpersonal relations social hierarchy and harmonymaintenances this model is designed to be used to provide an understanding of the cultural values inherent in the design of chinese social media platform the first step of the research process is presented in the next section where the authors analyse existing features of wechat alongside chinese cultural values this model can then be used to further explore the design of the wechat application data will be collected through interviews with designers and developers of wechat we will employ a snowballing interview technique which is common in qualitative research one of the key problems of snowballing as identified by biernacki and waldorf is finding participants and starting a referral chain we can overcome this problem because one of the authors has personal connections to employees at tencent a social media platform is developed and eventually launched it grows and at some point will peter out unless it innovates aral et al suggest that by thinking deeply about platform design platform designers have an opportunity to consider addon features and other forms of innovation to extend a platforms functionality and usability in its relatively short history wechat has been able to adapt and alter their life cycle through innovation 2 concept matrix of analyzed articles and organizational design components framework organization design can be viewed as a chain of decisions and choices and collectively refers to the process of configuring structures processes reward systems and people practices to create an effective organization capable of achieving the digital business strategy initially it originates from galbraith wellestablished organizational design framework that consists of the intertwined components of strategy structures processes rewards and people the following paragraph introduces each component briefly the component strategy determines a companys course of action and can be understand as the cornerstone of the organizational design it origins from the decisionmakers understanding of the various environmental influences such as new technologies competitors customers suppliers etc essentially it is the success formula to gain a competitive advantage and differentiation structure refers to the organizational chart and key roles some common types of organizational structures are functional product geographic or customerscentric structures it represents the possibilities of how to group different people together in an organization furthermore it clarifies responsibilities decisionmaking powers and authorities the component processes refers to any connected activity that is linked with the information flow within and across an organization processes dissolve collaboration barriers that may result from an organizations structure welldesigned processes ensure that eg the right people find each other to innovate a new product processes can determine mechanisms for collaboration and therefore how well units within and across organizations work together rewards have the purpose to harmonize the behavior and performance of individuals with the overall goals of an organization it includes eg rewards based on measures or variable compensation the component people contains practices like selecting training staffing and developing of people to gain desired capabilities and a mindset to successfully execute the strategy this may include eg competencies like interpersonal skills and decision making capabilities such as considering multiple points of view transforming our lives t weinrich reviewing organizational design components for digital business strategy 661 stakeholders like customers alliances employees suppliers etc such an understanding is the foundation to lever digital resources and create value for an organization in so doing it may help an organization to preserve a competitive advantage or to gain new competencies and define a new competitive advantage nevertheless managers need to be capable to communicate the dbs and their beliefs organization wide to create a common understanding this is especially important because dbs affects the whole organization and any change may bring resistance to some degree digital talents can either be recruited externally or internally by hiring people with the sufficient experience from academic institution or other organizations mergers and acquisitions or training via dedicated digital training programs summary and conclusion overall this literature review contributes to the body of dbs and organizational design it sheds light on dbs and organizational design by specifically looking at the components of strategy structure processes rewards and people considering strategy it is evident that digital technologies have to be an integral part of dbs yet the majority of identified articles specializes on certain digital technologies under dbs and do not treat them in a holistic manner as frequently emphasized additionally there is a strong focus on harnessing cloud computing analytics and social media under dbs whereas mobile technologies are underrepresented but not less important in terms of structures this piece of research points out that under dbs organizational functions become increasingly decentralized it is also evident that the reporting structures and decisionmaking power shifts since dbs is an organizationwide endeavor and needs orchestration within and across the organization however how organizations achieve this is quite heterogeneous regarding the component processes an increasing interfacing with the ecosystem which includes customers partners suppliers and possibly competitors is key organizations need to be capable to lever their ecosystem because it is a critical source of value creation by eg fostering innovation regarding the component rewards this literature review found surprisingly little on harmonizing individual behavior with the overall goal of an organization while literature mentions the importance of this aspect only little information is given finally the component people shows that to follow a dbs digitally skilled employees and leaders are needed which understand digital technologies their strategic implications and know how to create business value from it overall this literature review is able to show that in order to carry out a dbs organization design requires a large shift yet the presented organizational design components for dbs should not be treated mutually exclusive but as interrelating components which need to be closely aligned to complement each other to be successful similar to chong liu luo kengboon the basic technology acceptance model was extended with three additional external variables which enabled us to include all of our research questions health concerns were included in the model according to the results of previous studies on rfid adoption perceived trust has similar to hc gained a lot of attention in the research community furthermore age was included as a predictor variable of behaviour intention to use since younger people are more prone to adopt new technologies rfid microchip with the development of technology and robotic production the capacity of microchip has multiplied while the size of it was minimised the biggest challenge today is not the size of a microchip the problem is the size of the antenna that should be at least 1mm long to get reliable results depending on power needed for operating rfid microchips are categorised into three types passive active and semipassive while passive devices dont need any internal power the active do and their life time depends on battery capacity usually not longer than one year semipassive devices present a combination of both other types while data stored in a passive nfc rfidsm microchip can be read with the help of electromagnetic field produced by a reader device the sensor needs a power supply to overcome this problem the researchers are trying to develop rechargeable implanted batteries that produce electricity with the chemical reaction of body fluidsglucose biobatteries we can find the application of rfid microchip in manufacturing supply chain management logistic automotive industry livestock production food production and public sector rfid microchip is used in shops passports proximity cards automated tollpayment transponders ignition keys contactless creditcards smart bracelets smart finger rings smart watches etc in healthcare we can use rfid for resource management there are also rfid systems for tracking patients and personnel besides the high number of health care errors causing death can be reduced when using rfid system for monitoring patients there were several attempts of using rfidsm in vivo the first human with active rfidsm implant was professor kevin warwick in 1998 he was able to programme doors to open and lights to switch on when he approaches the rfid reader he removed the chip after nine days in order to avoid possible health complications due to the battery lifetime in 2002 the jacobs family members were implanted by very chip one of first recorded commercial use of rfidsm was in 2004 in the baja beach club in barcelona spain and rotterdam an rfidsm with a unique code for identification of very important persons was used to enable electronic payment and access to vip areas of the club the name of the person was displayed publicly on screens upon their entrance to the club in 2005 three employees of the us company citywatchercom were implanted with microchips for access control application in the same year the very chip was used for medical reasons to identify patients for the first time in the usa volunteers were chipped in hand or arm with local anaesthetics the system was able to recognize 16 digit identification code to identify and gain an insight into patient medical record data the author of the book rfid toys amal graafstras initial motivation to get a chip implant was for the convenience of eliminating keys in 2013 first commercial company called dangerous things was established and started to sale the first rfidsm for home use the presented study considered the usage of the passive nfc rfidsm of size 2mm x 12mm similar to the glasscoated used for animals identification there are more than 5 million house pets with such chips which enable identification of the pets owner research approach data collection the study about attitudes toward rfidsm among slovenians was performed from april to december 2016 the link to the web questionnaire was sent via email to members of researchers social networks and it was posted on the faculty web page questionnaire and research hypotheses the research model includes all three basic concepts of tam perceived ease of use perceived usefulness and behaviour intention to use the basic concepts are combined with two pu has seven items which are in accordance with items proposed by proposed by davis in the original tam model five of them were adopted from and two additional items on storing information about organ donation and a general statement on saving lives in different medical conditions were added peu and pt items were adopted based on davis and smith respectively pt refers to an individuals trust that the state banks and healthcare systems will be able to ensure the security and protection of gathered personal data items composing hc construct were prepared based on extensive literature review of medical research papers and they measure possible threats of rfidsm usage biu reflects four different possible types of the rfidsm usage as pointed out in the interviews the exact items wording can be found in table 1 as noted above each model component was measured by several items the items of hc pt the last item of pu and peu were measured on a 5point likerttype scale of agreement the first six items for pu were measured on a 5point likerttype scale of acceptability while the items of biu were measured as dichotomous variable research hypotheses are presented in figure 1 we proposed ten hypotheses nine of them were adopted from the 2014 study and one new was added we assumed that perceived experience on implantation procedure has a positive impact on hc the predicted relationships among concepts included in the model are presented with arrows where a plus sign represents positive impact and a minus sign negative impact data analyses the proposed hypotheses in the research model were analysed with structural equation modelling in this paper presented results were obtained based on the analyses of 291 respondents who provided at least partial responses on the variables included in the model there is no general recommendation on minimal sample size required for sem hair et al suggested the sample size between 150 and 400 while loehlins rule of thumb suggests that the sample size should be at least 50 more than eight times the number of measured items in the model since our model consists of 25 measured variables the minimal sample size should be 250 which indicates that the analysed sample size of 291 respondents is sufficient to achieve the statistical power necessary for sem with three or more measured items per latent variable to use all also partial information obtained from the respondents multiple imputations was used when analysing the data in order to improve the validity of the results the research model was evaluated in two steps first measurement model was investigated followed by the analyses of the structural model to confirm that the constructs are correctly defined first data screening and confirmatory factor analysis was performed followed by sem our hypotheses assume several relationships between variables which could be analysed with several multiple regressions but sem was employed for its ability to analyse relationships between latent and observed variables simultaneously several statistics were calculated before sem and the detailed results are omitted due to limitation of the paper length here we will only list the performed analyses to justify the corrections of the data analyses and results presented to assess whether the data are approximately normal and therefore appropriate for cfa and sem the absolute values of skewness and kurtosis were calculated the cronbachs alpha coefficients were calculated for each of the five constructs in our research model to determine the extent of the internal reliability the construct validity of each scale was assessed using cfa and it was evaluated via the convergent validity and the discriminant validity the convergent validity was examined based on three concepts a estimates of the standardized factor loadings which should exceed 05 b composite reliability for each latent variable which should exceed 07 and c average variance extracted measuring the amount of the common variance between the indicators and their construct in relation to the amount of variance attributable to measurement error for each latent variable which should exceed 05 in order to investigate the discriminant validity of the measurement model the square root of ave of each latent variable was compared to the correlations between the latent variables in the final step to evaluate the impact of proposed relationships among constructs in the research model sem was used since there are endogenous binary variables in the model the robust weighted least squares mean and varianceadjusted estimation in the lavaan rpackage was used in order to assess the fit of the measurement model and the structural model the overall fit was examined based on various sets of commonlyused fit indices χ2df which should be lower than 3 indices tli and cfi which should be at least 09 in order to indicate adequate model fit the root mean square error of approximation should be below 006 or at least below 008 as proposed by results of the sem analyisis are presented in the results section the values of standardized path coefficients and corresponding zvalues reflect the relationships among the latent variables in terms of the magnitude and statistical significance for every endogenous latent variable the coefficient of determination is also calculated which should be above 01 to confirm the predictive capability of the model findings and results sample characteristics the sample consists of 59 of women and 41 of men among the respondents 33 are in primary school secondary school or at the university more than half of the respondents are employed 6 are unemployed while 7 are retired descriptive statistics of the questionnaire items under study table 1 presents descriptive statistics and standard deviation of 24 variables included in the research model on average respondents agree the most with the statement that subcutaneous microchips can integrate multiple functions at the same time if we examine the four items of hc closely we can see that respondents are worried due to treats of possible allergies and an impact on the nervous system on the other hand they are less concerned due to possibility of microchip movements in their bodies and due to effects on emotional behaviour items of biu were measured as dichotomous variables in table 1 the percentages of the respondents who positively answered on the individual question are presented the highest proportion of the respondents would insert an rfidsm for health care purposes and the smallest proportion of the respondents would have microchips for shopping and payment in a way that microchip would replace debit cards credit cards and profit cards the means were calculated also for four components mean values are above 3 for three components 308 for hc 376 for peu and 346 for pu which indicates that the overall response could be classified as positive the mean of pt is equal to 271 which indicates that perceived trust on security issues provided by state banks and healthcare system is somehow low health concerns subcutaneous microchips can be threatening to my health because of the possibility of movement in my body 297 1187 subcutaneous microchips may affect my emotional behaviour 295 1265 subcutaneous microchips can be threatening to my health because of possible allergies 327 1196 subcutaneous microchips can be threatening to my health because of their impact on the nervous system 314 1206 perceived trust the state will ensure the security and the protection of human rights 257 1271 banks will provide security 270 1297 the healthcare system will provide security 284 129 perceived usefulness subcutaneous microchips could be used for monitoring the health of the user eg pulse or blood pressure 360 1127 for warning about potential health problems or complications 3 results of the sem first measurement model was evaluated the item peu3 on rfidsm security protection was removed from the peu construct and consequently from the model due to combination of its standard loading slightly above 05 and its variance which was twice as big as for other construct items standardized factor loadings for items in the model exceed a threshold of 05 for convergent validity 19 of them exceed also stricter threshold of 07 the ave for all five constructs reach and exceeds a threshold of 05 for convergent validity in our measurement model the obtained value of χ2df 1465 is lower than 3 and both tli 089 and cfi 090 are close to 09 the rmsea is equal to 0040 and the upper bound of rmsea 90 confidence interval is lower than 006 according to the set of the calculated fit indices it could be concluded that measurement model fits the sample data reasonably well therefore the fit of the structural model could be evaluated the goodnessoffit of the sem was evaluated with the same set of indices as for the measurement model the results show that the model has a good fit χ2df 2154 tli 088 cfi 089 and rmsea 0063 with its 90 confidence interval painful procedure implanting rfidsm is a painful procedure 289 1167 would you insert a subcutaneous microchip percentage of positive responses behaviour intention to use for healthcare purposes 43 for identification purposes 28 for shopping and payment 20 for everyday home usage 23 if you were assured that gps positioning and tracking were not possible 29 the results of the structural model are presented with standardized path coefficients which reflect the strength of the relationships among the latent variables for every endogenous latent variable also the coefficient of determination is presented the predictive capability of the model is satisfactory because all coefficients of determination are above 01 the smallest r2 is for hc and it is equal to 0246 r2 for pt is 0278 for pu is equal to 0514 and the highest value of r2 is for biu figure 2 the results for structural model supported h5a perceived ease of use has positive impact on perceived trust supported h5b perceived ease of use has positive impact on perceived trust supported h5c perceived ease of use has positive impact on behaviour intention to use not supported h6 age has positive impact on behaviour intention to use supported we can see from figure 2 and the keyword search was performed on the databases of ebsco ieee and sciencedirect in title publication title abstract and keywords the first search string was supplemented with the terms consumer context and patient context as the initial number of search results was low only reviewed contributions published since the year 2000 and such that are written in english language were considered in order to ensure transparency of results on the one hand and currentness on the other hand the number of search results for all three keywords and the named restrictions was 146 and formed the basis for a deeper analysis each publication was screened in the named fields and if marked as relevant to the concept of customer context the fulltext was read to extract relevant items since it was found that context may either be related with application systems or their respective users a further restriction was made towards the user perspective this view aligns with the cdl perspective as it helps businesses to understand customers and their individual situationbased needs abstract erp acceptance by its users in companies has been researched by several authors while erp acceptance by students within study programmes has not been researched so often for teachers should be important to know which factors have influence on student erp acceptance our study researches student acceptance of erp solutions while they are exposed to erp solution and they are involved in erp actual use our research is based on tam which provides a basis for tracing impact of external factors on internal beliefs attitudes intentions and actual use research model includes additional external factors such as experience with computer computer selfefficiency personal innovativeness toward it computer anxiety user manuals system quality social influence training and education etc research was conduct within a group of 121 students after short interaction with microsoft dynamics nav erp solution results show that most important external factors for student erp acceptance are individual benefits training and education on erp system and quality of erp system transforming our lives the chosen perspective for the objectives of the research is that of explanatory research since little is known about the research topic this is combined with descriptive research in order to describe systematically the situation the mode of enquiry perspective is that of a qualitative approach and therefore the form of case studies is chosen to retain a holistic and realworld perspective a case study is interpretive and descriptive because it attempts to understand and portray resultsoriented planned maintenance through the participants interpretation of their context the case study design is also chosen because the main research question is a how question the researcher has no control over actual behavioural events and the degree of focus is on contemporary events the research aims to discover which coordination mechanisms are used to align goals and objectives in the supply chain to align decisionmaking by the supply chain partners to share information within the supply chain and to align cooperation in the supply chain but also to discover whether the benefits of scp improved project performance reduced project costs and reduced project risks are present in the cases further objectives are to investigate what ict systems are used the problems that occur in using the coordination mechanisms and how these problems can be improved this research consists of two cases for these cases a twocase case study design is chosen in order to describe and explain scp in planned maintenance at dutch housing associations the findings from these cases are assessed in a wider context through a survey research results are published four times during the research the first paper is a literature review the second paper is based on the results of the first case study the third paper is based on the results of the second case study and the fourth paper is based on the survey results the final thesis is composed based on the published papers figure 1 research method the coordination processes of supply chain integration at dutch housing associations are described through a literature study this is supported by literature on coordination theory agency theory boundary crossing and information management literature is found through desk research and snowballing using scientific databases such as science direct and scholargooglecom results of this literature review will be used in the case studies case study evidence may come from six sources documents archival records interviews direct observations participant observations and physical artefacts and because in case study research it is important to use multiple sources of evidence this research makes use of the following sources documents archival records interviews and direct observations the researcher will not participate in the maintenance process therefore participant observation is not used the researcher remains a passive observer watching and listening to activities and drawings conclusions from this also physical artefacts are not used because processes are researched not technical operations furthermore two types of interviews will be used prolonged case study interviews and survey interviews the direct observations will contain observations of meetings and maintenance activities both case studies are organised to the same theory in order to strive for generalizable findings that go beyond the specific cases this means that this research adopts the holistic multiplecase design and is a literal replication yin in all cases maintenance must be executed within a supply chain within the supply chain all partners commit to predetermined results maintenance is described by the housing association as technical performance demands and the contractor assures both housing association and tenants that the technical performances are achieved results from both case studies will be validated through a survey amongst other dutch housings associations and their maintenance contractors the first object of study is a maintenance supply chain at a local dutch housing association founded in 1913 for this housing association supply chain partnering is an important feature since 2011 they believe in the benefits of scp and execute 80 of their maintenance work through scp in this case study the main contractor is a new supply chain partner who has proven his reliability and skills in a small project the following roles are included in the study the project manager of the housing association the foreman of the main contractor the project manager of the most important subcontractor and the project manager of the supplier it is important to point out that the project that is researched is the first of this particular main contractor aspects of study are the subquestions as stated in section two expected results based on our study of the literature the following elements are a prerequisite for the improvement of the maintenance processes supply chain partners have a joint understanding of the mutual dependencies between all supply chain partners supply chain partners align their goals and objectives supply chain partners agree on the coordination of decisionmaking and supply chain partners agree on the exchange and availability of information and knowledge the assumption is that by identifying and applying the coordination mechanisms information management and supply chain partnering and thus maintenance processes will improve this will lead to all previously mentioned benefits preliminary case study observations show a difference in the approach to scp the property managers ambition is resultsoriented cooperation with a permanent network of supply chain partners based on affordability availability and quality he believes that data must be secured and available and knowledge must be assured for example by using bim the project manager however does not talk about resultsoriented cooperation but about performance oriented cooperation with responsible supply chain partners he also draws up performance oriented contracts per project which contravenes to both the literature on trust and scp and the housing associations own supply chain principles the main contractor has aligned his goals with those of the housing association regarding the project he puts the quality of living of the tenants during and after the maintenance activities first further research must give more insight into the actual cooperation process and its effects connecting things to transforming our lives a pucihar m kljajić borštnar c kittl p ravesteijn r clarke r bons personalization in digital services information technology supporting service personalization process olli korhonen abstract personalization technologies are widely applied for providing appropriate products and services for individual users service providers utilize personalization technologies for understanding the individual user needs and for personalizing their service offerings for those needs that perspective follows the value models of manufacturing wherein service provider personalizes the services for the user and where the roles of service provider and user are distinct however propositions that markets have transformed to services wherein services are cocreated between actors is not supporting the traditional personalization perspective properly for example healthcare services are not only personalized for the user but in cocreation with the user therefore in my research proposal the aim is to examine service personalization and the role of it in the service personalization process from the perspectives of different actors transforming our lives o korhonen personalization in digital services information technology supporting service personalization process 753 2007 as medical doctors are specialists in the healthcare domain the services are typically personalized based on their professional knowledge for individual healthcare users with support from it and other tangible technology in other words it is used as an artefact to provide the right information for the right person in the right format therefore our study focused on examining the role of it in the healthcare service personalization process our results from that study illustrate that personalization intertwines automatized support from it with a more collaborative nature where service personalization occurs in cocreation and interaction between actors therefore for illustrating our findings we categorized different personalization types under three main categories based on the automatization level provided by it 1 coercive personalization is automatized and does not allow interpretation of the human actor 2 data display personalization is automatized but interpreted manually by medical doctors 3 collaborationbased personalization is supported by automatization but the emphasis is on interpretation and cocreation between actors future development in the near future we have plans to conduct another case study in collaboration with a large service provider the aim is to examine both the user and service designer perspective and to provide insights how the personalized services are constructed in cocreation between these actors and what is the role it plays in the service cocreation for the final paper the aim is to draw an overview a holistic framework regarding to service personalization that framework covers the perspectives of different actors and presents the diverse role of it in the service personalization process

or other means now known or hereafter invented including photocopying and recording or in any information storage or retrieval system without permission in writing from the publisheruniverzitetna knjižnica maribor 65923004 082 00342 bled econference 30 2017 digital transformation from connecting things to transforming our lives elektronski vir conference proceedings 30th bled econference june 18 21 2017 bled slovenia

Although unplanned settlements grew in density and number after Zambia's independence from British colonial rule in 1964, such settlements were a pre-independence phenomenon . Their origins can be traced to colonial urban settlement policies, which forced poor urban settlers to reside in marginal areas of the city that had not been planned as residential areas by city authorities . New residents simply moved into the settlement areas and claimed parcels of land by constructing low-cost housing and other small structures such as shops and bars. The housing structures were relatively cheaper to rent and thus became a pull factor to many rural immigrants into the city looking for low-cost housing. With time, the population of these unplanned settlements expanded and by the early 2,000s accounted for around seventy per cent of the entire population of Lusaka city and comprised 20% of the city's residential land . Having such a large proportion of the city's inhabitants in unplanned areas has brought about a myriad of socio-economic and environmental challenges. The unplanned settlements occupy and encroach on contested spaces in the city and thus continue to be a source of health, environmental, social and moral problems . Furthermore, the houses were built without any building authorization by the city municipality as required legally. Zambia's population stands at 19.6 million people with a population density of 26.1 persons per square kilometer . Although the country's area covers 752,614 square kilometers, only twenty percent of the land, translating to about 200,000 land parcels, was fully registered and 600,000 parcels were at various stages of processing as of 2014. The rest was unregistered . This entails the vast majority of plots and houses are unregistered, illegal, and potentially resulting in diminished property rights and tenure insecurity. Tenure security refers to the degree of confidence held by people that they will not be arbitrarily deprived of their land rights or of the benefits derived from their land . Several scholars have observed that informality induces land tenure insecurity and has negative consequences on investments and land resources management . De Soto argued that the poor in developing countries fail to turn their land into capital because they lack formal mechanisms for protecting their property rights. Their tenure insecurity acts as a demotivating factor. --- . . Formalization of land rights Formalization of property rights involves the provision of legal representation of property in the form of title deeds, licenses, permits and contracts, all of which must receive official sanction and protection from legitimate national authorities . Land rights formalization is argued to be especially beneficial for residents of informal settlements, as the illegal status of such settlements presents a level of precariousness not experienced by other residents, be they in customary areas or formal settlements without documentation for their land. Residents of informal settlements can be evicted legally anytime. Some scholars posit that by formalizing their land rights, residents of informal settlements enhance their land rights claims and tenure security . Tenure security is associated with access to credit, stimulating entrepreneurship, provision of services and infrastructure, improved health conditions and the realization of the human right to adequate housing . Furthermore, land rights formalization is theorized to facilitate land market transactions which indirectly leads to higher overall investment in land . However, the empirical evidence from several countries in sub-Saharan Africa that have implemented a wide range of land formalization initiatives since 2000 reveals mixed results. Despite the numerous espoused benefits arising from titling programs, a variety of challenges impede implementation on a large scale. For instance, developing countries within and beyond sub-Saharan Africa lack the necessary finances and capacity to execute the land formalization process because of the high costs required for land survey, title registration and issuance of title on a large scale . Hence aid agencies and international financial institutions such as the World Bank, USAID, DFID, the European Union among others have financed formalization processes in some countries . Furthermore, land formalization manifests a gender dimension with women at a greater risk of land tenure insecurity despite de jure equality with respect to land access . The prevalence of unfavorable customary practices and attitudes that restrict women's control over land resources inhibit fair participation in land formalization programs. For example, in Ethiopia, despite the introduction of progressive land reforms that promote rural women's rights to inherit and own land, discriminatory practices such as restrictions on land ownership continue to persist . Similarly, in Malawi's matrilineal societies, though women possess inheritance rights to land, men, be it husbands or uncles, exercise leadership in decision making and control over land, thereby disenfranchising women . Consequently, as men secure their property rights, those of women risk being undermined . Further, the landless, women, and orphans may not only be unable to take advantage of formal rights to assets but may find avenues of access effectively closed through the price increases that invariably attend formalization . Essentially, a danger inherent in formalization is consolidating existing inequalities . Urban population growth presents challenges to large scale titling programs by triggering illegalities by wealthier individuals who include local residents, elites, politicians and local leaders in attempts to acquire property. This, however, is at the expense of the relatively poor and marginalized individuals. This high demand for urban property often leads to land conflicts and in some instances land grabbing which often overwhelm local government authorities . Other challenges of large-scale titling include increased perceptions of displacements and tenure insecurity among marginalized individuals, lengthy processes, lack of policies to support titling objectives, failure to achieve intended titling goals and high interests in land by commercial entities . Some scholars have noted that land rights formalization programs result in heightened insecurity due to displacements, especially among the marginalized groups in society, i.e., the poor and widows . For example, in Kenya, the process of converting communal pasture into private plots reinforced male dominance in property ownership as titles were issued to the men, hence increasing inequalities. Further, women lost their access to previously available resources such as livestock and other food products which they previously obtained through communal bargaining processes . In Zambia, the state embarked on an ambitious National Land Titling Program in 2015. The objectives of the program were to regularize ownership of untitled properties in towns and cities and by so doing, promote security of tenure for property owners on state land, reduce displacements, promote internal security and increase the revenue base and investment in the country and thus contribute to socio-economic development . During the issuance of the first 92 certificates of title to residents of Madido area in December, 2017, the then minister of the Ministry of Lands and Natural Resources explained that the initiative was motivated by the government's resolve to accelerate social and economic development. This was to be accomplished by regularizing ownership of untitled properties in towns and cities, eradicating inequalities in gaining access to land in order to cater for all, and providing citizens with the impetus for access to credit . The Zambia National Land Titling Program had a target of processing and issuing 300,000 certificates of title to landowners in areas where the program was being piloted by 2018. The Ministry of Land and Natural Resources established a unit specifically to deal with land titling under the National Land Titling Program. This is the National Land Titling Center. Later, it engaged a private company called Medici Land Governance to expand the program. However, reality fell short of aspirations, as program implementers faced challenges characteristic of such initiatives. The challenges included determining land ownership for claimants with incomplete or no documentation, determining property boundaries and upgrading paths to access roads to meet statutory standards. Since private infrastructure had been developed with little or no considerations for building standards, concessions had to be made between demolishing properties that were too close to public roads and those without sufficient space for access roads and providing title security to poor residents with no other opportunities to own land with secure and enforceable land rights. Arguably, this legalization of illegalities was instrumental to achieving the public good of social-economic development through the provision of legal property rights and all the opportunities this presented. Thus, this study sought to determine how land rights formalization had affected land tenure security among men and women landowners in the pilot areas. Furthermore, it explored how social norms on land inheritance, decision making over land and marital trust had been affected by the changed nature of land rights. Lastly, land conflicts, an indicator of threats to land claims was examined to determine the extent to which the land rights formalization had addressed this threat. Land rights formalization in the two study sites started as part of the national land titling program, an initiative by the state to document all unregistered land in urban areas. Once the initial skepticism and fear of demolition of illegal structures and forcible evictions was over, landowners in the two study sites agreed to participate in the program, and mobilized the initial mandatory payments. The initial payment was ZMW 1,260 for Madido and ZMW 625 for Bauleni. This covered the survey fees and enabled the program implementers to survey the sites and draw sitemaps. The rest of the payments were to be made in monthly installments of ZMW 100 for up to 36 months, for a total of ZMW 4,990 in Madido and ZMW 3,747.93 in Bauleni. This is about half what landowners spent to acquire title deeds through the normal process. Residents that managed to secure payments early were among the first to receive the title deeds. Better resourced households thus benefitted early in the process. --- . . Conceptual framework for the study The conceptual framework is adapted from Doss and Meinzen-Dick . The adaptation includes the addition of men to the analysis and its application to an urban setting. The framework incorporates four broad areas: the context, threats and opportunities, action arena, and outcomes . The context includes both formal and informal institutions , socio-economy and history. The threats and opportunities to land rights include the catalysts of change, both those that strengthen and those that weaken tenure security for men and women. The action arena includes both actors and action resources. The actors include every-one who influences land tenure security. The action resources are those resources that different actors can use to seek their preferred outcomes, and include money, education, networks and social status. Finally, men's and women's land tenure security is the outcome of interest, and feeds back to shape the context for men and women's land rights in the future. Land tenure security has three components, Completeness of the bundle of rights Duration, and Robustness. Completeness of the bundle of rights looks at the extent to which one person or persons hold the various rights. Duration is about whether the rights are held for a short or long-term and /or if the length of time is known. Robustness is an examination of whether the rights are known by the holders, accepted by the community, and are enforceable. --- FIGURE Conceptual framework of factors a ecting women and men's land tenure security [adapted from ]. The rest of the paper is organized as follows. In the next section, the paper describes the study sites and the study methodology. Section 3 presents and discusses the empirical results. The last section concludes the paper and draws out policy implications. . Materials and methods --- . . Study context and background Fieldwork was conducted from two study sites, Bauleni and Madido residential areas between August and October 2020. The two areas were selected as study sites as they were pilot areas for the National Land Titling Program in the Lusaka city region and thus were ideal for an examination of program outcomes. The two study sites are located in Lusaka and Chongwe districts respectively. Of the total area covered by the country , Bauleni covers an area of about 1.533 square kilometers and Madido about 0.891 square kilometers. The areas experience a humid subtropical climate, and are overlain on uneven depth of folded and faulted schist. Bauleni had a population of 64,000 while Madido's was at 210, 672 in 2010. Bauleni and Madido have 3,697 and 2,109 households respectively. Bauleni consists of low-income and middle-income households. Most of its residents are in informal employment. The situation is different for Madido with most of its residents in formal employment, and a large majority of them are middle income households. The genesis of the two areas is very different . Bauleni started in the 1970s as a small unauthorized squatter settlement formed by laborers who worked in nearby commercial farms . With time, its population grew. It was legalized in 1998. Implementation of the National Land Titling Program started in Bauleni in 2018. Madido-also known as Chelstone Extension to the residentsis located on land that previously belonged to a public agricultural college, the Natural Resource Development College. Around 2006, local party officials of the then ruling political party, the Movement for Multi-Party Democracy encroached on the land, illegally demarcated it into land parcels and sold them to interested persons. The population quickly grew and Madido became an informal settlement. The Ministry of Lands subsequently canceled the college's land ownership rights before offering them to the illegal settlers and has since regularized their ownership through the issuance of title deeds . Implementation of the National Land Titling Program started in Madido 2017 . --- . . Data collection An explanatory sequential mixed methods approach was employed . In order to come up with a sampling frame of households that had obtained title deeds, a mapping exercise was conducted. Every household in the two study sites was visited and a short survey conducted to establish whether it had participated in the land titling program, whether title deeds had been obtained, and if so when. The mapping exercise was conducted with the help of community members that were widely known and well regarded. For Bauleni, it was with the participation of a long-term female resident whose family was the first to settle in the area. The resident was identified with assistance from the local authority officers based at the Lusaka City Council office in the area. The resident had first-hand knowledge of almost all the housing properties and their owners. She was well known in the area as an executive member of several local development initiatives. She was deputized by two females familiar with the area through their parttime work with Lusaka City Council as distributors of water bills in the area. In Madido, the field team was assisted in the mapping exercise by two male residents who had been the central figures as they had been actively involved in the illegal demarcation and subsequent sale of land parcels. Further, When the National Land Titling Program commenced, the two were recruited as resource persons to explain the program to community members and to encourage the community members to participate in the program. The two were thus trusted by the residents, who were otherwise wary of strangers asking about land matters, given the illegal genesis of the residential area. After the mapping exercise, all the households that had title deeds at the time of the survey were interviewed. These were 54 from Bauleni and 248 from Madido. The survey commenced with a pilot study to test the data collection instrument. During piloting, each of the four research assistants interviewed two respondents each, a male and a female from among the households with title deeds. Thus, a total of eight interviews were conducted during the pilot study. The pilot study was conducted within a day, at the end of which a debriefing session was held. Some questions in the questionnaire were modified, while a few were removed as they were found to be redundant, and some new ones were added after the feedback from the pilot interviews. The eight interviewees from the pilot study were excluded from the survey. After the questionnaire survey, two 3-in-1 focus group discussions were conducted in the two study sites. The discussants were recruited from the pool of respondents, on the basis of having extensive knowledge of the land titling process. Each of the four enumerators recommended two male, and two female discussants from the batch of respondents each had interviewed from the two study sites. The discussions were held in two phases. In the first phase, discussions were conducted with men and women separately. The men's FGDs were facilitated by a male researcher while the women's FGDs were facilitated by a female researcher. This initial separation into single gender groups was to minimize any influence of unequal gender relations such as the social and cultural superiority of men to women that could otherwise limit participation in the discussions based on gender norms. The men and women's groups were later brought together in a plenary discussion and asked to present summaries of their group deliberations. The plenary phase of the FGDs resulted in co-production of knowledge by men and women discussants through the detailed discussions that ensued from the single gender group presentations. One member of the research team expertly facilitated the discussion while another observed the proceedings and took notes. The facilitator alternated which group shared its results first. Both facilitator and observer paid attention to the verbal reactions and non-verbal communication of the women to the men's answers, and vice versa. These included voice tone, facial expressions and demeanor. These cues were used to guide the facilitator on whether or not there were disagreements between the two groups, and to probe appropriately . Four key informants were interviewed. These included a representative from the private entity recruited by the state to implement the National Titling Program, and a spatial planner from the Ministry of Local Government and Housing, with extensive experience in planning who had been seconded to the National Land Titling Program. Others were two key informants with extensive knowledge on land related matters in the two study sites. They were both long term residents of their respective informal settlements and their families had been important players in the establishing of the illegal settlements. Both were also involved in the National Land Titling Program as community representatives. This role entailed communicating community concerns to the government, providing information on undocumented land parcels to the state, and updating community members on program activities. Free, prior and informed consent was verbally obtained from all respondents and key informants, all of whom were adults aged over 18 years of age. Permission to record the focus group discussions using digital recorders was sought from the discussants and granted for all the sessions. Approval to conduct the research was granted by ERES Converge IRB, a nationally accredited research ethics clearance organization. --- . . Data analysis The questionnaire survey data was entered into Microsoft Excel sheets. After the data entry was completed, an accuracy check was conducted by randomly selecting ten percent of the completed questionnaires and comparing them to the data entered about them. The data was then copied to Minitab 18 and analyzed using basic descriptive statistics such as frequencies, means, standard deviation and two sample Independent T-test. The T-test was used to test the hypothesis that male household heads were older than their female counterparts. The recordings of the FGDs and key informant interviews were transcribed and categorized into themes based on research questions. The themes were sense of tenure security; sense of ownership; decision-making; land inheritance, land related family conflicts; love and trust and threats and opportunities presented by land rights formalization. --- . Results and discussion Overall, the average age of household heads was 56.4+ and 48.5 in Bauleni and Madido respectively. When disaggregated by the gender of the household head, the data reveals that around 20% of the interviewed households were headed by females; the average age of male household heads in Madido was lower than for the female heads while in Bauleni, there was no statistically significant difference in the mean ages of the male and female household heads. Almost half of the respondents reported the housing property owned by a married male household head while a quarter reported joint ownership by husband and wife. Joint ownership by husband and wife entails that both the couple's names are included on the title. The rest reported ownership by female headed households and by wives . Female household heads are unmarried . There were no unmarried male housing property owners in the sample. When disaggregated by study site, the general trend was the same with a few nuances; About 49% and 40% of the housing property owners were male household heads in Madido and Bauleni respectively. Joint ownership was reported in 36% and 23% of the housing properties in Bauleni and Madido respectively. Housing property owned by the wife comprised about 12% of the cases in both study sites, while about 15% and 10% of the housing properties were owned by female household heads. Family owned housing was the least common with only 2% of the properties in Bauleni and 6% in Madido. The rest of this section presents and discusses the findings based on themes derived from the research questions and those emerging from the data collected. --- . . Land tenure security is an outcome of land rights formalization A large majority of the respondents in both study sites thought that women's sense of tenure security had greatly increased , while a small percentage thought the increase was only moderate . If feelings of tenure security increase greatly, it means someone feels that it is highly unlikely that someone can arbitrarily expropriate their land. Similarly, if an owner's sense of security of tenure is moderate, it means they feel that it is not so likely that anyone can dispossess them of their property arbitrarily although they may have some lingering feeling that someone might actually do so. The women FGDs in Bauleni revealed that title deeds were "witnesses" or testimony to land ownership and that in the future no one would take the land away from them or their children because the title deeds would serve as proof of ownership. Similar views were expressed by the women FGDs from Madido. In the words of one focus group discussant, "before we got title deeds, we were very worried. Now we are safe, after getting the title deeds. Now we can expand our houses. We are very secure now." These views are shared by women that jointly owned their land with their spouses and those from households where only the male household head is included on the title. Noteworthy is that even married women whose names are not included on the title deeds as joint owners enjoy tenure security because of the provisions of the Intestate Act of 1989 which protects the rights of surviving spouses and children to inherit property. Enhanced tenure security for women after land rights formalization has been reported elsewhere in sub-Saharan Africa. Some interventions in Uganda , Ethiopia and Nepal showed --- FIGURE Sense of tenure security after land titling by women and men in Bauleni and Madido. a notable increase in women's tenure security than was previously held. Such cases notwithstanding, Viña urges caution. She posits that a woman having title deeds is not a sufficient condition for tenure security as titling may not necessarily translate to decision making about and deriving benefits from the land. Over 80% of the respondents in both sites believed that men's sense of tenure security had greatly increased after land titling . During the FGDs with men in Bauleni, a contrast was made between tenure security before and after land titling. The men unanimously agreed that before titling, anyone could lay claims on their land, but after titling, this was not possible. They all felt very secure post-titling. Their counterparts from Madido observed that before titling, they had been afraid that their houses could be demolished. The state did not provide any public services to the area because it was considered an illegal settlement. But after titling, "the government has brought water, sewerage and roads. We are proud now. There is just that sense of pride that this is my property", one of the discussants narrated. These sentiments suggest that land rights offered by title deeds are known to the rights holders and are enforceable. The rights owners knew that their title deeds, and the rights guaranteed therein, were valid for 99 years. This applies for both men and women land rights holders. A large majority of the respondents reported increases in the sense of ownership for both men and women in both study sites while a small minority indicated that there was a moderate increase of sense of ownership. The stronger sense of ownership was premised on landowners in both Bauleni and Madido having exclusive rights and control over the land parcels they owned. This was in line with the results from the FGDs. The focus group discussants from both Madido and Bauleni observed that the title deeds have accorded them ownership rights, which they never had before the issuance of title deeds. They narrated that prior to land rights formalization; anyone could come at any point and grab the land from them. However, with the title deeds issued to them, all focus group discussants confirmed having full ownership rights. They believed that no entity could grab land from them or demolish their properties without compensation. The focus group discussants further noted that land rights formalization has resulted in their empowerment. That is, they have powers to put up and extend immovable structures, because they have secure land rights to their land parcels. Clearly, landowners are able to enforce their rights when under threat as the rights have been legitimized by the state. A similar study from Tanzania conducted by Parsa et al. reported that most residents with property licenses felt that the municipality was unlikely to carry out demolitions and if conducted they had a better chance of being compensated by the authority. Having addressed tenure security, the paper proceeds to explore the context under which men and women have gained tenure security and delve into which land rights claimants are able to assert their claims to the secured land rights, how they assert their claims and the conditions under which they do so. --- . . The context In this section, the paper presents results on social norms obtaining around property in the context of titling. Social norms are defined as "rules of action shared by people in a given society or group; they define what is considered normal and acceptable behavior for the members of that group" . Social norms change from time to time. It would be interesting to know how titling affects some of the social norms in the study sites. --- . . . Social norms on inheritance A large proportion of the respondents in Bauleni and Madido respectively, and 74% overall claimed that there was an increase in the inheritance rights to property for daughters due to land rights formalization . A minority of the respondents indicated that there was no change in inheritance rights to property for daughters post land rights formalization . In the FGDs debate on land rights inheritance by daughters and sons, some discussants maintained that it was not the best idea to put daughters' names on title deeds because once they got married, they could let their husband take over the property to the detriment of the daughter's siblings. In the words of one male discussant from Bauleni, "For daughters, they can get married and let the man control the property." Conversely, another discussant from the same group argued for land rights inheritance by daughters, "It is better for a girl child to get inheritance because as the boy gets married and dies, his widow will inherit the property." This sentiment was echoed by discussants from Madido. One discussant elaborated the following: Girl child should be on a title deed. Even when the girl child gets married and it happens that the marriage does not work out, the daughter can go back to the house unlike the boy child because when he marries and dies, his wife will inherit the house [Focus Group Discussion, Madido, Zambia 20th October 2020]. Nancekivell et al. shared this view when they contended that a girl child should be on title because even if she were to get married, she could still look after the property and in cases where the marriage failed to work out, she could go back to the property. Almost 90% of the respondents perceived rights to inherit housing property to have increased due to land rights formalization . During focus group discussions, a lot of skepticism was expressed about sons inheriting property rights to land. The discussants averred that sons could sell the land and chase their siblings. This excerpt typifies this sentiment among Bauleni discussants, "It is best not to put [include] sons on a title because they can sell the land and chase their siblings." A similar view from Madido, "A son may even let the wife control and chase away siblings". The focus group discussants from Madido and Bauleni residential areas expressed strong preferences for including all the children on the title deeds so that no single child could change the land ownership. Half of the respondents from Bauleni and forty percent from Madido claimed that there was no change in the inheritance rights to property for nephews after land rights formalization . About ten percent of the respondents in both areas thought there had been an increase while the rest viewed the rights to have decreased. Similar sentiments were expressed for nieces . The explanations for these results were provided during the focus group discussions. The discussants contended that adding nephews and nieces' names on title deeds was problematic because their parents could later claim the land parcels as theirs. The following verbatim represent this view from a Bauleni discussant, "Putting names of nephews or nieces may result in problems because their parents may come to make claims" Both respondents and focus group discussants noted that only biological children had inheritance rights and should be the only ones included as land rights claimants on title deeds, besides the parents. This norm was a measure to prevent land claims from extended family members. Either one name or more can be on a title deed. The key beneficiaries are the children, biological children, and no one can claim the land from them [Focus group discussant, Madido, Zambia, 20th October, 2020]. Gibson and Walrath in Iowa of the United States of America also made this observation when they noted that the inheritance of property rights by nephews such as inheriting the house, farmland or plot following the death of the owner of the property was perceived negatively. Normally, when nephews inherit property rights, it is very likely that their biological parents may claim it is their property when in the actual sense it is not . In Rwanda, the land registration and titling program, implemented alongside the 1999 Law of Succession, and the National Land policy of 2004 resulted in; increased inheritance rights of daughters similar to sons, permanent land rights for divorced or widowed women, and increased ability to resist restrictive customary practices, e.g. polygamy, where wives property rights were not recognized by the state . --- . . . Decision-making authority by men and women household heads Decision-making is an indicator of control. Being able to exercise agency over what happens to land suggests an acceptance as part with rights and /or interest in the property. Decision making over land is influenced by social norms over who is considered a legitimate decision maker. In both study sites, about 32% of the women respondents noted that the acquisition of land titles had greatly increased the decision-making authority of land owners while 15% noted a moderate increase . For the men, 22% perceived decision making authority to have greatly increased among titled land owners, while 17% thought the increase was moderate, in both study sites. About 5% of the male respondents in both study sites asserted that decision making had moderately decreased while <1% of the women thought so, in both study sites . Close to half of all respondents did not attribute any changes in the decision-making authority to acquisition of title deeds. Despite few respondents citing increased decision-making authority, FGDs revealed that the acquisition of title deeds facilitates for men and women household heads to acquire financial loans using titles as collateral and enables them to decide who should inherit their property. Further, discussants noted that title deeds provide men and women household heads legal ownership and consequently authority to invest in their properties thereby increasing the monetary worth of the properties. Land formalization programs implemented across sub-Saharan Africa show positive outcomes in securing property rights and upholding equality across both genders. In Rwanda, equal decision-making rights between formally registered spouses to alienate property and rights to earn independent incomes through private property were reported . Agarwal and Panda noted that establishing women's property rights empowers them with decision making authority and enhanced control over resources and ensures the welfare of their households. Titling, however, must be supplemented with ancillary empowering interventions for women . As Viña avers, focusing on titling alone "without addressing the persistent barriers faced by women, not only misses the mark, but could also end up being counterproductive" Some scholars have argued that the presence of a title does not guarantee access to financial credit to residents, i.e., men and women especially in low-income areas citing low value of most properties as well as unwillingness by financial institutions to offer loans . However, these negative outcomes are unlikely to apply to residents of our study sites as they are in the city and title is for individualized housing units unlike the case of rural communal pasture or bargaining. --- . . Threats and opportunities presented by land rights formalization Focus group discussants from both study sites articulated that tenure insecurity among informal settlement landowners without formalized land rights is high, with evictions and demolitions pervasive threats. They asserted that the land reforms to regularize land ownership presents an opportunity for informal area residents to secure their land rights and make them enforceable and easily transferable. Scholars have observed that land titling is not without threats. Informal settlements expand unexpectedly and ultimately lead to a change in the use of space and structure of activities, in ways not in conformity with land use planning and legal requirements and may cause contradictions and conflicts . --- . . Land conflicts, love and trust among family members Intra-family tensions and contestations are reported over bequest, usage, or sharing of land . As Wong notes, disputes among spouses or family members can arise from deteriorating family relations such as a marriage breakdown or from third parties making counterclaims to the property. This study therefore sought to find out, in part, how land tilting had affected internal family relations in terms of conflicts related to land. The conflicts manifested in a number of ways in the two study sites including verbal quarrels and cutting of family ties. Just over half of the respondents in Bauleni indicated that land rights formalization had not influenced landrelated family conflicts. This is compared to below half of Madido respondents. Interestingly, only <10% of respondents in Bauleni indicated a decrease in land related conflicts among family members while about a third of Madido said land related family conflicts had decreased. In both study sites, <10% reported that land related family conflicts had increased following titling; seven and eight per cent for Bauleni and Madido respectively. On whether land related family conflicts had increased moderately only 11% and 10% responded in the affirmative for Bauleni and Madido, respectively. Overall, 18 and 19% of respondents from Bauleni and Madido, respectively, reported a moderate or great increase in land related family conflict following titling of their land. While tenure for agricultural land for women has been associated with women empowerment and reduced gender-based violence in India, the scarcity of land has resulted in tensions between spouses in Kenya over prioritization of consumption crops or commercial crops . According to Rukema and Khan , family conflicts in Rwanda relating to land are sparked by polygamy with competing inheritance claims from the various wives and their children. However, in Zambia, polygamy is illegal under statutory law and though legal under customary law, polygamy is rare in urban areas. In both Madido and Bauleni, no polygamous marriage was reported by respondents. The other causes of land-related conflicts Rukema and Khan cite are illiteracy and ignorance of the law empowering women with land ownership. Our study revealed a case where the husband had deserted the wife and children to go and live with another woman carrying the land title with him. One woman in Bauleni, a teacher by profession, reported contributing toward the land title. However, the husband had been elusive, giving contradictory claims that he had received the title and denying this when contacted by the wife during the interview. Love and trust between spouses can potentially be affected by titling with land being more marketable or being used as collateral, for instance. Furthermore, titling could mean adding both spouses on the title deed as co-owners. Over half of the respondents in Bauleni and only 37% in Madido said the love and trust for their spouse had not changed after obtaining title deeds. In both areas very few reported a decrease in their love and trust toward a spouse, that is, <1%. A third of respondents in Bauleni stated that their love and trust for their spouse had increased modestly or greatly while 41% said so in Madido. Overall, the vast majority of respondents in both areas indicated an improvement or no change in their trust and love toward the spouse. Interestingly, seventeen respondents in Madido claimed not to know how or whether titling had affected their spousal relationship compared to none being not sure in Bauleni. --- . . Perverse incentives for illegal land allocations There is a risk that legalizing and formalizing land rights to illegally settled land could provide perverse incentives for new land encroachments. In Bauleni, authorities bypassed regulations about plot size, and distance from public infrastructure such as roads and water pipes in numerous cases during the surveying and subsequent titling process. Furthermore, the legalization of settlement on land that previously belonged to a public college in the case of Madido could motivate future illegal settlements of public land in the expectation of future regularization. Chitonge and Mfune cited the illegal allocation of idle and vacant public or private land by political party cadres as important in the creation of informal settlements in Lusaka city. --- . . Visibility for residents Landowners are now "visible" to the state, in that they can use their title deeds as proof of residence, a requirement in accessing numerous services provided by both the public and private sector. For example, in order to open a bank account with a formal banking institution, proof of residence is required. Before the acquisition of title deeds, residents had no way of providing this proof. Land rights formalization has spurred increased participation in local development initiatives, such as through ward development committees. This increased participation is positive for local area development as residents are able to articulate issues of interest to them. --- . . Actors and action arenas Local political players were cardinal in the mobilization of residents. In Madido, the clique of ruling party officials that had appropriated land from the college and sold it were engaged to help the technocrats liaise with the community. Due to the illegal way in which the land had been obtained, residents had lived with the threat of eviction and were very apprehensive about any land related discussions. The land sellers were instrumental in providing confirmation of landowners in the numerous cases where proof of sale was missing. They worked hard to assure the community members that the initiative was genuinely meant to provide title deeds to them and was not an eviction exercise. Local political elites have been influential in illegal land allocations in Zambia . During fieldwork, one of them admitted that, "it is not possible for the state to remove people from illegally occupied land, once the land has been allocated by political cadres. That would not auger well for the ruling party. All the state can do is provide public services such as water, schools, clinics and roads". Residents tended to publicly align themselves with party officials of the ruling party or those they knew to be influential in local community development structures as a way to protect their interests. This has engendered patron-client relationships between residents and local political party officials on one hand, and local party officials and higher level politicians and technocrats. Local party officials have been known to usurp the authority of local development officials and technocrats in matters of land administration. This usurpation has been demonstrated in the collection by political cadres of tax that should be collected by local authorities as revenue for service delivery (Beardsworth et al., --- FIGURE Titled houses situated less than a meter from a public drainage channel and road, Bauleni Lusaka. --- 2022 ). There is a risk that the national land titling program may be overtaken by political elements if this clientelism is not addressed. Our research indicates that the issuance of title deeds is faster since Medici Land Governance became involved than was the case with the pilots under the Ministry of Lands and Natural Resources. Interviews with key informants revealed that Medici Land Governance is more efficient because it makes use of geographical information systems and uses block chain technology and is able to get title deeds issued in batches, unlike the traditional Ministry of Lands and Natural Resources system which provides approval per parcel. This is an opportunity for streamlined issuance of title deeds with potential to handle the land volumes expected once the program is fully fledged. --- . Conclusion This study set out to examine how land rights formalization has affected land tenure security, sense of ownership, decision making, land conflicts, love and trust among men and women landowners in two study areas in Lusaka, Zambia. Our research findings show that the ongoing land rights formalization program in Zambia has provided land tenure security for residents of informal settlements that previously lived under constant threat of eviction from their land. Both men and women have similarly benefitted from the formalization initiative through land laws and local norms that allow equitable access to land and land inheritance. Ownership rights and decision making has also been enhanced among both men and women landowners in the two study sites as they can easily alienate their property. Land rights formalization has in some instances curtailed land rights for secondary claimants such as extended family members, in preference for man, spouse and biological children. This is in line with the majority of the respondents in both study areas who were of the view that only the spouse or biological children's names should be on the title deed and have the right to inherit the property. The process of formalizing land rights in informal settlements has entailed putting aside regulations on plot boundary specifications and plot locations; essentially the legalization of illegalities to achieve the states goals of providing land tenure security to poor urbanites who would not otherwise have recourse to legal or regularized land. The study commends the initiative as a propoor initiative that is enabling socially marginalized groups to access legal land documentation and become visible in urban landscapes that have historically not catered for their land and housing needs. As the National Titling Program is expanded to other districts, implementers should develop robust mechanisms for keeping track of the payments made by program beneficiaries through their community municipality offices such as a short messaging system to send alerts whenever payments are made. The messages should include information on the amount paid and balance remaining. Program implementers should also continue to improve on the time between initial payments and issuance of title deeds. Policy makers are cautioned not to incentivize illegal land allocations by not extending the initiative to areas illegally occupied after the start of the program. --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

This study investigated how land rights formalization had a ected land tenure security among landowners in two informal settlements of Lusaka and Chongwe districts, Zambia. It explored how social norms on land inheritance, decision making over land, marital trust and land related conflicts had been a ected by the changed nature of land rights. Data was collected through a questionnaire survey of all the households that had obtained title deeds at the time of the survey, two -in-focus group discussions and four key informant interviews. Results suggest that land tenure security is now a reality for residents that hitherto lived under constant threat of eviction. Landowners have benefitted from the formalization initiative through land laws and local norms that allow equitable access to land. Land rights formalization has curtailed land rights for secondary claimants such as extended family members, in preference for man, spouse and biological children. A sense of ownership undisputedly increased for men and women in the two study sites. About % of the respondents in both study sites indicated that formalization of land rights had not resulted in family conflicts. At least one-third from both sites reported an increase in love and trust between spouses after land rights formalization. About half of the respondents reported that no change in decision-making authority had occurred for men while % reported an increase. Formalizing land rights in informal settlements has entailed legalizing illegalities as regulations on plot boundaries are set aside by the state to achieve its aspirations of providing land tenure security to poor urbanites who would not otherwise have recourse to legal or regularized land. We recommend that caution be taken in promoting what is unarguably a pro-poor initiative to ensure that such initiatives should not incentivize future land encroachments.

although unplanned settlements grew in density and number after zambias independence from british colonial rule in 1964 such settlements were a preindependence phenomenon their origins can be traced to colonial urban settlement policies which forced poor urban settlers to reside in marginal areas of the city that had not been planned as residential areas by city authorities new residents simply moved into the settlement areas and claimed parcels of land by constructing lowcost housing and other small structures such as shops and bars the housing structures were relatively cheaper to rent and thus became a pull factor to many rural immigrants into the city looking for lowcost housing with time the population of these unplanned settlements expanded and by the early 2000s accounted for around seventy per cent of the entire population of lusaka city and comprised 20 of the citys residential land having such a large proportion of the citys inhabitants in unplanned areas has brought about a myriad of socioeconomic and environmental challenges the unplanned settlements occupy and encroach on contested spaces in the city and thus continue to be a source of health environmental social and moral problems furthermore the houses were built without any building authorization by the city municipality as required legally zambias population stands at 196 million people with a population density of 261 persons per square kilometer although the countrys area covers 752614 square kilometers only twenty percent of the land translating to about 200000 land parcels was fully registered and 600000 parcels were at various stages of processing as of 2014 the rest was unregistered this entails the vast majority of plots and houses are unregistered illegal and potentially resulting in diminished property rights and tenure insecurity tenure security refers to the degree of confidence held by people that they will not be arbitrarily deprived of their land rights or of the benefits derived from their land several scholars have observed that informality induces land tenure insecurity and has negative consequences on investments and land resources management de soto argued that the poor in developing countries fail to turn their land into capital because they lack formal mechanisms for protecting their property rights their tenure insecurity acts as a demotivating factor formalization of land rights formalization of property rights involves the provision of legal representation of property in the form of title deeds licenses permits and contracts all of which must receive official sanction and protection from legitimate national authorities land rights formalization is argued to be especially beneficial for residents of informal settlements as the illegal status of such settlements presents a level of precariousness not experienced by other residents be they in customary areas or formal settlements without documentation for their land residents of informal settlements can be evicted legally anytime some scholars posit that by formalizing their land rights residents of informal settlements enhance their land rights claims and tenure security tenure security is associated with access to credit stimulating entrepreneurship provision of services and infrastructure improved health conditions and the realization of the human right to adequate housing furthermore land rights formalization is theorized to facilitate land market transactions which indirectly leads to higher overall investment in land however the empirical evidence from several countries in subsaharan africa that have implemented a wide range of land formalization initiatives since 2000 reveals mixed results despite the numerous espoused benefits arising from titling programs a variety of challenges impede implementation on a large scale for instance developing countries within and beyond subsaharan africa lack the necessary finances and capacity to execute the land formalization process because of the high costs required for land survey title registration and issuance of title on a large scale hence aid agencies and international financial institutions such as the world bank usaid dfid the european union among others have financed formalization processes in some countries furthermore land formalization manifests a gender dimension with women at a greater risk of land tenure insecurity despite de jure equality with respect to land access the prevalence of unfavorable customary practices and attitudes that restrict womens control over land resources inhibit fair participation in land formalization programs for example in ethiopia despite the introduction of progressive land reforms that promote rural womens rights to inherit and own land discriminatory practices such as restrictions on land ownership continue to persist similarly in malawis matrilineal societies though women possess inheritance rights to land men be it husbands or uncles exercise leadership in decision making and control over land thereby disenfranchising women consequently as men secure their property rights those of women risk being undermined further the landless women and orphans may not only be unable to take advantage of formal rights to assets but may find avenues of access effectively closed through the price increases that invariably attend formalization essentially a danger inherent in formalization is consolidating existing inequalities urban population growth presents challenges to large scale titling programs by triggering illegalities by wealthier individuals who include local residents elites politicians and local leaders in attempts to acquire property this however is at the expense of the relatively poor and marginalized individuals this high demand for urban property often leads to land conflicts and in some instances land grabbing which often overwhelm local government authorities other challenges of largescale titling include increased perceptions of displacements and tenure insecurity among marginalized individuals lengthy processes lack of policies to support titling objectives failure to achieve intended titling goals and high interests in land by commercial entities some scholars have noted that land rights formalization programs result in heightened insecurity due to displacements especially among the marginalized groups in society ie the poor and widows for example in kenya the process of converting communal pasture into private plots reinforced male dominance in property ownership as titles were issued to the men hence increasing inequalities further women lost their access to previously available resources such as livestock and other food products which they previously obtained through communal bargaining processes in zambia the state embarked on an ambitious national land titling program in 2015 the objectives of the program were to regularize ownership of untitled properties in towns and cities and by so doing promote security of tenure for property owners on state land reduce displacements promote internal security and increase the revenue base and investment in the country and thus contribute to socioeconomic development during the issuance of the first 92 certificates of title to residents of madido area in december 2017 the then minister of the ministry of lands and natural resources explained that the initiative was motivated by the governments resolve to accelerate social and economic development this was to be accomplished by regularizing ownership of untitled properties in towns and cities eradicating inequalities in gaining access to land in order to cater for all and providing citizens with the impetus for access to credit the zambia national land titling program had a target of processing and issuing 300000 certificates of title to landowners in areas where the program was being piloted by 2018 the ministry of land and natural resources established a unit specifically to deal with land titling under the national land titling program this is the national land titling center later it engaged a private company called medici land governance to expand the program however reality fell short of aspirations as program implementers faced challenges characteristic of such initiatives the challenges included determining land ownership for claimants with incomplete or no documentation determining property boundaries and upgrading paths to access roads to meet statutory standards since private infrastructure had been developed with little or no considerations for building standards concessions had to be made between demolishing properties that were too close to public roads and those without sufficient space for access roads and providing title security to poor residents with no other opportunities to own land with secure and enforceable land rights arguably this legalization of illegalities was instrumental to achieving the public good of socialeconomic development through the provision of legal property rights and all the opportunities this presented thus this study sought to determine how land rights formalization had affected land tenure security among men and women landowners in the pilot areas furthermore it explored how social norms on land inheritance decision making over land and marital trust had been affected by the changed nature of land rights lastly land conflicts an indicator of threats to land claims was examined to determine the extent to which the land rights formalization had addressed this threat land rights formalization in the two study sites started as part of the national land titling program an initiative by the state to document all unregistered land in urban areas once the initial skepticism and fear of demolition of illegal structures and forcible evictions was over landowners in the two study sites agreed to participate in the program and mobilized the initial mandatory payments the initial payment was zmw 1260 for madido and zmw 625 for bauleni this covered the survey fees and enabled the program implementers to survey the sites and draw sitemaps the rest of the payments were to be made in monthly installments of zmw 100 for up to 36 months for a total of zmw 4990 in madido and zmw 374793 in bauleni this is about half what landowners spent to acquire title deeds through the normal process residents that managed to secure payments early were among the first to receive the title deeds better resourced households thus benefitted early in the process conceptual framework for the study the conceptual framework is adapted from doss and meinzendick the adaptation includes the addition of men to the analysis and its application to an urban setting the framework incorporates four broad areas the context threats and opportunities action arena and outcomes the context includes both formal and informal institutions socioeconomy and history the threats and opportunities to land rights include the catalysts of change both those that strengthen and those that weaken tenure security for men and women the action arena includes both actors and action resources the actors include everyone who influences land tenure security the action resources are those resources that different actors can use to seek their preferred outcomes and include money education networks and social status finally mens and womens land tenure security is the outcome of interest and feeds back to shape the context for men and womens land rights in the future land tenure security has three components completeness of the bundle of rights duration and robustness completeness of the bundle of rights looks at the extent to which one person or persons hold the various rights duration is about whether the rights are held for a short or longterm and or if the length of time is known robustness is an examination of whether the rights are known by the holders accepted by the community and are enforceable figure conceptual framework of factors a ecting women and mens land tenure security adapted from the rest of the paper is organized as follows in the next section the paper describes the study sites and the study methodology section 3 presents and discusses the empirical results the last section concludes the paper and draws out policy implications materials and methods study context and background fieldwork was conducted from two study sites bauleni and madido residential areas between august and october 2020 the two areas were selected as study sites as they were pilot areas for the national land titling program in the lusaka city region and thus were ideal for an examination of program outcomes the two study sites are located in lusaka and chongwe districts respectively of the total area covered by the country bauleni covers an area of about 1533 square kilometers and madido about 0891 square kilometers the areas experience a humid subtropical climate and are overlain on uneven depth of folded and faulted schist bauleni had a population of 64000 while madidos was at 210 672 in 2010 bauleni and madido have 3697 and 2109 households respectively bauleni consists of lowincome and middleincome households most of its residents are in informal employment the situation is different for madido with most of its residents in formal employment and a large majority of them are middle income households the genesis of the two areas is very different bauleni started in the 1970s as a small unauthorized squatter settlement formed by laborers who worked in nearby commercial farms with time its population grew it was legalized in 1998 implementation of the national land titling program started in bauleni in 2018 madidoalso known as chelstone extension to the residentsis located on land that previously belonged to a public agricultural college the natural resource development college around 2006 local party officials of the then ruling political party the movement for multiparty democracy encroached on the land illegally demarcated it into land parcels and sold them to interested persons the population quickly grew and madido became an informal settlement the ministry of lands subsequently canceled the colleges land ownership rights before offering them to the illegal settlers and has since regularized their ownership through the issuance of title deeds implementation of the national land titling program started in madido 2017 data collection an explanatory sequential mixed methods approach was employed in order to come up with a sampling frame of households that had obtained title deeds a mapping exercise was conducted every household in the two study sites was visited and a short survey conducted to establish whether it had participated in the land titling program whether title deeds had been obtained and if so when the mapping exercise was conducted with the help of community members that were widely known and well regarded for bauleni it was with the participation of a longterm female resident whose family was the first to settle in the area the resident was identified with assistance from the local authority officers based at the lusaka city council office in the area the resident had firsthand knowledge of almost all the housing properties and their owners she was well known in the area as an executive member of several local development initiatives she was deputized by two females familiar with the area through their parttime work with lusaka city council as distributors of water bills in the area in madido the field team was assisted in the mapping exercise by two male residents who had been the central figures as they had been actively involved in the illegal demarcation and subsequent sale of land parcels further when the national land titling program commenced the two were recruited as resource persons to explain the program to community members and to encourage the community members to participate in the program the two were thus trusted by the residents who were otherwise wary of strangers asking about land matters given the illegal genesis of the residential area after the mapping exercise all the households that had title deeds at the time of the survey were interviewed these were 54 from bauleni and 248 from madido the survey commenced with a pilot study to test the data collection instrument during piloting each of the four research assistants interviewed two respondents each a male and a female from among the households with title deeds thus a total of eight interviews were conducted during the pilot study the pilot study was conducted within a day at the end of which a debriefing session was held some questions in the questionnaire were modified while a few were removed as they were found to be redundant and some new ones were added after the feedback from the pilot interviews the eight interviewees from the pilot study were excluded from the survey after the questionnaire survey two 3in1 focus group discussions were conducted in the two study sites the discussants were recruited from the pool of respondents on the basis of having extensive knowledge of the land titling process each of the four enumerators recommended two male and two female discussants from the batch of respondents each had interviewed from the two study sites the discussions were held in two phases in the first phase discussions were conducted with men and women separately the mens fgds were facilitated by a male researcher while the womens fgds were facilitated by a female researcher this initial separation into single gender groups was to minimize any influence of unequal gender relations such as the social and cultural superiority of men to women that could otherwise limit participation in the discussions based on gender norms the men and womens groups were later brought together in a plenary discussion and asked to present summaries of their group deliberations the plenary phase of the fgds resulted in coproduction of knowledge by men and women discussants through the detailed discussions that ensued from the single gender group presentations one member of the research team expertly facilitated the discussion while another observed the proceedings and took notes the facilitator alternated which group shared its results first both facilitator and observer paid attention to the verbal reactions and nonverbal communication of the women to the mens answers and vice versa these included voice tone facial expressions and demeanor these cues were used to guide the facilitator on whether or not there were disagreements between the two groups and to probe appropriately four key informants were interviewed these included a representative from the private entity recruited by the state to implement the national titling program and a spatial planner from the ministry of local government and housing with extensive experience in planning who had been seconded to the national land titling program others were two key informants with extensive knowledge on land related matters in the two study sites they were both long term residents of their respective informal settlements and their families had been important players in the establishing of the illegal settlements both were also involved in the national land titling program as community representatives this role entailed communicating community concerns to the government providing information on undocumented land parcels to the state and updating community members on program activities free prior and informed consent was verbally obtained from all respondents and key informants all of whom were adults aged over 18 years of age permission to record the focus group discussions using digital recorders was sought from the discussants and granted for all the sessions approval to conduct the research was granted by eres converge irb a nationally accredited research ethics clearance organization data analysis the questionnaire survey data was entered into microsoft excel sheets after the data entry was completed an accuracy check was conducted by randomly selecting ten percent of the completed questionnaires and comparing them to the data entered about them the data was then copied to minitab 18 and analyzed using basic descriptive statistics such as frequencies means standard deviation and two sample independent ttest the ttest was used to test the hypothesis that male household heads were older than their female counterparts the recordings of the fgds and key informant interviews were transcribed and categorized into themes based on research questions the themes were sense of tenure security sense of ownership decisionmaking land inheritance land related family conflicts love and trust and threats and opportunities presented by land rights formalization results and discussion overall the average age of household heads was 564 and 485 in bauleni and madido respectively when disaggregated by the gender of the household head the data reveals that around 20 of the interviewed households were headed by females the average age of male household heads in madido was lower than for the female heads while in bauleni there was no statistically significant difference in the mean ages of the male and female household heads almost half of the respondents reported the housing property owned by a married male household head while a quarter reported joint ownership by husband and wife joint ownership by husband and wife entails that both the couples names are included on the title the rest reported ownership by female headed households and by wives female household heads are unmarried there were no unmarried male housing property owners in the sample when disaggregated by study site the general trend was the same with a few nuances about 49 and 40 of the housing property owners were male household heads in madido and bauleni respectively joint ownership was reported in 36 and 23 of the housing properties in bauleni and madido respectively housing property owned by the wife comprised about 12 of the cases in both study sites while about 15 and 10 of the housing properties were owned by female household heads family owned housing was the least common with only 2 of the properties in bauleni and 6 in madido the rest of this section presents and discusses the findings based on themes derived from the research questions and those emerging from the data collected land tenure security is an outcome of land rights formalization a large majority of the respondents in both study sites thought that womens sense of tenure security had greatly increased while a small percentage thought the increase was only moderate if feelings of tenure security increase greatly it means someone feels that it is highly unlikely that someone can arbitrarily expropriate their land similarly if an owners sense of security of tenure is moderate it means they feel that it is not so likely that anyone can dispossess them of their property arbitrarily although they may have some lingering feeling that someone might actually do so the women fgds in bauleni revealed that title deeds were witnesses or testimony to land ownership and that in the future no one would take the land away from them or their children because the title deeds would serve as proof of ownership similar views were expressed by the women fgds from madido in the words of one focus group discussant before we got title deeds we were very worried now we are safe after getting the title deeds now we can expand our houses we are very secure now these views are shared by women that jointly owned their land with their spouses and those from households where only the male household head is included on the title noteworthy is that even married women whose names are not included on the title deeds as joint owners enjoy tenure security because of the provisions of the intestate act of 1989 which protects the rights of surviving spouses and children to inherit property enhanced tenure security for women after land rights formalization has been reported elsewhere in subsaharan africa some interventions in uganda ethiopia and nepal showed figure sense of tenure security after land titling by women and men in bauleni and madido a notable increase in womens tenure security than was previously held such cases notwithstanding viña urges caution she posits that a woman having title deeds is not a sufficient condition for tenure security as titling may not necessarily translate to decision making about and deriving benefits from the land over 80 of the respondents in both sites believed that mens sense of tenure security had greatly increased after land titling during the fgds with men in bauleni a contrast was made between tenure security before and after land titling the men unanimously agreed that before titling anyone could lay claims on their land but after titling this was not possible they all felt very secure posttitling their counterparts from madido observed that before titling they had been afraid that their houses could be demolished the state did not provide any public services to the area because it was considered an illegal settlement but after titling the government has brought water sewerage and roads we are proud now there is just that sense of pride that this is my property one of the discussants narrated these sentiments suggest that land rights offered by title deeds are known to the rights holders and are enforceable the rights owners knew that their title deeds and the rights guaranteed therein were valid for 99 years this applies for both men and women land rights holders a large majority of the respondents reported increases in the sense of ownership for both men and women in both study sites while a small minority indicated that there was a moderate increase of sense of ownership the stronger sense of ownership was premised on landowners in both bauleni and madido having exclusive rights and control over the land parcels they owned this was in line with the results from the fgds the focus group discussants from both madido and bauleni observed that the title deeds have accorded them ownership rights which they never had before the issuance of title deeds they narrated that prior to land rights formalization anyone could come at any point and grab the land from them however with the title deeds issued to them all focus group discussants confirmed having full ownership rights they believed that no entity could grab land from them or demolish their properties without compensation the focus group discussants further noted that land rights formalization has resulted in their empowerment that is they have powers to put up and extend immovable structures because they have secure land rights to their land parcels clearly landowners are able to enforce their rights when under threat as the rights have been legitimized by the state a similar study from tanzania conducted by parsa et al reported that most residents with property licenses felt that the municipality was unlikely to carry out demolitions and if conducted they had a better chance of being compensated by the authority having addressed tenure security the paper proceeds to explore the context under which men and women have gained tenure security and delve into which land rights claimants are able to assert their claims to the secured land rights how they assert their claims and the conditions under which they do so the context in this section the paper presents results on social norms obtaining around property in the context of titling social norms are defined as rules of action shared by people in a given society or group they define what is considered normal and acceptable behavior for the members of that group social norms change from time to time it would be interesting to know how titling affects some of the social norms in the study sites social norms on inheritance a large proportion of the respondents in bauleni and madido respectively and 74 overall claimed that there was an increase in the inheritance rights to property for daughters due to land rights formalization a minority of the respondents indicated that there was no change in inheritance rights to property for daughters post land rights formalization in the fgds debate on land rights inheritance by daughters and sons some discussants maintained that it was not the best idea to put daughters names on title deeds because once they got married they could let their husband take over the property to the detriment of the daughters siblings in the words of one male discussant from bauleni for daughters they can get married and let the man control the property conversely another discussant from the same group argued for land rights inheritance by daughters it is better for a girl child to get inheritance because as the boy gets married and dies his widow will inherit the property this sentiment was echoed by discussants from madido one discussant elaborated the following girl child should be on a title deed even when the girl child gets married and it happens that the marriage does not work out the daughter can go back to the house unlike the boy child because when he marries and dies his wife will inherit the house focus group discussion madido zambia 20th october 2020 nancekivell et al shared this view when they contended that a girl child should be on title because even if she were to get married she could still look after the property and in cases where the marriage failed to work out she could go back to the property almost 90 of the respondents perceived rights to inherit housing property to have increased due to land rights formalization during focus group discussions a lot of skepticism was expressed about sons inheriting property rights to land the discussants averred that sons could sell the land and chase their siblings this excerpt typifies this sentiment among bauleni discussants it is best not to put include sons on a title because they can sell the land and chase their siblings a similar view from madido a son may even let the wife control and chase away siblings the focus group discussants from madido and bauleni residential areas expressed strong preferences for including all the children on the title deeds so that no single child could change the land ownership half of the respondents from bauleni and forty percent from madido claimed that there was no change in the inheritance rights to property for nephews after land rights formalization about ten percent of the respondents in both areas thought there had been an increase while the rest viewed the rights to have decreased similar sentiments were expressed for nieces the explanations for these results were provided during the focus group discussions the discussants contended that adding nephews and nieces names on title deeds was problematic because their parents could later claim the land parcels as theirs the following verbatim represent this view from a bauleni discussant putting names of nephews or nieces may result in problems because their parents may come to make claims both respondents and focus group discussants noted that only biological children had inheritance rights and should be the only ones included as land rights claimants on title deeds besides the parents this norm was a measure to prevent land claims from extended family members either one name or more can be on a title deed the key beneficiaries are the children biological children and no one can claim the land from them focus group discussant madido zambia 20th october 2020 gibson and walrath in iowa of the united states of america also made this observation when they noted that the inheritance of property rights by nephews such as inheriting the house farmland or plot following the death of the owner of the property was perceived negatively normally when nephews inherit property rights it is very likely that their biological parents may claim it is their property when in the actual sense it is not in rwanda the land registration and titling program implemented alongside the 1999 law of succession and the national land policy of 2004 resulted in increased inheritance rights of daughters similar to sons permanent land rights for divorced or widowed women and increased ability to resist restrictive customary practices eg polygamy where wives property rights were not recognized by the state decisionmaking authority by men and women household heads decisionmaking is an indicator of control being able to exercise agency over what happens to land suggests an acceptance as part with rights and or interest in the property decision making over land is influenced by social norms over who is considered a legitimate decision maker in both study sites about 32 of the women respondents noted that the acquisition of land titles had greatly increased the decisionmaking authority of land owners while 15 noted a moderate increase for the men 22 perceived decision making authority to have greatly increased among titled land owners while 17 thought the increase was moderate in both study sites about 5 of the male respondents in both study sites asserted that decision making had moderately decreased while 1 of the women thought so in both study sites close to half of all respondents did not attribute any changes in the decisionmaking authority to acquisition of title deeds despite few respondents citing increased decisionmaking authority fgds revealed that the acquisition of title deeds facilitates for men and women household heads to acquire financial loans using titles as collateral and enables them to decide who should inherit their property further discussants noted that title deeds provide men and women household heads legal ownership and consequently authority to invest in their properties thereby increasing the monetary worth of the properties land formalization programs implemented across subsaharan africa show positive outcomes in securing property rights and upholding equality across both genders in rwanda equal decisionmaking rights between formally registered spouses to alienate property and rights to earn independent incomes through private property were reported agarwal and panda noted that establishing womens property rights empowers them with decision making authority and enhanced control over resources and ensures the welfare of their households titling however must be supplemented with ancillary empowering interventions for women as viña avers focusing on titling alone without addressing the persistent barriers faced by women not only misses the mark but could also end up being counterproductive some scholars have argued that the presence of a title does not guarantee access to financial credit to residents ie men and women especially in lowincome areas citing low value of most properties as well as unwillingness by financial institutions to offer loans however these negative outcomes are unlikely to apply to residents of our study sites as they are in the city and title is for individualized housing units unlike the case of rural communal pasture or bargaining threats and opportunities presented by land rights formalization focus group discussants from both study sites articulated that tenure insecurity among informal settlement landowners without formalized land rights is high with evictions and demolitions pervasive threats they asserted that the land reforms to regularize land ownership presents an opportunity for informal area residents to secure their land rights and make them enforceable and easily transferable scholars have observed that land titling is not without threats informal settlements expand unexpectedly and ultimately lead to a change in the use of space and structure of activities in ways not in conformity with land use planning and legal requirements and may cause contradictions and conflicts land conflicts love and trust among family members intrafamily tensions and contestations are reported over bequest usage or sharing of land as wong notes disputes among spouses or family members can arise from deteriorating family relations such as a marriage breakdown or from third parties making counterclaims to the property this study therefore sought to find out in part how land tilting had affected internal family relations in terms of conflicts related to land the conflicts manifested in a number of ways in the two study sites including verbal quarrels and cutting of family ties just over half of the respondents in bauleni indicated that land rights formalization had not influenced landrelated family conflicts this is compared to below half of madido respondents interestingly only 10 of respondents in bauleni indicated a decrease in land related conflicts among family members while about a third of madido said land related family conflicts had decreased in both study sites 10 reported that land related family conflicts had increased following titling seven and eight per cent for bauleni and madido respectively on whether land related family conflicts had increased moderately only 11 and 10 responded in the affirmative for bauleni and madido respectively overall 18 and 19 of respondents from bauleni and madido respectively reported a moderate or great increase in land related family conflict following titling of their land while tenure for agricultural land for women has been associated with women empowerment and reduced genderbased violence in india the scarcity of land has resulted in tensions between spouses in kenya over prioritization of consumption crops or commercial crops according to rukema and khan family conflicts in rwanda relating to land are sparked by polygamy with competing inheritance claims from the various wives and their children however in zambia polygamy is illegal under statutory law and though legal under customary law polygamy is rare in urban areas in both madido and bauleni no polygamous marriage was reported by respondents the other causes of landrelated conflicts rukema and khan cite are illiteracy and ignorance of the law empowering women with land ownership our study revealed a case where the husband had deserted the wife and children to go and live with another woman carrying the land title with him one woman in bauleni a teacher by profession reported contributing toward the land title however the husband had been elusive giving contradictory claims that he had received the title and denying this when contacted by the wife during the interview love and trust between spouses can potentially be affected by titling with land being more marketable or being used as collateral for instance furthermore titling could mean adding both spouses on the title deed as coowners over half of the respondents in bauleni and only 37 in madido said the love and trust for their spouse had not changed after obtaining title deeds in both areas very few reported a decrease in their love and trust toward a spouse that is 1 a third of respondents in bauleni stated that their love and trust for their spouse had increased modestly or greatly while 41 said so in madido overall the vast majority of respondents in both areas indicated an improvement or no change in their trust and love toward the spouse interestingly seventeen respondents in madido claimed not to know how or whether titling had affected their spousal relationship compared to none being not sure in bauleni perverse incentives for illegal land allocations there is a risk that legalizing and formalizing land rights to illegally settled land could provide perverse incentives for new land encroachments in bauleni authorities bypassed regulations about plot size and distance from public infrastructure such as roads and water pipes in numerous cases during the surveying and subsequent titling process furthermore the legalization of settlement on land that previously belonged to a public college in the case of madido could motivate future illegal settlements of public land in the expectation of future regularization chitonge and mfune cited the illegal allocation of idle and vacant public or private land by political party cadres as important in the creation of informal settlements in lusaka city visibility for residents landowners are now visible to the state in that they can use their title deeds as proof of residence a requirement in accessing numerous services provided by both the public and private sector for example in order to open a bank account with a formal banking institution proof of residence is required before the acquisition of title deeds residents had no way of providing this proof land rights formalization has spurred increased participation in local development initiatives such as through ward development committees this increased participation is positive for local area development as residents are able to articulate issues of interest to them actors and action arenas local political players were cardinal in the mobilization of residents in madido the clique of ruling party officials that had appropriated land from the college and sold it were engaged to help the technocrats liaise with the community due to the illegal way in which the land had been obtained residents had lived with the threat of eviction and were very apprehensive about any land related discussions the land sellers were instrumental in providing confirmation of landowners in the numerous cases where proof of sale was missing they worked hard to assure the community members that the initiative was genuinely meant to provide title deeds to them and was not an eviction exercise local political elites have been influential in illegal land allocations in zambia during fieldwork one of them admitted that it is not possible for the state to remove people from illegally occupied land once the land has been allocated by political cadres that would not auger well for the ruling party all the state can do is provide public services such as water schools clinics and roads residents tended to publicly align themselves with party officials of the ruling party or those they knew to be influential in local community development structures as a way to protect their interests this has engendered patronclient relationships between residents and local political party officials on one hand and local party officials and higher level politicians and technocrats local party officials have been known to usurp the authority of local development officials and technocrats in matters of land administration this usurpation has been demonstrated in the collection by political cadres of tax that should be collected by local authorities as revenue for service delivery beardsworth et al figure titled houses situated less than a meter from a public drainage channel and road bauleni lusaka 2022 there is a risk that the national land titling program may be overtaken by political elements if this clientelism is not addressed our research indicates that the issuance of title deeds is faster since medici land governance became involved than was the case with the pilots under the ministry of lands and natural resources interviews with key informants revealed that medici land governance is more efficient because it makes use of geographical information systems and uses block chain technology and is able to get title deeds issued in batches unlike the traditional ministry of lands and natural resources system which provides approval per parcel this is an opportunity for streamlined issuance of title deeds with potential to handle the land volumes expected once the program is fully fledged conclusion this study set out to examine how land rights formalization has affected land tenure security sense of ownership decision making land conflicts love and trust among men and women landowners in two study areas in lusaka zambia our research findings show that the ongoing land rights formalization program in zambia has provided land tenure security for residents of informal settlements that previously lived under constant threat of eviction from their land both men and women have similarly benefitted from the formalization initiative through land laws and local norms that allow equitable access to land and land inheritance ownership rights and decision making has also been enhanced among both men and women landowners in the two study sites as they can easily alienate their property land rights formalization has in some instances curtailed land rights for secondary claimants such as extended family members in preference for man spouse and biological children this is in line with the majority of the respondents in both study areas who were of the view that only the spouse or biological childrens names should be on the title deed and have the right to inherit the property the process of formalizing land rights in informal settlements has entailed putting aside regulations on plot boundary specifications and plot locations essentially the legalization of illegalities to achieve the states goals of providing land tenure security to poor urbanites who would not otherwise have recourse to legal or regularized land the study commends the initiative as a propoor initiative that is enabling socially marginalized groups to access legal land documentation and become visible in urban landscapes that have historically not catered for their land and housing needs as the national titling program is expanded to other districts implementers should develop robust mechanisms for keeping track of the payments made by program beneficiaries through their community municipality offices such as a short messaging system to send alerts whenever payments are made the messages should include information on the amount paid and balance remaining program implementers should also continue to improve on the time between initial payments and issuance of title deeds policy makers are cautioned not to incentivize illegal land allocations by not extending the initiative to areas illegally occupied after the start of the program data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

this study investigated how land rights formalization had a ected land tenure security among landowners in two informal settlements of lusaka and chongwe districts zambia it explored how social norms on land inheritance decision making over land marital trust and land related conflicts had been a ected by the changed nature of land rights data was collected through a questionnaire survey of all the households that had obtained title deeds at the time of the survey two infocus group discussions and four key informant interviews results suggest that land tenure security is now a reality for residents that hitherto lived under constant threat of eviction landowners have benefitted from the formalization initiative through land laws and local norms that allow equitable access to land land rights formalization has curtailed land rights for secondary claimants such as extended family members in preference for man spouse and biological children a sense of ownership undisputedly increased for men and women in the two study sites about of the respondents in both study sites indicated that formalization of land rights had not resulted in family conflicts at least onethird from both sites reported an increase in love and trust between spouses after land rights formalization about half of the respondents reported that no change in decisionmaking authority had occurred for men while reported an increase formalizing land rights in informal settlements has entailed legalizing illegalities as regulations on plot boundaries are set aside by the state to achieve its aspirations of providing land tenure security to poor urbanites who would not otherwise have recourse to legal or regularized land we recommend that caution be taken in promoting what is unarguably a propoor initiative to ensure that such initiatives should not incentivize future land encroachments

Time Well Wasted? Online Procrastination in Periods of Unemployment --- Introduction In recent years, discussions have increasingly focused on whether the Internet makes us more easily distracted and whether it leads to increased procrastination, which is "to voluntarily delay an intended course of action despite expecting to be worse off for the delay" . A typical procrastination scenario is the needless delay of pending tasks with the excuse of carrying them out later. Such behaviour seems to be widespread; however, prior research has demonstrated that the frequent and habitual delay of actions and/or decisions is highly dysfunctional . Several studies on the motivations for media use have shown that procrastination is one reason why individuals use entertainment media . Media is perceived as enjoyable and distracting, and it is frequently used during working and leisure time . Regarding the Internet, research has revealed that online media is a frequently used but detrimental tool for procrastination . While research has examined procrastination in the workplace , few studies have evaluated such behaviour in the context of unemployment . Against this background, we seek to explore whether the Internet might tempt unemployed users to procrastinate online rather than searching for a new position. We thus seek to extend existing research on non-work-related Internet usage in the workplace that shows the potential for anti-productive tendencies, such as cyberslacking or cyberloafing , to a situation that is similar but involves the opposite of "working" per se: unemployment. Being unemployed is an open-ended situation in that an unemployed person typically has a substantial amount of free time with little structure. Searching and applying for reemployment may take some time, but there are also long stretches of the day spent waiting with much less tangible guidance on what activities to perform -particularly compared with being employed. Frequently, much time is spent at home, and this time is often filled with media usage. Historically, the classic case of media usage has been watching television . However, as computers and the Internet have become more important, online media has increasingly become a new pastime with new benefits and challenges. On the one hand, the Internet may contribute to alleviating the downside of being unemployed and help establish new possibilities to overcome unemployment's negative consequences by facilitating online relationships and finding new employment opportunities. On the other hand, spending time online may also prove to be a double-edged sword. Many heavy Internet users experience problems in their interpersonal relationships and use the Internet as their primary means of alleviating stress and depression . Because the computer is typically easily accessible, it may be tempting to use it to procrastinate. Subjectively, procrastination might be a reasonable activity; if searching for a job is considered frustrating, online procrastination might help by detaching from the situation. On the other hand, the ubiquitous availability of media content is linked to challenges for media users' self-control capacity . Distraction from important but unpleasant tasks can be easily achieved through the Internet, inhibiting the achievement of long-term goals and obligations . Thus, media can be potentially threatening for self-control and goal achievement in everyday life . On that account, media related procrastination is prevalently conceptualized as a behavioural outcome of failed self-regulation . A low self-control capacity increases the likelihood of giving in to short-term temptations instead of engaging in intended but postponed rewarding activities . Online procrastination may thus disadvantage the unemployed due to a failure of selfcontrol. Against this background, the present study aims to better understand the Internet usage of the unemployed and whether they risk using the medium to spend too much time procrastinating online. More specifically, we are interested in the following: finding the antecedents of online procrastination during unemployment and the points of influence as well as determining the outcomes of online procrastination in terms of paving the way for reemployment through efforts spent on searching for a new position. --- Literature and Research Model Periods of unemployment, particularly those that last longer than six months, are associated with significant deleterious effects on psychological and physical well-being . Unemployment is linked to mental health problems, including depression, somatisation, anxiety, and substance abuse . Unemployment creates a psychological void that people aim to fill by finding different outlets for self-expression and attempting to maintain their psychological well-being . Among other deprivations, unemployment creates a lack of identity and time structure, and many unemployed people miss the sense of purposeful and structured time use that they had as part of the labour market . When unemployed, individuals tend to feel their best when they try to keep busy, continue their routines, and maintain a sense of purpose that approximates a work situation and that provides them with latent benefits related to higher psychological well-being . Some unemployed individuals may use the Internet for procrastination purposes to reduce stress and alleviate the negative feelings that may be associated with unemployment. Some research has shown that increased Internet usage may be associated with decreased levels of loneliness and depression as well as increased levels of social support and self-esteem . However, turning to the Internet to procrastinate may oftentimes lead to the overuse of the medium, which can be to the detriment of everyday functionality . From a displacement perspective, Internet use may detract from the time that is available for more traditional social activities -such as face-to-face socialising -because time is a limited resource that must be budgeted among competing activities . However, from a coping perspective, we might argue for a more positive interpretation of media procrastination than its traditional understanding. According to Reinecke and Hofmann , the almost permanent availability of media content is associated with many benefits for self-regulation: media exposure offers the possibility of regulating mood and arousal , supports intrinsic need satisfaction , and facilitates recovery from stress and strain . Problem-focused coping involves seeking to change or eliminate the stressor itself, whereas emotion-focused coping involves seeking to reduce or manage the emotional consequences associated with the stressor. In nearly all stressful occurrences, both approaches are employed. The question is whether the emotional coping response of online procrastination is detrimental to the job search process that aims at solving the problem of unemployment. In the following, we propose the following hypothesis model. Unemployment often leads to both material and social deprivation. Being unemployed is financially straining, and money-related sorrows are common. Socially, being unemployed makes it increasingly difficult to maintain contact with friends, particularly work colleagues . Social isolation, which is a correlate of subjectively experienced loneliness, is a stressor and risk factor for mental health problems . Studies have noted that feeling powerlessness or meaninglessness or feeling ideologically or socially isolatedand deprived -leads to the desire to escape; frequently, mass media are the means used to satisfy this desire . In periods of unemployment, with more time available during the day -but with limited financial resources, friends at their jobs and damaged self-esteem -much time is spent at home and using media. By combining the findings of prior research, we expect the perceived exclusion experienced through unemployment to lead to higher levels of online procrastination. Therefore, we formulate the following hypothesis: --- H1. Social exclusion is positively related to procrastination. In the literature, there is no clear evidence that social exclusion is directly caused by unemployment, but it appears to be contingent upon broader cultural patterns . However, for those unemployed individuals who feel excluded because of a lack of social support networks or general hopelessness about the success of their job search, exclusion may negatively affect happiness and well-being . These negative effects may be detrimental to the speed and success of finding reemployment; thus, research on reemployment has shown that positive emotions such as en-thusiasm, energy, and alertness are good for motivational control and that maintaining a positive self-perception as well as keeping one's options open for finding reemployment leads to greater commitment to the job search process . Research has also shown that individuals who feel excluded show distorted time perceptions, an emphasis on the present rather than on the future, lethargic passivity, and an avoidance of self-awareness . There are different hypotheses regarding the effects of such perceived exclusion. One opinion, the reconnection hypotheses, posits that individuals respond to exclusion with increased motivation to build social bonds . However, this motivational drive is only favoured when conditions exist for actual interaction to occur or when such interaction is anticipated to occur ; of course, these conditions do not characterise the reemployment process but might apply to online contacts that might not be employment related. We thus assume that perceived exclusion has predominately negative effects both on motivational control as an antecedent and on job search effort as an outcome; accordingly, we propose the following two hypotheses: --- H2. Social exclusion is negatively related to motivational control. --- H3. Social exclusion is negatively related to job search effort. Finding employment and emerging from unemployment requires extensive self-regulation in terms of both effort and emotion. Self-regulation of effort is needed to sustain a job search over time, despite continued rejections and the monotony of the process. Self-regulation of emotion is needed when individuals feel discouraged, angry, worried, or frustrated about the multiple stressors involved in searching for a job and in unemployment in general . To abstain from procrastination and maintain high levels of effort and persistence in an activity, unem-ployed individuals must adopt self-initiated processes, such as goal setting, planning, and envisioning goal accomplishment . According to Turban et al. , unemployed individuals with stronger motivational control tend to show goal-directed behaviour and are less likely to procrastinate. Based on these findings, the following hypothesis is proposed: --- H4. Motivational control is negatively related to procrastination. During a job search, job seekers must use self-regulation strategies to manage thoughts and behaviours, to accomplish job search tasks in a timely manner and to maintain effort during the job search . Motivational control is important in situations in which motivation tends to fade, such as during an extended job search , and this control is positively related to job search intensity . Self-regulation is needed particularly with respect to the attainment of distal goals that involve lengthy processes consisting of tasks low on intrinsic motivation and high on extrinsic motivation . The stronger a job seekers' motivation to obtain a job, the more likely it is that he/she will allocate the resources needed to self-regulate and to conduct a high-quality search . Consistent with these findings, we formulate the following hypothesis: --- H5. Motivation control is positively related to job search effort. Overcoming unemployment is a process that requires many actions on the part of the unemployed, including searching for employment opportunities , acquiring information about such opportunities, and actively applying for job openings . Job search behaviour is a major determinant of finding em-ployment . Job seekers must engage in goal-directed behaviours, including completing applications and replying to potential employers in a timely manner . Based on prior research on the relationship between online procrastination and detrimental outcomes , we assume that online procrastination is largely detrimental to the job search process. The process of seeking a job is largely self-organised and self-managed and involves setting a goal, then planning, monitoring, and evaluating the progress made towards the goal . Kanfer et al. noted that job search behaviour can be evaluated with respect to intensity of effort and content direction . Additionally, the type and quality of job search activities performed is an important dimension of a job search . Job search activities are rarely considered enjoyable and entertaining. Instead, the job search process is generally experienced as difficult and filled with negative emotions . Based on the above considerations, the following hypothesis is proposed: --- H6. Procrastination is negatively related to job search effort. --- Methods --- Sample Description Accessing the client database of the German Federal Employment Agency, we conducted an analysis to determine how those seeking work use the Internet in general and social media in particular to re-enter the job market and to determine which factors affect the job search efforts of the unemployed. Data were collected from clients of the German Federal Employment Agency who were randomly selected from a database that included all unemployed people in Germany at that time and who were invited to participate in a telephone-based survey during February and March 2012. No incentive was offered to the participants. Overall, 2,414 unemployed individuals completed a computer-assisted telephone survey. From the representative sample, we were looking for regular Internet users among the unemployed. Of all participants, 386 were identified as regular users; these participants were characterised by broad experience, a high frequency of use, and a wide range of applications. The remaining participants were identified as inexperienced and infrequent users, utilizing few applications; therefore, they were not considered in the analysis. Compared with the overall sample, in which a gender and region composition of the sample that was representative of the German general population was ensured by defining quotas for these attributes, the resulting sub-sample of the regular users differs in its socio-demographic composition: male participants are overrepresented at 57.0%. Age is below the population average: 67.4% of participants are between 18 and 25 years old, and 26.9% are between 26 and 40 years of age. Most respondents hold a high school diploma that allows no direct access to a university or college . The sub-samples were further tested for differences in job importance and self-efficacy. Table 1 summarises the profiles and demographics of the respondents. --- TABLE 1 Sample Profile ABOUT HERE The questionnaire was based on measures on Internet usage, job search experience, and social psychology in the literature. The scale for perceived exclusion was adapted from Bude and Lantermann . Motivational control was measured using the personal mastery subscale of the Motivational Trait Questionnaire . The procrastination construct was derived from Davis et al. . The scale for job search behaviour was adapted from Caplan et al. . The precise phrasing of all items was adjusted based on a pilot test in which 40 unemployed persons were asked to comment on the wording of the listed items. Each item was rated by the survey participants based on a fivepoint Likert scale . --- Measurement Model Overall, we considered four latent constructs with a total of 15 items in the measurement model. First, we conducted a confirmatory factor analysis to test for uni-dimensionality and scale reliability on the item and construct levels. On the construct level, we used Cronbach's alpha , composite reliability , and average variance extracted to assess the internal consistency of the scales. Table 2 lists the results of this assessment. After this procedure, one item was eliminated from the job search scale because its inclusion decreased the reliability coefficients. After this adjustment, the results from the α, CR, and AVE tests were above the required criterion values. As shown in Table 3, the measurement model has discriminant validity. Overall, these statistics indicate a good fit for the model. --- Results --- Structural Model Based on our hypotheses, we initially estimated the model shown in Figure 1 with the statistical software Mplus. The results include the standardised coefficients based on robust maximum likelihood estimation and the total variance explained for each dependent construct for all participants without missing values. As shown in Table 4, the model provided good fitness indices. All but one of the hypothesised and estimated paths were significant. --- Figure 1 Structural Equation Model on the Antecedents of Job Search Efforts and Procrastination ABOUT HERE TABLE 4 Fit Indices ABOUT HERE In the overall model, we find strong confirmation for our hypotheses. Perceived exclusion positively affected both online procrastination and job search effort: perceived exclusion had a strong significant effect on online procrastination , although the effect on job search effort was both weaker and less significant . Perceived exclusion showed a negative effect on motivational control . In other words, perceived exclusion primarily influenced online procrastination, but its effects on job search effort and motivational control were also significant. The higher the perceived exclusion, the more the respondent was prone to online procrastination. Concurrently, but to a lesser extent, higher levels of perceived exclusion lead to higher levels of job search efforts and lower levels of motivational control. In regards to the effects of motivational control, we again find strong support for both online procrastination and job search effort. Motivational control negatively affected online procrastination and positively affected job search effort . Participants with stronger motivational control were less prone to online procrastination and more active in seeking a new job than participants with weaker motivational control. We presumed job search effort to be more of a challenge in the context of online procrastination and therefore expected that online procrastination would have an effect on job search effort. However, online procrastination had no significant effect on job search effort, indicating that online procrastination is not detrimental for an unemployed individual's job-seeking efforts. In total, the examined factors accounted for 3.6% of the observed variance in motivational control, 23.8% of the variance in online procrastination, and 11.6% of the variance in job search effort. Hence, of all the examined factors, our model has the highest explanatory power for online procrastination, revealing that social exclusion and motivational control are important antecedents of online procrastination. --- Discussion Our analysis sought to determine whether the Internet and its opportunities for diversion have negative effects during periods of unemployment. The data indicated that online procrastination is present among the unemployed and is fuelled by their current situation. The perceived exclusion and motivational control of unemployed individuals are important factors in explaining eventual procrastination. Online procrastination is among the behaviours that are often implicitly regarded as problematic and detrimental for self-conscious emotions. Prior research has shown that for those engaging in procrastination, the impression of needlessly delaying tasks triggers more regret, apprehension, and feelings of guilt than enjoyment . Feelings of guilt, in turn, have been reported to frequently reduce recovery experience, media enjoyment and overall well-being after media use . However, positive effects, such as the short-term satisfaction of hedonic needs or recovery from stress and strain with media used for procrastination, have also been observed . Since occasional online procrastination is an almost ubiquitous behaviour , it is important to question the extent to which procrastination is indeed problematic, not only with regards to self-conscious emotions but particularly concerning job search behaviour as a correlate for subsequent reemployment. The results of the structural model have shown on one hand that in the context of unemployment, the increased amount of available time and the perception of social exclusion appear to amplify problematic Internet use patterns. On the other hand, procrastination may not impact job search effort. Thus, the two activities are not mutually exclusive; instead, it is possible that even if some individuals use the Internet to defer job-searching activities, the overall effort exerted to find a job may not suffer. Even when large periods of time are procrastinated away, it appears that a sufficient amount of the time budget remains to achieve a certain level of jobsearch results using the Internet. Therefore, the established negative connotation of procrastination in the context of unemployment may not universally hold. The data from our study provide insight into how new media and technologies influence methods of coping with unemployment. Contrary to the rather negative connotation of the concept, our results reveal that procrastination is not a purposeless form of Internet usage. Procrastination does not exert direct effects on observed levels of job search efforts throughout the unemployment experience of Internet users. According to our study, procrastination tendencies do not interfere with the success of the transition phase. The study has some limitations. First, all constructs were measured as self-reporting scales and items. At first glance, this method might be viewed as a limitation of the validity of our results. However, we controlled for social desirability, and there was no significant correlation between the social desirability scale and the constructs we employed. Selfreported data can be problematic in situations of unemployment, as the procrastinators might have ego-protection incentives to deceive themselves about the effects of their procrastination on their job search. If the procrastination takes place in the context of job searching, they may report off-task activity as being active. However, the method of self-reporting has some viability as a next-best approach, not least because the perception of exclusion, job search effort, and procrastination are all in themselves highly subjective constructs. Future research gathering additional data with real time measurements of actual computer use in addition to selfreport would help to shed more clarity on this. Second, online media use can be detrimental to employment in ways other than online procrastination as it was measured in this study, e.g., through mere time displacement, overuse of escapist coping through the Internet, or increased feelings of social isolation through passive social media use. Nonetheless, some amount of procrastination might help individuals to cope with unemployment. For instance, indulging in activities that primarily satisfy the desire to escape may actually have certain positive effects. For example, while using social media networks to delay other tasks, one might find informational or emotional support for coping with unemployment, which may in turn prove to be an asset with respect to motivation control and job search effort. Unfortunately, our research design is not yet capable of assessing the use of specific online activities. To identify and analyse the role of these potential positive effects, further research might focus on the specific applications that individuals use when procrastinating to ensure that time spent online is indeed less about time wasted and more about time wasted well. --- Using the Internet is a way to forget about the things I must do but don't really want to do. --- Job Search Effort --- JSE_1 In the last quarter, I was searching for a job on the Internet. JSE_2 I am very active in searching for a job. JSE_3 I plan to continue actively searching for a job. JSE_4 In the future, I will use the Internet even more in my job search. JSE_5 I am always working on further improving my job search.

This article examines the argument regarding whether perceived social exclusion during unemployment leads to procrastination through online media, which in turn lessens the job search efforts of the unemployed. Based on data from 386 unemployed Internet users, we argue that online procrastination plays an important role in the lives of the unemployed but has no immediate effects on their perceived job search efforts. Contextual factors play an important role; that is, the amount of motivational control that the unemployed can muster exerts a strong effect on job search efforts. Generally, unemployed Internet users with low motivational control struggle more with their job search efforts. Thus, the recreational use of online media as such is not necessarily detrimental to the efforts invested in finding a job; instead, online skill-building and motivational support are key antecedents to better empower the unemployed to use the Internet productively for finding reemployment.

time well wasted online procrastination in periods of unemployment introduction in recent years discussions have increasingly focused on whether the internet makes us more easily distracted and whether it leads to increased procrastination which is to voluntarily delay an intended course of action despite expecting to be worse off for the delay a typical procrastination scenario is the needless delay of pending tasks with the excuse of carrying them out later such behaviour seems to be widespread however prior research has demonstrated that the frequent and habitual delay of actions andor decisions is highly dysfunctional several studies on the motivations for media use have shown that procrastination is one reason why individuals use entertainment media media is perceived as enjoyable and distracting and it is frequently used during working and leisure time regarding the internet research has revealed that online media is a frequently used but detrimental tool for procrastination while research has examined procrastination in the workplace few studies have evaluated such behaviour in the context of unemployment against this background we seek to explore whether the internet might tempt unemployed users to procrastinate online rather than searching for a new position we thus seek to extend existing research on nonworkrelated internet usage in the workplace that shows the potential for antiproductive tendencies such as cyberslacking or cyberloafing to a situation that is similar but involves the opposite of working per se unemployment being unemployed is an openended situation in that an unemployed person typically has a substantial amount of free time with little structure searching and applying for reemployment may take some time but there are also long stretches of the day spent waiting with much less tangible guidance on what activities to perform particularly compared with being employed frequently much time is spent at home and this time is often filled with media usage historically the classic case of media usage has been watching television however as computers and the internet have become more important online media has increasingly become a new pastime with new benefits and challenges on the one hand the internet may contribute to alleviating the downside of being unemployed and help establish new possibilities to overcome unemployments negative consequences by facilitating online relationships and finding new employment opportunities on the other hand spending time online may also prove to be a doubleedged sword many heavy internet users experience problems in their interpersonal relationships and use the internet as their primary means of alleviating stress and depression because the computer is typically easily accessible it may be tempting to use it to procrastinate subjectively procrastination might be a reasonable activity if searching for a job is considered frustrating online procrastination might help by detaching from the situation on the other hand the ubiquitous availability of media content is linked to challenges for media users selfcontrol capacity distraction from important but unpleasant tasks can be easily achieved through the internet inhibiting the achievement of longterm goals and obligations thus media can be potentially threatening for selfcontrol and goal achievement in everyday life on that account media related procrastination is prevalently conceptualized as a behavioural outcome of failed selfregulation a low selfcontrol capacity increases the likelihood of giving in to shortterm temptations instead of engaging in intended but postponed rewarding activities online procrastination may thus disadvantage the unemployed due to a failure of selfcontrol against this background the present study aims to better understand the internet usage of the unemployed and whether they risk using the medium to spend too much time procrastinating online more specifically we are interested in the following finding the antecedents of online procrastination during unemployment and the points of influence as well as determining the outcomes of online procrastination in terms of paving the way for reemployment through efforts spent on searching for a new position literature and research model periods of unemployment particularly those that last longer than six months are associated with significant deleterious effects on psychological and physical wellbeing unemployment is linked to mental health problems including depression somatisation anxiety and substance abuse unemployment creates a psychological void that people aim to fill by finding different outlets for selfexpression and attempting to maintain their psychological wellbeing among other deprivations unemployment creates a lack of identity and time structure and many unemployed people miss the sense of purposeful and structured time use that they had as part of the labour market when unemployed individuals tend to feel their best when they try to keep busy continue their routines and maintain a sense of purpose that approximates a work situation and that provides them with latent benefits related to higher psychological wellbeing some unemployed individuals may use the internet for procrastination purposes to reduce stress and alleviate the negative feelings that may be associated with unemployment some research has shown that increased internet usage may be associated with decreased levels of loneliness and depression as well as increased levels of social support and selfesteem however turning to the internet to procrastinate may oftentimes lead to the overuse of the medium which can be to the detriment of everyday functionality from a displacement perspective internet use may detract from the time that is available for more traditional social activities such as facetoface socialising because time is a limited resource that must be budgeted among competing activities however from a coping perspective we might argue for a more positive interpretation of media procrastination than its traditional understanding according to reinecke and hofmann the almost permanent availability of media content is associated with many benefits for selfregulation media exposure offers the possibility of regulating mood and arousal supports intrinsic need satisfaction and facilitates recovery from stress and strain problemfocused coping involves seeking to change or eliminate the stressor itself whereas emotionfocused coping involves seeking to reduce or manage the emotional consequences associated with the stressor in nearly all stressful occurrences both approaches are employed the question is whether the emotional coping response of online procrastination is detrimental to the job search process that aims at solving the problem of unemployment in the following we propose the following hypothesis model unemployment often leads to both material and social deprivation being unemployed is financially straining and moneyrelated sorrows are common socially being unemployed makes it increasingly difficult to maintain contact with friends particularly work colleagues social isolation which is a correlate of subjectively experienced loneliness is a stressor and risk factor for mental health problems studies have noted that feeling powerlessness or meaninglessness or feeling ideologically or socially isolatedand deprived leads to the desire to escape frequently mass media are the means used to satisfy this desire in periods of unemployment with more time available during the day but with limited financial resources friends at their jobs and damaged selfesteem much time is spent at home and using media by combining the findings of prior research we expect the perceived exclusion experienced through unemployment to lead to higher levels of online procrastination therefore we formulate the following hypothesis h1 social exclusion is positively related to procrastination in the literature there is no clear evidence that social exclusion is directly caused by unemployment but it appears to be contingent upon broader cultural patterns however for those unemployed individuals who feel excluded because of a lack of social support networks or general hopelessness about the success of their job search exclusion may negatively affect happiness and wellbeing these negative effects may be detrimental to the speed and success of finding reemployment thus research on reemployment has shown that positive emotions such as enthusiasm energy and alertness are good for motivational control and that maintaining a positive selfperception as well as keeping ones options open for finding reemployment leads to greater commitment to the job search process research has also shown that individuals who feel excluded show distorted time perceptions an emphasis on the present rather than on the future lethargic passivity and an avoidance of selfawareness there are different hypotheses regarding the effects of such perceived exclusion one opinion the reconnection hypotheses posits that individuals respond to exclusion with increased motivation to build social bonds however this motivational drive is only favoured when conditions exist for actual interaction to occur or when such interaction is anticipated to occur of course these conditions do not characterise the reemployment process but might apply to online contacts that might not be employment related we thus assume that perceived exclusion has predominately negative effects both on motivational control as an antecedent and on job search effort as an outcome accordingly we propose the following two hypotheses h2 social exclusion is negatively related to motivational control h3 social exclusion is negatively related to job search effort finding employment and emerging from unemployment requires extensive selfregulation in terms of both effort and emotion selfregulation of effort is needed to sustain a job search over time despite continued rejections and the monotony of the process selfregulation of emotion is needed when individuals feel discouraged angry worried or frustrated about the multiple stressors involved in searching for a job and in unemployment in general to abstain from procrastination and maintain high levels of effort and persistence in an activity unemployed individuals must adopt selfinitiated processes such as goal setting planning and envisioning goal accomplishment according to turban et al unemployed individuals with stronger motivational control tend to show goaldirected behaviour and are less likely to procrastinate based on these findings the following hypothesis is proposed h4 motivational control is negatively related to procrastination during a job search job seekers must use selfregulation strategies to manage thoughts and behaviours to accomplish job search tasks in a timely manner and to maintain effort during the job search motivational control is important in situations in which motivation tends to fade such as during an extended job search and this control is positively related to job search intensity selfregulation is needed particularly with respect to the attainment of distal goals that involve lengthy processes consisting of tasks low on intrinsic motivation and high on extrinsic motivation the stronger a job seekers motivation to obtain a job the more likely it is that heshe will allocate the resources needed to selfregulate and to conduct a highquality search consistent with these findings we formulate the following hypothesis h5 motivation control is positively related to job search effort overcoming unemployment is a process that requires many actions on the part of the unemployed including searching for employment opportunities acquiring information about such opportunities and actively applying for job openings job search behaviour is a major determinant of finding employment job seekers must engage in goaldirected behaviours including completing applications and replying to potential employers in a timely manner based on prior research on the relationship between online procrastination and detrimental outcomes we assume that online procrastination is largely detrimental to the job search process the process of seeking a job is largely selforganised and selfmanaged and involves setting a goal then planning monitoring and evaluating the progress made towards the goal kanfer et al noted that job search behaviour can be evaluated with respect to intensity of effort and content direction additionally the type and quality of job search activities performed is an important dimension of a job search job search activities are rarely considered enjoyable and entertaining instead the job search process is generally experienced as difficult and filled with negative emotions based on the above considerations the following hypothesis is proposed h6 procrastination is negatively related to job search effort methods sample description accessing the client database of the german federal employment agency we conducted an analysis to determine how those seeking work use the internet in general and social media in particular to reenter the job market and to determine which factors affect the job search efforts of the unemployed data were collected from clients of the german federal employment agency who were randomly selected from a database that included all unemployed people in germany at that time and who were invited to participate in a telephonebased survey during february and march 2012 no incentive was offered to the participants overall 2414 unemployed individuals completed a computerassisted telephone survey from the representative sample we were looking for regular internet users among the unemployed of all participants 386 were identified as regular users these participants were characterised by broad experience a high frequency of use and a wide range of applications the remaining participants were identified as inexperienced and infrequent users utilizing few applications therefore they were not considered in the analysis compared with the overall sample in which a gender and region composition of the sample that was representative of the german general population was ensured by defining quotas for these attributes the resulting subsample of the regular users differs in its sociodemographic composition male participants are overrepresented at 570 age is below the population average 674 of participants are between 18 and 25 years old and 269 are between 26 and 40 years of age most respondents hold a high school diploma that allows no direct access to a university or college the subsamples were further tested for differences in job importance and selfefficacy table 1 summarises the profiles and demographics of the respondents table 1 sample profile about here the questionnaire was based on measures on internet usage job search experience and social psychology in the literature the scale for perceived exclusion was adapted from bude and lantermann motivational control was measured using the personal mastery subscale of the motivational trait questionnaire the procrastination construct was derived from davis et al the scale for job search behaviour was adapted from caplan et al the precise phrasing of all items was adjusted based on a pilot test in which 40 unemployed persons were asked to comment on the wording of the listed items each item was rated by the survey participants based on a fivepoint likert scale measurement model overall we considered four latent constructs with a total of 15 items in the measurement model first we conducted a confirmatory factor analysis to test for unidimensionality and scale reliability on the item and construct levels on the construct level we used cronbachs alpha composite reliability and average variance extracted to assess the internal consistency of the scales table 2 lists the results of this assessment after this procedure one item was eliminated from the job search scale because its inclusion decreased the reliability coefficients after this adjustment the results from the α cr and ave tests were above the required criterion values as shown in table 3 the measurement model has discriminant validity overall these statistics indicate a good fit for the model results structural model based on our hypotheses we initially estimated the model shown in figure 1 with the statistical software mplus the results include the standardised coefficients based on robust maximum likelihood estimation and the total variance explained for each dependent construct for all participants without missing values as shown in table 4 the model provided good fitness indices all but one of the hypothesised and estimated paths were significant figure 1 structural equation model on the antecedents of job search efforts and procrastination about here table 4 fit indices about here in the overall model we find strong confirmation for our hypotheses perceived exclusion positively affected both online procrastination and job search effort perceived exclusion had a strong significant effect on online procrastination although the effect on job search effort was both weaker and less significant perceived exclusion showed a negative effect on motivational control in other words perceived exclusion primarily influenced online procrastination but its effects on job search effort and motivational control were also significant the higher the perceived exclusion the more the respondent was prone to online procrastination concurrently but to a lesser extent higher levels of perceived exclusion lead to higher levels of job search efforts and lower levels of motivational control in regards to the effects of motivational control we again find strong support for both online procrastination and job search effort motivational control negatively affected online procrastination and positively affected job search effort participants with stronger motivational control were less prone to online procrastination and more active in seeking a new job than participants with weaker motivational control we presumed job search effort to be more of a challenge in the context of online procrastination and therefore expected that online procrastination would have an effect on job search effort however online procrastination had no significant effect on job search effort indicating that online procrastination is not detrimental for an unemployed individuals jobseeking efforts in total the examined factors accounted for 36 of the observed variance in motivational control 238 of the variance in online procrastination and 116 of the variance in job search effort hence of all the examined factors our model has the highest explanatory power for online procrastination revealing that social exclusion and motivational control are important antecedents of online procrastination discussion our analysis sought to determine whether the internet and its opportunities for diversion have negative effects during periods of unemployment the data indicated that online procrastination is present among the unemployed and is fuelled by their current situation the perceived exclusion and motivational control of unemployed individuals are important factors in explaining eventual procrastination online procrastination is among the behaviours that are often implicitly regarded as problematic and detrimental for selfconscious emotions prior research has shown that for those engaging in procrastination the impression of needlessly delaying tasks triggers more regret apprehension and feelings of guilt than enjoyment feelings of guilt in turn have been reported to frequently reduce recovery experience media enjoyment and overall wellbeing after media use however positive effects such as the shortterm satisfaction of hedonic needs or recovery from stress and strain with media used for procrastination have also been observed since occasional online procrastination is an almost ubiquitous behaviour it is important to question the extent to which procrastination is indeed problematic not only with regards to selfconscious emotions but particularly concerning job search behaviour as a correlate for subsequent reemployment the results of the structural model have shown on one hand that in the context of unemployment the increased amount of available time and the perception of social exclusion appear to amplify problematic internet use patterns on the other hand procrastination may not impact job search effort thus the two activities are not mutually exclusive instead it is possible that even if some individuals use the internet to defer jobsearching activities the overall effort exerted to find a job may not suffer even when large periods of time are procrastinated away it appears that a sufficient amount of the time budget remains to achieve a certain level of jobsearch results using the internet therefore the established negative connotation of procrastination in the context of unemployment may not universally hold the data from our study provide insight into how new media and technologies influence methods of coping with unemployment contrary to the rather negative connotation of the concept our results reveal that procrastination is not a purposeless form of internet usage procrastination does not exert direct effects on observed levels of job search efforts throughout the unemployment experience of internet users according to our study procrastination tendencies do not interfere with the success of the transition phase the study has some limitations first all constructs were measured as selfreporting scales and items at first glance this method might be viewed as a limitation of the validity of our results however we controlled for social desirability and there was no significant correlation between the social desirability scale and the constructs we employed selfreported data can be problematic in situations of unemployment as the procrastinators might have egoprotection incentives to deceive themselves about the effects of their procrastination on their job search if the procrastination takes place in the context of job searching they may report offtask activity as being active however the method of selfreporting has some viability as a nextbest approach not least because the perception of exclusion job search effort and procrastination are all in themselves highly subjective constructs future research gathering additional data with real time measurements of actual computer use in addition to selfreport would help to shed more clarity on this second online media use can be detrimental to employment in ways other than online procrastination as it was measured in this study eg through mere time displacement overuse of escapist coping through the internet or increased feelings of social isolation through passive social media use nonetheless some amount of procrastination might help individuals to cope with unemployment for instance indulging in activities that primarily satisfy the desire to escape may actually have certain positive effects for example while using social media networks to delay other tasks one might find informational or emotional support for coping with unemployment which may in turn prove to be an asset with respect to motivation control and job search effort unfortunately our research design is not yet capable of assessing the use of specific online activities to identify and analyse the role of these potential positive effects further research might focus on the specific applications that individuals use when procrastinating to ensure that time spent online is indeed less about time wasted and more about time wasted well using the internet is a way to forget about the things i must do but dont really want to do job search effort jse1 in the last quarter i was searching for a job on the internet jse2 i am very active in searching for a job jse3 i plan to continue actively searching for a job jse4 in the future i will use the internet even more in my job search jse5 i am always working on further improving my job search

this article examines the argument regarding whether perceived social exclusion during unemployment leads to procrastination through online media which in turn lessens the job search efforts of the unemployed based on data from 386 unemployed internet users we argue that online procrastination plays an important role in the lives of the unemployed but has no immediate effects on their perceived job search efforts contextual factors play an important role that is the amount of motivational control that the unemployed can muster exerts a strong effect on job search efforts generally unemployed internet users with low motivational control struggle more with their job search efforts thus the recreational use of online media as such is not necessarily detrimental to the efforts invested in finding a job instead online skillbuilding and motivational support are key antecedents to better empower the unemployed to use the internet productively for finding reemployment

Introduction The purpose of this discussion piece is to reflect on the environmental, health, and ethical dimensions of the impacts of intensive natural resource extraction on Northern British Columbia in Canada. Within the province of BC, northern BC comprises over 70% of the landmass of the province, less than 10% of the total population, over 50% of the Indigenous population and is the site of approximately 65% of all the active or proposed projects related to intensive resource extraction and manufacturing [1]. In this region, whether from mining, fishing, forestry, or oil and gas, communities are directly and indirectly impacted by intensive resource extraction . The Northern Health Authority, responsible for the public health of this region, describes that resource projects can have not only positive impacts such as economic growth but also negative impacts on health as it puts pressure on health care infrastructure and services, places strains on communities, intensifies the impacts of the socio-economic determinants of health and increases environmental health impacts [2]. This region is, therefore, a clear illustration of the ways in which human health and wellbeing is shaped not only by the social and economic contexts and conditions within which people are "born, live, learn, love, work, play, worship, and age" [3] but also by ecological systems and services. In other words, in Northern BC we can clearly see that people's health not only begins in their "homes, schools, workplaces, neighborhoods, and communities" [4] but also in the --- Materials and Methods Literature reviews on the subjects of the public health impacts of intensive resource extraction on health and on treaty rights of First Nations groups in the area were conducted and the findings presented in the third Results Section. Both research articles and policy documents were consulted in this analysis. We rely on a more traditional philosophical analysis to highlight key items for discussion and to suggest ways to frame this issue that can be used to guide further investigations, which is found in the fourth Discussion and fifth Conclusion Sections. Our framework for philosophical analysis is drawn from contemporary discussion in Philosophy of Science, including discussions of mechanisms as a form of scientific explanation [10][11][12][13], discussions of philosophy of ecosystems [14][15][16], and discussions of values in science [17,18]. This approach is easily applied to environmental issues such as ecosystem harm, and to the ways in which differences between different indicator methodologies are value-laden in their effects, since it was developed to be applied to exactly those kinds of cases. We extend this approach by analyzing health and social justice indicators in terms of mechanisms that are analogous in relevant ways to the environmental ones. This utilizes a familiar concept of intersectionality [19] but implements it in a new approach by applying it to axes along which to measure harm, with identifiable biological and social mechanisms by which these axes interact at their intersections. --- Results This section provides more detailed information on the case study. We propose three key axes along which to identify types of potential harm that can vary in severity. These three axes are: Environment; Health; and Social Justice. Part of our framing of the results in this way is meant to highlight ethical considerations pertaining to the methodologies used to measure impacts along each axis. --- Blueberry River First Nations The Blueberry River First Nation's peoples are Dane-zaa and are part of the Northern Athapaskan language group, although this nation now includes both Dane-zaa and Cree speakers [20] . Today, the primary BRFN Indian Reserve is located at Blueberry River, approximately 80 km northwest of Fort St. John, BC . A second BRFN Indian Reserve is located at the southern half of Beaton River . These two reserves are also nested within other jurisdictional and geographical boundaries including the Peace Region in BC and Treaty No. 8, established in 1899 [22] . The Treaty 8 area is comprised of 324,900 sq. miles of territory which spans "the northern half of Alberta, the northeast quarter of British Columbia, the northwest corner of Saskatchewan, and the area south of Hay River and Great Slave Lake in the Northwest Territories" [23]. The Peace River region has long been acknowledged to contain a wealth of natural resources. Scholars observe that, in the late 19th century, Treaty 8 was demarcated "partially in response to the growing tensions between Aboriginal peoples and settlers over land and resources [24] . Against a history of colonization, pulses of pressure on this area have also occurred; for example, particular requests by the government were made to the Dane-zaa to relinquish further territory and rights to natural resources after both the First and Second World War [25] , [26] , [27] . Today, the impacts of a history of intensive resource extraction are increasingly visible as this single land base has undergone widespread change as it is here that a number of industrial interests converge. --- Environmental Impacts In order for a large scale project to be executed, such as a mine, pipeline, or dam, approval is required, which includes undertaking an Environmental Assessment intended to function as a cooperative endeavor between provincial and federal processes. With any large scale development in Canada, the proponent is also required to conduct consultations with the general public as well as with impacted Aboriginal groups . Projects are approved on a case by case basis, once they have met the required conditions. The impact of each project is thus considered separately from that of other projects in the area, even if they will have overlapping impacts on the same communities, geographical areas, and ecosystems. Cumulative impact of the totality of projects, either those currently active or those active plus those that have already been completed, is not taken into account as part of the EA. This disaggregated approach stands in stark contrast to the realities of intensive resource development occurring in Canada, including in Northern BC. Scholars following these developments describe that the majority of the "mature forests, rivers, wetlands, and other ecosystems have already been changed by logging, mining, oil and gas development , water withdrawals and stream crossings, large-scale hydro development , agricultural conversion and other industrial developments" [28] . Others note that this region harbours substantial sources of resources and potential energy generation which will continue to --- Environmental Impacts In order for a large scale project to be executed, such as a mine, pipeline, or dam, approval is required, which includes undertaking an Environmental Assessment intended to function as a cooperative endeavor between provincial and federal processes. With any large scale development in Canada, the proponent is also required to conduct consultations with the general public as well as with impacted Aboriginal groups . Projects are approved on a case by case basis, once they have met the required conditions. The impact of each project is thus considered separately from that of other projects in the area, even if they will have overlapping impacts on the same communities, geographical areas, and ecosystems. Cumulative impact of the totality of projects, either those currently active or those active plus those that have already been completed, is not taken into account as part of the EA. This disaggregated approach stands in stark contrast to the realities of intensive resource development occurring in Canada, including in Northern BC. Scholars following these developments describe that the majority of the "mature forests, rivers, wetlands, and other ecosystems have already been changed by logging, mining, oil and gas development , water withdrawals and stream crossings, large-scale hydro development , agricultural conversion and other industrial developments" [28] . Others note that this region harbours substantial sources of resources and potential energy generation which will continue to attract industrial interest. Recent developments include, "2 large-scale hydroelectric dams, 11 mines , 8000 oil and gas well sites, 8 wind farms, various support facilities, 10,000 pipelines, numerous power lines, and smaller uses such agriculture and guide-outfitting" [29] . The BRFN reserve is notably impacted by such this range of industrial activity and the federal and provincial ambitions that enable them [28] . For example, "more than one-half of all the oil and gas facilities are within the Beatton watershed" [30] and in this northeastern part of the territory, 90.8% of the territory has been disturbed as have the community, which has already been evacuated due to real or potential gas leaks in the pipelines [28] . Chief Yahey shares: "Blueberry's ancestors would not recognize our territory today. It is covered by oil and gas wells, roads, pipelines, mines, clear cuts, hydro and seismic lines, private land holdings, and waste disposal sites, amongst other things...The pace and scale of development have accelerated in the last 25 years, and are now at unprecedented levels." [31]. While each sector is influenced by industrial and economic push and pull factors, the recent bust in oil prices has overall dampened activity in the region. Nevertheless, the impacts of exploration have already been tremendous as has been the development of supporting infrastructure. For example, while there are currently 19 proposals for LNG terminals along B.C.'s coast and only a few terminals will actually reach completion, their creation alone places considerable pressure to increase the development of B.C.'s shale gas resources in the northeast-one of many forms of IRE in the region. In addition, for communities farther up the supply chain, the loss of revenue have also been significant. Offering frameworks for contextualizing and integrating the impacts of liquid natural gas, for example, the Cumulative Impacts Research Consortia proposes that one way to understand the impact on communities is to consider how they are distributed across the supply chain using the schema of "upstream" gas producing regions , "midstream" transportation areas , and "downstream" processing and export communities [32]. The figure below compares industrial activity in the BRFN territory as of 2015 [33] . While each project represented as a dot on the map has been approved separately, for the communities impacted, the impacts accrue. The cumulative impacts, the community alleges, have had adverse impacts to the "land, water, fish and wildlife" in their territory [34] which has resulted in the loss, displacement and the curtailment of their ability to exercise treaty rights [34] . The rate and scale of industrial development has accelerated over time, with implications for how effectively humans, animals, and ecosystems will be able to adapt to the changes occurring. The BRFN Land Stewardship Framework documents some of these changes and underscores that the BRFN territory has one of the highest burdens of IR in all of BC [35]. For example, in 1950 less than 50% of the Blueberry watershed was disturbed yet by 2016, 84% of the whole territory is within 500 m of industrial disturbance [36] . The BRFN and the David Suzuki Foundation commissioned Ecotrust Canada to produce, based on government data and existing maps, the "Atlas of Cumulative Landscape Disturbance in the Traditional Territory of Blueberry River First Nations" [37]. This report finds that, to date, within BRFN territory, the BC government has authorized the construction of more than "2600 oil and gas wells, 1884 km of petroleum access and permanent roads, 740 km of petroleum development roads, 1500 km of new pipelines and 9400 km of seismic lines and approximately 290 forestry cutblocks were harvested" [37] . David Suzuki, describes that all of this development one encounters road, seismic line, or industrial infrastructure within every half a kilometer and emphasizes that: "A natural functioning landscape with species including large predators requires a maximum density limit of 0.6 km of linear disturbances-roads and seismic and transmission lines-per square kilometer. Blueberry River has 2.88 km of linear disturbance per square km, totaling 110,300 km-including 45,603 km of seismic lines constructed over the past 10 years, nearly eight times the length of the Trans-Canada Highway from Vancouver to Halifax" [38]. The impacts of IRE extraction are of concern at present but will also have an effect on future generations-a fact which underscores the moral imperative of addressing these issues with focus and a sense of urgency, particularly in light of the possibility that thresholds and tipping points in the region may have already been reached. One of the many projects that is having an impact is BC Hydro's Site C Clean Energy Project [39,40] which is proposed to be an earthfill dam and hydroelectric generating station on the Peace River in northeast B.C. The plan is for the dam to be 1050 m long and 60 m high above the riverbed while the Site-C reservoir is intended to stretch 83 km long and extend the current width of the river by 2-3 times. This will require the flooding of 5430 hectares of land [27] . While the The impacts of IRE extraction are of concern at present but will also have an effect on future generations-a fact which underscores the moral imperative of addressing these issues with focus and a sense of urgency, particularly in light of the possibility that thresholds and tipping points in the region may have already been reached. One of the many projects that is having an impact is BC Hydro's Site C Clean Energy Project [39,40] which is proposed to be an earthfill dam and hydroelectric generating station on the Peace River in northeast B.C. The plan is for the dam to be 1050 m long and 60 m high above the riverbed while the Site-C reservoir is intended to stretch 83 km long and extend the current width of the river by 2-3 times. This will require the flooding of 5430 hectares of land [27] . While the project is marketed as a "clean energy project" a study on the role of the Peace River Region in mitigating against climate change shows that the construction of Site C will not only disrupt the ability of the region to sequester Green House Gases in the valley's plants and soils but will also produce significant GHG emissions in its construction, which is planned to span approximately 10 years [39]. BC Hydro, in its efforts to develop the proposed Site C Dam, reports it has conducted over 500 consultations. It also initiated an EA which is intended to produce an evidence-based understanding of the baseline conditions and background information about the potential impacts of the project and to aid in planning to address their effects. Following the protocols laid out for Environmental Assessment in BC, 22 valued components were identified for the EA which fall under five "pillars": environmental, economic, social, heritage, and health [37] . BC Hydro confirms that the VC assessment of potential effects was conducted by identifying which pillars that would be effected by the proposed project and then to ascertain which are the technically and economically feasible mitigation strategies. The environmental assessment certificate was eventually approved subject to 77 conditions. However, for the BRFN, the building of this dam would represent the potential loss of "5000 hectares of productive land base" which would "lead to the effective loss of rights to hunt elk, moose, caribou, and other animals; loss of bear habitat; mercury contamination of fish; downstream effects; and cumulative effects from the Project in combination with extensive existing and future developments, particularly oil and gas development in their territory..." [37] . With approximately 73% of the industrial disturbances occurring with 250-500 m of BRFN traditional territory, the impacts on human, animal, and ecological health are cumulative and require urgent response. --- Health Impacts Current work is explicitly exploring the key areas of impact on human health which include physiological, psychological, cultural/spiritual, and ecological domains [41,42]. Agencies responsible for the public health and wellbeing of people in northern BC, the Northern Health Authority , and the First Nations Health Authority , are reporting increased public health service needs in boom times where there are intensive resource extraction initiatives and large temporary work camps. Health challenges also emerge during bust eras when the sector goes into decline and communities are left in economic and social turmoil, housing and food instability increases, mental health issues can lead to higher rates of substance misuse as well as domestic and sexual violence and related infection and trauma sequela [43]. At the same time that the health authorities are trying to assemble a picture of the precise health needs of both Indigenous and non-Indigenous communities in order to respond to the increasing rate and scale of emergent requests, research attention is being placed on understanding the mechanisms through which public health is and may be impacted by intensive resource extraction writ large as well as by boom and bust cycles more specifically. For the BRFN, however, understanding the health impacts to the community requires considering not only the environmental, social, and cultural health impacts generally but also the three cornerstone impacts expressed within Indigenous Determinants of Health scholarship, which are the impacts of IRE on the community's: 1. Connection to land; 2. Cultural continuity; and 3. Ongoing impacts of colonization [44]. It also underscores the importance of mainstream health services responding in culturally sensitive and regionally relevant ways to existing and emergent health issues. --- Social Justice Impacts The BRFN, despite all this development, continue to be not only culturally and spiritually connected to the Peace River but also reliant upon the land [37] . One thing that has remained constant over the centuries is that country food, including wildlife, and traditional practices remain an important part of life and survival for BRFN. For example, the BRFN hunt both sides of the Peace River for moose, elk, deer, bear, mountain sheep, and caribou [27]. They also fish for a range of species including dolly varden, rainbow trout, bull trout, kokanee, jackfish/pike, pickerel/walleye, suckers, whitefish, lingcod, and grayling [25] . For modern Indigenous peoples, "the land remains an important resource for subsistence purposes, as well as the foundation of their way of life, culture, and identity" [10] . Olson and DeRoy underscore that their research reinforces the message that "the ability of BRFN members to practice their treaty rights has been significantly impacted by industrial development in and around BRFN territory [10] . They go on to illustrate that, in order to exercise their treaty rights, for example to "hunt, trap, fish, and practice their traditional mode of life and culture", the BRFN must live within intact ecosystems [10] . Yet, Olson and DeRoy, go on to argue, development initiatives have led to impacts which include "environmental degradation, contamination of the land, air and water, habitat fragmentation, and disturbance of key sites to BRFN , amongst others" [10] . For example, if BC Hydro's Site C dam goes forward, loosing "5000 hectares of productive land base" which would "lead to the effective loss of rights to hunt elk, moose, caribou, and other animals; loss of bear habitat; mercury contamination of fish; downstream effects; and cumulative effects from the Project in combination with extensive existing and future developments, particularly oil and gas development in their territory..." [37] . The inextricable link between animal and environmental health and its core importance to BRFN health underscore that to accurately understand cumulative impacts, the variables considered must reflect the realities and domains of relevance for the people and places that are impacted. For the BRFN, the approach to IRE undertaken by private companies and enabled by federal and provincial governance bodies, led them to file a civil claim against the Province of BC on 3 March 2015 for breaching their fiduciary obligations [34,45]. The first statement of facts in the claim requests that the Province: "stop the consistent and increasingly accelerated degradation of the Nation's traditional territory, and to protect and enforce the Nation's constitutionally protected rights against the cumulative impacts of Crown authorized activities on their traditional territory" [34] . The BRFN alleged that the cumulative effect of industrial development in the Treaty 8 area has made or will soon make it impossible for its members to meaningfully exercise treaty rights such as hunting and fishing and therefore argue that the Crown has breached treaty obligations, as well as interim and permanent injunctions to prohibit the Province from doing or permitting any activities that amount to a further breach" [46] . At the center of this lawsuit is the argument that "the cumulative effect of the industrial development in the Treaty 8 area had become so extensive that it amounted to a violation of a treaty right" [46] . They maintain, "each new incursion becomes more significant than the last. In that sense, any portion of the overall loss in this case, if it is found to exist, should be characterized as irreparable harm" [46] . Court challenges like this by First Nations are made in a context of neoliberal visions to economic growth and clear and consistent track records of a disregard for the social and ecological sustainability in the region. Financial incentives, however, can impact the priorities and practices not only of industries but also can influence how governmental and nongovernmental bodies alike interact with First Nations. For example, BC Hydro recently offered land transfers of more than 5000 hectares to eight First Nations bands; however, there is secrecy around what deal each band has been offered and concern that these arrangements would not only serve to divide First Nations communities but also reduce public access to crown land in the Peace River region [47,48]. At present, there has been a great deal of criticism about BC Hydro's strategy. All of this is occurring in a region dominated by IRE where communities, sometimes reliant on single resource economies, are significantly impacted by national and international economics. Boom and bust economies, whether analyzed through the lens of labor studies or public health, are understood to bring with them myriad problems which significantly affect the most vulnerable, as will be described in the following section. Booms in resource economies are characteristically unstable and typically lead to eventual economic busts and in June 2015, the LNG industry in northern BC entered a bust cycle. In addition to the decline in oil prices and a reduced demand for LNG globally, Canadian LNG can be hard to sell competitively on the international market as it is costly to produce. It is an unenviable task to weather boom and bust cycles. For people living in communities in northern BC, this means being buffeted about by fluctuations in economies over which they have little or no control, it often means that temporary workers leave and those who are long-term residents of host communities are left to find ways to live within towns that are being dismantled socially and economically. For all residents of the region, but most significantly for Indigenous peoples, it also means that the local populations are left to resource essential ecosystem services-such as clean air, water, soil, country foods, and wildlife-from landscapes which have been dramatically altered and often contaminated. --- Discussion With these details in place, we turn to a more philosophical analysis of the three axes we proposed by which to organize the effects of IRE: environmental, health, and social justice. Drawing from this case study background, we consider here how these axes intersect, and highlight mechanisms by which the impact of one axis can be amplified through its interaction with another intersecting axis. The mechanisms discussed here are not exhaustive of the ways in which IRE may impact, but are conceptually illustrative of how the intersections of these already identified axes can serve as the locus to amplify negative impacts from one axis to indirectly perpetuate further negative impacts on the other axes. We also highlight the ethical dimension of choosing to measure harm in terms of individual indicators and individual projects, rather than in terms of cumulative impacts. This use of individual indicators involves a commitment to reductionism that Morrison has argued is an inappropriate methodology for biological systems, including ecosystems [49]. We extend her intersectional analysis to the health and social justice axes. There are ethical implications for practices which use discrete and disaggregated indicators to measure impact, which raises interesting questions about current practices when analyzed through the lens of environmental ethics. A key distinction is that of measuring impact by a collection of indicators, each of which are assessed separately in terms of a threshold, for instance; versus measuring impact cumulatively across a range of indicators where the overall impact of the indicators is considered in addition to whether any individual indicator crosses a threshold. In terms of our case study, along each of the axes, specific indicators are used to operationalize what can and will be measured in terms of the impact of various IRE projects. The indicators thus serve to stand in for the axis as a whole, such that the way in which these indicators are chosen, how they are measured, and how impacts on them are assessed, comprised the methodology used to maintain the integrity of each axis. A commitment to using measures that reflect cumulative harm is thus a commitment to more accurately measure the impact not merely of one project, but of the entirety of the projects. This is a commitment with ethical dimensions, since a full-fledged commitment to prevent or mitigate harm requires consideration of cumulative as well as individual impacts. By dividing the measurement of impacts into single-project EAs, and considering each project in isolation from others in the area, the overall EA and consultation process is in principle unable to reflect the full picture of how IRE is affecting the local health of people, animals, and the environment. There is no further point in any given process for approval in current British Columbia practice such that the full extent of all projects up to that point can be considered. By using individual indicators and/or by failing to have a separate process whereby the cumulative impacts of multiple projects across multiple potential avenues of harm, there is a structural failure of the process for communities like the BRFN. The choice of methodology for measuring harm itself covers over the full extent of the harm, while at the same time appearing to have the appropriate scientific credibility. The ethical implications of measuring each of these three axes can be analyzed in more detail by considering mechanisms by which impacts along one axis reverberate along another axis. The concept of intersectionality was originally developed for understanding how different personal identities or groups to which a person could belong could yield impacts in terms of marginalization that are either magnified or substantially different at intersections of those identities. A classic example is that of marginalization as a member of the group of women, and marginalization as a member of a visible minority, where women who are visible minorities experience marginalization in both of those identities, such that their experiences differ from that of men in the same visible minority, or women who are not a visible minority. This concept of intersection can be applied to these three axes as well, an extension from its original application to identities that highlights a very similar pattern where the axes of impact intersect [50]. Consider the intersection of the Environmental and Health axes. There are mechanisms by which cumulative harm to the environment also results in cumulative harm to local people living in that environment, but does so in ways that cannot be tied to a single project at a time. The BRFN have responded to the environmental assessment for the Site C Dam by conducting their own Traditional Land Use Study pertaining to the Site C Dam [25] . According to BRFN members, cumulative industrial effects include, but are not limited to, the following changes: --- • Less water, dried up springs and creeks ; • Contaminants in water, air, animals, and plants ; and • Access roads, seismic lines, well sites, and other land disturbances [28] . Flooding would increase the release of Methyl Mercury into the water which would likely biomagnify and bioaccumulate in fish and soils [51]. Pollutants such as Methyl Mercury accumulate in watersheds such that individual projects may fall below a specified limit for safe release, while the totality of projects far exceed it. The impact such pollutants have can be direct on individuals, if a local water source becomes contaminated; but can also be indirect, when, for instance, fish or other game animals are consumed that have biomagnified the toxins and thus expose people to dramatically elevated levels. The exposure through animal exposure is an example of an indirect harm on health that is mediated by the direct harm on the environment, and is distinct from the direct harm such pollutants may also have on local people. At this intersection of environment and health axes, the negative effects on environment amplify the negative effects of the pollutants on people. This amplification is heightened when we consider social justice impacts. There are a number of key factors that together result in the abrogation of full Treaty rights for the BRFN bands; the impact of cumulative environmental fragmentation, pollution, and watershed changes impedes the meaningful exercise of treaty rights. It is widely recognized that when a right cannot be meaningfully exercised, it is effectively being violated. The environmental harm is direct when pollutants are released into the watershed. There is indirect amplification of harm on the intersecting health axis, on the health of the local people who may consume animals that have been exposed. There is also further indirect amplification of harm on the intersecting social justice axis through the impedance of full exercise of traditional treaty rights. The right to hunt game and fish freely on these lands is effectively abrogated when the game and fish cannot be safely consumed or even processed in clean waters in traditional ways. Capping pollutant release to certain threshold levels for indicators measuring environmental impacts fails to measure these further impacts on health and social justice. The way in which environmental harm intersects with social justice harm thus includes the inability to freely exercise treaty rights such as hunting and fishing. But this intersection also has further consequences on health, beyond those just noted. If fish and game are not available because of pollutants in the watershed, those food sources must be replaced with some other food source. This can add both less healthy food items, and additional economic burdens because of the displaced traditional food sources. A further factor to consider in social justice impacts is the economic boom and bust cycles associated with the massive IRE projects, many of which bring in large numbers of outside workers for comparatively short periods of time. Large IRE projects set up the conditions for sharp booms at the beginning of such projects, with the scarcities that can come with abrupt competition between sometimes thousands of other workers for commodities and housing. Similarly, sharp busts also occur, with the rapid drawing-down of work force levels and a sudden drop in consumption in the area. Boom and bust cycles preclude the kind of stable normal economic development that the bands might otherwise be able to rely on. As such, their economic autonomy is compromised by the outside pressures of these projects and their workforces in a way that is outside of local control or influence. The biological, physiological, mental, and emotional impacts that are felt by community members as well as those employed by the sector can be multifold but are customarily addressed as discrete problems. The biomedical model promotes the idea of an atomized body which medical specialism have been developed to treat illness and disease. This framework is informed by philosophical ideas such as the Cartesian separation of mind from body. As a result, an illness phenomenon like stress tends to be diagnosed and treated as a health issue unrelated to physical ailments. Not only are different dimensions of the body and health separated from one another, individual cases tend to be disaggregated from collective ones. As a result, for problems to be defined as public health issues, individual issues have to be recorded and their accumulation formally tallied for them to be deemed a cluster of impacts which convey a population-wide effect. In addition, in underfunded and under resourced health care systems, like in Northern BC, the capacity of practitioners to focus on upstream prevention is significantly curtailed, particularly when it is already overwhelmed with the challenge of treating individuals presenting with acute health care challenges. The cumulative character of these multifold health impacts can constitute a systemic social justice issue at this intersection of the health and social justice axes. Finally, consider the very way in which the Blueberry River First Nations bands are consulted for EAs. This is part of the process by which their rights are to be respected in the approval process. This is direct, in that consultation is required by the treaty for such projects. It is also indirect, in that such consultation is the primary vehicle by which the bands may voice concerns over various aspects of a given proposal, such as its potential impact on the watershed or on a particular animal species. However, the sheer volume of such projects also needs to be considered. Each of these projects must involve a consultation with the relevant First Nations bands, but when the scale of the number of projects grows, the consultation process itself becomes an enormous burden on the bands themselves. They are faced with a dubious dilemma. On one horn of the dilemma, they must be involved in a large number of these consultations involving at least some knowledge of each project. This is more than a full time job, even though it is not compensated for in the EA process. The burden of consultation on a project, considered individually, is not particularly onerous. However, the cumulative burden of ongoing consultations for such a large number of projects becomes manifestly burdensome. On the other horn of the dilemma, though, this consultation process is the only avenue within the EA process by which the BRFN may assert control over their territory and by which they can ensure at least some respect for the area. If they do not engage in these consultations in a meaningful way, then problematic projects may get approved that further degrade the meaningful exercise of their treaty rights. Engagement fatigue results from the use of consultation as the primary means of navigating the intersection of these three axes. It places the burden of navigating the IRE with treaty rights disproportionately on the bands themselves. The consultation process itself is required for each project considered individually, thus preventing harm along the social justice axis. Yet considered cumulatively, the sheer number of such consultations can have a different valence as negatively impacting the BRFN along that very same axis. --- Conclusions As noted above, the term "health" has a double meaning in this context, since it applies both to the health of the people in the area as well as to the health of the ecosystems. Each of these kinds of health can be measured separately along its own axis, and when considered separately, each can also be measured using individual indicators on a project by project basis, or in terms of cumulative impacts. There are further mechanisms by which these two axes interact and amplify harm when they intersect, however, so that both the direct and the indirect implications must be considered to get a fuller view. This has a variety of implications for assessing projects for approval using the current procedures in place in BC. The BC government has begun moving to a cumulative effect model for understanding environmental impacts; however, the capacity to use a cumulative impacts framework to understand the health impacts produced at the intersection between ecological and social factors-such as treaty rights-is still in its nascent stages. Furthermore, there will need to be movement to a cumulative impacts framework that is also accompanied by an appropriate intersectional analysis of the three axes identified here-environment, health, and social justice-such that the direct and indirect mechanisms of harm can be identified and mitigated without inducing further burdens of consultation and ensuring engagement fatigue. ---

We consider the case of intensive resource extractive projects in the Blueberry River First Nations in Northern British Columbia, Canada, as a case study. Drawing on the parallels between concepts of cumulative environmental and cumulative health impacts, we highlight three axes along which to gauge the effects of intensive extraction projects. These are environmental, health, and social justice axes. Using an intersectional analysis highlights the way in which using individual indicators to measure impact, rather than considering cumulative effects, hides the full extent by which the affected First Nations communities are impacted by intensive extraction projects. We use the case study to contemplate several mechanisms at the intersection of these axes whereby the negative effects of each not only add but also amplify through their interactions. For example, direct impact along the environmental axis indirectly amplifies other health and social justice impacts separately from the direct impacts on those axes. We conclude there is significant work still to be done to use cumulative indicators to study the impacts of extractive industry projects-like liquefied natural gas-on peoples, environments, and health.

introduction the purpose of this discussion piece is to reflect on the environmental health and ethical dimensions of the impacts of intensive natural resource extraction on northern british columbia in canada within the province of bc northern bc comprises over 70 of the landmass of the province less than 10 of the total population over 50 of the indigenous population and is the site of approximately 65 of all the active or proposed projects related to intensive resource extraction and manufacturing 1 in this region whether from mining fishing forestry or oil and gas communities are directly and indirectly impacted by intensive resource extraction the northern health authority responsible for the public health of this region describes that resource projects can have not only positive impacts such as economic growth but also negative impacts on health as it puts pressure on health care infrastructure and services places strains on communities intensifies the impacts of the socioeconomic determinants of health and increases environmental health impacts 2 this region is therefore a clear illustration of the ways in which human health and wellbeing is shaped not only by the social and economic contexts and conditions within which people are born live learn love work play worship and age 3 but also by ecological systems and services in other words in northern bc we can clearly see that peoples health not only begins in their homes schools workplaces neighborhoods and communities 4 but also in the materials and methods literature reviews on the subjects of the public health impacts of intensive resource extraction on health and on treaty rights of first nations groups in the area were conducted and the findings presented in the third results section both research articles and policy documents were consulted in this analysis we rely on a more traditional philosophical analysis to highlight key items for discussion and to suggest ways to frame this issue that can be used to guide further investigations which is found in the fourth discussion and fifth conclusion sections our framework for philosophical analysis is drawn from contemporary discussion in philosophy of science including discussions of mechanisms as a form of scientific explanation 10 11 12 13 discussions of philosophy of ecosystems 14 15 16 and discussions of values in science 1718 this approach is easily applied to environmental issues such as ecosystem harm and to the ways in which differences between different indicator methodologies are valueladen in their effects since it was developed to be applied to exactly those kinds of cases we extend this approach by analyzing health and social justice indicators in terms of mechanisms that are analogous in relevant ways to the environmental ones this utilizes a familiar concept of intersectionality 19 but implements it in a new approach by applying it to axes along which to measure harm with identifiable biological and social mechanisms by which these axes interact at their intersections results this section provides more detailed information on the case study we propose three key axes along which to identify types of potential harm that can vary in severity these three axes are environment health and social justice part of our framing of the results in this way is meant to highlight ethical considerations pertaining to the methodologies used to measure impacts along each axis blueberry river first nations the blueberry river first nations peoples are danezaa and are part of the northern athapaskan language group although this nation now includes both danezaa and cree speakers 20 today the primary brfn indian reserve is located at blueberry river approximately 80 km northwest of fort st john bc a second brfn indian reserve is located at the southern half of beaton river these two reserves are also nested within other jurisdictional and geographical boundaries including the peace region in bc and treaty no 8 established in 1899 22 the treaty 8 area is comprised of 324900 sq miles of territory which spans the northern half of alberta the northeast quarter of british columbia the northwest corner of saskatchewan and the area south of hay river and great slave lake in the northwest territories 23 the peace river region has long been acknowledged to contain a wealth of natural resources scholars observe that in the late 19th century treaty 8 was demarcated partially in response to the growing tensions between aboriginal peoples and settlers over land and resources 24 against a history of colonization pulses of pressure on this area have also occurred for example particular requests by the government were made to the danezaa to relinquish further territory and rights to natural resources after both the first and second world war 25 26 27 today the impacts of a history of intensive resource extraction are increasingly visible as this single land base has undergone widespread change as it is here that a number of industrial interests converge environmental impacts in order for a large scale project to be executed such as a mine pipeline or dam approval is required which includes undertaking an environmental assessment intended to function as a cooperative endeavor between provincial and federal processes with any large scale development in canada the proponent is also required to conduct consultations with the general public as well as with impacted aboriginal groups projects are approved on a case by case basis once they have met the required conditions the impact of each project is thus considered separately from that of other projects in the area even if they will have overlapping impacts on the same communities geographical areas and ecosystems cumulative impact of the totality of projects either those currently active or those active plus those that have already been completed is not taken into account as part of the ea this disaggregated approach stands in stark contrast to the realities of intensive resource development occurring in canada including in northern bc scholars following these developments describe that the majority of the mature forests rivers wetlands and other ecosystems have already been changed by logging mining oil and gas development water withdrawals and stream crossings largescale hydro development agricultural conversion and other industrial developments 28 others note that this region harbours substantial sources of resources and potential energy generation which will continue to environmental impacts in order for a large scale project to be executed such as a mine pipeline or dam approval is required which includes undertaking an environmental assessment intended to function as a cooperative endeavor between provincial and federal processes with any large scale development in canada the proponent is also required to conduct consultations with the general public as well as with impacted aboriginal groups projects are approved on a case by case basis once they have met the required conditions the impact of each project is thus considered separately from that of other projects in the area even if they will have overlapping impacts on the same communities geographical areas and ecosystems cumulative impact of the totality of projects either those currently active or those active plus those that have already been completed is not taken into account as part of the ea this disaggregated approach stands in stark contrast to the realities of intensive resource development occurring in canada including in northern bc scholars following these developments describe that the majority of the mature forests rivers wetlands and other ecosystems have already been changed by logging mining oil and gas development water withdrawals and stream crossings largescale hydro development agricultural conversion and other industrial developments 28 others note that this region harbours substantial sources of resources and potential energy generation which will continue to attract industrial interest recent developments include 2 largescale hydroelectric dams 11 mines 8000 oil and gas well sites 8 wind farms various support facilities 10000 pipelines numerous power lines and smaller uses such agriculture and guideoutfitting 29 the brfn reserve is notably impacted by such this range of industrial activity and the federal and provincial ambitions that enable them 28 for example more than onehalf of all the oil and gas facilities are within the beatton watershed 30 and in this northeastern part of the territory 908 of the territory has been disturbed as have the community which has already been evacuated due to real or potential gas leaks in the pipelines 28 chief yahey shares blueberrys ancestors would not recognize our territory today it is covered by oil and gas wells roads pipelines mines clear cuts hydro and seismic lines private land holdings and waste disposal sites amongst other thingsthe pace and scale of development have accelerated in the last 25 years and are now at unprecedented levels 31 while each sector is influenced by industrial and economic push and pull factors the recent bust in oil prices has overall dampened activity in the region nevertheless the impacts of exploration have already been tremendous as has been the development of supporting infrastructure for example while there are currently 19 proposals for lng terminals along bcs coast and only a few terminals will actually reach completion their creation alone places considerable pressure to increase the development of bcs shale gas resources in the northeastone of many forms of ire in the region in addition for communities farther up the supply chain the loss of revenue have also been significant offering frameworks for contextualizing and integrating the impacts of liquid natural gas for example the cumulative impacts research consortia proposes that one way to understand the impact on communities is to consider how they are distributed across the supply chain using the schema of upstream gas producing regions midstream transportation areas and downstream processing and export communities 32 the figure below compares industrial activity in the brfn territory as of 2015 33 while each project represented as a dot on the map has been approved separately for the communities impacted the impacts accrue the cumulative impacts the community alleges have had adverse impacts to the land water fish and wildlife in their territory 34 which has resulted in the loss displacement and the curtailment of their ability to exercise treaty rights 34 the rate and scale of industrial development has accelerated over time with implications for how effectively humans animals and ecosystems will be able to adapt to the changes occurring the brfn land stewardship framework documents some of these changes and underscores that the brfn territory has one of the highest burdens of ir in all of bc 35 for example in 1950 less than 50 of the blueberry watershed was disturbed yet by 2016 84 of the whole territory is within 500 m of industrial disturbance 36 the brfn and the david suzuki foundation commissioned ecotrust canada to produce based on government data and existing maps the atlas of cumulative landscape disturbance in the traditional territory of blueberry river first nations 37 this report finds that to date within brfn territory the bc government has authorized the construction of more than 2600 oil and gas wells 1884 km of petroleum access and permanent roads 740 km of petroleum development roads 1500 km of new pipelines and 9400 km of seismic lines and approximately 290 forestry cutblocks were harvested 37 david suzuki describes that all of this development one encounters road seismic line or industrial infrastructure within every half a kilometer and emphasizes that a natural functioning landscape with species including large predators requires a maximum density limit of 06 km of linear disturbancesroads and seismic and transmission linesper square kilometer blueberry river has 288 km of linear disturbance per square km totaling 110300 kmincluding 45603 km of seismic lines constructed over the past 10 years nearly eight times the length of the transcanada highway from vancouver to halifax 38 the impacts of ire extraction are of concern at present but will also have an effect on future generationsa fact which underscores the moral imperative of addressing these issues with focus and a sense of urgency particularly in light of the possibility that thresholds and tipping points in the region may have already been reached one of the many projects that is having an impact is bc hydros site c clean energy project 3940 which is proposed to be an earthfill dam and hydroelectric generating station on the peace river in northeast bc the plan is for the dam to be 1050 m long and 60 m high above the riverbed while the sitec reservoir is intended to stretch 83 km long and extend the current width of the river by 23 times this will require the flooding of 5430 hectares of land 27 while the the impacts of ire extraction are of concern at present but will also have an effect on future generationsa fact which underscores the moral imperative of addressing these issues with focus and a sense of urgency particularly in light of the possibility that thresholds and tipping points in the region may have already been reached one of the many projects that is having an impact is bc hydros site c clean energy project 3940 which is proposed to be an earthfill dam and hydroelectric generating station on the peace river in northeast bc the plan is for the dam to be 1050 m long and 60 m high above the riverbed while the sitec reservoir is intended to stretch 83 km long and extend the current width of the river by 23 times this will require the flooding of 5430 hectares of land 27 while the project is marketed as a clean energy project a study on the role of the peace river region in mitigating against climate change shows that the construction of site c will not only disrupt the ability of the region to sequester green house gases in the valleys plants and soils but will also produce significant ghg emissions in its construction which is planned to span approximately 10 years 39 bc hydro in its efforts to develop the proposed site c dam reports it has conducted over 500 consultations it also initiated an ea which is intended to produce an evidencebased understanding of the baseline conditions and background information about the potential impacts of the project and to aid in planning to address their effects following the protocols laid out for environmental assessment in bc 22 valued components were identified for the ea which fall under five pillars environmental economic social heritage and health 37 bc hydro confirms that the vc assessment of potential effects was conducted by identifying which pillars that would be effected by the proposed project and then to ascertain which are the technically and economically feasible mitigation strategies the environmental assessment certificate was eventually approved subject to 77 conditions however for the brfn the building of this dam would represent the potential loss of 5000 hectares of productive land base which would lead to the effective loss of rights to hunt elk moose caribou and other animals loss of bear habitat mercury contamination of fish downstream effects and cumulative effects from the project in combination with extensive existing and future developments particularly oil and gas development in their territory 37 with approximately 73 of the industrial disturbances occurring with 250500 m of brfn traditional territory the impacts on human animal and ecological health are cumulative and require urgent response health impacts current work is explicitly exploring the key areas of impact on human health which include physiological psychological culturalspiritual and ecological domains 4142 agencies responsible for the public health and wellbeing of people in northern bc the northern health authority and the first nations health authority are reporting increased public health service needs in boom times where there are intensive resource extraction initiatives and large temporary work camps health challenges also emerge during bust eras when the sector goes into decline and communities are left in economic and social turmoil housing and food instability increases mental health issues can lead to higher rates of substance misuse as well as domestic and sexual violence and related infection and trauma sequela 43 at the same time that the health authorities are trying to assemble a picture of the precise health needs of both indigenous and nonindigenous communities in order to respond to the increasing rate and scale of emergent requests research attention is being placed on understanding the mechanisms through which public health is and may be impacted by intensive resource extraction writ large as well as by boom and bust cycles more specifically for the brfn however understanding the health impacts to the community requires considering not only the environmental social and cultural health impacts generally but also the three cornerstone impacts expressed within indigenous determinants of health scholarship which are the impacts of ire on the communitys 1 connection to land 2 cultural continuity and 3 ongoing impacts of colonization 44 it also underscores the importance of mainstream health services responding in culturally sensitive and regionally relevant ways to existing and emergent health issues social justice impacts the brfn despite all this development continue to be not only culturally and spiritually connected to the peace river but also reliant upon the land 37 one thing that has remained constant over the centuries is that country food including wildlife and traditional practices remain an important part of life and survival for brfn for example the brfn hunt both sides of the peace river for moose elk deer bear mountain sheep and caribou 27 they also fish for a range of species including dolly varden rainbow trout bull trout kokanee jackfishpike pickerelwalleye suckers whitefish lingcod and grayling 25 for modern indigenous peoples the land remains an important resource for subsistence purposes as well as the foundation of their way of life culture and identity 10 olson and deroy underscore that their research reinforces the message that the ability of brfn members to practice their treaty rights has been significantly impacted by industrial development in and around brfn territory 10 they go on to illustrate that in order to exercise their treaty rights for example to hunt trap fish and practice their traditional mode of life and culture the brfn must live within intact ecosystems 10 yet olson and deroy go on to argue development initiatives have led to impacts which include environmental degradation contamination of the land air and water habitat fragmentation and disturbance of key sites to brfn amongst others 10 for example if bc hydros site c dam goes forward loosing 5000 hectares of productive land base which would lead to the effective loss of rights to hunt elk moose caribou and other animals loss of bear habitat mercury contamination of fish downstream effects and cumulative effects from the project in combination with extensive existing and future developments particularly oil and gas development in their territory 37 the inextricable link between animal and environmental health and its core importance to brfn health underscore that to accurately understand cumulative impacts the variables considered must reflect the realities and domains of relevance for the people and places that are impacted for the brfn the approach to ire undertaken by private companies and enabled by federal and provincial governance bodies led them to file a civil claim against the province of bc on 3 march 2015 for breaching their fiduciary obligations 3445 the first statement of facts in the claim requests that the province stop the consistent and increasingly accelerated degradation of the nations traditional territory and to protect and enforce the nations constitutionally protected rights against the cumulative impacts of crown authorized activities on their traditional territory 34 the brfn alleged that the cumulative effect of industrial development in the treaty 8 area has made or will soon make it impossible for its members to meaningfully exercise treaty rights such as hunting and fishing and therefore argue that the crown has breached treaty obligations as well as interim and permanent injunctions to prohibit the province from doing or permitting any activities that amount to a further breach 46 at the center of this lawsuit is the argument that the cumulative effect of the industrial development in the treaty 8 area had become so extensive that it amounted to a violation of a treaty right 46 they maintain each new incursion becomes more significant than the last in that sense any portion of the overall loss in this case if it is found to exist should be characterized as irreparable harm 46 court challenges like this by first nations are made in a context of neoliberal visions to economic growth and clear and consistent track records of a disregard for the social and ecological sustainability in the region financial incentives however can impact the priorities and practices not only of industries but also can influence how governmental and nongovernmental bodies alike interact with first nations for example bc hydro recently offered land transfers of more than 5000 hectares to eight first nations bands however there is secrecy around what deal each band has been offered and concern that these arrangements would not only serve to divide first nations communities but also reduce public access to crown land in the peace river region 4748 at present there has been a great deal of criticism about bc hydros strategy all of this is occurring in a region dominated by ire where communities sometimes reliant on single resource economies are significantly impacted by national and international economics boom and bust economies whether analyzed through the lens of labor studies or public health are understood to bring with them myriad problems which significantly affect the most vulnerable as will be described in the following section booms in resource economies are characteristically unstable and typically lead to eventual economic busts and in june 2015 the lng industry in northern bc entered a bust cycle in addition to the decline in oil prices and a reduced demand for lng globally canadian lng can be hard to sell competitively on the international market as it is costly to produce it is an unenviable task to weather boom and bust cycles for people living in communities in northern bc this means being buffeted about by fluctuations in economies over which they have little or no control it often means that temporary workers leave and those who are longterm residents of host communities are left to find ways to live within towns that are being dismantled socially and economically for all residents of the region but most significantly for indigenous peoples it also means that the local populations are left to resource essential ecosystem servicessuch as clean air water soil country foods and wildlifefrom landscapes which have been dramatically altered and often contaminated discussion with these details in place we turn to a more philosophical analysis of the three axes we proposed by which to organize the effects of ire environmental health and social justice drawing from this case study background we consider here how these axes intersect and highlight mechanisms by which the impact of one axis can be amplified through its interaction with another intersecting axis the mechanisms discussed here are not exhaustive of the ways in which ire may impact but are conceptually illustrative of how the intersections of these already identified axes can serve as the locus to amplify negative impacts from one axis to indirectly perpetuate further negative impacts on the other axes we also highlight the ethical dimension of choosing to measure harm in terms of individual indicators and individual projects rather than in terms of cumulative impacts this use of individual indicators involves a commitment to reductionism that morrison has argued is an inappropriate methodology for biological systems including ecosystems 49 we extend her intersectional analysis to the health and social justice axes there are ethical implications for practices which use discrete and disaggregated indicators to measure impact which raises interesting questions about current practices when analyzed through the lens of environmental ethics a key distinction is that of measuring impact by a collection of indicators each of which are assessed separately in terms of a threshold for instance versus measuring impact cumulatively across a range of indicators where the overall impact of the indicators is considered in addition to whether any individual indicator crosses a threshold in terms of our case study along each of the axes specific indicators are used to operationalize what can and will be measured in terms of the impact of various ire projects the indicators thus serve to stand in for the axis as a whole such that the way in which these indicators are chosen how they are measured and how impacts on them are assessed comprised the methodology used to maintain the integrity of each axis a commitment to using measures that reflect cumulative harm is thus a commitment to more accurately measure the impact not merely of one project but of the entirety of the projects this is a commitment with ethical dimensions since a fullfledged commitment to prevent or mitigate harm requires consideration of cumulative as well as individual impacts by dividing the measurement of impacts into singleproject eas and considering each project in isolation from others in the area the overall ea and consultation process is in principle unable to reflect the full picture of how ire is affecting the local health of people animals and the environment there is no further point in any given process for approval in current british columbia practice such that the full extent of all projects up to that point can be considered by using individual indicators andor by failing to have a separate process whereby the cumulative impacts of multiple projects across multiple potential avenues of harm there is a structural failure of the process for communities like the brfn the choice of methodology for measuring harm itself covers over the full extent of the harm while at the same time appearing to have the appropriate scientific credibility the ethical implications of measuring each of these three axes can be analyzed in more detail by considering mechanisms by which impacts along one axis reverberate along another axis the concept of intersectionality was originally developed for understanding how different personal identities or groups to which a person could belong could yield impacts in terms of marginalization that are either magnified or substantially different at intersections of those identities a classic example is that of marginalization as a member of the group of women and marginalization as a member of a visible minority where women who are visible minorities experience marginalization in both of those identities such that their experiences differ from that of men in the same visible minority or women who are not a visible minority this concept of intersection can be applied to these three axes as well an extension from its original application to identities that highlights a very similar pattern where the axes of impact intersect 50 consider the intersection of the environmental and health axes there are mechanisms by which cumulative harm to the environment also results in cumulative harm to local people living in that environment but does so in ways that cannot be tied to a single project at a time the brfn have responded to the environmental assessment for the site c dam by conducting their own traditional land use study pertaining to the site c dam 25 according to brfn members cumulative industrial effects include but are not limited to the following changes • less water dried up springs and creeks • contaminants in water air animals and plants and • access roads seismic lines well sites and other land disturbances 28 flooding would increase the release of methyl mercury into the water which would likely biomagnify and bioaccumulate in fish and soils 51 pollutants such as methyl mercury accumulate in watersheds such that individual projects may fall below a specified limit for safe release while the totality of projects far exceed it the impact such pollutants have can be direct on individuals if a local water source becomes contaminated but can also be indirect when for instance fish or other game animals are consumed that have biomagnified the toxins and thus expose people to dramatically elevated levels the exposure through animal exposure is an example of an indirect harm on health that is mediated by the direct harm on the environment and is distinct from the direct harm such pollutants may also have on local people at this intersection of environment and health axes the negative effects on environment amplify the negative effects of the pollutants on people this amplification is heightened when we consider social justice impacts there are a number of key factors that together result in the abrogation of full treaty rights for the brfn bands the impact of cumulative environmental fragmentation pollution and watershed changes impedes the meaningful exercise of treaty rights it is widely recognized that when a right cannot be meaningfully exercised it is effectively being violated the environmental harm is direct when pollutants are released into the watershed there is indirect amplification of harm on the intersecting health axis on the health of the local people who may consume animals that have been exposed there is also further indirect amplification of harm on the intersecting social justice axis through the impedance of full exercise of traditional treaty rights the right to hunt game and fish freely on these lands is effectively abrogated when the game and fish cannot be safely consumed or even processed in clean waters in traditional ways capping pollutant release to certain threshold levels for indicators measuring environmental impacts fails to measure these further impacts on health and social justice the way in which environmental harm intersects with social justice harm thus includes the inability to freely exercise treaty rights such as hunting and fishing but this intersection also has further consequences on health beyond those just noted if fish and game are not available because of pollutants in the watershed those food sources must be replaced with some other food source this can add both less healthy food items and additional economic burdens because of the displaced traditional food sources a further factor to consider in social justice impacts is the economic boom and bust cycles associated with the massive ire projects many of which bring in large numbers of outside workers for comparatively short periods of time large ire projects set up the conditions for sharp booms at the beginning of such projects with the scarcities that can come with abrupt competition between sometimes thousands of other workers for commodities and housing similarly sharp busts also occur with the rapid drawingdown of work force levels and a sudden drop in consumption in the area boom and bust cycles preclude the kind of stable normal economic development that the bands might otherwise be able to rely on as such their economic autonomy is compromised by the outside pressures of these projects and their workforces in a way that is outside of local control or influence the biological physiological mental and emotional impacts that are felt by community members as well as those employed by the sector can be multifold but are customarily addressed as discrete problems the biomedical model promotes the idea of an atomized body which medical specialism have been developed to treat illness and disease this framework is informed by philosophical ideas such as the cartesian separation of mind from body as a result an illness phenomenon like stress tends to be diagnosed and treated as a health issue unrelated to physical ailments not only are different dimensions of the body and health separated from one another individual cases tend to be disaggregated from collective ones as a result for problems to be defined as public health issues individual issues have to be recorded and their accumulation formally tallied for them to be deemed a cluster of impacts which convey a populationwide effect in addition in underfunded and under resourced health care systems like in northern bc the capacity of practitioners to focus on upstream prevention is significantly curtailed particularly when it is already overwhelmed with the challenge of treating individuals presenting with acute health care challenges the cumulative character of these multifold health impacts can constitute a systemic social justice issue at this intersection of the health and social justice axes finally consider the very way in which the blueberry river first nations bands are consulted for eas this is part of the process by which their rights are to be respected in the approval process this is direct in that consultation is required by the treaty for such projects it is also indirect in that such consultation is the primary vehicle by which the bands may voice concerns over various aspects of a given proposal such as its potential impact on the watershed or on a particular animal species however the sheer volume of such projects also needs to be considered each of these projects must involve a consultation with the relevant first nations bands but when the scale of the number of projects grows the consultation process itself becomes an enormous burden on the bands themselves they are faced with a dubious dilemma on one horn of the dilemma they must be involved in a large number of these consultations involving at least some knowledge of each project this is more than a full time job even though it is not compensated for in the ea process the burden of consultation on a project considered individually is not particularly onerous however the cumulative burden of ongoing consultations for such a large number of projects becomes manifestly burdensome on the other horn of the dilemma though this consultation process is the only avenue within the ea process by which the brfn may assert control over their territory and by which they can ensure at least some respect for the area if they do not engage in these consultations in a meaningful way then problematic projects may get approved that further degrade the meaningful exercise of their treaty rights engagement fatigue results from the use of consultation as the primary means of navigating the intersection of these three axes it places the burden of navigating the ire with treaty rights disproportionately on the bands themselves the consultation process itself is required for each project considered individually thus preventing harm along the social justice axis yet considered cumulatively the sheer number of such consultations can have a different valence as negatively impacting the brfn along that very same axis conclusions as noted above the term health has a double meaning in this context since it applies both to the health of the people in the area as well as to the health of the ecosystems each of these kinds of health can be measured separately along its own axis and when considered separately each can also be measured using individual indicators on a project by project basis or in terms of cumulative impacts there are further mechanisms by which these two axes interact and amplify harm when they intersect however so that both the direct and the indirect implications must be considered to get a fuller view this has a variety of implications for assessing projects for approval using the current procedures in place in bc the bc government has begun moving to a cumulative effect model for understanding environmental impacts however the capacity to use a cumulative impacts framework to understand the health impacts produced at the intersection between ecological and social factorssuch as treaty rightsis still in its nascent stages furthermore there will need to be movement to a cumulative impacts framework that is also accompanied by an appropriate intersectional analysis of the three axes identified hereenvironment health and social justicesuch that the direct and indirect mechanisms of harm can be identified and mitigated without inducing further burdens of consultation and ensuring engagement fatigue

we consider the case of intensive resource extractive projects in the blueberry river first nations in northern british columbia canada as a case study drawing on the parallels between concepts of cumulative environmental and cumulative health impacts we highlight three axes along which to gauge the effects of intensive extraction projects these are environmental health and social justice axes using an intersectional analysis highlights the way in which using individual indicators to measure impact rather than considering cumulative effects hides the full extent by which the affected first nations communities are impacted by intensive extraction projects we use the case study to contemplate several mechanisms at the intersection of these axes whereby the negative effects of each not only add but also amplify through their interactions for example direct impact along the environmental axis indirectly amplifies other health and social justice impacts separately from the direct impacts on those axes we conclude there is significant work still to be done to use cumulative indicators to study the impacts of extractive industry projectslike liquefied natural gason peoples environments and health

Issues such as meaning in life or the meaning of life have been the subject of philosophical thought and theology for centuries. With the observations of the Austrian psychiatrist Victor Frankl ) in the Nazi concentration camps, this concept began to be studied in the field of mental health. Meaning in life, which is the subject of positive psychology, is the way people make sense of their lives, different from the absolute meaning of life . It can also be expressed as the degree to which people perceive meaning, value and mission in their lives . Since Frankl, meaning in life has been conceptualized by researchers in various ways and has been studied together with different variables, following the development of measurement tools for the concept. When looking at some of the variables with which meaning in life is positively correlated, many positive variables can be found such as positive emotions , psychological wellbeing , hope and life satisfaction . In light of these relationships, the importance of meaning in life from a positive psychological point of view stands out. It has also been reported that those who experience higher meaning in life show lower depression along with higher self-confidence and are better off even in poor health conditions than those who experience lower meaning in life . The contribution of theoretical explanations and various measurement tools based on self-report method is indisputable. However, a problem that this method poses is the issue of the reliability of self-reporting, especially when it comes to meaning in life. While people may cheerfully express that their lives are full of meaning, they can do this without evaluating the nature of a meaningful life or their own sources of meaning . In fact, it has been suggested that while some sources provide more satisfaction than others , measurement tools rarely get beyond the question, "Is there meaning in this person's life or not?" . Another seeming problem is that not much is known about the relationship between one's meaning in life and developmental stage. As individuals are viewed from a holistic perspective, it is difficult to consider a complex concept such as meaning in life separately from their current developmental stage. Despite individual differences, each stage of life has its own characteristics . The number of studies that focus on meaning in life from a developmental point of view is limited and different findings can be observed. In addition to the studies that show higher presence of meaning in older age , there are also findings that observe lower presence of meaning . The theory of meaning in life that the existing measurement tools embrace can be considered as an important factor in these different findings. In fact, it has been argued that observing low meaning in older age in Ryff's Psychological Well-Being Scale may be possible but misleading because meaning here is measured through purpose and one's goals are likely to decline in older age . Moreover, it is known that emerging adulthood is characterized by discovery and development of identity, career and social roles . For these reasons, it can be expected that search for meaning would be higher in emerging adulthood and even more adaptive than in other stages of life. In fact, it has been shown that higher search for meaning is associated with lower well-being in later ages compared with emerging adulthood . Despite potential differences between age groups, it has been stated that meaning in life is important for all developmental stages, starting from adolescence . Concepts such as meaning, purpose and sources of meaning in life are important in terms of psychological well-being and life satisfaction, but it seems that quantitative methods fail to shed light on how people experience meaning in life. Moreover, the fact that many studies have been based on Western and undergraduate samples provides limited light on the phenomenon. Therefore, it seems necessary to examine meaning in life through qualitative studies, as suggested by previous research , and to do research that touches on different developmental stages and cultural contexts. In the light of all this, the aim of the present study was to examine the views and experiences of individuals from three different Turkish generations in the same family concerning meaning in life. Qualitative research method is particularly likely to provide the opportunity to examine the phenomenon in a more flexible, realistic and rich way. With the qualitative research method, it is possible to go beyond the question "Is there meaning in one's life or not?" and to shed light on many aspects of the phenomenon as to what meaningful life experiences look like, which elements play a role in adding meaning to life, what kind of goals there are in a meaningful life or what the nature of searching for meaning is. The present study is thought to be unique in that, while addressing all these aspects, it also does this by offering developmental comparisons with three different generations in Turkey. Although the qualitative method does not allow a statistical comparison between groups, it is possible to describe the reflections of the phenomenon in different stages of life through thematic comparisons. In addition, the fact that the individuals of different stages in the study come from the same family makes the comparative inferences more valid by keeping the sociocultural structure relatively equal. It is hoped that the study would contribute to theoretical knowledge by describing the views and experiences of individuals from three different generations, that is, emerging adulthood, middle adulthood and late adulthood; help develop a deeper understanding of meaning in life as a phenomenon and thus guide prevention and intervention studies in positive psychology; and pioneer future studies, especially in Turkey on meaning in life. --- Method Participants Criterion sampling method was used in the present study. The criterion was that the child in the family would be 18-25 years old , the parents 40-65 years old , and the grandparents 65 years and older . Snowball sampling method was used to reach families that had met the required criteria. The snowball technique is used in situations in which it is difficult to reach the participants who meet the criteria determined by the researcher . A total of 42 people from 14 families in the province of Izmir took part in the study. 27 participants were women and 15 were men. Of emerging adults, there were five women and nine men. Of middle adults, there were 10 females and four males. Lastly, of late adults, there were 12 females and two males. The average ages for the emerging, middle and late adults were respectively 21, 48 and 71. Detailed demographic information for each family is presented below in Table 1. --- Preparing The Interview Form The study data were obtained through semi-structured interviewing method. The required ethics approval application was made to and obtained from the Research Ethics Committee of Dokuz Eylul University for the project "Viewing Meaning in Life in Three Generations: A Qualitative Study" . The questions prepared to be used in the semi-structured interview form were created based on literature review and were also tested with pilot interviews. In addition, with the aim of improving the relevance and intelligibility of the interview questions, the draft interview form was sent to 10 academicians who completed their doctorate in guidance and counseling. The questions were revised according to their feedback, and then the form was finalized. The interview questions were as follows: 1. What generally comes to your mind when you think of the meaning of life? 2. What are the things that are currently giving meaning to your life? 3. Do you remember a specific moment when you found your life the most meaningful? How would you describe this moment? What was it that made this moment this meaningful? --- Data Collection A certain day and time suitable for the families was determined for the interviews, and the interviews were carried out in the families' home environment. The participants were notified of the content, purpose and confidentiality principles of the research both verbally and in written form prior to the interviews and their written consent was obtained. Then, demographic information was collected, and interviews were conducted. The interviews were recorded by the first author using a smart phone, and these recordings were later transcribed. During the interview, participants were asked semi-structured interview form questions. Attention was paid to asking open-ended questions in the order determined for the reliability of the research, and interviews were completed between 10-30 minutes. All the data were collected in 2019-2020 before the COVID-19 outbreak. --- Data Analysis A phenomenological approach was used to analyze the data. The goal with this approach was to understand meaning in life as a phenomenon. For this purpose, sources and experiences that make participants' lives meaningful, their experiences with search for meaning, their life goals and current levels of meaning were investigated. The transcribed data were analyzed via NVivo 11. At the very beginning of the data analysis process, a family was selected and analyzed independently by both the first author and the second author . Before the analysis process, the five main themes that had been created according to the interview questions were determined by the authors and the first coding was done accordingly. Two different analyses based on a certain family were compared with one another on NVivo 11, and interrater reliability was calculated. This calculation was made on NVivo 11, and Cohen's kappa coefficient was found to be .80. Considering that values of .80 and above indicate strong inter-coder reliability, the reliability between coders in the study was quite good . Content analysis and descriptive analysis methods were used in analyzing the research data. Content analysis is mainly used in phenomenological designs, in which themes that may be hidden in the data are revealed and interpreted . Descriptive method, on the other hand, involves organizing and tabulating the data . In order to increase reliability, the data were analyzed and quantified on a frequency basis, and the obtained data were presented with direct quotations. Quotations were emphasized in italics and the participant from which the quotations are made was indicated in parentheses . The first number in the code names refers to the family, the second refers to the generation , and the third refers to the gender . When names of certain people had been mentioned by any participant, these names were removed for confidentiality purposes and replaced by words such as my friend, son or daughter, depending upon how that person relates to the participant. --- Results The interview questions of the study were taken as themes, and the data were coded accordingly. The first two questions were handled within one theme and the remaining five questions were handled within five themes, and a total of five general themes were presented. These general themes are: sources of meaning, meaningful life experience, search for meaning, goals in life and present meaning. Salient categories that emerged were identified under these general themes. The five themes and the salient categories of the study can be seen below with their frequencies in Table 2. The salient categories are listed in descending order according to their frequency of utterance. Those with the same frequency of utterance are listed alphabetically. Family , happiness , health --- Meaningful life experience Success , personal growth , happiness , being with loved ones Having a child , freedom from hardship , happiness Being with loved ones , happiness , success --- Search for meaning Existential inquiries , uncertainty of the future , being alone Frustration , contemplating the past , relational problems Frustration , absence of search , contemplating the past , being alone --- Goals in life Career goals Note. Numbers between parentheses refer to the frequency of utterances/observations. --- Theme 1: Sources of Meaning The answers given by individuals regarding the meaning of their lives and what adds meaning to their lives were gathered under the theme of sources of meaning. --- Emerging Adults. Family. Family emerged as the most uttered source of meaning among emerging adults. Here, a married individual referred to his spouse, and the remainder emphasized their parents and siblings. "When it comes to the meaning of life, family comes to my mind. Sharing love, respect, happiness and beautiful moments within family tie ... " Activities. Secondly, the emerging adults mentioned activities as a source of meaning. Under this category were activities such as sports, music and movies. "Music is giving meaning to my life right now. I'm young anyway. I am a 19-year-old university student. As with every university student, I, too, can say music." Friends. Another category that shared the second place for emerging adults was friends. Here, other than family members and romantic partners, the social environment of the participants was included. --- "My social environment also gives me meaning. Because my circle of friends in general is very wide. Spending time with them makes me very happy." Happiness. Happiness also appeared as the second salient category that has the same frequency with activities and friends. --- "If you have things in your life that you love, if you do things that make you happy, life is then meaningful for you." --- Middle Adults. Family. As with emerging adults, family is the most salient source of meaning for middle adults as well. Here, most of the participants firstly mentioned their own children and then their spouses. Limited emphasis was placed on their parents and siblings. --- "Of course, my family is my priority. My wife, my daughter… They are the things that give meaning to me… Their happiness makes me happy, too. Their being healthy makes me healthy, too." Happiness. Secondly, middle adult participants talked about happiness as a source of meaning. --- "When I think of the meaning of life, what comes to my mind is to be happy and to be able to make people around you happy." Health. Another category that emerged along with happiness was health. One participant expressed his emphasis on health as follows: "Life means a lot to me as long as I know that I am healthy or when I know that the people around me are healthy." --- Late Adults. Family and happiness. Late adults emphasized their children and grandchildren while talking about family and stated that they generally experienced happiness through family members. Therefore, it can be said that the categories of family and happiness emerged together for late adults and were seen as the primary sources of meaning. --- "A healthy life with my children and their being around me… I am happy with my family and children around me. I am happy with their presence." Health. Another source of meaning that was mentioned almost as much as happiness by late adults was health. --- "When it comes to the meaning of life, health comes first to me. It is very important for people of our age." --- Theme 2: Meaningful Life Experience The categories under this theme were identified by analyzing participants' experiences. Here, the aim was to mention the themes within the experiences of participants rather than the experiences themselves. However, common experiences that emerged quite frequently have been presented in the table as a different category, and they were also treated under other categories like freedom from hardship and happiness. When participants mentioned more than one experience, all of these were included in the analysis. --- Emerging Adults. Success. A male emerging adult who emphasized his experience of success described the most meaningful moment of his life with the following sentences: "It may be that moment when I got into this engineering program at university. Because I had not studied that hard since childhood until then. I only studied for this exam. That exam was actually worse than I expected, but when I got that result... That moment is one of those moments that I will never forget, that gives me meaning." When asked what made this moment so meaningful, the participant answered: "I had always been unsuccessful until that day. It was like having passed an exam for the first time other than the driving license test." Personal growth. Personal growth emerged as another meaningful life experience in emerging adults. Here, the participants talked about experiences that changed their perspective, brought them awareness, and enabled them to learn some personal lessons. A male participant mentioned some of his academic and romantic experiences that he had in the second year of high school. Despite their negativity, the participant stated that these experiences made great contributions to his character: "At first, I started studying for the Mathematics Olympiad that year. That is why I am absolutely sure that that year contributed to my thinking. I also loved one person. It ended a little unhappy. I learned a lot. I felt that I was maturing myself, too. It created an awareness. I learned that people shouldn't be trusted that much. I used to see everyone as myself, but I learned that everyone is different." Happiness and being with loved ones. Happiness was another experience that emerged in meaningful life experiences. It seems difficult to say that the participants emphasized only happiness in their experiences, but it can be said that happiness frequently accompanied those meaningful experiences. Being with loved ones, which was identified as a different category, was mostly expressed with happiness and therefore, reported here under the same heading. A male participant described an evening spent with family and relatives as follows: "Everyone was happy. We didn't have any problems. Most of the financial problems in the whole family, among all my relatives, had been solved, and it was like a meal to celebrate it." --- Middle Adults. Having a child, freedom from hardship and happiness. The experience that middle adults mentioned the most was having a child. Five out of 10 female participants and four out of four male participants stated this experience as the most meaningful experience of their lives. Having a child emerged alongside freedom from hardship and happiness. Participants' statements about the birth process revealed that the process was a crisis for some of the middle adults. It seemed that both the happiness of having a child and the end of this difficult process was quite meaningful for them. "I could not give natural birth. It was always to and fro. We were going to the hospital all the time. And the hospital was far away. There was a distance of about 85 km. I wanted this process to end as soon as possible. Perhaps this could have triggered a little more. This trouble, this process ... We were going there every three days. We were constantly going for tests. Waiting to see if the baby is moving ... Of course, it makes one very happy to encounter such a beautiful thing as a result. I think that's the reason. The stress and boredom I was experiencing at that moment." --- Late Adults. Being with loved ones and happiness. Late adult women mentioned that the most meaningful times of their lives were when they were together with their deceased husbands. Other answers included spending time with their family in childhood. The meaning in these experiences was also defined by the participants mostly through happiness. A late adult female participant, who lost her spouse in the ninth year of her marriage, emphasized firstly the time spent with her husband, and another participant mentioned the time spent with her family in childhood: "When I was with my husband… I lost him 28 years ago. I had very good days. The best twenty years of my life passed with him." "There are times in my first childhood. Those were special times for me. I had my mother and father… You are waiting for a mother who will come from work, prepare food for you, her love… They were very special days for me." Success. Another meaningful life experience that emerged for late adults was success. A female participant , who had never attended school in her childhood, mentioned how she decided to go to a literacy course at the age of 59 and managed to receive a certificate. Seeing this as one of her most meaningful experience, the participant expressed her success and happiness as follows: "My child, I have never studied. I went to school at the age of fifty-nine and got a certificate. It is my most meaningful day. I can start studying even now if I want to. I love it so much. It is the most meaningful thing. I got a certificate for reading and writing. I was very happy to have gotten it. I said I will do it and I went and did it. I went and got it when I was fifty-nine." --- Theme 3: Search for Meaning Another phenomenon addressed in the present study was search for meaning. Participants were asked whether they would find themselves in search for meaning at times. 37 of the 42 participants said that they sometimes did find themselves in search for meaning. --- Emerging Adults. Existential inquiries and being alone. The emerging adults' experiences of search for meaning largely coincided with the existential inquiry category. The moments when they question their world views, fail to reach any conclusions and thus fail to find an absolute meaning were covered under this category. The category of being alone, as another salient category, emerged mostly simultaneously with existential inquiries. So, the emerging adults experienced search for meaning when they got into existential inquiries, and according to their statements, these inquiries usually occurred when they were alone. "Yes, I find myself . Like every human being, I think about why we exist, what the meaning of this struggle is, we will die anyway, why we are working… When we come to the question "What is the purpose for our living?", it always comes to a dead end. I can't find a solution, a way out. We put in so much effort... all wasted actually. As they say, this world is mortal… I don't know the why either, but we keep going." Uncertainty of the future. Emerging adults also talked about how uncertain their future looks. The answers addressed in this category had more to do with what awaits them in the future rather than questioning man's existence. "You want to have a profession, you want to put your life in order, but none of them are clear in front of us. I'm making an effort, but will I be able to get there? … One wants to see the result." Middle Adults. Frustration. The most salient category in middle adult's search experiences was frustration. Here, participants talked about their expectations that could not be met. "You know, you labor or you try hard for something, or I don't know, something about your child… You try really hard, you sacrifice but you, you know, don't get rewarded. Like there is no result." Contemplating the past. Middle adult participants also mentioned that from time to time, they reviewed their past and tried to envision what their current lives would be like, if they had taken some different steps. Participants, who were not fully satisfied with a certain point of their past, referred to these retrospective moments as an experience of searching for meaning. "Well, when I look into the past, one experiences an "I wish" moment, even if it is just a little "I wish." After reaching a certain age, you think of the past. Sure, today is fine, too, but then I think like, if I had done this or that, maybe things would have been different." Relational problems. Another salient category in middle adults' experience of searching for meaning was relational problems. Here, the participants talked about their problems with family and colleagues. Frustration. Like middle adults in the study, late adults also seemed to experience frustration when they were in search for meaning. Here, participants' experiences of sadness, distress and unhappiness were collected under this category. A female late adult , who used to live in the same building with her daughter and grandchildren for a long time, told that her daughter's family moved to another place and that this distance saddened her. "My grandchildren used to live upstairs. They moved out and left here. I got saddened by their leave at one stage. This makes me meaningless. Like why did this happen? I wish we lived closer. I wish we visited one another at nights, too..." Absence of search. Another category under search for meaning was identified as absence of search. 5 out of 42 participants stated that they did not experience any search for meaning, and three of these were late adults. --- "No, I lived life to the fullest." "I am actually… Well, I am a positive person. You know, I'm healthy… You know… I always think of turning bad things into good." Contemplating the past and being alone. Like middle adults, late adults also described contemplating their past as a meaning seeking experience. Participants seemed to experience these moments while they were alone. "Sometimes, when financial means are short, I say like… would it be different if we had done this or that? Could we at least offer our children other opportunities?" --- Theme 4: Goals in Life Since goals play an important part in meaning in life, participants were asked about their short-term and longterm goals with the aim of investigating meaning qualitatively across generations. Here, answers were quite varied and expressed clearly by the participants. Their responses were analyzed with a descriptive perspective. --- Emerging Adults. Career goals. Both the short-term and long-term goals of the emerging adults were mostly career related. Participants mentioned goals such as: to complete their education, to do their desired profession, to settle abroad or to start a master's degree. Goals to restructure life. The third category, which emerged in relation to children and career-related goals, was the goals of middle adults to restructure their lives. The participants stated that after their children gained their independence, they would focus more on themselves, travel around and live a life away from the city with their spouses. "As soon as my sons are able to go their own way, my whole thing… the meaning of my life then will be my wife and me. I will take time for both of us. Then, I'm going to say, 'to myself' a little bit." Late Adults. --- Goals for children. As in middle adults, the first goal category identified in the late adult group was goals for children as well. Compared to emerging adults and middle adults, the participants here in particular emphasized their "wishes" rather than goals. Their children and grandchildren seemed to be the base of their wishes. Goals such as witnessing the happiness of one's own children , being visited by them, spending time with them, not being dependent or burden on them and the like were addressed in this category. --- " to see my children happy, to watch their lives getting better all the time." "Just that my children be happy. I want nothing else. Just that they care about me, too." Decline in goals. Another salient category in the late adult group was decline in goals. When the participants were asked about life goals, they stated that they did not have many goals at this stage of life. --- "I can no longer have goals. Why? I have achieved my goals. I'm seventy-four already. I have nowhere to go from now on." "Oh son… How old are we now? What goals?" Physical health goals. Another goal category that did not emerge in the other groups was physical health goals. Late adults thirdly mentioned goals about their health. --- "My goal is health. That I can keep doing my physical exercises for a few more and have good health." "Well, it is health. That is what I ask from God." --- Theme 5: Present Meaning Participants' views on their present level of meaning were discussed under this theme. Participants sometimes rated their opinions with adjectives, sometimes made Likert-type statements, and sometimes gave answers based on percentages. The answers were gathered on a common ground and presented under the categories of meaninglessness, low meaning, half meaning, moderate meaning and high meaning. Emerging Adults. More than half of the emerging adults viewed their lives as half meaningful, lowly meaningful, or meaningless. Half meaning. The reason why the first category was presented with the word "half" is that the participants stated that they had some meaning in their lives, but it was incomplete until some things happened. "I don't think it's exactly meaningful actually. I mean, there are people who give meaning to my life, but I think it will be much more meaningful when I fully get a job, make a life for myself and take my own economic freedom." Moderate meaning. A male participant who emphasized his future plans and current situation stated that he found his life meaningful: "Of course, my life has meaning. I am happy now. I have future plans. School will end. I will move and I will live abroad…" Low meaning. Another male participant , who approached the topic with existential questioning, stated that his own life did not mean much when viewed from a cosmic perspective. The statement of the participant considered under the low meaning category was as follows: --- " doesn't make much sense right now. Because when we look at it considering all humanity, I wonder what humanity would lose if I was not there… So my life is a little bit meaningless." Meaninglessness. Another female participant , who was coming from a similar perspective, stated that her life had no meaning: --- "I think, my life is very meaningless. It can be meaningful when you look at it with all its goals and efforts, but I'd say it has no meaning looking from the outside." High meaning. Another emerging adult , referring to the importance of the decisions he was about to make at this stage of his life, told that this stage and therefore his entire life were very meaningful for him: --- "It is really meaningful for me right now. Because I'm laying the foundation of my life. In the slightest mistake, I would throw away all the next 40 years -if I'll have them, of course. I'm not sure if my peers think that way about it. But this stage is very important for me." Middle Adults. When middle adults' responses were analyzed, it was observed that nine out of 14 participants considered their lives highly meaningful, four moderately meaningful and one meaningless. High meaning. Most of the participants stated that they viewed their lives highly meaningful and referring to their sources of meaning, they generally emphasized family and happiness here as well. --- "My life is very meaningful right now… I think I now live a much better life than I imagined. I wouldn't have imagined a life like this. I have comfort. Comfort in an economical sense and also, I am very comfortable in my family relationships. I have a husband who loves me and understands me. I have a child that I value very much." Moderate meaning. The participants who did not emphasize high meaning but viewed their lives as meaningful were included in the category of moderate meaning. "Right now, I am pretty close to the last steps. I am at a point where I can understand that life has a meaning, that it is something worth living." Late Adults. Late adults' answers on their present meaning in life were gathered under the categories of high meaning, half meaning and moderate meaning. While seven out of 14 participants found life highly meaningful, four participants saw in it a half meaning and the remaining three found it moderately meaningful. High meaning. Like middle adults, the late adult group also generally found life meaningful. Parallel to sources of meaning, participants sometimes emphasized their children, grandchildren and health. " quite meaningful for me. I'm fine, healthy, happy. Of course, there are things I feel sad about, but this is life. I think, God willing, everything will pass with goodness and beauty. I have children. I must always be there for them. I praise God for the fact that I live." Half meaning. Some late adults, on the other hand, referring to their family and health problems, stated that their lives were meaningful to some extent. In order to preserve the name of the category in emerging adulthood, these answers were also handled under "half meaning." As a matter of fact, participants mentioned some shortcomings here as well. --- "These days I just want to have a calm mind. I mean this is what I want. I don't want sadness. But it is impossible not to be sad right now. Grandchildren and so on... Calmer, happier… This is what I am looking for but it's hard to find. So, I would say medium level . It's neither bad nor good." Moderate meaning. Other late adults, on the other hand, responded that their lives were meaningful, even though they did not specify high level of meaning. --- "Every day has its own beauty. Every morning has its own sunrise. I think every age in life has its own beauty. I am happy with my old age. If I am healthy, if I am walking, you should be thankful for all of this." --- Discussion The above-mentioned findings for three different generations under five main themes showed both commonalities and distinctions from a developmental point of view. Therefore, they were discussed separately. --- Common Categories The salient categories which emerged commonly in all developmental groups were relationships, happiness and success. This observation seems to be consistent with other studies in the literature. Relationships , happiness and success are variables that have been shown in many different qualitative and quantitative studies on meaning in life. In particular, positive relationships and concepts such as environmental control, autonomy, and efficacy that can be considered under the category of success play a part in different well-being theories and theories of meaning in life . What was particularly interesting here was that these relationships were largely family relationships. Although not as frequent in the emerging adult group as in the middle and late adult groups, all three groups stated that family was the primary source of meaning for them. Again, when examined from a developmental perspective, different studies on meaning in life have shown that relationships with spouses and children and relationships with parents and relatives are at the forefront in middle adulthood . In addition, a study conducted with people over 65 years of age found that emotional support from family among different types of social support was associated with higher meaning in life. However, that family was seen as the primary source of meaning in emerging adulthood along with other stages may indicate cultural emphasis. In this developmental stage that is characterized by identity discovery and close relationships , self-focus becomes prominent . Therefore, it seems a little unlikely that emerging adults will see their families as the primary source of meaning. However, this study was performed in a Turkish context, where familial and social ties are strong and collectivistic characteristics are stronger . However, both quantitative and qualitative studies in the American context also suggest that family remains an important source of meaning in emerging adulthood. Researchers argued that individuals in this transitional period may be returning to their families repeatedly to find support and direction . Another important finding was that happiness emerged both as a source of meaning and as an emotion accompanying meaningful life experiences. Previous research has shown that happiness is related to meaning in life in all three developmental periods . However, while meaning in life is a eudaimonic variable, happiness is a hedonic variable, and the overlaps and differences of these concepts are still debated. The study seems to support the discussion that meaning in life will almost always bring happiness . By explaining the relationship between meaning in life and positive affect with learning, researchers argued that if the experience of meaning emerges with positive emotions over and over again, the connection between these two variables becomes strongly etched in memory via these learning experiences . In this way, thinking about one triggers thoughts about the other and the two become conceptually related . Moreover, since this study comes from a phenomenological point of view, it can be said that cultural understanding of meaning or happiness may change and the on-going debate on eudaimonic vs. hedonic wellbeing should include cultural context. The degree to which a variable is eudaimonic or hedonic could have more to do with experiential differences rather than conceptual differences. --- Developmentally Distinct Categories In addition to the findings mentioned above, the most important findings in this study were the seeming reflections of developmental stage on meaning in life. Health as a source of meaning in middle and late adulthood. In the middle and late adult groups, health emerged as a source of meaning, different from the emerging adults. Given the characteristics of these stages, this observation is expected. In middle adulthood, which is defined as the period of gains and losses, the individual tries to adapt to various physical and psychological changes, while at the same time fulfilling his professional and family responsibilities . Therefore, it is very important for middle adults to maintain their physical health to maintain their quality of life. Throughout late adulthood, health quality further decreases, and different health problems arise. In the light of all these, health becoming more important in one's meaning in life in older ages can be explained by the fact that older ages are when health problems begin to emerge. Previous research showed that a positive relationship between physical health and meaning in life exists and that health plays a major role in older adults' life satisfaction and meaning in life . Therefore, it can be argued that health is a component of meaning in life but will not be seen as a primary source of meaning until health issues arise. Existential inquiries in emerging adulthood and search for meaning manifested with future anxiety. When emerging adults' meaning seeking experiences were examined, the salient categories were identified as existential inquiries, uncertainty of the future and being alone. These salient categories reflect the key characteristics of emerging adulthood. Questioning one's own world and shaping one's personality through personal convictions are some of the tasks performed in this stage . It has been discussed that as a stage characterized by discovery of identity, emerging adulthood may also be linked to search for meaning in life . Participants seemed to struggle with holistic meaning and therefore were led to search for meaning. It can be said that a meaningful life is not only a purposeful life, but also a life that can be justly explained by one's worldview. This is especially relevant for emerging adulthood. The second salient category in the emerging adults' search for meaning was uncertainty of the future. Uncertainty is another important factor in the lives of emerging adults . In this transitional period, they experience many academic, social and personal changes, and these changes pose an uncertainty for the emerging adult. Participants seemed to experience these changes from various angles, and they were particularly concerned about whether their education will provide tangible feedback. Previous qualitative findings showed that the theme of uncertainty about the future emerged with the theme of meaninglessness . Hence, it can be argued that the ability to cope with uncertainty seems even more necessary in emerging adulthood. Indeed, many theorists agree that perceived loss of control will shake the individual's meaning in life . Search for meaning manifested with relational problems in middle adulthood. Unlike late adults, another experience that middle adult associated with the search for meaning was their relational problems. As the categories of family, friends and being with loved ones, which emerge under the themes of sources of meaning and meaningful life experience, support the importance of relationships for a meaningful life, relational problems under the theme of search for meaning further strengthens the emphasis on relationships. According to the participants, while continual satisfaction in relationships makes life meaningful, having problems in relationships seems to lead the individual to search for meaning. This observation seems to be in line with previous research that showed that relationships are an important source of meaning for different age groups and that lack of satisfaction in relationships is likely to lead to search for meaning . That middle adults described relational problems as an experience leading to search for meaning may be due to the quantity of relationships in this developmental stage. Especially in family context, a parent stays in contact with not only their children, but also their spouse and their own parents. Apart from this, the individual also maintains other relations in and outside the workplace. Therefore, compared to late adults, it seems more likely that a negativity in the relationships of middle adults who have many social roles will lead to a search for meaning. Search for meaning in middle and late adulthood manifested with frustration and negative contemplation of the past. Unlike emerging adults, the first category that stood out in middle and late adults' experience of search for meaning was frustration. These two groups did not mention any existential inquiries or future anxiety, but rather the situations in which their expectations were not met. In other words, the participants seemed to search for meaning when their expectations about themselves, other people or life in general were not satisfied. This observation can be interpreted in opposition to the category of happiness in meaningful life experiences. It can be said that while positive emotions may lead one to see life more meaningful , negative emotions are likely to result in the opposite effect. Research showed that increasing sadness, fear and shame is indeed related to increasing search for meaning . It seems that various negative emotions can be experienced within the phenomenon of disappointment and therefore lead the individual to search for meaning. Similar emotions seemed to be experienced also when the same participants review their own pasts. Within the category of contemplating the past, participants expressed their "I wish" moments. It is known that with aging, adults seem to focus more on the past . When the statements of participants are examined, it can be seen that this retrospective look generally focuses on negative experiences. Participants associated the search for meaning in life particularly with past experiences that they were not satisfied with. Previous research seems to support this observation that search for meaning is associated with focusing on past negativity . Therefore, it can be argued that a meaningful life requires contentment not only with the present, but also with the past. As argued by Baumeister in his four needs for meaning , it appears that for a meaningful life, one must be able to positively justify his own actions, and these actions also include past experiences. Decreasing search for meaning in late adulthood, though sometimes manifested with loneliness. Some late adult participants stated that they never find themselves in search for meaning. This observation can be explained by maturation, in that, it is expected that the "why" questions forming one's world view will be relatively completed throughout emerging adulthood . In addition, there is more diversity of experiences in emerging adulthood than middle and especially late adults who have already accomplished certain goals in life . Therefore, it can be said that they are less likely to view the future as that uncertain and less likely to experience future anxiety. When asked about their search for meaning in life, the late adult participants also mentioned the times when they are alone. The late adults in this study mostly included either retired or widowed participants and therefore, it can be argued that they were more likely to search for meaning in these times compared to middle adults. And also, unlike emerging adults, it seems that loneliness itself created a problem for late adults, rather than the existential questions that being alone provokes. This observation further supports the important role relationships play in meaning in life, particularly in late adulthood where physical and social losses and loneliness become characteristics of the stage . Career goals in emerging adulthood. The emerging adults of the study seemed to have largely career goals. Given the developmental tasks of the stage and that all these participants continued their education, this observation is to be expected. In this stage of possibilities , individuals tend to have many both short and long-term goals, many of which are career-related . However, this result can also be seen as extension of Turkey's current situation. Especially with the increase in population and the number of universities in the last twenty years in Turkey, unemployment is rising . According to the Turkish statistics in 2020 , youth unemployment rate was about 25% . It is also helpful to note that career uncertainty is considered as a characteristic of the 21st century and therefore, in the midst of this uncertainty, it can be argued that emerging adults are likely to seek safety in the first place. --- Goals for children in middle and late adulthood. The middle adults in the study mostly mentioned their goals for their children. In both sources of meaning and meaningful life experiences, it seemed that children of middle adults were at the center of their lives. Other goals that followed were career goals and goals to restructure their lives. These three elements seem to clearly reflect middle adult developmental tasks conceptualized by Havighurst . To help young children become responsible and happy adults, to achieve and maintain vocational satisfaction, to nurture the marriage relationship and to develop appropriate leisure activities are the developmental tasks in middle adulthood . All the salient goals mentioned by the middle adults of this study remarkably coincided with these developmental tasks. Goals and concerns about the future of children and their career have also been supported by studies in various countries . Similar to middle adults, late adults also mentioned goals for their children as their primary goals. However, the participants took a more passive position in these goals. In general, middle adults talked about supporting the building of their children's future, whereas late adults talked about seeing the happiness of their own children and grandchildren. In other words, it can be said that middle adults described themselves in the role of a "helper", while late adults were more in the role of a "spectator." This observation seems to point to the changing life roles in personal goals across developmental stages. Research have shown that while goal orientation at younger ages moves toward personal development, at later ages this orientation focuses more on maintenance and reducing loss . Decline in goals in late adulthood. Goals for maintenance and reducing loss can be seen in late adults' following salient goals that are identified as physical health goals and decline in goals. The participants mentioned that after this age, they no longer had many goals and basically just wanted to be healthy. This decline in goals that the participants expressed is an important finding. As argued, scales on meaning in life that contain goal-oriented items could yield developmentally problematic results , since in this stage of role loss , individuals have fewer goals to achieve . This qualitative study seems to further support this discussion. Low meaning in life in emerging adulthood. Only one-third of the participants in emerging adulthood stated that they had a really meaningful life, while the rest mentioned that they experience meaninglessness, low meaning or half meaning. Especially when compared with the responses of the participants in the other two generations, emerging adults was the group that expressed the least meaning in the study. As can be seen in their expressions about their search for meaning, the emerging adults here told that they could not make sense of the world and its events, and that the future was very uncertain for them at the moment. This observation seems to point to the cognitive dimension of meaning in life that is emphasized theoretically . Being able to comprehend life at a cognitive level and coming up with satisfactory answers with regards to why everything exists seem quite important for a meaningful life , which also has been conceptualized as holistic meaning and cosmic meaning . In accordance, the expressions of the participants in this study about meaninglessness or low meaning revealed their difficulties in making sense of life from a cosmic perspective. The dominance of expressions reflecting cosmic meaning issues in the emerging adult group indicates that it would be indeed helpful to approach the phenomenon from a developmental perspective. In this stage, individuals enter into a discovery , becoming preoccupied with their identity, careers and social roles and reevaluating the ready-made meaning systems coming from family and the society . It has been argued that search for meaning may be in a sense normative in emerging adulthood, leading them to a higher search in comparison to middle and late adults . The qualitative findings in the current study are thought to strengthen this debate. Moreover, the uncertainty about achieving personal goals seemed to pose a problem for the participants. Therefore, in addition to cosmic meaning, a motivational fulfillment can be seen as another important factor in meaningful life. Since emerging adults tend to have many career goals, their experience of uncertainty and anxiety may lead them to experience a life that is not complete . The concepts of competence and self-efficacy are likely to play a special role in the lives of emerging adults. High meaning in life in middle and late adulthood. Middle adult and late adult participants mostly stated that their lives were very meaningful and emphasized their children and happiness. In terms of frequency, the middle adult group was the group that expressed the highest meaning in this study. Although it is not possible to indicate a statistical difference, there is a remarkable difference in the expressed meaning levels between these two generations and the third generation . The fact that the middle and late adults are likely have accomplished many social and professional goals and that certain goals are still present may provide satisfaction and meaning for the participants. The participants' sources of meaning and their goals in life seemed to support this observation. High meaning in life in older ages has also been shown by previous research . --- Summary The present qualitative study showed that the participants in emerging, middle and late adulthood mostly and commonly emphasized relationships, happiness and success in both their sources of meaning and meaningful life experiences. As discussed above, these findings were in line with previous qualitative and quantitative research . The fact that these findings were obtained from participants from three different generations of the same family is thought to further strengthen the emphasis on these concepts. However, it can be argued that the most important findings of this study were the reflections of developmental stage characteristics on meaning in life. In addition to the common salient categories, salient categories that differed across generations also emerged in this study and are as follows: an emphasis on health as a source of meaning in middle and late adulthood; emerging adults seeking meaning together with existential inquiries and uncertainty of the future and, in their own words, experience low meaning in their lives; middle and late adults experiencing lower search for meaning and stating that these searches are generally related to relational problems and past negativity; emerging adults having largely career-related goals, middle adults having goals for their children and late adults having likewise goals for their children/grandchildren and also decreasing goals; and finally, highest meaning shown firstly by middle adults and then late adults. Most importantly, having selected participants of different developmental stages from the same family should in a sense exclude many social, economic and cultural variables and allow making comments on a developmental basis. --- Suggestions Future research is needed to examine meaning in life, particularly using mixed designs, in which quantitative and qualitative methods are combined. As a matter of fact, one major limitation of the study is that the qualitative findings cannot be generalized. Also, for practical purposes, snowball sampling method was used to find families as participants who would meet the required criteria. One family mentioning another family as potential participants was likely to cause the participant group to be less heterogenous and thus further complicate interpreting the findings. This could explain the reason for another limitation of the study, which was that the study was largely based on a single perceived socioeconomic status . Moreover, among the reached families, the majority of the late adults were female . It should also be noted that the study was conducted in the province of Izmir, that is, Western Turkey. Findings across the Turkish land could yield different results as Turkey hosts various cultural climates, of which Izmir is only one minority. Therefore, the results of this study should be considered within the context of the particular sample. So, future research can investigate meaning in life across socioeconomic statuses and genders as well as different cultural contexts. Another limitation might have to do with accessing thoughts about meaning in life. Upon asking Question 1 in the interview form , many participants had to take their time to answer it, explicitly indicating that this was not an easy question. It could be discussed whether a preparation phase prior to the interview would in fact confound or help the research. In addition, many different variables such as family, worldview, efficacy, career concerns, health, and life goals seem to be important in meaning in life, all of which can be the focus of both psychological research and therapeutic practices. Finally, considering the reflections of developmental stage characteristics in this study, it would be helpful for future research on meaning in life to include developmental and especially longitudinal examinations. Author Contributions: This study was produced from the Master's thesis titled "Viewing meaning in life in three generations: A qualitative study" prepared by the first author under the supervision of the second author. --- --- Data Availability: The data sets are available from the corresponding author upon reasonable request. Ethical Disclosure: The ethics committee approval of the study was obtained from Dokuz Eylul University Institute of Educational Sciences Ethics Committee on 14/11/2019 .

The aim of this study was to understand meaning in life as a phenomenon in three different stages of life. Accordingly, this study aimed to investigate the similarities and differences in the way those in emerging, middle and late adulthood from different families view and experience meaning in life. In the 14 Turkish families who participated in this study, the children were in emerging adulthood, the parents in middle adulthood and the grandparents in late adulthood. The data were collected through one-on-one semi-structured interviews. Based on the questions of the semi-structured questionnaire, five main themes were identified, and the data were analyzed in view of these five themes. The main themes identified were: sources of meaning, meaningful life experiences, search for meaning, goals in life and present meaning. The emerged categories were presented separately for three developmental stages. The results were discussed in light of the literature and some suggestions were made for future research.

issues such as meaning in life or the meaning of life have been the subject of philosophical thought and theology for centuries with the observations of the austrian psychiatrist victor frankl in the nazi concentration camps this concept began to be studied in the field of mental health meaning in life which is the subject of positive psychology is the way people make sense of their lives different from the absolute meaning of life it can also be expressed as the degree to which people perceive meaning value and mission in their lives since frankl meaning in life has been conceptualized by researchers in various ways and has been studied together with different variables following the development of measurement tools for the concept when looking at some of the variables with which meaning in life is positively correlated many positive variables can be found such as positive emotions psychological wellbeing hope and life satisfaction in light of these relationships the importance of meaning in life from a positive psychological point of view stands out it has also been reported that those who experience higher meaning in life show lower depression along with higher selfconfidence and are better off even in poor health conditions than those who experience lower meaning in life the contribution of theoretical explanations and various measurement tools based on selfreport method is indisputable however a problem that this method poses is the issue of the reliability of selfreporting especially when it comes to meaning in life while people may cheerfully express that their lives are full of meaning they can do this without evaluating the nature of a meaningful life or their own sources of meaning in fact it has been suggested that while some sources provide more satisfaction than others measurement tools rarely get beyond the question is there meaning in this persons life or not another seeming problem is that not much is known about the relationship between ones meaning in life and developmental stage as individuals are viewed from a holistic perspective it is difficult to consider a complex concept such as meaning in life separately from their current developmental stage despite individual differences each stage of life has its own characteristics the number of studies that focus on meaning in life from a developmental point of view is limited and different findings can be observed in addition to the studies that show higher presence of meaning in older age there are also findings that observe lower presence of meaning the theory of meaning in life that the existing measurement tools embrace can be considered as an important factor in these different findings in fact it has been argued that observing low meaning in older age in ryffs psychological wellbeing scale may be possible but misleading because meaning here is measured through purpose and ones goals are likely to decline in older age moreover it is known that emerging adulthood is characterized by discovery and development of identity career and social roles for these reasons it can be expected that search for meaning would be higher in emerging adulthood and even more adaptive than in other stages of life in fact it has been shown that higher search for meaning is associated with lower wellbeing in later ages compared with emerging adulthood despite potential differences between age groups it has been stated that meaning in life is important for all developmental stages starting from adolescence concepts such as meaning purpose and sources of meaning in life are important in terms of psychological wellbeing and life satisfaction but it seems that quantitative methods fail to shed light on how people experience meaning in life moreover the fact that many studies have been based on western and undergraduate samples provides limited light on the phenomenon therefore it seems necessary to examine meaning in life through qualitative studies as suggested by previous research and to do research that touches on different developmental stages and cultural contexts in the light of all this the aim of the present study was to examine the views and experiences of individuals from three different turkish generations in the same family concerning meaning in life qualitative research method is particularly likely to provide the opportunity to examine the phenomenon in a more flexible realistic and rich way with the qualitative research method it is possible to go beyond the question is there meaning in ones life or not and to shed light on many aspects of the phenomenon as to what meaningful life experiences look like which elements play a role in adding meaning to life what kind of goals there are in a meaningful life or what the nature of searching for meaning is the present study is thought to be unique in that while addressing all these aspects it also does this by offering developmental comparisons with three different generations in turkey although the qualitative method does not allow a statistical comparison between groups it is possible to describe the reflections of the phenomenon in different stages of life through thematic comparisons in addition the fact that the individuals of different stages in the study come from the same family makes the comparative inferences more valid by keeping the sociocultural structure relatively equal it is hoped that the study would contribute to theoretical knowledge by describing the views and experiences of individuals from three different generations that is emerging adulthood middle adulthood and late adulthood help develop a deeper understanding of meaning in life as a phenomenon and thus guide prevention and intervention studies in positive psychology and pioneer future studies especially in turkey on meaning in life method participants criterion sampling method was used in the present study the criterion was that the child in the family would be 1825 years old the parents 4065 years old and the grandparents 65 years and older snowball sampling method was used to reach families that had met the required criteria the snowball technique is used in situations in which it is difficult to reach the participants who meet the criteria determined by the researcher a total of 42 people from 14 families in the province of izmir took part in the study 27 participants were women and 15 were men of emerging adults there were five women and nine men of middle adults there were 10 females and four males lastly of late adults there were 12 females and two males the average ages for the emerging middle and late adults were respectively 21 48 and 71 detailed demographic information for each family is presented below in table 1 preparing the interview form the study data were obtained through semistructured interviewing method the required ethics approval application was made to and obtained from the research ethics committee of dokuz eylul university for the project viewing meaning in life in three generations a qualitative study the questions prepared to be used in the semistructured interview form were created based on literature review and were also tested with pilot interviews in addition with the aim of improving the relevance and intelligibility of the interview questions the draft interview form was sent to 10 academicians who completed their doctorate in guidance and counseling the questions were revised according to their feedback and then the form was finalized the interview questions were as follows 1 what generally comes to your mind when you think of the meaning of life 2 what are the things that are currently giving meaning to your life 3 do you remember a specific moment when you found your life the most meaningful how would you describe this moment what was it that made this moment this meaningful data collection a certain day and time suitable for the families was determined for the interviews and the interviews were carried out in the families home environment the participants were notified of the content purpose and confidentiality principles of the research both verbally and in written form prior to the interviews and their written consent was obtained then demographic information was collected and interviews were conducted the interviews were recorded by the first author using a smart phone and these recordings were later transcribed during the interview participants were asked semistructured interview form questions attention was paid to asking openended questions in the order determined for the reliability of the research and interviews were completed between 1030 minutes all the data were collected in 20192020 before the covid19 outbreak data analysis a phenomenological approach was used to analyze the data the goal with this approach was to understand meaning in life as a phenomenon for this purpose sources and experiences that make participants lives meaningful their experiences with search for meaning their life goals and current levels of meaning were investigated the transcribed data were analyzed via nvivo 11 at the very beginning of the data analysis process a family was selected and analyzed independently by both the first author and the second author before the analysis process the five main themes that had been created according to the interview questions were determined by the authors and the first coding was done accordingly two different analyses based on a certain family were compared with one another on nvivo 11 and interrater reliability was calculated this calculation was made on nvivo 11 and cohens kappa coefficient was found to be 80 considering that values of 80 and above indicate strong intercoder reliability the reliability between coders in the study was quite good content analysis and descriptive analysis methods were used in analyzing the research data content analysis is mainly used in phenomenological designs in which themes that may be hidden in the data are revealed and interpreted descriptive method on the other hand involves organizing and tabulating the data in order to increase reliability the data were analyzed and quantified on a frequency basis and the obtained data were presented with direct quotations quotations were emphasized in italics and the participant from which the quotations are made was indicated in parentheses the first number in the code names refers to the family the second refers to the generation and the third refers to the gender when names of certain people had been mentioned by any participant these names were removed for confidentiality purposes and replaced by words such as my friend son or daughter depending upon how that person relates to the participant results the interview questions of the study were taken as themes and the data were coded accordingly the first two questions were handled within one theme and the remaining five questions were handled within five themes and a total of five general themes were presented these general themes are sources of meaning meaningful life experience search for meaning goals in life and present meaning salient categories that emerged were identified under these general themes the five themes and the salient categories of the study can be seen below with their frequencies in table 2 the salient categories are listed in descending order according to their frequency of utterance those with the same frequency of utterance are listed alphabetically family happiness health meaningful life experience success personal growth happiness being with loved ones having a child freedom from hardship happiness being with loved ones happiness success search for meaning existential inquiries uncertainty of the future being alone frustration contemplating the past relational problems frustration absence of search contemplating the past being alone goals in life career goals note numbers between parentheses refer to the frequency of utterancesobservations theme 1 sources of meaning the answers given by individuals regarding the meaning of their lives and what adds meaning to their lives were gathered under the theme of sources of meaning emerging adults family family emerged as the most uttered source of meaning among emerging adults here a married individual referred to his spouse and the remainder emphasized their parents and siblings when it comes to the meaning of life family comes to my mind sharing love respect happiness and beautiful moments within family tie activities secondly the emerging adults mentioned activities as a source of meaning under this category were activities such as sports music and movies music is giving meaning to my life right now im young anyway i am a 19yearold university student as with every university student i too can say music friends another category that shared the second place for emerging adults was friends here other than family members and romantic partners the social environment of the participants was included my social environment also gives me meaning because my circle of friends in general is very wide spending time with them makes me very happy happiness happiness also appeared as the second salient category that has the same frequency with activities and friends if you have things in your life that you love if you do things that make you happy life is then meaningful for you middle adults family as with emerging adults family is the most salient source of meaning for middle adults as well here most of the participants firstly mentioned their own children and then their spouses limited emphasis was placed on their parents and siblings of course my family is my priority my wife my daughter… they are the things that give meaning to me… their happiness makes me happy too their being healthy makes me healthy too happiness secondly middle adult participants talked about happiness as a source of meaning when i think of the meaning of life what comes to my mind is to be happy and to be able to make people around you happy health another category that emerged along with happiness was health one participant expressed his emphasis on health as follows life means a lot to me as long as i know that i am healthy or when i know that the people around me are healthy late adults family and happiness late adults emphasized their children and grandchildren while talking about family and stated that they generally experienced happiness through family members therefore it can be said that the categories of family and happiness emerged together for late adults and were seen as the primary sources of meaning a healthy life with my children and their being around me… i am happy with my family and children around me i am happy with their presence health another source of meaning that was mentioned almost as much as happiness by late adults was health when it comes to the meaning of life health comes first to me it is very important for people of our age theme 2 meaningful life experience the categories under this theme were identified by analyzing participants experiences here the aim was to mention the themes within the experiences of participants rather than the experiences themselves however common experiences that emerged quite frequently have been presented in the table as a different category and they were also treated under other categories like freedom from hardship and happiness when participants mentioned more than one experience all of these were included in the analysis emerging adults success a male emerging adult who emphasized his experience of success described the most meaningful moment of his life with the following sentences it may be that moment when i got into this engineering program at university because i had not studied that hard since childhood until then i only studied for this exam that exam was actually worse than i expected but when i got that result that moment is one of those moments that i will never forget that gives me meaning when asked what made this moment so meaningful the participant answered i had always been unsuccessful until that day it was like having passed an exam for the first time other than the driving license test personal growth personal growth emerged as another meaningful life experience in emerging adults here the participants talked about experiences that changed their perspective brought them awareness and enabled them to learn some personal lessons a male participant mentioned some of his academic and romantic experiences that he had in the second year of high school despite their negativity the participant stated that these experiences made great contributions to his character at first i started studying for the mathematics olympiad that year that is why i am absolutely sure that that year contributed to my thinking i also loved one person it ended a little unhappy i learned a lot i felt that i was maturing myself too it created an awareness i learned that people shouldnt be trusted that much i used to see everyone as myself but i learned that everyone is different happiness and being with loved ones happiness was another experience that emerged in meaningful life experiences it seems difficult to say that the participants emphasized only happiness in their experiences but it can be said that happiness frequently accompanied those meaningful experiences being with loved ones which was identified as a different category was mostly expressed with happiness and therefore reported here under the same heading a male participant described an evening spent with family and relatives as follows everyone was happy we didnt have any problems most of the financial problems in the whole family among all my relatives had been solved and it was like a meal to celebrate it middle adults having a child freedom from hardship and happiness the experience that middle adults mentioned the most was having a child five out of 10 female participants and four out of four male participants stated this experience as the most meaningful experience of their lives having a child emerged alongside freedom from hardship and happiness participants statements about the birth process revealed that the process was a crisis for some of the middle adults it seemed that both the happiness of having a child and the end of this difficult process was quite meaningful for them i could not give natural birth it was always to and fro we were going to the hospital all the time and the hospital was far away there was a distance of about 85 km i wanted this process to end as soon as possible perhaps this could have triggered a little more this trouble this process we were going there every three days we were constantly going for tests waiting to see if the baby is moving of course it makes one very happy to encounter such a beautiful thing as a result i think thats the reason the stress and boredom i was experiencing at that moment late adults being with loved ones and happiness late adult women mentioned that the most meaningful times of their lives were when they were together with their deceased husbands other answers included spending time with their family in childhood the meaning in these experiences was also defined by the participants mostly through happiness a late adult female participant who lost her spouse in the ninth year of her marriage emphasized firstly the time spent with her husband and another participant mentioned the time spent with her family in childhood when i was with my husband… i lost him 28 years ago i had very good days the best twenty years of my life passed with him there are times in my first childhood those were special times for me i had my mother and father… you are waiting for a mother who will come from work prepare food for you her love… they were very special days for me success another meaningful life experience that emerged for late adults was success a female participant who had never attended school in her childhood mentioned how she decided to go to a literacy course at the age of 59 and managed to receive a certificate seeing this as one of her most meaningful experience the participant expressed her success and happiness as follows my child i have never studied i went to school at the age of fiftynine and got a certificate it is my most meaningful day i can start studying even now if i want to i love it so much it is the most meaningful thing i got a certificate for reading and writing i was very happy to have gotten it i said i will do it and i went and did it i went and got it when i was fiftynine theme 3 search for meaning another phenomenon addressed in the present study was search for meaning participants were asked whether they would find themselves in search for meaning at times 37 of the 42 participants said that they sometimes did find themselves in search for meaning emerging adults existential inquiries and being alone the emerging adults experiences of search for meaning largely coincided with the existential inquiry category the moments when they question their world views fail to reach any conclusions and thus fail to find an absolute meaning were covered under this category the category of being alone as another salient category emerged mostly simultaneously with existential inquiries so the emerging adults experienced search for meaning when they got into existential inquiries and according to their statements these inquiries usually occurred when they were alone yes i find myself like every human being i think about why we exist what the meaning of this struggle is we will die anyway why we are working… when we come to the question what is the purpose for our living it always comes to a dead end i cant find a solution a way out we put in so much effort all wasted actually as they say this world is mortal… i dont know the why either but we keep going uncertainty of the future emerging adults also talked about how uncertain their future looks the answers addressed in this category had more to do with what awaits them in the future rather than questioning mans existence you want to have a profession you want to put your life in order but none of them are clear in front of us im making an effort but will i be able to get there … one wants to see the result middle adults frustration the most salient category in middle adults search experiences was frustration here participants talked about their expectations that could not be met you know you labor or you try hard for something or i dont know something about your child… you try really hard you sacrifice but you you know dont get rewarded like there is no result contemplating the past middle adult participants also mentioned that from time to time they reviewed their past and tried to envision what their current lives would be like if they had taken some different steps participants who were not fully satisfied with a certain point of their past referred to these retrospective moments as an experience of searching for meaning well when i look into the past one experiences an i wish moment even if it is just a little i wish after reaching a certain age you think of the past sure today is fine too but then i think like if i had done this or that maybe things would have been different relational problems another salient category in middle adults experience of searching for meaning was relational problems here the participants talked about their problems with family and colleagues frustration like middle adults in the study late adults also seemed to experience frustration when they were in search for meaning here participants experiences of sadness distress and unhappiness were collected under this category a female late adult who used to live in the same building with her daughter and grandchildren for a long time told that her daughters family moved to another place and that this distance saddened her my grandchildren used to live upstairs they moved out and left here i got saddened by their leave at one stage this makes me meaningless like why did this happen i wish we lived closer i wish we visited one another at nights too absence of search another category under search for meaning was identified as absence of search 5 out of 42 participants stated that they did not experience any search for meaning and three of these were late adults no i lived life to the fullest i am actually… well i am a positive person you know im healthy… you know… i always think of turning bad things into good contemplating the past and being alone like middle adults late adults also described contemplating their past as a meaning seeking experience participants seemed to experience these moments while they were alone sometimes when financial means are short i say like… would it be different if we had done this or that could we at least offer our children other opportunities theme 4 goals in life since goals play an important part in meaning in life participants were asked about their shortterm and longterm goals with the aim of investigating meaning qualitatively across generations here answers were quite varied and expressed clearly by the participants their responses were analyzed with a descriptive perspective emerging adults career goals both the shortterm and longterm goals of the emerging adults were mostly career related participants mentioned goals such as to complete their education to do their desired profession to settle abroad or to start a masters degree goals to restructure life the third category which emerged in relation to children and careerrelated goals was the goals of middle adults to restructure their lives the participants stated that after their children gained their independence they would focus more on themselves travel around and live a life away from the city with their spouses as soon as my sons are able to go their own way my whole thing… the meaning of my life then will be my wife and me i will take time for both of us then im going to say to myself a little bit late adults goals for children as in middle adults the first goal category identified in the late adult group was goals for children as well compared to emerging adults and middle adults the participants here in particular emphasized their wishes rather than goals their children and grandchildren seemed to be the base of their wishes goals such as witnessing the happiness of ones own children being visited by them spending time with them not being dependent or burden on them and the like were addressed in this category to see my children happy to watch their lives getting better all the time just that my children be happy i want nothing else just that they care about me too decline in goals another salient category in the late adult group was decline in goals when the participants were asked about life goals they stated that they did not have many goals at this stage of life i can no longer have goals why i have achieved my goals im seventyfour already i have nowhere to go from now on oh son… how old are we now what goals physical health goals another goal category that did not emerge in the other groups was physical health goals late adults thirdly mentioned goals about their health my goal is health that i can keep doing my physical exercises for a few more and have good health well it is health that is what i ask from god theme 5 present meaning participants views on their present level of meaning were discussed under this theme participants sometimes rated their opinions with adjectives sometimes made likerttype statements and sometimes gave answers based on percentages the answers were gathered on a common ground and presented under the categories of meaninglessness low meaning half meaning moderate meaning and high meaning emerging adults more than half of the emerging adults viewed their lives as half meaningful lowly meaningful or meaningless half meaning the reason why the first category was presented with the word half is that the participants stated that they had some meaning in their lives but it was incomplete until some things happened i dont think its exactly meaningful actually i mean there are people who give meaning to my life but i think it will be much more meaningful when i fully get a job make a life for myself and take my own economic freedom moderate meaning a male participant who emphasized his future plans and current situation stated that he found his life meaningful of course my life has meaning i am happy now i have future plans school will end i will move and i will live abroad… low meaning another male participant who approached the topic with existential questioning stated that his own life did not mean much when viewed from a cosmic perspective the statement of the participant considered under the low meaning category was as follows doesnt make much sense right now because when we look at it considering all humanity i wonder what humanity would lose if i was not there… so my life is a little bit meaningless meaninglessness another female participant who was coming from a similar perspective stated that her life had no meaning i think my life is very meaningless it can be meaningful when you look at it with all its goals and efforts but id say it has no meaning looking from the outside high meaning another emerging adult referring to the importance of the decisions he was about to make at this stage of his life told that this stage and therefore his entire life were very meaningful for him it is really meaningful for me right now because im laying the foundation of my life in the slightest mistake i would throw away all the next 40 years if ill have them of course im not sure if my peers think that way about it but this stage is very important for me middle adults when middle adults responses were analyzed it was observed that nine out of 14 participants considered their lives highly meaningful four moderately meaningful and one meaningless high meaning most of the participants stated that they viewed their lives highly meaningful and referring to their sources of meaning they generally emphasized family and happiness here as well my life is very meaningful right now… i think i now live a much better life than i imagined i wouldnt have imagined a life like this i have comfort comfort in an economical sense and also i am very comfortable in my family relationships i have a husband who loves me and understands me i have a child that i value very much moderate meaning the participants who did not emphasize high meaning but viewed their lives as meaningful were included in the category of moderate meaning right now i am pretty close to the last steps i am at a point where i can understand that life has a meaning that it is something worth living late adults late adults answers on their present meaning in life were gathered under the categories of high meaning half meaning and moderate meaning while seven out of 14 participants found life highly meaningful four participants saw in it a half meaning and the remaining three found it moderately meaningful high meaning like middle adults the late adult group also generally found life meaningful parallel to sources of meaning participants sometimes emphasized their children grandchildren and health quite meaningful for me im fine healthy happy of course there are things i feel sad about but this is life i think god willing everything will pass with goodness and beauty i have children i must always be there for them i praise god for the fact that i live half meaning some late adults on the other hand referring to their family and health problems stated that their lives were meaningful to some extent in order to preserve the name of the category in emerging adulthood these answers were also handled under half meaning as a matter of fact participants mentioned some shortcomings here as well these days i just want to have a calm mind i mean this is what i want i dont want sadness but it is impossible not to be sad right now grandchildren and so on calmer happier… this is what i am looking for but its hard to find so i would say medium level its neither bad nor good moderate meaning other late adults on the other hand responded that their lives were meaningful even though they did not specify high level of meaning every day has its own beauty every morning has its own sunrise i think every age in life has its own beauty i am happy with my old age if i am healthy if i am walking you should be thankful for all of this discussion the abovementioned findings for three different generations under five main themes showed both commonalities and distinctions from a developmental point of view therefore they were discussed separately common categories the salient categories which emerged commonly in all developmental groups were relationships happiness and success this observation seems to be consistent with other studies in the literature relationships happiness and success are variables that have been shown in many different qualitative and quantitative studies on meaning in life in particular positive relationships and concepts such as environmental control autonomy and efficacy that can be considered under the category of success play a part in different wellbeing theories and theories of meaning in life what was particularly interesting here was that these relationships were largely family relationships although not as frequent in the emerging adult group as in the middle and late adult groups all three groups stated that family was the primary source of meaning for them again when examined from a developmental perspective different studies on meaning in life have shown that relationships with spouses and children and relationships with parents and relatives are at the forefront in middle adulthood in addition a study conducted with people over 65 years of age found that emotional support from family among different types of social support was associated with higher meaning in life however that family was seen as the primary source of meaning in emerging adulthood along with other stages may indicate cultural emphasis in this developmental stage that is characterized by identity discovery and close relationships selffocus becomes prominent therefore it seems a little unlikely that emerging adults will see their families as the primary source of meaning however this study was performed in a turkish context where familial and social ties are strong and collectivistic characteristics are stronger however both quantitative and qualitative studies in the american context also suggest that family remains an important source of meaning in emerging adulthood researchers argued that individuals in this transitional period may be returning to their families repeatedly to find support and direction another important finding was that happiness emerged both as a source of meaning and as an emotion accompanying meaningful life experiences previous research has shown that happiness is related to meaning in life in all three developmental periods however while meaning in life is a eudaimonic variable happiness is a hedonic variable and the overlaps and differences of these concepts are still debated the study seems to support the discussion that meaning in life will almost always bring happiness by explaining the relationship between meaning in life and positive affect with learning researchers argued that if the experience of meaning emerges with positive emotions over and over again the connection between these two variables becomes strongly etched in memory via these learning experiences in this way thinking about one triggers thoughts about the other and the two become conceptually related moreover since this study comes from a phenomenological point of view it can be said that cultural understanding of meaning or happiness may change and the ongoing debate on eudaimonic vs hedonic wellbeing should include cultural context the degree to which a variable is eudaimonic or hedonic could have more to do with experiential differences rather than conceptual differences developmentally distinct categories in addition to the findings mentioned above the most important findings in this study were the seeming reflections of developmental stage on meaning in life health as a source of meaning in middle and late adulthood in the middle and late adult groups health emerged as a source of meaning different from the emerging adults given the characteristics of these stages this observation is expected in middle adulthood which is defined as the period of gains and losses the individual tries to adapt to various physical and psychological changes while at the same time fulfilling his professional and family responsibilities therefore it is very important for middle adults to maintain their physical health to maintain their quality of life throughout late adulthood health quality further decreases and different health problems arise in the light of all these health becoming more important in ones meaning in life in older ages can be explained by the fact that older ages are when health problems begin to emerge previous research showed that a positive relationship between physical health and meaning in life exists and that health plays a major role in older adults life satisfaction and meaning in life therefore it can be argued that health is a component of meaning in life but will not be seen as a primary source of meaning until health issues arise existential inquiries in emerging adulthood and search for meaning manifested with future anxiety when emerging adults meaning seeking experiences were examined the salient categories were identified as existential inquiries uncertainty of the future and being alone these salient categories reflect the key characteristics of emerging adulthood questioning ones own world and shaping ones personality through personal convictions are some of the tasks performed in this stage it has been discussed that as a stage characterized by discovery of identity emerging adulthood may also be linked to search for meaning in life participants seemed to struggle with holistic meaning and therefore were led to search for meaning it can be said that a meaningful life is not only a purposeful life but also a life that can be justly explained by ones worldview this is especially relevant for emerging adulthood the second salient category in the emerging adults search for meaning was uncertainty of the future uncertainty is another important factor in the lives of emerging adults in this transitional period they experience many academic social and personal changes and these changes pose an uncertainty for the emerging adult participants seemed to experience these changes from various angles and they were particularly concerned about whether their education will provide tangible feedback previous qualitative findings showed that the theme of uncertainty about the future emerged with the theme of meaninglessness hence it can be argued that the ability to cope with uncertainty seems even more necessary in emerging adulthood indeed many theorists agree that perceived loss of control will shake the individuals meaning in life search for meaning manifested with relational problems in middle adulthood unlike late adults another experience that middle adult associated with the search for meaning was their relational problems as the categories of family friends and being with loved ones which emerge under the themes of sources of meaning and meaningful life experience support the importance of relationships for a meaningful life relational problems under the theme of search for meaning further strengthens the emphasis on relationships according to the participants while continual satisfaction in relationships makes life meaningful having problems in relationships seems to lead the individual to search for meaning this observation seems to be in line with previous research that showed that relationships are an important source of meaning for different age groups and that lack of satisfaction in relationships is likely to lead to search for meaning that middle adults described relational problems as an experience leading to search for meaning may be due to the quantity of relationships in this developmental stage especially in family context a parent stays in contact with not only their children but also their spouse and their own parents apart from this the individual also maintains other relations in and outside the workplace therefore compared to late adults it seems more likely that a negativity in the relationships of middle adults who have many social roles will lead to a search for meaning search for meaning in middle and late adulthood manifested with frustration and negative contemplation of the past unlike emerging adults the first category that stood out in middle and late adults experience of search for meaning was frustration these two groups did not mention any existential inquiries or future anxiety but rather the situations in which their expectations were not met in other words the participants seemed to search for meaning when their expectations about themselves other people or life in general were not satisfied this observation can be interpreted in opposition to the category of happiness in meaningful life experiences it can be said that while positive emotions may lead one to see life more meaningful negative emotions are likely to result in the opposite effect research showed that increasing sadness fear and shame is indeed related to increasing search for meaning it seems that various negative emotions can be experienced within the phenomenon of disappointment and therefore lead the individual to search for meaning similar emotions seemed to be experienced also when the same participants review their own pasts within the category of contemplating the past participants expressed their i wish moments it is known that with aging adults seem to focus more on the past when the statements of participants are examined it can be seen that this retrospective look generally focuses on negative experiences participants associated the search for meaning in life particularly with past experiences that they were not satisfied with previous research seems to support this observation that search for meaning is associated with focusing on past negativity therefore it can be argued that a meaningful life requires contentment not only with the present but also with the past as argued by baumeister in his four needs for meaning it appears that for a meaningful life one must be able to positively justify his own actions and these actions also include past experiences decreasing search for meaning in late adulthood though sometimes manifested with loneliness some late adult participants stated that they never find themselves in search for meaning this observation can be explained by maturation in that it is expected that the why questions forming ones world view will be relatively completed throughout emerging adulthood in addition there is more diversity of experiences in emerging adulthood than middle and especially late adults who have already accomplished certain goals in life therefore it can be said that they are less likely to view the future as that uncertain and less likely to experience future anxiety when asked about their search for meaning in life the late adult participants also mentioned the times when they are alone the late adults in this study mostly included either retired or widowed participants and therefore it can be argued that they were more likely to search for meaning in these times compared to middle adults and also unlike emerging adults it seems that loneliness itself created a problem for late adults rather than the existential questions that being alone provokes this observation further supports the important role relationships play in meaning in life particularly in late adulthood where physical and social losses and loneliness become characteristics of the stage career goals in emerging adulthood the emerging adults of the study seemed to have largely career goals given the developmental tasks of the stage and that all these participants continued their education this observation is to be expected in this stage of possibilities individuals tend to have many both short and longterm goals many of which are careerrelated however this result can also be seen as extension of turkeys current situation especially with the increase in population and the number of universities in the last twenty years in turkey unemployment is rising according to the turkish statistics in 2020 youth unemployment rate was about 25 it is also helpful to note that career uncertainty is considered as a characteristic of the 21st century and therefore in the midst of this uncertainty it can be argued that emerging adults are likely to seek safety in the first place goals for children in middle and late adulthood the middle adults in the study mostly mentioned their goals for their children in both sources of meaning and meaningful life experiences it seemed that children of middle adults were at the center of their lives other goals that followed were career goals and goals to restructure their lives these three elements seem to clearly reflect middle adult developmental tasks conceptualized by havighurst to help young children become responsible and happy adults to achieve and maintain vocational satisfaction to nurture the marriage relationship and to develop appropriate leisure activities are the developmental tasks in middle adulthood all the salient goals mentioned by the middle adults of this study remarkably coincided with these developmental tasks goals and concerns about the future of children and their career have also been supported by studies in various countries similar to middle adults late adults also mentioned goals for their children as their primary goals however the participants took a more passive position in these goals in general middle adults talked about supporting the building of their childrens future whereas late adults talked about seeing the happiness of their own children and grandchildren in other words it can be said that middle adults described themselves in the role of a helper while late adults were more in the role of a spectator this observation seems to point to the changing life roles in personal goals across developmental stages research have shown that while goal orientation at younger ages moves toward personal development at later ages this orientation focuses more on maintenance and reducing loss decline in goals in late adulthood goals for maintenance and reducing loss can be seen in late adults following salient goals that are identified as physical health goals and decline in goals the participants mentioned that after this age they no longer had many goals and basically just wanted to be healthy this decline in goals that the participants expressed is an important finding as argued scales on meaning in life that contain goaloriented items could yield developmentally problematic results since in this stage of role loss individuals have fewer goals to achieve this qualitative study seems to further support this discussion low meaning in life in emerging adulthood only onethird of the participants in emerging adulthood stated that they had a really meaningful life while the rest mentioned that they experience meaninglessness low meaning or half meaning especially when compared with the responses of the participants in the other two generations emerging adults was the group that expressed the least meaning in the study as can be seen in their expressions about their search for meaning the emerging adults here told that they could not make sense of the world and its events and that the future was very uncertain for them at the moment this observation seems to point to the cognitive dimension of meaning in life that is emphasized theoretically being able to comprehend life at a cognitive level and coming up with satisfactory answers with regards to why everything exists seem quite important for a meaningful life which also has been conceptualized as holistic meaning and cosmic meaning in accordance the expressions of the participants in this study about meaninglessness or low meaning revealed their difficulties in making sense of life from a cosmic perspective the dominance of expressions reflecting cosmic meaning issues in the emerging adult group indicates that it would be indeed helpful to approach the phenomenon from a developmental perspective in this stage individuals enter into a discovery becoming preoccupied with their identity careers and social roles and reevaluating the readymade meaning systems coming from family and the society it has been argued that search for meaning may be in a sense normative in emerging adulthood leading them to a higher search in comparison to middle and late adults the qualitative findings in the current study are thought to strengthen this debate moreover the uncertainty about achieving personal goals seemed to pose a problem for the participants therefore in addition to cosmic meaning a motivational fulfillment can be seen as another important factor in meaningful life since emerging adults tend to have many career goals their experience of uncertainty and anxiety may lead them to experience a life that is not complete the concepts of competence and selfefficacy are likely to play a special role in the lives of emerging adults high meaning in life in middle and late adulthood middle adult and late adult participants mostly stated that their lives were very meaningful and emphasized their children and happiness in terms of frequency the middle adult group was the group that expressed the highest meaning in this study although it is not possible to indicate a statistical difference there is a remarkable difference in the expressed meaning levels between these two generations and the third generation the fact that the middle and late adults are likely have accomplished many social and professional goals and that certain goals are still present may provide satisfaction and meaning for the participants the participants sources of meaning and their goals in life seemed to support this observation high meaning in life in older ages has also been shown by previous research summary the present qualitative study showed that the participants in emerging middle and late adulthood mostly and commonly emphasized relationships happiness and success in both their sources of meaning and meaningful life experiences as discussed above these findings were in line with previous qualitative and quantitative research the fact that these findings were obtained from participants from three different generations of the same family is thought to further strengthen the emphasis on these concepts however it can be argued that the most important findings of this study were the reflections of developmental stage characteristics on meaning in life in addition to the common salient categories salient categories that differed across generations also emerged in this study and are as follows an emphasis on health as a source of meaning in middle and late adulthood emerging adults seeking meaning together with existential inquiries and uncertainty of the future and in their own words experience low meaning in their lives middle and late adults experiencing lower search for meaning and stating that these searches are generally related to relational problems and past negativity emerging adults having largely careerrelated goals middle adults having goals for their children and late adults having likewise goals for their childrengrandchildren and also decreasing goals and finally highest meaning shown firstly by middle adults and then late adults most importantly having selected participants of different developmental stages from the same family should in a sense exclude many social economic and cultural variables and allow making comments on a developmental basis suggestions future research is needed to examine meaning in life particularly using mixed designs in which quantitative and qualitative methods are combined as a matter of fact one major limitation of the study is that the qualitative findings cannot be generalized also for practical purposes snowball sampling method was used to find families as participants who would meet the required criteria one family mentioning another family as potential participants was likely to cause the participant group to be less heterogenous and thus further complicate interpreting the findings this could explain the reason for another limitation of the study which was that the study was largely based on a single perceived socioeconomic status moreover among the reached families the majority of the late adults were female it should also be noted that the study was conducted in the province of izmir that is western turkey findings across the turkish land could yield different results as turkey hosts various cultural climates of which izmir is only one minority therefore the results of this study should be considered within the context of the particular sample so future research can investigate meaning in life across socioeconomic statuses and genders as well as different cultural contexts another limitation might have to do with accessing thoughts about meaning in life upon asking question 1 in the interview form many participants had to take their time to answer it explicitly indicating that this was not an easy question it could be discussed whether a preparation phase prior to the interview would in fact confound or help the research in addition many different variables such as family worldview efficacy career concerns health and life goals seem to be important in meaning in life all of which can be the focus of both psychological research and therapeutic practices finally considering the reflections of developmental stage characteristics in this study it would be helpful for future research on meaning in life to include developmental and especially longitudinal examinations author contributions this study was produced from the masters thesis titled viewing meaning in life in three generations a qualitative study prepared by the first author under the supervision of the second author data availability the data sets are available from the corresponding author upon reasonable request ethical disclosure the ethics committee approval of the study was obtained from dokuz eylul university institute of educational sciences ethics committee on 14112019

the aim of this study was to understand meaning in life as a phenomenon in three different stages of life accordingly this study aimed to investigate the similarities and differences in the way those in emerging middle and late adulthood from different families view and experience meaning in life in the 14 turkish families who participated in this study the children were in emerging adulthood the parents in middle adulthood and the grandparents in late adulthood the data were collected through oneonone semistructured interviews based on the questions of the semistructured questionnaire five main themes were identified and the data were analyzed in view of these five themes the main themes identified were sources of meaning meaningful life experiences search for meaning goals in life and present meaning the emerged categories were presented separately for three developmental stages the results were discussed in light of the literature and some suggestions were made for future research

Introduction The HIV epidemic disproportionately affects Black youth , particularly those in the southern United States . Youth account for 22% of new HIV infections in the U.S. and over half of these cases are among Black youth . In addition, despite making up 37% of the U.S. population, about 45% of people with an HIV diagnosis live in the southern U.S., and Black youth bear the burden of new infections in the region . The disproportionate impact on Black youth is rooted in disparities in social and structural determinants of health . For example, socioeconomic status and racism are fundamental causes of health inequities that have structured the course of the HIV epidemic . Structural determinants of health also adversely impact retention in HIV prevention and care among youth . There is a critical need to understand HIV risk among Black youth in the U.S. South to ensure that HIV prevention interventions are relevant and applicable to this population. Pre-Exposure Prophylaxis is a daily pill that reduces the risk of HIV infection in people at high risk via sexual transmission by over 90% and has been approved for youth since 2018. While it is a promising approach to HIV prevention, uptake among youth-particularly Black youth-has been low due to a lack of awareness, accurate knowledge, assumptions about PrEP, perceived lack of risk, and structural factors . To understand the reasons for low PrEP uptake and develop strategies to increase the use of PrEP, it is critical to engage Black youth in the research process. In 2018, we began a community-engaged research project on PrEP interest and uptake among Black youth in Durham, North Carolina , a city that is nearly 40% Black and has the sixth-highest rate of reported HIV infection in NC . The COVID-19 pandemic began in 2020 and its impact on Black communities has followed a similar storyline to other health conditions, such as HIV, that disproportionately affect Black communities . For example, Black individuals have been disproportionately hospitalized for and died from COVID-19 with Black individuals dying at 1.4 times the rate of White individuals . The disproportionate impacts of COVID-19 on Black communities stem from the same structural determinants of health that have shaped the course of the HIV epidemic . This results in communities with high proportions of people of color living in poverty, crowded housing, and high levels of racialized economic segregation experiencing high burdens of COVID-19 cases and deaths . Given the disproportionate impact of both HIV and COVID-19 on Black communities, it is critical that HIV prevention and PrEP care remain in place during the COVID-19 pandemic. However, the HIV prevention continuum, including PrEP, has been disrupted, with disproportionate impacts patterned by structural determinants of health . These disruptions are compounded for Black individuals, who already experienced more disruptions to PrEP care before the COVID-19 pandemic than others , and for youth, for whom typical barriers to care are heightened . The COVID-19 pandemic has disproportionately affected Black youth beyond physical health and healthcare access. Black youth are more likely than their White counterparts to experience poverty and food insecurity, to have had parents lose their jobs, and to be exposed to distance learning and school closures during the pandemic . Given the focus of our work on HIV prevention with Black youth, the far-reaching effects of the COVID-19 pandemic on this community, and COVID-19 restrictions on in-person meetings, we adapted our community- engaged research approaches accordingly . In this report, we identify the lessons learned from continuing our community-engaged HIV prevention project with Black youth, transitioning it to a remote setting, and pivoting to more broadly think about structural determinants of health during the COVID-19 pandemic. --- Methods Background on Community Partnerships Project IFE was a community-academic partnership focused on long-term HIV prevention among Black women in Durham Housing Authority communities in Durham, NC . A key finding from Project IFE's formative research with DHA residents was the need to reach youth in the community. The project discussed here was developed in response to this community concern and provided an opportunity for a group of locally-based researchers to conduct community-engaged research focused on HIV prevention among youth. Our three-part project involved: 1) building an Adolescent Health Working Group to engage local stakeholders focused on youth sexual health; 2) conducting participatory youth workshops to understand youth perspectives; and 3) conducting surveys and interviews with youth about PrEP awareness. --- The Process of Pivoting The pandemic affected our three-part project in different ways. The majority of Parts 1 and 2 occurred prior to the COVID-19 pandemic, whereas Part 3 occurred during the COVID-19 pandemic. The AHWG, comprised of stakeholders from the DHA, LGBTQ advocacy groups, adolescent healthcare providers, community-based organizations and non-profit groups, faith leaders, Departments of Public Health, as well as parents and adolescents, met six times to provide critical stakeholder input and guidance to the project. The pandemic necessitated that our final two AHWG meetings be conducted remotely. For Phase 2, we were able to hold three participatory youth workshops using the Youth Generating and Organizing ! methodology prior to the pandemic which is described elsewhere . Phase 3 took place fully remotely and our team added questions on COVID-19 in the context of this adaptation. This report discusses the overall process of transitioning our project during COVID-19. This process was shaped by feedback from the AHWG at the beginning of the COVID-19 pandemic through meetings notes and a running list of topics recommended by the AHWG members at each meeting. Our research team iteratively conducted pile sorting to organize the key themes from our AHWG feedback and subsequently revise the project . Preliminary analyses from Part 3 qualitative interviews focused on COVID-19's effect on youth also shaped this process. --- Results Challenges When the COVID-19 pandemic began, all in-person activities were halted. As all three parts of the project were intended to be held in person and relied on in-person community engagement, there was no clear immediate path forward. For example, the Phase 3 survey and interviews had not started prior to COVID-19 and were held entirely virtually. We began outreach in June of 2020 through Facebook advertisements and e-mailing local community listservs to reach as wide a population of youth and their parents as possible. Between June and September of 2020, we recruited only 17% of our sample target through Facebook and listserv recruitment, as these were not platforms youth themselves were regularly using. Furthermore, it was clear that the COVID-19 pandemic was having a negative impact on youth involved in the AHWG and on those participating in the participatory youth workshops via increased isolation and virtual school. --- Strategies To address the halting of in-person meetings, Phase 1's final two of six AHWG meetings were held on a virtual platform-Zoom-and guided the remaining study activities. No AHWG members expressed concern with pivoting to a virtual format and we were able to meet individuals individually in outdoor spaces to provide them with payment. Some AHWG members struggled with digital accessibility but we were able to follow-up individually with these individuals. Based on feedback from these virtual meetings, AHWG members felt comfortable expressing their thoughts in a virtual format, felt training youth in research would amplify youth voices, and that an e-newsletter could maintain community engagement while in-person gatherings were restricted. We used feedback from this evaluation form in real-time to structure the remaining aspects of our project and in our decision to continue this piece of the project virtually. The last Phase 2 participatory youth workshop session was not held virtually due to the sensitivity of talking about youth sexual health and youth's privacy, and the collaborative and interactive format of the participatory workshops was not conducive to a virtual environment. In September 2020, we pivoted to relying on Phase 1 AHWG community members to recruit and complete enrollment targets for surveys and interviews. Using this strategy, we reached 87% of recruitment goals for interviews and surveys within 3 months. The interview guides were created at the beginning of the COVID-19 pandemic and multiple questions and prompts were added to broadly contextualize the impact of COVID-19 on Black youth in the community broadly . More specifically, we asked how COVID-19 intersected with HIV prevention efforts and behaviors that would put youth at risk for acquiring HIV. Interviews with youth highlighted the need to address structural barriers to healthcare engagement for HIV , particularly during the COVID-19 pandemic. While the youth were grateful for time with family, they described "quarantine depression" due to COVID-mandated virtual schooling, physical distancing, and overwhelming racial injustices portrayed in media. Discussion: Lessons Learned The current study reports on a community-engaged project on HIV prevention among Black youth that was adapted in the context of the COVID-19 pandemic. The impact COVID-19 was having on Black youth in Durham, NC, required us to consider how social and structural determinants of health affect intersecting concerns like COVID-19, HIV risk, and HIV prevention. Through pivoting our project to be remote, discussing with AHWG members and youth about what aspects of the project would be appropriate to continue, and using their feedback in real-time, we developed a more holistic understanding of what was taking place in youths' lives that affected HIV prevention and health and well-being more broadly. This process points to the importance of addressing structural determinants of health and addressing overlapping health concerns when conducting community-engaged work. It is incumbent that future studies work to more fully center youth's voices and address the structural issues that may inhibit them from engaging in HIV prevention. To address HIV prevention during 2020 among Black youth, one central lesson learned was that it was necessary to also acknowledge COVID-19 and its profound impact on Black communities. Community-engaged research provided us with the process to expand our research and to ensure our research was meaningful and attentive to the community's needs. Community engagement prior to the pandemic was also essential for completing our research goals during the pandemic and provided a platform for feedback to be flexible in the goals of the original research plan. For example, some parts of our data collection were paused due to youths' levels of comfort with sharing virtually. At the same time, our qualitative research expanded to explore youths' daily lives and stressors related to COVID, which also affected their ability to engage in preventative health measures. --- Limitations Due to the COVID-19 pandemic quickly altering the course of our research, we were unable to solicit specific feedback on certain aspects of the project. For example, while AHWG members said that they wanted to continue with a virtual platform, we did not ask about the content of the virtual meetings . We believe that more specific feedback would have been particularly helpful in retaining youth in our AHWG. Additionally, this project was focused in Durham, NC, and youths' experiences in other regions and in more rural areas are likely widely varied. Therefore, factors that may have been relevant in adapting our research may be less generalizable in other settings. Relatedly, this project did not specifically focus on youth experiencing the greatest disparities, who may have had different experiences, and whose lives may have been impacted differently by the COVID-19 pandemic. Conclusions Through this process, our research team learned that the following were critical components to this engaged research: 1) actively listening to and responding to community feedback by creating an e-newsletter, halting portions of the project that would be particularly sensitive to conduct in a virtual format, and relying on Phase 1 AHWG community members for recruitment; 2) continuing to be in the community during COVID-19 via virtual Zoom meetings and one-on-one outdoor meetups; 3) centering youth's voices by regularly checking in with youth to ensure data collection strategies were appropriate for capturing their perspectives and applying to additional funding to conduct youth-focused training for participatory research; and 4) acknowledging community needs beyond HIV prevention by incorporating COVID-19-specific questions and structural barriers to care into surveys. Importantly, having established community engagement was essential for completing our research goals during the COVID-19 pandemic. It is incumbent that we continue to assess the impact of COVID-19 in partnership with this community and that we understand the trajectory of the HIV epidemic within this context. --- Declaration Of Interests The authors have no declarations of interest to report.

Mitigating HIV burden among Black youth requires true community engagement. This brief report identifies challenges, strategies, and lessons learned from transitioning our three-phased, community-engaged HIV prevention project with Black youth to a remote format during COVID-19. The project involved (1) building a community-academic partnership on youth sexual health, (2) participatory youth workshops, and (3) youth surveys and interviews about HIV prevention. Feedback from community-academic partnership, pile sorting themes, and preliminary qualitative analyses guided this report. Challenges included a disruption to in-person engagement while strategies included relying heavily on pre-existing partnerships to recruit youth for interviews. We learned that pre-existing community engagement was essential for completing phase three remotely. More education is needed to support Pre-Exposure Prophylaxis (PrEP) awareness for HIV prevention and there is a need to address structural barriers to healthcare engagement such as community violence and mental illness. Community-engaged HIV research focused on youth can adapt if anchored in community relationships. Future studies must work to more fully center youth's voices and address the structural issues that may inhibit them from engaging in HIV prevention.

introduction the hiv epidemic disproportionately affects black youth particularly those in the southern united states youth account for 22 of new hiv infections in the us and over half of these cases are among black youth in addition despite making up 37 of the us population about 45 of people with an hiv diagnosis live in the southern us and black youth bear the burden of new infections in the region the disproportionate impact on black youth is rooted in disparities in social and structural determinants of health for example socioeconomic status and racism are fundamental causes of health inequities that have structured the course of the hiv epidemic structural determinants of health also adversely impact retention in hiv prevention and care among youth there is a critical need to understand hiv risk among black youth in the us south to ensure that hiv prevention interventions are relevant and applicable to this population preexposure prophylaxis is a daily pill that reduces the risk of hiv infection in people at high risk via sexual transmission by over 90 and has been approved for youth since 2018 while it is a promising approach to hiv prevention uptake among youthparticularly black youthhas been low due to a lack of awareness accurate knowledge assumptions about prep perceived lack of risk and structural factors to understand the reasons for low prep uptake and develop strategies to increase the use of prep it is critical to engage black youth in the research process in 2018 we began a communityengaged research project on prep interest and uptake among black youth in durham north carolina a city that is nearly 40 black and has the sixthhighest rate of reported hiv infection in nc the covid19 pandemic began in 2020 and its impact on black communities has followed a similar storyline to other health conditions such as hiv that disproportionately affect black communities for example black individuals have been disproportionately hospitalized for and died from covid19 with black individuals dying at 14 times the rate of white individuals the disproportionate impacts of covid19 on black communities stem from the same structural determinants of health that have shaped the course of the hiv epidemic this results in communities with high proportions of people of color living in poverty crowded housing and high levels of racialized economic segregation experiencing high burdens of covid19 cases and deaths given the disproportionate impact of both hiv and covid19 on black communities it is critical that hiv prevention and prep care remain in place during the covid19 pandemic however the hiv prevention continuum including prep has been disrupted with disproportionate impacts patterned by structural determinants of health these disruptions are compounded for black individuals who already experienced more disruptions to prep care before the covid19 pandemic than others and for youth for whom typical barriers to care are heightened the covid19 pandemic has disproportionately affected black youth beyond physical health and healthcare access black youth are more likely than their white counterparts to experience poverty and food insecurity to have had parents lose their jobs and to be exposed to distance learning and school closures during the pandemic given the focus of our work on hiv prevention with black youth the farreaching effects of the covid19 pandemic on this community and covid19 restrictions on inperson meetings we adapted our community engaged research approaches accordingly in this report we identify the lessons learned from continuing our communityengaged hiv prevention project with black youth transitioning it to a remote setting and pivoting to more broadly think about structural determinants of health during the covid19 pandemic methods background on community partnerships project ife was a communityacademic partnership focused on longterm hiv prevention among black women in durham housing authority communities in durham nc a key finding from project ifes formative research with dha residents was the need to reach youth in the community the project discussed here was developed in response to this community concern and provided an opportunity for a group of locallybased researchers to conduct communityengaged research focused on hiv prevention among youth our threepart project involved 1 building an adolescent health working group to engage local stakeholders focused on youth sexual health 2 conducting participatory youth workshops to understand youth perspectives and 3 conducting surveys and interviews with youth about prep awareness the process of pivoting the pandemic affected our threepart project in different ways the majority of parts 1 and 2 occurred prior to the covid19 pandemic whereas part 3 occurred during the covid19 pandemic the ahwg comprised of stakeholders from the dha lgbtq advocacy groups adolescent healthcare providers communitybased organizations and nonprofit groups faith leaders departments of public health as well as parents and adolescents met six times to provide critical stakeholder input and guidance to the project the pandemic necessitated that our final two ahwg meetings be conducted remotely for phase 2 we were able to hold three participatory youth workshops using the youth generating and organizing methodology prior to the pandemic which is described elsewhere phase 3 took place fully remotely and our team added questions on covid19 in the context of this adaptation this report discusses the overall process of transitioning our project during covid19 this process was shaped by feedback from the ahwg at the beginning of the covid19 pandemic through meetings notes and a running list of topics recommended by the ahwg members at each meeting our research team iteratively conducted pile sorting to organize the key themes from our ahwg feedback and subsequently revise the project preliminary analyses from part 3 qualitative interviews focused on covid19s effect on youth also shaped this process results challenges when the covid19 pandemic began all inperson activities were halted as all three parts of the project were intended to be held in person and relied on inperson community engagement there was no clear immediate path forward for example the phase 3 survey and interviews had not started prior to covid19 and were held entirely virtually we began outreach in june of 2020 through facebook advertisements and emailing local community listservs to reach as wide a population of youth and their parents as possible between june and september of 2020 we recruited only 17 of our sample target through facebook and listserv recruitment as these were not platforms youth themselves were regularly using furthermore it was clear that the covid19 pandemic was having a negative impact on youth involved in the ahwg and on those participating in the participatory youth workshops via increased isolation and virtual school strategies to address the halting of inperson meetings phase 1s final two of six ahwg meetings were held on a virtual platformzoomand guided the remaining study activities no ahwg members expressed concern with pivoting to a virtual format and we were able to meet individuals individually in outdoor spaces to provide them with payment some ahwg members struggled with digital accessibility but we were able to followup individually with these individuals based on feedback from these virtual meetings ahwg members felt comfortable expressing their thoughts in a virtual format felt training youth in research would amplify youth voices and that an enewsletter could maintain community engagement while inperson gatherings were restricted we used feedback from this evaluation form in realtime to structure the remaining aspects of our project and in our decision to continue this piece of the project virtually the last phase 2 participatory youth workshop session was not held virtually due to the sensitivity of talking about youth sexual health and youths privacy and the collaborative and interactive format of the participatory workshops was not conducive to a virtual environment in september 2020 we pivoted to relying on phase 1 ahwg community members to recruit and complete enrollment targets for surveys and interviews using this strategy we reached 87 of recruitment goals for interviews and surveys within 3 months the interview guides were created at the beginning of the covid19 pandemic and multiple questions and prompts were added to broadly contextualize the impact of covid19 on black youth in the community broadly more specifically we asked how covid19 intersected with hiv prevention efforts and behaviors that would put youth at risk for acquiring hiv interviews with youth highlighted the need to address structural barriers to healthcare engagement for hiv particularly during the covid19 pandemic while the youth were grateful for time with family they described quarantine depression due to covidmandated virtual schooling physical distancing and overwhelming racial injustices portrayed in media discussion lessons learned the current study reports on a communityengaged project on hiv prevention among black youth that was adapted in the context of the covid19 pandemic the impact covid19 was having on black youth in durham nc required us to consider how social and structural determinants of health affect intersecting concerns like covid19 hiv risk and hiv prevention through pivoting our project to be remote discussing with ahwg members and youth about what aspects of the project would be appropriate to continue and using their feedback in realtime we developed a more holistic understanding of what was taking place in youths lives that affected hiv prevention and health and wellbeing more broadly this process points to the importance of addressing structural determinants of health and addressing overlapping health concerns when conducting communityengaged work it is incumbent that future studies work to more fully center youths voices and address the structural issues that may inhibit them from engaging in hiv prevention to address hiv prevention during 2020 among black youth one central lesson learned was that it was necessary to also acknowledge covid19 and its profound impact on black communities communityengaged research provided us with the process to expand our research and to ensure our research was meaningful and attentive to the communitys needs community engagement prior to the pandemic was also essential for completing our research goals during the pandemic and provided a platform for feedback to be flexible in the goals of the original research plan for example some parts of our data collection were paused due to youths levels of comfort with sharing virtually at the same time our qualitative research expanded to explore youths daily lives and stressors related to covid which also affected their ability to engage in preventative health measures limitations due to the covid19 pandemic quickly altering the course of our research we were unable to solicit specific feedback on certain aspects of the project for example while ahwg members said that they wanted to continue with a virtual platform we did not ask about the content of the virtual meetings we believe that more specific feedback would have been particularly helpful in retaining youth in our ahwg additionally this project was focused in durham nc and youths experiences in other regions and in more rural areas are likely widely varied therefore factors that may have been relevant in adapting our research may be less generalizable in other settings relatedly this project did not specifically focus on youth experiencing the greatest disparities who may have had different experiences and whose lives may have been impacted differently by the covid19 pandemic conclusions through this process our research team learned that the following were critical components to this engaged research 1 actively listening to and responding to community feedback by creating an enewsletter halting portions of the project that would be particularly sensitive to conduct in a virtual format and relying on phase 1 ahwg community members for recruitment 2 continuing to be in the community during covid19 via virtual zoom meetings and oneonone outdoor meetups 3 centering youths voices by regularly checking in with youth to ensure data collection strategies were appropriate for capturing their perspectives and applying to additional funding to conduct youthfocused training for participatory research and 4 acknowledging community needs beyond hiv prevention by incorporating covid19specific questions and structural barriers to care into surveys importantly having established community engagement was essential for completing our research goals during the covid19 pandemic it is incumbent that we continue to assess the impact of covid19 in partnership with this community and that we understand the trajectory of the hiv epidemic within this context declaration of interests the authors have no declarations of interest to report

mitigating hiv burden among black youth requires true community engagement this brief report identifies challenges strategies and lessons learned from transitioning our threephased communityengaged hiv prevention project with black youth to a remote format during covid19 the project involved 1 building a communityacademic partnership on youth sexual health 2 participatory youth workshops and 3 youth surveys and interviews about hiv prevention feedback from communityacademic partnership pile sorting themes and preliminary qualitative analyses guided this report challenges included a disruption to inperson engagement while strategies included relying heavily on preexisting partnerships to recruit youth for interviews we learned that preexisting community engagement was essential for completing phase three remotely more education is needed to support preexposure prophylaxis prep awareness for hiv prevention and there is a need to address structural barriers to healthcare engagement such as community violence and mental illness communityengaged hiv research focused on youth can adapt if anchored in community relationships future studies must work to more fully center youths voices and address the structural issues that may inhibit them from engaging in hiv prevention

Background Tooth loss is an important oral health problem with consequences for physical and psychosocial health as well as the quality of life [1][2][3]. It is a good proxy for the cumulative oral health status [4] summarizing the impacts of adverse circumstances throughout the life course of individuals [5]. Despite a significant decline in the prevalence and incidence of severe tooth loss in the past two decades [6], socioeconomic inequalities in this condition persist across the globe, including Brazil [4,[7][8][9]. The socioeconomic inequalities in tooth loss have been studied considering compositional and contextual effects based mainly on the pathways linking income inequality to health [10][11][12][13][14]. Metanalysis research with 11 studies showed that adults with lower levels of income presented a greater chance of tooth loss [13]. Regarding the contextual-level, collective evidence has shown associations between high income-based inequality and worse oral health [15]. Compositional explanations suggest that the effect of income inequality is a result of how individual incomes affect oral health. The proposed mechanisms involve the material resources , access to symbolic resources and behavioral/cultural explanations, which stress the role of poor health behaviors due to low income [14,16]. Contextual explanations sustain that income inequality has broader psychosocial effects on oral health via stress-induced oral-health-related behaviors [17]. Income inequality also may result from lower social spending on public services and infrastructure, including dental care services and water fluoridation [18]. The income inequality had been a frequently studied contextual social determinant of oral health. However, all dimensions in which social inequality can occur may not be evaluated by this measure. Different levels of education can also explain such disparities, because this socioeconomic indicator may capture the long-term influences of both early life circumstances on adult health, as well as the influence of adult resources on health [19]. Previous studies have shown a consistent independent effect of lower individual education on tooth loss among adults [20][21][22][23] and elders [24]. Education equips individuals with knowledge and skills that are useful for the prevention of disease and attitudes toward healthy behavior. Also, higher educational attainment confers greater prestige and status within the community as well as serving as a credential for employment [14]. Beyond the interest in distinguishing the individual source of variation from the contextual on socioeconomic inequalities studies, it is crucial to evaluate whether contextual factors affect every income and education group in the same manner [25]. Hence, it is reasonable to assess whether the variations among areas are similar for different income or education groups or whether the variations differ for different education and income groups. This approach is crucial from an equality policy perspective to target interventions to specific groups living in specific areas. Additionally, it takes into account that socioeconomic diversity may minimize or potentialize the adverse oral health consequences of those living in an area with concentrated disadvantage [26]. The influence of contextual determinants on oral health after accounting for individual-level factors had been extensively shown assuming the fixed effects [18,[20][21][22][23][24][27][28][29][30][31][32][33]. In general, these studies had found higher tooth loss in socially disadvantaged areas independently of individual socioeconomic indicators [22,24,[32][33][34]. The evidence also showed attenuation on income inequalities among American adults and Brazilian teenagers by public policies, including dental care services and water fluoridation [18,35]. A fewer number of studies assessed the interaction between oral health and contextual level factors, and most of them were focused on income inequality [20,23,31,35,36]. Differential effects of public policies on oral health among individuals with higher education and income had been observed [28,35]. These results have conducted to discuss if the public policy may both decrease or increase the social gap in oral health, considering the aim, the target population, and the approach of implementation of them . Can the disadvantage resulting from low education and income be decreased in areas which present more opportunities and conditions for healthy living? Or Do public policies have more effect on groups that are already socially advantaged? The double disadvantage, characterized by concomitantly presenting a worse social situation in the individual and contextual level, has been reported on oral epidemiology [37,38]. For that, it is crucial to investigate the income and education-based inequality considering the social characteristics of contextual level. A composite indicator of social development can reflect the contextual differences as a result of public policy. The starting point was to estimate the magnitude of income and education-based inequality according to areas with different social development. The aims of this study were, therefore: i) to evaluate income and education-based inequalities in tooth loss comparing Brazilian municipalities with high and low Human Development Index ; ii) to investigate the association between tooth loss and socioeconomic indicators on individual and contextual levels; iii) to determine if the social environment modifies the relationship between income/ education and tooth loss. We hypothesized that tooth loss would be inversely associated with an individual's household income and education, but that the magnitude of the association would be more pronounced in affluent municipalities than in poor municipalities . --- Methods Data from the present analysis came from the 2010 National Oral Health Survey conducted by the Brazilian Ministry of Health in Brazilian urban areas [39] between February and November 2010. The sample was obtained through the random selection of municipalities and census sectors, via multi-stage cluster sampling with probability of selection proportional to population size. Detailed information on the methods is found in other publications [40,41]. Data for adults aged between 35 and 44 years were used in this study. Individual interviews using a structured questionnaire was used to obtain demographic and socioeconomic characteristics. Oral health examinations were conducted in people's homes by calibrated dentists under natural light following the guidelines of the WHO manual for epidemiological studies [42]. The DMFT index was used to determine tooth status. --- Outcome variable The outcome variable was the number of teeth that was missing for any reason, determined by the sum of codes 4 and 5 of the DMFT index. --- Exposures Education and income were used as measures of socioeconomic position at the individual level. Income was measured as total income received by all family members in the month preceding the survey . For our analysis, the monthly household income was converted into multiples of the minimum wage, based on the current value at the time of survey and collapsed into four categories: up to 1, 1 to 2.9, 3 to 4.9, 5 or more times the minimum wage. This grouping was defined to distingue mechanisms in which income exerts its effects. Education was asked as the number of years of formal schooling and classified as less than 4 years , 4-7 , 8-10 , and 11 or more , according to the formal education system in Brazil. We used the Municipal Human Development Index as an indicator of municipal area socioeconomic status. The Brazilian HDI considers three dimensions: Longevity, Education , and Income [43]. The HDI was obtained from the 2013 Brazil Atlas of Human Development, which allows a selection based on data extracted from the 2010 demographic. The values of HDI of sampled municipalities ranged from 0.481 to 0.847, and the groups are defined as very low , low , medium , high and very high . According to this classification, the frequency of sampled municipalities was: low and very low , medium , and high and very high . In this study municipalities were aggregated into low versus high . --- Covariates The covariables at individual level were age , sex , skin color , time since the last dental visit . Skin color refers to the classification adopted in the demographic census performed in Brazil: whites, blacks, browns, yellows, and Amerindians. In this study, this variable was dichotomized: white versus blacks, browns, yellows, and Amerindians. At the contextual level, we included the presence of fluoridated water supply . The data regarding fluoridation was obtained on the National Basic Sanitation Survey performed by the Brazilian Institute of Geography and Statistics in 2008 [44]. We also included the estimated coverage of the population by primary care oral health services, which corresponds to the mean monthly number of primary care oral health teams for every 3000 individuals to the total population of the municipality in the analyzed year. Higher oral health services coverage indicated higher potential access to basic dental services. The cut off for this variable was 40% that was the goal to be achieved in the biennium 2010/2011 [45]. Data about coverage were obtained from the website of the Department of Information Technology of the Unified Health System . --- Statistical analysis Comparison of income and education-based inequalities between municipalities with high and low HDI Descriptive analysis was performed to obtain mean tooth loss for each municipality, and the results were shown separately according to the HDI level . The magnitude of relative and absolute educational and income-based inequalities in the tooth loss was calculated using the Relative Index of Inequality , Slope Index of Inequality and Relative and Absolute Concentration Index for municipalities with high and low HDI. RII and SII are summary measures recommended when making comparisons across populations [46]. These indices are regression-based and take the whole socioeconomic distribution into account, rather than only comparing the two most extreme groups. For municipalities with high and low HDI, the population in each education or income category was assigned a modified ridit-score based on the midpoint of the range in the cumulative distribution of the participants in the given category. We used generalized linear models , with a logarithmic link function to calculate RIIs and with an identity link function to calculate SIIs [47]. Both indices were estimated with 95% confidence intervals. The RII can be interpreted as the rate ratio, and the SII can be interpreted as the rate difference at the bottom and the top of the educational or income hierarchy. If there is no inequality, RII assumes a value of 1.0. The further the value of RII from 1.0, the higher the level of inequality. RII assumes only positive values, with values larger than one indicating a concentration of the indicator among the advantaged and values smaller than one indicating a concentration of the indicator among the disadvantaged. If there is no inequality, SII takes the value of zero. Greater absolute values indicate higher levels of inequality. Positive values indicate higher coverage in the advantaged subgroups, and negative values indicate higher coverage in the disadvantaged subgroups [46]. RCI and ACI were estimated based on the methodology described by Clarke et al. [48]. The RCI provides a measure of the relative differences among education/ income groups. Considering that the RCI was based on morbidity measure , a negative RCI indicates inequality favoring higher income groups. The ACI quantified the absolute differences in health between education and income groups, and this index is not affected by whether it is measured concerning health or morbidity. As RII/SII are mathematically related to RCI/ACI, they will produce the same rank ordering of health inequality between groups but will differ in scale. --- Association between tooth loss and socioeconomic indicators Multilevel Poisson regression procedures with unstructured covariances matrix were used to model the twolevel structure of individuals nested within municipalities . Multilevel techniques of analyses provide the overall relationship between the individual, compositional factors, and oral health , and the variation between areas that cannot be accountable for such factors . Besides, it is possible to assess the variation in certain individual relationships between municipalities and the interaction between individual and contextual characteristics . A five-step sequential modeling strategy was adopted: i) model 1: a model without the inclusion of any covariates, in which the variance in tooth loss is inspected between municipalities. A significant random intercept variance indicates the presence of unexplained differences in tooth loss between municipalities. The Wald test evaluated the significance of random intercept, and the Median Rate Ratio measured the heterogeneity among municipalities, according to Austin et al. [49]. There is no variation between municipalities if the MRR is 1.0, but the higher the MRR, the greater the area-level variation. ii) model 2 : considers all the individual-level variables in the fixed part. This model assessed the association between tooth loss and income and education adjusted for covariables at the individual level. The variation between municipalities is allowed for, conditional on the individual, compositional factors. iii) model 3: as model 2, but including the municipalities-level variables. The proportional change in variance was calculated according to Merlo et al. [50], using the following formula: PCV = /variance model 1. iv) model 4 : as model 2, but the model allows both the intercept and slope to be random parameters. Therefore, each municipality has its intercept and slope in which the variability from the overall intercept and slope can be investigated with the addition of individual and municipality variables and their interactions . Random slopes for education and income were considered. The comparison of goodness fit between model 2 and model 4 was performed using the LR-test. v) model 5: as model 4, including the municipalities-level variables, in which the cross-level interactions between education/income and HDI were considered. The interaction term represents the change in the slope of education/ income on tooth loss across municipalities when HDI changed from low to high. The estimated mean of missing teeth according to individual socioeconomic variables for municipalities with high and low HDI was demonstrated using a graph of the predicted model. Procedures for complex sample design were used to calculate the proportions of adults according to investigated variables, the age-and sex-adjusted estimates of the outcomes, SII, RII and ACI. Statistical analyses were performed using STATA version 15 --- Results The sample was 9633 adults, residing in 157 municipalities; 146 individuals in 20 municipalities with a sample of fewer than 10 adults were excluded. The characterization of the sample and mean of missing teeth according to investigated variables are shown in Table 1. The mean number of adults per municipalities was 61.36 and ranged from 10 to 496. The mean of HDI was 0.71 and 76.28% presented high HDI. The goal of oral health services coverage was achieved by 39.18 of the municipalities and 82.56 of those had fluoridation of water supply. The mean number of missing teeth among Brazilian adults was 7.36 . This value was 9.52 in municipalities with low HDI and 6.95 in those with high HDI . The inequalities indexes show a higher number of missing teeth in disadvantaged groups . Higher relative and absolute education-based inequality were observed among municipalities with high HDI. For income-based inequalities, higher SII was observed in municipalities with lower HDI . The multilevel crude estimates showed that all individuals variables were significantly associated with tooth loss . Table 4 shows the multilevel models assuming random intercept and fixed effects. The empty model shows that the contextual level variation was significant, suggesting differences in tooth loss among municipalities , and the MRR also indicated variation across municipalities. The MRR, as well as the between-municipality variance, come down from 20.09 to 14.17 after the inclusion of individual variables . In model 3, assuming fixed effects, a social gradient in tooth loss for income and education was observed. Municipalities with high HDI presented a lower number of tooth loss . The inclusion of municipalities level variables represented an additional 12.7% decrease in variability of tooth loss among municipalities . Table 5 shows the models whereby the nature of between-municipalities variation was modeled as a function of individual education . The 5). The other random slopes were shown as an additional file . The graph of fitted lines shows how the municipal variation is more pronounced among individuals with higher education . Model 5 shows that when the association between education and tooth loss was allowed to vary across municipalities, the main effect of HDI was not significant. The social gradient in tooth loss by individual income and education continue to be observed. Municipalities with fluoridated water showed a lower number of missing teeth . The cross-level interaction between education and HDI was significant, indicating that the association between these two variables is not constant across municipalities, with steeper slopes observed in municipalities with high HDI. There is some evidence that the number of missing teeth is lower for the high-education group when they live in municipalities with high HDI compared with those with the same education level living in municipalities with low HDI. For individuals with the lowest education level, there was no difference in the number of teeth comparing those from municipalities with high versus low HDI. The fixed effect of individual and contextual variables did not change with the inclusion of cross-level interactions . When the variation was modeled as a function of individual income, the model was very similar to obtained with fixed effect . The graph of fitted lines shows that the municipal variation is similar through income levels . The cross-level interaction between individual income and HDI was not significant . --- Discussion The tooth loss represents an "end state" in oral health, and the present study reaffirmed the persistent concentration of tooth loss among the most disadvantaged individuals. Over and above individual disparities, our findings also demonstrated that the magnitude of educational and income-based inequalities varied between municipalities with high versus low HDI. Our results showed that educational attainment was "less protective" against tooth loss when people live in disadvantaged areas. Conversely, adults with the lowest levels of education and income had greater tooth loss regardless of whether they lived in a municipality with high or low HDI. Our study replicated the inverse association between socioeconomic status and tooth loss after adjusting for all covariates at the individual and municipality levels [10][11][12]. Using different outcomes related to tooth loss , previous studies have consistently shown more tooth loss among the more disadvantaged groups. Quasi-experimental evidence that worsened economic circumstances are associated with tooth loss was provided by a natural experiment following exposure to the 2011 Great East Japan Earthquake and Tsunami [51]. A meta-analysis of 10 cohort studies and two crosssectional studies found a significant association between low income and tooth loss [13]. Those living in poverty suffer a greater burden of oral diseases, such as dental caries and periodontitis [52,53], the main causes of tooth loss in adults. They also have a higher prevalence of systemic conditions, such as diabetes, cardiovascular disease, and obesity [54,55], that are related to tooth loss. Besides these biological explanations, the conceptual mediators of the effect of socioeconomic status on oral health include material deprivation, psychosocial distress, and behavioral factors [14,17,19]. Besides, the association between economic constraints and the type of dental treatment delivered has been demonstrated. While subjects in the lower income brackets are more prone to dental extraction, individuals with higher income are more likely to seek periodic routine appointments and conservative dental treatment, resulting in a higher number of retained teeth [56,57]. In Brazil, the higher tooth loss associated with socioeconomic disadvantage can result from systemic factors related to the organization and delivery of oral health services. The national oral health policy, also known as Smiling Brazil , was implemented only in 2004, ensuring universal coverage [58]. This policy increased the access of adults to oral health services, who historically had significant ongoing unmet needs with only urgent care available in public services [58]. The lack of access to restorative and preventive services in public health services may have contributed to tooth loss, especially among the most disadvantaged individuals. Moreover, previous studies have shown that a change in access to oral health services does not necessarily result in reduced oral health disparities [59]. The explanation was because people take time to change their behaviors, e.g., seeking periodic preventive dental services. Our results also showed differences in tooth loss inequalities according to municipal HDI, with higher absolute and relative education-based inequality found in municipalities with high HDI and higher absolute income-inequality found in municipalities with low HDI. The high education-based inequality among municipalities with high HDI shows the double disadvantage of adults who share the lowest education and living in places with the worst social indicators [38]. These results suggest that public policies may not reach the persons in the same way, increasing the gap among social groups. The association between education and tooth loss was not constant across Brazilian municipalities. The significant cross-interaction term reveals that the magnitude of the association between education and tooth loss was lower in municipalities with high HDI. This result suggests that contextual factors may weaken the potential protective effect of schooling at the individual level. Low HDI municipalities in Brazil are smaller cities with lower wealth, higher rates of urban violence, lower sanitation conditions, and urban infrastructure. These contextual aspects may represent fewer opportunities for healthy living for its residents . Our result shows that where one lives has an effect on oral health and that this effect must be evaluated considering the characteristics of the people. On the other hand, the significant cross-level interactions reinforce the hypothesis that public policies can increase the gap among social groups to the extent that it may not reach people in the same way. The crossinteraction was significant after adjusting by oral health policies and fluoridation of water supply. HDI is an indicator that incorporating a life expectancy, education, and a modified measure of income in a contextual level. However, these indicators may demonstrate the effect of other policies and environmental characteristics that favor access to primary health care in general, sanitation, access to cultural and social opportunities, more social capital, more work and economic security, and more healthy food available. All these contextual factors are potential mediators of the association between HDI and tooth loss and have been pointed out as determinants of oral health [34,60] in previous studies that had demonstrated the main effect of social-level indicators on tooth loss using multilevel approaches in Brazil, United States, European countries, Australia and Japan [18,[20][21][22][23][24][27][28][29][30][31][32]. The analysis performed in this study is advancing, as it may contribute to more targeted policies for the groups with the greatest need, in specific contexts. The only significant contextual factor we found was the fluoridation of the water supply. Individuals living in municipalities with water fluoridation presented lower tooth loss. The importance of this intervention was previously shown in maintaining functional dentition [21] and tooth retention [23]. Natural experiments applied in oral health context from Brazil showed that adults who accessed fluoridate water < 50% of their lifetime presented a higher mean rate ratio of DMFT index compared with those living > 75% of their life with residential access to fluoridated water. Longer residential lifetime access to fluoridated water was associated with less dental caries, even in the context of multiple exposures to fluoride [61]. We adjusted our models only for key covariates. Similar to the most multilevel studies, the sampling and analytic convenience was the reason for the choice of contextual variables rather than an explicit theory linking area disadvantage and oral health. Therefore, associations among these variables are likely to be underestimated. However, the Brazilian municipalities have to deliver basic education, sanitation, and primary healthcare. Therefore, our chosen contextual factors must fit the area border. We used cross-sectional data where the distinction between current and past exposures cannot be made. Similarly, income can change throughout life resulting in upward and downward social mobility. --- Conclusions There was a social gradient in tooth loss by education and income. Living in disadvantaged municipalities cannot overcome the risk associated with low schooling. The protective effect of higher education can be reduced when people live in disadvantaged areas. This differential effect of education on tooth loss among municipalities with high and low DHI can increase the gap among social groups. The persistent inequality demands for innovative strategies and policies that address the wider social determinants of health, considering the differential effect of public policies among --- --- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12903-020-01238-9. Additional file 1. Parameters of the random part of the multilevel models with random intercept and slope between individual and municipalities level variables among 35-44-year old in Brazil, 2010. Additional file 2. Municipalities-specific slopes of education on tooth loss. Additional file 3. Count ratios of tooth loss in multilevel models with random intercept and slope between individual and municipalities level variables among 35-44-year old in Brazil, 2010. Additional file 4. Municipalities-specific slopes of income on tooth loss. Authors'contributions RCF analyzed and interpreted the data, wrote the manuscript. MIBS, LGR, FLC and AEBLM contributed to data analysis and interpretation. IK was the study supervisor, made substantial contributions to: data analysis and interpretation and made a critical review of the intellectual content. All authors read and approved the final manuscript. --- Funding Raquel Conceição Ferreira received financial support CAPES and from FAPEMIG, Brazil . This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil -Finance Code 001. These sponsors had no role in study design; collection, analysis, and interpretation of data; writing of the report; the decision to submit the article for publication. --- --- --- Competing interests The authors RCF is a member of the editorial board of the BMC Oral Health. ---

Background: Socioeconomic inequalities in tooth loss might be minimized or potentialized by the characteristics of the context where people live. We examined whether there is contextual variation in socioeconomic inequalities in tooth loss across Brazilian municipalities. Methods: Data from the 2010 National Oral Health Survey of 9633 adults living in 157 Brazilian municipalities were used. The individual socioeconomic indicators were education and household income. At the municipal level, we used the Municipal Human Development Index (HDI) as our contextual indicator of socioeconomic status (low:< 0.699 versus high: > 0.70). The Relative (RII) and Slope (SII) Indexes of Inequality, Relative (RCI), and Absolute (ACI) Concentration Indexes were calculated to compare the magnitude of education and income-based inequalities among municipalities with low versus high HDI. Multilevel Poisson regression models with random intercepts and slopes were developed. Results: At the individual level, adults with lower education & income reported more tooth loss. The mean number of missing teeth was 9.52 (95% CI: 7.93-11.13) and 6.95 (95% CI: 6.43-7.49) in municipalities with low and high HDI, respectively. Municipalities with high HDI showed higher relative and absolute education-based inequality. For income-based inequalities, higher SII and RCI was observed in municipalities with lower HDI. A significant crosslevel interaction indicated that high-education adults reported fewer missing teeth when they lived in municipalities with high HDI compared to adults with the same education level living in low HDI municipalities. For individuals with the lowest education level, there was no difference in the number of teeth between those from municipalities with high and low HDI. Conclusions: There was a social gradient in tooth loss by education and income. Living in disadvantaged municipalities cannot overcome the risk associated with low schooling. The protective effect of higher education can be reduced when people live in disadvantaged areas.

background tooth loss is an important oral health problem with consequences for physical and psychosocial health as well as the quality of life 1 2 3 it is a good proxy for the cumulative oral health status 4 summarizing the impacts of adverse circumstances throughout the life course of individuals 5 despite a significant decline in the prevalence and incidence of severe tooth loss in the past two decades 6 socioeconomic inequalities in this condition persist across the globe including brazil 4 7 8 9 the socioeconomic inequalities in tooth loss have been studied considering compositional and contextual effects based mainly on the pathways linking income inequality to health 10 11 12 13 14 metanalysis research with 11 studies showed that adults with lower levels of income presented a greater chance of tooth loss 13 regarding the contextuallevel collective evidence has shown associations between high incomebased inequality and worse oral health 15 compositional explanations suggest that the effect of income inequality is a result of how individual incomes affect oral health the proposed mechanisms involve the material resources access to symbolic resources and behavioralcultural explanations which stress the role of poor health behaviors due to low income 1416 contextual explanations sustain that income inequality has broader psychosocial effects on oral health via stressinduced oralhealthrelated behaviors 17 income inequality also may result from lower social spending on public services and infrastructure including dental care services and water fluoridation 18 the income inequality had been a frequently studied contextual social determinant of oral health however all dimensions in which social inequality can occur may not be evaluated by this measure different levels of education can also explain such disparities because this socioeconomic indicator may capture the longterm influences of both early life circumstances on adult health as well as the influence of adult resources on health 19 previous studies have shown a consistent independent effect of lower individual education on tooth loss among adults 20 21 22 23 and elders 24 education equips individuals with knowledge and skills that are useful for the prevention of disease and attitudes toward healthy behavior also higher educational attainment confers greater prestige and status within the community as well as serving as a credential for employment 14 beyond the interest in distinguishing the individual source of variation from the contextual on socioeconomic inequalities studies it is crucial to evaluate whether contextual factors affect every income and education group in the same manner 25 hence it is reasonable to assess whether the variations among areas are similar for different income or education groups or whether the variations differ for different education and income groups this approach is crucial from an equality policy perspective to target interventions to specific groups living in specific areas additionally it takes into account that socioeconomic diversity may minimize or potentialize the adverse oral health consequences of those living in an area with concentrated disadvantage 26 the influence of contextual determinants on oral health after accounting for individuallevel factors had been extensively shown assuming the fixed effects 18 20 21 22 23 24 27 28 29 30 31 32 33 in general these studies had found higher tooth loss in socially disadvantaged areas independently of individual socioeconomic indicators 2224 32 33 34 the evidence also showed attenuation on income inequalities among american adults and brazilian teenagers by public policies including dental care services and water fluoridation 1835 a fewer number of studies assessed the interaction between oral health and contextual level factors and most of them were focused on income inequality 2023313536 differential effects of public policies on oral health among individuals with higher education and income had been observed 2835 these results have conducted to discuss if the public policy may both decrease or increase the social gap in oral health considering the aim the target population and the approach of implementation of them can the disadvantage resulting from low education and income be decreased in areas which present more opportunities and conditions for healthy living or do public policies have more effect on groups that are already socially advantaged the double disadvantage characterized by concomitantly presenting a worse social situation in the individual and contextual level has been reported on oral epidemiology 3738 for that it is crucial to investigate the income and educationbased inequality considering the social characteristics of contextual level a composite indicator of social development can reflect the contextual differences as a result of public policy the starting point was to estimate the magnitude of income and educationbased inequality according to areas with different social development the aims of this study were therefore i to evaluate income and educationbased inequalities in tooth loss comparing brazilian municipalities with high and low human development index ii to investigate the association between tooth loss and socioeconomic indicators on individual and contextual levels iii to determine if the social environment modifies the relationship between income education and tooth loss we hypothesized that tooth loss would be inversely associated with an individuals household income and education but that the magnitude of the association would be more pronounced in affluent municipalities than in poor municipalities methods data from the present analysis came from the 2010 national oral health survey conducted by the brazilian ministry of health in brazilian urban areas 39 between february and november 2010 the sample was obtained through the random selection of municipalities and census sectors via multistage cluster sampling with probability of selection proportional to population size detailed information on the methods is found in other publications 4041 data for adults aged between 35 and 44 years were used in this study individual interviews using a structured questionnaire was used to obtain demographic and socioeconomic characteristics oral health examinations were conducted in peoples homes by calibrated dentists under natural light following the guidelines of the who manual for epidemiological studies 42 the dmft index was used to determine tooth status outcome variable the outcome variable was the number of teeth that was missing for any reason determined by the sum of codes 4 and 5 of the dmft index exposures education and income were used as measures of socioeconomic position at the individual level income was measured as total income received by all family members in the month preceding the survey for our analysis the monthly household income was converted into multiples of the minimum wage based on the current value at the time of survey and collapsed into four categories up to 1 1 to 29 3 to 49 5 or more times the minimum wage this grouping was defined to distingue mechanisms in which income exerts its effects education was asked as the number of years of formal schooling and classified as less than 4 years 47 810 and 11 or more according to the formal education system in brazil we used the municipal human development index as an indicator of municipal area socioeconomic status the brazilian hdi considers three dimensions longevity education and income 43 the hdi was obtained from the 2013 brazil atlas of human development which allows a selection based on data extracted from the 2010 demographic the values of hdi of sampled municipalities ranged from 0481 to 0847 and the groups are defined as very low low medium high and very high according to this classification the frequency of sampled municipalities was low and very low medium and high and very high in this study municipalities were aggregated into low versus high covariates the covariables at individual level were age sex skin color time since the last dental visit skin color refers to the classification adopted in the demographic census performed in brazil whites blacks browns yellows and amerindians in this study this variable was dichotomized white versus blacks browns yellows and amerindians at the contextual level we included the presence of fluoridated water supply the data regarding fluoridation was obtained on the national basic sanitation survey performed by the brazilian institute of geography and statistics in 2008 44 we also included the estimated coverage of the population by primary care oral health services which corresponds to the mean monthly number of primary care oral health teams for every 3000 individuals to the total population of the municipality in the analyzed year higher oral health services coverage indicated higher potential access to basic dental services the cut off for this variable was 40 that was the goal to be achieved in the biennium 20102011 45 data about coverage were obtained from the website of the department of information technology of the unified health system statistical analysis comparison of income and educationbased inequalities between municipalities with high and low hdi descriptive analysis was performed to obtain mean tooth loss for each municipality and the results were shown separately according to the hdi level the magnitude of relative and absolute educational and incomebased inequalities in the tooth loss was calculated using the relative index of inequality slope index of inequality and relative and absolute concentration index for municipalities with high and low hdi rii and sii are summary measures recommended when making comparisons across populations 46 these indices are regressionbased and take the whole socioeconomic distribution into account rather than only comparing the two most extreme groups for municipalities with high and low hdi the population in each education or income category was assigned a modified riditscore based on the midpoint of the range in the cumulative distribution of the participants in the given category we used generalized linear models with a logarithmic link function to calculate riis and with an identity link function to calculate siis 47 both indices were estimated with 95 confidence intervals the rii can be interpreted as the rate ratio and the sii can be interpreted as the rate difference at the bottom and the top of the educational or income hierarchy if there is no inequality rii assumes a value of 10 the further the value of rii from 10 the higher the level of inequality rii assumes only positive values with values larger than one indicating a concentration of the indicator among the advantaged and values smaller than one indicating a concentration of the indicator among the disadvantaged if there is no inequality sii takes the value of zero greater absolute values indicate higher levels of inequality positive values indicate higher coverage in the advantaged subgroups and negative values indicate higher coverage in the disadvantaged subgroups 46 rci and aci were estimated based on the methodology described by clarke et al 48 the rci provides a measure of the relative differences among education income groups considering that the rci was based on morbidity measure a negative rci indicates inequality favoring higher income groups the aci quantified the absolute differences in health between education and income groups and this index is not affected by whether it is measured concerning health or morbidity as riisii are mathematically related to rciaci they will produce the same rank ordering of health inequality between groups but will differ in scale association between tooth loss and socioeconomic indicators multilevel poisson regression procedures with unstructured covariances matrix were used to model the twolevel structure of individuals nested within municipalities multilevel techniques of analyses provide the overall relationship between the individual compositional factors and oral health and the variation between areas that cannot be accountable for such factors besides it is possible to assess the variation in certain individual relationships between municipalities and the interaction between individual and contextual characteristics a fivestep sequential modeling strategy was adopted i model 1 a model without the inclusion of any covariates in which the variance in tooth loss is inspected between municipalities a significant random intercept variance indicates the presence of unexplained differences in tooth loss between municipalities the wald test evaluated the significance of random intercept and the median rate ratio measured the heterogeneity among municipalities according to austin et al 49 there is no variation between municipalities if the mrr is 10 but the higher the mrr the greater the arealevel variation ii model 2 considers all the individuallevel variables in the fixed part this model assessed the association between tooth loss and income and education adjusted for covariables at the individual level the variation between municipalities is allowed for conditional on the individual compositional factors iii model 3 as model 2 but including the municipalitieslevel variables the proportional change in variance was calculated according to merlo et al 50 using the following formula pcv variance model 1 iv model 4 as model 2 but the model allows both the intercept and slope to be random parameters therefore each municipality has its intercept and slope in which the variability from the overall intercept and slope can be investigated with the addition of individual and municipality variables and their interactions random slopes for education and income were considered the comparison of goodness fit between model 2 and model 4 was performed using the lrtest v model 5 as model 4 including the municipalitieslevel variables in which the crosslevel interactions between educationincome and hdi were considered the interaction term represents the change in the slope of education income on tooth loss across municipalities when hdi changed from low to high the estimated mean of missing teeth according to individual socioeconomic variables for municipalities with high and low hdi was demonstrated using a graph of the predicted model procedures for complex sample design were used to calculate the proportions of adults according to investigated variables the ageand sexadjusted estimates of the outcomes sii rii and aci statistical analyses were performed using stata version 15 results the sample was 9633 adults residing in 157 municipalities 146 individuals in 20 municipalities with a sample of fewer than 10 adults were excluded the characterization of the sample and mean of missing teeth according to investigated variables are shown in table 1 the mean number of adults per municipalities was 6136 and ranged from 10 to 496 the mean of hdi was 071 and 7628 presented high hdi the goal of oral health services coverage was achieved by 3918 of the municipalities and 8256 of those had fluoridation of water supply the mean number of missing teeth among brazilian adults was 736 this value was 952 in municipalities with low hdi and 695 in those with high hdi the inequalities indexes show a higher number of missing teeth in disadvantaged groups higher relative and absolute educationbased inequality were observed among municipalities with high hdi for incomebased inequalities higher sii was observed in municipalities with lower hdi the multilevel crude estimates showed that all individuals variables were significantly associated with tooth loss table 4 shows the multilevel models assuming random intercept and fixed effects the empty model shows that the contextual level variation was significant suggesting differences in tooth loss among municipalities and the mrr also indicated variation across municipalities the mrr as well as the betweenmunicipality variance come down from 2009 to 1417 after the inclusion of individual variables in model 3 assuming fixed effects a social gradient in tooth loss for income and education was observed municipalities with high hdi presented a lower number of tooth loss the inclusion of municipalities level variables represented an additional 127 decrease in variability of tooth loss among municipalities table 5 shows the models whereby the nature of betweenmunicipalities variation was modeled as a function of individual education the 5 the other random slopes were shown as an additional file the graph of fitted lines shows how the municipal variation is more pronounced among individuals with higher education model 5 shows that when the association between education and tooth loss was allowed to vary across municipalities the main effect of hdi was not significant the social gradient in tooth loss by individual income and education continue to be observed municipalities with fluoridated water showed a lower number of missing teeth the crosslevel interaction between education and hdi was significant indicating that the association between these two variables is not constant across municipalities with steeper slopes observed in municipalities with high hdi there is some evidence that the number of missing teeth is lower for the higheducation group when they live in municipalities with high hdi compared with those with the same education level living in municipalities with low hdi for individuals with the lowest education level there was no difference in the number of teeth comparing those from municipalities with high versus low hdi the fixed effect of individual and contextual variables did not change with the inclusion of crosslevel interactions when the variation was modeled as a function of individual income the model was very similar to obtained with fixed effect the graph of fitted lines shows that the municipal variation is similar through income levels the crosslevel interaction between individual income and hdi was not significant discussion the tooth loss represents an end state in oral health and the present study reaffirmed the persistent concentration of tooth loss among the most disadvantaged individuals over and above individual disparities our findings also demonstrated that the magnitude of educational and incomebased inequalities varied between municipalities with high versus low hdi our results showed that educational attainment was less protective against tooth loss when people live in disadvantaged areas conversely adults with the lowest levels of education and income had greater tooth loss regardless of whether they lived in a municipality with high or low hdi our study replicated the inverse association between socioeconomic status and tooth loss after adjusting for all covariates at the individual and municipality levels 10 11 12 using different outcomes related to tooth loss previous studies have consistently shown more tooth loss among the more disadvantaged groups quasiexperimental evidence that worsened economic circumstances are associated with tooth loss was provided by a natural experiment following exposure to the 2011 great east japan earthquake and tsunami 51 a metaanalysis of 10 cohort studies and two crosssectional studies found a significant association between low income and tooth loss 13 those living in poverty suffer a greater burden of oral diseases such as dental caries and periodontitis 5253 the main causes of tooth loss in adults they also have a higher prevalence of systemic conditions such as diabetes cardiovascular disease and obesity 5455 that are related to tooth loss besides these biological explanations the conceptual mediators of the effect of socioeconomic status on oral health include material deprivation psychosocial distress and behavioral factors 141719 besides the association between economic constraints and the type of dental treatment delivered has been demonstrated while subjects in the lower income brackets are more prone to dental extraction individuals with higher income are more likely to seek periodic routine appointments and conservative dental treatment resulting in a higher number of retained teeth 5657 in brazil the higher tooth loss associated with socioeconomic disadvantage can result from systemic factors related to the organization and delivery of oral health services the national oral health policy also known as smiling brazil was implemented only in 2004 ensuring universal coverage 58 this policy increased the access of adults to oral health services who historically had significant ongoing unmet needs with only urgent care available in public services 58 the lack of access to restorative and preventive services in public health services may have contributed to tooth loss especially among the most disadvantaged individuals moreover previous studies have shown that a change in access to oral health services does not necessarily result in reduced oral health disparities 59 the explanation was because people take time to change their behaviors eg seeking periodic preventive dental services our results also showed differences in tooth loss inequalities according to municipal hdi with higher absolute and relative educationbased inequality found in municipalities with high hdi and higher absolute incomeinequality found in municipalities with low hdi the high educationbased inequality among municipalities with high hdi shows the double disadvantage of adults who share the lowest education and living in places with the worst social indicators 38 these results suggest that public policies may not reach the persons in the same way increasing the gap among social groups the association between education and tooth loss was not constant across brazilian municipalities the significant crossinteraction term reveals that the magnitude of the association between education and tooth loss was lower in municipalities with high hdi this result suggests that contextual factors may weaken the potential protective effect of schooling at the individual level low hdi municipalities in brazil are smaller cities with lower wealth higher rates of urban violence lower sanitation conditions and urban infrastructure these contextual aspects may represent fewer opportunities for healthy living for its residents our result shows that where one lives has an effect on oral health and that this effect must be evaluated considering the characteristics of the people on the other hand the significant crosslevel interactions reinforce the hypothesis that public policies can increase the gap among social groups to the extent that it may not reach people in the same way the crossinteraction was significant after adjusting by oral health policies and fluoridation of water supply hdi is an indicator that incorporating a life expectancy education and a modified measure of income in a contextual level however these indicators may demonstrate the effect of other policies and environmental characteristics that favor access to primary health care in general sanitation access to cultural and social opportunities more social capital more work and economic security and more healthy food available all these contextual factors are potential mediators of the association between hdi and tooth loss and have been pointed out as determinants of oral health 3460 in previous studies that had demonstrated the main effect of sociallevel indicators on tooth loss using multilevel approaches in brazil united states european countries australia and japan 18 20 21 22 23 24 27 28 29 30 31 32 the analysis performed in this study is advancing as it may contribute to more targeted policies for the groups with the greatest need in specific contexts the only significant contextual factor we found was the fluoridation of the water supply individuals living in municipalities with water fluoridation presented lower tooth loss the importance of this intervention was previously shown in maintaining functional dentition 21 and tooth retention 23 natural experiments applied in oral health context from brazil showed that adults who accessed fluoridate water 50 of their lifetime presented a higher mean rate ratio of dmft index compared with those living 75 of their life with residential access to fluoridated water longer residential lifetime access to fluoridated water was associated with less dental caries even in the context of multiple exposures to fluoride 61 we adjusted our models only for key covariates similar to the most multilevel studies the sampling and analytic convenience was the reason for the choice of contextual variables rather than an explicit theory linking area disadvantage and oral health therefore associations among these variables are likely to be underestimated however the brazilian municipalities have to deliver basic education sanitation and primary healthcare therefore our chosen contextual factors must fit the area border we used crosssectional data where the distinction between current and past exposures cannot be made similarly income can change throughout life resulting in upward and downward social mobility conclusions there was a social gradient in tooth loss by education and income living in disadvantaged municipalities cannot overcome the risk associated with low schooling the protective effect of higher education can be reduced when people live in disadvantaged areas this differential effect of education on tooth loss among municipalities with high and low dhi can increase the gap among social groups the persistent inequality demands for innovative strategies and policies that address the wider social determinants of health considering the differential effect of public policies among supplementary information supplementary information accompanies this paper at 1186s12903020012389 additional file 1 parameters of the random part of the multilevel models with random intercept and slope between individual and municipalities level variables among 3544year old in brazil 2010 additional file 2 municipalitiesspecific slopes of education on tooth loss additional file 3 count ratios of tooth loss in multilevel models with random intercept and slope between individual and municipalities level variables among 3544year old in brazil 2010 additional file 4 municipalitiesspecific slopes of income on tooth loss authorscontributions rcf analyzed and interpreted the data wrote the manuscript mibs lgr flc and aeblm contributed to data analysis and interpretation ik was the study supervisor made substantial contributions to data analysis and interpretation and made a critical review of the intellectual content all authors read and approved the final manuscript funding raquel conceição ferreira received financial support capes and from fapemig brazil this study was financed in part by the coordenação de aperfeiçoamento de pessoal de nível superior brasil finance code 001 these sponsors had no role in study design collection analysis and interpretation of data writing of the report the decision to submit the article for publication competing interests the authors rcf is a member of the editorial board of the bmc oral health

background socioeconomic inequalities in tooth loss might be minimized or potentialized by the characteristics of the context where people live we examined whether there is contextual variation in socioeconomic inequalities in tooth loss across brazilian municipalities methods data from the 2010 national oral health survey of 9633 adults living in 157 brazilian municipalities were used the individual socioeconomic indicators were education and household income at the municipal level we used the municipal human development index hdi as our contextual indicator of socioeconomic status low 0699 versus high 070 the relative rii and slope sii indexes of inequality relative rci and absolute aci concentration indexes were calculated to compare the magnitude of education and incomebased inequalities among municipalities with low versus high hdi multilevel poisson regression models with random intercepts and slopes were developed results at the individual level adults with lower education income reported more tooth loss the mean number of missing teeth was 952 95 ci 7931113 and 695 95 ci 643749 in municipalities with low and high hdi respectively municipalities with high hdi showed higher relative and absolute educationbased inequality for incomebased inequalities higher sii and rci was observed in municipalities with lower hdi a significant crosslevel interaction indicated that higheducation adults reported fewer missing teeth when they lived in municipalities with high hdi compared to adults with the same education level living in low hdi municipalities for individuals with the lowest education level there was no difference in the number of teeth between those from municipalities with high and low hdi conclusions there was a social gradient in tooth loss by education and income living in disadvantaged municipalities cannot overcome the risk associated with low schooling the protective effect of higher education can be reduced when people live in disadvantaged areas

INTRODUCTION The experience of sexuality is a process of interaction between human development and insertion in the social group. Individual and social aspects constantly interfere on human sexual development; even the biological aspects of sexuality must be analyzed in conjunction with the social and cultural aspect . The idea of continuity and inseparability of the sex-gender-desire triad on the sexuality of individuals are established. Based on sexual norms, this ideology proposes a normal system of structuring sexuality based on binary and compulsory heterosexuality , which inserts individuals into sexual socialization. Socialization is a longitudinal process of learning: the behaviors, codes, codes, norms, processes, and many other elements that are shared with individuals enable their insertion in society . Environmental stimuli contribute by mediating the individual's development . It is through this journey that the subject formulates, for example, their sexual scripts and some gender issues. Therefore, sexual socialization is, in general, an intrapsychic, interpersonal and sociocultural process ; after all, all these different systems are participants in this formulation. This text describes and reflects on the development and sexual socialization of young transgender people in contemporary Brazil, based on their life history. As a Latin culture, Brazil has a number of myths about the expression of sexuality that span many areas, from the idea of a liberal and permissive sexual culture to the perpetuation of a historical machismo that violates groups and individuals on a daily basis . About two decades ago, the debate in gender studies revolved around the image and objectification of the Safiotti Brazilian woman. Even without the dissolution of this issue , other topics arise, especially the issue of homosexuality and prejudice against sexual minorities, including the trans population . Today, an ultra-conservative, politically and religiously based trend is plaguing the country and affecting the experience of sexuality. We are thinking here of a specific group, noncisgender young people and their sexual socialization. In view of this, trans social identity would be the way for people with dissident gender experiences to socio-politically position themselves on behalf of specific demands in the face of cisgenerity . Cisgender is the name given to the experience of identifying with the gender attributed by birth. Cisgenerity, as well as compulsory cisgenerity or cisnormativity, is the analytical concepts used to structurally understand the cis experience as a stabilizer of gender norms, just as heterosexuality stands for sexual orientation . Silva and Oliveira investigated what they called the process of transsexualization and development. This process "consists of the path toward self-recognition as transsexual and the production of transsexual identity from personal experiences" . In their interviews, three important variables in this process are noted, which appear with substantial frequency in the narratives of research in general: childhood plays and games; puberty disguise strategies; and relationships with family and friends. It is difficult to trace elements that would be involved in this process and would be common to all experiences, but the social network supporting the social identity of transgender people appears as an important variable. As discussed, Silva and Cerqueira-Santos showed that the development of social identity, that is, their awareness of themselves and the groups they belong to, is associated with the ways of thinking body and gender as shared by family, friends, and other subjects from a social network. The trans body is then a volatile, ephemeral, transformable institution that also resides in the field of the nameless in terms of socio-cultural perceptions and sensations . Vasco suggested a different approach to access development memories; she tried to understand what was the relationship that the subjects had with their photographs from childhood and adolescence. There, photography, which could initially be understood only by its indicative character, that is, as the affirmation of a pre-social transition life, appears as a mechanism for elaborating the process of building their gender identities. In qualitative research, the use of photography becomes more complex; the researcher is interested in gaining access to singularities, i.e., access to the subject's internal world through senses and meanings that encroach on the study subject . Photography appears as a privileged instrument, because in photo-elicitation interviews, i.e., in interviews where there is the presence of photography, answers obtained are emotionally deeper . Thus, the process of contemplation of an image is taken into account, "since the image separated from thought becomes a mere residue of the photographed object" . Thus, Volpe stresses that photography is a way to signify the world, and that it acts as a sort of meeting place for narrative and memory. The aim of this research was to explore the meanings of childhood memory established by young people who identify themselves as trans. In addition, we sought to explore the ties between these memories and the dissident gender experience in youth. In order to do that, we used the self-photographic method, which consisted in the production of photographs and an unstructured interview on this process. --- MATERIALS AND METHODS --- --- Procedures and Instruments After accepting the survey invitation, six individual meetings were scheduled at times and places convenient to all participants. They were presented with the research, its objectives, the steps and asked about their consent for audio recording. Then the ethical undertaking document was signed and the participant was given a copy. A digital camera was given to the participants and they were instructed to take pictures that reminded or represented their childhood and adolescence able to "tell significant elements of that time, whether good or bad, and their implications for their gender experience." They can be abstract photos or of concrete elements, what matters is that they refer to that time. No need to hurry, but I ask you not to take them all at once, like in one afternoon, for example "Think carefully, after all the number is very restricted" . The deadline for returning the cameras was 1 week, when the researcher contacted the participants and met them to pick the pictures up. Each photograph was printed twice, so that one set would stay with the researcher and be used in the second interview and another set to be given back to the author in a second meeting. This second meeting was scheduled one day after the cameras were handed over, so that they could think about the shooting experience and the content the images referred to. Once again, with their consent, these meetings were recorded. Like the first time, this meeting was conducted along the lines set by Croghan et al. for the photo-elicitation interview. The individual interviews lasted about 60 min and were structured informally. Faced with the printed photographs, the participants were invited to talk about each of them in the order that was convenient for them and with little interference from the researcher. The initial statements described the images so that the interviewees would then address more emotionally complex topics such as family and self-image, as foreseen in the method. In their article, the authors describe the method for conducting an interview that uses photographs taken by the subject as triggering elements of speech. --- Data Analysis The data analysis sought to explore the meanings that each one laid down for their childhood memories, and for that, we based our studies on the formulations of Spink and Medrado on meaning production. The relationships between memories and the present, the contradictions, formulations of gender, and how all these issues resulted in a sense produced for their own stories were analyzed. --- RESULTS AND DISCUSSION For the three participants, the return to childhood revealed times when certain behaviors were interpreted as displacements of the gender assigned at birth. As part of the process of making sense of their stories, it was necessary for them to build a notion of gender and its relationship with their experience. The memories of childhood relate to the experience of dissident gender in youth through the uninterrupted process of building the social identity of participants. Recalling the preference of toys, clothes, the way they saw their bodies, as well as the way reference people returned these children's looks, all were important elements in this process and were symbolized in the photographs. The memories of these childhoods did not return as a painful ghost, but as clues to a potent life. Despite the faults, the forgetfulness, the comments, and the repressions, childhood was remembered as a fertile ground for the search for oneself and for the construction of a life story. Because I have my humanity denied, I my humanity was denied. But I also don't want that to limit my life. I do not mean that my experiences, my life, my childhood were just pain and suffering. So much so that the memories I had, the memories I had, none actually saddened me. It wasn't something that hurt me, it wasn't something that pained me. I think there were strong things, difficult things that I had to go through, but that didn't make me sad. I think I'm happy to have lived that and become who I am today! Because they have accepted their trans social identity for longer than K.K., I.S., and B.P. are used to questions such as: "Who are you? When did you recognize yourself as trans? What does it mean for you to be a woman/man?" Whether it is for sharing loci of militancy and potential visibility with the trans cause, or asking the questions people have asked them every day since transitioning. I.S. comments that society has forced her to think about gender so that people, especially her father, would understand that today she recognizes herself as a woman: "It was a process where he really needed to see that was really me, that I was sure of that." In this speech from I.S., there are highlights to discuss the relationship established between childhood memory and gender experience in youth. First, on reflecting about gender and its subsequent issues. All the time, I.S. seeks to "denaturalize gender, " understanding it as a social construction: ".over time, and we have come to understand who we are, but not that we are like this because we were born this way, we are like this because we built ourselves in this way over time." The "denaturalization of gender" referred to by I.S. is the refusal to reduce gender to biological bases, i.e., gender identity would not be a consequence of the genitalia with which the person is born . There is an effort in her speech to understand it from its relational and political character, as a reading of the differences imposed on women and men from their social construction, including questioning the natural kind of the binary paradigm . From this perspective, the naturalness of gender roles is called into question: men do not cry, they must be strong and providers for the home, while women are sensitive, fragile and devoted to their children. According to Lanz , people suffer from being tied up to these normative ideals. For I.S., there are models of men and women in society, and people, by "affinity, " recognizes themselves in one of these models or creates their own model. B.P. has an idea of gender more restricted to binaryism, although maintaining a strong criticism of gender stereotypes. These reflections meet the procedural and relational character of social identity, where the process of constitution takes time and occurs uninterruptedly . Tajfel states that belonging to one group is established through a relationship with the other, it is by comparison with the other that the subject perceives himself as belonging to a particular group. To identify oneself as belonging to the "trans world" is to be exposed to regulatory views that reduce dissident experiences to nosological categories. Because of these preconceptions, situations of violence against this population occur on a daily basis, so, as I.S. said, accepting oneself a transvestite or trans is a political act . Silva and Cerqueira-Santos argue that a sense of belonging to group in favor of cooperation among members can result in a source of social support. In the first interview, B.P. talks about this process: ". there is no 'when you acknowledged yourself, ' there is when you, when population, society finds out who you are, see? You stay there, you live all that in your childhood. You will only put the puzzle together later." Cisnormativity imposes models for men and women and it is based on them that gender roles expected from a child are assigned. It is in the period of childhood that performative utterances are internalized and when stylization of genres takes place . The three interviewees recalled moments through the photographs when they were scolded for behaviors that pointed out to a displacement: I.S. recalled how her father regulated the way he walked or the way he supported his hand, while K.K. and B.P. were chided attention, by the way they sat. These are experiences shared by most children, but which gain particular meaning for those who experience a dissident gender experience, as discussed earlier . The question of this other, who questions them, who reallocates the subject in this place of difference, exposes the relational character of both social identity and gender. I.S. recalled that: "People kept pointing at me, but I had no idea what it was about. Even though people kept saying: ' Ah, you're feminine! You're a faggot!' But I didn't even know what it was to be a fag!" The late notion of the social meaning of certain childhood behaviors was shared by the three participants, like a picture you take and only develop years later, during puberty. There is a tension between what is expected/assigned and the behavior of the child, and later the adolescent, who understands what it means to be called "fag" by their peers. Regarding support networks for trans social identity, Silva and Cerqueira-Santos state that self-awareness and about belonging groups has a close connection with the way the family, peers, and spouses/boyfriends view these "other" ways of feeling oneself as a woman/man and the gender identity of the subjects in question, since one is not born a subject, but rather becomes a subject from the moment it is possible to perceive oneself as belonging to a certain social and societal reality . In I.S.'s narrative, one can notice the fundamental role that the support network, supported mainly by cis and trans women, played in her trajectory. K.K. also acknowledges his mother's support as a child, just as he talked about his acknowledgment process a few weeks before the first interview. B.P. also finds support in his peers, in his husband and in his family; although inside his mother's house they do not call him by his name, a fact that justifies the difference due to his parents' generation. Regarding self-awareness, which includes aspects of body and sexual awareness, we can highlight the relationship of the external look in the trajectory of the three participants. In I.S.'s childhood, people generally interpreted her games, her way of walking, her desire to have long hair as signs of a "latent femininity." They warned her mother, called her a "fagot" at school, cut her off from relationships with other children. According to her, when she was thirteen, puberty comes and with it, masturbation, that's when she understood why they called her a "little woman" and what that meant. She began to think: "I think I'm gay." Even in her early teens, her first boyfriend says he didn't understand why he felt attracted to her as he didn't identify himself as gay. The same goes for the lesbian girls she approached. Even if at that point she had not had relations with any man, did not acknowledge herself as a gay teenager, that is how others see her. When you start taking hormone and wearing Goth makeup, people start to ask, "who are you?" Noteworthy are the episodes where she was questioned by her peers in the Candomblé worship place, where she claimed to be androgynous and that is why the men who related to her were heterosexual. Your acknowledgment process is mediated through and by your body, as well as by this outside look, as these are the elements that underlie your understanding of gender and help you build your story. And then I got to meet gay men and I didn't identify myself with them. I have started notice "Oh, I'm not like that!" I think differently, I don't know, I'm not like that. And I identified more with girls, I got closer to girls and I felt that the girls didn't see that in me, either. That matter I talked about last week, I think this gender issue, I avoid this cliché of saying "oh, my soul is like that or I was born that way." I don't think so, I think we build it all. But I think that, for sure, the physical part has nothing to do with it. Because in several periods of my life I noticed that people saw me as a woman, even without my looking as one, looks were irrelevant, see? People felt it, I showed it, even without having to show it by means of my body, appearance, physique, clothing or anything else. It is also possible to highlight the role of the external look in B.P.'s trajectory. During his childhood, despite constantly playing with his nephew, wearing men's clothing and preferring elements interpreted as from that world, he did not report direct challenges, as in the case of I.S. This is supposed to be because a boy playing with elements of the female world is interpreted as a more serious displacement than a girl playing with elements of the male world . Machismo is implicit in this relationship, as B.P. interprets the fact that his mother allowed him to play with his nephew at home, as being more acceptable for him to play with B.P., who "already acted kind of masculine, " than to let him play with a girl or the street boys, who disapproved of the behavior. During his teens, the relationship between his body, the outside look and gender issues intensified for B.P., especially after he started judo training. This is a time that is remembered with joy and as fundamental in his process of acknowledging his gender identity as a trans man. Because he was heavy, there were no girls to fight with or train at school, and that is why his boxing coach placed him with the boys' group. This recognition of the other differs from the case of I.S., which took place rather in relation to her behavior, while in B.P.'s case it was his body that set him apart. This was also present in the photographs presented by him. ...at school I always trained running with men. And then, my master always said that I had to have a man's resistance! So I thought that. "I'm really on the right track!" I just kept looking for the feminine in me. And so, on the one hand I just saw my name. In the name and genitalia. Only! Because as for the rest, I already recognized myself as a boy. So judo, judo was the mark of everything! To have a "man's resistance" means to have something of the male or figuratively to have the strength, the virility of that body. Thus, it was a body that did not correspond to the female stereotype, of a delicate and fragile body, and if it was not female, it was its male opposite. By this time, B.P. was already wearing other male-related cultural signs, such as short hair and short nails. Just like the men's pants her mother gave her, because the others "got too frayed." Yes. But as a result, it helps you to identify yourself. It's the same, today I am a man and I have breasts. It makes me no less a man, but without my breasts, I'll feel like the man. It's as if I was born in the shape I wanted! Again, a contradiction shows up in B.P.'s speech, where "it makes me no less a man" does not seem to relate to "I'll feel like the man, " especially by using the Portuguese male definite article "o" . Oliveira points out that among the trans men she researched, there was a type of hierarchy in relation to being more trans based on a comparison of bodies. The more muscle, the more body hair, the better your position relative to other trans men. Although B.P. does not stress this desire to have a body matching the normative standard, it is interesting to note in his speech the power of expressions referring to the male world. Also according to Oliveira , the only body part visible even with clothes that can denounce men are the breasts; therefore, they are considered as "invaders, " "undesirable" and need to be extirpated. K.K. recalls when he stopped running in his underwear in the street, commenting on the amazement and at the same time fascination with the idea that his breasts were growing. In much of the interview there was an expression of this feeling of duality about his body, as if K.K. wanted to experience it beyond the norms laid down for the genders. However, when his girlfriend cheated on him with another man in his teens, the issue of genitals comes up markedly for him: "Why am I not a guy?' I don't know. 'Why don't I have a dick?' Because I was not so relaxed at the time, for me men had to have dicks". In his speech there is not yet a proper established meaning for these reflections, but there is an attempt to detach himself from the biologizing notion of gender, similar to the efforts of I.S. and B.P. Furthermore, for K.K., the discovery of his body through sexual abuse suffered even as a child further complicates his process of understanding his gender identity. As well as understanding how this process of gender identity recognition fits into the discovery of your still very young body through someone who has abused you more than once. The body issue is complex and is something that needs to be stressed in the three participants: at the time of the interview, K.K. was experiencing his body from the beginning of hormone therapy, enjoying the first mustache strands that sprouted on his face. I.S. did not take hormones and at no time reported having issues with her body, she even used feminist arguments to build her sense of her body beyond normative standards. B.P. took hormones and yearned for mastectomy surgery, even though his speech showed contradictions. In general, researches report a question of inadequacy with the body in the speech of people who identify as gender-dissidents . They say things like "I was born in the wrong body" or "I hate my body." In this research, there were reports of body inscriptions of cultural signs of the genre where one recognizes oneself, whether absence/presence of hair, hair length, clothes, or even medical or surgical interventions. Still, it was not possible to identify the alleged disgust with the body or genitals in particular, beyond B.P.'s comment. The theme or the characteristics of the sample, such as its size or the age of the participants, may be the variables responsible for the matching answers. However, it is still worth stressing those narratives, which establish tension in discourses about the "true" trans experience. As stated by Bento , the narratives point to the diversity of relations with the body and challenge attempts to erase them and inscribe them into categories that homogenize them. Comparing these narratives with those found by Caravaca-Morera and Padilha , the relationship with the bodies of the participants of this research is close to the talk about the malleability of the bodies. This is related to the possibilities of body transformations, as it they were a blank canvas where you can paint a multitude of watercolors. The gimmicks may not be medications, but there is a construction of this body to meet an expectation of both internal and external gender. Thus, certain reverberations found here also fit the second matrix of the analysis of Caravaca-Morera and Padilha , where the body is understood as its own institution, but regulated and controlled by others. On this point, Rodovalho says "that in most social interactions there will be no time for you to say what you are, your body having to be able to convey the message as unambiguously as possible" . In the three stories, they recalled moments through the photographs when, during childhood, the body was an instrument of experimentation. Like the hair I.S. wanted to grow long, or in B.P.'s case, the hair that wouldn't grow long. For K.K., there was sensory experimentation, which he felt when he wore only underwear or when he tied the towel differently on his body. Interestingly, B.P. and K.K. began wearing wider, masculine clothing, prior to their identification as trans men. They both referred to a growing sense of being "comfortable" with those clothes. Just like I.S., who in her teens used hormones before self-identification. This was especially true of B.P., who started wearing two blouses and a coat as soon as her breasts began to grow. For Rodovalho , self-identification alone is not enough to understand the experience of the trans body; for her, there is always a tense negotiation of meanings between what it means to be and what it means to seem. In general, the three participants talk a little about this issue, as B.P. said: We talk a lot that, even though I am a trans man, I can reach the end of my life having everything that a man can get to the point of saying, is that really it? Is something still missing from me? Huh? Because sometimes we seek so much, it may be that I realize myself in every way as a man, I wish I was born a man, and yet I still lack something. Same thing as a child. I could have had it all and say, I was born a boy! And still think that something was missing, think I wish, let's say, even though I had a ball, a cart, played games, clothes, but I still had to feel that I was missing sneakers. I'm not complete yet, I still have to have male sneakers. Then, that's it. I think we need characteristics, objects to strengthen us. with trans men, so, I'm a trans man. Okay, if I don't dress like a man, how will people respect me, know I'm a man? Because we have to see it, despite what we want, we still have a society to face. This is my point of view. I really, really wanted to, so badly, I wish I didn't need so many masculine characteristics to fit into what a boy is, what a man is. But unfortunately, I live in a society that needs it, even cisgender men need it, they need to wear a beard, they need to wear a men's outfit, they need to enjoy playing football, and fly kites. So, if they need that, why don't I need that to recognize myself? But I need an object, of course I need it. Get it? The complexity of this relationship with the body and the way it affects the construction of their own story becomes evident in these narratives. The three participants restate the demands society imposes on them to make sure of their gender identity, and that this self-identification must be consistent with the signs that their bodies carry and express. However, even if such body inscriptions do occur, these people are daily exposed to violent reactions from others that will point to something in their bodies or behaviors. Transgender people are denied human dignity. While suffering from the regulation of discourses and incorporating normative cultural signs, the trans body is also a place of resistance production. ... because people don't understand that it's not that I have to boost the female stereotype, but that's the only thing I find trans, these stereotypes are what I can hold on to in order to show people that I'm female. I don't need to be a perfect housewife at home, but I can't get there like this; today I can, because the movement is evolving, but it's not easy yet, I get here with a beard on my face, and unshaved legs, like feminists claim. They can do that because they are already at another level of debate, we're still crawling behind. I always said and I will keep saying it: my fight as a transvestite is not to be recognized as a woman, because I think that's silly, when compared to the fight that I have to move forward, which is to be recognized as a human being! Researching the relationship between language and body in the discourses of transgender people, Cassana demonstrated that despite the sedimentation of senses, language is what also enables the formation of another social body legitimized by the discourse of the transsexual subject. "So, let the body be a celebration party of the impossible" . --- Final Considerations The more classical theories of psychology have for decades maintained that the way young people signify childhood has repercussions on their experiences and experiences in youth and adulthood . Developmental Psychology has historically contributed to this discussion by seeing unity in the developmental process from childhood to old age. The chain of experiences contributes to the personality, the formulations about oneself, and the historical integrity of the subjects. There is a rupture in common sense between the passage from childhood to adolescence or during the process of transsexualization; they are redefined under this rationale, adopting a view that aims at seeing the subject as historical and their development as continuous. The changes these young people experienced during childhood and youth are part of their socialization process . In our sample, gender socialization and sexual orientation were reported as procedural and historicist. Events and experiences seem to be quite integrated into the construction of even the most traumatic identities. This reinforces the view of the comprehensiveness of these subjects . The view of transsexuality signification as a historical breach did not seem evident in this sample. In contrast, trans experiences were linked to the significance of childhood, adolescence and the milestones in the developmental process. Even in the efforts and contradictions to give meaning and connectivity to events. The specificities of socialization of non-cisgender individuals need to be further investigated. The photography method applied in this study was important in eliciting in these young people a timeline of life history . The results demonstrated that this technique is effective for investigating historical events with meaningful integrity. In any case, this technique allows the past to make sense in the present. What was investigated here, therefore, was how non-cisgender young people build and understand their developmental process. And this does not focus on the accuracy of the facts, but on the individualization of these subjects. Transsexuality appeared as an important influential variable in socialization, and consequently, in individuation. By highlighting the elements that were present in the production of meaning in their stories, the participants consequently clarified the process of building their trans social identity. Reflections about gender and their role in understanding their trajectories stand out. In general, the cis-hetero-normative patterns for the experiments were questioned, resulting in an understanding of the idea of gender identity as a process, something continuous and uninterrupted. this study and was responsible for data gathering and analysis and writing part of the manuscript. MM was responsible for bibliography updating and writing and final proofing of the text. --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. --- ETHICS STATEMENT The studies involving human participants were reviewed and approved by the Federal University of Sergipe, Brazil. The patients/participants provided their written informed consent to participate in this study. --- --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Copyright © 2020 Cerqueira-Santos, de Santana and de Miranda Ramos. This is an open-access article distributed under the terms of the Creative Commons Attribution License . The use, distribution or reproduction in other forums is permitted, provided the original author and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

The aim of this research was to explore the meanings of childhood memory established by young people who identify themselves as trans. In a chauvinistic country such as Brazil, sexual socialization of non-cisgender youth is beset by unique challenges, such as discrimination and violence. This study was based on the proposal of a self-portrait method as a content trigger in interviews with three trans young women who reported their life stories. We analyzed data using the oral story technique, through which the described themes came up. The results presented developmental narratives related to gender issue from childhood, which reflected on the experience on youth. Reports of discrimination based on the image of others (family, school, and community) about the gender development of the participants and their relationship with their bodies stand out. We see the importance of reflecting on life history memories in trans identity in order to give meaning to this experience. The influence of heteronormative and sexist Brazilian culture is noticed in the participants' reports.

introduction the experience of sexuality is a process of interaction between human development and insertion in the social group individual and social aspects constantly interfere on human sexual development even the biological aspects of sexuality must be analyzed in conjunction with the social and cultural aspect the idea of continuity and inseparability of the sexgenderdesire triad on the sexuality of individuals are established based on sexual norms this ideology proposes a normal system of structuring sexuality based on binary and compulsory heterosexuality which inserts individuals into sexual socialization socialization is a longitudinal process of learning the behaviors codes codes norms processes and many other elements that are shared with individuals enable their insertion in society environmental stimuli contribute by mediating the individuals development it is through this journey that the subject formulates for example their sexual scripts and some gender issues therefore sexual socialization is in general an intrapsychic interpersonal and sociocultural process after all all these different systems are participants in this formulation this text describes and reflects on the development and sexual socialization of young transgender people in contemporary brazil based on their life history as a latin culture brazil has a number of myths about the expression of sexuality that span many areas from the idea of a liberal and permissive sexual culture to the perpetuation of a historical machismo that violates groups and individuals on a daily basis about two decades ago the debate in gender studies revolved around the image and objectification of the safiotti brazilian woman even without the dissolution of this issue other topics arise especially the issue of homosexuality and prejudice against sexual minorities including the trans population today an ultraconservative politically and religiously based trend is plaguing the country and affecting the experience of sexuality we are thinking here of a specific group noncisgender young people and their sexual socialization in view of this trans social identity would be the way for people with dissident gender experiences to sociopolitically position themselves on behalf of specific demands in the face of cisgenerity cisgender is the name given to the experience of identifying with the gender attributed by birth cisgenerity as well as compulsory cisgenerity or cisnormativity is the analytical concepts used to structurally understand the cis experience as a stabilizer of gender norms just as heterosexuality stands for sexual orientation silva and oliveira investigated what they called the process of transsexualization and development this process consists of the path toward selfrecognition as transsexual and the production of transsexual identity from personal experiences in their interviews three important variables in this process are noted which appear with substantial frequency in the narratives of research in general childhood plays and games puberty disguise strategies and relationships with family and friends it is difficult to trace elements that would be involved in this process and would be common to all experiences but the social network supporting the social identity of transgender people appears as an important variable as discussed silva and cerqueirasantos showed that the development of social identity that is their awareness of themselves and the groups they belong to is associated with the ways of thinking body and gender as shared by family friends and other subjects from a social network the trans body is then a volatile ephemeral transformable institution that also resides in the field of the nameless in terms of sociocultural perceptions and sensations vasco suggested a different approach to access development memories she tried to understand what was the relationship that the subjects had with their photographs from childhood and adolescence there photography which could initially be understood only by its indicative character that is as the affirmation of a presocial transition life appears as a mechanism for elaborating the process of building their gender identities in qualitative research the use of photography becomes more complex the researcher is interested in gaining access to singularities ie access to the subjects internal world through senses and meanings that encroach on the study subject photography appears as a privileged instrument because in photoelicitation interviews ie in interviews where there is the presence of photography answers obtained are emotionally deeper thus the process of contemplation of an image is taken into account since the image separated from thought becomes a mere residue of the photographed object thus volpe stresses that photography is a way to signify the world and that it acts as a sort of meeting place for narrative and memory the aim of this research was to explore the meanings of childhood memory established by young people who identify themselves as trans in addition we sought to explore the ties between these memories and the dissident gender experience in youth in order to do that we used the selfphotographic method which consisted in the production of photographs and an unstructured interview on this process materials and methods procedures and instruments after accepting the survey invitation six individual meetings were scheduled at times and places convenient to all participants they were presented with the research its objectives the steps and asked about their consent for audio recording then the ethical undertaking document was signed and the participant was given a copy a digital camera was given to the participants and they were instructed to take pictures that reminded or represented their childhood and adolescence able to tell significant elements of that time whether good or bad and their implications for their gender experience they can be abstract photos or of concrete elements what matters is that they refer to that time no need to hurry but i ask you not to take them all at once like in one afternoon for example think carefully after all the number is very restricted the deadline for returning the cameras was 1 week when the researcher contacted the participants and met them to pick the pictures up each photograph was printed twice so that one set would stay with the researcher and be used in the second interview and another set to be given back to the author in a second meeting this second meeting was scheduled one day after the cameras were handed over so that they could think about the shooting experience and the content the images referred to once again with their consent these meetings were recorded like the first time this meeting was conducted along the lines set by croghan et al for the photoelicitation interview the individual interviews lasted about 60 min and were structured informally faced with the printed photographs the participants were invited to talk about each of them in the order that was convenient for them and with little interference from the researcher the initial statements described the images so that the interviewees would then address more emotionally complex topics such as family and selfimage as foreseen in the method in their article the authors describe the method for conducting an interview that uses photographs taken by the subject as triggering elements of speech data analysis the data analysis sought to explore the meanings that each one laid down for their childhood memories and for that we based our studies on the formulations of spink and medrado on meaning production the relationships between memories and the present the contradictions formulations of gender and how all these issues resulted in a sense produced for their own stories were analyzed results and discussion for the three participants the return to childhood revealed times when certain behaviors were interpreted as displacements of the gender assigned at birth as part of the process of making sense of their stories it was necessary for them to build a notion of gender and its relationship with their experience the memories of childhood relate to the experience of dissident gender in youth through the uninterrupted process of building the social identity of participants recalling the preference of toys clothes the way they saw their bodies as well as the way reference people returned these childrens looks all were important elements in this process and were symbolized in the photographs the memories of these childhoods did not return as a painful ghost but as clues to a potent life despite the faults the forgetfulness the comments and the repressions childhood was remembered as a fertile ground for the search for oneself and for the construction of a life story because i have my humanity denied i my humanity was denied but i also dont want that to limit my life i do not mean that my experiences my life my childhood were just pain and suffering so much so that the memories i had the memories i had none actually saddened me it wasnt something that hurt me it wasnt something that pained me i think there were strong things difficult things that i had to go through but that didnt make me sad i think im happy to have lived that and become who i am today because they have accepted their trans social identity for longer than kk is and bp are used to questions such as who are you when did you recognize yourself as trans what does it mean for you to be a womanman whether it is for sharing loci of militancy and potential visibility with the trans cause or asking the questions people have asked them every day since transitioning is comments that society has forced her to think about gender so that people especially her father would understand that today she recognizes herself as a woman it was a process where he really needed to see that was really me that i was sure of that in this speech from is there are highlights to discuss the relationship established between childhood memory and gender experience in youth first on reflecting about gender and its subsequent issues all the time is seeks to denaturalize gender understanding it as a social construction over time and we have come to understand who we are but not that we are like this because we were born this way we are like this because we built ourselves in this way over time the denaturalization of gender referred to by is is the refusal to reduce gender to biological bases ie gender identity would not be a consequence of the genitalia with which the person is born there is an effort in her speech to understand it from its relational and political character as a reading of the differences imposed on women and men from their social construction including questioning the natural kind of the binary paradigm from this perspective the naturalness of gender roles is called into question men do not cry they must be strong and providers for the home while women are sensitive fragile and devoted to their children according to lanz people suffer from being tied up to these normative ideals for is there are models of men and women in society and people by affinity recognizes themselves in one of these models or creates their own model bp has an idea of gender more restricted to binaryism although maintaining a strong criticism of gender stereotypes these reflections meet the procedural and relational character of social identity where the process of constitution takes time and occurs uninterruptedly tajfel states that belonging to one group is established through a relationship with the other it is by comparison with the other that the subject perceives himself as belonging to a particular group to identify oneself as belonging to the trans world is to be exposed to regulatory views that reduce dissident experiences to nosological categories because of these preconceptions situations of violence against this population occur on a daily basis so as is said accepting oneself a transvestite or trans is a political act silva and cerqueirasantos argue that a sense of belonging to group in favor of cooperation among members can result in a source of social support in the first interview bp talks about this process there is no when you acknowledged yourself there is when you when population society finds out who you are see you stay there you live all that in your childhood you will only put the puzzle together later cisnormativity imposes models for men and women and it is based on them that gender roles expected from a child are assigned it is in the period of childhood that performative utterances are internalized and when stylization of genres takes place the three interviewees recalled moments through the photographs when they were scolded for behaviors that pointed out to a displacement is recalled how her father regulated the way he walked or the way he supported his hand while kk and bp were chided attention by the way they sat these are experiences shared by most children but which gain particular meaning for those who experience a dissident gender experience as discussed earlier the question of this other who questions them who reallocates the subject in this place of difference exposes the relational character of both social identity and gender is recalled that people kept pointing at me but i had no idea what it was about even though people kept saying ah youre feminine youre a faggot but i didnt even know what it was to be a fag the late notion of the social meaning of certain childhood behaviors was shared by the three participants like a picture you take and only develop years later during puberty there is a tension between what is expectedassigned and the behavior of the child and later the adolescent who understands what it means to be called fag by their peers regarding support networks for trans social identity silva and cerqueirasantos state that selfawareness and about belonging groups has a close connection with the way the family peers and spousesboyfriends view these other ways of feeling oneself as a womanman and the gender identity of the subjects in question since one is not born a subject but rather becomes a subject from the moment it is possible to perceive oneself as belonging to a certain social and societal reality in iss narrative one can notice the fundamental role that the support network supported mainly by cis and trans women played in her trajectory kk also acknowledges his mothers support as a child just as he talked about his acknowledgment process a few weeks before the first interview bp also finds support in his peers in his husband and in his family although inside his mothers house they do not call him by his name a fact that justifies the difference due to his parents generation regarding selfawareness which includes aspects of body and sexual awareness we can highlight the relationship of the external look in the trajectory of the three participants in iss childhood people generally interpreted her games her way of walking her desire to have long hair as signs of a latent femininity they warned her mother called her a fagot at school cut her off from relationships with other children according to her when she was thirteen puberty comes and with it masturbation thats when she understood why they called her a little woman and what that meant she began to think i think im gay even in her early teens her first boyfriend says he didnt understand why he felt attracted to her as he didnt identify himself as gay the same goes for the lesbian girls she approached even if at that point she had not had relations with any man did not acknowledge herself as a gay teenager that is how others see her when you start taking hormone and wearing goth makeup people start to ask who are you noteworthy are the episodes where she was questioned by her peers in the candomblé worship place where she claimed to be androgynous and that is why the men who related to her were heterosexual your acknowledgment process is mediated through and by your body as well as by this outside look as these are the elements that underlie your understanding of gender and help you build your story and then i got to meet gay men and i didnt identify myself with them i have started notice oh im not like that i think differently i dont know im not like that and i identified more with girls i got closer to girls and i felt that the girls didnt see that in me either that matter i talked about last week i think this gender issue i avoid this cliché of saying oh my soul is like that or i was born that way i dont think so i think we build it all but i think that for sure the physical part has nothing to do with it because in several periods of my life i noticed that people saw me as a woman even without my looking as one looks were irrelevant see people felt it i showed it even without having to show it by means of my body appearance physique clothing or anything else it is also possible to highlight the role of the external look in bps trajectory during his childhood despite constantly playing with his nephew wearing mens clothing and preferring elements interpreted as from that world he did not report direct challenges as in the case of is this is supposed to be because a boy playing with elements of the female world is interpreted as a more serious displacement than a girl playing with elements of the male world machismo is implicit in this relationship as bp interprets the fact that his mother allowed him to play with his nephew at home as being more acceptable for him to play with bp who already acted kind of masculine than to let him play with a girl or the street boys who disapproved of the behavior during his teens the relationship between his body the outside look and gender issues intensified for bp especially after he started judo training this is a time that is remembered with joy and as fundamental in his process of acknowledging his gender identity as a trans man because he was heavy there were no girls to fight with or train at school and that is why his boxing coach placed him with the boys group this recognition of the other differs from the case of is which took place rather in relation to her behavior while in bps case it was his body that set him apart this was also present in the photographs presented by him at school i always trained running with men and then my master always said that i had to have a mans resistance so i thought that im really on the right track i just kept looking for the feminine in me and so on the one hand i just saw my name in the name and genitalia only because as for the rest i already recognized myself as a boy so judo judo was the mark of everything to have a mans resistance means to have something of the male or figuratively to have the strength the virility of that body thus it was a body that did not correspond to the female stereotype of a delicate and fragile body and if it was not female it was its male opposite by this time bp was already wearing other malerelated cultural signs such as short hair and short nails just like the mens pants her mother gave her because the others got too frayed yes but as a result it helps you to identify yourself its the same today i am a man and i have breasts it makes me no less a man but without my breasts ill feel like the man its as if i was born in the shape i wanted again a contradiction shows up in bps speech where it makes me no less a man does not seem to relate to ill feel like the man especially by using the portuguese male definite article o oliveira points out that among the trans men she researched there was a type of hierarchy in relation to being more trans based on a comparison of bodies the more muscle the more body hair the better your position relative to other trans men although bp does not stress this desire to have a body matching the normative standard it is interesting to note in his speech the power of expressions referring to the male world also according to oliveira the only body part visible even with clothes that can denounce men are the breasts therefore they are considered as invaders undesirable and need to be extirpated kk recalls when he stopped running in his underwear in the street commenting on the amazement and at the same time fascination with the idea that his breasts were growing in much of the interview there was an expression of this feeling of duality about his body as if kk wanted to experience it beyond the norms laid down for the genders however when his girlfriend cheated on him with another man in his teens the issue of genitals comes up markedly for him why am i not a guy i dont know why dont i have a dick because i was not so relaxed at the time for me men had to have dicks in his speech there is not yet a proper established meaning for these reflections but there is an attempt to detach himself from the biologizing notion of gender similar to the efforts of is and bp furthermore for kk the discovery of his body through sexual abuse suffered even as a child further complicates his process of understanding his gender identity as well as understanding how this process of gender identity recognition fits into the discovery of your still very young body through someone who has abused you more than once the body issue is complex and is something that needs to be stressed in the three participants at the time of the interview kk was experiencing his body from the beginning of hormone therapy enjoying the first mustache strands that sprouted on his face is did not take hormones and at no time reported having issues with her body she even used feminist arguments to build her sense of her body beyond normative standards bp took hormones and yearned for mastectomy surgery even though his speech showed contradictions in general researches report a question of inadequacy with the body in the speech of people who identify as genderdissidents they say things like i was born in the wrong body or i hate my body in this research there were reports of body inscriptions of cultural signs of the genre where one recognizes oneself whether absencepresence of hair hair length clothes or even medical or surgical interventions still it was not possible to identify the alleged disgust with the body or genitals in particular beyond bps comment the theme or the characteristics of the sample such as its size or the age of the participants may be the variables responsible for the matching answers however it is still worth stressing those narratives which establish tension in discourses about the true trans experience as stated by bento the narratives point to the diversity of relations with the body and challenge attempts to erase them and inscribe them into categories that homogenize them comparing these narratives with those found by caravacamorera and padilha the relationship with the bodies of the participants of this research is close to the talk about the malleability of the bodies this is related to the possibilities of body transformations as it they were a blank canvas where you can paint a multitude of watercolors the gimmicks may not be medications but there is a construction of this body to meet an expectation of both internal and external gender thus certain reverberations found here also fit the second matrix of the analysis of caravacamorera and padilha where the body is understood as its own institution but regulated and controlled by others on this point rodovalho says that in most social interactions there will be no time for you to say what you are your body having to be able to convey the message as unambiguously as possible in the three stories they recalled moments through the photographs when during childhood the body was an instrument of experimentation like the hair is wanted to grow long or in bps case the hair that wouldnt grow long for kk there was sensory experimentation which he felt when he wore only underwear or when he tied the towel differently on his body interestingly bp and kk began wearing wider masculine clothing prior to their identification as trans men they both referred to a growing sense of being comfortable with those clothes just like is who in her teens used hormones before selfidentification this was especially true of bp who started wearing two blouses and a coat as soon as her breasts began to grow for rodovalho selfidentification alone is not enough to understand the experience of the trans body for her there is always a tense negotiation of meanings between what it means to be and what it means to seem in general the three participants talk a little about this issue as bp said we talk a lot that even though i am a trans man i can reach the end of my life having everything that a man can get to the point of saying is that really it is something still missing from me huh because sometimes we seek so much it may be that i realize myself in every way as a man i wish i was born a man and yet i still lack something same thing as a child i could have had it all and say i was born a boy and still think that something was missing think i wish lets say even though i had a ball a cart played games clothes but i still had to feel that i was missing sneakers im not complete yet i still have to have male sneakers then thats it i think we need characteristics objects to strengthen us with trans men so im a trans man okay if i dont dress like a man how will people respect me know im a man because we have to see it despite what we want we still have a society to face this is my point of view i really really wanted to so badly i wish i didnt need so many masculine characteristics to fit into what a boy is what a man is but unfortunately i live in a society that needs it even cisgender men need it they need to wear a beard they need to wear a mens outfit they need to enjoy playing football and fly kites so if they need that why dont i need that to recognize myself but i need an object of course i need it get it the complexity of this relationship with the body and the way it affects the construction of their own story becomes evident in these narratives the three participants restate the demands society imposes on them to make sure of their gender identity and that this selfidentification must be consistent with the signs that their bodies carry and express however even if such body inscriptions do occur these people are daily exposed to violent reactions from others that will point to something in their bodies or behaviors transgender people are denied human dignity while suffering from the regulation of discourses and incorporating normative cultural signs the trans body is also a place of resistance production because people dont understand that its not that i have to boost the female stereotype but thats the only thing i find trans these stereotypes are what i can hold on to in order to show people that im female i dont need to be a perfect housewife at home but i cant get there like this today i can because the movement is evolving but its not easy yet i get here with a beard on my face and unshaved legs like feminists claim they can do that because they are already at another level of debate were still crawling behind i always said and i will keep saying it my fight as a transvestite is not to be recognized as a woman because i think thats silly when compared to the fight that i have to move forward which is to be recognized as a human being researching the relationship between language and body in the discourses of transgender people cassana demonstrated that despite the sedimentation of senses language is what also enables the formation of another social body legitimized by the discourse of the transsexual subject so let the body be a celebration party of the impossible final considerations the more classical theories of psychology have for decades maintained that the way young people signify childhood has repercussions on their experiences and experiences in youth and adulthood developmental psychology has historically contributed to this discussion by seeing unity in the developmental process from childhood to old age the chain of experiences contributes to the personality the formulations about oneself and the historical integrity of the subjects there is a rupture in common sense between the passage from childhood to adolescence or during the process of transsexualization they are redefined under this rationale adopting a view that aims at seeing the subject as historical and their development as continuous the changes these young people experienced during childhood and youth are part of their socialization process in our sample gender socialization and sexual orientation were reported as procedural and historicist events and experiences seem to be quite integrated into the construction of even the most traumatic identities this reinforces the view of the comprehensiveness of these subjects the view of transsexuality signification as a historical breach did not seem evident in this sample in contrast trans experiences were linked to the significance of childhood adolescence and the milestones in the developmental process even in the efforts and contradictions to give meaning and connectivity to events the specificities of socialization of noncisgender individuals need to be further investigated the photography method applied in this study was important in eliciting in these young people a timeline of life history the results demonstrated that this technique is effective for investigating historical events with meaningful integrity in any case this technique allows the past to make sense in the present what was investigated here therefore was how noncisgender young people build and understand their developmental process and this does not focus on the accuracy of the facts but on the individualization of these subjects transsexuality appeared as an important influential variable in socialization and consequently in individuation by highlighting the elements that were present in the production of meaning in their stories the participants consequently clarified the process of building their trans social identity reflections about gender and their role in understanding their trajectories stand out in general the cisheteronormative patterns for the experiments were questioned resulting in an understanding of the idea of gender identity as a process something continuous and uninterrupted this study and was responsible for data gathering and analysis and writing part of the manuscript mm was responsible for bibliography updating and writing and final proofing of the text data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation to any qualified researcher ethics statement the studies involving human participants were reviewed and approved by the federal university of sergipe brazil the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest copyright © 2020 cerqueirasantos de santana and de miranda ramos this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

the aim of this research was to explore the meanings of childhood memory established by young people who identify themselves as trans in a chauvinistic country such as brazil sexual socialization of noncisgender youth is beset by unique challenges such as discrimination and violence this study was based on the proposal of a selfportrait method as a content trigger in interviews with three trans young women who reported their life stories we analyzed data using the oral story technique through which the described themes came up the results presented developmental narratives related to gender issue from childhood which reflected on the experience on youth reports of discrimination based on the image of others family school and community about the gender development of the participants and their relationship with their bodies stand out we see the importance of reflecting on life history memories in trans identity in order to give meaning to this experience the influence of heteronormative and sexist brazilian culture is noticed in the participants reports

Introduction Social network plays an important role in college students' life. It has become a part of college students' life, and has an incalculable influence on college students' information acquisition, thinking, learning and life [1][2][3][4][5]. Social network serves a window for college students to obtain information, show themselves and improve themselves [6][7][8][9]. College students are eager to succeed in their studies and life, but there are many complicated factors that affect their success, especially the social network support they have [10][11][12][13]. The greater the social network support they have, the more adequate social network resources they get, and the stronger their ability to cope with the challenges of study and life is. Existing studies have discussed how to provide necessary help to college students with insufficient social network resources, ignoring the influence of social network support on their academic success [14][15][16][17][18][19][20]. Learning autonomy represents the degree to which students actively adjust their learning strategies and efforts based on existing support conditions. It is necessary to study the evaluation method of college students' learning autonomy based on social network support. Fernández-Vera et al. [21] puts forward two studies, focusing on two research questions: How do college students in southern Chile communicate? Can mobile apps persuade college students to increase their communication patterns? To answer these questions, the document conducts a survey of 90 students in southern Chile, and then develops a persuasive app called Social + Me, designed to monitor communication with student support networks and persuade them to stay in touch. Previous studies have shown that learners' autonomy depends on the role of teachers. Huang [22] aims to explore the ideal and reality of college English teachers' promotion of learners' autonomy in blended learning classrooms. Quantitative research method is adopted. Two Likert questionnaires are conducted among 100 undergraduates. The collected data is processed in SPSS 25.0. The results show that teachers' practices are mostly inconsistent with students' expectations, which shows that teachers fail to meet students' needs. It is suggested to cultivate students' autonomy in blended learning environment. The purpose of Aziz et al. [23] is to emphasize the use of technology to improve learning autonomy in EL classrooms. At the same time, it enables learners to fully control their own learning process, so as to better understand the materials they have learned and learn EL. This article will study the use of technology to promote learners' autonomy in EL classroom, drawing on the new technology practice in educational research and teaching process. Student-centered learning requires students to be responsible for their own learning and become autonomous learners. Duarte [24] reports some research results of Portuguese mechanical engineering students' learning autonomy using hybrid method and sequential interpretation design. In this article, the focus is on the relationship between learners' autonomy and academic achievement, and how it translates into students' views on learning autonomy, its features and importance, and the ways of learners' autonomy improving their learning and build a bridge between research and practice in engineering education. The results show that students have positive views on their learning autonomy and its importance. Existing studies overemphasize the influence of social environment on college students' academic success, and do not pay special attention to the influence of the outside world on the change of college students' learning attitude. At the same time, the role of college students in social network is simply defined as negative and passive, ignoring the influence of college students' personal initiative behavior on themselves and social network. Therefore, it is necessary to adopt subjective, objective, qualitative and quantitative methods to evaluate college students' learning autonomy based on social network support, which can ensure the accuracy and rationality of the research results. Therefore, this article studies the evaluation method of college students' learning autonomy based on social network support. Firstly, in the second chapter 2, the local and global features of network nodes are extracted, and the social network roles of college students are divided. The third chapter constructs a new logical structure network based on the vector representation of each node, which maximizes the influence of relevant nodes on college students' social network support. The fourth chapter introduces meta-path walking algorithm on the basis of the new network structure, and evaluates college students' learning autonomy by obtaining the attribute features supported by social networks through network nodes. Experimental results verify the effectiveness of the proposed method. --- Division of college students' social network roles According to the role features of network nodes in college students' social support network, they can be divided into three categories: direct support nodes, indirect support nodes and ordinary nodes. The goal of this article is to design a feasible solution to classify and define the roles of social support network nodes for college students through the feature attributes of network nodes. In order to identify the direct support node s in the network, this article analyzes the influence of each node based on the extraction of local and global features of the network nodes. The local influence of Node i on Node j is influenced by Node i itself and the number of common friends of Nodes i and j. These two influences are usually determined by the degree of nodes and the number of common friends in social networks. Assuming that the local influence of Node i on Node j is represented by LI, the probability of information propagating from Node i to its one-hop neighbor node is represented by C, and the direct neighbor node of Node i is represented by Q, this article introduces equilibrium parameters β 1 and β 2 to quantify the local influence of network nodes of college students' social support network: LI C i Q i Q j Q i Q j ij = + β β 1 2 I U In the above formula, β 1 and β 2 satisfy β 1 + β 2 = 1. The local influence value of Node i is the average of the local influence of i on all its neighbors. Assuming that the neighborhood node set of Node i is represented by M, then: LI M i LI i i j j M i = ∈ ∑ 1 Assuming that the shortest number of paths between two Nodes j and l is represented by T jl , and the shortest number of paths with l through Node i is represented by T ijl , the mediation centrality index value can be calculated based on the local influence of i: Y i T T jil jl i l j U i j l , , , = ∈ ≠ ≠ ∑ The final influence of Node i, that's, the social network support provided to college students, can be the sum of the global and local structural information of Node i. The final influence of Node i represents the possibility and key of becoming the direct support node of college students' social network. Assuming that the direct support influence score of Node i is represented by W. The equilibrium parameters for adjusting the global and local influence ratio of nodes are expressed by γ 1 and γ 2 , then: W i LI Y i i = + γ γ 1 2 In the above formula, γ 1 and γ 2 satisfy γ 1 + γ 2 = 1. There are nodes spanning multiple social support sub-networks in college students' social support network, which promote the information exchange among social support sub-networks and can be regarded as structural hole nodes of the network. According to the complex network theory, the smaller the network constraint coefficient of college students' social support network is, the more structural hole nodes may be, and the greater the possibility of network structure hole is. Assuming that the network constraint coefficient value of Node i is represented by MD, and the proportion of the input of Node i to maintain the relationship with j to the total input is represented by η ij , then: MD i i j l U l i j ij il lj l Nei i j Nei i , = +       ∈ ≠ ∈ ∈ ∑ ∑ η ηη 2 The first k smaller nodes in the calculation results of the network constraint coefficient MD are selected and determined as indirect support nodes of the social support network for college students. The selection threshold of direct support and indirect support nodes in college students' social support network is used to adjust the proportion of the two types of nodes, which are represented by α 1 and α 2 . Assuming that the set of ordinary nodes is represented by E s , the set of direct support nodes is represented by E t , the set of indirect support nodes is represented by R p , and all node sets of social support network are represented by U, the following formula can give the expression of node set of ordinary network nodes in the network: Es U Et Rp Et U Rp U = -- = = , α α 1 2 3 --- Maximizing the influence of college students' social network support Based on the second chapter, it's possible to get the representation of all nodes in the social support network of college students: Ω ∈ S |U|×c . Because the larger the cosine similarity value of the vector represented by two nodes is, the greater the probability of mutual influence between the two nodes is. In order to make college students get the most social network support, this article constructs a new logical structure network based on the vector representation of each node. The schematic diagram of the realization process of maximizing the influence of social network support for college students is given in Figure 1. The new network constructed represents the influence probability relationship among network nodes, which can be defined as propagation probability network. In order to construct a new network structure, this article sets a similarity threshold ω to judge whether logical connection edges are added to the new network structure, which satisfies ω ∈. The following formula gives the calculation formula of connection edge strength between any two nodes in the new network structure: t UH i j if U i j otherwise i j ,, , = ≥    H ω 0 Assuming that the hyperparameter is represented by ω and satisfies ω ∈. The information propagation probability from Node i to Node j in the network can be characterized by the above formulas t i, j . By default, the influence probabilities between network nodes are independent of each other. Based on the propagation probability of neighbor nodes of Node i, the probability that the node is activated by its neighbor node FA for social network support for college students can be calculated: Ts U i t i j j FA i , = - - ∈ ∏ 1 1 Similarly, for each node j∈U, under the influence of the node set R that has provided social support, the total activation probability of all nodes that have not provided social support can be calculated by the following formula: xTs U R U t U t i j j FA i i U i j j FA i , , ) ∏ ∑ ∈ i U In the task of maximizing the influence of social network support, the ultimate goal of the constructed model is to activate more nodes that do not provide social support under the influence of R, in other words, to make the expectation Ts larger. The following formula gives the model optimization goal expression at this time: arg max arg max arg min , , R R i j j FA i i U R i j j U t U t = - - = - ∈ ∈ ∏ ∑ 1 1 1 1 1 ∈ ∈ ∈ ∏ ∑ FA i i U Because the model objective shown in the above formula cannot be optimized directly, this article chooses heuristic algorithm to solve it, so as to realize the effective selection of node set R that has provided social support. --- Evaluation of learning autonomy based on meta-path walking In the previous chapter, it's possible to get a perfect new network structure by dividing the roles of network nodes, inferring the influence probability relationship and determining the maximum influence goal in the social support network for college students. According to the general process of network node attribute inference of social support network for college students, the embedding features of network nodes can be further obtained based on the embedding model, and the network node attribute inference based on the ensemble learning model can be realized at the same time. This article evaluates college students' learning autonomy by obtaining the attribute features of social network support from network nodes. However, the node feature vectors obtained by statistical analysis or embedding model are not enough to characterize the influence of network nodes on college students' learning autonomy. Therefore, on the basis of the new network structure, this article introduces meta-path walking algorithm, and characterizes the positive incentive influence of social network support on college students' academic success through the multi-dimensional walking features of network nodes, that's, the promotion of college students' learning autonomy. The meta-path in the new network structure is defined as the sequential relationship between two node role types. Assuming that the meta-path in the new network structure is represented by T, the meta-nodes are represented by u 1 , u 2 … u k+1 ⊆ US, and the influence probability meta-relationship is represented by O 1 , O 2 … O k ⊆ O, the following formula gives a meta-path expression with a length of 1 from node role type u 1 to node role type u k+1 : T u u u O O k k =  →   →  + 1 2 1 1  Specific to the new network structure of college students' learning autonomy inference in this article, meta-nodes and meta-relationship can be redefined. For meta-nodes, the nodes can be divided into direct support nodes and indirect support nodes with positive incentive and ordinary nodes without incentive according to the results of node role determination during the construction of the new network structure. It is difficult to judge the nature of the influence probability relationship because of the complex types of relationships between meta-nodes. In order to solve this problem, based on the link embedding features of the new network structure and Kmeans clustering algorithm, this article obtains the best classification of node relationship for the incentive influence of college students' learning success. The specific acquisition steps are described as follows: 1) Based on the new network structure embedding model, the embedding representation of the influence probability relationship of all nodes is calculated. 2) Set the threshold value P, adjust the number of clustering algorithms in the range of [1, P], and perform P-times clustering operation on the embedding representation of node influence probability relationship facing the influence of college students' learning success incentive. 3) The obtained P different clustering results are evaluated based on Calinski-Harabasz scores. Assuming that the number of training set samples is represented by a, the number of clustering clusters is represented by l, the covariance matrix between categories is represented by Y l , the covariance matrix of data within categories is represented by Q l , and the trace of the matrix is represented by tr, then: CH l tr Y tr Q a l l l l = - -1 When the calculation result of the above formula is the largest, the number of categories of the corresponding meta-relationship is the best. Based on the redefinition of meta-path, it's possible to design a meta-path for inferring college students' learning autonomy. Considering that the subject body of college students' learning autonomy evaluation task is college students, and the starting node and ending node of meta-path are both college students' nodes, the designed meta-path needs to meet the bounded length less than or equal to 3. It is assumed that l' new network structure meta-paths are obtained after the previous analysis. Next, this article takes these meta-paths as constraints to infer the influence tendency attributes of college students' learning autonomy in network nodes. The identification of the influence tendency of college students' learning autonomy in network nodes based on meta-path walking is mainly divided into two stages: meta-path feature extraction, and network node representation and inference. The specific contents of the two stages are introduced below. For convenience of expression, it is assumed that the left endpoint set of metarelationship O 1 is represented by XC, the left endpoint set of meta-path T is represented by XC, the right endpoint set of meta-relationship O 1 is represented by XZ, and the right endpoint set of meta-path T is represented by XZ. Assuming that there is a meta-path T=u 1 → O1 u 2 … → O2 u k+1 , then starting from the query node set u w ⊆ XC, according to the rules of meta-path T, the influence tendency attribute features of any node x in XZ on college students' learning autonomy can be expressed by f uw,T , which can be calculated by the following formula when the length of T is 0: f x u if x u others u T w w w , , , = ∈      1 0 When the length of T is greater than 0, XZ needs to be eliminated, and the metapath is T' = u 1 → O1 u 2 … → Ok-1 f uw,T . Assuming that the activation function is represented by HS, f uw,T can be calculated by the following formula: f x f x HS O x x O x u T u T k k x XZ T w w , , ' ' = ⋅ ∈ ∑ It can be seen from the above formula that ,x) is false. Through the above process, get the eigenvalues f uw,T of college students' learning autonomy influence tendency attribute from u w ⊆ XC to any node x in XZ with regular load element path T. HS) is 1 if O k is true; oth- erwise HS) is 0 if O k (xʹ From the above calculation results, it can be seen that in the process of solving f uw,T , firstly, the known direct support nodes and indirect support nodes with positive incentives for college students' learning autonomy will be selected from the network nodes of the new network structure as the query node set u w + ⊆ XC, and the ordinary nodes u w -⊆ XC without incentives will be eliminated. After solving the eigenvalue f uw, T of any node x in u w , taking the known u w + as the starting point, according to the order of meta-path T = college student node → supporting relationship/supported relationship support node → sending neighbor ordinary node → sent college student node, f uw+,T can be further solved based on Formula 14, that's, the eigenvalues of college students' learning autonomy influence tendency attribute under meta-path T from u w + for all network nodes. The detailed process is shown in Figure 2. Based on meta-path walking network node, college students' learning autonomy influence tendency identification algorithm flow will traverse all meta-paths. Firstly, for each meta-path T i , the f uw,T value of any node x in the non-starting node set is calculated until the college student node set of T i is calculated, and the feature matrix F j of the college student node set of T i can be obtained. Repeating the above calculation process on all meta-paths can obtain the feature matrix F of college students' node set on all meta-paths, and taking the transposed F T of F as the input of the evaluation model of college students' learning autonomy, the inference result vector of college students' learning autonomy influence tendency of all network nodes can be obtained. In this chapter, firstly, a comparative experiment on the influence scope of college students' social network support under different node sets R scale that have provided social support is carried out. Figure 3 shows the simulation results of node influence corresponding to six networks with different R-scale conditions. It can be seen from the figure that the influence range of all network nodes on college students' social network support increases with the increase of R scale. When the R scale is smaller, the influence range of six different R scale networks on college students' social network support is close. With the increase of R scale, the constructed network model can still better char-acterize the influence probability relationship between network nodes, which shows obvious advantages in realizing the task of maximizing the influence of social network support for college students, and lays a foundation for further evaluation of students' learning autonomy. It is worth noting that due to the different scales of the node set R scale that have provided social support, the scale of the query node set for identifying the influence tendency of college students' learning autonomy in the experiment is also different. For example, in Network 1 with a query node set size of 40, a set of nodes having provided social support of up to 20 nodes is constructed. In Network 2 with a query node set size of 450, a set of nodes having provided social support of up to 200 nodes is constructed. In order to evaluate the efficiency of the proposed method in maximizing the influence of social network support for college students, Table 1 summarizes the average simulation results of six different networks under different balance parameter selection. This table gives the average of the influence range of network nodes on college students' social network support based on 18 experiments with different balance parameters. It can be seen from the table that the proposed method can obtain the best experimental results when the balance parameter is 0.4, especially for network 4 and network 6. Formula 7 introduces the similarity threshold ω, which is used to judge whether to add logical connection edges to the new network structure, to construct a new network which represents the influence probability relationship between network nodes. The value of this parameter will directly affect the accuracy of simulation results, so this article analyzes the value of this parameter. Similarly, considering the size of the node set R that has provided social support, this article sets different step sizes. Figure 4 shows the comparison of simulation results with different similarity thresholds ω. It can be seen from the figure that the similarity threshold ω has certain influence on the experimental results under the same R scale, but the influence degree of ω on the experimental results is different under different R scales. Because this article takes into account the influence of R scale nodes on the scope of social network support for college students, so this article further counts the different ω settings for different network sample sets and set the optimal ω value of different network sample sets. After the construction of the new network structure, in order to verify the effectiveness of the proposed evaluation method of college students' learning autonomy based on meta-path walking, this article explores the influence weights of all meta-path nodes involved in the new network structure in the inference of college students' learning autonomy influence tendency, and the results are shown in Figure 5. It can be seen from the figure that the influence weights of nodes involved in the same meta-path are different when the positive incentive node set is used as the query node set and the non-incentive node set is used as the query node set, which shows that these nodes provide different social support to college students. This phenomenon also shows that there are some differences in the meta-path construction models between the node sets with positive incentives and the node sets without incentives for college students' learning autonomy. Next, this article further explores the influence of meta-path walking feature integration on the evaluation performance of college students' learning autonomy. This experiment is a comparative experiment of four groups of feature integration methods. In the first group, it is designed to splice and integrate the walking features of u w + and u w -departure calculation; in the second group, it is designed to splice and integrate the walking features of u w + departure calculation and the embedding features of the influence probability relationship of all nodes; in the third group, it is designed to splice and integrate the walking features and embedding features of u w -departure calculation; in the fourth group, it is designed to splice and integrate the walking features and embedding features calculated by u w + and u w -. The experimental results are shown in Figure 6. It can be seen from the figure that after the completion of feature integration, compared with the two feature integration, the three feature integration can obtain more ideal evaluation accuracy and F1 value in the evaluation task of college students' learning autonomy, which proves that feature integration has a positive effect on the evaluation performance of college students' learning autonomy. At the same time, it's also possible to find that the walking feature of u w + departure calculation has a more significant dominant position. Moreover, the integration of the embedding features of the influence probability relationship of all nodes will obtain better performance evaluation results, which verifies that the embedding features representing the global information of the network complement the information not contained in the meta-path walking features representing the detailed features of the network. Therefore, the integration of the two will achieve better results in the evaluation of college students' learning autonomy. --- Conclusion This article studies the evaluation method of college students' learning autonomy based on social network support. Firstly, the local and global features of network nodes are extracted, and the social network roles of college students are divided. Then, a new logical structure network is constructed based on the vector representation of each node, which maximizes the influence of relevant nodes on college students' social network support. Finally, based on the new network structure, the meta-path walking algorithm is introduced to evaluate college students' learning autonomy by obtaining the attribute features supported by social networks through network nodes. Combined with experiments, the influence simulation results of nodes corresponding to six different R scale networks are given, and verify that the constructed network model can better characterize the influence probability relationship among network nodes. The experimental results of different balance parameters and similarity threshold ω on six different networks are compared, and an ideal new network structure is constructed. The influence weights of nodes in the evaluation of college students' learning autonomy are given, and the influence of feature integration on the evaluation performance of college students' learning autonomy is discussed to verify the effectiveness of the proposed evaluation method of college students' learning autonomy based on meta-path walking.

Social network plays an important role in college students' life. The greater the social network support they have, the more adequate social network resources they get, and the stronger their ability to cope with the challenges of study and life is. Existing studies have overemphasized the influence of social environment on college students' academic success, and have not paid special attention to the influence of the outside world on the change of college students' learning attitude. Therefore, this article studies the evaluation method of college students' learning autonomy based on social network support. Firstly, the local and global features of network nodes are extracted, and the social network roles of college students are divided. Then, a new logical structure network is constructed based on the vector representation of each node, which maximizes the influence of relevant nodes on college students' social network support. Finally, based on the new network structure, the meta-path walking algorithm is introduced to evaluate college students' learning autonomy by obtaining the attribute features supported by social networks through network nodes. Experimental results verify the effectiveness of the proposed method.

introduction social network plays an important role in college students life it has become a part of college students life and has an incalculable influence on college students information acquisition thinking learning and life 1 2 3 4 5 social network serves a window for college students to obtain information show themselves and improve themselves 6 7 8 9 college students are eager to succeed in their studies and life but there are many complicated factors that affect their success especially the social network support they have 10 11 12 13 the greater the social network support they have the more adequate social network resources they get and the stronger their ability to cope with the challenges of study and life is existing studies have discussed how to provide necessary help to college students with insufficient social network resources ignoring the influence of social network support on their academic success 14 15 16 17 18 19 20 learning autonomy represents the degree to which students actively adjust their learning strategies and efforts based on existing support conditions it is necessary to study the evaluation method of college students learning autonomy based on social network support fernándezvera et al 21 puts forward two studies focusing on two research questions how do college students in southern chile communicate can mobile apps persuade college students to increase their communication patterns to answer these questions the document conducts a survey of 90 students in southern chile and then develops a persuasive app called social me designed to monitor communication with student support networks and persuade them to stay in touch previous studies have shown that learners autonomy depends on the role of teachers huang 22 aims to explore the ideal and reality of college english teachers promotion of learners autonomy in blended learning classrooms quantitative research method is adopted two likert questionnaires are conducted among 100 undergraduates the collected data is processed in spss 250 the results show that teachers practices are mostly inconsistent with students expectations which shows that teachers fail to meet students needs it is suggested to cultivate students autonomy in blended learning environment the purpose of aziz et al 23 is to emphasize the use of technology to improve learning autonomy in el classrooms at the same time it enables learners to fully control their own learning process so as to better understand the materials they have learned and learn el this article will study the use of technology to promote learners autonomy in el classroom drawing on the new technology practice in educational research and teaching process studentcentered learning requires students to be responsible for their own learning and become autonomous learners duarte 24 reports some research results of portuguese mechanical engineering students learning autonomy using hybrid method and sequential interpretation design in this article the focus is on the relationship between learners autonomy and academic achievement and how it translates into students views on learning autonomy its features and importance and the ways of learners autonomy improving their learning and build a bridge between research and practice in engineering education the results show that students have positive views on their learning autonomy and its importance existing studies overemphasize the influence of social environment on college students academic success and do not pay special attention to the influence of the outside world on the change of college students learning attitude at the same time the role of college students in social network is simply defined as negative and passive ignoring the influence of college students personal initiative behavior on themselves and social network therefore it is necessary to adopt subjective objective qualitative and quantitative methods to evaluate college students learning autonomy based on social network support which can ensure the accuracy and rationality of the research results therefore this article studies the evaluation method of college students learning autonomy based on social network support firstly in the second chapter 2 the local and global features of network nodes are extracted and the social network roles of college students are divided the third chapter constructs a new logical structure network based on the vector representation of each node which maximizes the influence of relevant nodes on college students social network support the fourth chapter introduces metapath walking algorithm on the basis of the new network structure and evaluates college students learning autonomy by obtaining the attribute features supported by social networks through network nodes experimental results verify the effectiveness of the proposed method division of college students social network roles according to the role features of network nodes in college students social support network they can be divided into three categories direct support nodes indirect support nodes and ordinary nodes the goal of this article is to design a feasible solution to classify and define the roles of social support network nodes for college students through the feature attributes of network nodes in order to identify the direct support node s in the network this article analyzes the influence of each node based on the extraction of local and global features of the network nodes the local influence of node i on node j is influenced by node i itself and the number of common friends of nodes i and j these two influences are usually determined by the degree of nodes and the number of common friends in social networks assuming that the local influence of node i on node j is represented by li the probability of information propagating from node i to its onehop neighbor node is represented by c and the direct neighbor node of node i is represented by q this article introduces equilibrium parameters β 1 and β 2 to quantify the local influence of network nodes of college students social support network li c i q i q j q i q j ij β β 1 2 i u in the above formula β 1 and β 2 satisfy β 1 β 2 1 the local influence value of node i is the average of the local influence of i on all its neighbors assuming that the neighborhood node set of node i is represented by m then li m i li i i j j m i ∈ ∑ 1 assuming that the shortest number of paths between two nodes j and l is represented by t jl and the shortest number of paths with l through node i is represented by t ijl the mediation centrality index value can be calculated based on the local influence of i y i t t jil jl i l j u i j l ∈ ≠ ≠ ∑ the final influence of node i thats the social network support provided to college students can be the sum of the global and local structural information of node i the final influence of node i represents the possibility and key of becoming the direct support node of college students social network assuming that the direct support influence score of node i is represented by w the equilibrium parameters for adjusting the global and local influence ratio of nodes are expressed by γ 1 and γ 2 then w i li y i i γ γ 1 2 in the above formula γ 1 and γ 2 satisfy γ 1 γ 2 1 there are nodes spanning multiple social support subnetworks in college students social support network which promote the information exchange among social support subnetworks and can be regarded as structural hole nodes of the network according to the complex network theory the smaller the network constraint coefficient of college students social support network is the more structural hole nodes may be and the greater the possibility of network structure hole is assuming that the network constraint coefficient value of node i is represented by md and the proportion of the input of node i to maintain the relationship with j to the total input is represented by η ij then md i i j l u l i j ij il lj l nei i j nei i       ∈ ≠ ∈ ∈ ∑ ∑ η ηη 2 the first k smaller nodes in the calculation results of the network constraint coefficient md are selected and determined as indirect support nodes of the social support network for college students the selection threshold of direct support and indirect support nodes in college students social support network is used to adjust the proportion of the two types of nodes which are represented by α 1 and α 2 assuming that the set of ordinary nodes is represented by e s the set of direct support nodes is represented by e t the set of indirect support nodes is represented by r p and all node sets of social support network are represented by u the following formula can give the expression of node set of ordinary network nodes in the network es u et rp et u rp u α α 1 2 3 maximizing the influence of college students social network support based on the second chapter its possible to get the representation of all nodes in the social support network of college students ω ∈ s u×c because the larger the cosine similarity value of the vector represented by two nodes is the greater the probability of mutual influence between the two nodes is in order to make college students get the most social network support this article constructs a new logical structure network based on the vector representation of each node the schematic diagram of the realization process of maximizing the influence of social network support for college students is given in figure 1 the new network constructed represents the influence probability relationship among network nodes which can be defined as propagation probability network in order to construct a new network structure this article sets a similarity threshold ω to judge whether logical connection edges are added to the new network structure which satisfies ω ∈ the following formula gives the calculation formula of connection edge strength between any two nodes in the new network structure t uh i j if u i j otherwise i j ≥    h ω 0 assuming that the hyperparameter is represented by ω and satisfies ω ∈ the information propagation probability from node i to node j in the network can be characterized by the above formulas t i j by default the influence probabilities between network nodes are independent of each other based on the propagation probability of neighbor nodes of node i the probability that the node is activated by its neighbor node fa for social network support for college students can be calculated ts u i t i j j fa i ∈ ∏ 1 1 similarly for each node j∈u under the influence of the node set r that has provided social support the total activation probability of all nodes that have not provided social support can be calculated by the following formula xts u r u t u t i j j fa i i u i j j fa i ∏ ∑ ∈ i u in the task of maximizing the influence of social network support the ultimate goal of the constructed model is to activate more nodes that do not provide social support under the influence of r in other words to make the expectation ts larger the following formula gives the model optimization goal expression at this time arg max arg max arg min r r i j j fa i i u r i j j u t u t ∈ ∈ ∏ ∑ 1 1 1 1 1 ∈ ∈ ∈ ∏ ∑ fa i i u because the model objective shown in the above formula cannot be optimized directly this article chooses heuristic algorithm to solve it so as to realize the effective selection of node set r that has provided social support evaluation of learning autonomy based on metapath walking in the previous chapter its possible to get a perfect new network structure by dividing the roles of network nodes inferring the influence probability relationship and determining the maximum influence goal in the social support network for college students according to the general process of network node attribute inference of social support network for college students the embedding features of network nodes can be further obtained based on the embedding model and the network node attribute inference based on the ensemble learning model can be realized at the same time this article evaluates college students learning autonomy by obtaining the attribute features of social network support from network nodes however the node feature vectors obtained by statistical analysis or embedding model are not enough to characterize the influence of network nodes on college students learning autonomy therefore on the basis of the new network structure this article introduces metapath walking algorithm and characterizes the positive incentive influence of social network support on college students academic success through the multidimensional walking features of network nodes thats the promotion of college students learning autonomy the metapath in the new network structure is defined as the sequential relationship between two node role types assuming that the metapath in the new network structure is represented by t the metanodes are represented by u 1 u 2 … u k1 ⊆ us and the influence probability metarelationship is represented by o 1 o 2 … o k ⊆ o the following formula gives a metapath expression with a length of 1 from node role type u 1 to node role type u k1 t u u u o o k k  →   →  1 2 1 1  specific to the new network structure of college students learning autonomy inference in this article metanodes and metarelationship can be redefined for metanodes the nodes can be divided into direct support nodes and indirect support nodes with positive incentive and ordinary nodes without incentive according to the results of node role determination during the construction of the new network structure it is difficult to judge the nature of the influence probability relationship because of the complex types of relationships between metanodes in order to solve this problem based on the link embedding features of the new network structure and kmeans clustering algorithm this article obtains the best classification of node relationship for the incentive influence of college students learning success the specific acquisition steps are described as follows 1 based on the new network structure embedding model the embedding representation of the influence probability relationship of all nodes is calculated 2 set the threshold value p adjust the number of clustering algorithms in the range of 1 p and perform ptimes clustering operation on the embedding representation of node influence probability relationship facing the influence of college students learning success incentive 3 the obtained p different clustering results are evaluated based on calinskiharabasz scores assuming that the number of training set samples is represented by a the number of clustering clusters is represented by l the covariance matrix between categories is represented by y l the covariance matrix of data within categories is represented by q l and the trace of the matrix is represented by tr then ch l tr y tr q a l l l l 1 when the calculation result of the above formula is the largest the number of categories of the corresponding metarelationship is the best based on the redefinition of metapath its possible to design a metapath for inferring college students learning autonomy considering that the subject body of college students learning autonomy evaluation task is college students and the starting node and ending node of metapath are both college students nodes the designed metapath needs to meet the bounded length less than or equal to 3 it is assumed that l new network structure metapaths are obtained after the previous analysis next this article takes these metapaths as constraints to infer the influence tendency attributes of college students learning autonomy in network nodes the identification of the influence tendency of college students learning autonomy in network nodes based on metapath walking is mainly divided into two stages metapath feature extraction and network node representation and inference the specific contents of the two stages are introduced below for convenience of expression it is assumed that the left endpoint set of metarelationship o 1 is represented by xc the left endpoint set of metapath t is represented by xc the right endpoint set of metarelationship o 1 is represented by xz and the right endpoint set of metapath t is represented by xz assuming that there is a metapath tu 1 → o1 u 2 … → o2 u k1 then starting from the query node set u w ⊆ xc according to the rules of metapath t the influence tendency attribute features of any node x in xz on college students learning autonomy can be expressed by f uwt which can be calculated by the following formula when the length of t is 0 f x u if x u others u t w w w ∈      1 0 when the length of t is greater than 0 xz needs to be eliminated and the metapath is t u 1 → o1 u 2 … → ok1 f uwt assuming that the activation function is represented by hs f uwt can be calculated by the following formula f x f x hs o x x o x u t u t k k x xz t w w ⋅ ∈ ∑ it can be seen from the above formula that x is false through the above process get the eigenvalues f uwt of college students learning autonomy influence tendency attribute from u w ⊆ xc to any node x in xz with regular load element path t hs is 1 if o k is true oth erwise hs is 0 if o k xʹ from the above calculation results it can be seen that in the process of solving f uwt firstly the known direct support nodes and indirect support nodes with positive incentives for college students learning autonomy will be selected from the network nodes of the new network structure as the query node set u w ⊆ xc and the ordinary nodes u w ⊆ xc without incentives will be eliminated after solving the eigenvalue f uw t of any node x in u w taking the known u w as the starting point according to the order of metapath t college student node → supporting relationshipsupported relationship support node → sending neighbor ordinary node → sent college student node f uwt can be further solved based on formula 14 thats the eigenvalues of college students learning autonomy influence tendency attribute under metapath t from u w for all network nodes the detailed process is shown in figure 2 based on metapath walking network node college students learning autonomy influence tendency identification algorithm flow will traverse all metapaths firstly for each metapath t i the f uwt value of any node x in the nonstarting node set is calculated until the college student node set of t i is calculated and the feature matrix f j of the college student node set of t i can be obtained repeating the above calculation process on all metapaths can obtain the feature matrix f of college students node set on all metapaths and taking the transposed f t of f as the input of the evaluation model of college students learning autonomy the inference result vector of college students learning autonomy influence tendency of all network nodes can be obtained in this chapter firstly a comparative experiment on the influence scope of college students social network support under different node sets r scale that have provided social support is carried out figure 3 shows the simulation results of node influence corresponding to six networks with different rscale conditions it can be seen from the figure that the influence range of all network nodes on college students social network support increases with the increase of r scale when the r scale is smaller the influence range of six different r scale networks on college students social network support is close with the increase of r scale the constructed network model can still better characterize the influence probability relationship between network nodes which shows obvious advantages in realizing the task of maximizing the influence of social network support for college students and lays a foundation for further evaluation of students learning autonomy it is worth noting that due to the different scales of the node set r scale that have provided social support the scale of the query node set for identifying the influence tendency of college students learning autonomy in the experiment is also different for example in network 1 with a query node set size of 40 a set of nodes having provided social support of up to 20 nodes is constructed in network 2 with a query node set size of 450 a set of nodes having provided social support of up to 200 nodes is constructed in order to evaluate the efficiency of the proposed method in maximizing the influence of social network support for college students table 1 summarizes the average simulation results of six different networks under different balance parameter selection this table gives the average of the influence range of network nodes on college students social network support based on 18 experiments with different balance parameters it can be seen from the table that the proposed method can obtain the best experimental results when the balance parameter is 04 especially for network 4 and network 6 formula 7 introduces the similarity threshold ω which is used to judge whether to add logical connection edges to the new network structure to construct a new network which represents the influence probability relationship between network nodes the value of this parameter will directly affect the accuracy of simulation results so this article analyzes the value of this parameter similarly considering the size of the node set r that has provided social support this article sets different step sizes figure 4 shows the comparison of simulation results with different similarity thresholds ω it can be seen from the figure that the similarity threshold ω has certain influence on the experimental results under the same r scale but the influence degree of ω on the experimental results is different under different r scales because this article takes into account the influence of r scale nodes on the scope of social network support for college students so this article further counts the different ω settings for different network sample sets and set the optimal ω value of different network sample sets after the construction of the new network structure in order to verify the effectiveness of the proposed evaluation method of college students learning autonomy based on metapath walking this article explores the influence weights of all metapath nodes involved in the new network structure in the inference of college students learning autonomy influence tendency and the results are shown in figure 5 it can be seen from the figure that the influence weights of nodes involved in the same metapath are different when the positive incentive node set is used as the query node set and the nonincentive node set is used as the query node set which shows that these nodes provide different social support to college students this phenomenon also shows that there are some differences in the metapath construction models between the node sets with positive incentives and the node sets without incentives for college students learning autonomy next this article further explores the influence of metapath walking feature integration on the evaluation performance of college students learning autonomy this experiment is a comparative experiment of four groups of feature integration methods in the first group it is designed to splice and integrate the walking features of u w and u w departure calculation in the second group it is designed to splice and integrate the walking features of u w departure calculation and the embedding features of the influence probability relationship of all nodes in the third group it is designed to splice and integrate the walking features and embedding features of u w departure calculation in the fourth group it is designed to splice and integrate the walking features and embedding features calculated by u w and u w the experimental results are shown in figure 6 it can be seen from the figure that after the completion of feature integration compared with the two feature integration the three feature integration can obtain more ideal evaluation accuracy and f1 value in the evaluation task of college students learning autonomy which proves that feature integration has a positive effect on the evaluation performance of college students learning autonomy at the same time its also possible to find that the walking feature of u w departure calculation has a more significant dominant position moreover the integration of the embedding features of the influence probability relationship of all nodes will obtain better performance evaluation results which verifies that the embedding features representing the global information of the network complement the information not contained in the metapath walking features representing the detailed features of the network therefore the integration of the two will achieve better results in the evaluation of college students learning autonomy conclusion this article studies the evaluation method of college students learning autonomy based on social network support firstly the local and global features of network nodes are extracted and the social network roles of college students are divided then a new logical structure network is constructed based on the vector representation of each node which maximizes the influence of relevant nodes on college students social network support finally based on the new network structure the metapath walking algorithm is introduced to evaluate college students learning autonomy by obtaining the attribute features supported by social networks through network nodes combined with experiments the influence simulation results of nodes corresponding to six different r scale networks are given and verify that the constructed network model can better characterize the influence probability relationship among network nodes the experimental results of different balance parameters and similarity threshold ω on six different networks are compared and an ideal new network structure is constructed the influence weights of nodes in the evaluation of college students learning autonomy are given and the influence of feature integration on the evaluation performance of college students learning autonomy is discussed to verify the effectiveness of the proposed evaluation method of college students learning autonomy based on metapath walking

social network plays an important role in college students life the greater the social network support they have the more adequate social network resources they get and the stronger their ability to cope with the challenges of study and life is existing studies have overemphasized the influence of social environment on college students academic success and have not paid special attention to the influence of the outside world on the change of college students learning attitude therefore this article studies the evaluation method of college students learning autonomy based on social network support firstly the local and global features of network nodes are extracted and the social network roles of college students are divided then a new logical structure network is constructed based on the vector representation of each node which maximizes the influence of relevant nodes on college students social network support finally based on the new network structure the metapath walking algorithm is introduced to evaluate college students learning autonomy by obtaining the attribute features supported by social networks through network nodes experimental results verify the effectiveness of the proposed method

Introduction Nowadays, Violence against women is recognized as one of the most severe challenges to the health and social inclusion of women and girls worldwide. The dissemination of digital-based violent sexual issues certainly causes a severe impact on the lives of women and girls, especially for those who live alone, not only the harm to physical health but also to psychological part, community and family ties, reputation, dignity, etc. Social media here as a medium of dissemination might influence or modify how the public responds to this kind of violent event and the perceptions of these female victims. What do women in the same situation as the victim think when the media generates a certain amount of circulation? This is also one of the reasons for this research. In the meantime, another goal is to explore whether the reporting of such sexual violence is leading to an increase in similar incidents. This requires data analysis of many reported violent incidents over a period. Additionally, this research also aims to let society should pay more attention to sexual violence and the group of women living alone. --- 2. --- Literature Review How are incidents of sexual violence spread on social media? This is a fundamental question in this research. After browsing through the surveys on this site, it has inspired me. I can analyse the prevalence and impact of violent sexual issues in news article headlines or on other social media, such as Weibo in China, and so on. Here is a study done by BMC Public Health about violence against women in the mainstream news in Australia [1]. It aimed to establish a birth picture of the extent and nature of violence against women by the mainstream Australian news media. The study suggested that the content of violence against women in mainstream news media was expansive. Despite readiness among intelligencers and compendiums to engage in the news about violence against women, reporting that promotes public understanding of the issue is not always the norm. This study has the advantage of being complete, considering all the conditions. It also uses powerful data, presented through percentage calculations, simple frequencies, and bar graphs, to draw solid conclusions and inspire me. This resource can give me a brief direction of research and can be used as solid proof in my research. What is the impact and perception of reports of sexual violence by groups of women living alone? This is one of the questions I need to consider because what I want to highlight in this study is the group of women living alone. This organization on the 'OurWatch' website concentrates on the primary forestallment of violence against women and their children in Australia [2,3]. They had several interviews with the survivors and their family members that have experienced sexual violence. They have a first-person perspective on how it feels to have their events covered by the media. For example, one headline represented it as "murder on the dance floor", which is the name of a song. They focus on how to get others caught up in the subject and ignore the people caught up in the tragedy. Another person's sister was even worse. Some of the media's reporting was about her skin colour, cultural background, or in some way excusing the perpetrator's responsibilities for criminal actions because of culture or honour. It points out a severe problem that the world is now still facing, Gender Equality. If a case is brought to court, the victim usually ends up on trial. Did she drink or take drugs, what clothes did she wear and what was her sexual history? News coverage on social media is one of the most convenient and common ways to connect the public with actual events. It can have a significant impact if it is spread incorrectly and with unhealthy perceptions. Interviews are a compelling way to get accurate and valid information. However, one difficulty is that there is no way to simultaneously invite or meet so many interviewees in different places. In contrast, I would have found a more convenient way to get the information I wanted. --- Methodology In the following research, several findings will be included: Investigating the prevalence and impact of sexual violence issues in news article headlines or on other social media, such as Weibo in China, Twitter in the US, and so on. In more detail, words and pictures analysis can be considered. For example, when participants were free to select texts with harmless and threatening images, the reading time for these texts also increased. Here, threatening images create an emotional response in the reader that stimulates more significant and considered cognitive processing of subsequent texts without the images. The women who live alone want to follow the news because they, as people in the same situation, are more likely to empathize with the victims. Then is to investigate whether there has been an increase in sexual violence throughout propagation on social media. This can be done by looking for a starting incident of sexual violence and then observing the growth of other incidents of violence over a fixed period at a later stage. Finally, interviews were conducted with women living alone to obtain their thoughts on reporting these incidents of sexual violence and how they were affected. The research mentioned above collected media reports on incidents of womanish sexual violence in three Australian countries over a four-month period to examine the analysis and description of the content. At last, they confirmed 4615 news reports on violence against women. Results showed that most news reports were episodic ; a minority were thematic . They also analyze the violent types. The picture below is the findings. It also illustrates the significance of how social media reports similar violence, which can directly impact how compendiums are concerned about the matter and how it is latterly handled. --- Founding and Discussion My study will study sexual violence in China from June to August 2022. The social media selection is then news coverage and personal output on Weibo, TikTok, Racer and Bili Bili. On June 10, a video of a barbecue restaurant in Tangshan, China, surfaced on the internet about several men sexually harassing a woman and then beating her up when she refused. According to the footage, a man approaches a table of three unknown women and touches one of them on the back. The woman stops him and tries to push him away, but the man then assaults her, along with several of his friends, and drags her outside the restaurant, beating and kicking her. Other women in the shop were beaten when they tried to stop him. The Tangshan beating was a case of gender violence because it involved a power relationship between a man and a woman. On TikTok, most of this news has gone viral in the form of original videos. After this event was disseminated, the barbecue owner and passers-by uploaded the full five-minute-long video from the first perspective. Videotape is an efficient way to circulate as it conveys information snappily, quickly and amusingly. Compared to traditional print media, a videotape can be fluently streamlined andre-edited to target different followership. TikTok released the 2018 TikTok Big Data Report in China, which showed that as of December 2018, the number of TikTok's domestic daily active users exceeded 250 million. The number of domestic monthly active users exceeded 500 million [4]. With such a vast population using it, the relative amount of airplay will also grow hormonally, thus making this event spread faster. Additionally, one interview done by DW with Chinese feminist activist and gender studies scholar Lu Pin mentioned the role of social media in this event ) [5]. Lu Pin said It was a social media event that could not have grown as big as it did and evoked such strong emotions from so many people without the videos that presented the event in a sensory stimulating way. The Figure1： Types of gender-based violence contained in a news report video is not empowering; there were no women's voices. It does not provide any context. So the video itself is emotionally provocative in a very narrow way. In contrast to the direct presentation of TikTok, Weibo is mostly official or traditional news agencies that come forward to report on cases. After describing the incident, the text is mostly objective, such as "according to the law", "censorship", and "pursuing formal responsibility". The officials have been calm and have not made any statements about violence against women but have only highlighted the legal measures and the fact that the perpetrators have been dealt with by the law to reduce the fear of the community and tell everyone that this is a matter of a few bad people doing bad things. However, some felt that a broader discussion on the systemic issues behind the incident should be raised and that only continued public unrest would cause society to address women's feelings. This creates a conflict of opinion. When resentment continues to escalate in the perception of one party, it affects the whole community. This is also why hundreds of Weibo accounts are blocked for "stirring up gender antagonism". People are indeed waking up to the fact that this is a matter of gender violence; they realise in countless social media reports that this is not just a personal issue but an institutional, social and cultural one. Women are aware that society is very unfriendly to them and that they are in a state of deprivation. It is an awakening of consciousness [6].To the group of women living alone, what impact do these news reports of sexual violence on social media have? Data from the China Statistical Yearbook 2021 shows that the number of one-person households in China reached 125 million in 2020, accounting for 25% of the total number of households [7]. When the size of households is decreasing, and the proportion of people living alone is increasing, there is also a growing concern about the living conditions that correspond to living alone. In contrast to this exquisite fantasy, there have been several cases of people being killed living alone and tailgating in recent years. From the panic caused by the murder of a woman living alone in Shanghai to the widespread discussions about living alone caused by various social events, the safety of living alone has become a topic that cannot be ignored. Since this study focuses on sexual violence in China, two dozen women that lived alone across China completed a self-administered questionnaire. The questions are as follows: Q1: How long have you lived alone? Q2: Where do you live while living alone? Q3: Have you experienced any safety problems while living alone? Can you share specifics, if convenient? Q4: Are you afraid of living on your own? If so, when to feel afraid？ Q5: Do you usually follow social news like the murder cases of sexual violence in Shanghai and Hebei? Q6: What are your thoughts after browsing through the news？ Q7: Would you like to make a particular change after reading similar social news? Or, how has it affected you? Q8: Do you have any advice on living alone safely/have you done anything to keep safe when living alone before? Q9: If you were involved in such an incident, would you choose to stand up for yourself as a victim? After analysing all the respondents' answers, most answered "Yes" in question 4, e.g. fear of the night, when someone knocks on the door when walking alone. All answered "yes, concerned" to question 5. When expressing their own feelings about the impact of these times, the responses were usually "powerless", "disappointed", "angry", and "scared ". I have selected some of the more representative responses. A 21-year-old woman living alone responded to the question, "Do you get scared?" by saying, "When the murders of women in Shanghai and Xiamen occurred within a month of each other, many people in my circle of friends forwarded the news and I was terrified during that time." Another girl spoke of how "because of my own experience of being stalked, I can be very empathetic and feel scared when I see news of girls who live alone being murdered. It's shocking to watch. I used to think these types of cases were far from me. However, recently I would find out that they were around my age, which made me realize that this might be something that would happen to someone very close to us. Some of the descriptions in the tweets would really make me feel the fear of a girl when she lives alone." But when asked if they would come forward to speak out, many chose "no". They explained that it would damage their self-esteem and that they were more afraid of having to suffer public opinion after such a painful experience. In some cases, the internet may even accuse the victim of violently killing the perpetrator. One of the interviewees recounted her experience of being subjected to sexual harassment, after which she initially chose to speak out, only to be met with side-eye and comments from her colleagues. This led to thoughts of guilt and shame. After stopping the accusations, she would try to control and repress herself, thus suffering from severe depression. As women, they are taught to fear strangers and to keep themselves out of dark places at night. It's a sad truth. There was one event on a girl who had just finished her high school exams was murdered by a male trickster [8]. After the crime, it became clear that public opinion was not in the right place. Some netizens even started to "find excuses "for the demon. For example, 'the girl is innocent, but the man is also quite poor, and disabled family so poor, society does not pay attention to these disadvantaged groups caused by the evil consequences.' Even more terrible, 'that's all men and women are, what else could be the reason? The bachelor is so miserable, his life story is desperate to hear.' This kind of comment can be connected to the influence on the group of women living alone. If they see that public opinion can be biased in favour of the perpetrator of violence. How can they still stand up and speak out for their rights? This certainly puts pressure on them. --- Conclusion Living alone, as a topic that most people have to deal with when they get out of school, seems to be an attempt to connect them with society. However, when people start talking about living safely alone, it quickly becomes serious and heavy. Even in telephone interviews, through the voices of the interviewees, fear can be felt and unease they felt when talking about a particular dangerous experience. When men's and women's discourses are becoming increasingly polarized online, this interview also brings back views that are not polarized. Sometimes it is not just sexual gratification behind these incidents of sexual violence, but power and hierarchy.

This research paper seeks to examine how the spread of violence on social media affects the group of women living alone. The study used several methods to achieve this. Firstly by analysing news article headlines or other reports of sexual violence on social media, and secondly, by interviews with women living alone. The results show that different social media will report news about sexual violence in different ways; for example, TikTok presents events in a sensory stimulating way like videos, which will spread much more and evoke strong emotions in many people. On the other hand, Twitter mostly features official or traditional news agencies reporting on cases, with more emphasis on legal measures to reduce the fear of the public. Therefore, these two social media platforms can bring different feelings to women living alone through different modes of presentation. The interviews with the group of women living alone illustrate the different thoughts and emotions that most women living alone have when they share their experiences of sexual violence or talk about their experiences. It also shows the unequal status of women in this society and the pressure of public opinion.

introduction nowadays violence against women is recognized as one of the most severe challenges to the health and social inclusion of women and girls worldwide the dissemination of digitalbased violent sexual issues certainly causes a severe impact on the lives of women and girls especially for those who live alone not only the harm to physical health but also to psychological part community and family ties reputation dignity etc social media here as a medium of dissemination might influence or modify how the public responds to this kind of violent event and the perceptions of these female victims what do women in the same situation as the victim think when the media generates a certain amount of circulation this is also one of the reasons for this research in the meantime another goal is to explore whether the reporting of such sexual violence is leading to an increase in similar incidents this requires data analysis of many reported violent incidents over a period additionally this research also aims to let society should pay more attention to sexual violence and the group of women living alone 2 literature review how are incidents of sexual violence spread on social media this is a fundamental question in this research after browsing through the surveys on this site it has inspired me i can analyse the prevalence and impact of violent sexual issues in news article headlines or on other social media such as weibo in china and so on here is a study done by bmc public health about violence against women in the mainstream news in australia 1 it aimed to establish a birth picture of the extent and nature of violence against women by the mainstream australian news media the study suggested that the content of violence against women in mainstream news media was expansive despite readiness among intelligencers and compendiums to engage in the news about violence against women reporting that promotes public understanding of the issue is not always the norm this study has the advantage of being complete considering all the conditions it also uses powerful data presented through percentage calculations simple frequencies and bar graphs to draw solid conclusions and inspire me this resource can give me a brief direction of research and can be used as solid proof in my research what is the impact and perception of reports of sexual violence by groups of women living alone this is one of the questions i need to consider because what i want to highlight in this study is the group of women living alone this organization on the ourwatch website concentrates on the primary forestallment of violence against women and their children in australia 23 they had several interviews with the survivors and their family members that have experienced sexual violence they have a firstperson perspective on how it feels to have their events covered by the media for example one headline represented it as murder on the dance floor which is the name of a song they focus on how to get others caught up in the subject and ignore the people caught up in the tragedy another persons sister was even worse some of the medias reporting was about her skin colour cultural background or in some way excusing the perpetrators responsibilities for criminal actions because of culture or honour it points out a severe problem that the world is now still facing gender equality if a case is brought to court the victim usually ends up on trial did she drink or take drugs what clothes did she wear and what was her sexual history news coverage on social media is one of the most convenient and common ways to connect the public with actual events it can have a significant impact if it is spread incorrectly and with unhealthy perceptions interviews are a compelling way to get accurate and valid information however one difficulty is that there is no way to simultaneously invite or meet so many interviewees in different places in contrast i would have found a more convenient way to get the information i wanted methodology in the following research several findings will be included investigating the prevalence and impact of sexual violence issues in news article headlines or on other social media such as weibo in china twitter in the us and so on in more detail words and pictures analysis can be considered for example when participants were free to select texts with harmless and threatening images the reading time for these texts also increased here threatening images create an emotional response in the reader that stimulates more significant and considered cognitive processing of subsequent texts without the images the women who live alone want to follow the news because they as people in the same situation are more likely to empathize with the victims then is to investigate whether there has been an increase in sexual violence throughout propagation on social media this can be done by looking for a starting incident of sexual violence and then observing the growth of other incidents of violence over a fixed period at a later stage finally interviews were conducted with women living alone to obtain their thoughts on reporting these incidents of sexual violence and how they were affected the research mentioned above collected media reports on incidents of womanish sexual violence in three australian countries over a fourmonth period to examine the analysis and description of the content at last they confirmed 4615 news reports on violence against women results showed that most news reports were episodic a minority were thematic they also analyze the violent types the picture below is the findings it also illustrates the significance of how social media reports similar violence which can directly impact how compendiums are concerned about the matter and how it is latterly handled founding and discussion my study will study sexual violence in china from june to august 2022 the social media selection is then news coverage and personal output on weibo tiktok racer and bili bili on june 10 a video of a barbecue restaurant in tangshan china surfaced on the internet about several men sexually harassing a woman and then beating her up when she refused according to the footage a man approaches a table of three unknown women and touches one of them on the back the woman stops him and tries to push him away but the man then assaults her along with several of his friends and drags her outside the restaurant beating and kicking her other women in the shop were beaten when they tried to stop him the tangshan beating was a case of gender violence because it involved a power relationship between a man and a woman on tiktok most of this news has gone viral in the form of original videos after this event was disseminated the barbecue owner and passersby uploaded the full fiveminutelong video from the first perspective videotape is an efficient way to circulate as it conveys information snappily quickly and amusingly compared to traditional print media a videotape can be fluently streamlined andreedited to target different followership tiktok released the 2018 tiktok big data report in china which showed that as of december 2018 the number of tiktoks domestic daily active users exceeded 250 million the number of domestic monthly active users exceeded 500 million 4 with such a vast population using it the relative amount of airplay will also grow hormonally thus making this event spread faster additionally one interview done by dw with chinese feminist activist and gender studies scholar lu pin mentioned the role of social media in this event 5 lu pin said it was a social media event that could not have grown as big as it did and evoked such strong emotions from so many people without the videos that presented the event in a sensory stimulating way the figure1： types of genderbased violence contained in a news report video is not empowering there were no womens voices it does not provide any context so the video itself is emotionally provocative in a very narrow way in contrast to the direct presentation of tiktok weibo is mostly official or traditional news agencies that come forward to report on cases after describing the incident the text is mostly objective such as according to the law censorship and pursuing formal responsibility the officials have been calm and have not made any statements about violence against women but have only highlighted the legal measures and the fact that the perpetrators have been dealt with by the law to reduce the fear of the community and tell everyone that this is a matter of a few bad people doing bad things however some felt that a broader discussion on the systemic issues behind the incident should be raised and that only continued public unrest would cause society to address womens feelings this creates a conflict of opinion when resentment continues to escalate in the perception of one party it affects the whole community this is also why hundreds of weibo accounts are blocked for stirring up gender antagonism people are indeed waking up to the fact that this is a matter of gender violence they realise in countless social media reports that this is not just a personal issue but an institutional social and cultural one women are aware that society is very unfriendly to them and that they are in a state of deprivation it is an awakening of consciousness 6 to the group of women living alone what impact do these news reports of sexual violence on social media have data from the china statistical yearbook 2021 shows that the number of oneperson households in china reached 125 million in 2020 accounting for 25 of the total number of households 7 when the size of households is decreasing and the proportion of people living alone is increasing there is also a growing concern about the living conditions that correspond to living alone in contrast to this exquisite fantasy there have been several cases of people being killed living alone and tailgating in recent years from the panic caused by the murder of a woman living alone in shanghai to the widespread discussions about living alone caused by various social events the safety of living alone has become a topic that cannot be ignored since this study focuses on sexual violence in china two dozen women that lived alone across china completed a selfadministered questionnaire the questions are as follows q1 how long have you lived alone q2 where do you live while living alone q3 have you experienced any safety problems while living alone can you share specifics if convenient q4 are you afraid of living on your own if so when to feel afraid？ q5 do you usually follow social news like the murder cases of sexual violence in shanghai and hebei q6 what are your thoughts after browsing through the news？ q7 would you like to make a particular change after reading similar social news or how has it affected you q8 do you have any advice on living alone safelyhave you done anything to keep safe when living alone before q9 if you were involved in such an incident would you choose to stand up for yourself as a victim after analysing all the respondents answers most answered yes in question 4 eg fear of the night when someone knocks on the door when walking alone all answered yes concerned to question 5 when expressing their own feelings about the impact of these times the responses were usually powerless disappointed angry and scared i have selected some of the more representative responses a 21yearold woman living alone responded to the question do you get scared by saying when the murders of women in shanghai and xiamen occurred within a month of each other many people in my circle of friends forwarded the news and i was terrified during that time another girl spoke of how because of my own experience of being stalked i can be very empathetic and feel scared when i see news of girls who live alone being murdered its shocking to watch i used to think these types of cases were far from me however recently i would find out that they were around my age which made me realize that this might be something that would happen to someone very close to us some of the descriptions in the tweets would really make me feel the fear of a girl when she lives alone but when asked if they would come forward to speak out many chose no they explained that it would damage their selfesteem and that they were more afraid of having to suffer public opinion after such a painful experience in some cases the internet may even accuse the victim of violently killing the perpetrator one of the interviewees recounted her experience of being subjected to sexual harassment after which she initially chose to speak out only to be met with sideeye and comments from her colleagues this led to thoughts of guilt and shame after stopping the accusations she would try to control and repress herself thus suffering from severe depression as women they are taught to fear strangers and to keep themselves out of dark places at night its a sad truth there was one event on a girl who had just finished her high school exams was murdered by a male trickster 8 after the crime it became clear that public opinion was not in the right place some netizens even started to find excuses for the demon for example the girl is innocent but the man is also quite poor and disabled family so poor society does not pay attention to these disadvantaged groups caused by the evil consequences even more terrible thats all men and women are what else could be the reason the bachelor is so miserable his life story is desperate to hear this kind of comment can be connected to the influence on the group of women living alone if they see that public opinion can be biased in favour of the perpetrator of violence how can they still stand up and speak out for their rights this certainly puts pressure on them conclusion living alone as a topic that most people have to deal with when they get out of school seems to be an attempt to connect them with society however when people start talking about living safely alone it quickly becomes serious and heavy even in telephone interviews through the voices of the interviewees fear can be felt and unease they felt when talking about a particular dangerous experience when mens and womens discourses are becoming increasingly polarized online this interview also brings back views that are not polarized sometimes it is not just sexual gratification behind these incidents of sexual violence but power and hierarchy

this research paper seeks to examine how the spread of violence on social media affects the group of women living alone the study used several methods to achieve this firstly by analysing news article headlines or other reports of sexual violence on social media and secondly by interviews with women living alone the results show that different social media will report news about sexual violence in different ways for example tiktok presents events in a sensory stimulating way like videos which will spread much more and evoke strong emotions in many people on the other hand twitter mostly features official or traditional news agencies reporting on cases with more emphasis on legal measures to reduce the fear of the public therefore these two social media platforms can bring different feelings to women living alone through different modes of presentation the interviews with the group of women living alone illustrate the different thoughts and emotions that most women living alone have when they share their experiences of sexual violence or talk about their experiences it also shows the unequal status of women in this society and the pressure of public opinion

Classroom Ethnic Composition and Social Integration The ethnic composition of U.S. public schools varies widely by demographic setting and geographic location. Roughly one in three ethnic minority children and one in eight European American children are enrolled in the nation's 100 largest school districts; 71% of children in these districts are ethnic minorities . Many urban schools are multiethnic, having substantial representation from three or more ethnic groups. There is considerable heterogeneity in the ethnic composition of urban districts. For example, in New York City, the nation's largest school district, 39% of children are Latino, 33% are African American, and 15% are European American; Los Angeles, the second largest school district, is less balanced: 73% Latino, 12% African American, and 9% European American . Variability in urban school demographics permits investigation into how diversity relates to schooling outcomes. Psychological research generally finds support for the benefits of diversity and intergroup contact in schools and other social settings . Juvonen and colleagues investigated student perceptions of school safety in 11 urban, multiethnic middle schools; students felt safer and less lonely, experienced less peer harassment, and exhibited higher self-worth the more ethnically diverse were their classrooms and schools. The authors attributed the positive findings in part to a more equitable distribution of numerical power across ethnic groups. Recent work in political science , however, offers the provocative claim that living in more diverse settings leads to less interpersonal connection and trust for African Americans and European Americans alike. Aptly termed "hunkering down," this phenomenon signals that both "bonding" social capital and "bridging" social capital can suffer for years in the face of increasing diversity until a society has progressed . As applied to children, the "hunkering down" perspective suggests that exposure to greater ethnic diversity in a classroom may not readily lead to true integration, but instead may yield social cleavages , thus suspending the realization of diversity's potential benefits. Despite recent demographic growth among ethnic minority populations, the multiethnic school is the exception . Indeed, the majority of children in the U.S.-roughly two in three ethnic minorities and seven in eight European Americansattend smaller and less diverse districts than those in large urban centers . In less diverse districts, African American and European American children typically attend ethnically segregated schools or, to a lesser extent, schools with a numerical balance of African American and European Americans. The present study examines social integration within elementary schools where African American and European American students together compose the majority of the school population, with one ethnic group predominating. Of particular interest is whether the ethnic composition of the classroom differentially affects social integration patterns of African American and European American children. Social integration patterns among African American children may be particularly sensitive to classroom and school ethnic distribution. Jackson, Barth, Powell, and Lochman asked children in 59 fifth-grade classrooms whom they "liked most" and "liked least," and who were the "leaders" in their classrooms. African American children received more liked most and leader nominations, and fewer liked least nominations, when they had more African American classmates; in contrast, ratings for European American children were similar across classrooms, regardless of their status as a classroom majority or minority. Bellmore, Nishina, Witkow, Graham, and Juvonen surveyed over 1100 sixth graders from multicultural schools with Latina/o, African American, European American, and Asian American children; they measured peer acceptance , peer rejection , and perceptions of being "cool." Children of all ethnic groups received more acceptance and cool nominations from same-ethnicity peers in classrooms with higher percentages of same-ethnicity classmates. However, African American children in particular were less accepted by cross-ethnicity peers when they had fewer same-ethnicity classmates. Thus, both Jackson et al. and Bellmore et al. find that African American children, more than European American children, are viewed less positively by classmates when their classrooms have fewer same-ethnicity peers. The present study examines whether Jackson and colleagues and Bellmore and colleagues' findings on acceptance and rejection generalize to children's relationships. To the extent that African Americans are less accepted by crossethnicity peers when they are classroom minorities, African Americans who are classroom minorities should have more segregated relationships ; for European American children, segregation ratios should be similar across classrooms of different ethnic composition. In contrast, a "hunkering down" perspective might suggest that ethnic composition effects would be similar for African American and European American children alike. --- Social Integration and Social Status An ideal scenario for the integrated elementary school is when children value peers with many positive cross-ethnicity relationships and few negative cross-ethnicity relationships. In this case, true social integration is supported by the children themselves. Indeed, children with integrated social relationships may be particularly well adjusted, with reputations as influential class leaders . On the other hand, children with segregated relationships might also enjoy high social status. Castelli et al. interviewed White Italian children about drawings of White protagonists interacting with White and/or Black children. White Italian preschoolers and first graders preferred White protagonists who played exclusively with other White children, although in middle childhood this effect was not present. Bellmore et al. , in their multicultural sample of U.S. sixth graders, report that African American and European American children who nominated more same-ethnicity classmates as "liked most" were in turn liked more by same-ethnicity peers. Thus, Castelli et al. and Bellmore et al. find positive associations between children's preference for same-ethnicity peers and their acceptance by same-ethnicity peers. The present research extends the scope of these investigations to examine whether children with segregated social relationships are perceived to be popular among same-ethnicity peers, and for that matter among cross-ethnicity peers. Perceived popularity gives insight into the social status of African American and European American children beyond social preference and its "liked most" and "liked least" components . One child can like another without perceiving him or her to be generally popular, and one child can perceive another to be popular without feelings of personal affection, and possibly even with feelings of personal dislike . Social preference expresses a personal sentiment , but perceived popularity represents a judgment about what others value and the consensual norms of the peer ecology . Social preference is positively associated with prosocial characteristics and negatively associated with aggressive characteristics, whereas perceived popularity has only modest correlations with aggression . When applied to perceived popularity, research turns from the preference-based question, "Do children especially like same- ethnicity peers with more segregated social relationships?" to the popularity-based question, "Do children perceive same- ethnicity peers with more segregated social relationships to have greater status and influence?" In addition, the inclusion of perceived popularity as an index of social status allows for a fresh examination of whether social segregation patterns differentially affect the social status of African American and European American children. Children's negative interpersonal sentiments are not extensively studied , so it is unclear whether children who disproportionately dislike cross-ethnicity peers are more preferred or perceived as more popular by their same-ethnicity classmates. Bellmore et al. did not find an association between disliking peers of another ethnicity and being preferred by peers of one's own ethnicity. Yet since negative relationships can make a person's other relationships more cohesive , it is reasonable to suspect that children may in fact value sameethnicity peers who demonstrate cross-ethnicity dislike. Social segregation can also bring costs : Children with segregated social relationships may be better liked by their same-ethnicity peers, but are probably disliked or perceived as unpopular by crossethnicity peers. --- Study Overview This study broadens previous research on how children's intergroup relations are associated with two characteristics of elementary classroom peer ecologies: classroom ethnic context and peer social status. The methods of this study have several notable strengths. First, integration patterns are assessed using multiple positive and negative ties. Including a social network measure such as group affiliation is particularly appropriate for a study of children's intergroup relations, but previous research has mainly considered acceptance and friendship choices, reflecting a larger trend in social development literature to focus on individuals and dyads more than groups and social networks . Of procedures for identifying children's groups , this study used Social Cognitive Mapping . SCM has the benefit of being multi-informant, meaning that children report their own affiliative groups and those of other children in the classroom. Social network block modeling procedures are typically constructed to consider only who is your friend or affiliate. The multi-informant aspect of SCM contributes to the stability of identified peer groups, and is particularly robust for the identification of aggressive and unpopular children . Second, analyses feature a compositionally invariant segregation index that correctly controls for the differing opportunities for same-and cross-ethnicity contact in classrooms of varying ethnic composition ; this index provides a ratio of bonding social capital to bridging social capital . Third, primary study analyses are multilevel and control for the key social behavior variables of peer-perceived prosocial behavior, and relational and overt aggression. There are well-established connections between these behaviors and social status , and additional evidence indicates that status-behavior associations may vary by individual ethnicity and classroom ethnic composition . Fourth, the sample is ethnically heterogeneous at individual and classroom levels. Most classrooms have a clear numeric ethnic majority, but also sufficient numeric minority children to permit quantitative analysis. Finally, the sociometric design of this investigation has children nominate classmates with whom they were friends, whom they believed to be popular, whom they liked least, etc., but children were not asked about race, ethnicity, African Americans, or European Americans per se. This minimizes social desirability effects. --- Method Participants Participants attended nine elementary schools across three Midwestern school districts located in small-to moderate-size urban areas. The schools varied considerably in ethnic composition and socioeconomic status as indicated by school lunch status. A school was targeted for inclusion in this study if its student ethnic distribution approximated a 60:40 ratio of African American to European American students, or vice versa. The 60:40 ratio balances having a clear ethnic majority with having enough ethnic minority participants to permit quantitative analysis of within-classroom social relations. The actual percentage of ethnic minority students in each school ranged from 34.1% to 86.8% . The percentage of students in each school who received free or reduced lunch ranged from 36.0% to 83.3% . The neighborhoods in which the schools were located varied considerably in SES as measured by per capita income and the percentage of individuals below poverty level . Neighborhood per capita income ranged from $11,100 to $36,700, with a median of $15,000. The percentage of individuals in each neighborhood living below poverty level ranged from 5.6 to 39.5, with a median of 21.6 percent. The correlation between the percentage of individuals living below poverty level and the percentage of African Americans in each neighborhood was .71 . The study sample consisted of 34 third and fourth grade classrooms in which there were at least two African American and two European American children. Within these classrooms, there were 757 children : ten in second grade, 337 in third grade, 387 in fourth grade, and 23 in fifth grade. One classroom was mixed second/third grade; two others were mixed fourth/fifth grade. All findings were very similar when second and fifth grade children were excluded from analysis. The mean ethnic distribution of classrooms as reported by teachers was 44.1% African American, 41.1% European American, 7.9% Asian, 2.8% Latino/a, and 4.1% other. Classroom ethnic distributions varied considerably, from 8.0% to 78.6% African American , and from 9.1% to 70.8% European American . Analyses considered only African American and European American participants. The final sample included 486 children in 34 classrooms: 235 African American and 251 European American children . --- Procedure Study participation required parental/guardian consent and individual assent; the participation rate was 77.0%. Researchers surveyed children in the Spring semester. For each classroom, surveys were conducted in two 30-minute sessions on two consecutive days. To guard against biases due to reading difficulties, a member of the research team read each item aloud, while at least two others walked around the room to monitor students' progress and answer questions. The order of administration of measures for each classroom was randomized. --- Measures Friendship-Children were asked to circle yes or no to the question, "Some kids have a number of close friends, but others have just one best friend, and still others don't have a best friend. What about you? Do you have a best friend?" Children responding affirmatively were prompted to write an unlimited number of names of children whom they considered to be their best friends. Of the 486 participants, 450 nominated at least one best friend. Peer affiliations-Peer groups were determined using the SCM procedure . We first asked participants, "Do you hang around together a lot with some kids in your classroom?" Participants responding affirmatively were prompted to check off boxes adjacent to the first names and last initials of peers in their classroom under the heading, "MY GROUP." We then asked, "Besides the group that you're in, are there other kids in your classroom who hang around together a lot?" Participants responding affirmatively were prompted to write the first names and last initials of every child in each group they could recall. The frequency of being named to the same group is correlated with observable interaction rates . Group membership was processed using the SCM version 4.0 program. Of the 486 participants, 458 were named to a group. Social behavior-Social behavior scores were obtained from unlimited peer nominations. Proportions were calculated for each child from the quotient of nominations received over the number of nominators in a classroom, with self-nominations excluded. Proportions were log-transformed for normality. Prosocial was the average of cooperative and nice . Relational aggression was the average of makes fun and says mean things . Overt aggression was the average of fights and trouble . Social status-Social status scores were obtained from unlimited peer nominations. Social preference was computed as the difference between liked most and liked least . Perceived popularity was computed as the difference between popular and unpopular . Social status scores were calculated separately with regard to same-and cross-ethnicity nominators. Thus, same-ethnicity social preference and perceived popularity were the quotients of same-ethnicity nominations received over the number of same-ethnicity nominators in a classroom, with self-nominations excluded. Similarly, cross-ethnicity social preference and perceived popularity were the quotients of cross-ethnicity nominations received over the number of cross-ethnicity nominators in a classroom. Same-and crossethnicity social preference and perceived popularity scores were normally distributed without log-transformation, so raw proportions were used in multilevel analyses. Ethnic segregation-Each child's pattern of sent friendship nominations, peer group affiliations, and sent liked least nominations were used to calculate up to three ethnic segregation indices. Friendship and like least nominations were unilateral . We calculated all valid indices for each child; for example, if a child was named to a peer group and named at least one peer as liked least, but did not name a best friend in the classroom, segregation indices were calculated only for peer affiliations and dislike. Calculating segregation indices was similar for all three constructs, so we illustrate the process for friendships and then note how it differed slightly for affiliations and dislike . To measure friendship segregation, we used the compositionally invariant odds ratio, α, which controls for opportunities present for sameand cross-ethnicity contact in classrooms of varying ethnic composition . Measures of segregation that do not maintain compositional invariance, such as strict proportions, yield misleading results . For each child, an ethnicityby-nominations cross-tabulation was constructed. In this table, A is the number of sameethnicity ties, B is the number of cross-ethnicity ties, C is the number of same-ethnicity peers with whom the child did not have ties, and D is the number of cross-ethnicity peers with whom the child did not have ties. Only ties among African American and European American children based on sent nominations were considered. The cross-tabulation yields an odds ratio, namely α = AD/BC. Wherever there was a zero value in one or more cells of the cross-tabulation, 0.5 was added to each cell. The formula for friendship segregation is log α = log . On this scale, positive values favor same-ethnicity friendships, negative values favor cross-ethnicity friendships, and zero is a neutrality point. The larger the absolute value, the stronger is the same-or cross-ethnicity favoritism. Consider an example of a classroom with twenty students: 13 African American , six European American , and one Asian American . A female African American student in this classroom has friendships with two African American classmates and one European American classmate . Thus, her index of friendship segregation is log α = log = log /[1 × 10]) = log = 0. Thus, this student exhibits no same-or cross-ethnicity favoritism within this classroom; this is true even though she has more same-ethnicity than cross-ethnicity friends, because she has proportionately more opportunities for same-ethnicity friends. To calculate segregation in children's peer group affiliations, SCM-identified peer groups were found, and then group affiliates were used in the place of friendships to calculate log α. For like least nominations, the odds ratio was inverted, where log α = log , to maintain a consistent valence across all three measures of ethnic segregation. Positive values reflect disproportionate like least nominations towards cross-ethnicity peers and negative values reflect disproportionate like least nominations towards same-ethnicity peers. Ethnic context of classroom: Percentage of same-ethnicity peers-The percentage of children in the classroom who were either African American or European American was used to measure classroom ethnic context. Percentage of African American classmates was used in multilevel models at level-2 for African American children, and percentage of European American classmates was used in models at level-2 for European American children. --- Analysis Plan The plan of analysis had two stages; each stage employed multilevel linear modeling techniques. We performed separate analyses for African American and European American children . Preliminary three-level unconditional models revealed that no outcome measure varied significantly across schools . Thus, each model had a two-level hierarchical structure, with children nested within classrooms. To better detect betweenclassroom differences, we did not standardize independent and dependent variables . Preliminary models detected no significant grade effects. Ethnic segregation-First, we modeled how individual characteristics and classroom ethnic context accounted for individual-level variance in three types of ethnic segregation: friendships, group affiliations, and dislike. There were three models each for African American and European American children, where one form of segregation was the dependent variable in each model; gender and perceived prosocial behavior, relational aggression, and overt aggression were level-one independent variables; and percentage same-ethnicity was the level-two independent variable. Social status-We then modeled individual-level variance in social preference and perceived popularity as a function of children's segregation patterns and the classroom ethnic context. There were four sets of models in all: same-ethnicity preference and popularity for African American children; same-ethnicity preference and popularity for European American children; cross-ethnicity preference and popularity for African American children; and cross-ethnicity preference and popularity for European American children. Gender and social behavior variables were entered as controls to better identify unique associations between segregation patterns and social status in these four sets of models. --- Results --- Preliminary Analyses Gender and ethnic differences in segregation, social behavior, and social status-Table 1 presents the means and standard deviations of all individual-level variables by ethnicity and gender; we provide standardized scores in this analysis to better illustrate gender and ethnicity differences. A multiple analysis of variance was performed with gender and ethnicity as independent variables to test for gender, ethnicity, and gender x ethnicity interactions. Results confirmed three significant gender differences: Compared to boys, girls were reported by their classmates as more prosocial , less relationally aggressive , and less overtly aggressive . There were nine significant ethnic differences and one gender x ethnicity interaction. Compared to European Americans, African American children had more segregated friendships and peer groups . For cross-ethnicity dislike, there was a significant gender x ethnicity interaction: European American girls disproportionately disliked African American peers more than did European American boys , but African American boys disproportionately disliked European American peers more than did African American girls . In terms of social behavior, African Americans were perceived as more relationally aggressive , more overtly aggressive , and less prosocial than European Americans. With respect to same-ethnicity social status, African Americans were more preferred and perceived as more popular than European Americans. Finally, with respect to cross-ethnicity social status, African Americans were less preferred but perceived as more popular than European Americans. 2 presents bivariate correlations between all individual-level variables, computed separately for African American and European American children, ignoring nesting within classrooms; where relevant, Fisher's z-statistics are provided below to highlight between-group differences. The correlations among the three ethnic segregation measures indicate that, for both ethnic groups, students high on one measure of segregation tended to be high on the two other measures of segregation ; friendship segregation and peer group segregation were the most highly correlated . --- Correlations among individual-level variables-Table The correlations between ethnic segregation and social status for African American and European American children are of greatest interest in this study. For each ethnic group, friendship segregation and peer group segregation were positively correlated with same-ethnicity social preference but negatively correlated with cross-ethnicity social preference . However, friendship segregation, peer group segregation, and cross-ethnicity dislike were positively correlated with same-ethnicity perceived popularity for African Americans , but not for European Americans ; each pair of correlations between the ethnic segregation and same-ethnicity popularity measures differed significantly across ethnic groups . Friendship segregation, peer group segregation, and cross-ethnicity dislike each was negatively correlated with cross-ethnicity perceived popularity for European Americans , but not for African Americans ; each pair of these correlations also differed significantly across ethnic groups . These preliminary findings point to ethnicity differences in integration patterns and social status. However, they do not account for classroom-level variability-in particular, how the ethnic context of a classroom might moderate children's social integration patterns and social status. Multilevel analyses were performed to address these issues. --- Multilevel Models of Ethnic Segregation Multilevel models were performed separately for African American and European American children for friendship segregation, peer group segregation, and cross-ethnicity dislike using PROC MIXED, SAS 9.1 . Table 3 presents variance components and intraclass correlations for all outcome variables. African Americans evidenced significant classroom-level variance in friendship segregation and peer group segregation , but not in cross-ethnicity dislike . European Americans evidenced significant classroom-level variance in peer group segregation and cross-ethnicity dislike , but not in friendship segregation . Preliminary analyses revealed no effects for gender or overt aggression, including interactions. The remaining level-one predictors were perceived prosocial behavior and relational aggression; the level-two predictor was mean-centered percent same-ethnicity. Final models are presented in Table 4; for each model, the null model intercept represents the mean classroom value of the dependent variable. The meta-R 2 value for each hierarchical linear model assesses explained variance, indicating specifically the proportional reduction of error for predicting an individual outcome . African Americans' segregation patterns-African American children had moderately segregated friendships and peer groups . African American children were particularly likely to have more segregated friendships and peer groups in classrooms where there were fewer African Americans. African American children disproportionately disliked European American children , but this did not vary by classroom context. African American children who were viewed as more relationally aggressive had more segregated friendships and peer groups , and demonstrated greater cross-ethnicity dislike . Prosocial behavior was not significant in any of the models. European Americans' segregation patterns-European American children also had relatively segregated friendships and peer groups ; in contrast to African Americans, segregation patterns were not associated with relational aggression or classroom ethnic context. European Americans who were viewed as more prosocial had more segregated friendships and peer groups . European American children disproportionately disliked African American peers ; this tendency increased with more European Americans in the classroom . --- Summary-African American and European American children displayed same-ethnicity segregation in their friendships and peer groups, and both disproportionately disliked crossethnicity peers. However, classroom ethnic context differentially predicted children's segregation levels. African Americans had more segregated friendships and peer groups with fewer same-ethnicity peers in the classroom . Conversely, European American children disliked more of their African American peers in classrooms that were mostly European American . In addition, perceived relational aggression positively predicted African American children's segregation, but perceived prosocial behavior positively predicted European American children's segregation. --- Multilevel Models of Social Status Perceived by Same-and Cross-Ethnicity Peers Same-and cross-ethnicity social preference and perceived popularity were dependent variables in two-level multilevel models performed separately for African American and European American children. As indicated in Table 3, African Americans evidenced significant classroom-level variance in same-ethnicity and cross-ethnicity social preference, but not in same-ethnicity or crossethnicity perceived popularity; European Americans evidenced significant classroom-level variance in same-ethnicity and cross-ethnicity social preference, as well as in cross-ethnicity perceived popularity , but not in sameethnicity perceived popularity . Individual level predictors were entered simultaneously and were: gender; the social behavior variables of perceived prosocial, relational aggression, and overt aggression; and the ethnic segregation variables of friendship, group affiliation, and cross-ethnicity dislike. The sole classroomlevel variable was percent same-ethnicity. In preliminary models, friendship segregation and percent same-ethnicity showed no significant effects after controlling for other predictors and were dropped. In other preliminary models, relational and overt aggression were aggregated into one four-item aggression construct to reduce variable colinearity . There was no instance where any significant association between the social status and social segregation variables of primary interest was altered by entering a global aggression construct rather than relational and overt aggression separately. Table 5 presents the final multilevel models; for each model, the null model intercept represents the mean classroom value of the dependent variable. Prosocial behavior was positively associated with social preference and perceived popularity for African American and European American children . Relational and/or overt aggression were significant predictors in five out of the eight Table 5 models, but there was not a clear pattern of effects. Primary findings regarding social status and social segregation patterns are discussed below. Same-ethnicity social preference and perceived popularity-Regarding social preference, African Americans were better liked by their same-ethnicity peers when they had more segregated peer groups and disproportionately disliked European Americans . European Americans were better liked by their same-ethnicity peers when they had segregated peer groups , but not when they disproportionately disliked African American peers. Regarding perceived popularity, African American children were viewed as more popular by their same-ethnicity peers when they had more segregated peer groups and disproportionately disliked European Americans . European American children's same-ethnicity perceived popularity was unrelated to segregation levels. Cross-ethnicity social preference and perceived popularity-African American children's peer group segregation and cross-ethnicity dislike were unrelated to their social preference among European Americans. In contrast, European American children were less preferred by their African American classmates when they had more segregated peer groups and disproportionately disliked African Americans . Regarding perceived popularity, African American children with more segregated peer groups were viewed by European Americans to be more popular , but there was no association with cross-ethnicity dislike. In contrast, European American children with more segregated peer groups and who disproportionately disliked African Americans were viewed as less popular by their African American classmates. Summary-Children of both ethnic groups were more preferred by same-ethnicity peers when they had more segregated peer groups. However, only African American children with more segregated peer groups were perceived by same-ethnicity peers to be more popular. African American children, but not European American children, were perceived as more popular and preferred by same-ethnicity peers when they disproportionately disliked crossethnicity peers. European American children with more segregated peer groups were viewed as less popular and preferred by their African American peers; however, African American children with more segregated peer groups were perceived as more popular by European American children. European American children who disproportionately disliked African American children were viewed as less popular and preferred by their African American peers. --- Discussion The research questions of this study asked whether or not the peer social ecologies of diverse elementary classrooms support the presence of positive, integrated relationships between African American and European American children. We examined two facets of the peer ecology: a) how the ethnic composition of the classroom moderates intergroup relationships; and b) social status structures-whether children with more segregated relationships are perceived to have higher social status by same-and cross-ethnicity peers. Compelling evidence emerged for each set of questions, discussed in turn. --- Classroom Ethnic Composition and Social Integration Overall, African American and European American children participated in moderately segregated peer groups and friendships, and showed a modest but significant tendency to dislike cross-ethnicity peers more than same-ethnicity peers. However, to consider only the average classroom would miss differential effects by ethnicity . Controlling for classroom opportunities for same-and cross-ethnicity contact, when African American children had fewer same-ethnicity classmates, they had disproportionately more segregated friendships and peer groups, and were more disliked by their European American peers. In contrast, the segregation patterns of European American children were similar across classroom contexts, and European Americans with numerical minority status were not more disliked by African Americans. Phrased differently, these findings present a variation to the "hunkering down" perspective : Children of both ethnic groups generally had more bonding than bridging social capital , but only African Americans "hunkered down" with their in-group in the face of cross-ethnic majorities. The present findings are consistent with prior research on children's intergroup relations. Jackson et al. and Bellmore et al. also found that African American children but not European American children were less liked when their classrooms had fewer sameethnicity peers. However, in contrast to Bellmore et al. , who found that African American children showed a general bias to nominate other African Americans for negative as well as positive nominations, the African American children in our sample disproportionately disliked cross-ethnicity peers. This latter discrepancy may reflect a key methodological difference: Bellmore et al. examined raw proportions of peer nominations given to same-and cross-ethnicity peers, but the present study used compositionally invariant odds ratios that directly control for opportunities for contact with same-and cross-ethnicity peers. In majority European American classrooms, African American children's ethnic segregation may act reciprocally with European American children's dislike of their African American peers. European American children over-attribute negative behavior to African Americans, particularly in majority European American schools . African American children are sensitive to prejudice and may come to expect discrimination in cross-ethnic social encounters . Thus, African American children's heightened segregation in majority European American contexts may be a protective mechanism, a kind of reaction to stereotype threat . Unfortunately, by reducing opportunities for authentic intergroup contact, these ethnic segregation patterns may reinforce the prejudices of European Americans . --- Social Integration and Social Status The findings of this study complement research suggesting that children who demonstrate greater preference for same-ethnicity peers are in turn more preferred by same-ethnicity peers . This view is consistent with Social Identity Theory , which proposes that identification with one's group is associated with in-group pride that satisfies a need for positive self-esteem. The present study had two main findings regarding the positive association between ethnic segregation and social status. First, the effect was much stronger for African American than for European American children. Second, distinctions between perceived popularity and social preference have important implications for understanding how peers reinforce segregation norms. Consistent with previous findings , European American and African American children with disproportionately more same-ethnicity relationships were more preferred by same-ethnicity peers. In addition, African American children exhibiting higher levels of cross-ethnicity dislike were more preferred by same-ethnicity peers. This finding is noteworthy because it was absent among European American children, and because research has generally shown little relationship between in-group favoritism and negative sentiments toward out-groups . African American children's preference for sameethnicity peers who disliked cross-ethnicity classmates may reflect an oppositional response that promotes group identity and differentiation . To the extent that African American children feel marginalized by the dominant European American group , or, as in a study of Black and White seven-year-olds in the United Kingdom, are less assertive in intergroup dialogue , one might expect European American children who interact mainly with other European Americans to command the top of the classroom social hierarchy, and thus be perceived as popular by same-and cross-ethnic peers. However, this pattern of findings was not present in this study. Instead, African American children were perceived to be more popular when they had higher levels of segregation and cross-ethnicity dislike. Perceived popularity is a marker of group values and norms , so African American children who have high levels of perceived popularity and segregated social relationships may symbolize group solidarity and ethnic pride. Surprisingly, African American children with more segregated relationships were even perceived to be popular-though not liked-by their European American classmates. One possible explanation for this finding is that children have different perceptions of societal majority and minority group members who display same-ethnicity preferences. That is, children of both ethnicities might view African American children's segregation to be a normative, adaptive response to being a societal minority. For European American children, however, social exclusivity might more likely be seen as a reflection of personal prejudice. A second possibility is that, at least in the schools targeted in this study, African Americans are generally seen as possessing social savoir-faire, or as being "cool," for reasons that go beyond classroom ethnic composition and prosocial and aggressive behavior. Interestingly, the connection between being cool and African American culture has been explored in literary work and developmental research . Perhaps these positive perceptions of African American children can be transformed into a building block towards more harmonious classroom peer ecologies. An intriguing direction for future work will be to examine if one form of positive intergroup perceptions can generalize to another with the establishment of actual, integrated social relationships. There is a large developmental literature on relations between social status and social behavior . This topic was not the focus of the present study, but there were some noteworthy findings regarding status-behavior linkages. Most important, prosocial behavior was consistently associated with social status. Prosocial children were preferred and perceived as popular by African American and European American children alike, for same-and cross-ethnicity nominations. This is a good sign for children's behavioral norms. A second finding is that African American children who tended to segregate were relationally but not overtly aggressive. This may speak to the savoir-faire of popular African American children who interact mainly with other African American children. There were a number of significant effects between relational and overt aggression regarding social preference and perceived popularity, effects that often differed by ethnicity . The substantive significance of these effects lies beyond the scope of this paper, and should be interpreted cautiously given high correlations between relational and overt aggression measures. The large correlation between relational and overt subtypes may explain why boys were perceived as more relationally aggressive than girls, whereas most studies do not show gender difference . It is clear that the complex relationships between aggression, social status, and ethnicity are a rich source for future study. --- Limitations and Future Directions This investigation was limited by not having other important individual and contextual data that may explain ethnic differences in social segregation at school, such as patterns of residential segregation and individual-level SES. The findings of this study may not generalize beyond this geographic region, where European Americans and African Americans together comprise the vast majority of the population. Having more than two ethnic groups in a classroom changes the dynamic from a school population that is mostly African American and European American to a truly multiethnic context . A strength of this investigation, namely that children were not asked explicitly about race and ethnicity, is also a weakness that prevents this study from answering questions about the role of perceived discrimination or ethnic identity. The development of a mature ethnic identity is associated with greater openness to people from other backgrounds , and can minimize negative outcomes that accompany discrimination, such as declines in academic self-concept and school achievement . Insofar as segregation may help ethnic minority children to forge a positive ethnic identity, having information on perceptions of discrimination and ethnic identity will better illuminate children's intergroup behavior in different contexts. Along similar lines, conjoining the sociometric methodology featured in this study with the type of social cognitive interviews and experimental manipulations offered by Killen, Sinno, and Margie would go a considerable distance towards synchronizing processes responsible for intergroup reasoning with those responsible for real-world intergroup preference. The findings of this study raise important developmental questions about changes in children's same-ethnicity preferences over middle childhood and early adolescence, and about operative causal pathways between social integration patterns and social status. A longitudinal study may have been more likely than the present cross-sectional analysis to find evidence of "hunkering down" . For example, Cillessen and Borch presented results on the proportion of ethnically segregated cliques among a diverse sample of children from the Northeastern U.S. followed annually from grades four to 12. Cillessen and Borch reported findings consistent with hunkering down, namely that "the proportion of ethnically diverse groups was much higher in the early grades than in the later ones even though the school system had become more diverse over the same time period" . By no means did the present investigation exhaustively test the "hunkering down" hypothesis; there is much work to be done examining developmental changes in children's social integration patterns. It is imperative to uncover the realities of social integration between African American and European American children in the school settings of today. Under pressure from residential segregation patterns , dwindling public attention , and the U.S. Supreme Court decisions of Seattle and Louisville , today's integrated elementary school is growing scarce. Is this cause for concern? Does the presence of integrated elementary schools impact children's social development? According to the results of this study, and to Putnam , the answer is "Yes": Schools were once "among the most efficacious instruments for… enabling us all to become comfortable with diversity," and so could be again. A critical challenge is to build on the positive ties that already exist between African American and European American children, and from there to cultivate integrated collaborations that enhance the development of all children, majority and minority alike. .0046 2.12 * Note. Percent same-ethnicity was mean-centered and entered as a level-2 variable. The null intercept represents the overall average classroom value for the dependent variable. Level-1 effects are represented by βs, and level-2 effects are represented by γs. For African-Americans, meta-R 2 Child Dev. Author manuscript; available in PMC 2012 September 1.

With a sample of African American and European American 3 rd and 4 th grade children (N = 486, ages 8-11 years), this study examined classroom ethnic composition, peer social status (i.e., social preference and perceived popularity as nominated by same-and cross-ethnicity peers), and patterns of ethnic segregation (i.e., friendship, peer group, and cross-ethnicity dislike). African American-but not European American-children had more segregated relationships and were more disliked by cross-ethnicity peers when they had fewer same-ethnicity classmates. African American children's segregation was positively associated with same-ethnicity social preference and perceived popularity and with cross-ethnicity perceived popularity. European American children's segregation was positively associated with same-ethnicity social preference but negatively associated with cross-ethnicity social preference and perceived popularity. The integrated elementary school stands as one of America's proudest and most hard-won achievements. Yet true integration calls for more than just a diverse collection of children in the same building, but also for social integration. When it comes to relationships between African American and European American children-relationships of deep, historical significance to the United States-critical questions regarding social integration in American schools remain unanswered (Schofield & Hausmann, 2004). One question is whether African American and European American children have more positive social relationships in more ethnically diverse classrooms. Does greater exposure to cross-ethnicity peers result in more positive intergroup contact (e.g., Allport, 1954) or instead trigger mistrust and dislike (Putnam, 2007)? A second question concerns how children with integrated social relationships are perceived by peers. Are children who have diverse peer relationships viewed as class leaders (Kawataba & Crick, 2008;Lease & Blake, 2005), or might they be less popular (at least among same-ethnicity peers) than children with segregated social relationships (Castelli, De Amicis, & Sherman, 2007)? Taken together, the research questions of this study ask whether the peer social ecologies of contemporary elementary classrooms support or undermine the presence of positive, integrated relationships between African American and European American children.

classroom ethnic composition and social integration the ethnic composition of us public schools varies widely by demographic setting and geographic location roughly one in three ethnic minority children and one in eight european american children are enrolled in the nations 100 largest school districts 71 of children in these districts are ethnic minorities many urban schools are multiethnic having substantial representation from three or more ethnic groups there is considerable heterogeneity in the ethnic composition of urban districts for example in new york city the nations largest school district 39 of children are latino 33 are african american and 15 are european american los angeles the second largest school district is less balanced 73 latino 12 african american and 9 european american variability in urban school demographics permits investigation into how diversity relates to schooling outcomes psychological research generally finds support for the benefits of diversity and intergroup contact in schools and other social settings juvonen and colleagues investigated student perceptions of school safety in 11 urban multiethnic middle schools students felt safer and less lonely experienced less peer harassment and exhibited higher selfworth the more ethnically diverse were their classrooms and schools the authors attributed the positive findings in part to a more equitable distribution of numerical power across ethnic groups recent work in political science however offers the provocative claim that living in more diverse settings leads to less interpersonal connection and trust for african americans and european americans alike aptly termed hunkering down this phenomenon signals that both bonding social capital and bridging social capital can suffer for years in the face of increasing diversity until a society has progressed as applied to children the hunkering down perspective suggests that exposure to greater ethnic diversity in a classroom may not readily lead to true integration but instead may yield social cleavages thus suspending the realization of diversitys potential benefits despite recent demographic growth among ethnic minority populations the multiethnic school is the exception indeed the majority of children in the usroughly two in three ethnic minorities and seven in eight european americansattend smaller and less diverse districts than those in large urban centers in less diverse districts african american and european american children typically attend ethnically segregated schools or to a lesser extent schools with a numerical balance of african american and european americans the present study examines social integration within elementary schools where african american and european american students together compose the majority of the school population with one ethnic group predominating of particular interest is whether the ethnic composition of the classroom differentially affects social integration patterns of african american and european american children social integration patterns among african american children may be particularly sensitive to classroom and school ethnic distribution jackson barth powell and lochman asked children in 59 fifthgrade classrooms whom they liked most and liked least and who were the leaders in their classrooms african american children received more liked most and leader nominations and fewer liked least nominations when they had more african american classmates in contrast ratings for european american children were similar across classrooms regardless of their status as a classroom majority or minority bellmore nishina witkow graham and juvonen surveyed over 1100 sixth graders from multicultural schools with latinao african american european american and asian american children they measured peer acceptance peer rejection and perceptions of being cool children of all ethnic groups received more acceptance and cool nominations from sameethnicity peers in classrooms with higher percentages of sameethnicity classmates however african american children in particular were less accepted by crossethnicity peers when they had fewer sameethnicity classmates thus both jackson et al and bellmore et al find that african american children more than european american children are viewed less positively by classmates when their classrooms have fewer sameethnicity peers the present study examines whether jackson and colleagues and bellmore and colleagues findings on acceptance and rejection generalize to childrens relationships to the extent that african americans are less accepted by crossethnicity peers when they are classroom minorities african americans who are classroom minorities should have more segregated relationships for european american children segregation ratios should be similar across classrooms of different ethnic composition in contrast a hunkering down perspective might suggest that ethnic composition effects would be similar for african american and european american children alike social integration and social status an ideal scenario for the integrated elementary school is when children value peers with many positive crossethnicity relationships and few negative crossethnicity relationships in this case true social integration is supported by the children themselves indeed children with integrated social relationships may be particularly well adjusted with reputations as influential class leaders on the other hand children with segregated relationships might also enjoy high social status castelli et al interviewed white italian children about drawings of white protagonists interacting with white andor black children white italian preschoolers and first graders preferred white protagonists who played exclusively with other white children although in middle childhood this effect was not present bellmore et al in their multicultural sample of us sixth graders report that african american and european american children who nominated more sameethnicity classmates as liked most were in turn liked more by sameethnicity peers thus castelli et al and bellmore et al find positive associations between childrens preference for sameethnicity peers and their acceptance by sameethnicity peers the present research extends the scope of these investigations to examine whether children with segregated social relationships are perceived to be popular among sameethnicity peers and for that matter among crossethnicity peers perceived popularity gives insight into the social status of african american and european american children beyond social preference and its liked most and liked least components one child can like another without perceiving him or her to be generally popular and one child can perceive another to be popular without feelings of personal affection and possibly even with feelings of personal dislike social preference expresses a personal sentiment but perceived popularity represents a judgment about what others value and the consensual norms of the peer ecology social preference is positively associated with prosocial characteristics and negatively associated with aggressive characteristics whereas perceived popularity has only modest correlations with aggression when applied to perceived popularity research turns from the preferencebased question do children especially like same ethnicity peers with more segregated social relationships to the popularitybased question do children perceive same ethnicity peers with more segregated social relationships to have greater status and influence in addition the inclusion of perceived popularity as an index of social status allows for a fresh examination of whether social segregation patterns differentially affect the social status of african american and european american children childrens negative interpersonal sentiments are not extensively studied so it is unclear whether children who disproportionately dislike crossethnicity peers are more preferred or perceived as more popular by their sameethnicity classmates bellmore et al did not find an association between disliking peers of another ethnicity and being preferred by peers of ones own ethnicity yet since negative relationships can make a persons other relationships more cohesive it is reasonable to suspect that children may in fact value sameethnicity peers who demonstrate crossethnicity dislike social segregation can also bring costs children with segregated social relationships may be better liked by their sameethnicity peers but are probably disliked or perceived as unpopular by crossethnicity peers study overview this study broadens previous research on how childrens intergroup relations are associated with two characteristics of elementary classroom peer ecologies classroom ethnic context and peer social status the methods of this study have several notable strengths first integration patterns are assessed using multiple positive and negative ties including a social network measure such as group affiliation is particularly appropriate for a study of childrens intergroup relations but previous research has mainly considered acceptance and friendship choices reflecting a larger trend in social development literature to focus on individuals and dyads more than groups and social networks of procedures for identifying childrens groups this study used social cognitive mapping scm has the benefit of being multiinformant meaning that children report their own affiliative groups and those of other children in the classroom social network block modeling procedures are typically constructed to consider only who is your friend or affiliate the multiinformant aspect of scm contributes to the stability of identified peer groups and is particularly robust for the identification of aggressive and unpopular children second analyses feature a compositionally invariant segregation index that correctly controls for the differing opportunities for sameand crossethnicity contact in classrooms of varying ethnic composition this index provides a ratio of bonding social capital to bridging social capital third primary study analyses are multilevel and control for the key social behavior variables of peerperceived prosocial behavior and relational and overt aggression there are wellestablished connections between these behaviors and social status and additional evidence indicates that statusbehavior associations may vary by individual ethnicity and classroom ethnic composition fourth the sample is ethnically heterogeneous at individual and classroom levels most classrooms have a clear numeric ethnic majority but also sufficient numeric minority children to permit quantitative analysis finally the sociometric design of this investigation has children nominate classmates with whom they were friends whom they believed to be popular whom they liked least etc but children were not asked about race ethnicity african americans or european americans per se this minimizes social desirability effects method participants participants attended nine elementary schools across three midwestern school districts located in smallto moderatesize urban areas the schools varied considerably in ethnic composition and socioeconomic status as indicated by school lunch status a school was targeted for inclusion in this study if its student ethnic distribution approximated a 6040 ratio of african american to european american students or vice versa the 6040 ratio balances having a clear ethnic majority with having enough ethnic minority participants to permit quantitative analysis of withinclassroom social relations the actual percentage of ethnic minority students in each school ranged from 341 to 868 the percentage of students in each school who received free or reduced lunch ranged from 360 to 833 the neighborhoods in which the schools were located varied considerably in ses as measured by per capita income and the percentage of individuals below poverty level neighborhood per capita income ranged from 11100 to 36700 with a median of 15000 the percentage of individuals in each neighborhood living below poverty level ranged from 56 to 395 with a median of 216 percent the correlation between the percentage of individuals living below poverty level and the percentage of african americans in each neighborhood was 71 the study sample consisted of 34 third and fourth grade classrooms in which there were at least two african american and two european american children within these classrooms there were 757 children ten in second grade 337 in third grade 387 in fourth grade and 23 in fifth grade one classroom was mixed secondthird grade two others were mixed fourthfifth grade all findings were very similar when second and fifth grade children were excluded from analysis the mean ethnic distribution of classrooms as reported by teachers was 441 african american 411 european american 79 asian 28 latinoa and 41 other classroom ethnic distributions varied considerably from 80 to 786 african american and from 91 to 708 european american analyses considered only african american and european american participants the final sample included 486 children in 34 classrooms 235 african american and 251 european american children procedure study participation required parentalguardian consent and individual assent the participation rate was 770 researchers surveyed children in the spring semester for each classroom surveys were conducted in two 30minute sessions on two consecutive days to guard against biases due to reading difficulties a member of the research team read each item aloud while at least two others walked around the room to monitor students progress and answer questions the order of administration of measures for each classroom was randomized measures friendshipchildren were asked to circle yes or no to the question some kids have a number of close friends but others have just one best friend and still others dont have a best friend what about you do you have a best friend children responding affirmatively were prompted to write an unlimited number of names of children whom they considered to be their best friends of the 486 participants 450 nominated at least one best friend peer affiliationspeer groups were determined using the scm procedure we first asked participants do you hang around together a lot with some kids in your classroom participants responding affirmatively were prompted to check off boxes adjacent to the first names and last initials of peers in their classroom under the heading my group we then asked besides the group that youre in are there other kids in your classroom who hang around together a lot participants responding affirmatively were prompted to write the first names and last initials of every child in each group they could recall the frequency of being named to the same group is correlated with observable interaction rates group membership was processed using the scm version 40 program of the 486 participants 458 were named to a group social behaviorsocial behavior scores were obtained from unlimited peer nominations proportions were calculated for each child from the quotient of nominations received over the number of nominators in a classroom with selfnominations excluded proportions were logtransformed for normality prosocial was the average of cooperative and nice relational aggression was the average of makes fun and says mean things overt aggression was the average of fights and trouble social statussocial status scores were obtained from unlimited peer nominations social preference was computed as the difference between liked most and liked least perceived popularity was computed as the difference between popular and unpopular social status scores were calculated separately with regard to sameand crossethnicity nominators thus sameethnicity social preference and perceived popularity were the quotients of sameethnicity nominations received over the number of sameethnicity nominators in a classroom with selfnominations excluded similarly crossethnicity social preference and perceived popularity were the quotients of crossethnicity nominations received over the number of crossethnicity nominators in a classroom sameand crossethnicity social preference and perceived popularity scores were normally distributed without logtransformation so raw proportions were used in multilevel analyses ethnic segregationeach childs pattern of sent friendship nominations peer group affiliations and sent liked least nominations were used to calculate up to three ethnic segregation indices friendship and like least nominations were unilateral we calculated all valid indices for each child for example if a child was named to a peer group and named at least one peer as liked least but did not name a best friend in the classroom segregation indices were calculated only for peer affiliations and dislike calculating segregation indices was similar for all three constructs so we illustrate the process for friendships and then note how it differed slightly for affiliations and dislike to measure friendship segregation we used the compositionally invariant odds ratio α which controls for opportunities present for sameand crossethnicity contact in classrooms of varying ethnic composition measures of segregation that do not maintain compositional invariance such as strict proportions yield misleading results for each child an ethnicitybynominations crosstabulation was constructed in this table a is the number of sameethnicity ties b is the number of crossethnicity ties c is the number of sameethnicity peers with whom the child did not have ties and d is the number of crossethnicity peers with whom the child did not have ties only ties among african american and european american children based on sent nominations were considered the crosstabulation yields an odds ratio namely α adbc wherever there was a zero value in one or more cells of the crosstabulation 05 was added to each cell the formula for friendship segregation is log α log on this scale positive values favor sameethnicity friendships negative values favor crossethnicity friendships and zero is a neutrality point the larger the absolute value the stronger is the sameor crossethnicity favoritism consider an example of a classroom with twenty students 13 african american six european american and one asian american a female african american student in this classroom has friendships with two african american classmates and one european american classmate thus her index of friendship segregation is log α log log 1 × 10 log 0 thus this student exhibits no sameor crossethnicity favoritism within this classroom this is true even though she has more sameethnicity than crossethnicity friends because she has proportionately more opportunities for sameethnicity friends to calculate segregation in childrens peer group affiliations scmidentified peer groups were found and then group affiliates were used in the place of friendships to calculate log α for like least nominations the odds ratio was inverted where log α log to maintain a consistent valence across all three measures of ethnic segregation positive values reflect disproportionate like least nominations towards crossethnicity peers and negative values reflect disproportionate like least nominations towards sameethnicity peers ethnic context of classroom percentage of sameethnicity peersthe percentage of children in the classroom who were either african american or european american was used to measure classroom ethnic context percentage of african american classmates was used in multilevel models at level2 for african american children and percentage of european american classmates was used in models at level2 for european american children analysis plan the plan of analysis had two stages each stage employed multilevel linear modeling techniques we performed separate analyses for african american and european american children preliminary threelevel unconditional models revealed that no outcome measure varied significantly across schools thus each model had a twolevel hierarchical structure with children nested within classrooms to better detect betweenclassroom differences we did not standardize independent and dependent variables preliminary models detected no significant grade effects ethnic segregationfirst we modeled how individual characteristics and classroom ethnic context accounted for individuallevel variance in three types of ethnic segregation friendships group affiliations and dislike there were three models each for african american and european american children where one form of segregation was the dependent variable in each model gender and perceived prosocial behavior relational aggression and overt aggression were levelone independent variables and percentage sameethnicity was the leveltwo independent variable social statuswe then modeled individuallevel variance in social preference and perceived popularity as a function of childrens segregation patterns and the classroom ethnic context there were four sets of models in all sameethnicity preference and popularity for african american children sameethnicity preference and popularity for european american children crossethnicity preference and popularity for african american children and crossethnicity preference and popularity for european american children gender and social behavior variables were entered as controls to better identify unique associations between segregation patterns and social status in these four sets of models results preliminary analyses gender and ethnic differences in segregation social behavior and social statustable 1 presents the means and standard deviations of all individuallevel variables by ethnicity and gender we provide standardized scores in this analysis to better illustrate gender and ethnicity differences a multiple analysis of variance was performed with gender and ethnicity as independent variables to test for gender ethnicity and gender x ethnicity interactions results confirmed three significant gender differences compared to boys girls were reported by their classmates as more prosocial less relationally aggressive and less overtly aggressive there were nine significant ethnic differences and one gender x ethnicity interaction compared to european americans african american children had more segregated friendships and peer groups for crossethnicity dislike there was a significant gender x ethnicity interaction european american girls disproportionately disliked african american peers more than did european american boys but african american boys disproportionately disliked european american peers more than did african american girls in terms of social behavior african americans were perceived as more relationally aggressive more overtly aggressive and less prosocial than european americans with respect to sameethnicity social status african americans were more preferred and perceived as more popular than european americans finally with respect to crossethnicity social status african americans were less preferred but perceived as more popular than european americans 2 presents bivariate correlations between all individuallevel variables computed separately for african american and european american children ignoring nesting within classrooms where relevant fishers zstatistics are provided below to highlight betweengroup differences the correlations among the three ethnic segregation measures indicate that for both ethnic groups students high on one measure of segregation tended to be high on the two other measures of segregation friendship segregation and peer group segregation were the most highly correlated correlations among individuallevel variablestable the correlations between ethnic segregation and social status for african american and european american children are of greatest interest in this study for each ethnic group friendship segregation and peer group segregation were positively correlated with sameethnicity social preference but negatively correlated with crossethnicity social preference however friendship segregation peer group segregation and crossethnicity dislike were positively correlated with sameethnicity perceived popularity for african americans but not for european americans each pair of correlations between the ethnic segregation and sameethnicity popularity measures differed significantly across ethnic groups friendship segregation peer group segregation and crossethnicity dislike each was negatively correlated with crossethnicity perceived popularity for european americans but not for african americans each pair of these correlations also differed significantly across ethnic groups these preliminary findings point to ethnicity differences in integration patterns and social status however they do not account for classroomlevel variabilityin particular how the ethnic context of a classroom might moderate childrens social integration patterns and social status multilevel analyses were performed to address these issues multilevel models of ethnic segregation multilevel models were performed separately for african american and european american children for friendship segregation peer group segregation and crossethnicity dislike using proc mixed sas 91 table 3 presents variance components and intraclass correlations for all outcome variables african americans evidenced significant classroomlevel variance in friendship segregation and peer group segregation but not in crossethnicity dislike european americans evidenced significant classroomlevel variance in peer group segregation and crossethnicity dislike but not in friendship segregation preliminary analyses revealed no effects for gender or overt aggression including interactions the remaining levelone predictors were perceived prosocial behavior and relational aggression the leveltwo predictor was meancentered percent sameethnicity final models are presented in table 4 for each model the null model intercept represents the mean classroom value of the dependent variable the metar 2 value for each hierarchical linear model assesses explained variance indicating specifically the proportional reduction of error for predicting an individual outcome african americans segregation patternsafrican american children had moderately segregated friendships and peer groups african american children were particularly likely to have more segregated friendships and peer groups in classrooms where there were fewer african americans african american children disproportionately disliked european american children but this did not vary by classroom context african american children who were viewed as more relationally aggressive had more segregated friendships and peer groups and demonstrated greater crossethnicity dislike prosocial behavior was not significant in any of the models european americans segregation patternseuropean american children also had relatively segregated friendships and peer groups in contrast to african americans segregation patterns were not associated with relational aggression or classroom ethnic context european americans who were viewed as more prosocial had more segregated friendships and peer groups european american children disproportionately disliked african american peers this tendency increased with more european americans in the classroom summaryafrican american and european american children displayed sameethnicity segregation in their friendships and peer groups and both disproportionately disliked crossethnicity peers however classroom ethnic context differentially predicted childrens segregation levels african americans had more segregated friendships and peer groups with fewer sameethnicity peers in the classroom conversely european american children disliked more of their african american peers in classrooms that were mostly european american in addition perceived relational aggression positively predicted african american childrens segregation but perceived prosocial behavior positively predicted european american childrens segregation multilevel models of social status perceived by sameand crossethnicity peers sameand crossethnicity social preference and perceived popularity were dependent variables in twolevel multilevel models performed separately for african american and european american children as indicated in table 3 african americans evidenced significant classroomlevel variance in sameethnicity and crossethnicity social preference but not in sameethnicity or crossethnicity perceived popularity european americans evidenced significant classroomlevel variance in sameethnicity and crossethnicity social preference as well as in crossethnicity perceived popularity but not in sameethnicity perceived popularity individual level predictors were entered simultaneously and were gender the social behavior variables of perceived prosocial relational aggression and overt aggression and the ethnic segregation variables of friendship group affiliation and crossethnicity dislike the sole classroomlevel variable was percent sameethnicity in preliminary models friendship segregation and percent sameethnicity showed no significant effects after controlling for other predictors and were dropped in other preliminary models relational and overt aggression were aggregated into one fouritem aggression construct to reduce variable colinearity there was no instance where any significant association between the social status and social segregation variables of primary interest was altered by entering a global aggression construct rather than relational and overt aggression separately table 5 presents the final multilevel models for each model the null model intercept represents the mean classroom value of the dependent variable prosocial behavior was positively associated with social preference and perceived popularity for african american and european american children relational andor overt aggression were significant predictors in five out of the eight table 5 models but there was not a clear pattern of effects primary findings regarding social status and social segregation patterns are discussed below sameethnicity social preference and perceived popularityregarding social preference african americans were better liked by their sameethnicity peers when they had more segregated peer groups and disproportionately disliked european americans european americans were better liked by their sameethnicity peers when they had segregated peer groups but not when they disproportionately disliked african american peers regarding perceived popularity african american children were viewed as more popular by their sameethnicity peers when they had more segregated peer groups and disproportionately disliked european americans european american childrens sameethnicity perceived popularity was unrelated to segregation levels crossethnicity social preference and perceived popularityafrican american childrens peer group segregation and crossethnicity dislike were unrelated to their social preference among european americans in contrast european american children were less preferred by their african american classmates when they had more segregated peer groups and disproportionately disliked african americans regarding perceived popularity african american children with more segregated peer groups were viewed by european americans to be more popular but there was no association with crossethnicity dislike in contrast european american children with more segregated peer groups and who disproportionately disliked african americans were viewed as less popular by their african american classmates summarychildren of both ethnic groups were more preferred by sameethnicity peers when they had more segregated peer groups however only african american children with more segregated peer groups were perceived by sameethnicity peers to be more popular african american children but not european american children were perceived as more popular and preferred by sameethnicity peers when they disproportionately disliked crossethnicity peers european american children with more segregated peer groups were viewed as less popular and preferred by their african american peers however african american children with more segregated peer groups were perceived as more popular by european american children european american children who disproportionately disliked african american children were viewed as less popular and preferred by their african american peers discussion the research questions of this study asked whether or not the peer social ecologies of diverse elementary classrooms support the presence of positive integrated relationships between african american and european american children we examined two facets of the peer ecology a how the ethnic composition of the classroom moderates intergroup relationships and b social status structureswhether children with more segregated relationships are perceived to have higher social status by sameand crossethnicity peers compelling evidence emerged for each set of questions discussed in turn classroom ethnic composition and social integration overall african american and european american children participated in moderately segregated peer groups and friendships and showed a modest but significant tendency to dislike crossethnicity peers more than sameethnicity peers however to consider only the average classroom would miss differential effects by ethnicity controlling for classroom opportunities for sameand crossethnicity contact when african american children had fewer sameethnicity classmates they had disproportionately more segregated friendships and peer groups and were more disliked by their european american peers in contrast the segregation patterns of european american children were similar across classroom contexts and european americans with numerical minority status were not more disliked by african americans phrased differently these findings present a variation to the hunkering down perspective children of both ethnic groups generally had more bonding than bridging social capital but only african americans hunkered down with their ingroup in the face of crossethnic majorities the present findings are consistent with prior research on childrens intergroup relations jackson et al and bellmore et al also found that african american children but not european american children were less liked when their classrooms had fewer sameethnicity peers however in contrast to bellmore et al who found that african american children showed a general bias to nominate other african americans for negative as well as positive nominations the african american children in our sample disproportionately disliked crossethnicity peers this latter discrepancy may reflect a key methodological difference bellmore et al examined raw proportions of peer nominations given to sameand crossethnicity peers but the present study used compositionally invariant odds ratios that directly control for opportunities for contact with sameand crossethnicity peers in majority european american classrooms african american childrens ethnic segregation may act reciprocally with european american childrens dislike of their african american peers european american children overattribute negative behavior to african americans particularly in majority european american schools african american children are sensitive to prejudice and may come to expect discrimination in crossethnic social encounters thus african american childrens heightened segregation in majority european american contexts may be a protective mechanism a kind of reaction to stereotype threat unfortunately by reducing opportunities for authentic intergroup contact these ethnic segregation patterns may reinforce the prejudices of european americans social integration and social status the findings of this study complement research suggesting that children who demonstrate greater preference for sameethnicity peers are in turn more preferred by sameethnicity peers this view is consistent with social identity theory which proposes that identification with ones group is associated with ingroup pride that satisfies a need for positive selfesteem the present study had two main findings regarding the positive association between ethnic segregation and social status first the effect was much stronger for african american than for european american children second distinctions between perceived popularity and social preference have important implications for understanding how peers reinforce segregation norms consistent with previous findings european american and african american children with disproportionately more sameethnicity relationships were more preferred by sameethnicity peers in addition african american children exhibiting higher levels of crossethnicity dislike were more preferred by sameethnicity peers this finding is noteworthy because it was absent among european american children and because research has generally shown little relationship between ingroup favoritism and negative sentiments toward outgroups african american childrens preference for sameethnicity peers who disliked crossethnicity classmates may reflect an oppositional response that promotes group identity and differentiation to the extent that african american children feel marginalized by the dominant european american group or as in a study of black and white sevenyearolds in the united kingdom are less assertive in intergroup dialogue one might expect european american children who interact mainly with other european americans to command the top of the classroom social hierarchy and thus be perceived as popular by sameand crossethnic peers however this pattern of findings was not present in this study instead african american children were perceived to be more popular when they had higher levels of segregation and crossethnicity dislike perceived popularity is a marker of group values and norms so african american children who have high levels of perceived popularity and segregated social relationships may symbolize group solidarity and ethnic pride surprisingly african american children with more segregated relationships were even perceived to be popularthough not likedby their european american classmates one possible explanation for this finding is that children have different perceptions of societal majority and minority group members who display sameethnicity preferences that is children of both ethnicities might view african american childrens segregation to be a normative adaptive response to being a societal minority for european american children however social exclusivity might more likely be seen as a reflection of personal prejudice a second possibility is that at least in the schools targeted in this study african americans are generally seen as possessing social savoirfaire or as being cool for reasons that go beyond classroom ethnic composition and prosocial and aggressive behavior interestingly the connection between being cool and african american culture has been explored in literary work and developmental research perhaps these positive perceptions of african american children can be transformed into a building block towards more harmonious classroom peer ecologies an intriguing direction for future work will be to examine if one form of positive intergroup perceptions can generalize to another with the establishment of actual integrated social relationships there is a large developmental literature on relations between social status and social behavior this topic was not the focus of the present study but there were some noteworthy findings regarding statusbehavior linkages most important prosocial behavior was consistently associated with social status prosocial children were preferred and perceived as popular by african american and european american children alike for sameand crossethnicity nominations this is a good sign for childrens behavioral norms a second finding is that african american children who tended to segregate were relationally but not overtly aggressive this may speak to the savoirfaire of popular african american children who interact mainly with other african american children there were a number of significant effects between relational and overt aggression regarding social preference and perceived popularity effects that often differed by ethnicity the substantive significance of these effects lies beyond the scope of this paper and should be interpreted cautiously given high correlations between relational and overt aggression measures the large correlation between relational and overt subtypes may explain why boys were perceived as more relationally aggressive than girls whereas most studies do not show gender difference it is clear that the complex relationships between aggression social status and ethnicity are a rich source for future study limitations and future directions this investigation was limited by not having other important individual and contextual data that may explain ethnic differences in social segregation at school such as patterns of residential segregation and individuallevel ses the findings of this study may not generalize beyond this geographic region where european americans and african americans together comprise the vast majority of the population having more than two ethnic groups in a classroom changes the dynamic from a school population that is mostly african american and european american to a truly multiethnic context a strength of this investigation namely that children were not asked explicitly about race and ethnicity is also a weakness that prevents this study from answering questions about the role of perceived discrimination or ethnic identity the development of a mature ethnic identity is associated with greater openness to people from other backgrounds and can minimize negative outcomes that accompany discrimination such as declines in academic selfconcept and school achievement insofar as segregation may help ethnic minority children to forge a positive ethnic identity having information on perceptions of discrimination and ethnic identity will better illuminate childrens intergroup behavior in different contexts along similar lines conjoining the sociometric methodology featured in this study with the type of social cognitive interviews and experimental manipulations offered by killen sinno and margie would go a considerable distance towards synchronizing processes responsible for intergroup reasoning with those responsible for realworld intergroup preference the findings of this study raise important developmental questions about changes in childrens sameethnicity preferences over middle childhood and early adolescence and about operative causal pathways between social integration patterns and social status a longitudinal study may have been more likely than the present crosssectional analysis to find evidence of hunkering down for example cillessen and borch presented results on the proportion of ethnically segregated cliques among a diverse sample of children from the northeastern us followed annually from grades four to 12 cillessen and borch reported findings consistent with hunkering down namely that the proportion of ethnically diverse groups was much higher in the early grades than in the later ones even though the school system had become more diverse over the same time period by no means did the present investigation exhaustively test the hunkering down hypothesis there is much work to be done examining developmental changes in childrens social integration patterns it is imperative to uncover the realities of social integration between african american and european american children in the school settings of today under pressure from residential segregation patterns dwindling public attention and the us supreme court decisions of seattle and louisville todays integrated elementary school is growing scarce is this cause for concern does the presence of integrated elementary schools impact childrens social development according to the results of this study and to putnam the answer is yes schools were once among the most efficacious instruments for… enabling us all to become comfortable with diversity and so could be again a critical challenge is to build on the positive ties that already exist between african american and european american children and from there to cultivate integrated collaborations that enhance the development of all children majority and minority alike 0046 212 note percent sameethnicity was meancentered and entered as a level2 variable the null intercept represents the overall average classroom value for the dependent variable level1 effects are represented by βs and level2 effects are represented by γs for africanamericans metar 2 child dev author manuscript available in pmc 2012 september 1

with a sample of african american and european american 3 rd and 4 th grade children n 486 ages 811 years this study examined classroom ethnic composition peer social status ie social preference and perceived popularity as nominated by sameand crossethnicity peers and patterns of ethnic segregation ie friendship peer group and crossethnicity dislike african americanbut not european americanchildren had more segregated relationships and were more disliked by crossethnicity peers when they had fewer sameethnicity classmates african american childrens segregation was positively associated with sameethnicity social preference and perceived popularity and with crossethnicity perceived popularity european american childrens segregation was positively associated with sameethnicity social preference but negatively associated with crossethnicity social preference and perceived popularity the integrated elementary school stands as one of americas proudest and most hardwon achievements yet true integration calls for more than just a diverse collection of children in the same building but also for social integration when it comes to relationships between african american and european american childrenrelationships of deep historical significance to the united statescritical questions regarding social integration in american schools remain unanswered schofield hausmann 2004 one question is whether african american and european american children have more positive social relationships in more ethnically diverse classrooms does greater exposure to crossethnicity peers result in more positive intergroup contact eg allport 1954 or instead trigger mistrust and dislike putnam 2007 a second question concerns how children with integrated social relationships are perceived by peers are children who have diverse peer relationships viewed as class leaders kawataba crick 2008lease blake 2005 or might they be less popular at least among sameethnicity peers than children with segregated social relationships castelli de amicis sherman 2007 taken together the research questions of this study ask whether the peer social ecologies of contemporary elementary classrooms support or undermine the presence of positive integrated relationships between african american and european american children

Introduction The SARS-CoV-2 virus, which causes COVID-19, is highly contagious and pathogenic. It has sparked a global pandemic that has resulted in a large number of deaths around the world. Although there is debate about the exact origin and source of the virus, Wuhan-an emerging economic and commercial hub in China initially saw an outbreak of a new coronavirus by the end of 2019 that killed over 1,800 people and infected over 70,000 individuals in the first 50 days of the COVID-19 epidemic. In 2003 a viral infection caused by the SARS coronavirus broke out in southern China's Guangdong province , which created a pandemic that affected 26 countries worldwide and claimed more than 8,000 infections and 776 deaths . However, SRAS-CoV had a fatality rate of 9 percent , whereas SRAS-CoV-2 has infected 619,836,103 people in 228 countries and territories with 6,539,363 deaths , indicating that SARS-CoV-2 has an even greater transmission rate than SRAS-CoV. Bangladesh officially declared its first identified COVID-19 case on March 8, 2020, and confirmed the first death on March 18, 2020, which puts us at 2,020,768 confirmed cases and 29,347 deaths until January 2022 . According to the Bangladesh Medical Association, about 8,890 frontline healthcare workers tested positive among the infected, and 87 died . Besides the healthcare workers, frontline workers, including 833 journalists, 8,331 police officers, and 150 administrative workers, were identified as COVID-19 positive; around 60 died among them . The countless frontline workers who continue to work despite the adversities and health hazards associated with the COVID-19 outbreak are the true heroes of our time. They work very hard amidst the severity of the pandemic to keep people safe and healthy. Global evidence also reports that the number of infections among frontline workers, especially healthcare providers, is higher than in general people . In addition, due to the nature of work frontline workers worldwide suffer from various psychological and physiological problems . Several studies have shown a high prevalence of mental health symptoms, such as anxiety, insomnia, distress, and psychological burden among frontline healthcare workers while treating patients with COVID-19 . Studies also revealed that frontline workers faced various professional and psycho-social challenges during this pandemic that included a harsh working environment, fear of contaminating family members and others, adaptation to continuously changing guidelines, and a lack of PPE . Moreover, COVID-19-positive frontline workers have been seen to hide their symptoms from their loved ones because of the fear of stigmatization . Numerous studies are being undertaken throughout the world to examine the psycho-social experiences of frontline workers caring for COVID-19 patients during this pandemic . Nevertheless, a few global studies describe COVID-19-positive frontline workers' lived experiences . For example, Siagian and Rantung explored the lived experiences of seven Indonesian healthcare nurses who tested positive for COVID-19 in a descriptive phenomenological study. They recognized the pre-isolation, isolation, and post-isolation lived experiences of survivors in their study, which included, among other things, fear, reaction, feelings in the isolation room, and post-COVID-19 condition. Similar to this, De Simone et al. examined the lived experiences of Italian frontline nurses and doctors who were affected by COVID-19. They looked at the strong emotional impact of COVID-19 on nurses and doctors who contracted it while performing their duties, including feelings of fear and loneliness on the one hand and impotence and guilt for not being able to help on the other. However, prior to this study, there was a dearth of literature in Bangladesh about the lived experiences of front-line healthcare workers who tested positive for COVID-19.The majority of COVID-19 studies in Bangladesh have concentrated on the work experiences of frontline workers, their mental health problems, and associated stigma in healthcare settings and outside . In addition, a group of researchers in Bangladesh conducted a telephonebased survey of 322 healthcare professionals to examine their quality of life after being cured of coronavirus . Moreover, prior COVID-19 research did not examine the lived experiences of various infected frontline workers, including healthcare providers, law enforcement personnel, journalists, and bankers. The current study will address this knowledge gap by examining the experiences of Bangladeshi frontline workers who tested positive for COVID-19. Moreover, as individual viewpoints might vary depending on a person's culture and society, it is crucial to explain and comprehend frontline workers' experiences in a particular context. Additionally, their untold stories about their work, diagnosis, isolation, sociopsychological vulnerabilities, social support, and organizational support throughout and after their quarantine will help policymakers and stakeholders design efficient strategies to lessen their work-related burden and discrimination in Bangladesh. --- Materials and methods --- Research design Using Colaizzi's phenomenological method we qualitatively analyzed the lived experiences of frontline workers in Bangladesh who were identified as COVID-19-positive patients. This approach seeks to comprehend people's daily experiences. It identifies common patterns of meaning rather than unique characteristics in the research subjects, ensuring the validity of the information gathered from the participants . --- --- Interview outline We developed the interview outline after reviewing pertinent literature and getting feedback from group members at numerous meetings. The interview subjects were asked the following questions: What was your earlier life before infection? How did you come to know about your infection? What were your initial responses after identifying yourself as a COVID-19 patient? What were your experiences during the isolation days? How did you cope with this situation? What aspects of life changed after your recovery from COVID-19? --- Data collection An email including a consent form and an interview guide was sent to participants who indicated an interest in participating in this study. After the participants gave their consent, an interview was scheduled and held whenever it suited them. The five research team members conducted each interview. Due to the pandemic, the interviews were carried out over the telephone and on online platforms . Each interview lasted 35-60 min and was conducted in Bangla. With the participants' consent, all interviews were audio recorded. --- Data analysis Within 24 h of each interview, the team translated the audio recording from Bangla to English. The first two authors then read each transcript several times to identify significant statements. Next, they took the meaning units from these statements and provided codes. After creating a preliminary list of themes that emerged from the diversity of transcripts, the connections between themes were established. The research team then engaged in frequent online meetings to extrapolate themes and subthemes from the coding. Finally, divergent opinions on the content of the topics were addressed and resolved by a professor with experience in qualitative research. We also conducted another interview with the participants to share the study's findings for validation. This study followed the ethical agreement of the Helsinki declaration. The study participants had the right to withdraw from the research at any time. In gathering the data we maintained objectivity and built strong bonds with the individuals. Each participant's name was changed to a pseudonym to protect their identity. We kept all the information in a password-protected Google Drive storage system that was only available to us. --- Results --- Characteristics of the participants Our study comprised three medical frontline workers and seven non-medical frontline workers who had been diagnosed as COVID-19 patients and were between the ages of 28 and 45. Their average age was 34 years. Three of them provided healthcare services, three worked in lawenforcement agencies and bureaucracy, and the remaining four worked in the financial sector and print media industries. Moreover, 30% of respondents were single, whereas 70% were married. In addition, seven respondents received treatment at home, while three others were admitted to COVID-19dedicated hospitals. The duration of treatment lasted between 14 and 32 days. The participant's characteristics are outlined in Table 1. However, we analyzed the lived experiences of COVID-19-positive frontline workers in Bangladesh using phenomenological techniques. Four significant themes and 13 subthemes emerged from Figure 1. The analysis of the participant's responses is outlined below. --- Theme I: Experiences in a new working environment Frontline workers in the COVID-19 situation encountered numerous challenges in a new work situation that impacted their physical, psychological, and social wellbeing. This theme consisted of three subthemes: workload and adaptations; maintaining health protocol and social distance, and the fear of being infected by others. --- Workload and adaptations None of the frontline workers in this study had worked in a pandemic environment like the current COVID-19 pandemic in Bangladesh. Therefore, they had to adapt to the new working situations and policies. Specially, medical frontline workers had to face dire conditions due to their direct involvement in treating COVID-19 patients in the corona unit. In addition, because of the increasing number of COVID-19 patients in Bangladesh, non-medical frontline workers were deployed and assigned to different places outside their routine work. "Since I am a government employee, I had to go to different places to perform official duties at the beginning of the corona infection in Bangladesh. I started working to ensure social distancing from the period when the government announced that no more than 10 or 15 people could gather in a place. Control of public gatherings at various institutions, wedding houses, religious and social functions, to ensure the home quarantine and isolation of expatriates and those who came from outside the district, etc., were my prime official duties during that time" . "I have been on the field since the beginning of Corona, highlighting the plight of patients in hospitals, including the mismanagement of sample collections, the neglect of unsuspected people, and the corporate propaganda called 'corona drug.' While other stations shut down their crime investigation programs, Searchlight did not shut down for a single episode" . --- Maintaining health protocols and social distance Most of the frontline workers in this study expressed that they always tried to follow the health rules of the Directorate General of Health Services and World Health Organization properly. Initially, medical frontline healthcare workers in Bangladesh had shortages of personal protective equipments and they had to work long hours in COVID-19 dedicated isolation units with corona patients. So maintaining health protocols were challenging at the beginning. But gradually this situation improved. However, for nonmedical frontline workers it was very difficult to work with complete personal equipment and maintain a social distance because of their nature of work in diverse areas and people. "When I went to bury Corona suspicious person's body, I wore full PPE . However, when I went to the work court or other work, I used a mask, gloves, and head cover. It is tough to ensure social distance in Bangladesh due to the people's indifference. I tried but could not always maintain it" . The fear of being infected by others Because of the severity of the virus, misinformation, data, nature, and workload, the survivors experienced fear of contracting the virus. In addition, most participants feared spreading the virus to their families and close ones. "As I was the only earning member of my family, I always feared being affected by the virus." So, I tried to maintain necessary precautions like wearing a mask, washing my hands frequently, and trying to maintain distance as much as possible" . Another participant involved in financial services closely observed a patient with COVID-19 symptoms who were not granted leave by the authorities. As a result, she feared going to the office every day. According to her statement, "I was afraid of going to the office regularly. One incident in my office that I want to mention here. One of our colleagues was suffering from a cold during the lockdown situation. Although she applied for leave, she was not granted it. As a result, she frequently met all of us, and we became horrified" . --- Theme II: Diagnosis This theme centered on survivors' experiences of being infected and the diagnosis center. Three subthemes emerged from this, such as the origin of infection, physiological symptoms, and experiences in the diagnosis center. --- Origin of infection Those frontline workers whose duty was to provide public services and welfare amidst the severity of COVID-19 believed that they had been infected because of their frequent visits to public places and contacts. "The way both of us have done our professional work in dealing with the Corona situation, we assumed today or tomorrow we would be infected because we did not have the opportunity to stay at home" . The same was true for another healthcare frontline worker who treated COVID-19 patients at a private hospital and experienced the tragic loss of three family members due to COVID-19. "As I was taking care of my father, like taking him to the ICU when he developed severe respiratory problems, though I was doing everything with protection, of course, I thought that I should test myself. There was a likelihood that I may have transferred the germ to my other colleagues as I was working with them in the hospital" . --- Physiological symptoms When the respondents were interviewed the most reported symptoms were fever, neck pain, headaches, coughs, body aches, and loss of taste and smell, as indicators of their general weakness. The comments here include examples of the earlier symptoms that the front-line workers reported. "I had no such symptoms except some minor neck pain. However, gradually, I developed other symptoms, and my physical situation worsened" . "My wife and I tested a corona examination on May 11 at Bangabandhu Sheikh Mujib Medical University with symptoms of fever, headache, slight cough, and severe pain around the ears" . --- FIGURE Major themes and sub-themes. However, two respondents stated that they did not display any physical symptoms in their bodies in the initial stages of the disease or even after it was diagnosed. Even though everything about them was fine, they were listed as COVID-19-positive patients after the test. "Even in my case, I was certain that I was carrying the germ and infected my wife, though I had no such symptoms to be sure of my disease" . --- Experiences in the diagnosis center When they went to the diagnosis center for a diagnosis, those frontline employees involved in government services received tremendous support. However, even though they were not required to keep queues for providing samples in the medical center, one of the respondents described his encounter with the testing facility as follows: "I did not need to pay any fees for my test, as it was free for all government officials. I also did not face harassment while doing tests standing in a queue or others. Instead, I went to the hospital, filled out a form with some information, gave a sample, and returned" . However, people from lower socio-economic backgrounds who worked in the private sector struggled in the diagnosis centers. Another one commented, "When I went to the Upazilla health complex to do a blood test, the doctor left the hospital for having lunch" . --- Theme III: Recovery days This theme covers a significant area of the survivors' experiences after identifying themselves as COVID-19 positive. Their initial reactions after the test report, experiences in the isolation center/home isolation, and coping mechanisms are discussed here. This theme includes earlier reactions ; experiences in isolation center/home isolation ; and coping mechanisms . --- Earlier reaction --- Fear of death Some frontline workers experienced fear of death and anxiety after identifying themselves as COVID-19 patients. However, they informed us throughout our conversation that they were fully aware of how Bangladeshi family members and relatives consider the corpse of a corona patient as something unpleasant and unexpected. "When I heard it, I felt that the whole sky had broken down on me. I might die soon. Life is very short. We are just like guests on this earth" . "After getting the report, my whole situation changed. I became anxious. Suddenly, my hands and feet were shaking. I started thinking about death and afterward" . --- Depression and emotion While being identified as COVID-19 patients after the test, most of the individuals in this study reported feeling depressed. In addition, some of them have started to experience emotional instability. Even one participant with no physical symptoms of illness developed psychological weakness. The reason for this is that after the disease was reported, they were worried about the severity of the virus and its burden. "I was broken at first after hearing the news. Especially when Sayda hugged me and cried and said, We do not even have a baby" . However, a 35-year-old female assistant commissioner of Kishorgonj Upazilla who initially experienced depression later revealed that she gradually turned her depression into strength. "I became a little depressed. However, I convinced myself that if I remained frustrated, I would die. So I had to convert my depression into mental strength" . --- Surprisement At least two respondents who had no physical symptoms expressed surprise when they had identified themselves as COVID-19 positive. When we interviewed them they said that they had always kept a social distance, been extremely cautious from the beginning and adhered to health regulations . They found it difficult to believe because they were certain they had followed the precautionary measure. One of the respondents said as "I tested only to be sure of my situation but I was astonished seeing that I was also positive while I had no symptoms" . --- Anxiety about family Nearly all participants admitted to becoming extremely concerned for their families after receiving confirmation of their infection. This is because they were the primary breadwinners in their household. As a result, they started to worry about what would happen to their families if the virus harmed them. "At that time, the first thing that came to my mind was my family, especially my younger sister" . "I became anxious about my family, especially about my little children" . Another respondent who was a non-medical frontline workers had to keep his sickness a secret from his family. He was far away from them and just did not want to upset them. According to him, "I did not tell family members about my infection as I was far away from them. I did so because everyone was so afraid and anxious during that time of pandemic outbreak that if anyone was identified as a COVID-19 patient, people believed that that person would die soon or thought that he/she was very prone to death. So I decided not to inform my family and relatives because it could make them more sacred" . --- Prior mental preparation We also found a new situation after our interview. The majority of the frontline workers were panicked and became anxious, however, a 37-year-old frontline financial service provider kept her composure despite knowing she was sick. This is because, prior to becoming ill, her family had COVID-19 survivors. Therefore, she took mental preparation in advance of her infection as well as remained calm knowing the nature and severity of this virus. According to her, "I was not afraid. You know, it is not a dangerous disease. I was conscious only of my smell problem. However, I got used to this situation because two more people had been infected in our house. I saw them closely" . --- Experiences in isolation Care vs. denial Most of the frontline workers we have interviewed remained in isolation at home. Only three were admitted to hospitals designed explicitly for COVID-19, where they were isolated for a minimum of 14 days. They consequently experienced positive and negative interactions with the caregivers while in isolation. However, one of the respondents, a police officer, said that the hospitals provided adequate healthcare when we asked him about his hospital experiences. "I was admitted to the district police hospital in Sylhet." Moreover, three of my colleagues, who were also positive, remained in the room. The hospital authorities provided us with good treatment and everything that we required. They sent every necessary accessory as soon as we informed them over the telephone or mobile phone . On the other hand, another non-medical frontline workers shared his bitter experiences while receiving treatment at COVID-19 dedicated hospital. He was shocked that no one, not even physicians or nurses, had ever seen him physically during his 22 days of isolation in hospitals. "During our 22 days of hospitalization, no doctors, nurses, or other medical staff ever visited us physically in the hospital, but only in some critical situations. Instead, they talked to us over the phone and provided only virtual advice. It frustrated me a lot to think that this is happening because we are COVID-19 patients" . --- Self-isolation At least two respondents described similar instances of self-isolation from family and friends. They internalized their condition and prioritized their family members' wellbeing. Even one of the responders could not go to his father's burial because he felt that other people would fall in danger of infection. "I have grief for not attending my father's funeral, but I took the right step at the right moment because my presence could infect others in a way that I could never accept" . --- Fear, dilemma, and mental struggle Almost all frontline workers experienced various forms of emotional distress in isolation, including dilemmas, insomnia, and fear of deaths. One of the frontline workers who was away from her house because of job obligations struggled to sleep and experienced death fears while alone in an isolation room at a government estate. She could not communicate with anyone because her home was kept in strict lockdown during her quarantine. She asserts, "Since I had trouble breathing almost every night when I went to bed, I was afraid that I might not be able to get up in the morning. I was scared to death. I thought I had these psychological problems because I was living alone" . Another survivor, a well-known journalist, and author in Bangladesh experienced difficulty, uncertainty, and emotional stress during his mandatory home quarantine. According to him, "The doctor advised us to avoid social media, especially Facebook, and suggested we be busy with housework and selfcare. But unfortunately, I did not listen to the doctor but once or twice used Facebook. Later, I saw that it truly created anxiety and mental pressure on me. Especially when you see that everything in the world is running smoothly, nothing is stopped because of your illness" . Furthermore, a medical professional who cared for coronavirus patients in a private hospital in Dhaka shared similar worries with us. "The doctor told us to follow the routine and to become worry-free." But nevertheless, is it possible to remain worryfree after all of this? I was shocked that even a little gastric pain was short of breath! "Corona was such a mental torture" . --- Social stigma The COVID-19 infection had an impact not only on the patients but also on their interpersonal and societal interactions. People purposefully avoid COVID-19 patients due to an overarching fear of infection. During their solitude, survivors allegedly experienced rejection and ostracism from those who were closest to them. At least two of non-medical frontline workers shared similar stories of denial from their colleagues and close ones when they caught COVID-19. "The building where I live was completely locked down. I faced some social stigma. After I got sick, I heard many officers who worked with me were terrified. Many of my colleagues around me wanted to escape. For example, after hearing the news of my infection, the naib of my office went to his village. He was afraid I might order him to work for me, but I think I have faced fewer social vulnerabilities due to my social status than other survivors" . Even families of patients who tested positive for COVID-19 had to deal with unfavorable behaviors from their kin and neighbors Due to this stigmatization, a 38-year-old doctor who treated Corona patients in a private hospital in Dhaka had to endure severe repercussions. In his opinion: "As frontline workers, we had to give service directly to the COVID-19 patients. When I returned from the hospital, I understood that they feared me. However, when four other members of my family and I were infected with the COVID-19 virus, they completely avoided us" . Another participant, a non-medical frontline workers who lost his father due to COVID-19 infection shared similar stories of being stigmatization by his neighbors. He also claimed that owing to stigma, he could not even convince anyone to hold the corpse after his father's death. The same rejection events occurred when he got infected. According to him: "When the villagers learned about my father's disease, they started to treat us like wild animals. Even when my father died, none of my neighbors visited our home, and there was no one to hold the corpse bed. After that, they stopped coming to our pond to take a bath when I got infected" . --- Coping mechanism --- Change in diet The majority of patients who received treatment at home altered their diet plans. They thought eating a lot would make them more prone to the illness. Some respondents stated that they also regularly engaged in breathing exercises, steamed hot baths, and sunbathing, all of which assisted their recovery from the infection. "According to the doctor's advice, I ate nutritious foods like milk, eggs, fish, meat, lemons, and vitamin C daily. I also took hot water vapor and followed the hygiene rules" . --- Prayer and listening to Wazz Bangladesh has a large Muslim population. During times of isolation, faith in God and practicing religion were very effective coping mechanisms for the survivors. Nearly everyone we had a conversation claimed that their faith in God helped them find relief from their sufferings. According to one of the respondents, "Most of the time of the day I prayed salah and recited dua. As I was free from all worldly activities, I concentrated more on religious activities that gave me relief " . Another participant who received treatment at a COVID-19-dedicated hospital regularly listened to various religious lectures on YouTube, which provided him with moral support to recover. --- Music, movies, and reading books Most of the frontline workers admitted that they avoided social media sites while remaining in isolation because it created anxiety and mental pressure upon them. One of the nonmedical frontline workers asserted that he became mentally more vulnerable when he found everything around him was okay except him while scrolling into Facebook. However, most of the frontline workers passed their isolation times by watching movies, reading books, and a few of them involved in gardening. "I did not use social media. I read books, walked around the house, watched funny movies, and spent time gardening" . "Netflix and Amazon Prime helped me overcome this challenge. In series like Breaking Bad, Picky Blinders, House of Cards, Walter-Jesse's Math Lab, Celian Murphy's outstanding performance, and the political intelligence of the Underwood family, I forgot I had a fatal illness" . --- Telemedicine Before this pandemic, the general people of Bangladesh were not comfortable with telemedicine services. But due to the shortage of COVID-19 designated beds in public and private hospitals telemedicine services became very popular among the patients who received care remaining at home. Three individuals in our study also regularly consulted with their doctors about their health related problems over the phone, which helped them recovering from this disease. According to one of the respondents: "We decided to take treatment from home until the situation worsens." In that case, we need to be under the supervision of a specialist doctor. "Doctor X provided us treatment via telemedicine regularly" . --- Self-motivation Due to the severity and concealed nature of COVID-19 at the initial stages of infection, Bangladeshi people, notably frontline workers, were more susceptible. In addition, a couple of the individuals we interviewed said that their family was their source of mental strength, aiding their recovery from this illness. One of the frontline worker who was kept in isolation in her government estate describe this situation as: "I have done self-counseling by convincing myself that many people depend on me. So I have to live for my siblings and my family's future. This mental strength has inspired me to recover" . --- Social support Almost all of the frontline workers received immense support from their family members and relatives, which helped them to recover quickly. Even if, in some instances, the family members were not physically present while they were in the hospital or home isolation, their support-such as food, comfort, and religious guidance-were tremendously helpful in enabling them to heal and cope. "Although I was in a COVID-19 dedicated hospital in an isolation room, I received immense support from my family. Whenever I talked with my wife over the phone, she told me not to be afraid. She motivated me in such a way that I am going to recover very soon. Even she took care of my family, children, and business in my absence" . Some survivors also received much help from their colleagues, office managers, and friends, which was a huge help in their recovery. One of the respondents, who was admitted into a COVID-19 dedicated hospital along with four other colleagues, stated that because of their shared experiences, they could help one another and manage the situation even while remaining in a segregated unit. As said; "... As we were living together in a hospital room, it was great to support us all. When we felt upset, we gossiped with one another, had fun and joked, and shared our grief to maintain social distance. It worked great to recover from our psychological hardship and effectively overcome our trouble. It had a tremendous impact on us that would not have been possible if I had stayed alone in a room." Although most frontline workers reported having their neighbors denied and rejected them, an author and journalist told us that his house owner offered adequate support and cooperation when the couple became infected. Due to their comparative higher social status and their connections with the power structure they were most privileged even in the age of COVID-19, but the general situation is completely different in Bangladesh. According to the respondents: "We informed the homeowner at the outset so that no one got panicked." He helped us a lot from the beginning. He provided us with food, fruits, and bottled water, in addition to the constant search. He also hired a doorman who would bring emergency supplies and take down the garbage can . --- Theme IV: Post-COVID-days Following their recovery, survivors also reported post-COVID-19 physiological and psychological issues, such as chest pain, sleep issues, anxiety, and shortness of breath, as well as specific social issues, such as financial loss. However, they also started to view life more optimistically. There are four subthemes under this main theme: excitement, fear and confusion, physiological problems, financial stress, and changes in philosophy. --- Excitement, fear, and confusion Survivors undoubtedly felt joy when they returned to normal life. Although, medical-frontline workers had to return to their previous job as there was scarcity of physicians and nurses in COVID-19 dedicated hospitals in Bangladesh. However, some participants concurred that they were afraid of spreading the virus to others after they were fully recovered. Therefore, they stayed away from places where the public congregates, like bazaars, tea shops, and playgrounds. When we questioned why they felt this way, they admitted that their test results had left them perplexed. During the pandemic, some private hospitals and clinics issued fake corona test results, which led to significant discrepancies. According to them: "After recovery, I tried to avoid visiting public places like bazaars, tea stalls, or friends' houses because I was scared if someone would be infected by me again. So, I tried to maintain all medical rules when communicating with others" . "When I fully recovered I could not believe in myself! I wanted to meet my friends and close ones. However, you know I was frightened of mixing with them. I have little trust in corona testing. So, I do not want to put anyone at risk" . Some survivors also experienced negative attitudes from their neighbors even after their recovery from the COVID-19 virus. Despite being healed, their bodies were marked as something to be afraid of. As a result, neighbors tried to avoid them for fear of contracting an infection. According to one of the respondents: "Even after the report came back negative, many people stayed far away from me. So I do not know if it was for awareness or if people were scared of me". --- Physiological problems The survivors experienced various physiological problems following their recovery. For instance, among the survivors breathing difficulties, respiratory issues, weakness, etc., were frequent. In addition, one survivor informed us that for a month, he could not move from one place to another owing to physical sickness. "Even after recovery, I often had shortness of breath. I still have some respiratory problems and have also reduced my 4 kg weight" . --- Financial stress Corona is a substantial financial burden on patients. Although, those frontline workers we interviewed were comparatively remained in a better socio-economic condition rather than the general population in Bangladesh, but they reported having some form of financial hardship to support their families after recuperation. One of the participants who was a doctor lost his job due to corona infection. To her surprise: "There has been some economic loss. The prices of daily necessities, including masks, sanitizers, fish meat, and eggs, have increased significantly. As a result, family expenses have increased immensely" . --- Changes in philosophy The participants returned to their everyday lives when the swab test results were reported as negative. Corona improved most of the survivors' outlooks, but a few of them who were highly educated were still uncertain about their sources of infection and the importance of mask in preventing corona virus. This is against our general beliefs about those who are illiterate are more suspicious and superstitious about the severity of corona virus. One of the non-medical frontline workers assert as: "I do not believe a mask can protect us from corona" . However, participants also claimed that they developed a stronger spiritual bond with God due to their COVID-19 experience. They prayed to God frequently while in the hospital and formed regular prayer routines. For example, one of the respondents who was agnostic now became a devoted follower of religion. According to him: "Although from the beginning I was conscientious, I was infected." It surprised me a lot, and "I realized it was Allah's will. Therefore, I have developed a firm belief in the almighty that led me to be involved in religious rituals during my hospital days" . --- Discussion We analyzed the lived experiences of Bangladeshi COVID-19-positive frontline workers in this study. We have identified four major themes and 13 subthemes from this study. In summary, our study showed that frontline workers in Bangladesh faced significant physiological, psychological, and social challenges while working in a new COVID-19 environment. Thus, when they contracted the infection and were isolated at home or in a hospital unit, they experienced anxiety, fear, wrath, frustration, and stigma. However, they could quickly deal with this adverse situation by altering their eating habits, relying on telemedicine for assistance, being self-motivated, having social support, and enjoying movies. The research also revealed that frontline workers continued to experience physical, emotional, economical, and social sufferings after fully recovered. In addition, when experiencing financial crisis and stigma they emphasized more on religiosity which in turn helped them to overcome those hardships. Similar themes emerged from another study on Indonesian frontline nurses who were kept in quarantine because of their infection . To begin with, our study reveals that since the beginning of the COVID-19 pandemic, Bangladeshi frontline workers have been facing immense physical, psychological, and social challenges because of the changing working environment, their fear of infection, and separation from family and close friends. Although, they tried to maintain health protocols and social distance from the beginning, however, non-medical frontline workers told us that it was quite possible for them to maintain appropriate social distance as they had to render direct services to the general public for various reasons. Even during the period of national lockdown , for example, non-medical frontline financial service workers had to regularly provide banking services to the general population . As a result, among Bangladesh's frontline workers, fear of infection, trauma, distress, worry, misinformation, and social stigma are more prevalent. We also found similar findings in previous research in Bangladesh and across the world . Secondly, it was evident from the findings that most of the non-medical frontline workers were infected by this virus because of their frequent visits to different public gatherings. On contrary, medical frontline workers were reported as infected while working with the Corona unit. However, almost all the frontline workers went to the associated test centers with the physiological symptoms of fever, neck pain, headaches, coughs, body aches, and loss of taste and smell which are in line with the clinical signs of SARS-CoV-2 infection . Besides, some frontline workers became very surprised that even though they had no physical symptoms, they were found positive after the test. Researchers from the University of Illinois at Chicago found similar cases. In their study Patel et al., found that of thirty five infected cases, thirteen never posed any symptoms . Moreover, due to misinformation , fake COVID-19-test reports of some private hospitals , and media, some frontline workers of this study expressed their concern and confusion about the diagnosis process. In addition, most of the medical and non-medical frontline workers received adequate treatment facilities from both the test centers as well as the COVID-19 dedicated hospitals due to their upper socio-economic profiles in Bangladesh. Thirdly, our study participants also revealed that fear of death, anxiety, depression, and frustration-were their immediate reactions after identifying themselves as COVID-19positive patients. These findings are also consistent with Taylor et al. and Liu Q. et al.'s studies . From Liu et al.'s study we came to know that in Hubei, China, more than 3,000 healthcare providers were infected by the coronavirus at the initial stage which caused trauma and fear among all the frontline workers across the world. Another UK based survey study revealed that compared to the general population, frontline health care providers experienced higher levels of anxiety and depression after being infected . On contrary, our study revealed that some frontline workers in Bangladesh felt less stressed as they had prior mental preparation about the severity of this virus. Again, this study showed that most of the frontline workers we interviewed remained in isolation at home during their recovery days. Only a few went to the government's dedicated COVID-19 hospitals where they stayed in complete isolation units along with other COVID-19 patients. As there is scarcity of COVID-19 dedicated beds and people are not comfortable with remaining in isolation, like the general populations frontline workers tended to receive treatment staying at home. Similarly, in Philippines, it was found that COVID-19 survivors are more reluctant to stay at home than at the isolation center . The data showed that Bangladeshi frontline workers had received good care at the COVID-19 dedicated hospitals because of their upper socio-economic status. On the other hand" some of the non-medical frontline workers were denied face-to-face treatment by the healthcare providers because of the fear of infection and stigma which is pertinent to studies conducted in India . Research in India also reported that some patients are stigmatized because they are COVID-19 patients . As a result, some frontline workers in Bangladesh were also found to hide their disease from their friends, relatives, neighbors, and even family members when they stayed in isolation. Not only that those who received treatment at home experienced fear, anxiety, sleepiness, stress, depression, and stigmatization during their recovery days which are also consistent with a study conducted by Fawaz and Samaha over the quarantined frontline nurses in Lebanese . Apart from this, some frontline workers believed that remaining in home isolation surrounded by the family members might positively impact on their recovery process. Some studies also showed that positive emotions and hope play an essential role in a patient's recovery . Furthermore, frontline workers' various coping mechanisms during their recovery days are also evident in this study. Most frontline workers coped with this adverse situation by altering food habits, relying on telemedicine, religiosity, having social and organizational support, and engaging in recreational activities . We also found that nurses in Saudi Arabia and Qatar considered changing their eating habits a solid coping mechanism against this virus . Again, like this study, studies conducted in Indonesia and the Philippines substantiated strong positive connections between religion and mental health . As most of the frontline workers in this study were Muslim, they felt a strong connection with God, which worked like a placebo effect on their healing process. Besides, some of the frontline workers mentioned that music, movies, and books were influential sources of coping strategies for stress management during isolation. The influence of music on reducing stress for quarantined COVID-19 patients is also evident in some studies . In addition, support from family members, friends, colleagues, and neighbors were also mentioned as strong coping mechanism by the Bangladeshi frontline workers. The association between social support and healing is also consistent with previous studies . Although, government of Bangladesh declared institutional supports for the COVID-19 infected frontline workers, none of the frontline workers received any organizational support of this study. Besides, no one in this study required any psychotherapy or counseling for their recovery which was evident in other countries. Even in Bangladesh, according to the survivors' experiences, strict isolation is not recommended for the survivors healing because it creates more anxiety, loneliness, and fear among the patients. Henceforth, social and organizational support could be the best coping strategies for the COVID-19 frontline workers in Bangladesh. Therefore, future researchers in Bangladesh might investigate the impact of social and organizational support on the healing process of COVID-19 survivors. Lastly, the study revealed that frontline workers in Bangladesh faced several psychological and physiological challenges even after being fully recovered from the virus. Likewise, Guo et al., in their study, also found that fatigue, shortness of breath, fear, trauma, and stigma are common to many medical frontline workers after their recovery . Similar results are also found in some studies conducted in the UK and Wuhan in China . Meanwhile, our respondents also mentioned that they also faced various social and economic crisis in their post-COVID-19 days which is also consistent with some other studies across the world . --- Strengths and limitations This study has some limitations. Due to the spread of the virus across the nation, it was first and foremost impossible to conduct face-to-face interviews in all instances. So, again, we only conducted ten interviews, which do not represent the whole population. Earlier, we had disagreements about our study participants. Generally, healthcare providers, e.g., doctors, and nurses are considered frontline workers. However, we believe defining frontline workers is not specific but contextualized. Hence, after getting inspiration from the definition given by Rana and Islam in their recent study, we included law enforcement agencies, bureaucrats, bankers, and journalists, along with healthcare providers, as frontline workers in our study. Therefore, our study's conclusions cannot be applied to any specific group of Bangladeshi frontline workers. Despite all of these limitations, to the author's knowledge, the current study is one of the first to analyze the lived experiences of positive COVID-19 frontline workers in Bangladesh, providing in-depth detailed information on their particular experiences of suffering and coping mechanisms. --- Implications Despite all the limitations, this paper provides comprehensive insights for the policymakers. Firstly, healthcare policymakers should design health policies based on the social setting of Bangladeshi society. In Bangladesh, there is a practice to follow and copy policies from the developed countries blindly without considering their relevance. Lockdown without a social safety net program to combat COVID-19 was not fruitful in Bangladesh. Secondly, stigma can negatively affect the victims, leading to isolation, depression, anxiety, or public embarrassment. Stigmatized individuals usually hide symptoms of their illness and restrict themselves from taking medical care. This behavior might create challenging situations to control the spread of any pandemic. Therefore, health policymakers should develop sustainable behavioral change programs to combat the social stigma associated with public health. Lastly, policymakers should develop a robust monitoring mechanism to eradicate discrimination regarding one's socio-economic status when getting medical services. This type of discrimination is a violation of constitutional rights. --- Conclusion In any epidemic or pandemic, frontline workers suffer psychologically and socially. The lived experience of this cohort depends on various interactions between demographics and socio-economic status. Therefore, they urgently need guidance for physical rehabilitation, psychological growth, social support, and protection from social stigma. Although across the world, including Bangladesh, frontline workers' mental health conditions are studied, their everyday lived experiences as COVID-19 survivors are merely studied. This study provides a comprehensive and in-depth insight into the lived experiences of frontline workers. This study thus has other policy implications for Bangladesh. This study is significant for healthcare policymakers in planning healthcare management systems based on the social settings of Bangladesh society. This paper also suggests that national policymakers implement long-term behavioral change programs to reduce social stigma. At the same time, it suggests the government end discrimination regarding an individual's socio-economic status to get medical assistance. --- Data availability statement Latest version of data will be available at doi: 10.17632/ymwydhvztj.2. --- Ethics --- Ethics statement Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

The whole sky has broken down on me. I might die alone": A qualitative study on the lived experiences of COVID-positive frontline workers in Bangladesh.

introduction the sarscov2 virus which causes covid19 is highly contagious and pathogenic it has sparked a global pandemic that has resulted in a large number of deaths around the world although there is debate about the exact origin and source of the virus wuhanan emerging economic and commercial hub in china initially saw an outbreak of a new coronavirus by the end of 2019 that killed over 1800 people and infected over 70000 individuals in the first 50 days of the covid19 epidemic in 2003 a viral infection caused by the sars coronavirus broke out in southern chinas guangdong province which created a pandemic that affected 26 countries worldwide and claimed more than 8000 infections and 776 deaths however srascov had a fatality rate of 9 percent whereas srascov2 has infected 619836103 people in 228 countries and territories with 6539363 deaths indicating that sarscov2 has an even greater transmission rate than srascov bangladesh officially declared its first identified covid19 case on march 8 2020 and confirmed the first death on march 18 2020 which puts us at 2020768 confirmed cases and 29347 deaths until january 2022 according to the bangladesh medical association about 8890 frontline healthcare workers tested positive among the infected and 87 died besides the healthcare workers frontline workers including 833 journalists 8331 police officers and 150 administrative workers were identified as covid19 positive around 60 died among them the countless frontline workers who continue to work despite the adversities and health hazards associated with the covid19 outbreak are the true heroes of our time they work very hard amidst the severity of the pandemic to keep people safe and healthy global evidence also reports that the number of infections among frontline workers especially healthcare providers is higher than in general people in addition due to the nature of work frontline workers worldwide suffer from various psychological and physiological problems several studies have shown a high prevalence of mental health symptoms such as anxiety insomnia distress and psychological burden among frontline healthcare workers while treating patients with covid19 studies also revealed that frontline workers faced various professional and psychosocial challenges during this pandemic that included a harsh working environment fear of contaminating family members and others adaptation to continuously changing guidelines and a lack of ppe moreover covid19positive frontline workers have been seen to hide their symptoms from their loved ones because of the fear of stigmatization numerous studies are being undertaken throughout the world to examine the psychosocial experiences of frontline workers caring for covid19 patients during this pandemic nevertheless a few global studies describe covid19positive frontline workers lived experiences for example siagian and rantung explored the lived experiences of seven indonesian healthcare nurses who tested positive for covid19 in a descriptive phenomenological study they recognized the preisolation isolation and postisolation lived experiences of survivors in their study which included among other things fear reaction feelings in the isolation room and postcovid19 condition similar to this de simone et al examined the lived experiences of italian frontline nurses and doctors who were affected by covid19 they looked at the strong emotional impact of covid19 on nurses and doctors who contracted it while performing their duties including feelings of fear and loneliness on the one hand and impotence and guilt for not being able to help on the other however prior to this study there was a dearth of literature in bangladesh about the lived experiences of frontline healthcare workers who tested positive for covid19the majority of covid19 studies in bangladesh have concentrated on the work experiences of frontline workers their mental health problems and associated stigma in healthcare settings and outside in addition a group of researchers in bangladesh conducted a telephonebased survey of 322 healthcare professionals to examine their quality of life after being cured of coronavirus moreover prior covid19 research did not examine the lived experiences of various infected frontline workers including healthcare providers law enforcement personnel journalists and bankers the current study will address this knowledge gap by examining the experiences of bangladeshi frontline workers who tested positive for covid19 moreover as individual viewpoints might vary depending on a persons culture and society it is crucial to explain and comprehend frontline workers experiences in a particular context additionally their untold stories about their work diagnosis isolation sociopsychological vulnerabilities social support and organizational support throughout and after their quarantine will help policymakers and stakeholders design efficient strategies to lessen their workrelated burden and discrimination in bangladesh materials and methods research design using colaizzis phenomenological method we qualitatively analyzed the lived experiences of frontline workers in bangladesh who were identified as covid19positive patients this approach seeks to comprehend peoples daily experiences it identifies common patterns of meaning rather than unique characteristics in the research subjects ensuring the validity of the information gathered from the participants interview outline we developed the interview outline after reviewing pertinent literature and getting feedback from group members at numerous meetings the interview subjects were asked the following questions what was your earlier life before infection how did you come to know about your infection what were your initial responses after identifying yourself as a covid19 patient what were your experiences during the isolation days how did you cope with this situation what aspects of life changed after your recovery from covid19 data collection an email including a consent form and an interview guide was sent to participants who indicated an interest in participating in this study after the participants gave their consent an interview was scheduled and held whenever it suited them the five research team members conducted each interview due to the pandemic the interviews were carried out over the telephone and on online platforms each interview lasted 3560 min and was conducted in bangla with the participants consent all interviews were audio recorded data analysis within 24 h of each interview the team translated the audio recording from bangla to english the first two authors then read each transcript several times to identify significant statements next they took the meaning units from these statements and provided codes after creating a preliminary list of themes that emerged from the diversity of transcripts the connections between themes were established the research team then engaged in frequent online meetings to extrapolate themes and subthemes from the coding finally divergent opinions on the content of the topics were addressed and resolved by a professor with experience in qualitative research we also conducted another interview with the participants to share the studys findings for validation this study followed the ethical agreement of the helsinki declaration the study participants had the right to withdraw from the research at any time in gathering the data we maintained objectivity and built strong bonds with the individuals each participants name was changed to a pseudonym to protect their identity we kept all the information in a passwordprotected google drive storage system that was only available to us results characteristics of the participants our study comprised three medical frontline workers and seven nonmedical frontline workers who had been diagnosed as covid19 patients and were between the ages of 28 and 45 their average age was 34 years three of them provided healthcare services three worked in lawenforcement agencies and bureaucracy and the remaining four worked in the financial sector and print media industries moreover 30 of respondents were single whereas 70 were married in addition seven respondents received treatment at home while three others were admitted to covid19dedicated hospitals the duration of treatment lasted between 14 and 32 days the participants characteristics are outlined in table 1 however we analyzed the lived experiences of covid19positive frontline workers in bangladesh using phenomenological techniques four significant themes and 13 subthemes emerged from figure 1 the analysis of the participants responses is outlined below theme i experiences in a new working environment frontline workers in the covid19 situation encountered numerous challenges in a new work situation that impacted their physical psychological and social wellbeing this theme consisted of three subthemes workload and adaptations maintaining health protocol and social distance and the fear of being infected by others workload and adaptations none of the frontline workers in this study had worked in a pandemic environment like the current covid19 pandemic in bangladesh therefore they had to adapt to the new working situations and policies specially medical frontline workers had to face dire conditions due to their direct involvement in treating covid19 patients in the corona unit in addition because of the increasing number of covid19 patients in bangladesh nonmedical frontline workers were deployed and assigned to different places outside their routine work since i am a government employee i had to go to different places to perform official duties at the beginning of the corona infection in bangladesh i started working to ensure social distancing from the period when the government announced that no more than 10 or 15 people could gather in a place control of public gatherings at various institutions wedding houses religious and social functions to ensure the home quarantine and isolation of expatriates and those who came from outside the district etc were my prime official duties during that time i have been on the field since the beginning of corona highlighting the plight of patients in hospitals including the mismanagement of sample collections the neglect of unsuspected people and the corporate propaganda called corona drug while other stations shut down their crime investigation programs searchlight did not shut down for a single episode maintaining health protocols and social distance most of the frontline workers in this study expressed that they always tried to follow the health rules of the directorate general of health services and world health organization properly initially medical frontline healthcare workers in bangladesh had shortages of personal protective equipments and they had to work long hours in covid19 dedicated isolation units with corona patients so maintaining health protocols were challenging at the beginning but gradually this situation improved however for nonmedical frontline workers it was very difficult to work with complete personal equipment and maintain a social distance because of their nature of work in diverse areas and people when i went to bury corona suspicious persons body i wore full ppe however when i went to the work court or other work i used a mask gloves and head cover it is tough to ensure social distance in bangladesh due to the peoples indifference i tried but could not always maintain it the fear of being infected by others because of the severity of the virus misinformation data nature and workload the survivors experienced fear of contracting the virus in addition most participants feared spreading the virus to their families and close ones as i was the only earning member of my family i always feared being affected by the virus so i tried to maintain necessary precautions like wearing a mask washing my hands frequently and trying to maintain distance as much as possible another participant involved in financial services closely observed a patient with covid19 symptoms who were not granted leave by the authorities as a result she feared going to the office every day according to her statement i was afraid of going to the office regularly one incident in my office that i want to mention here one of our colleagues was suffering from a cold during the lockdown situation although she applied for leave she was not granted it as a result she frequently met all of us and we became horrified theme ii diagnosis this theme centered on survivors experiences of being infected and the diagnosis center three subthemes emerged from this such as the origin of infection physiological symptoms and experiences in the diagnosis center origin of infection those frontline workers whose duty was to provide public services and welfare amidst the severity of covid19 believed that they had been infected because of their frequent visits to public places and contacts the way both of us have done our professional work in dealing with the corona situation we assumed today or tomorrow we would be infected because we did not have the opportunity to stay at home the same was true for another healthcare frontline worker who treated covid19 patients at a private hospital and experienced the tragic loss of three family members due to covid19 as i was taking care of my father like taking him to the icu when he developed severe respiratory problems though i was doing everything with protection of course i thought that i should test myself there was a likelihood that i may have transferred the germ to my other colleagues as i was working with them in the hospital physiological symptoms when the respondents were interviewed the most reported symptoms were fever neck pain headaches coughs body aches and loss of taste and smell as indicators of their general weakness the comments here include examples of the earlier symptoms that the frontline workers reported i had no such symptoms except some minor neck pain however gradually i developed other symptoms and my physical situation worsened my wife and i tested a corona examination on may 11 at bangabandhu sheikh mujib medical university with symptoms of fever headache slight cough and severe pain around the ears figure major themes and subthemes however two respondents stated that they did not display any physical symptoms in their bodies in the initial stages of the disease or even after it was diagnosed even though everything about them was fine they were listed as covid19positive patients after the test even in my case i was certain that i was carrying the germ and infected my wife though i had no such symptoms to be sure of my disease experiences in the diagnosis center when they went to the diagnosis center for a diagnosis those frontline employees involved in government services received tremendous support however even though they were not required to keep queues for providing samples in the medical center one of the respondents described his encounter with the testing facility as follows i did not need to pay any fees for my test as it was free for all government officials i also did not face harassment while doing tests standing in a queue or others instead i went to the hospital filled out a form with some information gave a sample and returned however people from lower socioeconomic backgrounds who worked in the private sector struggled in the diagnosis centers another one commented when i went to the upazilla health complex to do a blood test the doctor left the hospital for having lunch theme iii recovery days this theme covers a significant area of the survivors experiences after identifying themselves as covid19 positive their initial reactions after the test report experiences in the isolation centerhome isolation and coping mechanisms are discussed here this theme includes earlier reactions experiences in isolation centerhome isolation and coping mechanisms earlier reaction fear of death some frontline workers experienced fear of death and anxiety after identifying themselves as covid19 patients however they informed us throughout our conversation that they were fully aware of how bangladeshi family members and relatives consider the corpse of a corona patient as something unpleasant and unexpected when i heard it i felt that the whole sky had broken down on me i might die soon life is very short we are just like guests on this earth after getting the report my whole situation changed i became anxious suddenly my hands and feet were shaking i started thinking about death and afterward depression and emotion while being identified as covid19 patients after the test most of the individuals in this study reported feeling depressed in addition some of them have started to experience emotional instability even one participant with no physical symptoms of illness developed psychological weakness the reason for this is that after the disease was reported they were worried about the severity of the virus and its burden i was broken at first after hearing the news especially when sayda hugged me and cried and said we do not even have a baby however a 35yearold female assistant commissioner of kishorgonj upazilla who initially experienced depression later revealed that she gradually turned her depression into strength i became a little depressed however i convinced myself that if i remained frustrated i would die so i had to convert my depression into mental strength surprisement at least two respondents who had no physical symptoms expressed surprise when they had identified themselves as covid19 positive when we interviewed them they said that they had always kept a social distance been extremely cautious from the beginning and adhered to health regulations they found it difficult to believe because they were certain they had followed the precautionary measure one of the respondents said as i tested only to be sure of my situation but i was astonished seeing that i was also positive while i had no symptoms anxiety about family nearly all participants admitted to becoming extremely concerned for their families after receiving confirmation of their infection this is because they were the primary breadwinners in their household as a result they started to worry about what would happen to their families if the virus harmed them at that time the first thing that came to my mind was my family especially my younger sister i became anxious about my family especially about my little children another respondent who was a nonmedical frontline workers had to keep his sickness a secret from his family he was far away from them and just did not want to upset them according to him i did not tell family members about my infection as i was far away from them i did so because everyone was so afraid and anxious during that time of pandemic outbreak that if anyone was identified as a covid19 patient people believed that that person would die soon or thought that heshe was very prone to death so i decided not to inform my family and relatives because it could make them more sacred prior mental preparation we also found a new situation after our interview the majority of the frontline workers were panicked and became anxious however a 37yearold frontline financial service provider kept her composure despite knowing she was sick this is because prior to becoming ill her family had covid19 survivors therefore she took mental preparation in advance of her infection as well as remained calm knowing the nature and severity of this virus according to her i was not afraid you know it is not a dangerous disease i was conscious only of my smell problem however i got used to this situation because two more people had been infected in our house i saw them closely experiences in isolation care vs denial most of the frontline workers we have interviewed remained in isolation at home only three were admitted to hospitals designed explicitly for covid19 where they were isolated for a minimum of 14 days they consequently experienced positive and negative interactions with the caregivers while in isolation however one of the respondents a police officer said that the hospitals provided adequate healthcare when we asked him about his hospital experiences i was admitted to the district police hospital in sylhet moreover three of my colleagues who were also positive remained in the room the hospital authorities provided us with good treatment and everything that we required they sent every necessary accessory as soon as we informed them over the telephone or mobile phone on the other hand another nonmedical frontline workers shared his bitter experiences while receiving treatment at covid19 dedicated hospital he was shocked that no one not even physicians or nurses had ever seen him physically during his 22 days of isolation in hospitals during our 22 days of hospitalization no doctors nurses or other medical staff ever visited us physically in the hospital but only in some critical situations instead they talked to us over the phone and provided only virtual advice it frustrated me a lot to think that this is happening because we are covid19 patients selfisolation at least two respondents described similar instances of selfisolation from family and friends they internalized their condition and prioritized their family members wellbeing even one of the responders could not go to his fathers burial because he felt that other people would fall in danger of infection i have grief for not attending my fathers funeral but i took the right step at the right moment because my presence could infect others in a way that i could never accept fear dilemma and mental struggle almost all frontline workers experienced various forms of emotional distress in isolation including dilemmas insomnia and fear of deaths one of the frontline workers who was away from her house because of job obligations struggled to sleep and experienced death fears while alone in an isolation room at a government estate she could not communicate with anyone because her home was kept in strict lockdown during her quarantine she asserts since i had trouble breathing almost every night when i went to bed i was afraid that i might not be able to get up in the morning i was scared to death i thought i had these psychological problems because i was living alone another survivor a wellknown journalist and author in bangladesh experienced difficulty uncertainty and emotional stress during his mandatory home quarantine according to him the doctor advised us to avoid social media especially facebook and suggested we be busy with housework and selfcare but unfortunately i did not listen to the doctor but once or twice used facebook later i saw that it truly created anxiety and mental pressure on me especially when you see that everything in the world is running smoothly nothing is stopped because of your illness furthermore a medical professional who cared for coronavirus patients in a private hospital in dhaka shared similar worries with us the doctor told us to follow the routine and to become worryfree but nevertheless is it possible to remain worryfree after all of this i was shocked that even a little gastric pain was short of breath corona was such a mental torture social stigma the covid19 infection had an impact not only on the patients but also on their interpersonal and societal interactions people purposefully avoid covid19 patients due to an overarching fear of infection during their solitude survivors allegedly experienced rejection and ostracism from those who were closest to them at least two of nonmedical frontline workers shared similar stories of denial from their colleagues and close ones when they caught covid19 the building where i live was completely locked down i faced some social stigma after i got sick i heard many officers who worked with me were terrified many of my colleagues around me wanted to escape for example after hearing the news of my infection the naib of my office went to his village he was afraid i might order him to work for me but i think i have faced fewer social vulnerabilities due to my social status than other survivors even families of patients who tested positive for covid19 had to deal with unfavorable behaviors from their kin and neighbors due to this stigmatization a 38yearold doctor who treated corona patients in a private hospital in dhaka had to endure severe repercussions in his opinion as frontline workers we had to give service directly to the covid19 patients when i returned from the hospital i understood that they feared me however when four other members of my family and i were infected with the covid19 virus they completely avoided us another participant a nonmedical frontline workers who lost his father due to covid19 infection shared similar stories of being stigmatization by his neighbors he also claimed that owing to stigma he could not even convince anyone to hold the corpse after his fathers death the same rejection events occurred when he got infected according to him when the villagers learned about my fathers disease they started to treat us like wild animals even when my father died none of my neighbors visited our home and there was no one to hold the corpse bed after that they stopped coming to our pond to take a bath when i got infected coping mechanism change in diet the majority of patients who received treatment at home altered their diet plans they thought eating a lot would make them more prone to the illness some respondents stated that they also regularly engaged in breathing exercises steamed hot baths and sunbathing all of which assisted their recovery from the infection according to the doctors advice i ate nutritious foods like milk eggs fish meat lemons and vitamin c daily i also took hot water vapor and followed the hygiene rules prayer and listening to wazz bangladesh has a large muslim population during times of isolation faith in god and practicing religion were very effective coping mechanisms for the survivors nearly everyone we had a conversation claimed that their faith in god helped them find relief from their sufferings according to one of the respondents most of the time of the day i prayed salah and recited dua as i was free from all worldly activities i concentrated more on religious activities that gave me relief another participant who received treatment at a covid19dedicated hospital regularly listened to various religious lectures on youtube which provided him with moral support to recover music movies and reading books most of the frontline workers admitted that they avoided social media sites while remaining in isolation because it created anxiety and mental pressure upon them one of the nonmedical frontline workers asserted that he became mentally more vulnerable when he found everything around him was okay except him while scrolling into facebook however most of the frontline workers passed their isolation times by watching movies reading books and a few of them involved in gardening i did not use social media i read books walked around the house watched funny movies and spent time gardening netflix and amazon prime helped me overcome this challenge in series like breaking bad picky blinders house of cards walterjesses math lab celian murphys outstanding performance and the political intelligence of the underwood family i forgot i had a fatal illness telemedicine before this pandemic the general people of bangladesh were not comfortable with telemedicine services but due to the shortage of covid19 designated beds in public and private hospitals telemedicine services became very popular among the patients who received care remaining at home three individuals in our study also regularly consulted with their doctors about their health related problems over the phone which helped them recovering from this disease according to one of the respondents we decided to take treatment from home until the situation worsens in that case we need to be under the supervision of a specialist doctor doctor x provided us treatment via telemedicine regularly selfmotivation due to the severity and concealed nature of covid19 at the initial stages of infection bangladeshi people notably frontline workers were more susceptible in addition a couple of the individuals we interviewed said that their family was their source of mental strength aiding their recovery from this illness one of the frontline worker who was kept in isolation in her government estate describe this situation as i have done selfcounseling by convincing myself that many people depend on me so i have to live for my siblings and my familys future this mental strength has inspired me to recover social support almost all of the frontline workers received immense support from their family members and relatives which helped them to recover quickly even if in some instances the family members were not physically present while they were in the hospital or home isolation their supportsuch as food comfort and religious guidancewere tremendously helpful in enabling them to heal and cope although i was in a covid19 dedicated hospital in an isolation room i received immense support from my family whenever i talked with my wife over the phone she told me not to be afraid she motivated me in such a way that i am going to recover very soon even she took care of my family children and business in my absence some survivors also received much help from their colleagues office managers and friends which was a huge help in their recovery one of the respondents who was admitted into a covid19 dedicated hospital along with four other colleagues stated that because of their shared experiences they could help one another and manage the situation even while remaining in a segregated unit as said as we were living together in a hospital room it was great to support us all when we felt upset we gossiped with one another had fun and joked and shared our grief to maintain social distance it worked great to recover from our psychological hardship and effectively overcome our trouble it had a tremendous impact on us that would not have been possible if i had stayed alone in a room although most frontline workers reported having their neighbors denied and rejected them an author and journalist told us that his house owner offered adequate support and cooperation when the couple became infected due to their comparative higher social status and their connections with the power structure they were most privileged even in the age of covid19 but the general situation is completely different in bangladesh according to the respondents we informed the homeowner at the outset so that no one got panicked he helped us a lot from the beginning he provided us with food fruits and bottled water in addition to the constant search he also hired a doorman who would bring emergency supplies and take down the garbage can theme iv postcoviddays following their recovery survivors also reported postcovid19 physiological and psychological issues such as chest pain sleep issues anxiety and shortness of breath as well as specific social issues such as financial loss however they also started to view life more optimistically there are four subthemes under this main theme excitement fear and confusion physiological problems financial stress and changes in philosophy excitement fear and confusion survivors undoubtedly felt joy when they returned to normal life although medicalfrontline workers had to return to their previous job as there was scarcity of physicians and nurses in covid19 dedicated hospitals in bangladesh however some participants concurred that they were afraid of spreading the virus to others after they were fully recovered therefore they stayed away from places where the public congregates like bazaars tea shops and playgrounds when we questioned why they felt this way they admitted that their test results had left them perplexed during the pandemic some private hospitals and clinics issued fake corona test results which led to significant discrepancies according to them after recovery i tried to avoid visiting public places like bazaars tea stalls or friends houses because i was scared if someone would be infected by me again so i tried to maintain all medical rules when communicating with others when i fully recovered i could not believe in myself i wanted to meet my friends and close ones however you know i was frightened of mixing with them i have little trust in corona testing so i do not want to put anyone at risk some survivors also experienced negative attitudes from their neighbors even after their recovery from the covid19 virus despite being healed their bodies were marked as something to be afraid of as a result neighbors tried to avoid them for fear of contracting an infection according to one of the respondents even after the report came back negative many people stayed far away from me so i do not know if it was for awareness or if people were scared of me physiological problems the survivors experienced various physiological problems following their recovery for instance among the survivors breathing difficulties respiratory issues weakness etc were frequent in addition one survivor informed us that for a month he could not move from one place to another owing to physical sickness even after recovery i often had shortness of breath i still have some respiratory problems and have also reduced my 4 kg weight financial stress corona is a substantial financial burden on patients although those frontline workers we interviewed were comparatively remained in a better socioeconomic condition rather than the general population in bangladesh but they reported having some form of financial hardship to support their families after recuperation one of the participants who was a doctor lost his job due to corona infection to her surprise there has been some economic loss the prices of daily necessities including masks sanitizers fish meat and eggs have increased significantly as a result family expenses have increased immensely changes in philosophy the participants returned to their everyday lives when the swab test results were reported as negative corona improved most of the survivors outlooks but a few of them who were highly educated were still uncertain about their sources of infection and the importance of mask in preventing corona virus this is against our general beliefs about those who are illiterate are more suspicious and superstitious about the severity of corona virus one of the nonmedical frontline workers assert as i do not believe a mask can protect us from corona however participants also claimed that they developed a stronger spiritual bond with god due to their covid19 experience they prayed to god frequently while in the hospital and formed regular prayer routines for example one of the respondents who was agnostic now became a devoted follower of religion according to him although from the beginning i was conscientious i was infected it surprised me a lot and i realized it was allahs will therefore i have developed a firm belief in the almighty that led me to be involved in religious rituals during my hospital days discussion we analyzed the lived experiences of bangladeshi covid19positive frontline workers in this study we have identified four major themes and 13 subthemes from this study in summary our study showed that frontline workers in bangladesh faced significant physiological psychological and social challenges while working in a new covid19 environment thus when they contracted the infection and were isolated at home or in a hospital unit they experienced anxiety fear wrath frustration and stigma however they could quickly deal with this adverse situation by altering their eating habits relying on telemedicine for assistance being selfmotivated having social support and enjoying movies the research also revealed that frontline workers continued to experience physical emotional economical and social sufferings after fully recovered in addition when experiencing financial crisis and stigma they emphasized more on religiosity which in turn helped them to overcome those hardships similar themes emerged from another study on indonesian frontline nurses who were kept in quarantine because of their infection to begin with our study reveals that since the beginning of the covid19 pandemic bangladeshi frontline workers have been facing immense physical psychological and social challenges because of the changing working environment their fear of infection and separation from family and close friends although they tried to maintain health protocols and social distance from the beginning however nonmedical frontline workers told us that it was quite possible for them to maintain appropriate social distance as they had to render direct services to the general public for various reasons even during the period of national lockdown for example nonmedical frontline financial service workers had to regularly provide banking services to the general population as a result among bangladeshs frontline workers fear of infection trauma distress worry misinformation and social stigma are more prevalent we also found similar findings in previous research in bangladesh and across the world secondly it was evident from the findings that most of the nonmedical frontline workers were infected by this virus because of their frequent visits to different public gatherings on contrary medical frontline workers were reported as infected while working with the corona unit however almost all the frontline workers went to the associated test centers with the physiological symptoms of fever neck pain headaches coughs body aches and loss of taste and smell which are in line with the clinical signs of sarscov2 infection besides some frontline workers became very surprised that even though they had no physical symptoms they were found positive after the test researchers from the university of illinois at chicago found similar cases in their study patel et al found that of thirty five infected cases thirteen never posed any symptoms moreover due to misinformation fake covid19test reports of some private hospitals and media some frontline workers of this study expressed their concern and confusion about the diagnosis process in addition most of the medical and nonmedical frontline workers received adequate treatment facilities from both the test centers as well as the covid19 dedicated hospitals due to their upper socioeconomic profiles in bangladesh thirdly our study participants also revealed that fear of death anxiety depression and frustrationwere their immediate reactions after identifying themselves as covid19positive patients these findings are also consistent with taylor et al and liu q et als studies from liu et als study we came to know that in hubei china more than 3000 healthcare providers were infected by the coronavirus at the initial stage which caused trauma and fear among all the frontline workers across the world another uk based survey study revealed that compared to the general population frontline health care providers experienced higher levels of anxiety and depression after being infected on contrary our study revealed that some frontline workers in bangladesh felt less stressed as they had prior mental preparation about the severity of this virus again this study showed that most of the frontline workers we interviewed remained in isolation at home during their recovery days only a few went to the governments dedicated covid19 hospitals where they stayed in complete isolation units along with other covid19 patients as there is scarcity of covid19 dedicated beds and people are not comfortable with remaining in isolation like the general populations frontline workers tended to receive treatment staying at home similarly in philippines it was found that covid19 survivors are more reluctant to stay at home than at the isolation center the data showed that bangladeshi frontline workers had received good care at the covid19 dedicated hospitals because of their upper socioeconomic status on the other hand some of the nonmedical frontline workers were denied facetoface treatment by the healthcare providers because of the fear of infection and stigma which is pertinent to studies conducted in india research in india also reported that some patients are stigmatized because they are covid19 patients as a result some frontline workers in bangladesh were also found to hide their disease from their friends relatives neighbors and even family members when they stayed in isolation not only that those who received treatment at home experienced fear anxiety sleepiness stress depression and stigmatization during their recovery days which are also consistent with a study conducted by fawaz and samaha over the quarantined frontline nurses in lebanese apart from this some frontline workers believed that remaining in home isolation surrounded by the family members might positively impact on their recovery process some studies also showed that positive emotions and hope play an essential role in a patients recovery furthermore frontline workers various coping mechanisms during their recovery days are also evident in this study most frontline workers coped with this adverse situation by altering food habits relying on telemedicine religiosity having social and organizational support and engaging in recreational activities we also found that nurses in saudi arabia and qatar considered changing their eating habits a solid coping mechanism against this virus again like this study studies conducted in indonesia and the philippines substantiated strong positive connections between religion and mental health as most of the frontline workers in this study were muslim they felt a strong connection with god which worked like a placebo effect on their healing process besides some of the frontline workers mentioned that music movies and books were influential sources of coping strategies for stress management during isolation the influence of music on reducing stress for quarantined covid19 patients is also evident in some studies in addition support from family members friends colleagues and neighbors were also mentioned as strong coping mechanism by the bangladeshi frontline workers the association between social support and healing is also consistent with previous studies although government of bangladesh declared institutional supports for the covid19 infected frontline workers none of the frontline workers received any organizational support of this study besides no one in this study required any psychotherapy or counseling for their recovery which was evident in other countries even in bangladesh according to the survivors experiences strict isolation is not recommended for the survivors healing because it creates more anxiety loneliness and fear among the patients henceforth social and organizational support could be the best coping strategies for the covid19 frontline workers in bangladesh therefore future researchers in bangladesh might investigate the impact of social and organizational support on the healing process of covid19 survivors lastly the study revealed that frontline workers in bangladesh faced several psychological and physiological challenges even after being fully recovered from the virus likewise guo et al in their study also found that fatigue shortness of breath fear trauma and stigma are common to many medical frontline workers after their recovery similar results are also found in some studies conducted in the uk and wuhan in china meanwhile our respondents also mentioned that they also faced various social and economic crisis in their postcovid19 days which is also consistent with some other studies across the world strengths and limitations this study has some limitations due to the spread of the virus across the nation it was first and foremost impossible to conduct facetoface interviews in all instances so again we only conducted ten interviews which do not represent the whole population earlier we had disagreements about our study participants generally healthcare providers eg doctors and nurses are considered frontline workers however we believe defining frontline workers is not specific but contextualized hence after getting inspiration from the definition given by rana and islam in their recent study we included law enforcement agencies bureaucrats bankers and journalists along with healthcare providers as frontline workers in our study therefore our studys conclusions cannot be applied to any specific group of bangladeshi frontline workers despite all of these limitations to the authors knowledge the current study is one of the first to analyze the lived experiences of positive covid19 frontline workers in bangladesh providing indepth detailed information on their particular experiences of suffering and coping mechanisms implications despite all the limitations this paper provides comprehensive insights for the policymakers firstly healthcare policymakers should design health policies based on the social setting of bangladeshi society in bangladesh there is a practice to follow and copy policies from the developed countries blindly without considering their relevance lockdown without a social safety net program to combat covid19 was not fruitful in bangladesh secondly stigma can negatively affect the victims leading to isolation depression anxiety or public embarrassment stigmatized individuals usually hide symptoms of their illness and restrict themselves from taking medical care this behavior might create challenging situations to control the spread of any pandemic therefore health policymakers should develop sustainable behavioral change programs to combat the social stigma associated with public health lastly policymakers should develop a robust monitoring mechanism to eradicate discrimination regarding ones socioeconomic status when getting medical services this type of discrimination is a violation of constitutional rights conclusion in any epidemic or pandemic frontline workers suffer psychologically and socially the lived experience of this cohort depends on various interactions between demographics and socioeconomic status therefore they urgently need guidance for physical rehabilitation psychological growth social support and protection from social stigma although across the world including bangladesh frontline workers mental health conditions are studied their everyday lived experiences as covid19 survivors are merely studied this study provides a comprehensive and indepth insight into the lived experiences of frontline workers this study thus has other policy implications for bangladesh this study is significant for healthcare policymakers in planning healthcare management systems based on the social settings of bangladesh society this paper also suggests that national policymakers implement longterm behavioral change programs to reduce social stigma at the same time it suggests the government end discrimination regarding an individuals socioeconomic status to get medical assistance data availability statement latest version of data will be available at doi 1017632ymwydhvztj2 ethics ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their 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the whole sky has broken down on me i might die alone a qualitative study on the lived experiences of covidpositive frontline workers in bangladesh

Introduction The SARS-CoV-2 pandemic has spread around the globe [1] with millions infected and hundreds of thousands dead [2]. Apart from health consequences, it presents a significant economic burden that cannot be underestimated [3]. Considering these facts, governments and decision-makers have to focus on the transmission of the virus. Hence, they had to regulate everyday life by limiting contacts and the mobility of the population [1], whilst simultaneously taking care of the economy. With more knowledge about SARS-CoV-2, it became clear that the development of a vaccine is crucial to fight the pandemic and return to normal life [4]. Although vaccination is one of the most effective public health interventions [3,5], the challenge for policymakers is to encourage people to receive the vaccine and, in the case of COVID-19, to develop herd immunity [1]. Nonetheless, vaccine hesitancy and refusal are significant in many societies. Hence, the World Health Organization recently placed them in the top ten threats to global health [5][6][7]. For example, even though a well-known vaccination against influenza leads to a lower incidence of seasonal influenza-related respiratory diseases, lower costs, and reduced deaths, mainly among the elderly population, the vaccination coverage differs between countries [8]. For instance, low coverage was recently observed in Poland: during the 2016-2017 influenza season, it was 3.3% for the entire population. Nonetheless, similar results were noticed in other Central European countries such as Romania , Slovenia , or Estonia [9]. In the UK, however, the vaccination coverage was about 50% [9], and this result was convergent with the coverage reached in the USA. In the 2019-2020 influenza season, it was 48.4% among Americans who were more than 18 years old [10]. However, during the next season and in the time of the second and the third COVID-19 wave, influenza vaccination in elderly people increased in many countries, including, e.g., Italy , England , Poland , the Philippines , and the USA [11]. According to the study conducted by Dror et al. [7], people vaccinated against seasonal influenza have a clear and strong acceptance of a COVID-19 vaccine. Without such acceptance, conspiracy theories against vaccines develop. People are more likely to believe them when they feel anxious, in a time of crisis, and when faced with global events with several consequences, such as the COVID-19 pandemic [12]. Hence, we decided to conduct a survey related to seasonal influenza and COVID-19 vaccinations in three Central and Eastern European countries , of which Poland and Lithuania are European Union members and Ukraine is outside of the EU. Although these countries are neighboring and located in Central and Eastern Europe, they have essential differences. These are related to economic and geopolitical facets, and result from facts such as EU membership or population. Therefore, we assumed that the results of such analysis would be interesting both for the local and international readers or healthcare decision-makers. We aimed to evaluate societal attitudes towards influenza and COVID-19 vaccinations, and to examine the reasons for agreeing to or refusing to be vaccinated. We also intended to check the relationship between immunization against influenza in 2020-2021 and willingness to be vaccinated against COVID-19. --- Materials and Methods The study was conducted between December 2020 and May 2021, at a time when the countries which are the subjects of the research were between the second and third waves of the COVID-19 pandemic. We also tried to conduct the study in Latvia, but the obtained sample size was very low , and we decided to exclude the country from further analysis. An anonymous and self-designed questionnaire comprised of eleven closed-ended questions and a short socio-demographic section was one of the study tools. Questions concerned the same issues in each language version. We authored the questionnaire based on observation of the pandemic development, the literature, and our own market and healthcare experiences. Due to this fact, ten potential participants evaluated the study tool and then translated it into local languages before the actual analysis. This made it possible to assess whether the study tool was straightforward. Ultimately, these questionnaires were not included, because after this preliminary part of the study, we amended and simplified some points of the questionnaire. For instance, in questions concerning obligatory vaccinations , we decided to offer an answer describing people "from the risk group" instead of presenting seniors, teachers, and medical staff individually. In question 7, we added information about the PCR test in square brackets in order to clarify the question and COVID-19 infection. The final questions content and possible variants of answers are presented in Table 1. In each country, we only collected answers from those ≥16 years old. Participation was voluntary and personal data were not requested. We offered no incentives for participation. The questionnaire was administered by direct contact or mainly by e-mail or Facebook. Out of the 4849 gathered answers, we excluded 31 questionnaires ; for example, if no information was provided in the socio-demographic section or if participants did not answer some queries. In the case of online questionnaires, all responses were required to complete the study. Finally, we included 2753 answers from Poland, 1852 from Ukraine, and 213 from Lithuania. --- Results We decided to present most of the obtained results within tables, making this section, in our opinion, clearer and more reader-friendly. The leading groups of study participants were students or individuals about thirty years old . Between 61% and 72.9% of the study participants have never been vaccinated against influenza and almost the same number of negative answers concerned the willingness to be vaccinated against influenza in autumn/winter of 2020/21 . Detailed results are presented in Table 3. Contrary to in Lithuania, in Poland and Ukraine we observed a statistically significant difference analysing for responses to question 1 if we considered whether the studies/work of our respondents are related to healthcare. Compared to UE countries, in Ukraine 12% more participants claimed that vaccination against influenza should not be obligatory . The "Agree, but only for those from the risk group" option was chosen by 29% of respondents in Poland, 27.70% in Lithuania, and 16.3% in Ukraine. In Poland and Ukraine, we observed strong statistical significance between studies/work in healthcare and acceptance of obligatory influenza and COVID-19 vaccinations. In Lithuania, this held true only for influenza. Interestingly, in each country there was statistical significance between a patient's history of vaccination against influenza and willingness to be vaccinated against COVID-19, as well as acceptance of an obligatory COVID-19 vaccination . An analysis of COVID-19 infection history and willingness to be vaccinated against COVID-19 revealed statistical significance in Poland and Ukraine with p < 0.001 and p = 0.002, respectively. In Lithuania, p was 0.057. However, an analysis of COVID-19 infection history and the respondents' opinions about the obligation to vaccinate against COVID-19 revealed statistical significance in Poland and Lithuania , unlike Ukraine, where p was 0.223. In the section of the questionnaire dedicated to COVID-19, most respondents indicated that they have not tested positive for the coronavirus . Despite this, 67.6% of Polish respondents answered that they would like to be vaccinated against COVID-19. In Lithuania, 73.71% of answers to that question were affirmative. However, in Ukraine, 29.5% of responses were positive, and the rest of the respondents would not like to be vaccinated against COVID-19. We observed a statistically significant difference in this question: Poland vs. Lithuania, and Ukraine with p < 0.001. The difference was greater when it came to mandatory vaccination against COVID-19 with 67% apparent opponents in Ukraine, compared to 41.7% in Poland, and 30.99% in Lithuania . In both EU countries, more than 40% of responses were clearly positive. The "Agree, but only for those from the risk group" response was chosen by 17.2% of study participants in Poland, 24.41% in Lithuania, and 16.1% in Ukraine. We revealed a statistically significant difference for p < 0.05 between countries when comparing the answer "Agree" and "Agree, but only for those from the risk group" with p = 0.137. Due to the severity of answers obtained in questions 3, 4, 5, 9, and 10, we decided to present the three most frequent responses to these questions . --- Discussion The most important findings of our study are set forth below. There is low vaccination coverage against influenza in Poland, Lithuania, and Ukraine. However, a better coverage rate in the previous influenza season was made impossible by vaccination shortages. The willingness to be vaccinated against COVID-19 was distinctly lower in Ukraine than in the analysed EU countries. There are noticeably more opponents to obligatory vaccinations against COVID-19 and influenza in Ukraine than in Poland and Lithuania . There is a correlation between influenza vaccinations and the acceptance rate for COVID-19 vaccinations. According to the Patwardhan and Ohler study [13], the vaccine against influenza has already earned scepticism. It concerns the efficacy, disbeliefs and misconceptions about the safety and vaccine-hesitancy over the years. It may partially explain the low flu vaccine coverage in the countries analysed in the study [8,9]. Nevertheless, we revealed that in autumn 2020, when a vaccine against COVID-19 was still not available, almost 20% more respondents in Poland, 17% in Lithuania, and 12.5% in Ukraine wanted to be vaccinated against seasonal influenza than those who were actually vaccinated. For example, the interest in influenza vaccinations could have resulted from the fact that the flu vaccine was considered to afford protection against COVID-19 [14][15][16][17]. Considering that EU member states are trying to attain good influenza vaccination coverage, with an expected rate of 75% amongst the elderly population, for example [8], the influenza season was a great chance to boost the vaccination coverage in the analysed countries, bringing them closer to the level reached in the UK, or the USA [9,10], where a 75% coverage rate was exceeded during the 2020-2021 season [11]. However, the insufficient market stock of vaccines might be the result of drug shortages. This phenomenon arises from several facets such as disparities in drug prices among EU countries or the reverse traffic of medicines [18]. Nonetheless, it seems that all pharmaceutical market stakeholders had time to provide an adequate stock of flu vaccines in autumn 2020. In the societies of the analysed countries, an interest in vaccinations was already observed during the first wave of the pandemic and in the months preceding autumn. Notably, better coverage in immunization against seasonal influenza would also positively impact the attitude to COVID-19 vaccinations. Studies have shown that the best predictor of the uptake of a pandemic vaccine is the administration of an influenza vaccine in the previous season [1,7,14]. This was also confirmed by our study. Moreover, Patwardhan and Ohler [13] revealed that patients who received seasonal influenza vaccinations were less likely to develop symptomatic and severe infections. In turn, Conlon et al. [14] noticed that the percentage of patients who tested positive for COVID-19 was 0.9% lower among those who had received an influenza vaccine between 1 August 2019 and 15 July 2020. Conlon et al. and Zanettini et al. also observed an association between flu vaccination and reduced COVID-19 mortality, decreased need for intensive care treatment, as well as invasive respiratory support [14,16]. Nonetheless, vaccine availability does not guarantee a sufficient population vaccination rate, as shown by vaccine hesitancy [7]. Disbeliefs, conspiracy theories, and vaccine hesitancy became a real challenge in the fight against COVID-19. We also revealed that in the analysed countries, the main reason for unwillingness to be vaccinated against COVID-19 was fear of vaccine safety. This was followed by general disbelief in vaccines or a conviction that one is not in a risk group. The above confirms the need for uninterrupted societal education on COVID-19 and vaccinations [7]. It is also concurrent with the results of our study, where participants claimed that better knowledge about the vaccine composition and production process, as well as more extended market availability , may change their negative attitude towards COVID-19 vaccinations. Contrary to respondents from Ukraine , almost 68% in Poland and 74% of participants in Lithuania claimed that they would receive a COVID-19 vaccine if it only were to become available [19]. The difference observed between EU countries and Ukraine may result from the fact that in Poland, 61.2% of study participants were engaged in the provision of healthcare. In Lithuania, it was 53.5% and in Ukraine 38.4%. Moreover, the reluctance to be vaccinated against COVID-19 in Ukraine may also result from the geopolitical facets and the vaccine origin. Many Ukrainians present pro-Western attitudes, which are also visible in their approach to vaccines. Almost 70% of them do not trust the Chinese vaccine, and more than 80% do not trust the Russian one, whereas their acceptance for vaccines from the US or UK is higher [20,21]. Nonetheless, the acceptance rate gained in EU countries participating in our study is convergent with the result obtained in the USA by Mercadante and Law [19]. However, in the Middle Eastern population, COVID-19 vaccination acceptance was lower than in the analysed EU countries, but still higher than in Ukraine [3]. These differences may also result from the impact of social media on attitudes towards vaccines. Disbeliefs, misinformation, and unsubstantiated rumours, both about the pandemic and vaccination against COVID-19, have already begun to emerge on social media before the actual release of an effective vaccine [5]. Moreover, Earhshaw revealed that people who believed conspiracies trusted misinformation about COVID-19 from social media to a greater extent than participants who disbelieved them [12]. Besides, social media recently became a primary and trustworthy source of health information [22,23], making it an unstoppable communication tool. Extensive anti-vaccine content is often shared across social media. Exposure to such misinformation may directly fuel vaccine hesitancy [5]. Betsch et al. revealed that contact with vaccine-critical websites and blogs negatively impacts the intention to vaccinate [24]. Besides, amongst the top YouTube videos related to COVID-19 and the coronavirus, 27.5% contained non-factual information and had tens of millions of views [5]. Considering that the study participants were young adults in general, they were more likely to use social media. This may explain the worries presented by vaccine non-adopters who participated in our study. Respondents were mainly afraid of vaccine safety. They also believed that they were not in a risk group or did not believe in vaccines. This confirms the need for several actions [8] to overcome barriers of mistrust in the community and boost the role of trustworthy information presented by experts and health professionals about vaccine composition, manufacture, administration, and safety [25]. Although mandatory vaccination against COVID-19 might be considered controversial, we revealed a surprisingly high acceptance rate for it in Poland and Lithuania, with 41.7% and 44.6% in favour, respectively. In Ukraine, the acceptance rate was lower. A few months after we finished the study , some countries introduced mandatory vaccinations. Interestingly, in Tajikistan and Turkmenistan, vaccination against COVID-19 is obligatory for all adults. In countries like France, Italy, or the US, vaccines are compulsory for certain adults and sometimes in certain areas [26]. In many countries, including Poland, there are consultations and political discussions concerning mandatory vaccination for frontline health and social care staff [27]. Obligatory vaccinations for selected professional groups seem to have a higher acceptance rate in communities. In our study, the mandatory vaccination only for those from a selected professional risk group was chosen by 17.2% more Polish and 24.41% more Lithuanian participants than those who declared their support to obligatory vaccinations in general. In Ukraine, however, this option was accepted by 16% of respondents. Although mandatory COVID-19 vaccinations imply serious ethical hurdles, widespread acceptance of COVID-19 vaccines is crucial for achieving herd immunity and ending the global pandemic [28]. Thus, vaccination campaigns should focus on societal education in order to overcome the disbeliefs and vaccination mistrust created by very active groups which frequently use social media, for example, to promote non-factual information. --- Limitations It would be valuable to include more seniors in our study. However, it was difficult to add them into the study group due to limited contact possibilities; for example, older people are frequently unfamiliar with online communication. Although the discrepancy between the number of answers included in the following countries may seem to influence the results, there are differences in the population of analysed countries: 38 million, 42 million, and 2.8 million inhabitants in Poland, Ukraine, and Lithuania respectively. Thus, the presented difference seems to justify the comparability of the gathered questionnaires. Besides, we are aware that the study could benefit from the participation of respondents from other EU and non-EU countries. It would also be interesting to ask about personal beliefs on given vaccinations using their commercial names, such as "Sputnik", "AstraZeneca", or "Moderna". --- Conclusions Although the COVID-19 pandemic has significant health and economic consequences, many people present vaccine hesitancy or are opposed to vaccines. Thus, societal education is needed on the severity of possible side effects, their comparison with the side effects of other medicines , and the vaccine production process. It will also help in suppressing the scope of non-factual information, such as that coming from social media, for example. Vaccine hesitancy or refusal might also be related to vaccine origin and political facets. Shortages of influenza vaccination made it impossible to vaccinate those who were determined to be vaccinated. Considering that vaccination against seasonal influenza might also afford protection against COVID-19, full and fair access to vaccinations should be a priority for healthcare decision-makers. There is room for discussion about mandatory COVID-19 vaccinations, even for selected groups of workers. --- Institutional Review Board Statement: Ethical review and approval were waived for this study due to the fact that the study is not a medical experiment and according to the Polish law nad GCP regulations this research does not require approval of the Bioethics Committee at Poznan University of Medical Sciences. Informed Consent Statement: Not applicable. ---

The SARS-CoV-2 pandemic affected the entire world and contributed to severe health and economic consequences. A safe and effective vaccine is a tool allowing the pandemic to be controlled. Hence, we aimed to conduct a survey on vaccinations against seasonal influenza and COVID-19 in Poland, Lithuania, and Ukraine. We also evaluated societal attitudes towards influenza and COVID-19 vaccinations. Materials and methods: We conducted the study between December 2020 and May 2021. At the time, the countries subject to the research were between the second and third waves of the COVID-19 pandemic. We used an anonymous and self-designed questionnaire comprised of eleven closed-ended questions and a short socio-demographic section. The questionnaire was administered by direct contact or mainly (due to the COVID-19 pandemic) by e-mail or Facebook. Finally, we included 2753 answers from Poland, 1852 from Ukraine, and 213 from Lithuania. Results: Between 61% (Poland) and 72.9% (Ukraine) of the study participants have never been vaccinated against influenza (p < 0.05). Totals of 67.6% of the respondents in Poland, 73.71% in Lithuania, and 29.5% in Ukraine responded that they want to be vaccinated against COVID-19 (p < 0.05). Vaccine hesitancy was mainly related to worries about its side effects. There were also vaccine non-adopters in the study. In Ukraine, 67% of the respondents were clearly opposed to mandatory COVID-19 vaccines, compared to 41.7% in Poland and 30.99% in Lithuania (p < 0.05). Conclusions: There are still many people who present vaccine hesitancy or are opposed to vaccines. Thus, societal education about vaccination and the pandemic is crucial. Vaccine hesitancy or refusal might be related to vaccine origin. Shortages of influenza vaccines made it impossible to vaccinate those who were determined to be vaccinated. There is room for discussion of mandatory COVID-19 vaccinations.

introduction the sarscov2 pandemic has spread around the globe 1 with millions infected and hundreds of thousands dead 2 apart from health consequences it presents a significant economic burden that cannot be underestimated 3 considering these facts governments and decisionmakers have to focus on the transmission of the virus hence they had to regulate everyday life by limiting contacts and the mobility of the population 1 whilst simultaneously taking care of the economy with more knowledge about sarscov2 it became clear that the development of a vaccine is crucial to fight the pandemic and return to normal life 4 although vaccination is one of the most effective public health interventions 35 the challenge for policymakers is to encourage people to receive the vaccine and in the case of covid19 to develop herd immunity 1 nonetheless vaccine hesitancy and refusal are significant in many societies hence the world health organization recently placed them in the top ten threats to global health 5 6 7 for example even though a wellknown vaccination against influenza leads to a lower incidence of seasonal influenzarelated respiratory diseases lower costs and reduced deaths mainly among the elderly population the vaccination coverage differs between countries 8 for instance low coverage was recently observed in poland during the 20162017 influenza season it was 33 for the entire population nonetheless similar results were noticed in other central european countries such as romania slovenia or estonia 9 in the uk however the vaccination coverage was about 50 9 and this result was convergent with the coverage reached in the usa in the 20192020 influenza season it was 484 among americans who were more than 18 years old 10 however during the next season and in the time of the second and the third covid19 wave influenza vaccination in elderly people increased in many countries including eg italy england poland the philippines and the usa 11 according to the study conducted by dror et al 7 people vaccinated against seasonal influenza have a clear and strong acceptance of a covid19 vaccine without such acceptance conspiracy theories against vaccines develop people are more likely to believe them when they feel anxious in a time of crisis and when faced with global events with several consequences such as the covid19 pandemic 12 hence we decided to conduct a survey related to seasonal influenza and covid19 vaccinations in three central and eastern european countries of which poland and lithuania are european union members and ukraine is outside of the eu although these countries are neighboring and located in central and eastern europe they have essential differences these are related to economic and geopolitical facets and result from facts such as eu membership or population therefore we assumed that the results of such analysis would be interesting both for the local and international readers or healthcare decisionmakers we aimed to evaluate societal attitudes towards influenza and covid19 vaccinations and to examine the reasons for agreeing to or refusing to be vaccinated we also intended to check the relationship between immunization against influenza in 20202021 and willingness to be vaccinated against covid19 materials and methods the study was conducted between december 2020 and may 2021 at a time when the countries which are the subjects of the research were between the second and third waves of the covid19 pandemic we also tried to conduct the study in latvia but the obtained sample size was very low and we decided to exclude the country from further analysis an anonymous and selfdesigned questionnaire comprised of eleven closedended questions and a short sociodemographic section was one of the study tools questions concerned the same issues in each language version we authored the questionnaire based on observation of the pandemic development the literature and our own market and healthcare experiences due to this fact ten potential participants evaluated the study tool and then translated it into local languages before the actual analysis this made it possible to assess whether the study tool was straightforward ultimately these questionnaires were not included because after this preliminary part of the study we amended and simplified some points of the questionnaire for instance in questions concerning obligatory vaccinations we decided to offer an answer describing people from the risk group instead of presenting seniors teachers and medical staff individually in question 7 we added information about the pcr test in square brackets in order to clarify the question and covid19 infection the final questions content and possible variants of answers are presented in table 1 in each country we only collected answers from those ≥16 years old participation was voluntary and personal data were not requested we offered no incentives for participation the questionnaire was administered by direct contact or mainly by email or facebook out of the 4849 gathered answers we excluded 31 questionnaires for example if no information was provided in the sociodemographic section or if participants did not answer some queries in the case of online questionnaires all responses were required to complete the study finally we included 2753 answers from poland 1852 from ukraine and 213 from lithuania results we decided to present most of the obtained results within tables making this section in our opinion clearer and more readerfriendly the leading groups of study participants were students or individuals about thirty years old between 61 and 729 of the study participants have never been vaccinated against influenza and almost the same number of negative answers concerned the willingness to be vaccinated against influenza in autumnwinter of 202021 detailed results are presented in table 3 contrary to in lithuania in poland and ukraine we observed a statistically significant difference analysing for responses to question 1 if we considered whether the studieswork of our respondents are related to healthcare compared to ue countries in ukraine 12 more participants claimed that vaccination against influenza should not be obligatory the agree but only for those from the risk group option was chosen by 29 of respondents in poland 2770 in lithuania and 163 in ukraine in poland and ukraine we observed strong statistical significance between studieswork in healthcare and acceptance of obligatory influenza and covid19 vaccinations in lithuania this held true only for influenza interestingly in each country there was statistical significance between a patients history of vaccination against influenza and willingness to be vaccinated against covid19 as well as acceptance of an obligatory covid19 vaccination an analysis of covid19 infection history and willingness to be vaccinated against covid19 revealed statistical significance in poland and ukraine with p 0001 and p 0002 respectively in lithuania p was 0057 however an analysis of covid19 infection history and the respondents opinions about the obligation to vaccinate against covid19 revealed statistical significance in poland and lithuania unlike ukraine where p was 0223 in the section of the questionnaire dedicated to covid19 most respondents indicated that they have not tested positive for the coronavirus despite this 676 of polish respondents answered that they would like to be vaccinated against covid19 in lithuania 7371 of answers to that question were affirmative however in ukraine 295 of responses were positive and the rest of the respondents would not like to be vaccinated against covid19 we observed a statistically significant difference in this question poland vs lithuania and ukraine with p 0001 the difference was greater when it came to mandatory vaccination against covid19 with 67 apparent opponents in ukraine compared to 417 in poland and 3099 in lithuania in both eu countries more than 40 of responses were clearly positive the agree but only for those from the risk group response was chosen by 172 of study participants in poland 2441 in lithuania and 161 in ukraine we revealed a statistically significant difference for p 005 between countries when comparing the answer agree and agree but only for those from the risk group with p 0137 due to the severity of answers obtained in questions 3 4 5 9 and 10 we decided to present the three most frequent responses to these questions discussion the most important findings of our study are set forth below there is low vaccination coverage against influenza in poland lithuania and ukraine however a better coverage rate in the previous influenza season was made impossible by vaccination shortages the willingness to be vaccinated against covid19 was distinctly lower in ukraine than in the analysed eu countries there are noticeably more opponents to obligatory vaccinations against covid19 and influenza in ukraine than in poland and lithuania there is a correlation between influenza vaccinations and the acceptance rate for covid19 vaccinations according to the patwardhan and ohler study 13 the vaccine against influenza has already earned scepticism it concerns the efficacy disbeliefs and misconceptions about the safety and vaccinehesitancy over the years it may partially explain the low flu vaccine coverage in the countries analysed in the study 89 nevertheless we revealed that in autumn 2020 when a vaccine against covid19 was still not available almost 20 more respondents in poland 17 in lithuania and 125 in ukraine wanted to be vaccinated against seasonal influenza than those who were actually vaccinated for example the interest in influenza vaccinations could have resulted from the fact that the flu vaccine was considered to afford protection against covid19 14 15 16 17 considering that eu member states are trying to attain good influenza vaccination coverage with an expected rate of 75 amongst the elderly population for example 8 the influenza season was a great chance to boost the vaccination coverage in the analysed countries bringing them closer to the level reached in the uk or the usa 910 where a 75 coverage rate was exceeded during the 20202021 season 11 however the insufficient market stock of vaccines might be the result of drug shortages this phenomenon arises from several facets such as disparities in drug prices among eu countries or the reverse traffic of medicines 18 nonetheless it seems that all pharmaceutical market stakeholders had time to provide an adequate stock of flu vaccines in autumn 2020 in the societies of the analysed countries an interest in vaccinations was already observed during the first wave of the pandemic and in the months preceding autumn notably better coverage in immunization against seasonal influenza would also positively impact the attitude to covid19 vaccinations studies have shown that the best predictor of the uptake of a pandemic vaccine is the administration of an influenza vaccine in the previous season 1714 this was also confirmed by our study moreover patwardhan and ohler 13 revealed that patients who received seasonal influenza vaccinations were less likely to develop symptomatic and severe infections in turn conlon et al 14 noticed that the percentage of patients who tested positive for covid19 was 09 lower among those who had received an influenza vaccine between 1 august 2019 and 15 july 2020 conlon et al and zanettini et al also observed an association between flu vaccination and reduced covid19 mortality decreased need for intensive care treatment as well as invasive respiratory support 1416 nonetheless vaccine availability does not guarantee a sufficient population vaccination rate as shown by vaccine hesitancy 7 disbeliefs conspiracy theories and vaccine hesitancy became a real challenge in the fight against covid19 we also revealed that in the analysed countries the main reason for unwillingness to be vaccinated against covid19 was fear of vaccine safety this was followed by general disbelief in vaccines or a conviction that one is not in a risk group the above confirms the need for uninterrupted societal education on covid19 and vaccinations 7 it is also concurrent with the results of our study where participants claimed that better knowledge about the vaccine composition and production process as well as more extended market availability may change their negative attitude towards covid19 vaccinations contrary to respondents from ukraine almost 68 in poland and 74 of participants in lithuania claimed that they would receive a covid19 vaccine if it only were to become available 19 the difference observed between eu countries and ukraine may result from the fact that in poland 612 of study participants were engaged in the provision of healthcare in lithuania it was 535 and in ukraine 384 moreover the reluctance to be vaccinated against covid19 in ukraine may also result from the geopolitical facets and the vaccine origin many ukrainians present prowestern attitudes which are also visible in their approach to vaccines almost 70 of them do not trust the chinese vaccine and more than 80 do not trust the russian one whereas their acceptance for vaccines from the us or uk is higher 2021 nonetheless the acceptance rate gained in eu countries participating in our study is convergent with the result obtained in the usa by mercadante and law 19 however in the middle eastern population covid19 vaccination acceptance was lower than in the analysed eu countries but still higher than in ukraine 3 these differences may also result from the impact of social media on attitudes towards vaccines disbeliefs misinformation and unsubstantiated rumours both about the pandemic and vaccination against covid19 have already begun to emerge on social media before the actual release of an effective vaccine 5 moreover earhshaw revealed that people who believed conspiracies trusted misinformation about covid19 from social media to a greater extent than participants who disbelieved them 12 besides social media recently became a primary and trustworthy source of health information 2223 making it an unstoppable communication tool extensive antivaccine content is often shared across social media exposure to such misinformation may directly fuel vaccine hesitancy 5 betsch et al revealed that contact with vaccinecritical websites and blogs negatively impacts the intention to vaccinate 24 besides amongst the top youtube videos related to covid19 and the coronavirus 275 contained nonfactual information and had tens of millions of views 5 considering that the study participants were young adults in general they were more likely to use social media this may explain the worries presented by vaccine nonadopters who participated in our study respondents were mainly afraid of vaccine safety they also believed that they were not in a risk group or did not believe in vaccines this confirms the need for several actions 8 to overcome barriers of mistrust in the community and boost the role of trustworthy information presented by experts and health professionals about vaccine composition manufacture administration and safety 25 although mandatory vaccination against covid19 might be considered controversial we revealed a surprisingly high acceptance rate for it in poland and lithuania with 417 and 446 in favour respectively in ukraine the acceptance rate was lower a few months after we finished the study some countries introduced mandatory vaccinations interestingly in tajikistan and turkmenistan vaccination against covid19 is obligatory for all adults in countries like france italy or the us vaccines are compulsory for certain adults and sometimes in certain areas 26 in many countries including poland there are consultations and political discussions concerning mandatory vaccination for frontline health and social care staff 27 obligatory vaccinations for selected professional groups seem to have a higher acceptance rate in communities in our study the mandatory vaccination only for those from a selected professional risk group was chosen by 172 more polish and 2441 more lithuanian participants than those who declared their support to obligatory vaccinations in general in ukraine however this option was accepted by 16 of respondents although mandatory covid19 vaccinations imply serious ethical hurdles widespread acceptance of covid19 vaccines is crucial for achieving herd immunity and ending the global pandemic 28 thus vaccination campaigns should focus on societal education in order to overcome the disbeliefs and vaccination mistrust created by very active groups which frequently use social media for example to promote nonfactual information limitations it would be valuable to include more seniors in our study however it was difficult to add them into the study group due to limited contact possibilities for example older people are frequently unfamiliar with online communication although the discrepancy between the number of answers included in the following countries may seem to influence the results there are differences in the population of analysed countries 38 million 42 million and 28 million inhabitants in poland ukraine and lithuania respectively thus the presented difference seems to justify the comparability of the gathered questionnaires besides we are aware that the study could benefit from the participation of respondents from other eu and noneu countries it would also be interesting to ask about personal beliefs on given vaccinations using their commercial names such as sputnik astrazeneca or moderna conclusions although the covid19 pandemic has significant health and economic consequences many people present vaccine hesitancy or are opposed to vaccines thus societal education is needed on the severity of possible side effects their comparison with the side effects of other medicines and the vaccine production process it will also help in suppressing the scope of nonfactual information such as that coming from social media for example vaccine hesitancy or refusal might also be related to vaccine origin and political facets shortages of influenza vaccination made it impossible to vaccinate those who were determined to be vaccinated considering that vaccination against seasonal influenza might also afford protection against covid19 full and fair access to vaccinations should be a priority for healthcare decisionmakers there is room for discussion about mandatory covid19 vaccinations even for selected groups of workers institutional review board statement ethical review and approval were waived for this study due to the fact that the study is not a medical experiment and according to the polish law nad gcp regulations this research does not require approval of the bioethics committee at poznan university of medical sciences informed consent statement not applicable

the sarscov2 pandemic affected the entire world and contributed to severe health and economic consequences a safe and effective vaccine is a tool allowing the pandemic to be controlled hence we aimed to conduct a survey on vaccinations against seasonal influenza and covid19 in poland lithuania and ukraine we also evaluated societal attitudes towards influenza and covid19 vaccinations materials and methods we conducted the study between december 2020 and may 2021 at the time the countries subject to the research were between the second and third waves of the covid19 pandemic we used an anonymous and selfdesigned questionnaire comprised of eleven closedended questions and a short sociodemographic section the questionnaire was administered by direct contact or mainly due to the covid19 pandemic by email or facebook finally we included 2753 answers from poland 1852 from ukraine and 213 from lithuania results between 61 poland and 729 ukraine of the study participants have never been vaccinated against influenza p 005 totals of 676 of the respondents in poland 7371 in lithuania and 295 in ukraine responded that they want to be vaccinated against covid19 p 005 vaccine hesitancy was mainly related to worries about its side effects there were also vaccine nonadopters in the study in ukraine 67 of the respondents were clearly opposed to mandatory covid19 vaccines compared to 417 in poland and 3099 in lithuania p 005 conclusions there are still many people who present vaccine hesitancy or are opposed to vaccines thus societal education about vaccination and the pandemic is crucial vaccine hesitancy or refusal might be related to vaccine origin shortages of influenza vaccines made it impossible to vaccinate those who were determined to be vaccinated there is room for discussion of mandatory covid19 vaccinations

. This Central Asian yet local context of originally customarily legitimized violence against women is still not reflected in global bibliometric analyses covering recent decades . In the global literature on violence against women, Tavassoli et al. identified "a total of 2746 keywords suggested by the authors of the documents" to cover the widest range of typologies of such violence. However, kidnapping a woman in order to marry her against her autonomy and rights is missing among them. It may fall under several of the top 30 keywords listed by the authors, notably under "genderbased violence," "gender inequality" and "intimate partner violence," but at the same time it manifests its own peculiarities and deserves to be examined as a distinct category of violence. And investigating and documenting acts of violence against women and genderbased violence is essential for identifying them as crimes and effectively prosecuting their perpetrators. Since customs of this kind are culturally based and still receive social acceptability, this goal is still a distant one, and its implementation is also dependent on major changes in social and public mentality. Given the scarcity of scholarly literature on traditional forms of violence against women, such as bride kidnapping, our study has essentially no investigative ambition: we can only refer here to data from the few official sources and reliable research findings. Anecdotal sources are only mentioned as a reference for ongoing socio-cultural narratives. Thus, we provide examples of socio-cultural and literary narratives expressing approval of the custom of bride kidnapping in the Kazakh context. We can also indicate surrounding contexts, as Kazakhstan is not isolated in terms of the practice under consideration. This practice, i.e., bride kidnapping, has been documented also in Kyrgyzstan and Uzbekistan, among others. Furthermore, we are aware of a need for expert methods in the study of traditional forms of violence against women in societies that still accept it . Nonetheless, the problem of such violence in Kazakhstan, where the population of women is 10,277,000, deserves exposure even in the modest way that we propose in the following. Let us begin with two framework definitions of violence against women, gender-based violence, and bride kidnapping. According to the United Nations, violence against women includes any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life . Although "the terms 'gender-based violence' and 'violence against women' are frequently used interchangeably in literature and by advocates," "Bird in a Cage": Traditions and Customs the term gender-based violence refers to violence directed against a person because of his or her gender and expectations of his or her role in a society or culture. Gender-based violence highlights the gender dimension of these types of acts; in other words, the relationship between females' subordinate status in society and their increased vulnerability to violence. It is important to note, however, that men and boys may also be victims of gender-based violence, especially sexual violence . As for bride kidnapping, Although bride kidnapping can be a form of staged elopement, in the majority of cases it is forced abduction, and generally targets young women, including those under 18. The kidnapping is usually planned in advance, often with the assistance of the man's family. The most common scenario is that a woman is abducted off the street as she goes about her daily routine by a group of young men, stuffed into a vehicle, and taken to the "groom's" home, where she is held against her will, subjected to psychological pressure, and sometimes even raped to force her to submit to the marriage. In some cases, the woman may not even have met the man before the abduction . In addition, in rural environments across countries where bride kidnapping is still practiced, an unmarried woman's reputation can be irrevocably damaged if she spends even a single night outside her family home. As a result, victims often feel that the honor of their families is at stake, so they have no recourse other than to consent to the marriage. Even their families may pressure them to acquiesce . Between the most general and most specific categories of violence, the scope and type of properties , shortterm and long-term; physical, mental, emotional, and symbolic; personal, interpersonal, professional, and communal; more or less irreversible, that bride kidnapping harms, are specified. --- I. The Traditional Context of Gender-based Violence with the Focus on Bride Kidnapping in Kazakhstan Each nation has its own traditions and customs that have developed over centuries and still permeate social reality to one degree or another. But there is a Kazakh proverb "Dasturdin ozygy bar, tozygy bar" . People damage society by distorting and taking advantage of the basic meaning of a tradition that has continued for many years. One of these traditions is bride stealing. According to the Kazakh tradition, two young persons got married with the choice and consent of their fathers. However, when the parents did not allow the two young persons to get married, the man stole his beloved woman, forcefully married her and created a family with her . And now stealing a bride against her will is considered a violation of human rights. Forcing underage young women to marry, unplanned pregnancy and domestic violence are now very relevant in Kazakh society. Violence, neglect and disrespect towards Kazakh women have existed for a long time, no matter how harsh, insulting and unpatriotic this may sound. This attitude was largely one-sided, rude, and unfair: women were ashamed of failures, accidents, misfortunes, weakness -for belonging to the female sex, the female share. No one thought about what a Kazakh woman thinks, or dreams, what powers and abilities will remain undiscovered in her. She was a "guest" in her parents' house, then she became a wife, daughter-inlaw, mother, mother-in-law, grandmother, but hardly ever just a person. As we mentioned before, the true essence of the tradition has been distorted and now everyone gives it a different meaning, thereby carrying out their bad deeds against poor and helpless women. Speaking about the abduction of brides it should be noted that this crime is one of the types of violence against women. According to UN statistics, in the neighboring country, Kyrgyzstan, every fifth girl is abducted for the purpose of forced marriage, and according to Freedom House, about 10,000 documented cases of abduction of girls are recorded annually in the country. In Kazakhstan, these practices of abduction and forced marriage are also still very common, but, according to official statistics over the past year, only 20 cases of abduction of women and 27 cases of illegal imprisonment were recorded in the country . Here it is necessary to take into account the fact that in most cases criminal cases are not initiated and these figures do not show the real picture. What is the actual number of victims and what measures are being taken? The Kazakh tradition of bride stealing, known as "kyz alu" or "ala kauyru" , was common in some regions of Kazakhstan and neighboring countries in the past. However, it should be noted that this practice is considered outdated and prohibited by law in modern Kazakhstan. --- II. Have Brides Been Kidnapped in the Past without Their Consent? Historically, within the framework of this tradition, a young man, wanting to marry a certain girl, could organize the bride "theft." This usually happened with the consent of the bride herself, who played the role of the coveted "trophy." In the process of stealing the bride, a young man and his friends could "kidnap" the bride from her ancestral home or village. Then the game began, in which the bride's relatives tried to "free" her, and the groom and his supporters tried to keep the bride at home. Ethnographer Bulbul Kapovna gave an interview to massaget.kz, saying that in the past the girl was taken away for two reasons: "Bird in a Cage": Traditions and Customs The tradition of bride stealing has a long history, no one disputes this. One problem here is that there was never a unilateral agreement, the girl was taken away by mutual agreement between her and the guy. Why did he run away? The girl and the guy agree, but the parents were against it. This is the first case. The second case was when the girl was betrothed from the other side, paid healthy cattle, but if the girl objected, and the other guy was in the mood, the two ran away. This is reflected in many epic songs, in the history of Kalkaman-May, Enlik-Kebek 1 . However, it should be noted that the theft of the bride in the past was perceived as a custom that rather symbolized the consent of the bride to the marriage, rather than an actual crime or violence. It was a kind of game where all the participants knew what was going on and agreed to it. But some of the elders say the opposite, that Kazakh women used to have no rights to choose anything. This is evidenced by an interview from the information portal Qamshy.kz with an 80-year-old grandmother named Nazymkul: There was an escape in our time. The girl's consent to the abduction did not matter. When a girl does not agree, our older sisters and grandmothers lie on the threshold . If you cross over me, your garden will not open, I will give you a negative blessing, he coaxed the girl and put a white handkerchief on her head. Running away with a girl is a long-standing tradition. Thanks to this tradition, many families live a happy life, now they have a large family, grandchildren and great-grandchildren . This statement is a vivid reflection of that time, and it is also possible to imagine what the fate of women of that time were. But nevertheless, it would be a mistake to say that many women did not run away of their own accord. Let us delve into the traditions and customs of the Kazakh people to find out the reality of that time and the position of women in society. Kazakhs have such sayings as "balany zhastan, katyndy bastan". This saying translates as a child should be brought up from an early age, and a woman should be brought up kept in check. We would like to pay special attention to the statement "Zhol maksaty -zhetu, kyz maksaty -ketu," which means the following in English: The main goal of a girl in this life is to get married and leave her parents' house. Many Kazakh proverbs associated with girls, their social roles and destinations, only have meanings that express discrimination against the female sex. These proverbs still permeate social discourses in the country. Furthermore, from a psychological point of view, the huge pressure that society exerts on girls from a young age can be observed. These pressures are rooted in the discourse, and so the discourse includes powers such as the power to blame women, as suggested in this proverb "Kuyeu zhaman bolsa kyzynnan" . Therefore, our society is accustomed to accusing women even if they are victims of violence, referring to the fact that they themselves are to blame. 1 "Kalkaman-May" is a saga released in connection with a historical event that took place in 1722. The author is Shakarim Kudaiberdiuly. Although the young man Kalkaman and the beautiful girl may fall in love with each other, due to the fact that they are from the same clan, the two young people are sentenced to death for "breaking traditions." Available online at: https://kk.wikipedia. org/wiki/ --- III. Discriminatory and Harassment Practices Targeting Women The discriminatory treatment of a Kazakh girl is shown in the Oscar-awarded film Uly Dala Zary by Marina Kunarova, filmed in connection with the famine of 1932-1933 . Running away from the hungry wolves, the mother throws her little daughter to the wolves and takes her son with her. The poor girl, who was screaming "Mom, do not leave me," was eaten by wolves. The meaning here is that the mother is forced to save only her son, because the son is the progenitor. Of course, it is absolutely impossible to compare what happened then and the current situation. But there are many people in society who consider the birth of a boy to be joy and happiness, but are sad when a girl is born. If there are many girls in the family, a newborn boy is given the name "Ulbolsyn," "Ultuar" with the belief that a boy will be born after the youngest girl. And this means that the girl starts being discriminated against and is a child that family members did not want from the very beginning. From the beginning, therefore, boys learn to treat girls like a thing, even when they take girls and give them brides. This estranging and discriminatory social pattern destroys the fate of many girls and even causes death. Currently, bride stealing is common in the southern part of Kazakhstan. For example, in 2019, 210 cases of kidnapping of girls for the purpose of marriage were registered in the republic, the largest number of them were committed in the Turkestan region -102 cases. In particular, in Turkestan -29 cases; in the Sairam region and Kentau -19 cases, in Zhetysay region -11, and in Maktaaral, Keles and Tolebi regions -additional 6 cases . But these are just the official numbers. Unfortunately, many such cases are not disclosed and discussed. They end with the reconciliation of the parties, which contributes to the longevity and even renaissance of this 'tradition'. According to a women's rights organization, up to 5,000 bride kidnapping acts occur annually in Kazakhstan. The perpetrators take young women against their will and run away. To 'convince' them , the perpetrators even place the Holy Scripture in front of their victims. There are also cases when a girl is raped. As a result, she does not leave the perpetrator. Harassment comes from the belief that a woman who spent one night in the abductor's house is a priori considered "used," which for men is a reason to assume that they also have the right to "use" the victim of abduction to satisfy their sexual desires and lust. Rape victims, divorced women, widows, as well as women who have not married for some personal or independent reasons, i.e., single women, who, as a rule, have little support For many years, the victims of abduction and early marriages are most often women aged 15 and over. Among them are not only Kazakh women, but also representatives of ethnic minorities: Uighurs, Dungans, Turks, Kurds, Uzbeks, Azerbaijanis, Chechens, etc. Marriages with minors are not officially registered . There is no article in the Criminal Code of the Republic of Kazakhstan according to which it would be possible to enter into early marriages, and few people declare the facts of bride theft. The legal illiteracy of teenage girls is one of the reasons for the existence of these problems: it is in the hands of those who want to live not according to the laws of a secular country, but according to old traditions and religious norms. Unfortunately, harassment is still not a crime in the legislative acts of Kazakhstan. In total, since 1998, only twenty five convictions have been handed down under Article 123 of the Criminal Code of the Republic of Kazakhstan, while imprisonment has never been applied. In our contribution to the topic of stealing brides, we would like to add that in the minds of many Kazakhs, it is still considered a shameful thing to marry a divorced woman or one whose honor is in doubt. Since childhood, men have been instilled with the word from the depths of centuries "Esik korgendi alma -besik korgendi al" , which probably broke the life of more than one Kazakh woman. The saying suggests that you should not choose the one that has already slammed one door of another's house, but the one that did not go beyond its cradle. It turns out that a woman who was not a virgin, even if she was a victim of rape, until recently could not actually count on marriage with a healthy candidate "without a past," but on the proposal of a widower, an old man, a man with a physical or mental disability, as evidenced by "Barine birday kyz kaida? Biransaran katyn al" which relatives tell widowers or men with disabilities who are planning to get married. Now such discriminatory practices are mainly used in rural areas and are almost obsolete in large cities. --- Conclusion and Prospects We want to note that violence always breeds violence. If the attitude of the community to this phenomenon does indeed change, it would be foolish to expect drastic changes. On the one hand, it seems paradoxical that women are involved in these crimes. Usually, the abducted girls are persuaded by name to take the cards and observe the continuation of violence. On the other hand, there is no way to get help, because the violence of society has been normalized, and women do not know other models of behavior, they only know that resistance is useless. This happens because no one helped them at the time. Thus, according to the national research project Gender in Social Representations conducted by the National Statistical Commission of United Nations agencies, including "Women," 52% of respondents consider the participation of female relatives in the abduction of the bride to be the case, and almost a third of women justify their participation by saying that they should help their relatives . In order to solve all these problems, raising awareness must begin with the children. The basics of gender equality and the refusal to accept violence and discrimination need to be taught from the beginning. At the national level, it is necessary to improve the work of law enforcement agencies and courts dealing with cases of gender-based violence, and to tighten the penalties for all types of crimes against women. It is necessary to root out all patriarchal views and traditions that promote violence against women, destroy all stereotypes and adopt a serious program aimed at implementing all these measures. The authors -like their fellow female citizens of Kazakhstan -hope to live a safe, free, happy life in a safe, free, happy society that respects women, their rights, vital interests and basic freedoms, that does not discriminate against them and which, moreover, develops and legitimiszes institutions that are fair and just to women in all social positions and contexts . But at the same time, they understand that everything depends on public discourse , the community's voice which perpetuate violence against women, rather than by new legislation which is designed to limit such violence and protect against it. Among the noticeable challenges for researchers of the issue is the fact that the realities they seek to study are often "hidden violent realities" . Here we are referring to areas of spousal, family and domestic life that have been given their foundation by violence against women, such as kidnapping of brides. This violence may evolve in various and permanent patterns, which would represent a broad range of domestic violence and aggression. Moreover, in the case of the legal delegitimization and criminalization of the violence against women discussed here, if the latter occurred in discordance with toleration by society or its considerable part, respectively, this violence may be even more intensely hidden which is another challenge for researchers -and for the administration of justice as well. --- Ethics in Progress . Vol. 14

Systematic research on violence against socially, culturally or otherwise disadvantaged groups, or even just documenting it, is a difficult task. Access to those being directly harmed, who are subject to control by their harmers, is already difficult. This is precisely the case of the Kazakh women, which we would like to introduce here. It is barely explored also due to its complex history and geographical location. It concerns a particular type of violence, legitimized by certain traditional cultures that involves the abduction of women for forced marriage (the so-called bride kidnapping)

this central asian yet local context of originally customarily legitimized violence against women is still not reflected in global bibliometric analyses covering recent decades in the global literature on violence against women tavassoli et al identified a total of 2746 keywords suggested by the authors of the documents to cover the widest range of typologies of such violence however kidnapping a woman in order to marry her against her autonomy and rights is missing among them it may fall under several of the top 30 keywords listed by the authors notably under genderbased violence gender inequality and intimate partner violence but at the same time it manifests its own peculiarities and deserves to be examined as a distinct category of violence and investigating and documenting acts of violence against women and genderbased violence is essential for identifying them as crimes and effectively prosecuting their perpetrators since customs of this kind are culturally based and still receive social acceptability this goal is still a distant one and its implementation is also dependent on major changes in social and public mentality given the scarcity of scholarly literature on traditional forms of violence against women such as bride kidnapping our study has essentially no investigative ambition we can only refer here to data from the few official sources and reliable research findings anecdotal sources are only mentioned as a reference for ongoing sociocultural narratives thus we provide examples of sociocultural and literary narratives expressing approval of the custom of bride kidnapping in the kazakh context we can also indicate surrounding contexts as kazakhstan is not isolated in terms of the practice under consideration this practice ie bride kidnapping has been documented also in kyrgyzstan and uzbekistan among others furthermore we are aware of a need for expert methods in the study of traditional forms of violence against women in societies that still accept it nonetheless the problem of such violence in kazakhstan where the population of women is 10277000 deserves exposure even in the modest way that we propose in the following let us begin with two framework definitions of violence against women genderbased violence and bride kidnapping according to the united nations violence against women includes any act of genderbased violence that results in or is likely to result in physical sexual or psychological harm or suffering to women including threats of such acts coercion or arbitrary deprivation of liberty whether occurring in public or in private life although the terms genderbased violence and violence against women are frequently used interchangeably in literature and by advocates bird in a cage traditions and customs the term genderbased violence refers to violence directed against a person because of his or her gender and expectations of his or her role in a society or culture genderbased violence highlights the gender dimension of these types of acts in other words the relationship between females subordinate status in society and their increased vulnerability to violence it is important to note however that men and boys may also be victims of genderbased violence especially sexual violence as for bride kidnapping although bride kidnapping can be a form of staged elopement in the majority of cases it is forced abduction and generally targets young women including those under 18 the kidnapping is usually planned in advance often with the assistance of the mans family the most common scenario is that a woman is abducted off the street as she goes about her daily routine by a group of young men stuffed into a vehicle and taken to the grooms home where she is held against her will subjected to psychological pressure and sometimes even raped to force her to submit to the marriage in some cases the woman may not even have met the man before the abduction in addition in rural environments across countries where bride kidnapping is still practiced an unmarried womans reputation can be irrevocably damaged if she spends even a single night outside her family home as a result victims often feel that the honor of their families is at stake so they have no recourse other than to consent to the marriage even their families may pressure them to acquiesce between the most general and most specific categories of violence the scope and type of properties shortterm and longterm physical mental emotional and symbolic personal interpersonal professional and communal more or less irreversible that bride kidnapping harms are specified i the traditional context of genderbased violence with the focus on bride kidnapping in kazakhstan each nation has its own traditions and customs that have developed over centuries and still permeate social reality to one degree or another but there is a kazakh proverb dasturdin ozygy bar tozygy bar people damage society by distorting and taking advantage of the basic meaning of a tradition that has continued for many years one of these traditions is bride stealing according to the kazakh tradition two young persons got married with the choice and consent of their fathers however when the parents did not allow the two young persons to get married the man stole his beloved woman forcefully married her and created a family with her and now stealing a bride against her will is considered a violation of human rights forcing underage young women to marry unplanned pregnancy and domestic violence are now very relevant in kazakh society violence neglect and disrespect towards kazakh women have existed for a long time no matter how harsh insulting and unpatriotic this may sound this attitude was largely onesided rude and unfair women were ashamed of failures accidents misfortunes weakness for belonging to the female sex the female share no one thought about what a kazakh woman thinks or dreams what powers and abilities will remain undiscovered in her she was a guest in her parents house then she became a wife daughterinlaw mother motherinlaw grandmother but hardly ever just a person as we mentioned before the true essence of the tradition has been distorted and now everyone gives it a different meaning thereby carrying out their bad deeds against poor and helpless women speaking about the abduction of brides it should be noted that this crime is one of the types of violence against women according to un statistics in the neighboring country kyrgyzstan every fifth girl is abducted for the purpose of forced marriage and according to freedom house about 10000 documented cases of abduction of girls are recorded annually in the country in kazakhstan these practices of abduction and forced marriage are also still very common but according to official statistics over the past year only 20 cases of abduction of women and 27 cases of illegal imprisonment were recorded in the country here it is necessary to take into account the fact that in most cases criminal cases are not initiated and these figures do not show the real picture what is the actual number of victims and what measures are being taken the kazakh tradition of bride stealing known as kyz alu or ala kauyru was common in some regions of kazakhstan and neighboring countries in the past however it should be noted that this practice is considered outdated and prohibited by law in modern kazakhstan ii have brides been kidnapped in the past without their consent historically within the framework of this tradition a young man wanting to marry a certain girl could organize the bride theft this usually happened with the consent of the bride herself who played the role of the coveted trophy in the process of stealing the bride a young man and his friends could kidnap the bride from her ancestral home or village then the game began in which the brides relatives tried to free her and the groom and his supporters tried to keep the bride at home ethnographer bulbul kapovna gave an interview to massagetkz saying that in the past the girl was taken away for two reasons bird in a cage traditions and customs the tradition of bride stealing has a long history no one disputes this one problem here is that there was never a unilateral agreement the girl was taken away by mutual agreement between her and the guy why did he run away the girl and the guy agree but the parents were against it this is the first case the second case was when the girl was betrothed from the other side paid healthy cattle but if the girl objected and the other guy was in the mood the two ran away this is reflected in many epic songs in the history of kalkamanmay enlikkebek 1 however it should be noted that the theft of the bride in the past was perceived as a custom that rather symbolized the consent of the bride to the marriage rather than an actual crime or violence it was a kind of game where all the participants knew what was going on and agreed to it but some of the elders say the opposite that kazakh women used to have no rights to choose anything this is evidenced by an interview from the information portal qamshykz with an 80yearold grandmother named nazymkul there was an escape in our time the girls consent to the abduction did not matter when a girl does not agree our older sisters and grandmothers lie on the threshold if you cross over me your garden will not open i will give you a negative blessing he coaxed the girl and put a white handkerchief on her head running away with a girl is a longstanding tradition thanks to this tradition many families live a happy life now they have a large family grandchildren and greatgrandchildren this statement is a vivid reflection of that time and it is also possible to imagine what the fate of women of that time were but nevertheless it would be a mistake to say that many women did not run away of their own accord let us delve into the traditions and customs of the kazakh people to find out the reality of that time and the position of women in society kazakhs have such sayings as balany zhastan katyndy bastan this saying translates as a child should be brought up from an early age and a woman should be brought up kept in check we would like to pay special attention to the statement zhol maksaty zhetu kyz maksaty ketu which means the following in english the main goal of a girl in this life is to get married and leave her parents house many kazakh proverbs associated with girls their social roles and destinations only have meanings that express discrimination against the female sex these proverbs still permeate social discourses in the country furthermore from a psychological point of view the huge pressure that society exerts on girls from a young age can be observed these pressures are rooted in the discourse and so the discourse includes powers such as the power to blame women as suggested in this proverb kuyeu zhaman bolsa kyzynnan therefore our society is accustomed to accusing women even if they are victims of violence referring to the fact that they themselves are to blame 1 kalkamanmay is a saga released in connection with a historical event that took place in 1722 the author is shakarim kudaiberdiuly although the young man kalkaman and the beautiful girl may fall in love with each other due to the fact that they are from the same clan the two young people are sentenced to death for breaking traditions available online at orgwiki iii discriminatory and harassment practices targeting women the discriminatory treatment of a kazakh girl is shown in the oscarawarded film uly dala zary by marina kunarova filmed in connection with the famine of 19321933 running away from the hungry wolves the mother throws her little daughter to the wolves and takes her son with her the poor girl who was screaming mom do not leave me was eaten by wolves the meaning here is that the mother is forced to save only her son because the son is the progenitor of course it is absolutely impossible to compare what happened then and the current situation but there are many people in society who consider the birth of a boy to be joy and happiness but are sad when a girl is born if there are many girls in the family a newborn boy is given the name ulbolsyn ultuar with the belief that a boy will be born after the youngest girl and this means that the girl starts being discriminated against and is a child that family members did not want from the very beginning from the beginning therefore boys learn to treat girls like a thing even when they take girls and give them brides this estranging and discriminatory social pattern destroys the fate of many girls and even causes death currently bride stealing is common in the southern part of kazakhstan for example in 2019 210 cases of kidnapping of girls for the purpose of marriage were registered in the republic the largest number of them were committed in the turkestan region 102 cases in particular in turkestan 29 cases in the sairam region and kentau 19 cases in zhetysay region 11 and in maktaaral keles and tolebi regions additional 6 cases but these are just the official numbers unfortunately many such cases are not disclosed and discussed they end with the reconciliation of the parties which contributes to the longevity and even renaissance of this tradition according to a womens rights organization up to 5000 bride kidnapping acts occur annually in kazakhstan the perpetrators take young women against their will and run away to convince them the perpetrators even place the holy scripture in front of their victims there are also cases when a girl is raped as a result she does not leave the perpetrator harassment comes from the belief that a woman who spent one night in the abductors house is a priori considered used which for men is a reason to assume that they also have the right to use the victim of abduction to satisfy their sexual desires and lust rape victims divorced women widows as well as women who have not married for some personal or independent reasons ie single women who as a rule have little support for many years the victims of abduction and early marriages are most often women aged 15 and over among them are not only kazakh women but also representatives of ethnic minorities uighurs dungans turks kurds uzbeks azerbaijanis chechens etc marriages with minors are not officially registered there is no article in the criminal code of the republic of kazakhstan according to which it would be possible to enter into early marriages and few people declare the facts of bride theft the legal illiteracy of teenage girls is one of the reasons for the existence of these problems it is in the hands of those who want to live not according to the laws of a secular country but according to old traditions and religious norms unfortunately harassment is still not a crime in the legislative acts of kazakhstan in total since 1998 only twenty five convictions have been handed down under article 123 of the criminal code of the republic of kazakhstan while imprisonment has never been applied in our contribution to the topic of stealing brides we would like to add that in the minds of many kazakhs it is still considered a shameful thing to marry a divorced woman or one whose honor is in doubt since childhood men have been instilled with the word from the depths of centuries esik korgendi alma besik korgendi al which probably broke the life of more than one kazakh woman the saying suggests that you should not choose the one that has already slammed one door of anothers house but the one that did not go beyond its cradle it turns out that a woman who was not a virgin even if she was a victim of rape until recently could not actually count on marriage with a healthy candidate without a past but on the proposal of a widower an old man a man with a physical or mental disability as evidenced by barine birday kyz kaida biransaran katyn al which relatives tell widowers or men with disabilities who are planning to get married now such discriminatory practices are mainly used in rural areas and are almost obsolete in large cities conclusion and prospects we want to note that violence always breeds violence if the attitude of the community to this phenomenon does indeed change it would be foolish to expect drastic changes on the one hand it seems paradoxical that women are involved in these crimes usually the abducted girls are persuaded by name to take the cards and observe the continuation of violence on the other hand there is no way to get help because the violence of society has been normalized and women do not know other models of behavior they only know that resistance is useless this happens because no one helped them at the time thus according to the national research project gender in social representations conducted by the national statistical commission of united nations agencies including women 52 of respondents consider the participation of female relatives in the abduction of the bride to be the case and almost a third of women justify their participation by saying that they should help their relatives in order to solve all these problems raising awareness must begin with the children the basics of gender equality and the refusal to accept violence and discrimination need to be taught from the beginning at the national level it is necessary to improve the work of law enforcement agencies and courts dealing with cases of genderbased violence and to tighten the penalties for all types of crimes against women it is necessary to root out all patriarchal views and traditions that promote violence against women destroy all stereotypes and adopt a serious program aimed at implementing all these measures the authors like their fellow female citizens of kazakhstan hope to live a safe free happy life in a safe free happy society that respects women their rights vital interests and basic freedoms that does not discriminate against them and which moreover develops and legitimiszes institutions that are fair and just to women in all social positions and contexts but at the same time they understand that everything depends on public discourse the communitys voice which perpetuate violence against women rather than by new legislation which is designed to limit such violence and protect against it among the noticeable challenges for researchers of the issue is the fact that the realities they seek to study are often hidden violent realities here we are referring to areas of spousal family and domestic life that have been given their foundation by violence against women such as kidnapping of brides this violence may evolve in various and permanent patterns which would represent a broad range of domestic violence and aggression moreover in the case of the legal delegitimization and criminalization of the violence against women discussed here if the latter occurred in discordance with toleration by society or its considerable part respectively this violence may be even more intensely hidden which is another challenge for researchers and for the administration of justice as well ethics in progress vol 14

systematic research on violence against socially culturally or otherwise disadvantaged groups or even just documenting it is a difficult task access to those being directly harmed who are subject to control by their harmers is already difficult this is precisely the case of the kazakh women which we would like to introduce here it is barely explored also due to its complex history and geographical location it concerns a particular type of violence legitimized by certain traditional cultures that involves the abduction of women for forced marriage the socalled bride kidnapping

Introduction Culture is an important element in human life because it provides the implied meaning of various aspects of society. The significance of culture is strongly related to values, beliefs, ways of thinking, ways of living, and world views adopted by community members at certain times . Culture is not a thing that is only owned by a particular group of people but is owned by everyone and can be a unifier of the nation. Human beings and culture are never separable. In daily life, the human being is never detached from culture. As social beings, people interact with each other and follow habits that can become a culture . Pesurnay defines culture as an expression of the will of man in recognizable structures shared by those who inhabit the same world; therefore, the relationship between man and his cultural world is dynamic and dialectical. This concept informs a theory of social construction, including objectivity, internalization, and externalization. Pujiati argues that these three concepts outline a process of forming a tradition that goes hand in hand with that tradition itself and evolves continuously. The individual human being becomes an instrument involved in creating an objective social reality through a process of externalization, as the individual interprets influences through a process of internalization. Ngangi explains that this social construction can be dialectically illustrated as in Figure 1. Each process for the dialectical scheme of social construction is presented in Table 1. The human being is also seen as the creator of culture. Culture is closely related to tradition, which can be seen as formed through the community's continuous transmission of a culture. Tradition is a habit, behavior, or attitude of a society passed down from generation to generation and preserved by the local community as a reflection of that society with a distinctive culture. Tradition is a spirit of culture that strengthens a cultural system. Culture and all its products are the results of the process of human life . Local wisdom is a cultural product that includes philosophy, values, norms, ethics, rituals, beliefs, habits, customs, and so on . wisdom usually comes from ancestors, who are followed by community members from generation to generation . This local wisdom accumulates the good habits of generations. --- Table 1. Theoretical Dialectical Scheme of Social Construction No. --- Dialectical Scheme Description 1 Externalization Human generosity is directed towards the world in mental and physical activities. It is sometimes seen as the essence of man himself, and it is an anthropological imperative that man always devotes himself to the world in which he exists. Humans cannot understand themselves as detached self-enclosed beings separated from the outside world. --- Objectivation The results have been achieved both mentally and physically through human externalization activities. The results confront the producer himself because they are outside and different from the humans who produce them. Through this process, the community becomes a sui generis reality. Objectivation can manifest as sharing opinions concerning a social product that emerges within a community through public discourse, even without direct, in-person interaction between individuals and the creators of said social product. 3 --- Internalization It can be argued that the human person is an instrument in the process of creating objective social reality through a process of externalization, as she or he influences it through a process of internalization which reflects subjective reality. Individuals become members of society through this process of internalization or socialization. Local wisdom passed down by tradition becomes the basis for someone in a particular tribe to communicate with other tribes. Habits and the local wisdom they form give rise to a tradition with its customs, norms, and other cultural forms . Local wisdom is a form of community culture in the form of knowledge, products, and activities used for survival adapted to where they are from generation to generation. Local wisdom has philosophical values believed to be guidelines in life activities to maintain personal and group survival . Each region has a different tradition of commemorating or celebrating important events such as births, weddings and deaths. One area of Indonesia with a unique tradition is the Lahat Regency in South Sumatra Province. One of the national tribes that inhabits this region is the Besemah Tribe which is different from the peoples inhabiting other areas in celebrating weddings. The Besemah Tribe community still upholds the tradition of pantauan bunting inherited from its ancestral beginnings, especially when wedding celebrations are held. This is evident from researchers' direct observations; many still carry on this tradition. Some research shows that the Pantauan Bunting Tradition involves a pair of brides who will be accompanied by a man and a woman who in the Besemah language are called 'bujang ngantat' and 'gadis ngantat'. A 'bujang ngantat' or 'gadis ngantat' must be unmarried. The task of the 'gadis ngantat' and 'bujang ngantat' is to join the bride in surrounding the house of the residents who have called the couple. They also accompany the bride and groom from the time of the marriage proposal until the wedding reception . The research results of reveal several new things; the Pantauan Bunting tradition is still practiced by the Pasemah community, especially the Sukarami village community, in a series of marriage ceremony activities in the form of an invitation to eat from the local community to a newly married partner. The tradition of Pantauan Bunting is carried out to profit Muji Jurai or honor the descendants, as an act of gratitude and respect for their descendants because they are married, or it is also said to be a gift from the community to the bride. Zaman also reports on the uniqueness of marriage events in the community as exemplified in the performance of rituals such as the Rokat Tek-tek kemanten tradition which is imbued with institutionalized community values. These practices involve symbols that have sacred meanings in the Rokat tektek kemanten tradition. as it is an ancestral heritage of appreciating "bujuk nia" which determines social reality in the community as an institutional belief system. The process of social community formation occurs through simultaneous awareness and solidarity. --- Research Methods This study utilizes the qualitative method of ethnography to provide a detailed description of the social construction process involved in the Pantauan Bunting tradition within the Besemah Tribe Community. This research aims to shed light on how social constructs are formed by examining the stages of externalization, objectivation, and internalization. Additionally, the study will offer insights into the distribution, uniqueness, and prevalence of the Pantauan Bunting tradition specifically within Lahat Regency. Through this comprehensive analysis, a deeper understanding of the cultural significance and dynamics of the Pantauan Bunting tradition can be attained. --- Research Location This research study will be conducted in three zones selected by researchers based on the strength of the influence and distribution of the construction of the Pantauan Bunting tradition. In one zone, the tradition is still strong, in the second it is fading away, and in the third it no longer exists. Agung City Village is included in the zone that is still practicing the tradition. Pulau Pinang Village is included in the transition zone where the tradition is rarely practiced. Selawi Village is included in the zone where the Pantauan tradition is barely practiced anymore. The location of research is presented in Figure 2. --- Research Subject In qualitative research, the research subject, commonly referred to as 'the informant', is someone who provides information about the data to be studied. In this study, the subject of research is the Besemah tribe community in Lahat Regency. The Pasemah tribe, commonly called the Besemah Tribe, is one of the ethnic groups residing in the Province of South Sumatra, Indonesia. The majority of the people live in and around Mount Dempo, Pagaralam City, Lahat Regency, Empat Lawang Regency, and Muara Enim Regency. A small part of the tribe is spread across other districts. The subjects of this study were mainly people in Kota Agung Village, Pulau Pinang Village, and Selawi Village . The persons selected by the researcher to be used as informants in this study include traditional figures in Kota Agung Village, Pulau Pinang Village, and Selawi Village; Native people who are tribal to the Besemah nation in Kota Agung Village, Pulau Pinang Village, and Selawi Village. This study used the snowball sampling model to gather information. The method is called 'snowball' sampling because a researcher determines a person to be a sample based on the recommendations of people who have been a sample before . The specifics of this research study's informants are presented in Table 2. --- Research Instrument The instrument used in this study is the researcher himself because this study uses a qualitative approach that must interact directly with the surrounding community and involve interview guidelines, observations, recording tools, and documentation tools . --- Data Analysis Data analysis is a crucial stage in the process of conducting scientific research because it allows the researcher to arrive at answers or to the problems which the research has. Qualitative data analysis involves the sorting, coding, and thematizing of data derived from the data collection process involving interviewing study participants, recording the interview and taking notes, and reviewing the literature. --- Results and Discussion --- Social Construction: the Process of Forming the Pantauan Bunting Tradition in the Besemah Tribe Community Regions in Indonesia have many local forms of wisdom, cultures, traditions, customs, languages, and rituals or ceremonies that differ from one area to another . The cultural diversity of Indonesia consists of customs or traditions that develop in society into a distinctive view held by a particular community which is embodied in its acting as it behaves . In Indonesia, several traditions have been highlighted by research into traditions in particular locations. The Pararem custom in the mass marriage tradition found in Pengotan Village, Bangli Regency, is underpinned by the community's economic situation, cultural preservation, hereditary sustainability, and culturally-specific views of happiness . The tradition of Javanese customary marriage that prevails in Kalidadi Village is the wetonan custom, involving taboo understood as a form of caution, a way parents choose prospective partners for their children and protect their children's households from all the possible adverse effects that could befall them in the future . Susantin & Rijal highlight that the marriage tradition in Madura differs from that in Java. In Madura, the majority of the population adheres to the matrilineal tradition in which after marriage, husbands and wives are required to live in the wife's house. Before the wedding, the future husband carries BhenGibhen to the wife's house. The wife has a house to occupy. This contrasts with the ampa sabae tradition , which has developed over a long period in the Ambalawi community. The Ambalawi community understands this ancestral tradition as a solution to the problem which arises when women suffer detriment due to men's actions. It is a way for women to hold men accountable . A unique case is found in the bakar batu tradition, a traditional ceremony enacted by the Dani tribe. It involves the event of cooking a dish made from several pigs. This dish is served as the main part of the meal. A stone that had been burned as a cooking medium. The Dani tribe continues this tradition of baking stones as a form of gratitude to God as an expression of joy or of sorrow. It is a regular part of big events such as celebrations of marriages or births or the final tribute to God on the occasion of someone's death or thanksgiving for the blessings of the harvest . The tradition of marriage in the Bugis-Makassar tribal community has several long stages including determining the amount of panai money that the groom's family will hand over to the bride's family . In this tradition, it is not surprising to find marriage occurring at an early age as documented by . These researchers' findings shed light on the meanings attributed to early marriage customs in Nagari Tapan, Basa Ampek Balai Tapan District. Parents see early marriage as: 1) a way of avoiding shame, 2) an economic matter, 3) a rescue effort. A similar diversity of marriage traditions occurs in the Besemah tribe community. The marriage contract is usually signed the day before the wedding celebration. However, some people do this after the wedding. This is in accordance with the agreement of the community with the bride and groom when they will hold the Pantauan wedding festivity. Several processes are involved in keeping the tradition. They are presented in Table 3. The tradition of Pantauan Bunting continues to be carried out by the community, whether it is the Besemah tribe or even people outside the tribe. There are no traditional sanctions or customs about what other customs must be followed if people do not carry out the Pantauan Bunting tradition. However, the Pantauan Bunting Tradition uses a system of reciprocity. If we hold the traditional Pantauan Bunting celebration, relatives are going to be married, then the relatives will reciprocate by doing pantauan for us if we one day get married. Likewise, if we do not hold aPantauan Bunting celebration, other people will do the same thing and not have the celebration. This principle of reciprocity is also important in customary law in the Basemah community itself. Wardani argues that customary law is a living law that manifests itself as a community habit. This marital custom law could thus be considered an inseparable part of the human body in the community. Anyone going to get married informs the community beforehand by inviting the residents in the surrounding areas by visiting their houses . This is usually done two to three weeks before the wedding. The bride and groom who will be married usually first inform their families or close relatives. Thus, The community knows there will be a wedding so that they can prepare everything needed for Pantauan, including obtaining food and other necessities from far away. At this time, the inviting family will also bring 'lemang' to people in the community. The people who receive the 'lemang' understand that it signifies they are obliged to hold a Pantauan Bunting celebration. 2 Bemasak After being notified by the bride's family of the date of wedding, the community will prepare everything necessary for pantauan. The most prominent feature in the Pantauan Bunting Tradition is the presence of various dishes ranging from snacks such as cakes and fruits to more substantial food such as rice and side dishes. For this reason, the community will usually make or cook food to be served when the Pantauan Bunting celebration is held. Usually the day before the pantauan, the community will have prepared a dish that will be served during the pantauan. Some people even start gradually making food a week before the pantauan. There are no stipulations regarding what food should be available and served during the pantauan. However, some dishes are almost always part of the Pantauan Bunting tradition, lemang, dodol and pepes ikan, a typical food from the Besemah tribe. In addition to these two types of food, there is also always meat, but it is only served by close family members. This symbolizes that the family conducting the Pantauan Bunting celebration still has a blood relationship with the bride. --- Mantau Bunting The day before the wedding celebration, Mantau Bunting or calling the bride is done. After the marriage contract is signed, the community usually calls the bride and invite the bride to visit their homes. The Pantauan Bunting feast can also be held after the wedding celebration is over because there will not be enough time for the bride and groom to visit the homes of the residents of the surrounding areas in a single day. For this reason, before the pantauan begins, the community will agree when they will hold the traditional Pantauan Bunting celebration. Source: Field Research Results In Social Construction Theory, something can be formed due to the dialectic of externalization . This involves objectivity and internalization . The following is an explanation of the three social processes associated with this Pantauan Bunting Tradition. Based on this explanation of the dialectical process of Pantauan Bunting, the researcher sees it as having component parts as shown in Figure 3. --- Distribution of Pantauan Bunting Traditions in the Besemah Tribe Community Pasemah Tribe, commonly called the Besemah Tribe: The origins of the name 'Besemah' for this community are believed to be derived from the name of a fish that was formerly found in the Pagaralam area of South Sumatra Province. The Semah fish is a type of goldfish that lives in murky streams among rocks that are overgrown with moss and shaded by trees. However, many people call the Besemah Tribe the Pasemah Tribe. The name 'Pasemah' stopped being used because Dutch colonists found it difficult to pronounce the phoneme "pa" and pronounce it "be", so the name "Pasemah" became "besemah" . For the purposes of government authority and administration, the Besemah cultural area includes Pagaralam City, Lahat Regency, Empat Lawang Regency, Muara Enim Regency, and South Ogan Komering Ulus Regency in South Sumatra Province. Lahat Regency, specifically, includes the area of Jarai District, Tanjung Sakti District, and the area around Kota Agung District. The Besemah cultural area in Bengkulu Province includes Kaur Regency, Seluma Regency, and South Bengkulu Regency. Specifically, Kaur Regency includes Padang Guci Hulu District and Padang Guci Hilir District. Besemah culture is also found in Lampung Province, namely in South Lampung Regency. The spread of Besemah culture to various areas outside Pagaralam City was followed by changes and the formation of new cultural identities in these different regions but they all still recognize that their origin lies in Pagaralam . The Besemah Tribe is one of the tribes that inhabit Lahat Regency and its surroundings. The Besemah people are scattered in all areas both inside and outside the Province of South Sumatra. Thus, the Pantauan Bunting Tradition is not only to be found in one place in South Sumatra, but elsewhere too. In this study, researchers selected three different villages in Lahat Regency as a research location: Kota Agung Village, Pulau Pinang Village, and Selawi Village. Based on the results of the study, the researchers can say that Pantauan Bunting Tradition is still alive in these three areas. However, the numbers of members of the Besemah tribe differ in these areas. In Kota Agung Village, the Besemah tribe community is still widespread, and it can even be said that the majority of people in this village are from the Besemah tribe community. In Penang Village, by contrast, it is fairly uncommon to find people from the Besemah tribe because the majority of people in this village are from the Gumai Lembak tribe. Finally, in Selawi Village it is very difficult to find Besemah people because Selawi Village is located very close to the city center where there has been singificant mixing of tribes and cultures. The results of this research study also show that several factors cause the distribution of the Besemah tribe in Lahat Regency to vary from area to area. The first factor is physical factors that include location and distance. Kota Agung Village is quite far from the city center makes it difficult for people to move to other inhabited places. Therefore, the people of the Besemah Tribe tend to live in the village of Kota Agung. On the other hand, in Pulau Pinang Village, members of the Besemah community are rare. This is because Penang Village is a transition area between the village and the city center, so it is quite easy for people to move from one place to another. The concentration of the Besemah tribe in Selawi Village is almost the same as that in Penang Village; it is quite difficult to find people from the Besemah tribe because it is located very close to the city center. Social factors also affect differences in the distribution of the Besemah tribe in Lahat Regency. Social factors come from society itself. As explained above, in Kota Agung Village, the majority of the people are from the Besemah tribe. The people in Kota Agung Village are still classified as a traditional community. People still adhere to the existing traditions. The closed attitude of the community makes it difficult for this village to accept anything new that comes from outside and it tends to maintain its original culture. Therefore, if we visited Kota Agung Village, the Pantauan Bunting Tradition would still be very easy to find. The next research area is Pulau Pinang Village. The distribution of members of the Besemah tribe in Pulau Pinang Village is sparse because Pulau Pinang Village is a transition area between the countryside and the city center so there has been a lot of cultural mixing. The indigenous people in Penang are not the Besemah tribe, but the Gumai Lembak tribe; the ancestors who lived in this village came from the Gumai Lembak tribe. Most people now in Penang Village are not from the Besemah tribe, but the Gumai Lembak tribe. Researchers also find it difficult to interview informants about the Pantauan Bunting tradition. The Besemah tribe is only a minority and its members are immigrants. However, we can still see the Pantauan Bunting tradition in the Pulau Pinang Village. The Besemah people in this village still continue the tradition even though they are only few in number and are not the village's original inhabitants. In Selawi Village, members of the Besemah community are few and difficult to find. This is because this village has seen significant cultural mixing. This phenomenon cannot be avoided because Selawi Village is located very close to the city center, so many people from different ethnic groups migrate to this village on account of work, education, or marriage. In Selawi Village many people have moved with the times and have weddings with a modern vibe. This is also what makes the existence of the Pantauan Bunting tradition in this village difficult to find. The community has left many traditions behind that have been considered ancient. Social factors also affect the distribution of the Pantauan Bunting Tradition. One is amalgamation, the marriage of members of different tribes. Amalgamation can lead to assimilation and acculturation. Assimilation is a meeting between two cultures that brings about a new culture and replaces and erases the old culture. Acculturation, conversely, is the meeting of two different cultures that creates a new culture but does not eliminate or abandon the old one. This phenomenon does not only occur in the Basemah tribe. Several studies show the same process in different locations and involving different populations such as the amalgamation of Chinese and Madura ethnic groups in Bangkalan Madura Regency . Another example is the marriage amalgamation of Batak and Malay ethnic groups in Pangkalpinang City . Ethnic differences between Flores and Chinese in Trubus Village, Central Bangka Regency have likewise been amalgamated through marriage . A final example is that of Chinese amalgamated through marriage with members of indigenous peoples in Java . It depends on the community itself to assimilate or acculturate in a particular cultural environment. This is also the case with the Pantauan Bunting tradition. Society chooses to maintain or abandon this tradition in daily life. Every region in Java has an amalgamated community, with the exception of the three villages that the researchers chose, Kota Agung Village, Penang Village, and Selawi Village. Based on the results of field observations, the researchers can say that although there have been many amalgamations in Kota Agung and Pulau Pinang village, the community still maintains the traditional culture. Even if there is an amalgamation, other tribes follow the customs or traditions of the Besemah tribe. On the other hand, in Selawi Village, because there have been many assimilations and influences due to the location of the village very close to the city center, most people abandon existing traditions and keep up with the times slowly. The distribution of the Pantauan Bunting Tradition among the three villages exhibits variations, with some villages still having easy access to it, while others find it more challenging or even extremely rare to come across. These disparities can be attributed to the factors mentioned earlier. Despite these differences, the Besemah people strive to uphold and sustain this tradition. They view the Pantauan Bunting as an integral part of their lives that holds significant cultural value, hence the community's commitment to its preservation and continuation. --- The Existence of the Pantauan Bunting Tradition in the Besemah Tribal Community in Lahat Regency The Pantauan Bunting tradition is one of the customs which is distinctively that of the Besemah tribe. People will invite a bride to come to their house. The community will entertain the bride and groom, offering them various dishes ranging from snacks to heavy food. Pantauan Bunting is a tradition constructed by the Besemah people in ancient times and still exists today even though it is not as strong as it once was. The tradition is a special form of human interaction response with its living environment. The formation of an environment is determined by several factors, one of which is the local community's culture . The tradition of Pantauan Bunting is still found throughout all areas of Lahat District. Although in the modern era people compete to have wedding celebrations r with a modern feel and leave behind traditions considered old-fashioned, the Besemah community still continues the Pantauan Bunting tradition. These forms of kinship solidarity include the role of parents, routine social activities, feelings of energetic life, and traditional Javanese customs and rules of thumb that still apply to everyday life. The existence of Pantauan Bunting Tradition has many benefits for the community. In this study, the researchers selected 3 villages: Kota Agung Village, Pulau Pinang Village, and Selawi Village. The three villages were selected based on the difference in distance from the city. One village is far from the city center, namely Kota Agung Village, one village is in the transition area between the village and the city center, namely Pulau Pinang Village, and one village is close to the city center, Selawi Village. With these differences in distance from the city center, the researchers can compare the villages to see whether villages that are located within a close proximity to the city center and villages that are located long distances from the city center exhibit differences in their levels and methods of maintaining the existence of the Pantauan Bunting tradition. The numbers of people living in each area of Lahat District number are shown in Table 4. The Besemah tribe still maintains the Pantauan Bunting tradition. In Kota Agung, a majority the people are from the Besemah tribe. They still maintain the practices of the Pantauan Bunting tradition. By contrast, in Penang Village, the majority of the people are from the Gumai Lembak tribe, while people from the Besemah tribe form a minority. Nevertheless, the Besemah community in this village still carries on with the Pantauan Bunting tradition. In Selawi Village, located very close to the city center, significant cultural mixing has caused people to abandon their culture and traditions. The community has begun to be diverse and it is very rare to find people from the Besemah tribe who still maintain the Pantauan Bunting tradition. We therefore know that the villages' different locations and distances between the three villages and the city center impacts, but never quite eliminates, the Pantauan Bunting tradition. Many still hold to their traditions firmly and ensure that this tradition does not fade or disappear even in an advanced modern era. --- Conclusion The Pantauan Bunting tradition originates in the Besemah tribal community. It involves occasions when a couple in the community is to be marred. The bride-to-be is invited to come to the community members' houses in the village where the community will provide various dishes ranging from snacks to heavy food. This tradition is usually done the day before the wedding celebration is held. In doing Pantauan Bunting tradition, a bride-to-be will be accompanied by a single man and woman . The Pantauan Bunting Tradition is widespread in various areas across Lahat Regency. Several factors cause Pantauan Bunting Tradition in Lahat Regency to differ in each area where it is kept. Physical factors include the village's location and its distance from a city center. Social factors come from the community itself. In this study, we find that Kota Agung Village is a village where we can easily see the Pantauan Bunting tradition. This is because the majority of Kota Agung village community members are still classified as traditional and closed to something new. In addition, the people in this village have not intermingled much from other ethnic groups so the purity of the indigenous Besemah tribe in this village is still maintained. Whereas in Pulau Pinang Village and Selawi Village, the tradition has been difficult to find because this area has become a transition area between village and city where there have been many cultural confluences caused by amalgamation. Despite the advancing and modern times, the existence of Pantauan Bunting tradition continues to be preserved by the Besemah people in Lahat Regency. ---

Indonesia is a multi-cultural country characterised by hereditary traditions passed down by ancestors. Strands of this traditional culture are often specific to particular communities, for example the Pantuan Bunting tradition is expressed and passed down in the customs of the Besemah community of Lahat Regency, South Sumatra. The purpose of this study is to analyze the social construction of the process of the formation of Pantauan Bunting tradition, the distribution of Pantauan Bunting tradition in different regions, and the existence of Pantauan Bunting tradition in Besemah Tribe community in Lahat Regency. The method used in this study was qualitative with ethnographic, historiographic, and spatial approaches. This research was conducted in three locations, namely in Kota Agung Village, Penang Village, and Selawi Village where the research subjects consisted of traditional leaders, religious leaders, community leaders, and the Besemah community. The results of this study showed that (1) the Besemah community constructs Pantauan Bunting tradition since the time of its earliest ancestors and this process of transmission still continues. This tradition is characterised by a public invitation to prospective brides to come to their prospective bridegrooms' homes. (2) Pantauan Bunting Tradition has spread to various areas in Lahat Regency, such as Kota Agung Village, Pulau Pinang Village, and Selawi Village. (3) in the modern era, the existence of Pantauan Bunting tradition is maintained by the Besemah community, and we can still find it in various areas in Lahat Regency. The Pantauan Bunting tradition, practised in various parts of Lahat Regency since ancient times and firmly ingrained in the Besemah community, highlights the community's resiliency and commitment to preserving its cultural legacy.

introduction culture is an important element in human life because it provides the implied meaning of various aspects of society the significance of culture is strongly related to values beliefs ways of thinking ways of living and world views adopted by community members at certain times culture is not a thing that is only owned by a particular group of people but is owned by everyone and can be a unifier of the nation human beings and culture are never separable in daily life the human being is never detached from culture as social beings people interact with each other and follow habits that can become a culture pesurnay defines culture as an expression of the will of man in recognizable structures shared by those who inhabit the same world therefore the relationship between man and his cultural world is dynamic and dialectical this concept informs a theory of social construction including objectivity internalization and externalization pujiati argues that these three concepts outline a process of forming a tradition that goes hand in hand with that tradition itself and evolves continuously the individual human being becomes an instrument involved in creating an objective social reality through a process of externalization as the individual interprets influences through a process of internalization ngangi explains that this social construction can be dialectically illustrated as in figure 1 each process for the dialectical scheme of social construction is presented in table 1 the human being is also seen as the creator of culture culture is closely related to tradition which can be seen as formed through the communitys continuous transmission of a culture tradition is a habit behavior or attitude of a society passed down from generation to generation and preserved by the local community as a reflection of that society with a distinctive culture tradition is a spirit of culture that strengthens a cultural system culture and all its products are the results of the process of human life local wisdom is a cultural product that includes philosophy values norms ethics rituals beliefs habits customs and so on wisdom usually comes from ancestors who are followed by community members from generation to generation this local wisdom accumulates the good habits of generations table 1 theoretical dialectical scheme of social construction no dialectical scheme description 1 externalization human generosity is directed towards the world in mental and physical activities it is sometimes seen as the essence of man himself and it is an anthropological imperative that man always devotes himself to the world in which he exists humans cannot understand themselves as detached selfenclosed beings separated from the outside world objectivation the results have been achieved both mentally and physically through human externalization activities the results confront the producer himself because they are outside and different from the humans who produce them through this process the community becomes a sui generis reality objectivation can manifest as sharing opinions concerning a social product that emerges within a community through public discourse even without direct inperson interaction between individuals and the creators of said social product 3 internalization it can be argued that the human person is an instrument in the process of creating objective social reality through a process of externalization as she or he influences it through a process of internalization which reflects subjective reality individuals become members of society through this process of internalization or socialization local wisdom passed down by tradition becomes the basis for someone in a particular tribe to communicate with other tribes habits and the local wisdom they form give rise to a tradition with its customs norms and other cultural forms local wisdom is a form of community culture in the form of knowledge products and activities used for survival adapted to where they are from generation to generation local wisdom has philosophical values believed to be guidelines in life activities to maintain personal and group survival each region has a different tradition of commemorating or celebrating important events such as births weddings and deaths one area of indonesia with a unique tradition is the lahat regency in south sumatra province one of the national tribes that inhabits this region is the besemah tribe which is different from the peoples inhabiting other areas in celebrating weddings the besemah tribe community still upholds the tradition of pantauan bunting inherited from its ancestral beginnings especially when wedding celebrations are held this is evident from researchers direct observations many still carry on this tradition some research shows that the pantauan bunting tradition involves a pair of brides who will be accompanied by a man and a woman who in the besemah language are called bujang ngantat and gadis ngantat a bujang ngantat or gadis ngantat must be unmarried the task of the gadis ngantat and bujang ngantat is to join the bride in surrounding the house of the residents who have called the couple they also accompany the bride and groom from the time of the marriage proposal until the wedding reception the research results of reveal several new things the pantauan bunting tradition is still practiced by the pasemah community especially the sukarami village community in a series of marriage ceremony activities in the form of an invitation to eat from the local community to a newly married partner the tradition of pantauan bunting is carried out to profit muji jurai or honor the descendants as an act of gratitude and respect for their descendants because they are married or it is also said to be a gift from the community to the bride zaman also reports on the uniqueness of marriage events in the community as exemplified in the performance of rituals such as the rokat tektek kemanten tradition which is imbued with institutionalized community values these practices involve symbols that have sacred meanings in the rokat tektek kemanten tradition as it is an ancestral heritage of appreciating bujuk nia which determines social reality in the community as an institutional belief system the process of social community formation occurs through simultaneous awareness and solidarity research methods this study utilizes the qualitative method of ethnography to provide a detailed description of the social construction process involved in the pantauan bunting tradition within the besemah tribe community this research aims to shed light on how social constructs are formed by examining the stages of externalization objectivation and internalization additionally the study will offer insights into the distribution uniqueness and prevalence of the pantauan bunting tradition specifically within lahat regency through this comprehensive analysis a deeper understanding of the cultural significance and dynamics of the pantauan bunting tradition can be attained research location this research study will be conducted in three zones selected by researchers based on the strength of the influence and distribution of the construction of the pantauan bunting tradition in one zone the tradition is still strong in the second it is fading away and in the third it no longer exists agung city village is included in the zone that is still practicing the tradition pulau pinang village is included in the transition zone where the tradition is rarely practiced selawi village is included in the zone where the pantauan tradition is barely practiced anymore the location of research is presented in figure 2 research subject in qualitative research the research subject commonly referred to as the informant is someone who provides information about the data to be studied in this study the subject of research is the besemah tribe community in lahat regency the pasemah tribe commonly called the besemah tribe is one of the ethnic groups residing in the province of south sumatra indonesia the majority of the people live in and around mount dempo pagaralam city lahat regency empat lawang regency and muara enim regency a small part of the tribe is spread across other districts the subjects of this study were mainly people in kota agung village pulau pinang village and selawi village the persons selected by the researcher to be used as informants in this study include traditional figures in kota agung village pulau pinang village and selawi village native people who are tribal to the besemah nation in kota agung village pulau pinang village and selawi village this study used the snowball sampling model to gather information the method is called snowball sampling because a researcher determines a person to be a sample based on the recommendations of people who have been a sample before the specifics of this research studys informants are presented in table 2 research instrument the instrument used in this study is the researcher himself because this study uses a qualitative approach that must interact directly with the surrounding community and involve interview guidelines observations recording tools and documentation tools data analysis data analysis is a crucial stage in the process of conducting scientific research because it allows the researcher to arrive at answers or to the problems which the research has qualitative data analysis involves the sorting coding and thematizing of data derived from the data collection process involving interviewing study participants recording the interview and taking notes and reviewing the literature results and discussion social construction the process of forming the pantauan bunting tradition in the besemah tribe community regions in indonesia have many local forms of wisdom cultures traditions customs languages and rituals or ceremonies that differ from one area to another the cultural diversity of indonesia consists of customs or traditions that develop in society into a distinctive view held by a particular community which is embodied in its acting as it behaves in indonesia several traditions have been highlighted by research into traditions in particular locations the pararem custom in the mass marriage tradition found in pengotan village bangli regency is underpinned by the communitys economic situation cultural preservation hereditary sustainability and culturallyspecific views of happiness the tradition of javanese customary marriage that prevails in kalidadi village is the wetonan custom involving taboo understood as a form of caution a way parents choose prospective partners for their children and protect their childrens households from all the possible adverse effects that could befall them in the future susantin rijal highlight that the marriage tradition in madura differs from that in java in madura the majority of the population adheres to the matrilineal tradition in which after marriage husbands and wives are required to live in the wifes house before the wedding the future husband carries bhengibhen to the wifes house the wife has a house to occupy this contrasts with the ampa sabae tradition which has developed over a long period in the ambalawi community the ambalawi community understands this ancestral tradition as a solution to the problem which arises when women suffer detriment due to mens actions it is a way for women to hold men accountable a unique case is found in the bakar batu tradition a traditional ceremony enacted by the dani tribe it involves the event of cooking a dish made from several pigs this dish is served as the main part of the meal a stone that had been burned as a cooking medium the dani tribe continues this tradition of baking stones as a form of gratitude to god as an expression of joy or of sorrow it is a regular part of big events such as celebrations of marriages or births or the final tribute to god on the occasion of someones death or thanksgiving for the blessings of the harvest the tradition of marriage in the bugismakassar tribal community has several long stages including determining the amount of panai money that the grooms family will hand over to the brides family in this tradition it is not surprising to find marriage occurring at an early age as documented by these researchers findings shed light on the meanings attributed to early marriage customs in nagari tapan basa ampek balai tapan district parents see early marriage as 1 a way of avoiding shame 2 an economic matter 3 a rescue effort a similar diversity of marriage traditions occurs in the besemah tribe community the marriage contract is usually signed the day before the wedding celebration however some people do this after the wedding this is in accordance with the agreement of the community with the bride and groom when they will hold the pantauan wedding festivity several processes are involved in keeping the tradition they are presented in table 3 the tradition of pantauan bunting continues to be carried out by the community whether it is the besemah tribe or even people outside the tribe there are no traditional sanctions or customs about what other customs must be followed if people do not carry out the pantauan bunting tradition however the pantauan bunting tradition uses a system of reciprocity if we hold the traditional pantauan bunting celebration relatives are going to be married then the relatives will reciprocate by doing pantauan for us if we one day get married likewise if we do not hold apantauan bunting celebration other people will do the same thing and not have the celebration this principle of reciprocity is also important in customary law in the basemah community itself wardani argues that customary law is a living law that manifests itself as a community habit this marital custom law could thus be considered an inseparable part of the human body in the community anyone going to get married informs the community beforehand by inviting the residents in the surrounding areas by visiting their houses this is usually done two to three weeks before the wedding the bride and groom who will be married usually first inform their families or close relatives thus the community knows there will be a wedding so that they can prepare everything needed for pantauan including obtaining food and other necessities from far away at this time the inviting family will also bring lemang to people in the community the people who receive the lemang understand that it signifies they are obliged to hold a pantauan bunting celebration 2 bemasak after being notified by the brides family of the date of wedding the community will prepare everything necessary for pantauan the most prominent feature in the pantauan bunting tradition is the presence of various dishes ranging from snacks such as cakes and fruits to more substantial food such as rice and side dishes for this reason the community will usually make or cook food to be served when the pantauan bunting celebration is held usually the day before the pantauan the community will have prepared a dish that will be served during the pantauan some people even start gradually making food a week before the pantauan there are no stipulations regarding what food should be available and served during the pantauan however some dishes are almost always part of the pantauan bunting tradition lemang dodol and pepes ikan a typical food from the besemah tribe in addition to these two types of food there is also always meat but it is only served by close family members this symbolizes that the family conducting the pantauan bunting celebration still has a blood relationship with the bride mantau bunting the day before the wedding celebration mantau bunting or calling the bride is done after the marriage contract is signed the community usually calls the bride and invite the bride to visit their homes the pantauan bunting feast can also be held after the wedding celebration is over because there will not be enough time for the bride and groom to visit the homes of the residents of the surrounding areas in a single day for this reason before the pantauan begins the community will agree when they will hold the traditional pantauan bunting celebration source field research results in social construction theory something can be formed due to the dialectic of externalization this involves objectivity and internalization the following is an explanation of the three social processes associated with this pantauan bunting tradition based on this explanation of the dialectical process of pantauan bunting the researcher sees it as having component parts as shown in figure 3 distribution of pantauan bunting traditions in the besemah tribe community pasemah tribe commonly called the besemah tribe the origins of the name besemah for this community are believed to be derived from the name of a fish that was formerly found in the pagaralam area of south sumatra province the semah fish is a type of goldfish that lives in murky streams among rocks that are overgrown with moss and shaded by trees however many people call the besemah tribe the pasemah tribe the name pasemah stopped being used because dutch colonists found it difficult to pronounce the phoneme pa and pronounce it be so the name pasemah became besemah for the purposes of government authority and administration the besemah cultural area includes pagaralam city lahat regency empat lawang regency muara enim regency and south ogan komering ulus regency in south sumatra province lahat regency specifically includes the area of jarai district tanjung sakti district and the area around kota agung district the besemah cultural area in bengkulu province includes kaur regency seluma regency and south bengkulu regency specifically kaur regency includes padang guci hulu district and padang guci hilir district besemah culture is also found in lampung province namely in south lampung regency the spread of besemah culture to various areas outside pagaralam city was followed by changes and the formation of new cultural identities in these different regions but they all still recognize that their origin lies in pagaralam the besemah tribe is one of the tribes that inhabit lahat regency and its surroundings the besemah people are scattered in all areas both inside and outside the province of south sumatra thus the pantauan bunting tradition is not only to be found in one place in south sumatra but elsewhere too in this study researchers selected three different villages in lahat regency as a research location kota agung village pulau pinang village and selawi village based on the results of the study the researchers can say that pantauan bunting tradition is still alive in these three areas however the numbers of members of the besemah tribe differ in these areas in kota agung village the besemah tribe community is still widespread and it can even be said that the majority of people in this village are from the besemah tribe community in penang village by contrast it is fairly uncommon to find people from the besemah tribe because the majority of people in this village are from the gumai lembak tribe finally in selawi village it is very difficult to find besemah people because selawi village is located very close to the city center where there has been singificant mixing of tribes and cultures the results of this research study also show that several factors cause the distribution of the besemah tribe in lahat regency to vary from area to area the first factor is physical factors that include location and distance kota agung village is quite far from the city center makes it difficult for people to move to other inhabited places therefore the people of the besemah tribe tend to live in the village of kota agung on the other hand in pulau pinang village members of the besemah community are rare this is because penang village is a transition area between the village and the city center so it is quite easy for people to move from one place to another the concentration of the besemah tribe in selawi village is almost the same as that in penang village it is quite difficult to find people from the besemah tribe because it is located very close to the city center social factors also affect differences in the distribution of the besemah tribe in lahat regency social factors come from society itself as explained above in kota agung village the majority of the people are from the besemah tribe the people in kota agung village are still classified as a traditional community people still adhere to the existing traditions the closed attitude of the community makes it difficult for this village to accept anything new that comes from outside and it tends to maintain its original culture therefore if we visited kota agung village the pantauan bunting tradition would still be very easy to find the next research area is pulau pinang village the distribution of members of the besemah tribe in pulau pinang village is sparse because pulau pinang village is a transition area between the countryside and the city center so there has been a lot of cultural mixing the indigenous people in penang are not the besemah tribe but the gumai lembak tribe the ancestors who lived in this village came from the gumai lembak tribe most people now in penang village are not from the besemah tribe but the gumai lembak tribe researchers also find it difficult to interview informants about the pantauan bunting tradition the besemah tribe is only a minority and its members are immigrants however we can still see the pantauan bunting tradition in the pulau pinang village the besemah people in this village still continue the tradition even though they are only few in number and are not the villages original inhabitants in selawi village members of the besemah community are few and difficult to find this is because this village has seen significant cultural mixing this phenomenon cannot be avoided because selawi village is located very close to the city center so many people from different ethnic groups migrate to this village on account of work education or marriage in selawi village many people have moved with the times and have weddings with a modern vibe this is also what makes the existence of the pantauan bunting tradition in this village difficult to find the community has left many traditions behind that have been considered ancient social factors also affect the distribution of the pantauan bunting tradition one is amalgamation the marriage of members of different tribes amalgamation can lead to assimilation and acculturation assimilation is a meeting between two cultures that brings about a new culture and replaces and erases the old culture acculturation conversely is the meeting of two different cultures that creates a new culture but does not eliminate or abandon the old one this phenomenon does not only occur in the basemah tribe several studies show the same process in different locations and involving different populations such as the amalgamation of chinese and madura ethnic groups in bangkalan madura regency another example is the marriage amalgamation of batak and malay ethnic groups in pangkalpinang city ethnic differences between flores and chinese in trubus village central bangka regency have likewise been amalgamated through marriage a final example is that of chinese amalgamated through marriage with members of indigenous peoples in java it depends on the community itself to assimilate or acculturate in a particular cultural environment this is also the case with the pantauan bunting tradition society chooses to maintain or abandon this tradition in daily life every region in java has an amalgamated community with the exception of the three villages that the researchers chose kota agung village penang village and selawi village based on the results of field observations the researchers can say that although there have been many amalgamations in kota agung and pulau pinang village the community still maintains the traditional culture even if there is an amalgamation other tribes follow the customs or traditions of the besemah tribe on the other hand in selawi village because there have been many assimilations and influences due to the location of the village very close to the city center most people abandon existing traditions and keep up with the times slowly the distribution of the pantauan bunting tradition among the three villages exhibits variations with some villages still having easy access to it while others find it more challenging or even extremely rare to come across these disparities can be attributed to the factors mentioned earlier despite these differences the besemah people strive to uphold and sustain this tradition they view the pantauan bunting as an integral part of their lives that holds significant cultural value hence the communitys commitment to its preservation and continuation the existence of the pantauan bunting tradition in the besemah tribal community in lahat regency the pantauan bunting tradition is one of the customs which is distinctively that of the besemah tribe people will invite a bride to come to their house the community will entertain the bride and groom offering them various dishes ranging from snacks to heavy food pantauan bunting is a tradition constructed by the besemah people in ancient times and still exists today even though it is not as strong as it once was the tradition is a special form of human interaction response with its living environment the formation of an environment is determined by several factors one of which is the local communitys culture the tradition of pantauan bunting is still found throughout all areas of lahat district although in the modern era people compete to have wedding celebrations r with a modern feel and leave behind traditions considered oldfashioned the besemah community still continues the pantauan bunting tradition these forms of kinship solidarity include the role of parents routine social activities feelings of energetic life and traditional javanese customs and rules of thumb that still apply to everyday life the existence of pantauan bunting tradition has many benefits for the community in this study the researchers selected 3 villages kota agung village pulau pinang village and selawi village the three villages were selected based on the difference in distance from the city one village is far from the city center namely kota agung village one village is in the transition area between the village and the city center namely pulau pinang village and one village is close to the city center selawi village with these differences in distance from the city center the researchers can compare the villages to see whether villages that are located within a close proximity to the city center and villages that are located long distances from the city center exhibit differences in their levels and methods of maintaining the existence of the pantauan bunting tradition the numbers of people living in each area of lahat district number are shown in table 4 the besemah tribe still maintains the pantauan bunting tradition in kota agung a majority the people are from the besemah tribe they still maintain the practices of the pantauan bunting tradition by contrast in penang village the majority of the people are from the gumai lembak tribe while people from the besemah tribe form a minority nevertheless the besemah community in this village still carries on with the pantauan bunting tradition in selawi village located very close to the city center significant cultural mixing has caused people to abandon their culture and traditions the community has begun to be diverse and it is very rare to find people from the besemah tribe who still maintain the pantauan bunting tradition we therefore know that the villages different locations and distances between the three villages and the city center impacts but never quite eliminates the pantauan bunting tradition many still hold to their traditions firmly and ensure that this tradition does not fade or disappear even in an advanced modern era conclusion the pantauan bunting tradition originates in the besemah tribal community it involves occasions when a couple in the community is to be marred the bridetobe is invited to come to the community members houses in the village where the community will provide various dishes ranging from snacks to heavy food this tradition is usually done the day before the wedding celebration is held in doing pantauan bunting tradition a bridetobe will be accompanied by a single man and woman the pantauan bunting tradition is widespread in various areas across lahat regency several factors cause pantauan bunting tradition in lahat regency to differ in each area where it is kept physical factors include the villages location and its distance from a city center social factors come from the community itself in this study we find that kota agung village is a village where we can easily see the pantauan bunting tradition this is because the majority of kota agung village community members are still classified as traditional and closed to something new in addition the people in this village have not intermingled much from other ethnic groups so the purity of the indigenous besemah tribe in this village is still maintained whereas in pulau pinang village and selawi village the tradition has been difficult to find because this area has become a transition area between village and city where there have been many cultural confluences caused by amalgamation despite the advancing and modern times the existence of pantauan bunting tradition continues to be preserved by the besemah people in lahat regency

indonesia is a multicultural country characterised by hereditary traditions passed down by ancestors strands of this traditional culture are often specific to particular communities for example the pantuan bunting tradition is expressed and passed down in the customs of the besemah community of lahat regency south sumatra the purpose of this study is to analyze the social construction of the process of the formation of pantauan bunting tradition the distribution of pantauan bunting tradition in different regions and the existence of pantauan bunting tradition in besemah tribe community in lahat regency the method used in this study was qualitative with ethnographic historiographic and spatial approaches this research was conducted in three locations namely in kota agung village penang village and selawi village where the research subjects consisted of traditional leaders religious leaders community leaders and the besemah community the results of this study showed that 1 the besemah community constructs pantauan bunting tradition since the time of its earliest ancestors and this process of transmission still continues this tradition is characterised by a public invitation to prospective brides to come to their prospective bridegrooms homes 2 pantauan bunting tradition has spread to various areas in lahat regency such as kota agung village pulau pinang village and selawi village 3 in the modern era the existence of pantauan bunting tradition is maintained by the besemah community and we can still find it in various areas in lahat regency the pantauan bunting tradition practised in various parts of lahat regency since ancient times and firmly ingrained in the besemah community highlights the communitys resiliency and commitment to preserving its cultural legacy

INTRODUCTION Transportation systems are designed to serve communities by providing accessibility and mobility . Limitation in mobility occurs when a person cannot move between an origin and a desired destination because of external or individual factors. People with limited mobility include but are not limited to senior citizens, the poor, children, persons who do not speak English, people with physical disabilities, and people with developmental disabilities. Limitation in mobility may affect physical, social, and psychological well-being. There is a growing recognition in the fields of disability services, rehabilitation, education and psychology of the need to promote selfindependence for individuals with mental retardation and developmental disabilities . Transportation is considered one of the main means to determine the level of independence and self determination of PDD . Independence in transportation is a key towards achieving this goal. This study investigates the travel demands and activities of people with developmental disability residing or working in Hennepin County, Minnesota. The transportation needs were determined by conducting and analyzing a mail out -mail back survey that includes questions measuring the difficulty of reaching their desired destinations in the region to engage in some kind of activity . Only a few studies address the unmet needs of the transportation disadvantaged population. A literature search revealed that most researchers tend to use transportation options and modes as a mean to increase the independence of PDD yet none, to our knowledge, has documented the levels of independence or discussed the unmet needs of PDD. Trying to understand the transportation needs of a special population such as PDD can be achieved through answering the following research question. --- "What are the travel demands and activities of individuals with developmental disabilities?" This paper begins by defining developmental disabilities and mobility. It then reviews the literature on the transportation needs of persons with developmental disability. This is followed by the research design, survey method, identification of research partners. The survey itself is described, its pilot testing explained. Next we present summary statistics, this is followed by more detailed analysis and discussion. --- DEFINITIONS Disability in the context of travel behavior research has no succinct definition. In a study conducted using data from the London Area Travel Survey, disability was defined as "a longstanding health problem that affects [a participant's] ability to travel or get about" . Meanwhile the Oregon Department of Transportation defines people with disability as "individuals of all ages who are unable to transport themselves without special equipment or outside assistance due to a physical, cognitive, or psychiatric impairment" . We define people with transportation disability in this research as people who cannot meet some or all of their transportation needs without the direct help of others. This definition is wide enough to include our population of interest. This research paper concentrates on measuring the needs of people with developmental disabilities . Developmental disabilities are severe, chronic disabilities caused by mental and/or physical impairment. They typically appear before age 22 and last throughout a person's lifetime . The U.S. Department of Health and Human Services reports that developmental disabilities result in substantial limitations in three or more of the following areas: self-care, receptive and expressive language, learning, mobility, self direction, capacity for independent living, and economic self-sufficiency. The HHS Administration on Development Disabilities estimates there are about 4.5 million persons with developmental disabilities in the United States , which would translate to about 17,000 residents of Hennepin County, Minnesota. Better understanding the transportation needs of PDD is crucial to address their needs, while classifying them should be based on the type of disability due to the variations in the types of DD . This research aims to better understand the transportation needs and concerns of PDD as a special population. PDD have both met and unmet transportation needs. It is important to note that PDD as a population in general can include both transportation disadvantaged and advantaged people depending on the degree of disability and training. The term transportation disadvantaged people in this paper refers to people who cannot meet all their transportation needs independently and require some special attention from the community to help them in meeting those needs. In contrast, the transportation advantaged can independently meet all their needs through the existing system. PDD can be trained to certain levels where they can partially overcome their disability and use public transit for example, to fulfill their transportation needs. Listening to the concerns of both advantaged and disadvantaged is important to help better serve their special needs. Understanding these needs requires ascertaining two major pieces of information: the existing travel behavior patterns for the PDD population, and the unmet needs and wants of the relevant groups, e.g. what services they want but are not presently being provided. These provide a baseline of information to proceed with subsequent planning and decision-making. The perspective of the users of the services is critical to ensure an accurate measurement of both behaviors and desires. The major types of developmental disabilities that the Center for Disease Control and Prevention identifies on are: autism spectrum disorders, cerebral palsy, mental retardation, hearing loss, and vision impairment This study by design excluded persons with only sensory impairment, which have been treated elsewhere, though the studies involving those groups are reviewed below. In this study the majority of the samples are people with mental retardation followed by cerebral palsy then other kinds of DD It is generally acknowledged that there is a vital relationship between mobility and quality of life of PDD. However, because mobility is ill-or multiply-defined, this relationship is difficult to pin down. Mobility is often used synonymously with travel, but Metz points out that a loss of mobility implies more of a hardship than does simply traveling less. Metz proposes operationalizing mobility using five key elements: Travel to reach desired people and places; Psychological benefits of movement-of "getting out and about"; Exercise benefits; Involvement in the local community; and Potential travel. Existing research tends to address the first of these, disregarding benefits that do not go hand-in-hand with a travel destination. Previous studies on the travel behaviors of the people with disabilities have used a combination of categorical and operational ways of identifying the transportation disadvantaged population. --- LITERATURE REVIEW Most literature on travel needs and behaviors of people with disabilities has focused on people with physical disabilites some on those with sensory disabilities, very litlle of the literature has considered non-sensory developmental disabilities. Around 30% of people with hearing impairments or deaf and close to twothirds of children with vision impairment also have one or more other developmental disabilities . Although, hearing and vision impairments are not the focus of this study, the literature about them is germane In a survey of bus users in Washington, DC and subway users in New York City, Winakur found that the hearing impaired encountered problems with both bus and subway use. The problems experienced were mainly a result of difficulties in obtaining and using information about routes and fares and in communicating with the driver. For subway users, additional problems were encountered because people with hearing impairment were unable to hear loudspeaker announcements about emergencies or route changes and delays. Bettger & Pearson note similar problems in accommodating deaf and hard of hearing persons on buses, subways, and airplanes in Massachusetts, and make suggestions for improvements that could be made in each mode, from increasing awareness of telecommunication devices for the deaf services to using video monitors and electronic readerboards to convey information. ` Golledge, Costanzo, and Marston surveyed blind and vision-impaired populations in Santa Barbara, California to determine how non-driving impacts their quality of life and what types of transportation are most used. Respondents were recruited through local agencies that deal with the visually impaired. 55 people participated via mail survey, telephone survey, and in-person interviews. Around 51% of the respondents identified the local bus as their primary mode of travel [not random], and the top reasons given for using public transit were the fact that service met their needs, cost, and lack of alternative. Other forms of transportation used included household cars, walking, friend's cars, and agency vans. Sixty-seven percent of the sample depended on others for transportation, and four-fifths of these indicated frustration from this dependence. The authors noted some differences in activity patterns of the respondents from the sighted: Limited transit schedules constrained late-night and Sunday travel; participants needed assistance in traveling and, due to the necessity of living near a bus stop, choice of home location was restricted. Most participants were familiar with the range of services for people with disabilities in their community, and 58% felt these services met their needs. --- RESEARCH DESIGN The goal of this research is to measure the actual and un-met transportation needs of PDD residing or working in Hennepin County, Minnesota. Hennepin County is part of the Twin Cities seven counties region. The County consists of 46 cities including Minneapolis, Minnetonka, Maple Grove, Edina, Plymouth, Bloomington, Eden Prairie and Saint Louis Park. Since this research deals with a special population, the available secondary datasets are not sufficient to help in reaching this goal, accordingly conducting a survey and collecting primary data that measures the needs of this population is essential. Based on a theoretical background the research team constructed a transportation survey that can help in achieving the main goal of this study. Targeting PDD to answer this questionnaire can be accomplished most readily through partnership with several disability organizations and the residential communities that are dedicated to serve them. In other words, reaching the targeted population is done through people who provide services to them, where mailing lists and contact information are maintained. This partnership started with the early stages of the study, where several partners helped in reviewing the survey or even organizing meetings with PDD to pilot test the survey. After the return of several surveys from the pilot testing, the research team incorporated several changes to the survey to address the concerns and issues being raised by PDD who were part of the testing. The survey was then distributed to PDD through various channels of communication depending on the type of partnership being established between the research team and the community partners. Finally surveys were returned to start the analysis phase. Figure 1 outlines the flow of the research. --- Population and Sampling Method The population of interest in this study comprises PDD residing or working in Hennepin County. For purposes of this study, the PDD will be defined as those who are diagnosed with autism spectrum disorder, cerebral palsy, and mental retardation and any other traumatic brain injuries that lead to a DD. This is a broad enough definition to include all the people defined by CDC as PDD. In order to represent a diverse crosssection of PDD, the following characteristics are taken into account when selecting partners to recruit PDD to be part of the study: • Geographic location: Hennepin County includes the urban core of Minneapolis as well as suburbs and distant exurbs. Each of these types of locations offers a different set of transportation options to the PDD. • Independence level: Mobility is not just a function of type and level of disability, but also of relative independence level. Independence, as a concept, encompasses physical and mental disabilities. Living situation will be used as a proxy for independence level. PDD who are hospitalized or in hospice care may not be medically stable, and the difficulties associated with incorporating their participation is probably too great for it to be worthwhile. • Racial and ethnic diversity: Hennepin County is becoming a more diverse place in the year 2000, 21 percent of residents were non-white, up from 11 percent in 1990, though much of that diversity is in the younger immigrant population. To be fully representative, the study includes PDD from a variety of racial and ethnic backgrounds. One barrier to this is language: 46% of the state's foreign-born population lives in Hennepin County. PDD foreign-born Hennepin County residents may not be proficient in English, and producing survey materials in alternative languages is beyond the scope of the study. In order to account for all these elements of diversity, it was necessary to recruit participants from different sources. The most efficient way to recruit participants was to develop relationships with community partners, which include agencies and organizations that provide support to PDD and willing to allow and/or coordinate participant recruitment. --- Community Partners Community partners play a very important role in connecting the research team with the PDD they serve. PDD centers, programs, community services which supervise PDD centers and transportation programs located in Hennepin County were chosen to be the community partners that helped us in conducting this study. The research team contacted around 12 disability organizations serving PDD in Hennepin County. Of the 12 contacted, 5 partners who are agreed to help the research team in the study by either: 1. Introducing the study to a sample of PDD for pilot testing, 2. Distributing surveys at sites, and 3. Sending the surveys to PDD by mail through use of mailing lists. It is important to note that our sampling is biased towards the cities and areas which PDD organizations or community services agreed to help us and to the level of support we received from these partners. --- Survey In order to ascertain the transportation needs of PDD the research team designed a survey that contains a set of quantitative and qualitative questions. The quantitative questions in the survey include standard information about demographic and socioeconomics characteristics . In addition, a set of questions is targeted towards identifying the transportation modes and frequency of usage to reach these activities. Travel/activity diary information recording every trip or activity undertaken by an individual over the course of the day is also included in the survey. The qualitative questions are directed to the travel and activities that the PDD could and/or could not be undertake. Meanwhile a set of supporting questions are included to help in quantifying the reasons if any activity was not met and if the reason was due to a disability or the person's physical condition, or the location of the desired activities, and/or quality of existing transportation services or any other reasons. The main questions in the survey tried to cover the following areas: • The frequency of trips made to different destinations, • The two modes of transportation most used, • If there is a need of assistance in traveling, • Capability of making trips needed and /or wanted, • The use of automobile, • The use of paratransit, • The use of public transit, • Difficulty using public transit, • Concerns using public transit, • Attitudes using public transit, • Attitudes towards driving , • Concerns related to transportation, and • Demographic and socio economic questions. In addition two questions were added asking if the participant has any diagnosed medical condition or disability. An open ended question is included at the end of the survey for PDD to report any comments or concerns related to their transportation needs or limitations. This section helps in allowing the participants to raise topics and issues that are not covered in the survey. Another key question was asking who filled the survey the participant or someone else on behalf of him or her. --- Pilot Testing and Survey Distribution Since this research tries to capture the transportation needs of a special population, conducting a pilot test and getting feedback from a sample of PDD was essential. A group of PDD was used to assure that the questions proposed in the survey cover their transportation concerns. The PDD group was also used to test the ease of understanding the survey questions. Guardian approvals were obtained prior to the meeting. This meeting took place as part of the monthly leadership meeting at one of the PDD partners. The research team presented the survey and distributed it to the PDD attending the meeting. The pilot testing helped the research team finalize a survey that can capture the transportation needs of PDD. Ultimately 990 survey packets were prepared and printed for distribution to the partners. The survey packets included: Letter of invitation, survey, travel diary, trips you made today, trips you couldn't make today, consent form, assent form, and inserts from partners that explains the study and the support of the organization . A copy of the survey packet is provided in the final report . The distribution methods of the survey varied based on the agreement between the research team and the community partners. It was either mailed or handed to participants. Of the 990 survey packets that were printed and distributed. The research team received 124 returned envelopes of which 114 surveys were completed. The difference of 10 surveys came from PDD who did not want to participate in the study. Most of these cases the responses came mainly from the guardians stating that the targeted participant has severe degree of disability and his transportation needs are minor and being met by his family members. The total response rate was 11.51% for the survey and 9.49% for the travel diaries. --- DESCRIPTIVE STATISTICS It is important to note that the findings of this study only represent the characteristics of the people who received the surveys and responded to it. The majority of the returned surveys were filled by a guardian, relative, staff member, or volunteer on behalf of the subject. Only 16 surveys were filled by the PDD themselves. This number represents around 14% of the returned sample, while 15 returned surveys did not indicate how they were filled or by whom. --- Types of Development Disability Since the PDD is a unique and diverse population, the type of development disability will be used in this research as the main factor for classifying the results and the data. Two questions were used to determine the type of disability as mentioned earlier. The answers to these questions were classified into two main categories of development disability including: MR and others. The others category included answers as autism spectrum disorder, cerebral palsy , traumatic brain injuries, people with developmental disabilities , Noonan syndrome, multiple sclerosis, dependent personality disorder; various brain and nerve disorders, and people who answered that they would rather not discuss there type of disability. The reason for classifying the sample into MR and others category is because of the sample size that responded to the survey. The CP and ASD comprised only 11% of the entire population accordingly they were merged in the analysis to the Others category. The responses from MR population was A sample of 114 from a statistical standpoint may be considered small, yet when observing the type of population being studied such sample can be considered good enough to raise issues related to the needs of this small and disadvantaged population. --- Age and Gender Among the 114 returned surveys, 2 PDD did not report their age. Figure 2 shows the distribution of the PDD who responded to the survey by age group and type of disability. It is clear from observing Figure 2 that all age groups are presented in the total section. Approximately 56% of the responses came from males while around 43% came from females and one person refused to identify gender. --- Education Level of education and household income are two factors that tend to be highly correlated. The level of education that PDD have received is used as a proxy to understand their level of independency. Around 68% of the PDD who answered this question reported that they had education at the level of high school. Meanwhile only 25% had an education at the less than high school level. Only a few reported any college education. --- Place of residence The place where PDD live can also be used as an indicator for the level of independence. In the survey two questions were directed towards understanding where PDD reside and if they live with a relative or a non-relative. Around 53% of the total surveyed sample indicated that they live in a group facility. Meanwhile around 29% of the surveyed sample lives in private homes or condos, while 10% reside in apartments. The majority of PDD reside with non-relatives, while 25% lives with relatives. Around 8% of the surveyed sample resides by themselves in apartments, group facility and private condos. Two people indicated they reside by themselves in a group facility where they might be referring to their personal rooms in the facility where they do not share bedrooms with others. As expected it is clear that the level of independence in living arrangements tends to be low. --- Travel Diaries The total number of returned travel diaries was 100. Only 94 travel diaries were filled and included information related to trips. Around 19% of the PDD who returned the surveys had four trips reported as part of their diary. Meanwhile 10% of the returned and filled diaries reported that three trips took place during the day the diary was recorded, while 44% reported doing only two trips during the same period of time. Finally 25% of the returned and filled diaries who had an activity reported one trip being made. --- ANALYSIS AND DISCUSSION This section concentrates on displaying the major findings of the survey. In order to better understand the transportation needs of the surveyed sample, looking at some questions while controlling the type of DD is critical to understand the general trends and if there is a specific phenomenon associated to a certain DD group. --- Trip Purpose Observing the purpose of the trip, in the travel diaries, PDD reported trips to work, home, social and recreation and others as the top four purposes for traveling. Trip chaining is noticed to be part of 34% of the travel pattern among the surveyed sample who answered this section of the travel diaries . This indicates that fair amount of PDD engage in various activities after leaving their place of origin. Accordingly the purpose of leaving their homes is not just to conduct one activity but to conduct various activities. --- Frequency of Trips Observing the frequency of being engaged in work trips in the survey shows that around 74 participants responded they usually engage in such activity at least five to seven days per week, while 18 participants indicated they get engage in work trips at least for two to four days per week. These two numbers comprise around 80% of the total surveyed population. This relationship is displayed in Figure 3. It is also noticed that this observation is especially true among the MR group we sampled. More than 90% of the MR group indicated they work at least 2 days per week. Figure 4 shows the frequency of being engaged in recreational trips, while Figure 5 shows the frequency of being engaged in a social trip. Comparing the distribution of frequency of being engaged in social and recreational trips to the frequency of being involved in work trips we notice PDD tend to do more social than recreational trips, though work remains the most frequent trip purpose. --- Travel Needs The survey asks the participants if there are times they cannot make trips they need to make and asks them if there are times they cannot make trips they want to make. Around 55 participants responded "No" they can make both the trips they want to make and the trips they need to make. This number represents 50% of the surveyed sample. Meanwhile 29 participants responded yes they are facing problems in doing both the trips they need to make and the trips they want to make. Only 25% of the participants with MR had trips they needed to do but could not do. Similarly in the others group around 30% of the participants responded yes there are trips they need to but could not make. --- Travel Mode and Assistance Work and shopping are two main purposes for all persons and were noticed to be the major trips that PDD tend to be engaged in. Around 39% of the surveyed sample uses private cars as their primary mode of transportation for shopping. The number of people using other modes, which includes local services at home facilities, is quite high along with the MR group. Around 70% of the surveyed sample reported a need for assistance when conducting shopping trips. Around 52% of the surveyed sample reported a need for assistance when conducting work trips. --- Difficulties A question in the survey concentrated on the difficulties participants face when using public transit. These questions concentrated mainly on the physical difficulties associated with moving, standing, waking to the bus stop, climbing stairs, and reading the route numbers. Among MR participants 46% face problems in standing. From the total sample 46% of the participants indicated they face problems in reading schedules, while 49% indicated they face problems understanding schedules. Transit schedules in general are being written to time points. A user of the service not using a time point interpretations is required to determine the arrival and departure time. This way of writing schedules is even difficult for the general population to understand. Accordingly it is expected that PDD might face such issues. Difficulties in understanding the announcements being made on board of the bus were reported by 35% of the surveyed sample. --- Concerns of Transit Users Public transit was the second-most used mode of transportation for PDD. Around 51% of the surveyed sample reported that they are either concerned or very concerned that the bus service might not serve their destinations at their desired time. Meanwhile 55% were concerned with being a victim of a crime while using public transit. Fewer than 50% of the surveyed sample were concerned with transfers between various transportation systems during their trips. --- Familiarity with Services Around 75% of the surveyed sample indicated being familiar with services offered to PDD. Meanwhile around 25% of the surveyed sample indicated that they are not familiar with the services being offered to PDD. This indicates that more work may be needed in promoting the services to PDD. It is clear that paratransit service is used by only 62% of the surveyed sample. It is important to note that restrictions do exist when applying for paratransit, for example dial-a-ride service and not all PDD are qualified for such service. It is observed that around 30% of the surveyed sample have used Metro Transit either buses or light rail at some point in time as a mode of transportation. The variation among the various PDD groups seems to be minor. --- Independence Independence is measured directly through asking direct questions related to what extent PDD consider themselves as independent travelers. Around 48% of the participants in the survey reported that they do agree that they are independent travelers. Observing each PDD group we notice that the MR group feels least independent compared to the other PDD groups. The levels of independence of the other DD groups tend to be higher for the others group Surprisingly around 68% of the surveyed sample indicated it's their choice which mode of transportation they use. Finally a question related to public transit and the possibility of using it as a means of increasing the independence. Around 68% of the surveyed sample responded that they do agree that using public transit would increase their level of independence. The MR group tends to disagree more with this statement than other PDD. --- Travel Barriers The travel diaries included a question asking participants about the trips they could not make. Only 14% percent of the 94 participants who filled the diaries reported at least one trip they could not make. Meanwhile 7% of the participants who filled travel diaries had at least two trips they wanted to make but they could not make them, while 4% of the participants could not make at least three trips they wanted to make. Finally only 3% of the participants who filled travel diaries had at least four trips they wanted to make but they could not make. "No one available to drive" was the most widely cited reason why participants could not make their desired trips. Other reasons included: too late to make reservations, scooter battery died, weather, health, and service is too far to go to. --- CONCLUSION This paper presents the results of an 18 month research study into the transportation behavior and needs of PDD living or working in Hennepin County Minnesota. The paper describes previous research into the transportation behaviors of the disability, the methodology pursued in this study, and the findings and results of that study. Overall, most PDD responding to the surveys remain partially independent . This number might seem to be a little high for the PDD population in general, yet this might be related mainly to the characteristics of the studied sample. Being auto passengers, walking, public transit, and dial-a-ride are found to be the main modes of transportation participants tend to use to meet their transportation needs. PDD in the surveyed sample showed a willingness to use public transit more and indicated that they feel that using it will increase their independence. Several PDD indicated their willingness to drive yet they cannot afford to do so due to their conditions. Also several participants would like to use public transit yet report service does not exist around their homes or near their destinations; they felt using it was not possible for the time being. Issues related to understanding and interpreting the schedules was also raised. The needs of assistance are observed among almost half of the surveyed sample. Issues related to dial-a-ride services and complaints were a common factor in the comment sections. There was notable criticism of the long lead times for scheduling and unreliability of public paratransit services, though there was commendation for the paratransit provided by service providers directly. Several participants added some comments related to the walking distance to and from bus stops. Various participants raised safety concerns. The sampling of the survey was determined based on the level of cooperation between the PDD centers and research team. The sample is biased towards the locations where these centers tend to serve their population. Since only 14% of the PDD filled the surveys themselves, this study should be interpreted carefully since it reflects a mix of points of views of the guardians or relatives, as well as the PDD. Still this study remains a unique in the transportation field in trying to study and measure the needs of a population that has had very little transportation research conducted about their needs. --- List of Figures

The US Department of Health and Human Services Administration on Development Disabilities estimates the number of people diagnosed with a developmental disability in the United States as 4.5 million persons, which would translate to about 17,000 residents of Hennepin County, Minnesota. This research paper examines the transportation needs of adults with developmental disabilities either residing or working in Hennepin County through a survey of their existing travel behavior and their unmet transportation needs. The survey had both demographic and attitude questions as well as a travel diary to record both actual and desired but untaken trips. In this paper we report and discuss the main findings of the survey. It was clear from observing the returned sample that almost the entire surveyed population does not live independently. More than half of the surveyed population worked every day, while recreation occurred at least once a week for about two-thirds of the population, and more than half undertook social trips weekly. About 30% reported being unable to make trips they want to make and 46% unable to make trips they need to make. Public transit poses difficulties for this population both physically and intellectually. There were also specific complaints about the lack of transit service in addition to concerns regarding paratransit services. Community service providers received praise.

introduction transportation systems are designed to serve communities by providing accessibility and mobility limitation in mobility occurs when a person cannot move between an origin and a desired destination because of external or individual factors people with limited mobility include but are not limited to senior citizens the poor children persons who do not speak english people with physical disabilities and people with developmental disabilities limitation in mobility may affect physical social and psychological wellbeing there is a growing recognition in the fields of disability services rehabilitation education and psychology of the need to promote selfindependence for individuals with mental retardation and developmental disabilities transportation is considered one of the main means to determine the level of independence and self determination of pdd independence in transportation is a key towards achieving this goal this study investigates the travel demands and activities of people with developmental disability residing or working in hennepin county minnesota the transportation needs were determined by conducting and analyzing a mail out mail back survey that includes questions measuring the difficulty of reaching their desired destinations in the region to engage in some kind of activity only a few studies address the unmet needs of the transportation disadvantaged population a literature search revealed that most researchers tend to use transportation options and modes as a mean to increase the independence of pdd yet none to our knowledge has documented the levels of independence or discussed the unmet needs of pdd trying to understand the transportation needs of a special population such as pdd can be achieved through answering the following research question what are the travel demands and activities of individuals with developmental disabilities this paper begins by defining developmental disabilities and mobility it then reviews the literature on the transportation needs of persons with developmental disability this is followed by the research design survey method identification of research partners the survey itself is described its pilot testing explained next we present summary statistics this is followed by more detailed analysis and discussion definitions disability in the context of travel behavior research has no succinct definition in a study conducted using data from the london area travel survey disability was defined as a longstanding health problem that affects a participants ability to travel or get about meanwhile the oregon department of transportation defines people with disability as individuals of all ages who are unable to transport themselves without special equipment or outside assistance due to a physical cognitive or psychiatric impairment we define people with transportation disability in this research as people who cannot meet some or all of their transportation needs without the direct help of others this definition is wide enough to include our population of interest this research paper concentrates on measuring the needs of people with developmental disabilities developmental disabilities are severe chronic disabilities caused by mental andor physical impairment they typically appear before age 22 and last throughout a persons lifetime the us department of health and human services reports that developmental disabilities result in substantial limitations in three or more of the following areas selfcare receptive and expressive language learning mobility self direction capacity for independent living and economic selfsufficiency the hhs administration on development disabilities estimates there are about 45 million persons with developmental disabilities in the united states which would translate to about 17000 residents of hennepin county minnesota better understanding the transportation needs of pdd is crucial to address their needs while classifying them should be based on the type of disability due to the variations in the types of dd this research aims to better understand the transportation needs and concerns of pdd as a special population pdd have both met and unmet transportation needs it is important to note that pdd as a population in general can include both transportation disadvantaged and advantaged people depending on the degree of disability and training the term transportation disadvantaged people in this paper refers to people who cannot meet all their transportation needs independently and require some special attention from the community to help them in meeting those needs in contrast the transportation advantaged can independently meet all their needs through the existing system pdd can be trained to certain levels where they can partially overcome their disability and use public transit for example to fulfill their transportation needs listening to the concerns of both advantaged and disadvantaged is important to help better serve their special needs understanding these needs requires ascertaining two major pieces of information the existing travel behavior patterns for the pdd population and the unmet needs and wants of the relevant groups eg what services they want but are not presently being provided these provide a baseline of information to proceed with subsequent planning and decisionmaking the perspective of the users of the services is critical to ensure an accurate measurement of both behaviors and desires the major types of developmental disabilities that the center for disease control and prevention identifies on are autism spectrum disorders cerebral palsy mental retardation hearing loss and vision impairment this study by design excluded persons with only sensory impairment which have been treated elsewhere though the studies involving those groups are reviewed below in this study the majority of the samples are people with mental retardation followed by cerebral palsy then other kinds of dd it is generally acknowledged that there is a vital relationship between mobility and quality of life of pdd however because mobility is illor multiplydefined this relationship is difficult to pin down mobility is often used synonymously with travel but metz points out that a loss of mobility implies more of a hardship than does simply traveling less metz proposes operationalizing mobility using five key elements travel to reach desired people and places psychological benefits of movementof getting out and about exercise benefits involvement in the local community and potential travel existing research tends to address the first of these disregarding benefits that do not go handinhand with a travel destination previous studies on the travel behaviors of the people with disabilities have used a combination of categorical and operational ways of identifying the transportation disadvantaged population literature review most literature on travel needs and behaviors of people with disabilities has focused on people with physical disabilites some on those with sensory disabilities very litlle of the literature has considered nonsensory developmental disabilities around 30 of people with hearing impairments or deaf and close to twothirds of children with vision impairment also have one or more other developmental disabilities although hearing and vision impairments are not the focus of this study the literature about them is germane in a survey of bus users in washington dc and subway users in new york city winakur found that the hearing impaired encountered problems with both bus and subway use the problems experienced were mainly a result of difficulties in obtaining and using information about routes and fares and in communicating with the driver for subway users additional problems were encountered because people with hearing impairment were unable to hear loudspeaker announcements about emergencies or route changes and delays bettger pearson note similar problems in accommodating deaf and hard of hearing persons on buses subways and airplanes in massachusetts and make suggestions for improvements that could be made in each mode from increasing awareness of telecommunication devices for the deaf services to using video monitors and electronic readerboards to convey information golledge costanzo and marston surveyed blind and visionimpaired populations in santa barbara california to determine how nondriving impacts their quality of life and what types of transportation are most used respondents were recruited through local agencies that deal with the visually impaired 55 people participated via mail survey telephone survey and inperson interviews around 51 of the respondents identified the local bus as their primary mode of travel not random and the top reasons given for using public transit were the fact that service met their needs cost and lack of alternative other forms of transportation used included household cars walking friends cars and agency vans sixtyseven percent of the sample depended on others for transportation and fourfifths of these indicated frustration from this dependence the authors noted some differences in activity patterns of the respondents from the sighted limited transit schedules constrained latenight and sunday travel participants needed assistance in traveling and due to the necessity of living near a bus stop choice of home location was restricted most participants were familiar with the range of services for people with disabilities in their community and 58 felt these services met their needs research design the goal of this research is to measure the actual and unmet transportation needs of pdd residing or working in hennepin county minnesota hennepin county is part of the twin cities seven counties region the county consists of 46 cities including minneapolis minnetonka maple grove edina plymouth bloomington eden prairie and saint louis park since this research deals with a special population the available secondary datasets are not sufficient to help in reaching this goal accordingly conducting a survey and collecting primary data that measures the needs of this population is essential based on a theoretical background the research team constructed a transportation survey that can help in achieving the main goal of this study targeting pdd to answer this questionnaire can be accomplished most readily through partnership with several disability organizations and the residential communities that are dedicated to serve them in other words reaching the targeted population is done through people who provide services to them where mailing lists and contact information are maintained this partnership started with the early stages of the study where several partners helped in reviewing the survey or even organizing meetings with pdd to pilot test the survey after the return of several surveys from the pilot testing the research team incorporated several changes to the survey to address the concerns and issues being raised by pdd who were part of the testing the survey was then distributed to pdd through various channels of communication depending on the type of partnership being established between the research team and the community partners finally surveys were returned to start the analysis phase figure 1 outlines the flow of the research population and sampling method the population of interest in this study comprises pdd residing or working in hennepin county for purposes of this study the pdd will be defined as those who are diagnosed with autism spectrum disorder cerebral palsy and mental retardation and any other traumatic brain injuries that lead to a dd this is a broad enough definition to include all the people defined by cdc as pdd in order to represent a diverse crosssection of pdd the following characteristics are taken into account when selecting partners to recruit pdd to be part of the study • geographic location hennepin county includes the urban core of minneapolis as well as suburbs and distant exurbs each of these types of locations offers a different set of transportation options to the pdd • independence level mobility is not just a function of type and level of disability but also of relative independence level independence as a concept encompasses physical and mental disabilities living situation will be used as a proxy for independence level pdd who are hospitalized or in hospice care may not be medically stable and the difficulties associated with incorporating their participation is probably too great for it to be worthwhile • racial and ethnic diversity hennepin county is becoming a more diverse place in the year 2000 21 percent of residents were nonwhite up from 11 percent in 1990 though much of that diversity is in the younger immigrant population to be fully representative the study includes pdd from a variety of racial and ethnic backgrounds one barrier to this is language 46 of the states foreignborn population lives in hennepin county pdd foreignborn hennepin county residents may not be proficient in english and producing survey materials in alternative languages is beyond the scope of the study in order to account for all these elements of diversity it was necessary to recruit participants from different sources the most efficient way to recruit participants was to develop relationships with community partners which include agencies and organizations that provide support to pdd and willing to allow andor coordinate participant recruitment community partners community partners play a very important role in connecting the research team with the pdd they serve pdd centers programs community services which supervise pdd centers and transportation programs located in hennepin county were chosen to be the community partners that helped us in conducting this study the research team contacted around 12 disability organizations serving pdd in hennepin county of the 12 contacted 5 partners who are agreed to help the research team in the study by either 1 introducing the study to a sample of pdd for pilot testing 2 distributing surveys at sites and 3 sending the surveys to pdd by mail through use of mailing lists it is important to note that our sampling is biased towards the cities and areas which pdd organizations or community services agreed to help us and to the level of support we received from these partners survey in order to ascertain the transportation needs of pdd the research team designed a survey that contains a set of quantitative and qualitative questions the quantitative questions in the survey include standard information about demographic and socioeconomics characteristics in addition a set of questions is targeted towards identifying the transportation modes and frequency of usage to reach these activities travelactivity diary information recording every trip or activity undertaken by an individual over the course of the day is also included in the survey the qualitative questions are directed to the travel and activities that the pdd could andor could not be undertake meanwhile a set of supporting questions are included to help in quantifying the reasons if any activity was not met and if the reason was due to a disability or the persons physical condition or the location of the desired activities andor quality of existing transportation services or any other reasons the main questions in the survey tried to cover the following areas • the frequency of trips made to different destinations • the two modes of transportation most used • if there is a need of assistance in traveling • capability of making trips needed and or wanted • the use of automobile • the use of paratransit • the use of public transit • difficulty using public transit • concerns using public transit • attitudes using public transit • attitudes towards driving • concerns related to transportation and • demographic and socio economic questions in addition two questions were added asking if the participant has any diagnosed medical condition or disability an open ended question is included at the end of the survey for pdd to report any comments or concerns related to their transportation needs or limitations this section helps in allowing the participants to raise topics and issues that are not covered in the survey another key question was asking who filled the survey the participant or someone else on behalf of him or her pilot testing and survey distribution since this research tries to capture the transportation needs of a special population conducting a pilot test and getting feedback from a sample of pdd was essential a group of pdd was used to assure that the questions proposed in the survey cover their transportation concerns the pdd group was also used to test the ease of understanding the survey questions guardian approvals were obtained prior to the meeting this meeting took place as part of the monthly leadership meeting at one of the pdd partners the research team presented the survey and distributed it to the pdd attending the meeting the pilot testing helped the research team finalize a survey that can capture the transportation needs of pdd ultimately 990 survey packets were prepared and printed for distribution to the partners the survey packets included letter of invitation survey travel diary trips you made today trips you couldnt make today consent form assent form and inserts from partners that explains the study and the support of the organization a copy of the survey packet is provided in the final report the distribution methods of the survey varied based on the agreement between the research team and the community partners it was either mailed or handed to participants of the 990 survey packets that were printed and distributed the research team received 124 returned envelopes of which 114 surveys were completed the difference of 10 surveys came from pdd who did not want to participate in the study most of these cases the responses came mainly from the guardians stating that the targeted participant has severe degree of disability and his transportation needs are minor and being met by his family members the total response rate was 1151 for the survey and 949 for the travel diaries descriptive statistics it is important to note that the findings of this study only represent the characteristics of the people who received the surveys and responded to it the majority of the returned surveys were filled by a guardian relative staff member or volunteer on behalf of the subject only 16 surveys were filled by the pdd themselves this number represents around 14 of the returned sample while 15 returned surveys did not indicate how they were filled or by whom types of development disability since the pdd is a unique and diverse population the type of development disability will be used in this research as the main factor for classifying the results and the data two questions were used to determine the type of disability as mentioned earlier the answers to these questions were classified into two main categories of development disability including mr and others the others category included answers as autism spectrum disorder cerebral palsy traumatic brain injuries people with developmental disabilities noonan syndrome multiple sclerosis dependent personality disorder various brain and nerve disorders and people who answered that they would rather not discuss there type of disability the reason for classifying the sample into mr and others category is because of the sample size that responded to the survey the cp and asd comprised only 11 of the entire population accordingly they were merged in the analysis to the others category the responses from mr population was a sample of 114 from a statistical standpoint may be considered small yet when observing the type of population being studied such sample can be considered good enough to raise issues related to the needs of this small and disadvantaged population age and gender among the 114 returned surveys 2 pdd did not report their age figure 2 shows the distribution of the pdd who responded to the survey by age group and type of disability it is clear from observing figure 2 that all age groups are presented in the total section approximately 56 of the responses came from males while around 43 came from females and one person refused to identify gender education level of education and household income are two factors that tend to be highly correlated the level of education that pdd have received is used as a proxy to understand their level of independency around 68 of the pdd who answered this question reported that they had education at the level of high school meanwhile only 25 had an education at the less than high school level only a few reported any college education place of residence the place where pdd live can also be used as an indicator for the level of independence in the survey two questions were directed towards understanding where pdd reside and if they live with a relative or a nonrelative around 53 of the total surveyed sample indicated that they live in a group facility meanwhile around 29 of the surveyed sample lives in private homes or condos while 10 reside in apartments the majority of pdd reside with nonrelatives while 25 lives with relatives around 8 of the surveyed sample resides by themselves in apartments group facility and private condos two people indicated they reside by themselves in a group facility where they might be referring to their personal rooms in the facility where they do not share bedrooms with others as expected it is clear that the level of independence in living arrangements tends to be low travel diaries the total number of returned travel diaries was 100 only 94 travel diaries were filled and included information related to trips around 19 of the pdd who returned the surveys had four trips reported as part of their diary meanwhile 10 of the returned and filled diaries reported that three trips took place during the day the diary was recorded while 44 reported doing only two trips during the same period of time finally 25 of the returned and filled diaries who had an activity reported one trip being made analysis and discussion this section concentrates on displaying the major findings of the survey in order to better understand the transportation needs of the surveyed sample looking at some questions while controlling the type of dd is critical to understand the general trends and if there is a specific phenomenon associated to a certain dd group trip purpose observing the purpose of the trip in the travel diaries pdd reported trips to work home social and recreation and others as the top four purposes for traveling trip chaining is noticed to be part of 34 of the travel pattern among the surveyed sample who answered this section of the travel diaries this indicates that fair amount of pdd engage in various activities after leaving their place of origin accordingly the purpose of leaving their homes is not just to conduct one activity but to conduct various activities frequency of trips observing the frequency of being engaged in work trips in the survey shows that around 74 participants responded they usually engage in such activity at least five to seven days per week while 18 participants indicated they get engage in work trips at least for two to four days per week these two numbers comprise around 80 of the total surveyed population this relationship is displayed in figure 3 it is also noticed that this observation is especially true among the mr group we sampled more than 90 of the mr group indicated they work at least 2 days per week figure 4 shows the frequency of being engaged in recreational trips while figure 5 shows the frequency of being engaged in a social trip comparing the distribution of frequency of being engaged in social and recreational trips to the frequency of being involved in work trips we notice pdd tend to do more social than recreational trips though work remains the most frequent trip purpose travel needs the survey asks the participants if there are times they cannot make trips they need to make and asks them if there are times they cannot make trips they want to make around 55 participants responded no they can make both the trips they want to make and the trips they need to make this number represents 50 of the surveyed sample meanwhile 29 participants responded yes they are facing problems in doing both the trips they need to make and the trips they want to make only 25 of the participants with mr had trips they needed to do but could not do similarly in the others group around 30 of the participants responded yes there are trips they need to but could not make travel mode and assistance work and shopping are two main purposes for all persons and were noticed to be the major trips that pdd tend to be engaged in around 39 of the surveyed sample uses private cars as their primary mode of transportation for shopping the number of people using other modes which includes local services at home facilities is quite high along with the mr group around 70 of the surveyed sample reported a need for assistance when conducting shopping trips around 52 of the surveyed sample reported a need for assistance when conducting work trips difficulties a question in the survey concentrated on the difficulties participants face when using public transit these questions concentrated mainly on the physical difficulties associated with moving standing waking to the bus stop climbing stairs and reading the route numbers among mr participants 46 face problems in standing from the total sample 46 of the participants indicated they face problems in reading schedules while 49 indicated they face problems understanding schedules transit schedules in general are being written to time points a user of the service not using a time point interpretations is required to determine the arrival and departure time this way of writing schedules is even difficult for the general population to understand accordingly it is expected that pdd might face such issues difficulties in understanding the announcements being made on board of the bus were reported by 35 of the surveyed sample concerns of transit users public transit was the secondmost used mode of transportation for pdd around 51 of the surveyed sample reported that they are either concerned or very concerned that the bus service might not serve their destinations at their desired time meanwhile 55 were concerned with being a victim of a crime while using public transit fewer than 50 of the surveyed sample were concerned with transfers between various transportation systems during their trips familiarity with services around 75 of the surveyed sample indicated being familiar with services offered to pdd meanwhile around 25 of the surveyed sample indicated that they are not familiar with the services being offered to pdd this indicates that more work may be needed in promoting the services to pdd it is clear that paratransit service is used by only 62 of the surveyed sample it is important to note that restrictions do exist when applying for paratransit for example dialaride service and not all pdd are qualified for such service it is observed that around 30 of the surveyed sample have used metro transit either buses or light rail at some point in time as a mode of transportation the variation among the various pdd groups seems to be minor independence independence is measured directly through asking direct questions related to what extent pdd consider themselves as independent travelers around 48 of the participants in the survey reported that they do agree that they are independent travelers observing each pdd group we notice that the mr group feels least independent compared to the other pdd groups the levels of independence of the other dd groups tend to be higher for the others group surprisingly around 68 of the surveyed sample indicated its their choice which mode of transportation they use finally a question related to public transit and the possibility of using it as a means of increasing the independence around 68 of the surveyed sample responded that they do agree that using public transit would increase their level of independence the mr group tends to disagree more with this statement than other pdd travel barriers the travel diaries included a question asking participants about the trips they could not make only 14 percent of the 94 participants who filled the diaries reported at least one trip they could not make meanwhile 7 of the participants who filled travel diaries had at least two trips they wanted to make but they could not make them while 4 of the participants could not make at least three trips they wanted to make finally only 3 of the participants who filled travel diaries had at least four trips they wanted to make but they could not make no one available to drive was the most widely cited reason why participants could not make their desired trips other reasons included too late to make reservations scooter battery died weather health and service is too far to go to conclusion this paper presents the results of an 18 month research study into the transportation behavior and needs of pdd living or working in hennepin county minnesota the paper describes previous research into the transportation behaviors of the disability the methodology pursued in this study and the findings and results of that study overall most pdd responding to the surveys remain partially independent this number might seem to be a little high for the pdd population in general yet this might be related mainly to the characteristics of the studied sample being auto passengers walking public transit and dialaride are found to be the main modes of transportation participants tend to use to meet their transportation needs pdd in the surveyed sample showed a willingness to use public transit more and indicated that they feel that using it will increase their independence several pdd indicated their willingness to drive yet they cannot afford to do so due to their conditions also several participants would like to use public transit yet report service does not exist around their homes or near their destinations they felt using it was not possible for the time being issues related to understanding and interpreting the schedules was also raised the needs of assistance are observed among almost half of the surveyed sample issues related to dialaride services and complaints were a common factor in the comment sections there was notable criticism of the long lead times for scheduling and unreliability of public paratransit services though there was commendation for the paratransit provided by service providers directly several participants added some comments related to the walking distance to and from bus stops various participants raised safety concerns the sampling of the survey was determined based on the level of cooperation between the pdd centers and research team the sample is biased towards the locations where these centers tend to serve their population since only 14 of the pdd filled the surveys themselves this study should be interpreted carefully since it reflects a mix of points of views of the guardians or relatives as well as the pdd still this study remains a unique in the transportation field in trying to study and measure the needs of a population that has had very little transportation research conducted about their needs list of figures

the us department of health and human services administration on development disabilities estimates the number of people diagnosed with a developmental disability in the united states as 45 million persons which would translate to about 17000 residents of hennepin county minnesota this research paper examines the transportation needs of adults with developmental disabilities either residing or working in hennepin county through a survey of their existing travel behavior and their unmet transportation needs the survey had both demographic and attitude questions as well as a travel diary to record both actual and desired but untaken trips in this paper we report and discuss the main findings of the survey it was clear from observing the returned sample that almost the entire surveyed population does not live independently more than half of the surveyed population worked every day while recreation occurred at least once a week for about twothirds of the population and more than half undertook social trips weekly about 30 reported being unable to make trips they want to make and 46 unable to make trips they need to make public transit poses difficulties for this population both physically and intellectually there were also specific complaints about the lack of transit service in addition to concerns regarding paratransit services community service providers received praise

Introduction The global pandemic of COVID-19 has contributed to serious threats to the lives of people across the globe, and the pandemic has already claimed hundreds of thousands of lives worldwide [1]. COVID-19 broke out in Wuhan, China, in late 2019, spread to more than 200 countries, and infected more than 9 million people globally by 19 June 2020 [2]. As the spread of COVID-19 was associated with human social life, people had certain responsibilities to lessen its spread. To this end, executing awareness activities, including media campaigns, became crucial for the masses [3]. Therefore, many nations started using traditional and social media to initiate precautionary behaviors . These efforts are contingent on the already known literature recommendations; for example, scholars [4] posited that media dependency increases in disasters, and people rely on the media to get desired information to guide their actions. Global awareness campaigns were initiated in accordance with the guidelines mentioned above [5]. Numerous authorized entities attempted to enhance societal consciousness regarding precautionary measures and intervention strategies by disseminating routine updates on COVID-19 active cases through various media channels, including social media [6,7]. Despite the employment of diverse communication channels by various nations, it was noted that the impact of media campaigns varied among nations. As an illustration, certain nations, including Pakistan, reported persistent grievances from officials regarding the populace's reluctance to embrace suitable precautionary measures, despite the government's repeated endeavors to raise awareness on the matter [8]. Therefore, it is crucial to investigate why individuals exhibit varying degrees of adherence to media awareness campaigns promoting COVID-19 vaccine uptake, as this phenomenon is observed globally. Further research is needed to address this important issue. Previous research [9,10] has extensively examined the influence of various antecedents, including media surveillance, subjective norms, and perceived severity, on developing COVID-19 vaccine uptake intention. However, contextual factors such as culture and religiosity, which may also affect health behaviors, have not been considered collectively in these studies. Moreover, certain scholarly investigations [11] have documented the effects of media campaigns launched during the COVID-19 pandemic. However, these studies have provided limited evidence regarding how individuals process such information and subsequently develop precautionary behaviors. Numerous studies have emphasized the significance of media dependency in predicting preventive behaviors regarding risk information processing [12][13][14]. However, little research on health communication in the Asian context has indicated that exploring preventive health behaviors in Asian societies is multifaceted, hence the need to examine the impact of cultural context on individuals' preventative behaviors [15,16]. Examining what prompts individuals to embrace preventive measures against COVID-19 in Asian contexts, including Pakistan, is essential owing to these regions' diverse sociocultural beliefs and media landscapes. Moreover, this study makes a scholarly contribution by employing a comparative approach regarding individuals' dependency on diverse media formats, drawing upon established theories such as MDT and TPB. It addresses a gap in previous studies on COVID-19 by investigating a relatively unexplored phenomenon: how individuals respond to health-related information in their social and religious contexts. Therefore, this research examines how various health-related information disseminated on different media platforms influenced COVID-19 vaccine uptake intentions. As a result, the present study aims to elucidate factors that may prove advantageous in formulating a communication strategy, given its imperative role in addressing the urgent demands for public health safety, especially during a health crisis. The present research aims to provide policymakers with a comprehensive toolkit for implementing a suggestive communication strategy in response to health issues like the COVID-19 pandemic. This strategy involves the integration of traditional, social media, and interpersonal channels. --- Literature Review 2.1. Theoretical Underpinning and Framework Merely relying on media coverage is inadequate to fully gauge the impact of media on health-related preventive behaviors [12,17]. Media dependency pertains to the impact of media usage on the formation and enactment of human behavior. The media dependency theory provides an opportunity to tap the media's influences at various levels of investigation [18]. Scholars have categorized media dependency theory into three levels macro level, micro level, and individual level. The macro-level investigation is related to organizational dependency relationships between the media, social systems, and audiences. MDT suggests that individuals depend more on the media for information in uncertain situations such as crises or natural disasters [4]. Individuals' dependency on media will have disproportional influence at the micro level. Individuals' needs and fulfillment of the aims will depend on the information provided by social institutions or media organizations [19]. Hence, several factors, including the accessibility of alternate information resources and societal background dynamics, such as risk, can raise individuals' dependence on the message [20]. Limited research [21] conducted at the individual level of media dependency considered greater influences on individuals' attitudes or behaviors. Literature shows that media dependency can knowingly forecast variations in media audiences' behaviors [22]. For instance, it is revealed that factors such as news perspective and usage of slants predicted people's uncertainty regarding the reasons and impacts of climate change [23]. Hence, it is plausible that the copious dissemination of information through conventional and digital media regarding COVID-19 could potentially exacerbate the risk of contagion by raising public awareness about the impact of COVID-19 on their health. However, other contributory factors, such as cultural perspectives and psychological mechanisms, are also crucial to understanding this phenomenon. Extensive research that utilized various theoretical frameworks, including the Theory of Planned Behavior [24] , the Health Belief Model [25], and the Protective Motivation Theory [26], has been conducted. The Theory of Planned Behavior is considered a well-known theory in studying and understanding the psychological mechanisms related to the development of health behaviors, and the Theory of Planned Behavior is considered a well-known theory [27]. TPB has offered constructs such as attitudes, subjective norms, perceived behavioral control, and behavioral intention [28]. By doing so, TPB has underpinned the psychological and cultural factors that can predict behavioral intention. Behavioral intention is a substitute for measuring real behavior [29]. TPB has been widely used in explaining the numerous health-related diverse outcomes, such as hand hygiene [30], dairy product consumption [31], smoking [32], and physical activity [33]. Furthermore, many meta-analyses have also validated the efficacy of its predictors in determining health-related outcomes [28]. It is noted that TPB has validated its usefulness in forecasting health behaviors among other information processing and social cognitive theories [34]. The comparative analysis of health behavior theories in different behavioral domains has demonstrated the effectiveness of TPB in predicting a diverse range of health-related behaviors. This effectiveness is supported by several strengths, including the addition of constructs that assess cognitive mechanisms, normative aspects, and individual motivational factors [24]. The attitude construct in TPB is an individual's extent of liking or disliking the behavior in question and directs the steady behavioral outcomes [29]. Hence, it can reflect contributory attributes and pragmatic attributes of action [12]. For instance, this perceived usefulness motivates some actions , while amusement motivates others ; however, various actions echo both cognitive and affective orientations. To this end, it would be imperative to integrate the notion of MDT with TPB to know how Pakistani respondents will react to COVID-19-related media campaigns. The other important predictor of behavior in TPB is the subjective norm, which is the individual's perception of a peer's endorsement or discontentment with the behavior in question [28]. According to TPB, individuals frequently make societal comparisons of their actions with those of their referent group members; they are more indubitably pretentious in their perceptions of in-group than out-group behaviors [12]. This study also considered collectivism as the antecedent for determining the subjective norm, which aligns with the Asian cultural tendency. The learned schemas of the culture guide the norms, and these social norms have varying impacts on behavioral patterns [35]. Therefore, it is eloquent to study how such cultural tendencies guide subjective norms, which serve as a mediating mechanism to develop vaccination intention in the case of COVID-19-related precautionary measures [27]. The perception of control is one of the numerous factors associated with an individual's engagement in healthy behaviors. Perception of control refers to a person's subjective perspective or comprehension of their influence or authority over a given situation or outcome. The capacity to ascertain or exert control over something is called perceived behavioral control [36]. In the present context, the term 'something' refers either to the behavior in question or to the consequences resulting from the said behavior. Consider, for instance, the health-related practice of seeking medical attention for a comprehensive physical examination every year. In the context provided, perceived control encompasses an individual's belief regarding their ability to exercise agency in deciding whether or not to seek medical attention, determining the timing of such visits, and even selecting a preferred healthcare provider. Additionally, it can also encompass the belief that one can enhance or sustain their state of health by undergoing routine medical evaluations. In both scenarios, individuals who perceive higher control over a given situation, whether over their behavior or the resulting consequences, are more inclined to engage in the specific behavior. This assertion holds true when all other factors remain constant. In the context of COVID-19 vaccine uptake, PBC is more critical, as the behavior in question involves several aspects, such as side effects that can hinder their intention [24]. The PBC might not be effective in other contexts, such as making purchase decisions; however, in a particular scenario of the COVID-19 vaccine, where a plethora of misinformation is accessible to individuals, it becomes a crucial factor. The willingness to get a COVID-19 shot is not comparable to one's ability to purchase a bicycle. Therefore, in the current study, we postulate that the perceived behavioral control of individuals would predict the COVID-19 vaccine uptake intention. In the given research context, the TPB emerges as a prominent theoretical framework for information processing [37]. The integration of TPB has encompassed various factors pertaining to communication, including media attention and social media platforms, to elucidate health behavior [37]. Moreover, the utilization of the TPB theoretical framework in this research incorporates context-specific variables such as religiosity that address the limitations observed in prior studies on the adoption of health behaviors. The TPB outlines the decision-making process at the individual level [38]. This study has incorporated the theoretical principles of the MDT, which are essential in understanding the adoption of health behaviors, such as the increased uncertainties surrounding COVID-19 vaccines. The MDT suggests that individuals turn to the media to fulfill their informational needs and subsequently influence their behavioral outcomes, particularly in uncertain situations. Thus, drawing an analogy between MDT [4] and TPB [27], we assume that people's reliance on traditional and social media will improve the information during a crisis. It is noted that such dependency on media outlets may predict deviations in individuals' attitudes regarding COVID-19 vaccine uptake intention [14,21]. However, considering the contextual factors, we assume that not only does this dependency determine individuals' behaviors, but factors such as religious tendency can intensify or diminish this dependency. For example, some Pakistani religious clerics asked people not to follow the COVID-19-related instructions disseminated in the media, which altered the people's attitude. Thus, we propose that it is crucial to consider factors such as religiosity or collectivism to underpin the development of precautionary behavior in Asian countries. In doing so, this study attempts to integrate MDT and TPB to explain certain levels of media dependence and cultural factors such as norms and religion. Therefore, we proposed the following conceptual model in Figure 1. --- Hypotheses Development --- Traditional Media and Social Media Dependency Media dependency refers to how individuals rely on the media for information garding politics, education, culture, and entertainment. Media dependency has b widely investigated in the field of mass communication. MDT was conceptualized by B Rokeach and DeFleur [4] to measure individual level, group or organ tions dependency, and social systems. The macro level pertains to the inte pendent relationships among audiences, mass media, and other social systems at a st tural level. At the micro level, media dependency theory reveals that individuals dep on information gathering, processing, and disseminating for their daily activities [19]. individual dependencies on media for the aforementioned purposes depend on sev alternative sources of information [17]. And these individuals' dependence on mass m as a source of information increases during crises, uncertainty, and societal disrupti This dependency has significant consequences for understanding the role of medi modern complex-mediated societies [4,19]. It is assumed that merely relying on m coverage is insufficient for predicting the impact of media coverage on health-related sues such as COVID-19. In other words, media content consumption could not be ceived as a determinant factor in shaping the conduct of individuals. Nonetheless, the scientific community paid little attention to individual-level m dependency effects. In this regard, Ref. [21] a survey conducted to document media pendency in the aftermath of the terrorist attacks on September 11 found that individ --- Hypotheses Development 2.2.1. Traditional Media and Social Media Dependency Media dependency refers to how individuals rely on the media for information regarding politics, education, culture, and entertainment. Media dependency has been widely investigated in the field of mass communication. MDT was conceptualized by Ball-Rokeach and DeFleur [4] to measure individual level, group or organizations dependency, and social systems. The macro level pertains to the interdependent relationships among audiences, mass media, and other social systems at a structural level. At the micro level, media dependency theory reveals that individuals depend on information gathering, processing, and disseminating for their daily activities [19]. The individual dependencies on media for the aforementioned purposes depend on several alternative sources of information [17]. And these individuals' dependence on mass media as a source of information increases during crises, uncertainty, and societal disruptions. This dependency has significant consequences for understanding the role of media in modern complex-mediated societies [4,19]. It is assumed that merely relying on media coverage is insufficient for predicting the impact of media coverage on health-related issues such as COVID-19. In other words, media content consumption could not be perceived as a determinant factor in shaping the conduct of individuals. Nonetheless, the scientific community paid little attention to individual-level media dependency effects. In this regard, Ref. [21] a survey conducted to document media dependency in the aftermath of the terrorist attacks on September 11 found that individuallevel media dependency was a significant predictor of attitudinal and behavioral changes in the respondents. In the context of social media dependencies, Ref. [39] found that social networking sites' "dependency had direct effects on individual users' levels of engagement with interactive activities on SNSs and indirect effects on offline interpersonal storytelling" . Likewise, scholars [40] concluded that individuals' dependence on YouTube provided them with a means to meet their emotional needs in times of crisis, such as the death of a public figure. Similarly, studies show that media messages enhance the willingness to accept vaccines [41][42][43]. Keeping this literature in view, we proposed the following hypotheses: H1. Traditional media dependency positively relates to attitude towards precautionary measures and COVID-19 vaccine uptake intention. H2. Social media dependency positively relates to attitude towards precautionary measures and COVID-19 vaccine uptake intention. --- Interpersonal Communication and COVID-19 Vaccine Uptake Intention Interpersonal communication is the verbal and nonverbal transfer of information and messages between two or more people. It entails the exchange of ideas via the use of words, body language, facial expressions, and other types of communication. In many contexts, including interpersonal relationships, business, education, and healthcare, among others, effective interpersonal communication is crucial. It involves attentive listening, empathy, and the capacity to comprehend others' needs and viewpoints and to respond effectively to them. Interpersonal communication can replace mass communication to convey information and influence people's actions. A study found a link between risk perceptions and interpersonal discussion of health concerns. The study does not, however, give enough details on how this link came to be [44]. Interpersonal communication has been recognized in earlier research as the primary source of social norms and perceived efficacy, and it has also been shown to impact people's attitudes and behaviors [45]. H3. Interpersonal communication is related to attitude towards precautionary measures and subjective norms. --- Collectivism Culture is the collective set of ideas, standards, and practices created by human societies to address social and environmental issues [46]. Societies must effectively manage substantial environmental risks like disease-causing viruses, and cultures have developed in response to these difficulties. The prevalence of infectious diseases in ecological areas has been associated with the development of a cultural syndrome known as collectivism [47]. The concept is rooted in the fundamental psychological differentiation between a selfperception that is interdependent with others and one that is independent and distinct from others [48]. The collectivism-individualism dichotomy is crucial for capturing cultural variance [49]. The link between pathogen prevalence and collectivism apparently arises due to some characteristics of a collectivist society serving as barriers to disseminating contagious illnesses. In particular, individuals who adhere to collectivist values tend to exhibit greater wariness when engaging with unfamiliar individuals, potentially mitigating the risk of encountering novel infections. They also place high importance on customs like food preparation, which might act as barriers to spreading COVID-19 [38]. Although it has been suggested that collectivist societies may be better able to control the dissemination of contagious illnesses, other aspects of collectivism may work against this goal. Individuals connect more frequently and closely in collectivist communities [48], which helps infectious diseases spread [50]. Collectivist societies have a propensity to marginalize the underprivileged and are linked to ineffective social programs for disadvantaged groups [49]. These elements contribute to the spread of infectious diseases. Given these conflicting claims, it is unclear to what extent collectivism can successfully combat a severe epidemic like COVID-19. On the other hand, an alternative body of literature posits an inverse association between collectivism and proactive health practices [46]. It is demonstrated that the sociability facet of extraversion, which pertains to the inclination towards social activities and a preference for socializing over solitude, is positively linked to the transmission of COVID-19 [51]. This sub-dimension is a characteristic of collectivism [48]. Given the increased likelihood of COVID-19 transmission in public settings, it is reasonable to suggest that the conduct of individuals who prioritize collective interests may be significantly impacted by their perceptions of societal norms surrounding preventative measures. The present argument posits that a collectivist mindset is more conducive to promoting preventive behaviors, provided societal norms widely accept such behaviors as appropriate. And we hypothesized that: H4. Collectivism is positively related to subjective norms. --- The Role of Attitude, Subjective Norms, and Behavioral Control TPB is considered a framework for understanding the psychological foundations of intentional behavior in humans [27,38]. This hypothesizes three primary antecedents to the formation of intentional behavior. These include attitudes, subjective norms, and perceived behavioral control. Ajzen and Fishbein contend that behavioral intention is a reliable indicator of actual behavior [52]. Perceived behavioral control pertains to an individual's evaluation of their ability to execute a specific behavior of interest. The level of perceived behavioral control is subject to variation depending on the situation and corresponding actions, as it is contingent upon an individual's perception of their ability to regulate their behavior in different contexts [27,33]. The TPB supplanted the Theory of Reasoned Action after adding the PBC [53]. The concept of perceived behavioral control is analogous to perceived self-efficacy, a central tenet of social cognitive theory [54]. Abundant research has demonstrated the generalizability of the TPB framework to a wide range of contexts [55,56]. Studies have demonstrated that individuals are more likely to develop a stronger sense of perceived control when confronted with a greater level of threat, such as the contagious COVID-19 [57]. For instance, an individual's conviction that implementing precautionary measures such as vaccination can effectively mitigate potential risks contributes to developing their PBC. The TPB suggests a positive relationship between PBC and behavioral intention, indicating that individuals are more likely to feel confident in their ability to take action when they perceive a high level of control [38]. Hence, in situations characterized by high risks, such as COVID-19, it is anticipated that individuals will exhibit positive behavioral modifications, such as a heightened willingness to adhere to COVID-19 preventive measures, as a result of the activation of the danger control mechanism. Previous health behavior research elucidates the intricate relationship among various cognitive constructs, such as PBC, that govern preventive outcomes [24]. PBC is a significant predictor of the response's characteristics, specifically the feasibility of implementing a preventive response such as COVID-19 vaccine uptake intention [38]. Previous research has indicated that individuals exhibit an augmented sense of PBC primarily due to adequate prompts for engaging in safety-related behaviors related to COVID-19 vaccine uptake [29]. The level of confidence in individuals' ability to effectively plan, implement, and oversee their future circumstances was found to be necessitating, as exemplified by the perception that COVID-19 vaccine uptake is a sustainable solution; thus, it is hypothesized that: H5. Perceived behavioral control is positively related to COVID-19 vaccine uptake intention. Subjective norms pertain to an individual's perception regarding the consensus of societal approval or disapproval of a particular behavior. This pertains to an individual's perceptions regarding their peers' and significant others' social norms and expectations concerning their engagement in a specific behavior. The norms could be categorized as descriptive and injunctive norms, which could manifest at both individual and communal levels. Individuals seek the degree of endorsement of a particular behavior within their peer groups and in broader society [58]. People socially compare their behaviors with those of their peer groups and are more vulnerable to the influence of in-groups than outgroups [59]. Previous research has demonstrated that descriptive and injunctive norms have differential effects on behavioral intentions [60,61]. Collectivistic societies differ in terms of assigning significance to subjective norms. Those who live in collectivistic societies give more importance to subjective norms, whereas those residing in individualistic societies tend to prioritize PBC in decision-making. We propose the following hypotheses: H6. Subjective norms are positively related to COVID-19 vaccine uptake intention. In Fishbein and Ajzen's conceptualization, attitudes refer to an individual's favorable or unfavorable evaluation of a particular behavior object, which subsequently corresponds to individuals' behavioral responses [62]. Attitudes may specify instrumental qualities, such as usefulness, and experiential qualities, such as pleasantness, of a particular behavior [63]. For instance, behaviors such as tooth brushing are utility oriented, while behaviors such as watching a movie are pleasure-seeking-oriented [64]. However, several behaviors reflect a combination of both utility and enjoyment orientations. The presence of a pessimistic outlook regarding vaccines and the reluctance of individuals to undergo the COVID-19 vaccination constitute a significant public health issue in managing the pandemic [65,66]. Attitude refers to a concise representation of the assessment of a psychological entity. For instance, individuals may have varying perceptions regarding the positive or negative aspects and the potential risks or safety associated with receiving a vaccine. According to the TPB, an individual's behavioral intentions are determined by their attitude towards the behavior. Prior studies have demonstrated that individuals' attitudes toward vaccination are reliable indicators of their intentions to get vaccinated [67,68]. In order to enhance vaccination intentions, it may be necessary to strengthen general attitudes toward vaccines [69]. Therefore, previous research has consistently confirmed the significant impact of attitude on vaccination intentions. --- H7. Attitude towards precautionary measures mediates the relationship between traditional media dependency, social media dependency, and Interpersonal communication with COVID-19 vaccine uptake intention. --- The Moderating Role of Religiosity Religious beliefs are also accorded substantial attention regarding COVID-19 precautionary behavior [70]. The impact of religious beliefs on attitudes toward vaccination can be discerned as individuals endeavor to harmonize scientific realities with their theological framework, leading to a heightened propensity for vaccine refusal [43,71]. The notion of religiosity pertains to the nature of an individual's religious convictions and encounters and religion's function within a given society. There is a significant correlation between religiosity and COVID-19 vaccine uptake intention. The concept pertains to the conviction that every event occurs solely at the discretion of the divine [72]. Hence, adherents are expected to conduct themselves in accordance with the precepts of God [73]. Literature indicates that scholars have directed their attention toward religiosity in the context of the COVID-19 pandemic [74]. Several studies revealed notable correlations between religiosity and various health behaviors [72,[75][76][77]. The results of these studies suggest a positive correlation between higher levels of religiosity and an increase in health-protective behaviors. Other studies revealed that individuals who identify as religious exhibit a heightened level of concern regarding the pandemic compared to those who do not identify as religious [78]. Hence, enhancing one's religious beliefs could potentially foster spiritual and psychological fortitude amidst the ongoing pandemic [79]. Several studies have observed that religious affiliation fosters effective coping mechanisms and confers psychological advantages, thereby mitigating the likelihood of developing depressive symptoms in the context of the pandemic [80,81]. These studies show insistent results; therefore, we propose that H8. Religiosity moderates the relationship between traditional media dependency and social media dependency with an attitude towards precautionary measures. --- Materials and Methods --- Design, Participants, and Procedure In the new communication environment, behavioral intervention programs have been diversified, and the usage of multiple means of communication has made the promotional phenomenon more complex. The current study used a cross-sectional research design via-a-vis a survey method to examine media dependency patterns in diverse settings. To do so, generalized data will be collected from Pakistan using a multistage sampling technique. Before data collection, the sample size was determined using two established methodologies: Morgan's Table and G-power analysis. Based on current statistical data, the estimated number of internet users in Pakistan is approximately 89.3 million. Based on Morgan's estimation, a total of 384 participants were deemed suitable. Subsequently, a Gpower analysis was performed to ascertain the necessary sample size for this investigation, taking into account the number of variables of interest. The results indicated that a sample size of 950 participants would be sufficient to generate predictions and inferences from the data, given the presence of five antecedents and one dependent variable. Although the sample size of 800 participants was sufficient for making predictions and drawing inferences, the study aimed to collect an additional 10% of data to address potential challenges related to data normalization in the context of structural equation modeling . In total, 993 responses were obtained, and a comprehensive analysis of the findings is presented in the subsequent section. The questionnaire and corresponding definitions of constructs were disseminated to six academic professionals for feedback and to ensure translational validity before the commencement of data collection. Slight modifications were implemented in accordance with the feedback provided by the individuals. Subsequently, a preliminary investigation was conducted, encompassing a sample of 50 students. The study's findings indicate that the scales' reliability was deemed satisfactory, with a value of less than 0.60. The ultimate survey comprised various items and constructed definitions. The subsequent section expounds on the specifics of the tools employed in this study. In developing measuring instruments, the researchers collected and adapted available instruments. Furthermore, based on the nature of the study, the selected instruments were translated into the local language. A back-translation technique was applied, and translational validity was attained by using face validity ratings from six experts . Upon getting feedback from the experts, the suggested amendments were made. Before carrying out the main study, a pilot study using 30 participants was conducted. Pakistan is considered for this research as it is a religiously sensitive country. Data analysis was desired to reveal whether psychological and contextual factors play any role in determining the impacts of media dependency. Finally, for analysis, PLS was used, as it is the right approach to deal with complex moderating-effect models. This study utilized a cross-sectional field survey method to collect data from a sample of 993 adults in Pakistan. The data was gathered from April to August 2022, utilizing enumerators from a specialized data collection firm. During a training session, the lead researcher provided a briefing to six enumerators associated with the local data collection firm. The briefing covered the primary objectives of the research as well as the sampling and data collection techniques to be employed. Data collection for the primary survey was carried out using a multistage sampling technique, specifically employing random and convenient sampling methods. The study used two sampling techniques to select the appropriate respondents. In the first stage of the study, a random sampling technique was utilized to select ten administrative units, such as districts, from Pakistan. The lottery method was employed for this purpose. Subsequently, a compilation comprising the names of subordinate units, such as sub-districts, was generated for each district that had been chosen. During this phase, a total of ten smaller administrative units were chosen from the list mentioned above. The data collection was conducted using a convenient sampling method. During the purposive sampling phase, the enumerators visited designated areas and included participants who consented to participate in this study. Subsequently, the participants were requested to complete the questionnaire, and the data was entered into a digital format using tablets and a Google Form. --- Instrumentation --- Attitude towards Precautionary Measures We modified three questions from Ajzen's research [82] to gauge respondents' attitudes towards precautionary measures on a semantic scale that taking precautionary measures against COVID-19 is worthwhile, significant, and pleasant, anchoring "1 = strongly disagree, 5 = strongly agree". --- Subjective Norms In order to measure subjective norms, we adjusted four questions from Park and Smith's work [61]. Respondents were asked to rate how strongly they agreed or disagreed with the assertions that their family members, close friends, and the general public would approve of their precautionary measures against COVID-19 on a five-point Likert scale, anchoring "1 = strongly disagree, 5 = strongly agree". --- Perceived Behavioral Control PBC respondents gave their opinions on the following three statements adapted from literature [82], which read as follows: "It is possible for me to take COVID-19 vaccine shot". "It is up to me whether I take COVID-19 vaccine shot. . .", "I believe I have complete control over taking COVID-19 vaccine shot. . .", on a five-point Likert scale anchoring "1 = strongly disagree, 5 = strongly agree". --- COVID-19 Vaccine Uptake Intention We modified three questions from Ajzen's work [82] to gauge respondents' COVID-19 vaccine uptake intention on a Likert scale anchoring "1 = strongly disagree, 5 = strongly agree". The items read as follows: "I intend to get the COVID-19 vaccine booster dose". I am willing to receive a COVID-19 vaccine booster dose" and "I plan to receive a COVID-19 vaccine booster dose as the media is advocating it". --- Media Dependency: Traditional Media and Social Media We adapted three items from Loges' research [83] to measure participants' reliance on traditional media. The participants expressed their concurrence with the following four statements. Reading newspapers and watching TV "helps me find out about precautionary measures against COVID-19", "helps me observe how others deal with COVID-19", and "helps me figure out how I can protect myself from COVID-19". The same statements were re-worded for participants who relied on social media. For instance, viewing social media "helps me find out about precautionary measures against COVID-19". All items were measured on a five-point Likert scale, anchoring "1 = strongly disagree, 5 = strongly agree". --- Interpersonal Communication Three items were used to measure the participants' reliance on interpersonal communication based on their discussions with friends, family, and colleagues about protection against COVID-19. I rely on discussions with friends, family, and colleagues to learn about precautionary measures against COVID-19. All items were measured on a five-point Likert scale, anchoring "1 = Never, 5 = All the time". --- Collectivism Four items were adopted from the work of Oyserman et al. [84] to measure collectivism on a five-point Likert scale. The items read as follows: " I make an effort to avoid disagreements with my group regarding precautionary measures against COVID-19, Before deciding COVID-19 vaccine uptake, I always consult with others, How I adopt precautionary measures against COVID-19 depends on who I am with, I have respect for the authority figures with whom I interact, and my COVID-19 vaccine uptake decision would depend on his/her advice". --- Religiosity Three items were adopted from the literature [85,86] to measure religiosity on a five-point Likert scale. The items read as follows " What religion offers me most is comfort in times of trouble like COVID-19, Although I am religious, but I don't let it affect my COVID-19 vaccine uptake decision, and although I am religious, but I don't let it affect my precautionary measure against COVID-19". Items two and three were reversed. --- Results --- Demographic and Descriptive Analysis The outcomes of the demographic analysis are shown in Table 1. The outcomes suggest diverse information concerning factors such as income, gender, educational achievement, and age. Subsequently, the descriptive analysis was conducted using SPSS 24.0. This entailed the assessment of normality checks, outliers, variable correlation, and multicollinearity. The analysis of normality, both visually and statistically, indicated that there were initial issues pertaining to the normality of the data. The process of identifying and removing outliers was carried out through the application of outlier evaluations. Following the removal of 59 cases, the data was found to conform to normality assumptions based on the threshold values of skewness and kurtosis when adjusted by the standard error reported, in accordance with the recommendation of [87]. The Variance Inflation Factor test was also performed to assess multicollinearity. The study observed that each item's Variance Inflation Factor values were below the threshold of 10. Consequently, in light of the absence of any multicollinearity concern in this investigation, the analysis progressed toward the Structural Equation Modeling technique. Furthermore, the presence of method biases was detected by conducting Herman's test via exploratory factor analysis on SPSS. In order to achieve this, all the constituent items of each variable, namely AT, CVI, IPC, RL, SM, SN, TM, BC, and COL, were loaded onto a unified factor. The exploratory factor analysis findings indicated a variance of merely 37.4%. Furthermore, no concerns were identified with respect to common method biases, thereby enabling the study to progress to the structural equation modeling phase. --- Confirmatory Factor Analysis This study employed partial least squares SEM. It encompasses a range of multivariate techniques that are used primarily for confirmatory purposes. In addition, PLS-SEM offers enhanced predictive precision and a substantially reduced likelihood of spurious correlations. Hence, variance-based SEM, such as PLS, is widely acknowledged as more advantageous than regression analysis. This is primarily attributed to its capability to illustrate the influence of direct and indirect independent variables [87]. In order to evaluate the measurement model's fit, convergent and discriminant validity, and potential for multidimensionality, the current study used a PLS-based SEM. The items were loaded into the parent constructs of AT, CVI, IPC, RL, SM, SN, TM, BC, and COL for confirmatory factor analysis using PLS 3.0. The Confirmatory Factor Analysis findings suggest empirical differentiation between AT, CVI, IPC, RL, SM, SN, TM, BC, and COL . Upon analysis, it was found that the model demonstrated a satisfactory fit after removing one item . Table 2 and Figure 2 present the reported item loadings. Upon achieving the desired level of model fitness, the research proceeded to estimate reliability. The findings of the analysis indicate that the constructs of AT, CVI, IPC, RL, SM, SN, TM, BC, and COL exhibit satisfactory reliability estimates across multiple indices, including Dijkstra-Henseler's rho , Jöreskog's rho , and Cronbach's alpha , as presented in Table 3. Various reliability indices, as introduced in PLS.3, were employed to perform cross-validation of the reliability estimations. The study assessed the convergent and discriminant validities by utilizing the Fornell-Larcker criterion method. Convergent validity is established when the items within a specific measure exhibit convergence by effectively representing the latent construct being measured. The Average Variance Extracted is computed by taking the average of the squared loadings of each indicator linked to a particular construct. Convergent validity is considered statistically established when AVE exceeds a threshold of 0.50. At the same time, discriminant validity is a crucial aspect of research methodology that aims to determine the distinctiveness of the constructs under investigation. The Fornell and Larcker Criterion posits that Discriminant validity can be deemed established if the square of the correlation between two constructs is less than the AVE for each construct. The fundamental basis of the AVE for a specific construct exhibited a higher magnitude than its correlation with all other constructs. These findings indicate that the constructs examined in the study possess distinct identities and exhibited moderate correlation with other constructs under investigation. The Confirmatory Factor Analysis findings indicated that the Composite Reliability of all variables was acceptable, as presented in the Table . In addition, the study computed the Average Variance Extracted and observed that the intercorrelations among AT, CVI, IPC, RL, SM, SN, TM, BC, and COL were below the square root of their respective AVE values . Subsequently, the research progressed to the application of inferential statistics. Upon analysis, it was found that the model demonstrated a satisfactory fit after removing one item . Table 2 and Figure 2 present the reported item loadings. Upon achieving the desired level of model fitness, the research proceeded to estimate reliability. The findings of the analysis indicate that the constructs of AT, CVI, IPC, RL, SM, SN, TM, BC, and COL exhibit satisfactory reliability estimates across multiple indices, including Dijkstra-Henseler's rho , Jöreskog's rho , and Cronbach's alpha , as presented in Table 3. Various reliability indices, as introduced in PLS.3, were employed to perform cross-validation of the reliability estimations. --- Hypothesis Testing This research posited numerous hypotheses to map the psychological and sociocultural influences on the precautionary measures regarding COVID-19. The hypotheses delineating the direct impact of traditional media , social media , and interpersonal communication on attitude were supported. The results of the SEM using PLS revealed that there is a positive influence of traditional media , social media , and interpersonal communication on attitude. Furthermore, the results demonstrated that traditional media and social media significantly predict COVID-19 vaccine uptake intention. Therefore, H1b and H2b were also supported. Likewise, results suggested that interpersonal communication and collectivism positively predict subjective norms, as posited in H3b and H4. Finally, results verified that behavioral control and subjective norms predict COVID-19 vaccine uptake intention significantly. Thus, H5 and H6 were also supported. Later, the mediation analysis revealed that attitude partially mediates the relationship between traditional media and COVID-19 vaccine uptake intention. Similarly, partial mediation of attitude was also found in the relationship between social media and COVID-19 vaccine uptake intention. Thus, H7a and H7b were also supported by the evidence presented in Figure 2 and Table 5. The present study posited the moderating influence of religiosity in determining the influence of the traditional and social media on attitudes. To determine the moderating influence specifically, the model included the two interaction terms . Surprisingly, the analysis findings indicate no significant moderation influence of religiosity on the relationship between traditional media and attitude; thereby, H8a was not supported. The findings of the analysis specify that there is a significant moderation effect of religiosity on the relationship between social media and attitude . The findings indicate that social media's impact on attitude is a function of religiosity. These results were statistically significant and supported hypothesis H8b. Overall, the model extracted 64.7% variance with a reasonable effect size, as presented in Table 6 --- Discussion This study used a cross-sectional research design vis à vis survey method to exami the influence of traditional media dependency, social media dependency, interperson communication, and collectivism on COVID-19 vaccine uptake intention. The study al --- Discussion This study used a cross-sectional research design vis à vis survey method to examine the influence of traditional media dependency, social media dependency, interpersonal communication, and collectivism on COVID-19 vaccine uptake intention. The study also investigated the mediated role of attitude towards precautionary measures, subjective norms, perceived behavioral control, and the moderating role of religiosity. Overall, the study proposed thirteen hypotheses. Of the 13 hypotheses, nine explored the direct impact, two the mediating role, and two the moderating role. The nine direct hypotheses were supported. Likewise, three mediating hypotheses were also supported. Of the two moderating hypotheses, one was supported and the other was rejected. The findings of hypotheses H1a and H1b revealed that traditional media dependency influenced attitudes towards precautionary measures and COVID-19 vaccine uptake intentions. Likewise, social media dependency impacts attitudes toward COVID-19 vaccine uptake intention, supporting hypotheses H2a and H2b. Put differently, the higher the media dependency on both traditional and social media, the higher the impacted attitude toward precautionary measures and COVID-19 vaccine uptake intention. These findings support the results of previous literature suggesting that higher media dependency during a crisis increases information seeking. This corresponds to a higher attitude toward adopting precautionary measures and boosts public COVID-19 vaccine uptake intentions [4,12]. Similarly, during uncertain times such as the COVID-19 crisis, individuals' interpersonal communication with family, friends, and colleagues was also enhanced many-fold. This increased interpersonal communication corresponds to an increased awareness of COVID-19. Consequently, these encounters impact their attitude toward precautionary measures and their intention to adopt them against COVID-19 supporting hypotheses H3a and H3b. This finding supports the previous literature [17]. Those who live in collectivist cultures adhere more to subjective norms. People from collectivist cultures stay in collectivist communities. The adherence to collectivism apparently arises due to some characteristics of a collectivist society, which serve as a barrier to spreading infectious illnesses. In particular, collectivists are more cautious when interacting with strangers. This results in few exposures to novel infectious diseases. They also place high importance on cleanliness, such as in customs like food preparation, which might act as barriers to spreading COVID-19. These findings align with the previous outcomes [46]. H5 posited that perceived behavioral control positively relates to COVID-19 vaccine uptake intention. The findings support the hypothesis. Perceived behavioral control is related to an individual's subjective assessment of their behavioral response, and it varies across situations and actions based on contexts [27]. It corresponds to precautionary measures against COVID-19 . The present study provides empirical evidence that supports the theoretical constructs associated with the intentions of vaccinated individuals to seek a COVID-19 booster vaccine. The factors pertaining to attitudes and subjective norms exhibited the most substantial effect sizes, suggesting that individuals' perceptions regarding the value and usefulness of the booster vaccine and the opinions of influential individuals significantly influenced their behavior. The findings align with previous studies that examined the acceptance of an initial COVID-19 vaccine. Therefore, they substantiate that individuals exhibit utilitarian behavior and prioritize the viewpoints of individuals they deem significant, such as their immediate family and close acquaintances [88,89]. Despite being less pronounced, the impact of risk perceptions and perceptions of control was equally significant. Previous research has primarily emphasized vaccine risk perceptions and self-efficacy, with relatively less attention given to the primary vaccine [90]. There exists a possibility that individuals who have undergone vaccination procedures may have previously formulated and executed intentions to partake in identical endeavors. Consequently, due to their prior exposure and the accessibility of immunizations, individuals' perceptions regarding the inherent risks associated with vaccination may have diminished, thereby bolstering their willingness to undergo vaccination once more. Consequently, this could potentially diminish the extent to which individuals rely on said information to decide their future choices regarding vaccination. H6 posited that there exists a positive correlation between subjective norms and the COVID-19 vaccine uptake intention. Subjective norms refer to how individuals and communities approve or disapprove of a particular behavior. This involves individuals seeking support for a specific behavior within their social circles and in wider society. The results of our study provide evidence in favor of the hypothesis that subjective norms are linked to adopting precautionary measures against COVID-19, as previously suggested by studies [58,59]. Furthermore, it is supported that the correlation between reliance on traditional media and reliance on social media is mediated by the attitude towards precautionary measures. The results indicate that individuals with a more positive attitude towards precautionary measures are more inclined to adopt preventive measures against COVID-19, thereby supporting hypotheses H7a and H7b. The results above corroborate existing literature affirming that media communications impact individuals' inclination to receive COVID-19 and Polio vaccinations [42,43,91]. Furthermore, a notable association between religiosity and adopting precautionary measures is observed. Individuals who strongly adhere to religious teachings tend to exhibit a greater inclination toward believing that all events are subject to the will of a higher power. The results of our study indicate that individuals who self-identify as religious and rely on conventional media as their primary source of COVID-19 information exhibit a lower propensity to adopt precautionary measures compared to those who are religious and rely on social media for COVID-19 information. These findings support hypotheses H8a and H8b, as previously proposed in the literature [78,79,92]. --- Theoretical Contributions Recognizing the actions identified to lessen infection risk is a strategic aim for behavioral researchers during the COVID-19 pandemic. It can offer a substantiated base of possibly manipulative reasons as objectives for interventions to promote health-related behavior and prevent COVID-19 pandemics. During health-related crises like the COVID-19 pandemic, identifying the predictors of health behavior becomes imperative. This study investigates the probable psychological and cultural factors involved in developing COVID-19 vaccine uptake intentions. In doing so, the study has proposed a conceptual model that can effectively measure the tendency to media dependency among individuals. To this point, it can provide evidence-based facts on how behavioral intrusions could be attained during crises. This study aims to evaluate the factors associated with promoting health-related behavior. This study proposed applying assumptions based on MDT and TPB to predict and explain health behavior. These assumptions help to predict the association of critical psychological and cultural factors related to the development of precautionary measures against COVID-19. Mapping and testing such processes allows this study to provide insight into many spheres. For instance, the evidence of informational dependency highlights the stipulated patterns and effectiveness of different modes of communication . On the other hand, the tradeoff between religiosity and culture in developing optimally operative interventions or not in promoting health precautionary behavior. This research's theoretical contribution is associating the evidence of the contextual factors' importance with the psychological process. Simultaneous inspection of the proposed model also gives insight into health behavior among individuals in an Asian nation. This research explored the moderating influence of religiosity, which has been widely observed in public discussions surrounding the COVID-19 pandemic. For example, an individual without specialized knowledge or expertise may justify their decision to avoid vaccination by attributing the outcome of their life to divine intervention. However, obtaining additional empirical evidence regarding one's dependency on the media is necessary. This research provides additional support to previous findings within the framework of a predominantly Muslim country, demonstrating that media interventions can effectively mitigate the adverse impact of fatalistic beliefs on health-related outcomes. --- Managerial Implications This study has several managerial implications for communication and social marketing practitioners and governments in designing and updating their communication and health behavior intervention programs in the future in times of crisis. The results of this investigation offer enhanced and in-depth comprehension for professionals in the field of public health to address the issue of reluctance toward COVID-19 vaccination. This study provides practical insights for relevant authorities regarding the strategic utilization of communication resources to mitigate obstacles, such as religious beliefs and societal misinformation, that impede the acceptance of COVID-19 vaccines on social media platforms. The scholarly literature suggests that in situations where obstacles give rise to doubts about vaccines, increased media attention could expose media consumers to some information to counter misinformation, disinformation, or fake news. Well-planned media content may increase public knowledge about the advantages of vaccines and correspond to an increased willingness to take vaccines. In this regard, media practitioners could utilize a media dependency framework during times of crisis, such as COVID-19, to better serve the public for the common good. On the other hand, vaccine hesitancy towards COVID-19 is regarded as an obstacle that diminishes public acceptance. Consequently, this research offers a significant strategic communication instrument for generating consciousness regarding the perceived risk of COVID-19 vaccination, enhancing the stakeholders' perception and protective attitude towards COVID-19. This can be achieved by employing strategic communication messages to augment the acceptance of the COVID-19 vaccination. Finally, this study will also promote collaboration among health and media experts to launch, collaborate on, and execute future promotional programs together. --- Limitations and Future Research The present study's results contribute to the existing literature by examining the acceptance of COVID-19 vaccines. However, the present investigation is subject to various constraints. The study employed a cross-sectional design, which captures a single area of the phenomenon being studied rather than providing a dynamic representation of the phenomenon through experimental designs. Henceforth, future research endeavors may employ longitudinal or experimental methodologies to monitor the evolving behavior concerning COVID-19 vaccine reluctance or to ascertain the factors contributing to the decrease in vaccine adoption. Furthermore, this study only measures exposure to media, and it is based on a narrow set of general traditional media and social media measures. Therefore, this study does not measure any media content or media perceptions. As such, its ability to make statements about media content and campaigns is quite limited. However, its contribution is focused on the intersection of religious culture and media culture as they influence individuals' attitudes and intentions to adopt health behaviors in the context of precautionary measures for COVID-19 boosters. Thereby, it is recommended that future research incorporate the influence of news frames, documentaries, and other related factors. Besides, the study was conducted solely in Pakistan. Thus, the generalizability of its findings to other countries and contexts should be approached with caution. --- Data Availability Statement: The data supporting this study's findings are available from the corresponding author upon reasonable request due to ethical and privacy restrictions. --- Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

Media exposure to health communication contents related to the COVID-19 pandemic alone is inadequate to measure the influence of media on individuals in adopting precautionary behaviors against COVID-19, such as vaccine uptake. Certain individuals may pay attention to and be influenced by communication content. However, literature has suggested other instrumental determinants in developing and adopting health precautionary measures, such as culture or religion, especially regarding vaccination. In times of crisis, such as the COVID-19 pandemic, it is valuable to examine the interrelationships among psychological, sociocultural, and informational factors. This can provide valuable insights for policymakers in developing effective communication strategies. Drawing an analogy between the Media dependency theory (MDT) and the Theory of Planned Behavior (TPB) model, this study unravels the factors underpinning the COVID-19 vaccine uptake intention among Pakistanis. The study utilized a cross-sectional research design and employed a survey method to gather data from a sample of 993 participants. The findings obtained from the PLS-SEM analysis confirmed that individuals relied on both traditional and social media to cope with the COVID-19 pandemic. The findings show that individuals rely more on the informational content disseminated through conventional media channels. The findings also suggest that individuals from Asian countries, such as Pakistan, tend to be more inclined toward collectivism. The findings about the moderating role of religiosity suggest that religious beliefs significantly shape individuals' reliance on traditional media. Hence, this study has uniquely contributed to public health and media management by providing a strategy for managers to address disseminating misinformation related to religion and its impact on vaccination-related health issues. The study has theoretically confirmed the principles of media dependency theory. As a result, it is recommended that various information sources be utilized to cultivate resilience among individuals to manage health crises effectively.

introduction the global pandemic of covid19 has contributed to serious threats to the lives of people across the globe and the pandemic has already claimed hundreds of thousands of lives worldwide 1 covid19 broke out in wuhan china in late 2019 spread to more than 200 countries and infected more than 9 million people globally by 19 june 2020 2 as the spread of covid19 was associated with human social life people had certain responsibilities to lessen its spread to this end executing awareness activities including media campaigns became crucial for the masses 3 therefore many nations started using traditional and social media to initiate precautionary behaviors these efforts are contingent on the already known literature recommendations for example scholars 4 posited that media dependency increases in disasters and people rely on the media to get desired information to guide their actions global awareness campaigns were initiated in accordance with the guidelines mentioned above 5 numerous authorized entities attempted to enhance societal consciousness regarding precautionary measures and intervention strategies by disseminating routine updates on covid19 active cases through various media channels including social media 67 despite the employment of diverse communication channels by various nations it was noted that the impact of media campaigns varied among nations as an illustration certain nations including pakistan reported persistent grievances from officials regarding the populaces reluctance to embrace suitable precautionary measures despite the governments repeated endeavors to raise awareness on the matter 8 therefore it is crucial to investigate why individuals exhibit varying degrees of adherence to media awareness campaigns promoting covid19 vaccine uptake as this phenomenon is observed globally further research is needed to address this important issue previous research 910 has extensively examined the influence of various antecedents including media surveillance subjective norms and perceived severity on developing covid19 vaccine uptake intention however contextual factors such as culture and religiosity which may also affect health behaviors have not been considered collectively in these studies moreover certain scholarly investigations 11 have documented the effects of media campaigns launched during the covid19 pandemic however these studies have provided limited evidence regarding how individuals process such information and subsequently develop precautionary behaviors numerous studies have emphasized the significance of media dependency in predicting preventive behaviors regarding risk information processing 12 13 14 however little research on health communication in the asian context has indicated that exploring preventive health behaviors in asian societies is multifaceted hence the need to examine the impact of cultural context on individuals preventative behaviors 1516 examining what prompts individuals to embrace preventive measures against covid19 in asian contexts including pakistan is essential owing to these regions diverse sociocultural beliefs and media landscapes moreover this study makes a scholarly contribution by employing a comparative approach regarding individuals dependency on diverse media formats drawing upon established theories such as mdt and tpb it addresses a gap in previous studies on covid19 by investigating a relatively unexplored phenomenon how individuals respond to healthrelated information in their social and religious contexts therefore this research examines how various healthrelated information disseminated on different media platforms influenced covid19 vaccine uptake intentions as a result the present study aims to elucidate factors that may prove advantageous in formulating a communication strategy given its imperative role in addressing the urgent demands for public health safety especially during a health crisis the present research aims to provide policymakers with a comprehensive toolkit for implementing a suggestive communication strategy in response to health issues like the covid19 pandemic this strategy involves the integration of traditional social media and interpersonal channels literature review 21 theoretical underpinning and framework merely relying on media coverage is inadequate to fully gauge the impact of media on healthrelated preventive behaviors 1217 media dependency pertains to the impact of media usage on the formation and enactment of human behavior the media dependency theory provides an opportunity to tap the medias influences at various levels of investigation 18 scholars have categorized media dependency theory into three levels macro level micro level and individual level the macrolevel investigation is related to organizational dependency relationships between the media social systems and audiences mdt suggests that individuals depend more on the media for information in uncertain situations such as crises or natural disasters 4 individuals dependency on media will have disproportional influence at the micro level individuals needs and fulfillment of the aims will depend on the information provided by social institutions or media organizations 19 hence several factors including the accessibility of alternate information resources and societal background dynamics such as risk can raise individuals dependence on the message 20 limited research 21 conducted at the individual level of media dependency considered greater influences on individuals attitudes or behaviors literature shows that media dependency can knowingly forecast variations in media audiences behaviors 22 for instance it is revealed that factors such as news perspective and usage of slants predicted peoples uncertainty regarding the reasons and impacts of climate change 23 hence it is plausible that the copious dissemination of information through conventional and digital media regarding covid19 could potentially exacerbate the risk of contagion by raising public awareness about the impact of covid19 on their health however other contributory factors such as cultural perspectives and psychological mechanisms are also crucial to understanding this phenomenon extensive research that utilized various theoretical frameworks including the theory of planned behavior 24 the health belief model 25 and the protective motivation theory 26 has been conducted the theory of planned behavior is considered a wellknown theory in studying and understanding the psychological mechanisms related to the development of health behaviors and the theory of planned behavior is considered a wellknown theory 27 tpb has offered constructs such as attitudes subjective norms perceived behavioral control and behavioral intention 28 by doing so tpb has underpinned the psychological and cultural factors that can predict behavioral intention behavioral intention is a substitute for measuring real behavior 29 tpb has been widely used in explaining the numerous healthrelated diverse outcomes such as hand hygiene 30 dairy product consumption 31 smoking 32 and physical activity 33 furthermore many metaanalyses have also validated the efficacy of its predictors in determining healthrelated outcomes 28 it is noted that tpb has validated its usefulness in forecasting health behaviors among other information processing and social cognitive theories 34 the comparative analysis of health behavior theories in different behavioral domains has demonstrated the effectiveness of tpb in predicting a diverse range of healthrelated behaviors this effectiveness is supported by several strengths including the addition of constructs that assess cognitive mechanisms normative aspects and individual motivational factors 24 the attitude construct in tpb is an individuals extent of liking or disliking the behavior in question and directs the steady behavioral outcomes 29 hence it can reflect contributory attributes and pragmatic attributes of action 12 for instance this perceived usefulness motivates some actions while amusement motivates others however various actions echo both cognitive and affective orientations to this end it would be imperative to integrate the notion of mdt with tpb to know how pakistani respondents will react to covid19related media campaigns the other important predictor of behavior in tpb is the subjective norm which is the individuals perception of a peers endorsement or discontentment with the behavior in question 28 according to tpb individuals frequently make societal comparisons of their actions with those of their referent group members they are more indubitably pretentious in their perceptions of ingroup than outgroup behaviors 12 this study also considered collectivism as the antecedent for determining the subjective norm which aligns with the asian cultural tendency the learned schemas of the culture guide the norms and these social norms have varying impacts on behavioral patterns 35 therefore it is eloquent to study how such cultural tendencies guide subjective norms which serve as a mediating mechanism to develop vaccination intention in the case of covid19related precautionary measures 27 the perception of control is one of the numerous factors associated with an individuals engagement in healthy behaviors perception of control refers to a persons subjective perspective or comprehension of their influence or authority over a given situation or outcome the capacity to ascertain or exert control over something is called perceived behavioral control 36 in the present context the term something refers either to the behavior in question or to the consequences resulting from the said behavior consider for instance the healthrelated practice of seeking medical attention for a comprehensive physical examination every year in the context provided perceived control encompasses an individuals belief regarding their ability to exercise agency in deciding whether or not to seek medical attention determining the timing of such visits and even selecting a preferred healthcare provider additionally it can also encompass the belief that one can enhance or sustain their state of health by undergoing routine medical evaluations in both scenarios individuals who perceive higher control over a given situation whether over their behavior or the resulting consequences are more inclined to engage in the specific behavior this assertion holds true when all other factors remain constant in the context of covid19 vaccine uptake pbc is more critical as the behavior in question involves several aspects such as side effects that can hinder their intention 24 the pbc might not be effective in other contexts such as making purchase decisions however in a particular scenario of the covid19 vaccine where a plethora of misinformation is accessible to individuals it becomes a crucial factor the willingness to get a covid19 shot is not comparable to ones ability to purchase a bicycle therefore in the current study we postulate that the perceived behavioral control of individuals would predict the covid19 vaccine uptake intention in the given research context the tpb emerges as a prominent theoretical framework for information processing 37 the integration of tpb has encompassed various factors pertaining to communication including media attention and social media platforms to elucidate health behavior 37 moreover the utilization of the tpb theoretical framework in this research incorporates contextspecific variables such as religiosity that address the limitations observed in prior studies on the adoption of health behaviors the tpb outlines the decisionmaking process at the individual level 38 this study has incorporated the theoretical principles of the mdt which are essential in understanding the adoption of health behaviors such as the increased uncertainties surrounding covid19 vaccines the mdt suggests that individuals turn to the media to fulfill their informational needs and subsequently influence their behavioral outcomes particularly in uncertain situations thus drawing an analogy between mdt 4 and tpb 27 we assume that peoples reliance on traditional and social media will improve the information during a crisis it is noted that such dependency on media outlets may predict deviations in individuals attitudes regarding covid19 vaccine uptake intention 1421 however considering the contextual factors we assume that not only does this dependency determine individuals behaviors but factors such as religious tendency can intensify or diminish this dependency for example some pakistani religious clerics asked people not to follow the covid19related instructions disseminated in the media which altered the peoples attitude thus we propose that it is crucial to consider factors such as religiosity or collectivism to underpin the development of precautionary behavior in asian countries in doing so this study attempts to integrate mdt and tpb to explain certain levels of media dependence and cultural factors such as norms and religion therefore we proposed the following conceptual model in figure 1 hypotheses development traditional media and social media dependency media dependency refers to how individuals rely on the media for information garding politics education culture and entertainment media dependency has b widely investigated in the field of mass communication mdt was conceptualized by b rokeach and defleur 4 to measure individual level group or organ tions dependency and social systems the macro level pertains to the inte pendent relationships among audiences mass media and other social systems at a st tural level at the micro level media dependency theory reveals that individuals dep on information gathering processing and disseminating for their daily activities 19 individual dependencies on media for the aforementioned purposes depend on sev alternative sources of information 17 and these individuals dependence on mass m as a source of information increases during crises uncertainty and societal disrupti this dependency has significant consequences for understanding the role of medi modern complexmediated societies 419 it is assumed that merely relying on m coverage is insufficient for predicting the impact of media coverage on healthrelated sues such as covid19 in other words media content consumption could not be ceived as a determinant factor in shaping the conduct of individuals nonetheless the scientific community paid little attention to individuallevel m dependency effects in this regard ref 21 a survey conducted to document media pendency in the aftermath of the terrorist attacks on september 11 found that individ hypotheses development 221 traditional media and social media dependency media dependency refers to how individuals rely on the media for information regarding politics education culture and entertainment media dependency has been widely investigated in the field of mass communication mdt was conceptualized by ballrokeach and defleur 4 to measure individual level group or organizations dependency and social systems the macro level pertains to the interdependent relationships among audiences mass media and other social systems at a structural level at the micro level media dependency theory reveals that individuals depend on information gathering processing and disseminating for their daily activities 19 the individual dependencies on media for the aforementioned purposes depend on several alternative sources of information 17 and these individuals dependence on mass media as a source of information increases during crises uncertainty and societal disruptions this dependency has significant consequences for understanding the role of media in modern complexmediated societies 419 it is assumed that merely relying on media coverage is insufficient for predicting the impact of media coverage on healthrelated issues such as covid19 in other words media content consumption could not be perceived as a determinant factor in shaping the conduct of individuals nonetheless the scientific community paid little attention to individuallevel media dependency effects in this regard ref 21 a survey conducted to document media dependency in the aftermath of the terrorist attacks on september 11 found that individuallevel media dependency was a significant predictor of attitudinal and behavioral changes in the respondents in the context of social media dependencies ref 39 found that social networking sites dependency had direct effects on individual users levels of engagement with interactive activities on snss and indirect effects on offline interpersonal storytelling likewise scholars 40 concluded that individuals dependence on youtube provided them with a means to meet their emotional needs in times of crisis such as the death of a public figure similarly studies show that media messages enhance the willingness to accept vaccines 41 42 43 keeping this literature in view we proposed the following hypotheses h1 traditional media dependency positively relates to attitude towards precautionary measures and covid19 vaccine uptake intention h2 social media dependency positively relates to attitude towards precautionary measures and covid19 vaccine uptake intention interpersonal communication and covid19 vaccine uptake intention interpersonal communication is the verbal and nonverbal transfer of information and messages between two or more people it entails the exchange of ideas via the use of words body language facial expressions and other types of communication in many contexts including interpersonal relationships business education and healthcare among others effective interpersonal communication is crucial it involves attentive listening empathy and the capacity to comprehend others needs and viewpoints and to respond effectively to them interpersonal communication can replace mass communication to convey information and influence peoples actions a study found a link between risk perceptions and interpersonal discussion of health concerns the study does not however give enough details on how this link came to be 44 interpersonal communication has been recognized in earlier research as the primary source of social norms and perceived efficacy and it has also been shown to impact peoples attitudes and behaviors 45 h3 interpersonal communication is related to attitude towards precautionary measures and subjective norms collectivism culture is the collective set of ideas standards and practices created by human societies to address social and environmental issues 46 societies must effectively manage substantial environmental risks like diseasecausing viruses and cultures have developed in response to these difficulties the prevalence of infectious diseases in ecological areas has been associated with the development of a cultural syndrome known as collectivism 47 the concept is rooted in the fundamental psychological differentiation between a selfperception that is interdependent with others and one that is independent and distinct from others 48 the collectivismindividualism dichotomy is crucial for capturing cultural variance 49 the link between pathogen prevalence and collectivism apparently arises due to some characteristics of a collectivist society serving as barriers to disseminating contagious illnesses in particular individuals who adhere to collectivist values tend to exhibit greater wariness when engaging with unfamiliar individuals potentially mitigating the risk of encountering novel infections they also place high importance on customs like food preparation which might act as barriers to spreading covid19 38 although it has been suggested that collectivist societies may be better able to control the dissemination of contagious illnesses other aspects of collectivism may work against this goal individuals connect more frequently and closely in collectivist communities 48 which helps infectious diseases spread 50 collectivist societies have a propensity to marginalize the underprivileged and are linked to ineffective social programs for disadvantaged groups 49 these elements contribute to the spread of infectious diseases given these conflicting claims it is unclear to what extent collectivism can successfully combat a severe epidemic like covid19 on the other hand an alternative body of literature posits an inverse association between collectivism and proactive health practices 46 it is demonstrated that the sociability facet of extraversion which pertains to the inclination towards social activities and a preference for socializing over solitude is positively linked to the transmission of covid19 51 this subdimension is a characteristic of collectivism 48 given the increased likelihood of covid19 transmission in public settings it is reasonable to suggest that the conduct of individuals who prioritize collective interests may be significantly impacted by their perceptions of societal norms surrounding preventative measures the present argument posits that a collectivist mindset is more conducive to promoting preventive behaviors provided societal norms widely accept such behaviors as appropriate and we hypothesized that h4 collectivism is positively related to subjective norms the role of attitude subjective norms and behavioral control tpb is considered a framework for understanding the psychological foundations of intentional behavior in humans 2738 this hypothesizes three primary antecedents to the formation of intentional behavior these include attitudes subjective norms and perceived behavioral control ajzen and fishbein contend that behavioral intention is a reliable indicator of actual behavior 52 perceived behavioral control pertains to an individuals evaluation of their ability to execute a specific behavior of interest the level of perceived behavioral control is subject to variation depending on the situation and corresponding actions as it is contingent upon an individuals perception of their ability to regulate their behavior in different contexts 2733 the tpb supplanted the theory of reasoned action after adding the pbc 53 the concept of perceived behavioral control is analogous to perceived selfefficacy a central tenet of social cognitive theory 54 abundant research has demonstrated the generalizability of the tpb framework to a wide range of contexts 5556 studies have demonstrated that individuals are more likely to develop a stronger sense of perceived control when confronted with a greater level of threat such as the contagious covid19 57 for instance an individuals conviction that implementing precautionary measures such as vaccination can effectively mitigate potential risks contributes to developing their pbc the tpb suggests a positive relationship between pbc and behavioral intention indicating that individuals are more likely to feel confident in their ability to take action when they perceive a high level of control 38 hence in situations characterized by high risks such as covid19 it is anticipated that individuals will exhibit positive behavioral modifications such as a heightened willingness to adhere to covid19 preventive measures as a result of the activation of the danger control mechanism previous health behavior research elucidates the intricate relationship among various cognitive constructs such as pbc that govern preventive outcomes 24 pbc is a significant predictor of the responses characteristics specifically the feasibility of implementing a preventive response such as covid19 vaccine uptake intention 38 previous research has indicated that individuals exhibit an augmented sense of pbc primarily due to adequate prompts for engaging in safetyrelated behaviors related to covid19 vaccine uptake 29 the level of confidence in individuals ability to effectively plan implement and oversee their future circumstances was found to be necessitating as exemplified by the perception that covid19 vaccine uptake is a sustainable solution thus it is hypothesized that h5 perceived behavioral control is positively related to covid19 vaccine uptake intention subjective norms pertain to an individuals perception regarding the consensus of societal approval or disapproval of a particular behavior this pertains to an individuals perceptions regarding their peers and significant others social norms and expectations concerning their engagement in a specific behavior the norms could be categorized as descriptive and injunctive norms which could manifest at both individual and communal levels individuals seek the degree of endorsement of a particular behavior within their peer groups and in broader society 58 people socially compare their behaviors with those of their peer groups and are more vulnerable to the influence of ingroups than outgroups 59 previous research has demonstrated that descriptive and injunctive norms have differential effects on behavioral intentions 6061 collectivistic societies differ in terms of assigning significance to subjective norms those who live in collectivistic societies give more importance to subjective norms whereas those residing in individualistic societies tend to prioritize pbc in decisionmaking we propose the following hypotheses h6 subjective norms are positively related to covid19 vaccine uptake intention in fishbein and ajzens conceptualization attitudes refer to an individuals favorable or unfavorable evaluation of a particular behavior object which subsequently corresponds to individuals behavioral responses 62 attitudes may specify instrumental qualities such as usefulness and experiential qualities such as pleasantness of a particular behavior 63 for instance behaviors such as tooth brushing are utility oriented while behaviors such as watching a movie are pleasureseekingoriented 64 however several behaviors reflect a combination of both utility and enjoyment orientations the presence of a pessimistic outlook regarding vaccines and the reluctance of individuals to undergo the covid19 vaccination constitute a significant public health issue in managing the pandemic 6566 attitude refers to a concise representation of the assessment of a psychological entity for instance individuals may have varying perceptions regarding the positive or negative aspects and the potential risks or safety associated with receiving a vaccine according to the tpb an individuals behavioral intentions are determined by their attitude towards the behavior prior studies have demonstrated that individuals attitudes toward vaccination are reliable indicators of their intentions to get vaccinated 6768 in order to enhance vaccination intentions it may be necessary to strengthen general attitudes toward vaccines 69 therefore previous research has consistently confirmed the significant impact of attitude on vaccination intentions h7 attitude towards precautionary measures mediates the relationship between traditional media dependency social media dependency and interpersonal communication with covid19 vaccine uptake intention the moderating role of religiosity religious beliefs are also accorded substantial attention regarding covid19 precautionary behavior 70 the impact of religious beliefs on attitudes toward vaccination can be discerned as individuals endeavor to harmonize scientific realities with their theological framework leading to a heightened propensity for vaccine refusal 4371 the notion of religiosity pertains to the nature of an individuals religious convictions and encounters and religions function within a given society there is a significant correlation between religiosity and covid19 vaccine uptake intention the concept pertains to the conviction that every event occurs solely at the discretion of the divine 72 hence adherents are expected to conduct themselves in accordance with the precepts of god 73 literature indicates that scholars have directed their attention toward religiosity in the context of the covid19 pandemic 74 several studies revealed notable correlations between religiosity and various health behaviors 72 75 76 77 the results of these studies suggest a positive correlation between higher levels of religiosity and an increase in healthprotective behaviors other studies revealed that individuals who identify as religious exhibit a heightened level of concern regarding the pandemic compared to those who do not identify as religious 78 hence enhancing ones religious beliefs could potentially foster spiritual and psychological fortitude amidst the ongoing pandemic 79 several studies have observed that religious affiliation fosters effective coping mechanisms and confers psychological advantages thereby mitigating the likelihood of developing depressive symptoms in the context of the pandemic 8081 these studies show insistent results therefore we propose that h8 religiosity moderates the relationship between traditional media dependency and social media dependency with an attitude towards precautionary measures materials and methods design participants and procedure in the new communication environment behavioral intervention programs have been diversified and the usage of multiple means of communication has made the promotional phenomenon more complex the current study used a crosssectional research design viaavis a survey method to examine media dependency patterns in diverse settings to do so generalized data will be collected from pakistan using a multistage sampling technique before data collection the sample size was determined using two established methodologies morgans table and gpower analysis based on current statistical data the estimated number of internet users in pakistan is approximately 893 million based on morgans estimation a total of 384 participants were deemed suitable subsequently a gpower analysis was performed to ascertain the necessary sample size for this investigation taking into account the number of variables of interest the results indicated that a sample size of 950 participants would be sufficient to generate predictions and inferences from the data given the presence of five antecedents and one dependent variable although the sample size of 800 participants was sufficient for making predictions and drawing inferences the study aimed to collect an additional 10 of data to address potential challenges related to data normalization in the context of structural equation modeling in total 993 responses were obtained and a comprehensive analysis of the findings is presented in the subsequent section the questionnaire and corresponding definitions of constructs were disseminated to six academic professionals for feedback and to ensure translational validity before the commencement of data collection slight modifications were implemented in accordance with the feedback provided by the individuals subsequently a preliminary investigation was conducted encompassing a sample of 50 students the studys findings indicate that the scales reliability was deemed satisfactory with a value of less than 060 the ultimate survey comprised various items and constructed definitions the subsequent section expounds on the specifics of the tools employed in this study in developing measuring instruments the researchers collected and adapted available instruments furthermore based on the nature of the study the selected instruments were translated into the local language a backtranslation technique was applied and translational validity was attained by using face validity ratings from six experts upon getting feedback from the experts the suggested amendments were made before carrying out the main study a pilot study using 30 participants was conducted pakistan is considered for this research as it is a religiously sensitive country data analysis was desired to reveal whether psychological and contextual factors play any role in determining the impacts of media dependency finally for analysis pls was used as it is the right approach to deal with complex moderatingeffect models this study utilized a crosssectional field survey method to collect data from a sample of 993 adults in pakistan the data was gathered from april to august 2022 utilizing enumerators from a specialized data collection firm during a training session the lead researcher provided a briefing to six enumerators associated with the local data collection firm the briefing covered the primary objectives of the research as well as the sampling and data collection techniques to be employed data collection for the primary survey was carried out using a multistage sampling technique specifically employing random and convenient sampling methods the study used two sampling techniques to select the appropriate respondents in the first stage of the study a random sampling technique was utilized to select ten administrative units such as districts from pakistan the lottery method was employed for this purpose subsequently a compilation comprising the names of subordinate units such as subdistricts was generated for each district that had been chosen during this phase a total of ten smaller administrative units were chosen from the list mentioned above the data collection was conducted using a convenient sampling method during the purposive sampling phase the enumerators visited designated areas and included participants who consented to participate in this study subsequently the participants were requested to complete the questionnaire and the data was entered into a digital format using tablets and a google form instrumentation attitude towards precautionary measures we modified three questions from ajzens research 82 to gauge respondents attitudes towards precautionary measures on a semantic scale that taking precautionary measures against covid19 is worthwhile significant and pleasant anchoring 1 strongly disagree 5 strongly agree subjective norms in order to measure subjective norms we adjusted four questions from park and smiths work 61 respondents were asked to rate how strongly they agreed or disagreed with the assertions that their family members close friends and the general public would approve of their precautionary measures against covid19 on a fivepoint likert scale anchoring 1 strongly disagree 5 strongly agree perceived behavioral control pbc respondents gave their opinions on the following three statements adapted from literature 82 which read as follows it is possible for me to take covid19 vaccine shot it is up to me whether i take covid19 vaccine shot i believe i have complete control over taking covid19 vaccine shot on a fivepoint likert scale anchoring 1 strongly disagree 5 strongly agree covid19 vaccine uptake intention we modified three questions from ajzens work 82 to gauge respondents covid19 vaccine uptake intention on a likert scale anchoring 1 strongly disagree 5 strongly agree the items read as follows i intend to get the covid19 vaccine booster dose i am willing to receive a covid19 vaccine booster dose and i plan to receive a covid19 vaccine booster dose as the media is advocating it media dependency traditional media and social media we adapted three items from loges research 83 to measure participants reliance on traditional media the participants expressed their concurrence with the following four statements reading newspapers and watching tv helps me find out about precautionary measures against covid19 helps me observe how others deal with covid19 and helps me figure out how i can protect myself from covid19 the same statements were reworded for participants who relied on social media for instance viewing social media helps me find out about precautionary measures against covid19 all items were measured on a fivepoint likert scale anchoring 1 strongly disagree 5 strongly agree interpersonal communication three items were used to measure the participants reliance on interpersonal communication based on their discussions with friends family and colleagues about protection against covid19 i rely on discussions with friends family and colleagues to learn about precautionary measures against covid19 all items were measured on a fivepoint likert scale anchoring 1 never 5 all the time collectivism four items were adopted from the work of oyserman et al 84 to measure collectivism on a fivepoint likert scale the items read as follows i make an effort to avoid disagreements with my group regarding precautionary measures against covid19 before deciding covid19 vaccine uptake i always consult with others how i adopt precautionary measures against covid19 depends on who i am with i have respect for the authority figures with whom i interact and my covid19 vaccine uptake decision would depend on hisher advice religiosity three items were adopted from the literature 8586 to measure religiosity on a fivepoint likert scale the items read as follows what religion offers me most is comfort in times of trouble like covid19 although i am religious but i dont let it affect my covid19 vaccine uptake decision and although i am religious but i dont let it affect my precautionary measure against covid19 items two and three were reversed results demographic and descriptive analysis the outcomes of the demographic analysis are shown in table 1 the outcomes suggest diverse information concerning factors such as income gender educational achievement and age subsequently the descriptive analysis was conducted using spss 240 this entailed the assessment of normality checks outliers variable correlation and multicollinearity the analysis of normality both visually and statistically indicated that there were initial issues pertaining to the normality of the data the process of identifying and removing outliers was carried out through the application of outlier evaluations following the removal of 59 cases the data was found to conform to normality assumptions based on the threshold values of skewness and kurtosis when adjusted by the standard error reported in accordance with the recommendation of 87 the variance inflation factor test was also performed to assess multicollinearity the study observed that each items variance inflation factor values were below the threshold of 10 consequently in light of the absence of any multicollinearity concern in this investigation the analysis progressed toward the structural equation modeling technique furthermore the presence of method biases was detected by conducting hermans test via exploratory factor analysis on spss in order to achieve this all the constituent items of each variable namely at cvi ipc rl sm sn tm bc and col were loaded onto a unified factor the exploratory factor analysis findings indicated a variance of merely 374 furthermore no concerns were identified with respect to common method biases thereby enabling the study to progress to the structural equation modeling phase confirmatory factor analysis this study employed partial least squares sem it encompasses a range of multivariate techniques that are used primarily for confirmatory purposes in addition plssem offers enhanced predictive precision and a substantially reduced likelihood of spurious correlations hence variancebased sem such as pls is widely acknowledged as more advantageous than regression analysis this is primarily attributed to its capability to illustrate the influence of direct and indirect independent variables 87 in order to evaluate the measurement models fit convergent and discriminant validity and potential for multidimensionality the current study used a plsbased sem the items were loaded into the parent constructs of at cvi ipc rl sm sn tm bc and col for confirmatory factor analysis using pls 30 the confirmatory factor analysis findings suggest empirical differentiation between at cvi ipc rl sm sn tm bc and col upon analysis it was found that the model demonstrated a satisfactory fit after removing one item table 2 and figure 2 present the reported item loadings upon achieving the desired level of model fitness the research proceeded to estimate reliability the findings of the analysis indicate that the constructs of at cvi ipc rl sm sn tm bc and col exhibit satisfactory reliability estimates across multiple indices including dijkstrahenselers rho jöreskogs rho and cronbachs alpha as presented in table 3 various reliability indices as introduced in pls3 were employed to perform crossvalidation of the reliability estimations the study assessed the convergent and discriminant validities by utilizing the fornelllarcker criterion method convergent validity is established when the items within a specific measure exhibit convergence by effectively representing the latent construct being measured the average variance extracted is computed by taking the average of the squared loadings of each indicator linked to a particular construct convergent validity is considered statistically established when ave exceeds a threshold of 050 at the same time discriminant validity is a crucial aspect of research methodology that aims to determine the distinctiveness of the constructs under investigation the fornell and larcker criterion posits that discriminant validity can be deemed established if the square of the correlation between two constructs is less than the ave for each construct the fundamental basis of the ave for a specific construct exhibited a higher magnitude than its correlation with all other constructs these findings indicate that the constructs examined in the study possess distinct identities and exhibited moderate correlation with other constructs under investigation the confirmatory factor analysis findings indicated that the composite reliability of all variables was acceptable as presented in the table in addition the study computed the average variance extracted and observed that the intercorrelations among at cvi ipc rl sm sn tm bc and col were below the square root of their respective ave values subsequently the research progressed to the application of inferential statistics upon analysis it was found that the model demonstrated a satisfactory fit after removing one item table 2 and figure 2 present the reported item loadings upon achieving the desired level of model fitness the research proceeded to estimate reliability the findings of the analysis indicate that the constructs of at cvi ipc rl sm sn tm bc and col exhibit satisfactory reliability estimates across multiple indices including dijkstrahenselers rho jöreskogs rho and cronbachs alpha as presented in table 3 various reliability indices as introduced in pls3 were employed to perform crossvalidation of the reliability estimations hypothesis testing this research posited numerous hypotheses to map the psychological and sociocultural influences on the precautionary measures regarding covid19 the hypotheses delineating the direct impact of traditional media social media and interpersonal communication on attitude were supported the results of the sem using pls revealed that there is a positive influence of traditional media social media and interpersonal communication on attitude furthermore the results demonstrated that traditional media and social media significantly predict covid19 vaccine uptake intention therefore h1b and h2b were also supported likewise results suggested that interpersonal communication and collectivism positively predict subjective norms as posited in h3b and h4 finally results verified that behavioral control and subjective norms predict covid19 vaccine uptake intention significantly thus h5 and h6 were also supported later the mediation analysis revealed that attitude partially mediates the relationship between traditional media and covid19 vaccine uptake intention similarly partial mediation of attitude was also found in the relationship between social media and covid19 vaccine uptake intention thus h7a and h7b were also supported by the evidence presented in figure 2 and table 5 the present study posited the moderating influence of religiosity in determining the influence of the traditional and social media on attitudes to determine the moderating influence specifically the model included the two interaction terms surprisingly the analysis findings indicate no significant moderation influence of religiosity on the relationship between traditional media and attitude thereby h8a was not supported the findings of the analysis specify that there is a significant moderation effect of religiosity on the relationship between social media and attitude the findings indicate that social medias impact on attitude is a function of religiosity these results were statistically significant and supported hypothesis h8b overall the model extracted 647 variance with a reasonable effect size as presented in table 6 discussion this study used a crosssectional research design vis à vis survey method to exami the influence of traditional media dependency social media dependency interperson communication and collectivism on covid19 vaccine uptake intention the study al discussion this study used a crosssectional research design vis à vis survey method to examine the influence of traditional media dependency social media dependency interpersonal communication and collectivism on covid19 vaccine uptake intention the study also investigated the mediated role of attitude towards precautionary measures subjective norms perceived behavioral control and the moderating role of religiosity overall the study proposed thirteen hypotheses of the 13 hypotheses nine explored the direct impact two the mediating role and two the moderating role the nine direct hypotheses were supported likewise three mediating hypotheses were also supported of the two moderating hypotheses one was supported and the other was rejected the findings of hypotheses h1a and h1b revealed that traditional media dependency influenced attitudes towards precautionary measures and covid19 vaccine uptake intentions likewise social media dependency impacts attitudes toward covid19 vaccine uptake intention supporting hypotheses h2a and h2b put differently the higher the media dependency on both traditional and social media the higher the impacted attitude toward precautionary measures and covid19 vaccine uptake intention these findings support the results of previous literature suggesting that higher media dependency during a crisis increases information seeking this corresponds to a higher attitude toward adopting precautionary measures and boosts public covid19 vaccine uptake intentions 412 similarly during uncertain times such as the covid19 crisis individuals interpersonal communication with family friends and colleagues was also enhanced manyfold this increased interpersonal communication corresponds to an increased awareness of covid19 consequently these encounters impact their attitude toward precautionary measures and their intention to adopt them against covid19 supporting hypotheses h3a and h3b this finding supports the previous literature 17 those who live in collectivist cultures adhere more to subjective norms people from collectivist cultures stay in collectivist communities the adherence to collectivism apparently arises due to some characteristics of a collectivist society which serve as a barrier to spreading infectious illnesses in particular collectivists are more cautious when interacting with strangers this results in few exposures to novel infectious diseases they also place high importance on cleanliness such as in customs like food preparation which might act as barriers to spreading covid19 these findings align with the previous outcomes 46 h5 posited that perceived behavioral control positively relates to covid19 vaccine uptake intention the findings support the hypothesis perceived behavioral control is related to an individuals subjective assessment of their behavioral response and it varies across situations and actions based on contexts 27 it corresponds to precautionary measures against covid19 the present study provides empirical evidence that supports the theoretical constructs associated with the intentions of vaccinated individuals to seek a covid19 booster vaccine the factors pertaining to attitudes and subjective norms exhibited the most substantial effect sizes suggesting that individuals perceptions regarding the value and usefulness of the booster vaccine and the opinions of influential individuals significantly influenced their behavior the findings align with previous studies that examined the acceptance of an initial covid19 vaccine therefore they substantiate that individuals exhibit utilitarian behavior and prioritize the viewpoints of individuals they deem significant such as their immediate family and close acquaintances 8889 despite being less pronounced the impact of risk perceptions and perceptions of control was equally significant previous research has primarily emphasized vaccine risk perceptions and selfefficacy with relatively less attention given to the primary vaccine 90 there exists a possibility that individuals who have undergone vaccination procedures may have previously formulated and executed intentions to partake in identical endeavors consequently due to their prior exposure and the accessibility of immunizations individuals perceptions regarding the inherent risks associated with vaccination may have diminished thereby bolstering their willingness to undergo vaccination once more consequently this could potentially diminish the extent to which individuals rely on said information to decide their future choices regarding vaccination h6 posited that there exists a positive correlation between subjective norms and the covid19 vaccine uptake intention subjective norms refer to how individuals and communities approve or disapprove of a particular behavior this involves individuals seeking support for a specific behavior within their social circles and in wider society the results of our study provide evidence in favor of the hypothesis that subjective norms are linked to adopting precautionary measures against covid19 as previously suggested by studies 5859 furthermore it is supported that the correlation between reliance on traditional media and reliance on social media is mediated by the attitude towards precautionary measures the results indicate that individuals with a more positive attitude towards precautionary measures are more inclined to adopt preventive measures against covid19 thereby supporting hypotheses h7a and h7b the results above corroborate existing literature affirming that media communications impact individuals inclination to receive covid19 and polio vaccinations 424391 furthermore a notable association between religiosity and adopting precautionary measures is observed individuals who strongly adhere to religious teachings tend to exhibit a greater inclination toward believing that all events are subject to the will of a higher power the results of our study indicate that individuals who selfidentify as religious and rely on conventional media as their primary source of covid19 information exhibit a lower propensity to adopt precautionary measures compared to those who are religious and rely on social media for covid19 information these findings support hypotheses h8a and h8b as previously proposed in the literature 787992 theoretical contributions recognizing the actions identified to lessen infection risk is a strategic aim for behavioral researchers during the covid19 pandemic it can offer a substantiated base of possibly manipulative reasons as objectives for interventions to promote healthrelated behavior and prevent covid19 pandemics during healthrelated crises like the covid19 pandemic identifying the predictors of health behavior becomes imperative this study investigates the probable psychological and cultural factors involved in developing covid19 vaccine uptake intentions in doing so the study has proposed a conceptual model that can effectively measure the tendency to media dependency among individuals to this point it can provide evidencebased facts on how behavioral intrusions could be attained during crises this study aims to evaluate the factors associated with promoting healthrelated behavior this study proposed applying assumptions based on mdt and tpb to predict and explain health behavior these assumptions help to predict the association of critical psychological and cultural factors related to the development of precautionary measures against covid19 mapping and testing such processes allows this study to provide insight into many spheres for instance the evidence of informational dependency highlights the stipulated patterns and effectiveness of different modes of communication on the other hand the tradeoff between religiosity and culture in developing optimally operative interventions or not in promoting health precautionary behavior this researchs theoretical contribution is associating the evidence of the contextual factors importance with the psychological process simultaneous inspection of the proposed model also gives insight into health behavior among individuals in an asian nation this research explored the moderating influence of religiosity which has been widely observed in public discussions surrounding the covid19 pandemic for example an individual without specialized knowledge or expertise may justify their decision to avoid vaccination by attributing the outcome of their life to divine intervention however obtaining additional empirical evidence regarding ones dependency on the media is necessary this research provides additional support to previous findings within the framework of a predominantly muslim country demonstrating that media interventions can effectively mitigate the adverse impact of fatalistic beliefs on healthrelated outcomes managerial implications this study has several managerial implications for communication and social marketing practitioners and governments in designing and updating their communication and health behavior intervention programs in the future in times of crisis the results of this investigation offer enhanced and indepth comprehension for professionals in the field of public health to address the issue of reluctance toward covid19 vaccination this study provides practical insights for relevant authorities regarding the strategic utilization of communication resources to mitigate obstacles such as religious beliefs and societal misinformation that impede the acceptance of covid19 vaccines on social media platforms the scholarly literature suggests that in situations where obstacles give rise to doubts about vaccines increased media attention could expose media consumers to some information to counter misinformation disinformation or fake news wellplanned media content may increase public knowledge about the advantages of vaccines and correspond to an increased willingness to take vaccines in this regard media practitioners could utilize a media dependency framework during times of crisis such as covid19 to better serve the public for the common good on the other hand vaccine hesitancy towards covid19 is regarded as an obstacle that diminishes public acceptance consequently this research offers a significant strategic communication instrument for generating consciousness regarding the perceived risk of covid19 vaccination enhancing the stakeholders perception and protective attitude towards covid19 this can be achieved by employing strategic communication messages to augment the acceptance of the covid19 vaccination finally this study will also promote collaboration among health and media experts to launch collaborate on and execute future promotional programs together limitations and future research the present studys results contribute to the existing literature by examining the acceptance of covid19 vaccines however the present investigation is subject to various constraints the study employed a crosssectional design which captures a single area of the phenomenon being studied rather than providing a dynamic representation of the phenomenon through experimental designs henceforth future research endeavors may employ longitudinal or experimental methodologies to monitor the evolving behavior concerning covid19 vaccine reluctance or to ascertain the factors contributing to the decrease in vaccine adoption furthermore this study only measures exposure to media and it is based on a narrow set of general traditional media and social media measures therefore this study does not measure any media content or media perceptions as such its ability to make statements about media content and campaigns is quite limited however its contribution is focused on the intersection of religious culture and media culture as they influence individuals attitudes and intentions to adopt health behaviors in the context of precautionary measures for covid19 boosters thereby it is recommended that future research incorporate the influence of news frames documentaries and other related factors besides the study was conducted solely in pakistan thus the generalizability of its findings to other countries and contexts should be approached with caution data availability statement the data supporting this studys findings are available from the corresponding author upon reasonable request due to ethical and privacy restrictions informed consent statement informed consent was obtained from all subjects involved in the study

media exposure to health communication contents related to the covid19 pandemic alone is inadequate to measure the influence of media on individuals in adopting precautionary behaviors against covid19 such as vaccine uptake certain individuals may pay attention to and be influenced by communication content however literature has suggested other instrumental determinants in developing and adopting health precautionary measures such as culture or religion especially regarding vaccination in times of crisis such as the covid19 pandemic it is valuable to examine the interrelationships among psychological sociocultural and informational factors this can provide valuable insights for policymakers in developing effective communication strategies drawing an analogy between the media dependency theory mdt and the theory of planned behavior tpb model this study unravels the factors underpinning the covid19 vaccine uptake intention among pakistanis the study utilized a crosssectional research design and employed a survey method to gather data from a sample of 993 participants the findings obtained from the plssem analysis confirmed that individuals relied on both traditional and social media to cope with the covid19 pandemic the findings show that individuals rely more on the informational content disseminated through conventional media channels the findings also suggest that individuals from asian countries such as pakistan tend to be more inclined toward collectivism the findings about the moderating role of religiosity suggest that religious beliefs significantly shape individuals reliance on traditional media hence this study has uniquely contributed to public health and media management by providing a strategy for managers to address disseminating misinformation related to religion and its impact on vaccinationrelated health issues the study has theoretically confirmed the principles of media dependency theory as a result it is recommended that various information sources be utilized to cultivate resilience among individuals to manage health crises effectively

socialization, politics largely takes place on them. Political candidates often exploit such media to interact with the electorate and to place targeted and personalized advertising. At the same time, partisan users utilize their social media accounts to engage in political discourse. Similarly, a large portion of society obtains its political news updates from social media sources. Two factors shape the final forms taken by political communication on social media: how a platform is designed, and who uses this space for political purposes. The design of a social media service configures the available information channels for political discourse; its user-base shapes both the generated political content and dictates whether or not a platform can prevail as a significant political space. Until now, researchers have considered Facebook, Twitter, and YouTube as the most politically relevant social media [48], given the vast number of users who engage daily with these platforms. Nevertheless, social media usage is dynamic. Users change or migrate from one service to another, and some platforms are abandoned as others become popular [31]. TikTok, a video-sharing social networking service, has recently witnessed a surge in its popularity. It became the world's second most downloaded app in 2019 [53]. --- Motivation Although researchers have extensively analyzed other popular social media platforms, both by explaining user political behavior and uncovering how platform design influences political communication, no study has focused on TikTok. The present study, therefore, aims to bridge this research gap, intending specifically to understand who uses TikTok for political purposes and how the design of this platform shapes the flow of political information. For this, we focus on US politics to answer the following research question: RQ: What are the features of political communication on TikTok in terms of partisan users, interaction structure, and diffused content? --- Original Contributions • We provide a first overview of political communication on TikTok by investigating videos of US Republican and Democratic partisans. • We employ computer vision, natural language processing, and statistical tools to evaluate the ways in which partisans combine sound, video, and text to spread their messages. • We study TikTok's interaction design and illustrate how partisans engage in political discussions. We show that Tik-Tok fosters a novel type of political interactivity that is not available on other online social networks. • We investigate user demographics and show that the partisan users are young and behave similarly regardless of their political preferences. We find that Republican users are more active in creating political content and that they receive more responses. We further find that Republicans prefer to engage in video discussions with other Republicans, while Democrats are more open to reach out to users with opposing views. • Finally, we discuss other issues related to political communication, privacy, and security on TikTok. --- BACKGROUND & RELATED WORK 2.1 Political Communication on Social Media The behavior of multiple actors determines the political communication that occurs on social media platforms. Politicians, partisans, and the general public interact constantly, generating complex communication patterns. The design and algorithms of the platforms influence these interactions along with malicious actors to generate a political landscape that can be difficult to understand. Researchers have therefore extensively analyzed various properties of Facebook, Twitter, YouTube, and other similar social media spaces to grasp the nature of politics on social media. Several studies have investigated how politicians use social media for political purposes. They have shown that politicians use platforms in different ways, depending on the audiences and sociotechnical environments [21,43,46,47]. They have also explained how services are used for personalized advertising campaigns [39] and whether the presence of politicians on these platforms affects their electoral popularity [19]. Other studies have explicitly focused on user political behavior. They have investigated how partisans of different political orientations use social media platforms [10,44], analyzed how user activities are generally distributed [40] and evaluated the spread messages' content and polarity [15,36,38,45]. Studies have also focused on the usage of social media in periods of social unrest [50], analyzed online social platforms as spaces for the coordination of social movements [49], investigated how different social groups behave, and scrutinized the conditions in which they help to polarize and segregate the citizenry [4,6,16]. Inseparable to political communication on social media is news consumption, with a large proportion of the public using the social media services as their primary information source pertaining to world events. Many studies have investigated agenda settings effects, as well as how different types of news coverage affect user behavior and contribute to attitude formation [9,23,29]. Moreover, researchers have also extensively studied how low credibility news and misinformation are diffused on social media platforms by real, fake, or automated accounts [3,17,22,27,28,51]. An equally important role in understanding user behavior is the analysis of the content filtering algorithms employed by social media services. Thus, researchers have investigated social platforms as algorithmic ecosystems and have studied whether and how recommendation algorithms influence the public's political behavior and opinions [5,32,37,40,41]. In the same vein, scholars have evaluated platform design features and how they shape information diffusion [21,33,47]. These dimensions of political communication have been extensively analyzed for the US on different social media platforms [2,20,25,26,30,52], but not yet on TikTok. --- TikTok TikTok was created by ByteDance, a Beijing-based tech company. The company had previously launched Douyin for the Chinese market in September 2016. Subsequently, the company launched TikTok in 2017 for markets outside China. Both services are similar, but they run on separate servers to comply with China's regulations. In 2018, TikTok merged with the social media app Musical.ly to create a larger video community. In October 2019, TikTok and Douyin jointly achieved 800 million monthly active users [34]. In the United States, 60% of TikTok's 26.5 million monthly active users are aged between 16 and 24 [24]. The platform is mainly accessible through a mobile app. Although it is possible to access posted videos from non-mobile devices, the features are limited as it is not possible to create content or read user comments. TikTok offers users a unique method of sharing creative videos of themselves, their surroundings, or a compilation of external audiovisual content. The simplest videos consist only of text superimposed onto a colored background. Videos can then be more complex by including images, video clips, and sounds. The images and video footage can be altered using the app's voice effects, image filters, and video speed controllers. The maximum length of a video post is 60 seconds, and they can consist of a collection of shorter video clips that tell a story when they are combined. When the users post videos, they can add a caption with hashtags to describe their clips. Like Twitter, the most used hashtags represent topics that are trending on the platform, and like Instagram, the video clips are classified according to their hashtags. TikTok is considered a social media platform because like Twitter and Instagram, its users have a social group of followers and other users they follow. However, the main feature that differentiates TikTok from other social media services, is the videos' background music, which represent the core message that the users want to convey. Users can select background music for their videos from a wide variety of music genres and can even create original sound clips. Any sound clip, including user voice messages, can be selected by other users to use in their videos. For many videos, the music serves as part of a dance routine, a lip-synching battle, or as the backdrop for a comedy skit. However, sound can also function as a story builder and can be used to deliver a specific message. For example, a famous original sound clip begins with La Roux's song, Bulletproof, remixed by Gamper & Dadoni. Then the music stops, four gunshots are heard, and a man's voice says "there's not any". Text messages appear in the part of the clip that plays the song, citing reasons why a particular cause should be supported, and the user points at the messages. When the gunshots begin, however, the user makes a gun sign with a hand and shoots at the text snippets containing the reasons for support. The user is implying that the citing reasons are invalid and that there is no real reason for people to support that cause. Users consume content by viewing an algorithmically generated feed of videos on the so-called "For you" page, which is the landing place when users open the app. Although there is no explanation of how the algorithm work, the videos that appear to the user largely rely on a central recommendation algorithm instead of on the activities of the user's social network [12]. According to TikTok, the "For you" page is "a personalized video feed specifically for you based on what you watch, like, and share." 1 This contrasts with Facebook's and Twitter's feed, which rely mostly on the user's social graph and resemble more YouTube's recommendation system. Users can also search for hashtags, sounds and find the trending videos on the "Discover" page. A unique feature on TikTok is the duet. A duet is a response video that allows users to reply directly to a video post with a video of their own. The original and duet videos play side by side and the music clip from the original video's audio is preserved. Since the audio does not change, the duet exhibits users responding through text snippets, images, or facial expressions. Users can also create a reply duet from an existing duet. In such instances, three videos appear together. Figure 1 shows a screenshot of a duet on TikTok. The original video is placed on the right and the duet video on the left. The screenshot displays the number of likes, comments, and shares the duet video attracts. The music that appears on the bottom is a music clip from a remixed song. In the image, both users point to a text snippet and communicate their perspectives as they dance to the same music. In this way, TikTok can be used to share opinions on controversial topics. In this study, we focus on political content to determine how TikTok users interact and show their support for a political party with the help of music, video, and image. Figure 1: Screenshot of a duet on TikTok. On the right is the original video and on the left, the video posted in response. 1 https://apps.apple.com/us/app/id835599320 --- DATA & METHODS 3.1 Data Collection TikTok allows users to search for videos with a specific hashtag and view the most popular results. We decided to crawl the videos containing the hashtags #republican and #democrat on February 1, 2020. The hashtag search yields a limited number of videos and it is not clear how this limit is defined. Popularity may play a role as a hashtag search showcases the most popular videos. For the two hashtag queries, we obtained a different number of videos. The collection process resulted in 3,310 videos: 2,362 with the hashtag republican, and 1,831 with the hashtag democrat. Of the total, 350 were duets; thus, we also collected the original videos from them if they were not yet in the data. To expand the dataset, we searched for duets to the videos we had collected. Unfortunately, TikTok does not offer a search by video feature that directly links a video to its duets. However, it is possible to search by sound clip. This search shows videos that have employed the same sound. Our approach was to search for the sound of each video and to add the videos that were dueting to the videos in our dataset. As with search by hashtag, only a limited number of results can be obtained. This presents a limitation to collecting all the duets to a video, especially for videos that use extremely popular sounds. Nonetheless, searching for original sounds often yielded only the duets of the given video. After this procedure was complete, our dataset consisted of 7,825 TikTok videos. Most of the videos were created between October 2019 and February 2020. The oldest included video was posted in March 2019. Before beginning the analysis, we manually labeled every original video and duet as pro-Republican, pro-Democrat, or nonpartisan. This coding was conducted by two of the main authors. Both authors labeled each video individually. For the cases where authors disagreed, the third author was consulted to resolve the coding conflict. Videos that directly supported or opposed a political party or a member of a party were classified accordingly. We labeled videos opposing one Democratic candidate but expressing support for another candidate of the same party as pro-Democrat. Videos in which users articulated their standpoints on issues such as abortion, guns, and LGBT rights, were not directly attributed to any political party. We only classified those videos that indicated a clear political affinity toward the Republican or Democratic parties as partisan. For example, social issue videos with both the republican and democrat hashtags were coded as nonpartisan. In total, we classified 5,946 videos as partisan posts. Apart from assigning partisanship, we grouped the partisan videos into four categories: 1) videos that included the user's face; 2) videos where the user appears but does not show its face or videos culled from other sources such as news clips; 3) videos solely comprised of images; and 4) videos that only showcased textual content. We used the same coding procedure as the classification of partisan videos. It was important for us to view all the videos to be able to understand TikTok's communication structures and the user behavior displayed on the platform. --- Methods TikTok videos are rich in features and extra pre-processing steps were required to extract the information for analysis. From the original videos, we started by extracting the text snippets from the videos. For this, we divided the videos into images every two seconds and then employed Tesseract, an optical character recognition engine. From the original videos that included the user's face, we used the images and processed them via Microsoft's Azure Face API 2 , which allows emotions, gender, and age to be extracted. Additionally, we employed IBM's text to speech API 3 to extract the audio from the videos that contained original sounds created by the users. To explore the difference in the usage of hashtags, we employed a measure of political valence introduced by Conover et al. [16]. They defined political valence V of a hashtag h as V = 2 * N N N N + N N -1 where N and N indicate the number of appearances of a hashtag, and N and N represent the total number of hashtags in the Democratic and Republican videos, respectively. This equation bounds the valence between -1 for hashtags only used in Democratic videos and +1 for hashtags appearing only in Republican videos. We created a graph of interactions where the users are the nodes and the directed edges represent duet interactions. This graph allows to measure the extent of cross-ideological and intra-party interactions . We used another measure from Conover et al., which divides the observed number of interactions with the expected number of interactions. The expected value assumes that the source of the edge is preserved and the target of the edge is randomly assigned to one user, irrespective of the individual's political orientation. For example, the expected interactions between Republicans and Democrats is defined as: E[R -→ D] = k R * U sers D U sers D + U sers R where k R refers to the number of edges originating from pro-Republican videos and U sers D denotes the number of Democratic users. Finally, we applied topic modeling to evaluate the content of video captions. We used a Latent Dirichlet Allocation algorithm [8] to extract the latent thematic topics and to calculate the empirical distribution of videos belonging to the identified topics f . Using this distribution, we computed and compared the amount of Democratic and Republican videos associated with each topic. In order to calibrate the number of topics and the latter model hyperparameters, we perform sensitivity analysis for various values and select the model with the highest topic coherence score, as suggested by Röder et al. [42]. --- RESULTS We illustrate different features of political communication on Tik-Tok in the following three subsections. First, we describe the general statistics of the collected dataset, including user demographics and activities. Second, we describe and evaluate political interactions between partisan users. Finally, we analyze the content 2 https://azure.microsoft.com/en-us/services/cognitive-services/face/ 3 https://www.ibm.com/cloud/watson-text-to-speech of different information channels used in TikTok videos to detail the nature of the political discourse. --- Descriptive Statistics Of the 5,946 partisan videos, 2,802 are original videos and 3,144 are duets. Table 1 shows the total number of videos classified as pro-Democrat or pro-Republican and the extent of the interactions generated by these videos. In our dataset, there are two times more Republican videos than Democratic videos. Overall, the Republican videos accumulate more likes, shares, and comments. We applied one-sided Mann-Whitney tests for each reaction to compare if there is a significant difference between the partisan videos. For likes, the Republican median is 497 and the Democratic median is 232 . In terms of shares, the Republican median is 6 and the Democratic median is 3 . With regard to the comments, the Republican median is 19 and the Democratic median is 13 . All the tests are significant and show that Republican videos attracted more interactions in general. Of the original videos, 70% included the user's face, 22% featured other video content, 7% comprised only image content, and 1% only exhibited text. We performed feature extraction for the original videos that included the user's face. To this end, we divided the videos into pictures and obtained the features for each picture. With Microsoft's API, we were able to extract gender, age and emotions, which include anger, contempt, fear, happiness, sadness, and surprise. Afterward, we averaged the emotions and ages of all the pictures to obtain the mean values for each video. We used the mode for gender given that it is a categorical feature. For age and gender, we aggregated the videos per user to obtain unique values. We manually categorized the users, for which the mode of the gender was inconclusive. From the original Republican videos, 219 users are male and 187 are female, whereas for the Democratic videos, 84 users are male and 118 are female. We perform goodness of fit chi-squared tests to evaluate the male-female user balance. For the overall population, gender is balanced . The same applies for the Republican partisans . However, a significantly larger number of Democratic partisans posting original videos are female . Figure 2 portrays the cumulative age distribution of Democratic and Republican users. We observe that in general, the Democratic users are younger than Republican supporters. The percentage of Republicans between 16 and 24 years old is close to 60%, which mirrors the percentage of US TikTok users in the same demographic group. For the Democratic users, however, this percentage is closer to 70%, younger than the mean user age. Nevertheless, the majority of users creating political content are below 40 for both parties in our data sample. 2 illustrates the average emotion expressed for the posted videos per party. We do not observe significant differences between the two groups. We conclude that users on TikTok express themselves similarly irrespective of the party they support. Interestingly, happiness and surprise have higher averages than anger or sadness. We presume that this finding is related to the nature of TikTok comedy skits. Indeed, we observed many videos that relied heavily on sarcasm: smiling and dancing individuals confronting users supporting the views of the opposite political party and mocking or belittling them. --- Interaction Structure Political communication on social media is influenced directly by the design of the platform by determining the interaction structure between users. The interactions can be ordered in consecutive levels of communication, with each increasing level representing a more direct response. We identify four levels of communication on TikTok. The first level corresponds to an indirect response when a user views a video. Although there is no active reaction from the user, the message is received and processed. Additionally, from the data perspective, the view counter on the video increases, and this metric can influence TikTok's recommendation algorithm. The second level of communication consists of a basic response that involves liking the video or sharing it. The next level constitutes written responses to a video through user comments. On other social media platforms, this is the highest level of user response to a posted element. On TikTok, however, a fourth level of communication allows users to respond with a video, a feature referred to as duet. The duet shows more similarities to face-to-face communication than to a written response, which can make the interaction between users feel more personal. The structure of duets directly affects how political communication takes place on TikTok. The duets follow a tree structure, where users create branches by responding to other videos. We depict this tree structure of communication in Figure 3. On top of the tree, there is a political issue, which partisan users use as their motive for the production of pro-Democrat or pro-Republican videos. Connected on the second depth level are the original content videos. The third depth level represents the duets to the original videos. The next level nodes on the tree denote duets posted in response to previous duets. It is possible to continue to react with duets further than the three duet depth levels displayed in Figure 3. Inner nodes on the duet nodes have been included in the illustration to represent that duets, previous duets, and original videos appear side by side on TikTok. A user interacting with a deep level duet video can directly observe the complete communication chain on-screen without needing to scroll down. This differentiates duets from any feature available on other social media networks. Using the manually labeled videos, we were able to quantify the duet interactions between partisan users. Table 3 shows the percentage of partisan and cross-ideological interactions. It also includes the observed interactions divided by the expected interactions as presented in Formula 2. We observe that 77% of the Republican duets represent responses to Republican users. In contrast, more than 80% of the Democratic duets were directed toward Republican supporters. This inverted dynamic also appears in the ratio between observed and expected interactions. Democrat-Republican and Republican-Republican interactions present a ratio larger than one . We include the ratio, as it is a standardized measure that can be used to compare to the outcomes of other studies. For example, Conover et al. [16] evaluated political communication in the US on Twitter and found that retweets had higher ratios than one for intra-partisan interactions and lower ratios than one for cross-partisan interactions . Mentions displayed a similar but less pronounced effect for both parties . Therefore, the authors found that user behavior with regard to Twitter mentions and retweets was unrelated to the political party. In contrast, we find that TikTok duets represent a party-specific structure. This difference shows the importance of studying the effects of different platform designs on the political communication that occurs between users. We portray the duet interaction between users in Figure 4. Each node represents a user and the edges represent two users of a duet. Blue nodes indicate Democrats and red nodes designate Republicans. We only find one account that posted both pro-Democrat and pro-Republican videos, and this account was omitted from the analysis. The graph shows a tight Republican cluster in the middle with some Democratic users interacting with this community. The boundaries evince large clusters of Democratic users responding to Republican accounts. These users are separated from the main cluster because they did not interact with accounts other than a specific Republican user. The graph confirms the result of high partisan interactions among Republicans and the high cross-ideological interactions from Democrats to Republicans. --- Content Analysis The content analysis of the various information channels on Tik-Tok provided important insights on how political communication takes place on the platform. Each information channel was used differently by partisans. Partisan users generally avoided political statements in their profile descriptions, except for some users whose username explicitly stated their political affiliations. Most users added links to their social media handles on other platforms such as Twitter or Instagram, and some provided their Venmo accounts for fans to support them financially. In contrast to the profile descriptions, video captions were extremely politicized. Users usually inserted as many political hashtags as possible from across the political spectrum, to ensure the visibility of their content. Their hashtag selections were also influenced by partisanship. Users inserted specific hashtags more often in accordance with their political orientation. To reveal this, we divided the valency spectrum in five equidistant groups and grouped the hashtags according to valences. Figure 6 presents the top ten words per group. Democratic partisans more frequently used hashtags related to the impeachment of Donald Trump, Bernie Sanders, Elizabeth Warren, and LGBT issues. Republican partisans more often used hashtags related to Trump's campaign slogans and phrases used by the alt-right to assign credibility to information such as #facts, #maketheswitch, and #openyoureyes. Regardless of partisanship, users added to their videos platform-specific hashtags such as #foryou, #foryourpage, and #xyzbca. These hashtags are irrelevant to the political discussions but constitute a cardinal aspect of TikTok interactions. The topic modeling algorithm provided more detailed information about partisan interests for the specific period on TikTok. The model optimization process for the video captions yielded ten topics on which both Republican and Democrats generated content. Figure 5 shows that although some topics were more prevalent in posts by Democrats or by Republicans, both groups engaged in the same discussions. The topics that were discussed more or less equally by both sides related to social issues such as religion and abortion, guns and the second amendment, as well as discussions associated with daily political developments. Democrats generated content related to their party, about Trump's impeachment trial, as well as social diversity. In comparison, Republicans created more The analysis of audio and the text embedded in the videos evidenced particular ways in which these communication channels were used . Both Republican and Democratic partisans used sound and embedded text to call out their opponents, setting the stage for the audiovisual discourses. Donald Trump was the focal character of these channels and was most frequently mentioned in the videos. Nevertheless, the embedded text contained additional information about the opinions of the partisans, and often mentioned other political candidates, expressing support for them or criticizing them. Furthermore, the text also included issues of interest to the partisan users, such as Donald Trump's impeachment, abortion rights, healthcare, and the second amendment. These results illustrate that partisans used audio, video, captions, and user descriptions in different ways, creating a complex multichannel information flow in their political interactions. bernie2020 #dumptrump #impeachtrump #voteblue #impeach #warren2020 #dumptrump2020 #bluewave #lgbt #voteblue2020 #democrat #liberal #politics #greenscreen #impeachment #democrats #impeach45 #republicans #socialism #bernie #duet #fyp #foryou #foryoupage #trump #viral #liberals #xyzbca #2020 #trending #trump2020 #republican #maga #conservative #donaldtrump #usa #foryourpage #4u #facts #foru #kag #trumptrain #america #prolife #blexit #maketheswitch #openyoureyes #snowflakes #blackconservative #2a Our final analysis assessed the extent of political content on TikTok in comparison to non-political content. TikTok's search tool reports the number of total user views for videos that include a particular hashtag. This allowed us to compare between political and non-political hashtags. Thus, we searched for a selected number of hashtags on February 1, 2020. Table 4 shows hashtags of several political actors, including their names and their names plus 2020. We also include three popular personalities and the most popular hashtags on TikTok, #foryou and #foryoupage, for comparison. Among the political hashtags, #Trump2020 leads by a substantial margin, with a total of 1.1 billion views. The political hashtag that comes second with 166.3 million views is #Bernie2020. Interestingly, the hashtags with the names of the candidate and 2020 have more views than hashtags that included only the candidate's name. The large difference between #Trump2020 and the rest of the Democratic candidates corroborates our finding pertaining to the greater number of pro-Republican videos seen in our data and evidences the absence of a possible sample bias effect in the collection procedure. Apart from politics, hashtags referring to singers Billie Eilish and Shawn Mendes have total views comparable to Trump-related videos, whereas Greta Thunberg videos have the number of views in the same order of magnitude as the videos related the Democratic candidates. The most famous hashtag on TikTok has 1,687 more views than #Trump2020. As a rough cross-platform comparison, we include the number of Instagram posts for the same hashtags in Table 4. Instagram's search tool displays the number of posts for a hashtag but not the number of views. The number of posts cannot be compared to the number of views as they represent two different quantities. The proportions on Instagram between politicians and popular personalities are similar to the proportion in views on TikTok. However, there are more videos with only the politicians' names than hashtags including 2020. This result could signify that there is more content focused on the 2020 US presidential campaign on TikTok than on Instagram. In sum, we conclude that not only does US political content takes place on TikTok, but it also accounts for a large ecosystem on the platform. --- DISCUSSION The results of this study demonstrate that a new form of political communication takes place on TikTok. Communication still preserves its decentralized character as on other social media platforms, with users generating, sharing, and diffusing information. However, TikTok users do not just merely circulate content and comment it; they become the content. In contrast to Facebook and Twitter, where users exchange news articles in the form of URLs and articulate their political opinions through comments or feedback posts, Tik-Tok users become active presenters of political information. Every TikTok user is a performer who externalizes personal political opinion via an audiovisual act, with political communication becoming a far more interactive experience than on YouTube or Instagram. Since every user seeks increased popularity to disseminate their messages more widely, they create short political spectacles resulting in the realization of politics as entertainment. Unlike television media where news anchors and political pundits are the showmen and women, everybody on TikTok is one. It is not a coincidence, therefore, that this intensive audiovisual universe attracts young users who actually "play" their politics on the platform. The duet function is one of the main reasons why political communication is so interactive on TikTok. Users can employ a variety of elements to respond to videos posted by other members. These features range from simple facial reactions to text snippets that serve as fact-checking points. Some users even overwrite the original video's text to "correct" the other user's stance on a topic and showcase opposing arguments. Moreover, the audience interacting with duet videos can directly compare the different points of view. This duet structure contrasts with other social media platforms where public exchanges take the form of written responses that appear as a list under the original post. Duets also allow users to exhibit their creativity, in showing support or making counterarguments. For these reasons, we argue that duets are the closest feature on social media to an actual online public debate. Given that TikTok's design introduces a novel way of conducting politics, it is reasonable to ask how this framework can transform other aspects of political communication. In this study, we illustrated how political partisans generate content and interact on TikTok. However, multiple other dimensions of political communication should also be investigated. For example, although news media URLs are not diffused as in other social platforms, many news media agencies already have TikTok profiles to broadcast reports to the public. The same applies to a handful of political candidates who use TikTok as a new medium of reaching the electorate. Recently, TikTok followed Twitter's suit and banned the placement of political advertisements on the platform [14]. These phenomena and decisions interfere directly with political campaigning and opinion formation; therefore, researchers should investigate these actions more comprehensively in the future. This also applies to researchers who plan to study the general user behavior on the platform. Scholars should seek to uncover whether the platform design and the deployed recommendation algorithms result in the polarization or segregation of social groups, and whether hyperactive user behavior has an agenda-setting effect on the platform. Although TikTok primarily involves real users who reveal themselves in front of the camera, it is equally important to study whether and how any misinformation attempts take place, as well as how users present controversial issues on the platform. Researchers should undertake the task of determining whether offensive and discriminatory content prevails on the platform. Besides the aspect of political communication, further political issues regarding user privacy and security should be addressed. Given TikTok's open nature, such concerns for the users have already been raised [7] but require more in-depth evaluation. Although users can create private videos visible only to their friends, the platform is mainly geared toward the production of viral videos. This means that data is easily reachable for data mining processes. Indeed, TikTok is a rich information source because its content reveals the personal features of users through the immediacy of audiovisual media to their appearances, personalities, traits, vocal attributes, and points of views. Moreover, users creating and interacting with political content can be classified by their partisanship as we did in this study. With the manually classified videos, a machine learning algorithm may be trained to identify political content and to automatically assign partisanship to a TikTok user. This information can then be employed for political or advertising purposes as it is already prevalent on other platforms like Facebook [35]. However, the potential risks are higher on TikTok because advances in facial recognition technologies make it possible to identify individual users and match them with citizenship records. Although this scenario is also possible on other platforms, active TikTok users are open to publicly share their biometric data. There is a greater danger, therefore, for TikTok users to become incorporated in electoral or other databases that can be exploited for varied purposes. Political campaigns and third parties may be eager to collect data on young people as many of them are first-time voters or are still not old enough to vote. As such, they are in the process of creating their political identity and the information they perceive on social media platforms can permeate their eventual ideology. TikTok can potentially redefine political communication as a new public arena for civic discourse. While other social media platforms are highly dependent on the friend structure and can thus foster echo-chambers [11,18], TikTok's open structure may allow a more cross-partisan dialogue. Whether this assumption holds can only be answered through future research. Even if the hypothesis is proven true, the caveat that political confrontation can be counterproductive exists, and maybe especially applicable to a platform that is highly focused on the virality and humor of its content. Videos with sarcastic and ridiculing content can exacerbate bullying and other harmful behaviors that particularly afflict teenagers [1]. The research community should conduct further analyses that include psychological examinations of the influence exercised by the platform on the youth. --- Ethical Concerns While conducting this study, we encountered serious ethical questions that must be taken into consideration. First, we crawled Tik-Tok and explicitly collected public data, a portion of which concerned the behavior of young users. Given their age, young users may not be yet be fully aware of the consequences of putting themselves in the public sphere. To maintain data protection, we deleted the collected materials after the analyses. However, we preserved the video ids to allow the replication of this study. These ids can be found in our GitHub repository 4 . We encountered further ethical issues during the use of the Microsoft Azure image recognition APIs for the detection of age and gender. First, researchers have shown that such algorithms can potentially misclassify minorities and social groups [13]. Second, the algorithms for gender classification only provide binary male/female inferences and automatically neglect the existence of other genders. These issues should be kept in mind when this study is read and addressed in the future to promote ethical and inclusive research. --- CONCLUSION In this paper, we studied political communication on TikTok for the first time. We focused on videos related to US politics and evaluated textual, aural and visual information extracted from them. We analyzed the different levels of communication made possible by the platform design and especially concentrated on TikTok's unique duet feature. We then investigated the duet interactions from pro-Republican and pro-Democrat users. In our sample, we find a larger collection of Republican videos, which, on average, attracted more interactions than Democratic videos. Although we find that Democratic users are younger than Republican users, the majority of the users in our data are below 40 years old. We observed that Republican users generated duet videos from users who professed the same ideology more often, whereas Democratic users interacted more with cross-ideological users. Irrespective of their political preferences, however, partisan users expressed themselves in similar ways. Finally, we identified that political content appears to be a relevant aspect of TikTok's ecosystem. Further research is needed to understand how political content is disseminated on this novel social media platform. It would be especially beneficial if prospective studies examined the platform's design and its recommendation system because they are pivotal to the creation of user communities and the shaping of political interactions. Only through rigorous auditing can it be ensured that TikTok represents an open and unbiased arena for political communication.

TikTok is a video-sharing social networking service, whose popularity is increasing rapidly. It was the world's second-most downloaded app in 2019. Although the platform is known for having users posting videos of themselves dancing, lip-syncing, or showcasing other talents, user-videos expressing political views have seen a recent spurt. This study aims to perform a primary evaluation of political communication on TikTok. We collect a set of US partisan Republican and Democratic videos to investigate how users communicated with each other about political issues. With the help of computer vision, natural language processing, and statistical tools, we illustrate that political communication on TikTok is much more interactive in comparison to other social media platforms, with users combining multiple information channels to spread their messages. We show that political communication takes place in the form of communication trees since users generate branches of responses to existing content. In terms of user demographics, we find that users belonging to both the US parties are young and behave similarly on the platform. However, Republican users generated more political content and their videos received more responses; on the other hand, Democratic users engaged significantly more in cross-partisan discussions.

socialization politics largely takes place on them political candidates often exploit such media to interact with the electorate and to place targeted and personalized advertising at the same time partisan users utilize their social media accounts to engage in political discourse similarly a large portion of society obtains its political news updates from social media sources two factors shape the final forms taken by political communication on social media how a platform is designed and who uses this space for political purposes the design of a social media service configures the available information channels for political discourse its userbase shapes both the generated political content and dictates whether or not a platform can prevail as a significant political space until now researchers have considered facebook twitter and youtube as the most politically relevant social media 48 given the vast number of users who engage daily with these platforms nevertheless social media usage is dynamic users change or migrate from one service to another and some platforms are abandoned as others become popular 31 tiktok a videosharing social networking service has recently witnessed a surge in its popularity it became the worlds second most downloaded app in 2019 53 motivation although researchers have extensively analyzed other popular social media platforms both by explaining user political behavior and uncovering how platform design influences political communication no study has focused on tiktok the present study therefore aims to bridge this research gap intending specifically to understand who uses tiktok for political purposes and how the design of this platform shapes the flow of political information for this we focus on us politics to answer the following research question rq what are the features of political communication on tiktok in terms of partisan users interaction structure and diffused content original contributions • we provide a first overview of political communication on tiktok by investigating videos of us republican and democratic partisans • we employ computer vision natural language processing and statistical tools to evaluate the ways in which partisans combine sound video and text to spread their messages • we study tiktoks interaction design and illustrate how partisans engage in political discussions we show that tiktok fosters a novel type of political interactivity that is not available on other online social networks • we investigate user demographics and show that the partisan users are young and behave similarly regardless of their political preferences we find that republican users are more active in creating political content and that they receive more responses we further find that republicans prefer to engage in video discussions with other republicans while democrats are more open to reach out to users with opposing views • finally we discuss other issues related to political communication privacy and security on tiktok background related work 21 political communication on social media the behavior of multiple actors determines the political communication that occurs on social media platforms politicians partisans and the general public interact constantly generating complex communication patterns the design and algorithms of the platforms influence these interactions along with malicious actors to generate a political landscape that can be difficult to understand researchers have therefore extensively analyzed various properties of facebook twitter youtube and other similar social media spaces to grasp the nature of politics on social media several studies have investigated how politicians use social media for political purposes they have shown that politicians use platforms in different ways depending on the audiences and sociotechnical environments 21434647 they have also explained how services are used for personalized advertising campaigns 39 and whether the presence of politicians on these platforms affects their electoral popularity 19 other studies have explicitly focused on user political behavior they have investigated how partisans of different political orientations use social media platforms 1044 analyzed how user activities are generally distributed 40 and evaluated the spread messages content and polarity 15363845 studies have also focused on the usage of social media in periods of social unrest 50 analyzed online social platforms as spaces for the coordination of social movements 49 investigated how different social groups behave and scrutinized the conditions in which they help to polarize and segregate the citizenry 4616 inseparable to political communication on social media is news consumption with a large proportion of the public using the social media services as their primary information source pertaining to world events many studies have investigated agenda settings effects as well as how different types of news coverage affect user behavior and contribute to attitude formation 92329 moreover researchers have also extensively studied how low credibility news and misinformation are diffused on social media platforms by real fake or automated accounts 31722272851 an equally important role in understanding user behavior is the analysis of the content filtering algorithms employed by social media services thus researchers have investigated social platforms as algorithmic ecosystems and have studied whether and how recommendation algorithms influence the publics political behavior and opinions 532374041 in the same vein scholars have evaluated platform design features and how they shape information diffusion 213347 these dimensions of political communication have been extensively analyzed for the us on different social media platforms 22025263052 but not yet on tiktok tiktok tiktok was created by bytedance a beijingbased tech company the company had previously launched douyin for the chinese market in september 2016 subsequently the company launched tiktok in 2017 for markets outside china both services are similar but they run on separate servers to comply with chinas regulations in 2018 tiktok merged with the social media app musically to create a larger video community in october 2019 tiktok and douyin jointly achieved 800 million monthly active users 34 in the united states 60 of tiktoks 265 million monthly active users are aged between 16 and 24 24 the platform is mainly accessible through a mobile app although it is possible to access posted videos from nonmobile devices the features are limited as it is not possible to create content or read user comments tiktok offers users a unique method of sharing creative videos of themselves their surroundings or a compilation of external audiovisual content the simplest videos consist only of text superimposed onto a colored background videos can then be more complex by including images video clips and sounds the images and video footage can be altered using the apps voice effects image filters and video speed controllers the maximum length of a video post is 60 seconds and they can consist of a collection of shorter video clips that tell a story when they are combined when the users post videos they can add a caption with hashtags to describe their clips like twitter the most used hashtags represent topics that are trending on the platform and like instagram the video clips are classified according to their hashtags tiktok is considered a social media platform because like twitter and instagram its users have a social group of followers and other users they follow however the main feature that differentiates tiktok from other social media services is the videos background music which represent the core message that the users want to convey users can select background music for their videos from a wide variety of music genres and can even create original sound clips any sound clip including user voice messages can be selected by other users to use in their videos for many videos the music serves as part of a dance routine a lipsynching battle or as the backdrop for a comedy skit however sound can also function as a story builder and can be used to deliver a specific message for example a famous original sound clip begins with la rouxs song bulletproof remixed by gamper dadoni then the music stops four gunshots are heard and a mans voice says theres not any text messages appear in the part of the clip that plays the song citing reasons why a particular cause should be supported and the user points at the messages when the gunshots begin however the user makes a gun sign with a hand and shoots at the text snippets containing the reasons for support the user is implying that the citing reasons are invalid and that there is no real reason for people to support that cause users consume content by viewing an algorithmically generated feed of videos on the socalled for you page which is the landing place when users open the app although there is no explanation of how the algorithm work the videos that appear to the user largely rely on a central recommendation algorithm instead of on the activities of the users social network 12 according to tiktok the for you page is a personalized video feed specifically for you based on what you watch like and share 1 this contrasts with facebooks and twitters feed which rely mostly on the users social graph and resemble more youtubes recommendation system users can also search for hashtags sounds and find the trending videos on the discover page a unique feature on tiktok is the duet a duet is a response video that allows users to reply directly to a video post with a video of their own the original and duet videos play side by side and the music clip from the original videos audio is preserved since the audio does not change the duet exhibits users responding through text snippets images or facial expressions users can also create a reply duet from an existing duet in such instances three videos appear together figure 1 shows a screenshot of a duet on tiktok the original video is placed on the right and the duet video on the left the screenshot displays the number of likes comments and shares the duet video attracts the music that appears on the bottom is a music clip from a remixed song in the image both users point to a text snippet and communicate their perspectives as they dance to the same music in this way tiktok can be used to share opinions on controversial topics in this study we focus on political content to determine how tiktok users interact and show their support for a political party with the help of music video and image figure 1 screenshot of a duet on tiktok on the right is the original video and on the left the video posted in response 1 data methods 31 data collection tiktok allows users to search for videos with a specific hashtag and view the most popular results we decided to crawl the videos containing the hashtags republican and democrat on february 1 2020 the hashtag search yields a limited number of videos and it is not clear how this limit is defined popularity may play a role as a hashtag search showcases the most popular videos for the two hashtag queries we obtained a different number of videos the collection process resulted in 3310 videos 2362 with the hashtag republican and 1831 with the hashtag democrat of the total 350 were duets thus we also collected the original videos from them if they were not yet in the data to expand the dataset we searched for duets to the videos we had collected unfortunately tiktok does not offer a search by video feature that directly links a video to its duets however it is possible to search by sound clip this search shows videos that have employed the same sound our approach was to search for the sound of each video and to add the videos that were dueting to the videos in our dataset as with search by hashtag only a limited number of results can be obtained this presents a limitation to collecting all the duets to a video especially for videos that use extremely popular sounds nonetheless searching for original sounds often yielded only the duets of the given video after this procedure was complete our dataset consisted of 7825 tiktok videos most of the videos were created between october 2019 and february 2020 the oldest included video was posted in march 2019 before beginning the analysis we manually labeled every original video and duet as prorepublican prodemocrat or nonpartisan this coding was conducted by two of the main authors both authors labeled each video individually for the cases where authors disagreed the third author was consulted to resolve the coding conflict videos that directly supported or opposed a political party or a member of a party were classified accordingly we labeled videos opposing one democratic candidate but expressing support for another candidate of the same party as prodemocrat videos in which users articulated their standpoints on issues such as abortion guns and lgbt rights were not directly attributed to any political party we only classified those videos that indicated a clear political affinity toward the republican or democratic parties as partisan for example social issue videos with both the republican and democrat hashtags were coded as nonpartisan in total we classified 5946 videos as partisan posts apart from assigning partisanship we grouped the partisan videos into four categories 1 videos that included the users face 2 videos where the user appears but does not show its face or videos culled from other sources such as news clips 3 videos solely comprised of images and 4 videos that only showcased textual content we used the same coding procedure as the classification of partisan videos it was important for us to view all the videos to be able to understand tiktoks communication structures and the user behavior displayed on the platform methods tiktok videos are rich in features and extra preprocessing steps were required to extract the information for analysis from the original videos we started by extracting the text snippets from the videos for this we divided the videos into images every two seconds and then employed tesseract an optical character recognition engine from the original videos that included the users face we used the images and processed them via microsofts azure face api 2 which allows emotions gender and age to be extracted additionally we employed ibms text to speech api 3 to extract the audio from the videos that contained original sounds created by the users to explore the difference in the usage of hashtags we employed a measure of political valence introduced by conover et al 16 they defined political valence v of a hashtag h as v 2 n n n n n n 1 where n and n indicate the number of appearances of a hashtag and n and n represent the total number of hashtags in the democratic and republican videos respectively this equation bounds the valence between 1 for hashtags only used in democratic videos and 1 for hashtags appearing only in republican videos we created a graph of interactions where the users are the nodes and the directed edges represent duet interactions this graph allows to measure the extent of crossideological and intraparty interactions we used another measure from conover et al which divides the observed number of interactions with the expected number of interactions the expected value assumes that the source of the edge is preserved and the target of the edge is randomly assigned to one user irrespective of the individuals political orientation for example the expected interactions between republicans and democrats is defined as e r → d k r u sers d u sers d u sers r where k r refers to the number of edges originating from prorepublican videos and u sers d denotes the number of democratic users finally we applied topic modeling to evaluate the content of video captions we used a latent dirichlet allocation algorithm 8 to extract the latent thematic topics and to calculate the empirical distribution of videos belonging to the identified topics f using this distribution we computed and compared the amount of democratic and republican videos associated with each topic in order to calibrate the number of topics and the latter model hyperparameters we perform sensitivity analysis for various values and select the model with the highest topic coherence score as suggested by röder et al 42 results we illustrate different features of political communication on tiktok in the following three subsections first we describe the general statistics of the collected dataset including user demographics and activities second we describe and evaluate political interactions between partisan users finally we analyze the content 2 3 of different information channels used in tiktok videos to detail the nature of the political discourse descriptive statistics of the 5946 partisan videos 2802 are original videos and 3144 are duets table 1 shows the total number of videos classified as prodemocrat or prorepublican and the extent of the interactions generated by these videos in our dataset there are two times more republican videos than democratic videos overall the republican videos accumulate more likes shares and comments we applied onesided mannwhitney tests for each reaction to compare if there is a significant difference between the partisan videos for likes the republican median is 497 and the democratic median is 232 in terms of shares the republican median is 6 and the democratic median is 3 with regard to the comments the republican median is 19 and the democratic median is 13 all the tests are significant and show that republican videos attracted more interactions in general of the original videos 70 included the users face 22 featured other video content 7 comprised only image content and 1 only exhibited text we performed feature extraction for the original videos that included the users face to this end we divided the videos into pictures and obtained the features for each picture with microsofts api we were able to extract gender age and emotions which include anger contempt fear happiness sadness and surprise afterward we averaged the emotions and ages of all the pictures to obtain the mean values for each video we used the mode for gender given that it is a categorical feature for age and gender we aggregated the videos per user to obtain unique values we manually categorized the users for which the mode of the gender was inconclusive from the original republican videos 219 users are male and 187 are female whereas for the democratic videos 84 users are male and 118 are female we perform goodness of fit chisquared tests to evaluate the malefemale user balance for the overall population gender is balanced the same applies for the republican partisans however a significantly larger number of democratic partisans posting original videos are female figure 2 portrays the cumulative age distribution of democratic and republican users we observe that in general the democratic users are younger than republican supporters the percentage of republicans between 16 and 24 years old is close to 60 which mirrors the percentage of us tiktok users in the same demographic group for the democratic users however this percentage is closer to 70 younger than the mean user age nevertheless the majority of users creating political content are below 40 for both parties in our data sample 2 illustrates the average emotion expressed for the posted videos per party we do not observe significant differences between the two groups we conclude that users on tiktok express themselves similarly irrespective of the party they support interestingly happiness and surprise have higher averages than anger or sadness we presume that this finding is related to the nature of tiktok comedy skits indeed we observed many videos that relied heavily on sarcasm smiling and dancing individuals confronting users supporting the views of the opposite political party and mocking or belittling them interaction structure political communication on social media is influenced directly by the design of the platform by determining the interaction structure between users the interactions can be ordered in consecutive levels of communication with each increasing level representing a more direct response we identify four levels of communication on tiktok the first level corresponds to an indirect response when a user views a video although there is no active reaction from the user the message is received and processed additionally from the data perspective the view counter on the video increases and this metric can influence tiktoks recommendation algorithm the second level of communication consists of a basic response that involves liking the video or sharing it the next level constitutes written responses to a video through user comments on other social media platforms this is the highest level of user response to a posted element on tiktok however a fourth level of communication allows users to respond with a video a feature referred to as duet the duet shows more similarities to facetoface communication than to a written response which can make the interaction between users feel more personal the structure of duets directly affects how political communication takes place on tiktok the duets follow a tree structure where users create branches by responding to other videos we depict this tree structure of communication in figure 3 on top of the tree there is a political issue which partisan users use as their motive for the production of prodemocrat or prorepublican videos connected on the second depth level are the original content videos the third depth level represents the duets to the original videos the next level nodes on the tree denote duets posted in response to previous duets it is possible to continue to react with duets further than the three duet depth levels displayed in figure 3 inner nodes on the duet nodes have been included in the illustration to represent that duets previous duets and original videos appear side by side on tiktok a user interacting with a deep level duet video can directly observe the complete communication chain onscreen without needing to scroll down this differentiates duets from any feature available on other social media networks using the manually labeled videos we were able to quantify the duet interactions between partisan users table 3 shows the percentage of partisan and crossideological interactions it also includes the observed interactions divided by the expected interactions as presented in formula 2 we observe that 77 of the republican duets represent responses to republican users in contrast more than 80 of the democratic duets were directed toward republican supporters this inverted dynamic also appears in the ratio between observed and expected interactions democratrepublican and republicanrepublican interactions present a ratio larger than one we include the ratio as it is a standardized measure that can be used to compare to the outcomes of other studies for example conover et al 16 evaluated political communication in the us on twitter and found that retweets had higher ratios than one for intrapartisan interactions and lower ratios than one for crosspartisan interactions mentions displayed a similar but less pronounced effect for both parties therefore the authors found that user behavior with regard to twitter mentions and retweets was unrelated to the political party in contrast we find that tiktok duets represent a partyspecific structure this difference shows the importance of studying the effects of different platform designs on the political communication that occurs between users we portray the duet interaction between users in figure 4 each node represents a user and the edges represent two users of a duet blue nodes indicate democrats and red nodes designate republicans we only find one account that posted both prodemocrat and prorepublican videos and this account was omitted from the analysis the graph shows a tight republican cluster in the middle with some democratic users interacting with this community the boundaries evince large clusters of democratic users responding to republican accounts these users are separated from the main cluster because they did not interact with accounts other than a specific republican user the graph confirms the result of high partisan interactions among republicans and the high crossideological interactions from democrats to republicans content analysis the content analysis of the various information channels on tiktok provided important insights on how political communication takes place on the platform each information channel was used differently by partisans partisan users generally avoided political statements in their profile descriptions except for some users whose username explicitly stated their political affiliations most users added links to their social media handles on other platforms such as twitter or instagram and some provided their venmo accounts for fans to support them financially in contrast to the profile descriptions video captions were extremely politicized users usually inserted as many political hashtags as possible from across the political spectrum to ensure the visibility of their content their hashtag selections were also influenced by partisanship users inserted specific hashtags more often in accordance with their political orientation to reveal this we divided the valency spectrum in five equidistant groups and grouped the hashtags according to valences figure 6 presents the top ten words per group democratic partisans more frequently used hashtags related to the impeachment of donald trump bernie sanders elizabeth warren and lgbt issues republican partisans more often used hashtags related to trumps campaign slogans and phrases used by the altright to assign credibility to information such as facts maketheswitch and openyoureyes regardless of partisanship users added to their videos platformspecific hashtags such as foryou foryourpage and xyzbca these hashtags are irrelevant to the political discussions but constitute a cardinal aspect of tiktok interactions the topic modeling algorithm provided more detailed information about partisan interests for the specific period on tiktok the model optimization process for the video captions yielded ten topics on which both republican and democrats generated content figure 5 shows that although some topics were more prevalent in posts by democrats or by republicans both groups engaged in the same discussions the topics that were discussed more or less equally by both sides related to social issues such as religion and abortion guns and the second amendment as well as discussions associated with daily political developments democrats generated content related to their party about trumps impeachment trial as well as social diversity in comparison republicans created more the analysis of audio and the text embedded in the videos evidenced particular ways in which these communication channels were used both republican and democratic partisans used sound and embedded text to call out their opponents setting the stage for the audiovisual discourses donald trump was the focal character of these channels and was most frequently mentioned in the videos nevertheless the embedded text contained additional information about the opinions of the partisans and often mentioned other political candidates expressing support for them or criticizing them furthermore the text also included issues of interest to the partisan users such as donald trumps impeachment abortion rights healthcare and the second amendment these results illustrate that partisans used audio video captions and user descriptions in different ways creating a complex multichannel information flow in their political interactions bernie2020 dumptrump impeachtrump voteblue impeach warren2020 dumptrump2020 bluewave lgbt voteblue2020 democrat liberal politics greenscreen impeachment democrats impeach45 republicans socialism bernie duet fyp foryou foryoupage trump viral liberals xyzbca 2020 trending trump2020 republican maga conservative donaldtrump usa foryourpage 4u facts foru kag trumptrain america prolife blexit maketheswitch openyoureyes snowflakes blackconservative 2a our final analysis assessed the extent of political content on tiktok in comparison to nonpolitical content tiktoks search tool reports the number of total user views for videos that include a particular hashtag this allowed us to compare between political and nonpolitical hashtags thus we searched for a selected number of hashtags on february 1 2020 table 4 shows hashtags of several political actors including their names and their names plus 2020 we also include three popular personalities and the most popular hashtags on tiktok foryou and foryoupage for comparison among the political hashtags trump2020 leads by a substantial margin with a total of 11 billion views the political hashtag that comes second with 1663 million views is bernie2020 interestingly the hashtags with the names of the candidate and 2020 have more views than hashtags that included only the candidates name the large difference between trump2020 and the rest of the democratic candidates corroborates our finding pertaining to the greater number of prorepublican videos seen in our data and evidences the absence of a possible sample bias effect in the collection procedure apart from politics hashtags referring to singers billie eilish and shawn mendes have total views comparable to trumprelated videos whereas greta thunberg videos have the number of views in the same order of magnitude as the videos related the democratic candidates the most famous hashtag on tiktok has 1687 more views than trump2020 as a rough crossplatform comparison we include the number of instagram posts for the same hashtags in table 4 instagrams search tool displays the number of posts for a hashtag but not the number of views the number of posts cannot be compared to the number of views as they represent two different quantities the proportions on instagram between politicians and popular personalities are similar to the proportion in views on tiktok however there are more videos with only the politicians names than hashtags including 2020 this result could signify that there is more content focused on the 2020 us presidential campaign on tiktok than on instagram in sum we conclude that not only does us political content takes place on tiktok but it also accounts for a large ecosystem on the platform discussion the results of this study demonstrate that a new form of political communication takes place on tiktok communication still preserves its decentralized character as on other social media platforms with users generating sharing and diffusing information however tiktok users do not just merely circulate content and comment it they become the content in contrast to facebook and twitter where users exchange news articles in the form of urls and articulate their political opinions through comments or feedback posts tiktok users become active presenters of political information every tiktok user is a performer who externalizes personal political opinion via an audiovisual act with political communication becoming a far more interactive experience than on youtube or instagram since every user seeks increased popularity to disseminate their messages more widely they create short political spectacles resulting in the realization of politics as entertainment unlike television media where news anchors and political pundits are the showmen and women everybody on tiktok is one it is not a coincidence therefore that this intensive audiovisual universe attracts young users who actually play their politics on the platform the duet function is one of the main reasons why political communication is so interactive on tiktok users can employ a variety of elements to respond to videos posted by other members these features range from simple facial reactions to text snippets that serve as factchecking points some users even overwrite the original videos text to correct the other users stance on a topic and showcase opposing arguments moreover the audience interacting with duet videos can directly compare the different points of view this duet structure contrasts with other social media platforms where public exchanges take the form of written responses that appear as a list under the original post duets also allow users to exhibit their creativity in showing support or making counterarguments for these reasons we argue that duets are the closest feature on social media to an actual online public debate given that tiktoks design introduces a novel way of conducting politics it is reasonable to ask how this framework can transform other aspects of political communication in this study we illustrated how political partisans generate content and interact on tiktok however multiple other dimensions of political communication should also be investigated for example although news media urls are not diffused as in other social platforms many news media agencies already have tiktok profiles to broadcast reports to the public the same applies to a handful of political candidates who use tiktok as a new medium of reaching the electorate recently tiktok followed twitters suit and banned the placement of political advertisements on the platform 14 these phenomena and decisions interfere directly with political campaigning and opinion formation therefore researchers should investigate these actions more comprehensively in the future this also applies to researchers who plan to study the general user behavior on the platform scholars should seek to uncover whether the platform design and the deployed recommendation algorithms result in the polarization or segregation of social groups and whether hyperactive user behavior has an agendasetting effect on the platform although tiktok primarily involves real users who reveal themselves in front of the camera it is equally important to study whether and how any misinformation attempts take place as well as how users present controversial issues on the platform researchers should undertake the task of determining whether offensive and discriminatory content prevails on the platform besides the aspect of political communication further political issues regarding user privacy and security should be addressed given tiktoks open nature such concerns for the users have already been raised 7 but require more indepth evaluation although users can create private videos visible only to their friends the platform is mainly geared toward the production of viral videos this means that data is easily reachable for data mining processes indeed tiktok is a rich information source because its content reveals the personal features of users through the immediacy of audiovisual media to their appearances personalities traits vocal attributes and points of views moreover users creating and interacting with political content can be classified by their partisanship as we did in this study with the manually classified videos a machine learning algorithm may be trained to identify political content and to automatically assign partisanship to a tiktok user this information can then be employed for political or advertising purposes as it is already prevalent on other platforms like facebook 35 however the potential risks are higher on tiktok because advances in facial recognition technologies make it possible to identify individual users and match them with citizenship records although this scenario is also possible on other platforms active tiktok users are open to publicly share their biometric data there is a greater danger therefore for tiktok users to become incorporated in electoral or other databases that can be exploited for varied purposes political campaigns and third parties may be eager to collect data on young people as many of them are firsttime voters or are still not old enough to vote as such they are in the process of creating their political identity and the information they perceive on social media platforms can permeate their eventual ideology tiktok can potentially redefine political communication as a new public arena for civic discourse while other social media platforms are highly dependent on the friend structure and can thus foster echochambers 1118 tiktoks open structure may allow a more crosspartisan dialogue whether this assumption holds can only be answered through future research even if the hypothesis is proven true the caveat that political confrontation can be counterproductive exists and maybe especially applicable to a platform that is highly focused on the virality and humor of its content videos with sarcastic and ridiculing content can exacerbate bullying and other harmful behaviors that particularly afflict teenagers 1 the research community should conduct further analyses that include psychological examinations of the influence exercised by the platform on the youth ethical concerns while conducting this study we encountered serious ethical questions that must be taken into consideration first we crawled tiktok and explicitly collected public data a portion of which concerned the behavior of young users given their age young users may not be yet be fully aware of the consequences of putting themselves in the public sphere to maintain data protection we deleted the collected materials after the analyses however we preserved the video ids to allow the replication of this study these ids can be found in our github repository 4 we encountered further ethical issues during the use of the microsoft azure image recognition apis for the detection of age and gender first researchers have shown that such algorithms can potentially misclassify minorities and social groups 13 second the algorithms for gender classification only provide binary malefemale inferences and automatically neglect the existence of other genders these issues should be kept in mind when this study is read and addressed in the future to promote ethical and inclusive research conclusion in this paper we studied political communication on tiktok for the first time we focused on videos related to us politics and evaluated textual aural and visual information extracted from them we analyzed the different levels of communication made possible by the platform design and especially concentrated on tiktoks unique duet feature we then investigated the duet interactions from prorepublican and prodemocrat users in our sample we find a larger collection of republican videos which on average attracted more interactions than democratic videos although we find that democratic users are younger than republican users the majority of the users in our data are below 40 years old we observed that republican users generated duet videos from users who professed the same ideology more often whereas democratic users interacted more with crossideological users irrespective of their political preferences however partisan users expressed themselves in similar ways finally we identified that political content appears to be a relevant aspect of tiktoks ecosystem further research is needed to understand how political content is disseminated on this novel social media platform it would be especially beneficial if prospective studies examined the platforms design and its recommendation system because they are pivotal to the creation of user communities and the shaping of political interactions only through rigorous auditing can it be ensured that tiktok represents an open and unbiased arena for political communication

tiktok is a videosharing social networking service whose popularity is increasing rapidly it was the worlds secondmost downloaded app in 2019 although the platform is known for having users posting videos of themselves dancing lipsyncing or showcasing other talents uservideos expressing political views have seen a recent spurt this study aims to perform a primary evaluation of political communication on tiktok we collect a set of us partisan republican and democratic videos to investigate how users communicated with each other about political issues with the help of computer vision natural language processing and statistical tools we illustrate that political communication on tiktok is much more interactive in comparison to other social media platforms with users combining multiple information channels to spread their messages we show that political communication takes place in the form of communication trees since users generate branches of responses to existing content in terms of user demographics we find that users belonging to both the us parties are young and behave similarly on the platform however republican users generated more political content and their videos received more responses on the other hand democratic users engaged significantly more in crosspartisan discussions

Introduction and background Transgender persons are those persons whose experience of their gender is incongruent with the sex they were assigned to at birth . The Census survey of 2011, which for the first time estimated the number of transgender persons in India, reports a total of 487,803 persons who identify as transgender . This may be an underreport as many transgender persons might have not shared their transgender identity or might have been counted in their transitioned identity as male or female. India, along with other countries in South Asia, has a unique history of people of transgender identity living together in ethno-cultural kinship communities known in various names specific to different regions. This includes the Hijra and Kinnar communities. In India, transgender persons are among the most vulnerable population groups . This is because of widespread marginalisation of the community which has resulted in lower levels of education, income, employment, and health status due to experiences of stigma, discrimination and violence . Many transgender persons in urban ethno-cultural communities are involved in begging, sex work and traditional blessing for their livelihood . Transgender persons face higher rates of mental health problems such as substance use and mental health disorders including mood disorders, eating disorders, suicide ideation and behaviours . Controlled studies from the US show that transgender persons have a two-to-three-fold higher risk of depression, anxiety and suicidal ideation and attempts as compared to cisgender persons . This higher rate of mental health problems in transgender persons needs to be viewed in the backdrop of unique social determinants of mental health among transgender persons which is best conceptualized by the Minority Stress Model . The model posits that people belonging to minority communities face negative stressors to mental health because of stigma, prejudice and discrimination. Studies that utilize this model find that stigma, discrimination, abuse, social isolation affect mental health of transgender persons negatively and social support, peer support, parental support and gender affirming care are beneficial . However, despite this higher burden of mental health problems in transgender persons, they face challenges in accessing mental healthcare and healthcare in general. Challenges before, or in, reaching the health facility include low health literacy, social exclusion, financial constraints and lower education . Challenges within the health facility include discrimination, misgendering, fear of being pathologized or stereotyped, insensitivity, lack of privacy and confidentiality, trans-negative mental health professionals, and verbal and physical abuse . Experiences with trans-negative health providers, in particular, have a negative impact on the mental health of transgender persons . --- The COVID-19 pandemic in India The COVID-19 pandemic started in India in early 2020 and in response the government initiated a nationwide lockdown overnight in March 2020 . Transgender persons have been particularly affected during the COVID-19 pandemic and its associated government responses in India, such as lockdowns, isolation and mandatory quarantine as they face an increased risk of COVID-19 due to poor housing, overcrowding, lower levels of immunity due to Hormone Replacement Therapy , Non-Communicable Diseases and substance use, poorer access to vaccination services and increased risk of HIV . In addition to this, the strict lockdown measures imposed in India had a particular risk to transgender persons as a large number of transgender persons are engaged in informal employment including begging, sex work and traditional blessing, all of which were difficult to pursue during the lockdown . The pandemic has impacted mental health across low-and middle-income countries . In terms of its impact on the transgender community, studies from the US show that it has adversely impacted the mental health of transgender persons more than that of cisgender persons and transgender persons had a relatively higher unmet need of mental health care during the pandemic . The increased risk of COVID-19, challenges with livelihood combined with uncertainty and anxiety around the pandemic over existing social discrimination and exclusion of transgender persons pose increased risk of mental distress and mental health problems . However, there is scarce data on the impact of the pandemic on the mental health of transgender persons in the Indian setting, especially covering diverse populations within the transgender community. The TransCare COVID-19 project fills this gap as it was a qualitative study focused on India and inclusive of diverse identities including transfeminine, transmasculine, gender nonbinary, gender fluid, gender queer as well as people belonging to the traditional ethnocultural communities such as the hijra and kinnar communities. Conceptualized to better understand community experiences during the pandemic, TCC-19 aimed to look at what are the experiences of transgender persons in accessing and navigating healthcare in India in general and, specifically, during the COVID-19 pandemic. In this paper, we draw from data in this study to specifically look at how the COVID-19 pandemic impacted the mental health of transgender persons in India. --- Methods This paper presents results from one of the key research questions of the TCC-19 study conducted by the authors. For all the research questions, a same set of methods were used guided by a community based participatory research approach. The main question was about the experiences transgender In-depth interviews and focus group discussions were conducted over a period of 6 months virtually from across India and inperson in Bhopal, Indore and New Delhi. The respondents in our study were transgender persons who were residing in India at the time of the study. The theoretical approach of the study was based on the intersectionality approach and the theory of intersectionality of identities which guided the sampling, data collection and data analysis. In addition, the analysis for this paper was informed by the Minority Stress Model . Ethics approval for the study was obtained from the institutional review board of Sangath . --- Use of participatory approach The study used principles of community-based participatory research . CBPR is an approach to co-design and coconduct research in the context of power differences between the researcher and the "researched" that are inherent in research with marginalized populations . CBPR was incorporated throughout the research process through several methods: participatory community workshops, an advisory board of members from the community and guidance from co-investigator AS and collaborator Sanjana Singh, who both identify as transwomen. A series of four participatory community workshops were conducted over a period of one year with the transgender community with an aim to take community inputs at all stages of the research process. Participants for the participatory component were reached out through the networks of co-authors HR, AS, Sanjana Singh and VP which made rapport and trust building easier. The first two workshops focused on co-designing the study. The third one focused on co-analysis of preliminary findings and the last one which was conducted in person focused on dissemination of study findings to plan subsequent research and advocacy. Workshops were conducted in-person or virtually over Zoom and lasted around 90-120 min. Documents were shared beforehand in Hindi and English for participants to review and then discussed during the workshop. In addition, we conducted in-person and virtual workshops to build capacity in the community in psychological support and in trans-sensitive research, respectively. The study was also guided by a consultation with an advisory board comprising of diverse persons from the transgender community. Further, where feasible we had members from the community to co-conduct the research data collection including AS and Sanjana Singh. --- Data collection For the study, transgender persons were defined as persons whose experience of their gender is incongruent with the sex they were assigned to at birth . In this study our basis of identification was selfidentification and included persons belonging to ethno-cultural transgender identities such as hijras and kinnars as well as gender non binary, gender fluid and gender queer persons from across India. Purposive sampling was done guided by the intersectionality approach and by discussions in the community workshops. For example, the sampling included transgender persons of different classes, castes, regions, cultural identities, gender identities and sexual orientations. An initial set of participants were chosen based on the intersectionality approach from the networks of AS, Sanjana Singh, HR and VP. Subsequently, participants were recruited through snowballing, where each participant was asked to suggest other potential participants and decision to recruit was made by the research team. The participants were reached via email, WhatsApp and by phone call and a pre-interview call was held when needed which helped in rapport building. Prior to initiating data collection, the data collection team was trained in gender sensitivity with focus on interviewing techniques by AS. The IDI and FGD guides were semi-structured and developed in consultation with research team and community members. The data collection was primarily conducted virtually because of restrictions due to the COVID-19 pandemic. Some data were also collected in-person with COVID-19 prevention measures to include the communities that do not have smooth digital access and understanding, such as the ethno-cultural Hijra/Kinnar communities. All the IDIs were audio recorded with consent of participants which was taken over email or verbally and recorded. Transcription was done by SP or consultants who signed a confidentiality agreement and translation was done where necessary to English. All identifiers including but not limited to name, place of residence, name of hospitals or healthcare professionals etc. were omitted from the transcripts to maintain anonymity. The participants were given an option to access their transcripts if they wished to. --- Data analysis A discussion of key observations and ideas after each IDI and FGD was conducted in weekly team meetings. The data analysis uses a two-stage thematic analysis approach . Coding was done using Microsoft Excel by SP, HR and CS. In the first stage an open coding approach was used where the codes were generated based on the data. Then the emerged codes were organized into a framework while keeping in mind the theoretical approach of intersectionality. In the second stage all the transcripts were coded in a deductive approach with space to accommodate new inductive codes as well. The code sheets were reviewed and double checked between the coding personnel and a codebook was developed that included codes and subcodes, a definition of the codes and a description of the codes with examples. This was finalized with consensus with all the members of the team. The framework was reviewed by the community in a participatory workshop and with the research team through multiple meetings. Research outputs such as --- Use of intersectionality approach Intersectionality deliberates on how each person's experience is not defined by one identity alone but a host of different identities some giving privileges, while other marginalising depending on the context and the power relations that each identity entail . In our study for intersectionality, we looked at the following identities other than the transgender identity: sex assigned at birth, gender identity, sexual orientation, ethno-cultural identity, regional identity, linguistic identity, class, caste and religion. We operationalized the approach through the following steps: intersectional representation in the advisory board and participatory community workshops; recruitment of diverse participants for data collection covering various intersectionalities; ensuring safe space for diverse participants in the data collection; specific questions about intersectionality in the interview guide including the use of an orientation video by AS on intersectionality that was played during the interview; data analysis looking specifically for role of intersectionality. --- Results 22 IDIs and 6 FGDs were conducted in TCC19, and all the transcripts were included in the analysis for this paper. Out of the persons contacted, 8 participants did not take part in the study. The reasons were not getting a response from the potential participants and/or scheduling/interest conflict. Participants included 15 transfeminine, 5 transmasculine and 2 gender non-binary persons. Of the 6 FGDs, 3 were with Kinnar communities in three different cities in Central and Northern India. One FGD each were with transfeminine, transmasculine and gender non-binary persons. Data collection was stopped in light of thematic saturation and maximum possible intersectionality that could be accommodated within the project limitations. Thematic saturation and intersectional sample saturation was determined through discussions in team meetings and in a community workshop. A summary of the thematic analysis is provided in Table 1. We focus on findings relevant to mental health in this paper. --- Anxieties due to an inaccessible health system exacerbated --- Anxieties because of death and suffering The COVID-19 pandemic had an adverse impact on the mental health of transgender persons. Many people were anxious about the disease and the uncertainties around it. This was linked to a lack of targeted and systematic communication by the government, especially one that was inclusive of diverse transgender communities. For many participants, seeing death and suffering of family members and other community members exacerbated their mental health problems. My father, my mother, my sister, all three of them had COVID. I also saw a lot of my friends suffering a lot. And some of them dying. -A transmasculine person from North India --- Anxiety about hospitalisation In addition, there was anxiety about getting hospitalized in case of getting infected. This was because of past traumatic experiences in healthcare settings and experiences of others, for example, where trans people where physically examined without consent. A transwoman spoke about feeling anxious about having to get admitted to a hospital. This was also because in India there was mandatory hospitalizations for COVID-19 in the initial phases. Next day I got the result; I was positive. The first thing that came to my mind is "okay, as long as I'm at home, it's okay". But if I have to go to a hospital, and actually get admitted there. I was so anxious of how I am going to be treated as a trans woman. -A transgender woman from Eastern India Some of my friends tried to find affirming medical care. It was terrible, it was very, very difficult and one trans person, for example, was subjected to physical examination without their consent… It had a tremendous effect on my mental health. -A recently graduated trans woman from North India Anxiety about hospitalizations was exacerbated with misinformation about the situation during COVID-19. For example, a hijra transwoman shared that she was scared to go to a hospital thinking that she will be killed in the hospital. I couldn't go to hospital during COVID because there were a lot of dead bodies, and nobody was going also as they were scared of it… It was widespread belief that even if a healthy person goes to a hospitalthey'll kill them also and will file a case also. -A hijra trans woman from North India in an FGD Another participant spoke about the mental distress about accessing healthcare because of the negative experiences faced as a transgender person such as neglect. So, every time I'm unwell it's not just the physical unwellness that I go through, but also the emotional and mental trauma of being neglected and ignored. -A gender fluid person from North-East India --- Mental distress because of challenges in vaccination Challenges in accessing vaccines and vaccine information also resulted in mental distress. One participant spoke of how transgender people were "being shooed away" from COVID-19 vaccination centers. Many had concerns about the safety of taking the vaccines while being on hormone replacement therapies. Risk of being dead-named in the vaccination certificate and the vaccination center being transphobic were anxietyprovoking. Some vaccination centers were more inclusive. I had to get vaccinated under my dead name. Fortunately, there was no gender discriminationgender binary separation at the vaccination center. There wasn't a separate place for men and women, everyone can sit and get vaccinated at the same place. So, that didn't trigger my dysphoria that much but still I have vaccination certificate [in my dead name] -Trans men in an FGD --- Mental healthcare access restricted COVID-19 related restrictions also had an impact on mental health by restricting access to mental healthcare. Access to hospitals was reduced because of travel restrictions. Limited mental healthcare was available on a virtual mode but were not found of acceptable quality. In addition, because of challenges with ensuring continued employment because of lockdowns meant that paying for mental health services also became difficult. There were challenges in getting psychiatric medications. I couldn't go to the hospital for therapy. And online therapy just didn't work for me. Plus, it was getting a little hard to afford it by myself, as I don't have a job. And so, I just discontinued that. -A non-binary person from South India I have to send the photo of my prescription to some other pharmacist who is going to try and deliver it back home… I am a little anxious about sharing my prescription with too many people. That definitely made it a little difficult to continue -A gender non-binary person from South India 3.2. COVID related restrictions affected mental health because of unique kinship and social support needs 3.2.1. Social isolation during the pandemic COVID-19 related restrictions impacted mental health of transgender persons adversely. For many people in the trans community support from their chosen family and other kinship structures play an important role in positive mental health. Travel restrictions meant that participants were socially isolated, lonely and felt "cut off" from their social networks. Participants were forced to be restricted in their parental homes which often resulted in conflict with family members with regards to their transgender and/or non-binary identity. As educational programmes and employment made a difficult transition during this time to an online mode, having to live with parents added to their mental distress. Being able to meet with others online was very helpful for many people but this was not accessible. Queer people, particularly, need to be connected with others in the community. Therefore, the pandemic and the lockdown particularly affected the queer community. Often conversations about gender identity come up when you are stuck at home with the family, for example, even things like "when are you going to get married?" … your freedom to speak to others freely becomes limited. A non-binary person from South India in an FGD The first few months of lockdown when I was at home some of my traumas came back to me…. So being locked, it does at times trigger your traumas which was giving me a lot of nightmares, sleeplessness, stress, anxiety, and a lot of depression. -A transwoman from Eastern India --- Domestic violence Having to live at the parental home also meant that many people had to come out earlier than planned. Also, many people faced domestic violence. Now they may be facing domestic violence and they perhaps even feel trapped in very violent circumstances or sexual assault as well. -A trans woman from South India --- Pandemic worsened mental health problems Participants spoke of how these multiple factors during the pandemic period "exponentially" worsened their mental health problems. One participant spoke of how their mental health problem "worsened ten times and resulted in two suicide attempts". Another transwoman spoke of loneliness and worsening of depression. There was like a like exponential worsening as they have like went up by at least 10 orders of magnitude. I tried ending my life twice, got admitted in [name of a renowned institution] both the times. -A trans woman from North India My depression has tremendously increased after the pandemic. Bouts of crying, random crying for no specific reason and a terrible amount of loneliness. -A recently graduated trans woman from North India --- COVID-19 exacerbated social determinants of mental health --- Stigma worsened The COVID-19 pandemic exacerbated other social determinants of mental health such as stigma and livelihood. COVID-19 brought new forms of stigma. For example, there was a disinformation campaign in a south Indian city targeting the transgender community, especially the ethnocultural hijra/ kinnar community as carriers of COVID with the justification being that they "brought HIV and AIDS". …a lot of people posted posters at railway stations and bus stops saying transgender and Hijra persons brought HIV and AIDS. They are the ones who will bring COVID. -A trans woman from South India … initially when COVID cases were raising, I was witnessing some kind of stigma being around trans people. -A trans woman health professional from South India --- Disrupted livelihoods Livelihood is an important social determinant of mental health. Employment being moved to an online mode was a difficult transition for many transgender people. Participants shared about working longer hours, even "15 h a day". A transwoman spoke of how working from home increased "pressure" at work which was worsened by a fear of losing her job amidst other layoffs. … when you're [working from] home, it's like you have work all the time… the whole company, the clients, everybody pressurizes and everybody's there. The fear is there of losing your job at that time. There were layoffs happening in my office. -A transgender woman from Eastern India People from the Hijra community who are otherwise dependent on traditional blessing, begging and sex work had major disruptions to their livelihood resulting in financial problems. At that time we didn't get anything. It was a troublesome period. At that time, for 2.5-3 months I was in [a western state's city]. Then I travelled to [a city in the central state] on foot as I was facing a lot of financial problems.-A Hijra trans woman from Central North India --- Difficulty in finding employment Some participants pointed out how the stress was also linked to the uncertainty around employment that many transgender people feel. A transwoman spoke about how challenges in getting a job as a transwoman was worsened by the pandemic and resulted in increased anxiety. [The pandemic] has created problems for everyone in terms of employment, especially when you are a trans person and you want employment… [with the pandemic] it has become even more skewed and difficult. So, that has increased my anxieties around whether I will sustain next year or not [in my job] -A recently graduated trans woman from North India 3.4. COVID-19 impacted mental health through variable effects on dysphoria and "passability" --- Dysphoria due to disrupted gender transition People who got COVID-19 were asked to stop hormone replacement therapy. In addition, difficulty to access gender affirming care because of pandemic linked restrictions made people feel dysphoric. Thus, both the COVID-19 infections and the pandemic linked restrictions limited the access to GAC which are vital to the mental health of transgender persons. When you are having COVID, you are advised to not take HRT for a month… So, for one month I had to stop that which was a lot of mental issues for me… having dysphoria during the time when you are suffering from COVID was very difficult for me. That added to my anxiety. -A transgender woman from Eastern India --- Positive effects of change in social interaction One of the aspects that reduces gender dysphoria is the ability to pass as the affirmed gender. Because of this, certain features of the COVID-19 pandemic and its linked restrictions had a positive impact on the mental health of transgender persons. Mask usage, for example, made some people feel more comfortable in social interaction as it felt easier to pass. Similarly, while many people found the shift of jobs to an online mode distressing, others found it more comfortable as cameras capture only the upper half of the body and there is always the freedom to keep cameras switched off. The inability to move out of the house also meant fewer in-person social gatherings which also was found as a positive factor for mental health. When --- Discussion This paper examined data from a larger study to examine the mental health impact of the COVID-19 pandemic on transgender persons in India. The study found that the pandemic impacted mental health of transgender persons both negatively and positively through several pathways. Fear of the pandemic and witnessing the associated suffering had a negative effect on transgender persons . Anxiety about potential hospitalizations was an added layer which is linked to a history of stigma and discrimination of transgender persons within healthcare settings . This indicates the urgent need to make general healthcare services trans-inclusive and trans-affirmative . In addition, there were challenges in accessing mental healthcare during the pandemic. This is in a background of increased mental healthcare need in the community, higher treatment gap and history of trauma within mental healthcare settings . These findings point to the need to bring systemic reform in making all healthcare services trans-affirmative including mental healthcare services. Participants were forced to live in their parental homes with instances of transphobic discrimination and having to come out earlier than expected. Lack of access to in-person peer support, safe spaces and conflict with parents lead to much mental distress and exacerbation of mental health problems . Parental support and connectedness play a significant role in the mental health of transgender youth . Where parental support is absent, non-parental forms of social support also can reduce risk of mental health problems and self-harm . When large scale movement restrictions such as lockdowns are instituted, it is important to develop strategies that allow transgender persons to access the form of social support and spaces that they are most comfortable with. Challenges with employment and livelihood, such as restrictions to continue badhaai and sex work that require physical interaction had a particular impact on mental health of transgender persons . This is related to the increased uncertainty and precarity around employment among transgender persons, which predates the pandemic but was further worsened by the pandemic . The study showed how the pandemic brought new forms of stigma to the transgender community, with them being accused of spreading COVID-19. This is in line with literature on trust during pandemics and parallels with South Korea where there was backlash against the LGBTQI + community who were accused of spreading COVID-19 . This is in a background of transgender-related stigma which negatively impact mental health for example through higher levels of depression and anxiety . The pandemic impacted mental health of transgender people through gender dysphoria. This was either because of access to GAC being restricted because of pandemic-linked restrictions or because of being advised to do so in the instance of being infected with COVID-19 . This points to the need to recognize GAC as an essential health service and the need to ensure its continued availability for better mental health of transgender persons, for example, through telehealth services . This is especially important given that GAC is associated with decreased suicide and anxiety in transgender individuals . On the other hand, an interesting finding linked to gender dysphoria is the finding of positive impacts of mask usage and virtual meetings. This is because appearance congruence is an important positive factor for mental health . This also points to how the transgender mental health, especially gender dysphoria, is intricately linked to how we work as a society. --- Conclusion The COVID-19 pandemic adversely impacted the mental health of transgender persons in India through several pathways. Firstly, the disease and its associated fear and suffering combined with pre-existing inaccessibility of healthcare and reduced access to mental health care exacerbated mental health problems. Secondly, the unique social support needs of transgender persons were disrupted by the pandemic and its linked restrictions thus affecting mental health. Thirdly, the pandemic impacted mental health because of exacerbations of pre-existing vulnerabilities such as precarious employment and underlying stigma. Finally, gender dysphoria was found to be a key mediating factor in the impact of COVID-19 on mental health with a negative and positive impact. The study reiterates the prevailing need to make systemic changes to make mental healthcare and general healthcare services trans-inclusive while also recognizing the essential nature of gender affirmative services and the need to continue them even during emergencies and disaster situations . In-service training and change of health professional curricula to make it trans-affirmative, changing health regulations such as in insurance policies to make it inclusive of transpersons' needs, especially of people from hijra/kinnar community, and revisiting definitions of essential health services are important . Government insurance schemes such as Ayushman Bharat in India has already started taking efforts to make them transinclusive but more needs to be done and also the same is needed in private health insurance schemes. There is a lot more to be done to provide insurance coverage for mental health services. In addition, the study brings some crucial insights in the intersection of gender and mental health. On one hand, the study brings out how public health emergencies can exacerbate vulnerabilitiesthrough precarious livelihood, unsupported kinship structures and new forms of underlying stigma. On the other it also shows how the lived mental health experience of transgender persons is intricately linked to the way work, travel and housing is structured in our society, which determine experiences of gender dysphoria and therefore points to the structural nature of the linkage between mental health and gender. Thus, this paper sheds light on the systemic and structural determinants of mental health, how health emergencies exacerbate them and uniquely impact marginalized communities. Being cognizant of these will help program managers and policy makers across the world make structurally informed interventions to improve mental health vulnerability. As this manuscript is a product of analysis of data from another study there were several limitations such as limited data. Future studies are warranted that can explore further several questions unearthed by this study. This includes questions such as: health access and its impact on mental health, kinship and social support structures of transgender persons and its role in mental health, precarious employment and its relationship with mental health and gender dysphoria in online spaces. Further, there is a need for a systematic effort to adapt the minority stress model to the transgender community in the Indian context. --- Data availability statement The datasets presented in this article are not readily available because they were collected from a marginalised community. Requests to access the datasets should be directed to the corresponding author. --- Ethics statement The studies involving human participants were reviewed and approved by Sangath Institutional Review Board . The patients/participants provided their recorded verbal or written informed consent to participate in this study. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Introduction: Transgender persons in India, who are one of the most vulnerable groups, were particularly impacted by the COVID-19 pandemic. Increased risk of COVID-19, challenges with continuing livelihood, uncertainty, and anxiety around the pandemic over pre-existing social discrimination and exclusion pose risk of a mental health impact as well. To investigate this further, this component of a larger study on experiences in healthcare of transgender persons in India during COVID-19 and looks into the question "How did the COVID-19 pandemic impact the mental health of transgender persons in India". Methods: 22 In-depth interviews (IDI) and 6 focus group discussions (FGD) were conducted virtually and in-person with persons self-identifying as transgender or belonging to ethnocultural transgender communities from different parts of India. Community based participatory research approach was used by ensuring representation from the community in the research team and through a series of consultative workshops. Purposive sampling with snowballing was used. The IDIs and FGDs were recorded, transcribed verbatim and analyzed using an inductive thematic analysis. Results: Mental health of transgender persons were affected in the following ways. Firstly, COVID-19, its associated fear and suffering combined with pre-existing inaccessibility of healthcare and reduced access to mental health care affected their mental health. Secondly, unique social support needs of transgender persons were disrupted by pandemic linked restrictions. Thirdly, pre-existing vulnerabilities such as precarious employment and underlying stigma were exacerbated. Finally, gender dysphoria was a key mediating factor in the impact of COVID-19 on mental health with a negative and positive impact.The study reiterates the need to make systemic changes to make mental healthcare and general healthcare services trans-inclusive while also recognizing the essential nature of gender affirmative services and the need to continue them even during emergencies and disaster situations. While this brings out how public health emergencies can exacerbate vulnerabilities, it also shows how the lived mental health experience of transgender person is intricately linked to the way work, travel and housing is structured in our society and therefore points to the structural nature of the linkage between mental health and gender.

introduction and background transgender persons are those persons whose experience of their gender is incongruent with the sex they were assigned to at birth the census survey of 2011 which for the first time estimated the number of transgender persons in india reports a total of 487803 persons who identify as transgender this may be an underreport as many transgender persons might have not shared their transgender identity or might have been counted in their transitioned identity as male or female india along with other countries in south asia has a unique history of people of transgender identity living together in ethnocultural kinship communities known in various names specific to different regions this includes the hijra and kinnar communities in india transgender persons are among the most vulnerable population groups this is because of widespread marginalisation of the community which has resulted in lower levels of education income employment and health status due to experiences of stigma discrimination and violence many transgender persons in urban ethnocultural communities are involved in begging sex work and traditional blessing for their livelihood transgender persons face higher rates of mental health problems such as substance use and mental health disorders including mood disorders eating disorders suicide ideation and behaviours controlled studies from the us show that transgender persons have a twotothreefold higher risk of depression anxiety and suicidal ideation and attempts as compared to cisgender persons this higher rate of mental health problems in transgender persons needs to be viewed in the backdrop of unique social determinants of mental health among transgender persons which is best conceptualized by the minority stress model the model posits that people belonging to minority communities face negative stressors to mental health because of stigma prejudice and discrimination studies that utilize this model find that stigma discrimination abuse social isolation affect mental health of transgender persons negatively and social support peer support parental support and gender affirming care are beneficial however despite this higher burden of mental health problems in transgender persons they face challenges in accessing mental healthcare and healthcare in general challenges before or in reaching the health facility include low health literacy social exclusion financial constraints and lower education challenges within the health facility include discrimination misgendering fear of being pathologized or stereotyped insensitivity lack of privacy and confidentiality transnegative mental health professionals and verbal and physical abuse experiences with transnegative health providers in particular have a negative impact on the mental health of transgender persons the covid19 pandemic in india the covid19 pandemic started in india in early 2020 and in response the government initiated a nationwide lockdown overnight in march 2020 transgender persons have been particularly affected during the covid19 pandemic and its associated government responses in india such as lockdowns isolation and mandatory quarantine as they face an increased risk of covid19 due to poor housing overcrowding lower levels of immunity due to hormone replacement therapy noncommunicable diseases and substance use poorer access to vaccination services and increased risk of hiv in addition to this the strict lockdown measures imposed in india had a particular risk to transgender persons as a large number of transgender persons are engaged in informal employment including begging sex work and traditional blessing all of which were difficult to pursue during the lockdown the pandemic has impacted mental health across lowand middleincome countries in terms of its impact on the transgender community studies from the us show that it has adversely impacted the mental health of transgender persons more than that of cisgender persons and transgender persons had a relatively higher unmet need of mental health care during the pandemic the increased risk of covid19 challenges with livelihood combined with uncertainty and anxiety around the pandemic over existing social discrimination and exclusion of transgender persons pose increased risk of mental distress and mental health problems however there is scarce data on the impact of the pandemic on the mental health of transgender persons in the indian setting especially covering diverse populations within the transgender community the transcare covid19 project fills this gap as it was a qualitative study focused on india and inclusive of diverse identities including transfeminine transmasculine gender nonbinary gender fluid gender queer as well as people belonging to the traditional ethnocultural communities such as the hijra and kinnar communities conceptualized to better understand community experiences during the pandemic tcc19 aimed to look at what are the experiences of transgender persons in accessing and navigating healthcare in india in general and specifically during the covid19 pandemic in this paper we draw from data in this study to specifically look at how the covid19 pandemic impacted the mental health of transgender persons in india methods this paper presents results from one of the key research questions of the tcc19 study conducted by the authors for all the research questions a same set of methods were used guided by a community based participatory research approach the main question was about the experiences transgender indepth interviews and focus group discussions were conducted over a period of 6 months virtually from across india and inperson in bhopal indore and new delhi the respondents in our study were transgender persons who were residing in india at the time of the study the theoretical approach of the study was based on the intersectionality approach and the theory of intersectionality of identities which guided the sampling data collection and data analysis in addition the analysis for this paper was informed by the minority stress model ethics approval for the study was obtained from the institutional review board of sangath use of participatory approach the study used principles of communitybased participatory research cbpr is an approach to codesign and coconduct research in the context of power differences between the researcher and the researched that are inherent in research with marginalized populations cbpr was incorporated throughout the research process through several methods participatory community workshops an advisory board of members from the community and guidance from coinvestigator as and collaborator sanjana singh who both identify as transwomen a series of four participatory community workshops were conducted over a period of one year with the transgender community with an aim to take community inputs at all stages of the research process participants for the participatory component were reached out through the networks of coauthors hr as sanjana singh and vp which made rapport and trust building easier the first two workshops focused on codesigning the study the third one focused on coanalysis of preliminary findings and the last one which was conducted in person focused on dissemination of study findings to plan subsequent research and advocacy workshops were conducted inperson or virtually over zoom and lasted around 90120 min documents were shared beforehand in hindi and english for participants to review and then discussed during the workshop in addition we conducted inperson and virtual workshops to build capacity in the community in psychological support and in transsensitive research respectively the study was also guided by a consultation with an advisory board comprising of diverse persons from the transgender community further where feasible we had members from the community to coconduct the research data collection including as and sanjana singh data collection for the study transgender persons were defined as persons whose experience of their gender is incongruent with the sex they were assigned to at birth in this study our basis of identification was selfidentification and included persons belonging to ethnocultural transgender identities such as hijras and kinnars as well as gender non binary gender fluid and gender queer persons from across india purposive sampling was done guided by the intersectionality approach and by discussions in the community workshops for example the sampling included transgender persons of different classes castes regions cultural identities gender identities and sexual orientations an initial set of participants were chosen based on the intersectionality approach from the networks of as sanjana singh hr and vp subsequently participants were recruited through snowballing where each participant was asked to suggest other potential participants and decision to recruit was made by the research team the participants were reached via email whatsapp and by phone call and a preinterview call was held when needed which helped in rapport building prior to initiating data collection the data collection team was trained in gender sensitivity with focus on interviewing techniques by as the idi and fgd guides were semistructured and developed in consultation with research team and community members the data collection was primarily conducted virtually because of restrictions due to the covid19 pandemic some data were also collected inperson with covid19 prevention measures to include the communities that do not have smooth digital access and understanding such as the ethnocultural hijrakinnar communities all the idis were audio recorded with consent of participants which was taken over email or verbally and recorded transcription was done by sp or consultants who signed a confidentiality agreement and translation was done where necessary to english all identifiers including but not limited to name place of residence name of hospitals or healthcare professionals etc were omitted from the transcripts to maintain anonymity the participants were given an option to access their transcripts if they wished to data analysis a discussion of key observations and ideas after each idi and fgd was conducted in weekly team meetings the data analysis uses a twostage thematic analysis approach coding was done using microsoft excel by sp hr and cs in the first stage an open coding approach was used where the codes were generated based on the data then the emerged codes were organized into a framework while keeping in mind the theoretical approach of intersectionality in the second stage all the transcripts were coded in a deductive approach with space to accommodate new inductive codes as well the code sheets were reviewed and double checked between the coding personnel and a codebook was developed that included codes and subcodes a definition of the codes and a description of the codes with examples this was finalized with consensus with all the members of the team the framework was reviewed by the community in a participatory workshop and with the research team through multiple meetings research outputs such as use of intersectionality approach intersectionality deliberates on how each persons experience is not defined by one identity alone but a host of different identities some giving privileges while other marginalising depending on the context and the power relations that each identity entail in our study for intersectionality we looked at the following identities other than the transgender identity sex assigned at birth gender identity sexual orientation ethnocultural identity regional identity linguistic identity class caste and religion we operationalized the approach through the following steps intersectional representation in the advisory board and participatory community workshops recruitment of diverse participants for data collection covering various intersectionalities ensuring safe space for diverse participants in the data collection specific questions about intersectionality in the interview guide including the use of an orientation video by as on intersectionality that was played during the interview data analysis looking specifically for role of intersectionality results 22 idis and 6 fgds were conducted in tcc19 and all the transcripts were included in the analysis for this paper out of the persons contacted 8 participants did not take part in the study the reasons were not getting a response from the potential participants andor schedulinginterest conflict participants included 15 transfeminine 5 transmasculine and 2 gender nonbinary persons of the 6 fgds 3 were with kinnar communities in three different cities in central and northern india one fgd each were with transfeminine transmasculine and gender nonbinary persons data collection was stopped in light of thematic saturation and maximum possible intersectionality that could be accommodated within the project limitations thematic saturation and intersectional sample saturation was determined through discussions in team meetings and in a community workshop a summary of the thematic analysis is provided in table 1 we focus on findings relevant to mental health in this paper anxieties due to an inaccessible health system exacerbated anxieties because of death and suffering the covid19 pandemic had an adverse impact on the mental health of transgender persons many people were anxious about the disease and the uncertainties around it this was linked to a lack of targeted and systematic communication by the government especially one that was inclusive of diverse transgender communities for many participants seeing death and suffering of family members and other community members exacerbated their mental health problems my father my mother my sister all three of them had covid i also saw a lot of my friends suffering a lot and some of them dying a transmasculine person from north india anxiety about hospitalisation in addition there was anxiety about getting hospitalized in case of getting infected this was because of past traumatic experiences in healthcare settings and experiences of others for example where trans people where physically examined without consent a transwoman spoke about feeling anxious about having to get admitted to a hospital this was also because in india there was mandatory hospitalizations for covid19 in the initial phases next day i got the result i was positive the first thing that came to my mind is okay as long as im at home its okay but if i have to go to a hospital and actually get admitted there i was so anxious of how i am going to be treated as a trans woman a transgender woman from eastern india some of my friends tried to find affirming medical care it was terrible it was very very difficult and one trans person for example was subjected to physical examination without their consent… it had a tremendous effect on my mental health a recently graduated trans woman from north india anxiety about hospitalizations was exacerbated with misinformation about the situation during covid19 for example a hijra transwoman shared that she was scared to go to a hospital thinking that she will be killed in the hospital i couldnt go to hospital during covid because there were a lot of dead bodies and nobody was going also as they were scared of it… it was widespread belief that even if a healthy person goes to a hospitaltheyll kill them also and will file a case also a hijra trans woman from north india in an fgd another participant spoke about the mental distress about accessing healthcare because of the negative experiences faced as a transgender person such as neglect so every time im unwell its not just the physical unwellness that i go through but also the emotional and mental trauma of being neglected and ignored a gender fluid person from northeast india mental distress because of challenges in vaccination challenges in accessing vaccines and vaccine information also resulted in mental distress one participant spoke of how transgender people were being shooed away from covid19 vaccination centers many had concerns about the safety of taking the vaccines while being on hormone replacement therapies risk of being deadnamed in the vaccination certificate and the vaccination center being transphobic were anxietyprovoking some vaccination centers were more inclusive i had to get vaccinated under my dead name fortunately there was no gender discriminationgender binary separation at the vaccination center there wasnt a separate place for men and women everyone can sit and get vaccinated at the same place so that didnt trigger my dysphoria that much but still i have vaccination certificate in my dead name trans men in an fgd mental healthcare access restricted covid19 related restrictions also had an impact on mental health by restricting access to mental healthcare access to hospitals was reduced because of travel restrictions limited mental healthcare was available on a virtual mode but were not found of acceptable quality in addition because of challenges with ensuring continued employment because of lockdowns meant that paying for mental health services also became difficult there were challenges in getting psychiatric medications i couldnt go to the hospital for therapy and online therapy just didnt work for me plus it was getting a little hard to afford it by myself as i dont have a job and so i just discontinued that a nonbinary person from south india i have to send the photo of my prescription to some other pharmacist who is going to try and deliver it back home… i am a little anxious about sharing my prescription with too many people that definitely made it a little difficult to continue a gender nonbinary person from south india 32 covid related restrictions affected mental health because of unique kinship and social support needs 321 social isolation during the pandemic covid19 related restrictions impacted mental health of transgender persons adversely for many people in the trans community support from their chosen family and other kinship structures play an important role in positive mental health travel restrictions meant that participants were socially isolated lonely and felt cut off from their social networks participants were forced to be restricted in their parental homes which often resulted in conflict with family members with regards to their transgender andor nonbinary identity as educational programmes and employment made a difficult transition during this time to an online mode having to live with parents added to their mental distress being able to meet with others online was very helpful for many people but this was not accessible queer people particularly need to be connected with others in the community therefore the pandemic and the lockdown particularly affected the queer community often conversations about gender identity come up when you are stuck at home with the family for example even things like when are you going to get married … your freedom to speak to others freely becomes limited a nonbinary person from south india in an fgd the first few months of lockdown when i was at home some of my traumas came back to me… so being locked it does at times trigger your traumas which was giving me a lot of nightmares sleeplessness stress anxiety and a lot of depression a transwoman from eastern india domestic violence having to live at the parental home also meant that many people had to come out earlier than planned also many people faced domestic violence now they may be facing domestic violence and they perhaps even feel trapped in very violent circumstances or sexual assault as well a trans woman from south india pandemic worsened mental health problems participants spoke of how these multiple factors during the pandemic period exponentially worsened their mental health problems one participant spoke of how their mental health problem worsened ten times and resulted in two suicide attempts another transwoman spoke of loneliness and worsening of depression there was like a like exponential worsening as they have like went up by at least 10 orders of magnitude i tried ending my life twice got admitted in name of a renowned institution both the times a trans woman from north india my depression has tremendously increased after the pandemic bouts of crying random crying for no specific reason and a terrible amount of loneliness a recently graduated trans woman from north india covid19 exacerbated social determinants of mental health stigma worsened the covid19 pandemic exacerbated other social determinants of mental health such as stigma and livelihood covid19 brought new forms of stigma for example there was a disinformation campaign in a south indian city targeting the transgender community especially the ethnocultural hijra kinnar community as carriers of covid with the justification being that they brought hiv and aids …a lot of people posted posters at railway stations and bus stops saying transgender and hijra persons brought hiv and aids they are the ones who will bring covid a trans woman from south india … initially when covid cases were raising i was witnessing some kind of stigma being around trans people a trans woman health professional from south india disrupted livelihoods livelihood is an important social determinant of mental health employment being moved to an online mode was a difficult transition for many transgender people participants shared about working longer hours even 15 h a day a transwoman spoke of how working from home increased pressure at work which was worsened by a fear of losing her job amidst other layoffs … when youre working from home its like you have work all the time… the whole company the clients everybody pressurizes and everybodys there the fear is there of losing your job at that time there were layoffs happening in my office a transgender woman from eastern india people from the hijra community who are otherwise dependent on traditional blessing begging and sex work had major disruptions to their livelihood resulting in financial problems at that time we didnt get anything it was a troublesome period at that time for 253 months i was in a western states city then i travelled to a city in the central state on foot as i was facing a lot of financial problemsa hijra trans woman from central north india difficulty in finding employment some participants pointed out how the stress was also linked to the uncertainty around employment that many transgender people feel a transwoman spoke about how challenges in getting a job as a transwoman was worsened by the pandemic and resulted in increased anxiety the pandemic has created problems for everyone in terms of employment especially when you are a trans person and you want employment… with the pandemic it has become even more skewed and difficult so that has increased my anxieties around whether i will sustain next year or not in my job a recently graduated trans woman from north india 34 covid19 impacted mental health through variable effects on dysphoria and passability dysphoria due to disrupted gender transition people who got covid19 were asked to stop hormone replacement therapy in addition difficulty to access gender affirming care because of pandemic linked restrictions made people feel dysphoric thus both the covid19 infections and the pandemic linked restrictions limited the access to gac which are vital to the mental health of transgender persons when you are having covid you are advised to not take hrt for a month… so for one month i had to stop that which was a lot of mental issues for me… having dysphoria during the time when you are suffering from covid was very difficult for me that added to my anxiety a transgender woman from eastern india positive effects of change in social interaction one of the aspects that reduces gender dysphoria is the ability to pass as the affirmed gender because of this certain features of the covid19 pandemic and its linked restrictions had a positive impact on the mental health of transgender persons mask usage for example made some people feel more comfortable in social interaction as it felt easier to pass similarly while many people found the shift of jobs to an online mode distressing others found it more comfortable as cameras capture only the upper half of the body and there is always the freedom to keep cameras switched off the inability to move out of the house also meant fewer inperson social gatherings which also was found as a positive factor for mental health when discussion this paper examined data from a larger study to examine the mental health impact of the covid19 pandemic on transgender persons in india the study found that the pandemic impacted mental health of transgender persons both negatively and positively through several pathways fear of the pandemic and witnessing the associated suffering had a negative effect on transgender persons anxiety about potential hospitalizations was an added layer which is linked to a history of stigma and discrimination of transgender persons within healthcare settings this indicates the urgent need to make general healthcare services transinclusive and transaffirmative in addition there were challenges in accessing mental healthcare during the pandemic this is in a background of increased mental healthcare need in the community higher treatment gap and history of trauma within mental healthcare settings these findings point to the need to bring systemic reform in making all healthcare services transaffirmative including mental healthcare services participants were forced to live in their parental homes with instances of transphobic discrimination and having to come out earlier than expected lack of access to inperson peer support safe spaces and conflict with parents lead to much mental distress and exacerbation of mental health problems parental support and connectedness play a significant role in the mental health of transgender youth where parental support is absent nonparental forms of social support also can reduce risk of mental health problems and selfharm when large scale movement restrictions such as lockdowns are instituted it is important to develop strategies that allow transgender persons to access the form of social support and spaces that they are most comfortable with challenges with employment and livelihood such as restrictions to continue badhaai and sex work that require physical interaction had a particular impact on mental health of transgender persons this is related to the increased uncertainty and precarity around employment among transgender persons which predates the pandemic but was further worsened by the pandemic the study showed how the pandemic brought new forms of stigma to the transgender community with them being accused of spreading covid19 this is in line with literature on trust during pandemics and parallels with south korea where there was backlash against the lgbtqi community who were accused of spreading covid19 this is in a background of transgenderrelated stigma which negatively impact mental health for example through higher levels of depression and anxiety the pandemic impacted mental health of transgender people through gender dysphoria this was either because of access to gac being restricted because of pandemiclinked restrictions or because of being advised to do so in the instance of being infected with covid19 this points to the need to recognize gac as an essential health service and the need to ensure its continued availability for better mental health of transgender persons for example through telehealth services this is especially important given that gac is associated with decreased suicide and anxiety in transgender individuals on the other hand an interesting finding linked to gender dysphoria is the finding of positive impacts of mask usage and virtual meetings this is because appearance congruence is an important positive factor for mental health this also points to how the transgender mental health especially gender dysphoria is intricately linked to how we work as a society conclusion the covid19 pandemic adversely impacted the mental health of transgender persons in india through several pathways firstly the disease and its associated fear and suffering combined with preexisting inaccessibility of healthcare and reduced access to mental health care exacerbated mental health problems secondly the unique social support needs of transgender persons were disrupted by the pandemic and its linked restrictions thus affecting mental health thirdly the pandemic impacted mental health because of exacerbations of preexisting vulnerabilities such as precarious employment and underlying stigma finally gender dysphoria was found to be a key mediating factor in the impact of covid19 on mental health with a negative and positive impact the study reiterates the prevailing need to make systemic changes to make mental healthcare and general healthcare services transinclusive while also recognizing the essential nature of gender affirmative services and the need to continue them even during emergencies and disaster situations inservice training and change of health professional curricula to make it transaffirmative changing health regulations such as in insurance policies to make it inclusive of transpersons needs especially of people from hijrakinnar community and revisiting definitions of essential health services are important government insurance schemes such as ayushman bharat in india has already started taking efforts to make them transinclusive but more needs to be done and also the same is needed in private health insurance schemes there is a lot more to be done to provide insurance coverage for mental health services in addition the study brings some crucial insights in the intersection of gender and mental health on one hand the study brings out how public health emergencies can exacerbate vulnerabilitiesthrough precarious livelihood unsupported kinship structures and new forms of underlying stigma on the other it also shows how the lived mental health experience of transgender persons is intricately linked to the way work travel and housing is structured in our society which determine experiences of gender dysphoria and therefore points to the structural nature of the linkage between mental health and gender thus this paper sheds light on the systemic and structural determinants of mental health how health emergencies exacerbate them and uniquely impact marginalized communities being cognizant of these will help program managers and policy makers across the world make structurally informed interventions to improve mental health vulnerability as this manuscript is a product of analysis of data from another study there were several limitations such as limited data future studies are warranted that can explore further several questions unearthed by this study this includes questions such as health access and its impact on mental health kinship and social support structures of transgender persons and its role in mental health precarious employment and its relationship with mental health and gender dysphoria in online spaces further there is a need for a systematic effort to adapt the minority stress model to the transgender community in the indian context data availability statement the datasets presented in this article are not readily available because they were collected from a marginalised community requests to access the datasets should be directed to the corresponding author ethics statement the studies involving human participants were reviewed and approved by sangath institutional review board the patientsparticipants provided their recorded verbal or written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction transgender persons in india who are one of the most vulnerable groups were particularly impacted by the covid19 pandemic increased risk of covid19 challenges with continuing livelihood uncertainty and anxiety around the pandemic over preexisting social discrimination and exclusion pose risk of a mental health impact as well to investigate this further this component of a larger study on experiences in healthcare of transgender persons in india during covid19 and looks into the question how did the covid19 pandemic impact the mental health of transgender persons in india methods 22 indepth interviews idi and 6 focus group discussions fgd were conducted virtually and inperson with persons selfidentifying as transgender or belonging to ethnocultural transgender communities from different parts of india community based participatory research approach was used by ensuring representation from the community in the research team and through a series of consultative workshops purposive sampling with snowballing was used the idis and fgds were recorded transcribed verbatim and analyzed using an inductive thematic analysis results mental health of transgender persons were affected in the following ways firstly covid19 its associated fear and suffering combined with preexisting inaccessibility of healthcare and reduced access to mental health care affected their mental health secondly unique social support needs of transgender persons were disrupted by pandemic linked restrictions thirdly preexisting vulnerabilities such as precarious employment and underlying stigma were exacerbated finally gender dysphoria was a key mediating factor in the impact of covid19 on mental health with a negative and positive impactthe study reiterates the need to make systemic changes to make mental healthcare and general healthcare services transinclusive while also recognizing the essential nature of gender affirmative services and the need to continue them even during emergencies and disaster situations while this brings out how public health emergencies can exacerbate vulnerabilities it also shows how the lived mental health experience of transgender person is intricately linked to the way work travel and housing is structured in our society and therefore points to the structural nature of the linkage between mental health and gender

Introduction Tobacco use among adolescents has evolved considerably over the past decade. Electronic cigarettes have been the most used tobacco product among non-Hispanic White and Hispanic/Latino youth from 2014 1 to 2021 . 2 Conversely, combustible cigars were the most used tobacco product among non-Hispanic Black youth over this time, 1,2 with the exception of 2019. 3 Over this time, cigarette smoking declined significantly among youth across all-racial and ethnic categories. 1,2 Combustible tobacco exposes the user to toxins and carcinogens as byproducts of combustion 4,5 that are not present in e-cigarettes. [4][5][6][7][8] Additionally, combustible tobacco smoking has greater odds of nicotine dependence than e-cigarette use during adolescence. [9][10][11][12] In other words, the most popular tobacco product among NHB youth is significantly more dangerous and addictive than the most popular tobacco product among NHW and Hispanic youth in the United States. Shifting patterns of tobacco use requires an understanding of the tobacco retail environment 13 and the commercial determinants of health. 14,15 In the United States, the tobacco industry has a documented record of marketing its products to youth, particularly NHB youth. [16][17][18][19] As noted by Garrett et al. , 16 the tobacco industry has attempted to link their products with Black culture through direct advertisements of select brands of combustible cigarettes and cigars 20,21 in print and online. Similarly, price promotions have been found to target zip codes with higher concentrations of NHB residents. 22 The historical and contemporary context of the tobacco industry targeting NHB youth necessitates extensive and quantitative investigation. e-Cigarette use is an important consideration in understanding trends in combustible tobacco smoking among youth in the United States. 6,8 While decades of epidemiological study are required to fully understand the direct health consequences of e-cigarette use during adolescence, 6,8 it is well-established that nicotine is an addictive, psychoactive stimulant, and neurotoxin for developing brains. [23][24][25] Further, e-cigarettes have been linked to current 12,26- 29 and future combustible tobacco smoking among youth, [30][31][32][33][34][35][36][37][38][39] though the causal pathway from e-cigarettes to combustible tobacco remains unclear. 34,40 Evidence-based intervention and regulatory policy will be needed to address adolescent tobacco use, particularly combustible tobacco smoking. Further, research is required to explore racial and ethnic differences in combustible tobacco smoking and the cause of these disparities, considering the rise in e-cigarette use, to inform evidence-based public health intervention and regulatory policy. Subsequently, research on combustible tobacco smoking will need to account for e-cigarette use given the prevalence of e-cigarette use 1,2 and the substantial overlap of e-cigarette use and combustible tobacco smoking [27][28][29] among youth. --- Study Aims and Hypotheses This study has three aims. First, we aim to examine combustible tobacco smoking trends among a nationally representative sample of middle and high school students from 2014 to 2020. Second, we aim to compare trends in combustible tobacco smoking across racial and ethnic categories: Non-Hispanic White ; Non-Hispanic Black ; Hispanic/Latino; and Non-Hispanic "Other" from 2014 to 2020. Based on prior surveillance data, we hypothesize that combustible tobacco smoking will decline slower among non-Hispanic Black youth, relative to non-Hispanic White youth, from 2014 to 2020. Findings will provide insights into changing tobacco product use among youth and evaluate the degree of racial and ethnic disparities in these trends. Finally, we aim to examine the role of e-cigarette use as a possible effect modifier on combustible tobacco smoking trends from 2014 to 2020 for the entire sample and stratified by the four racial and ethnic categories. --- Methods --- Study Sample and Population We pooled and analyzed seven years of National Youth Tobacco Survey data. The NYTS is an annual, cross-sectional survey of tobacco use behaviors among middle and high students in the United States. We did not use data from the 2021 NYTS surveys 41 given methodologic changes related to the COVID-19 pandemic and our focus on examining reliable trends. The CDC explicitly states, "the 2021 NYTS estimates should not be compared with previous NYTS survey waves." 41 A total of n = 132 003 middle and high school students completed the NTYS from 2014 to 2020. Approximately 5.6% of the sample had missing data on one or more study variables and were not included in the analytic model. The final sample was n = 124 151 middle and high school students from 2014 to 2020. We conducted a complete case analysis given our dataset's missingness rate and size. 42 --- Measures --- Past 30-Day Combustible Tobacco Smoking The study outcome was past 30-day smoking of one or more combustible tobacco products: cigarettes, cigar products , or hookah. This study did not incorporate bidis, pipe tobacco, or rollyour-own. Any value greater than 0 indicated any past 30-day use. The NYTS methodology guide directed weighted estimates, 43 applied to generate nationally representative prevalence data per year. We did not incorporate lesser-used tobacco products in order to isolate analyses to more prevalent tobacco products among youth. --- Annual Trend The survey years were modeled as a continuous and independent variable. Years ranged from 2014 to 2020 and increased in units of one . There were no gaps in the survey year. --- Race and Ethnicity This study examined trends in combustible tobacco smoking across racial and ethnic categories. Per CDC recommendations, 41 participants were classified as: non-Hispanic, White [NHW]; non-Hispanic Black ; Hispanic/Latino; or non-Hispanic "Other" [NHO], reflecting youth who identified as American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islanders, or any combination of race and ethnic categories. --- Covariates We controlled for sex; males served as the referents. We also controlled for grade level, with middle school indicating sixth-eighth grade students and high school indicating 9th 12th grade. Past 30-day e-cigarette use was incorporated as a covariate and possible effect modifier. Participants who reported using e-cigarettes on one or more days were considered e-cigarette users. --- Statistical Analyses First, we estimated the weighted prevalence of past 30-day combustible tobacco smoking by year and race/ethnicity for the total sample and stratified by past 30-day e-cigarette use . Study hypotheses were tested using a series of multivariate logistic regression models. First, we conducted weighted, logistic regression models examining combustible tobacco smoking trends from 2014 to 2020 among middle and high school students, controlling for sex, grade level, race/ethnicity, and past 30-day e-cigarette use. Next, we modeled the interaction between year and race/ethnicity to assess for differences in combustible tobacco smoking trends for NHB, Hispanic/Latino, and NHO youth relative to NHW. Then, weighted logistic regression analyses stratified by race/ethnicity were conducted to quantify the trends in combustible tobacco smoking from 2014 to 2020. Finally, we replicated the above analyses among youth who did and did not report past 30-day e-cigarette use; these analyses were conducted to account for the high rate of dual/poly tobacco product use among youth. [27][28][29] Analyses were performed using Stata 14.2 . Sampling weights were applied in all-models to generate nationally representative estimates. Nicotine and Tobacco Research, 2024, Vol. XX, No. XX --- Results --- Descriptive Statistics As seen in Table 1, combustible tobacco smoking declined from 12.1% in 2014 to 6.6% in 2020 for the entire sample; trends are also reported by race/ethnic category. Demographic characteristics of the study sample are reported in Table 2. --- Trends in Combustible Tobacco Smoking Among Youth We found that the odds of combustible tobacco smoking significantly declined each year from 2014 to 2020 among all-middle and high school students in the United States , adjusting for sex, race/ethnicity, grade level, and past 30-day e-cigarette use. However, these trends in combustible tobacco smoking differed significantly by race/ethnicity . Stratified analyses found that the odds of combustible tobacco smoking significantly declined each year among NHW , Hispanic/Latino , NHO , and NHB . Each analysis controlled for sex, grade level, and past 30-day e-cigarette use. Analyses for the full sample and stratified by race/ethnic category are provided in Table 3. --- Non-e-Cigarette Users As seen in Table 4, we found that the odds of combustible tobacco smoking significantly declined each year among none-cigarette users , adjusting for sex, race/ethnicity, and grade level. Analyses of non-ecigarette users stratified by race/ethnicity found that the odds of combustible tobacco smoking significantly declined each year among NHW youth , Hispanic/Latino , and NHO youth who did not use e-cigarettes. However, no decline in combustible tobacco smoking was observed from 2014 to 2020 among NHB youth who did not use e-cigarettes . Each analysis controlled for sex and grade level. --- e-Cigarette Users As seen in Table 4, we found that the odds of combustible tobacco smoking significantly declined each year among current e-cigarette users , adjusting for sex, race/ethnicity, and grade level. Analyses stratified by race/ethnicity found that the odds of combustible tobacco smoking significantly declined each year among NHW youth , Hispanic/Latino , and NHO youth who used e-cigarettes. However, no decline in combustible tobacco smoking was observed from 2014 to 2020 among NHB youth who used e-cigarettes . Each analysis controlled for sex and grade level. --- Discussion This study compared trends in combustible tobacco smoking by race/ethnic category among middle and high school students in the United States. We found odds of combustible tobacco smoking declined 21.5% per year among NHW youth from 2014 to 2020, which was 4.22 times greater than NHBs , ~1.39 times greater than NHOs , and ~1.26 times greater than Hispanic/Latinos . Racial/ ethnic disparities in combustible tobacco smoking trends from 2014 to 2020 were observed independent of e-cigarette use. These figures show that the reductions in adolescent tobacco use observed since 2014 have not equitably reached communities of color, particularly non-Hispanic-Black youth. This study has several implications for public health research and practice. From a regulatory perspective, our findings indicate a need to address the commercial and social determinants of health that have resulted in disparate trends in combustible tobacco smoking among NHB youth in the United States. For example, adolescent tobacco use is heavily influenced by exposure to direct advertising of tobacco. [5][6][7] There is an established racial and ethnic bias in tobacco marketing resulting in racial and ethnic differences in cigarette brand preferences. 18,[44][45][46][47] Historically, the tobacco industry has focused on cigarettes as the primary mode of nicotine delivery, with marketing efforts designed to promote differing brands and product characteristics and tailored this marketing by race and ethnicity. 18,[44][45][46][47] At present, less is known about the tactics and expenditures of tobacco industry marketing for noncigarette, combustible tobacco products and e-cigarettes. 48,49 Our findings raise concerns about racial and ethnic biases in the marketing of combustible tobacco products that may require regulatory oversight. These concerns are extended to the marketing of e-cigarettes, which is linked to e-cigarette use 50,51 and remains largely unregulated or systematically monitored. 48,49 The shifting behaviors in adolescent tobacco use suggest the need to research and, if necessary, address the marketing of specific tobacco products like cigars and e-cigarettes in line with combustible cigarettes to address adolescent tobacco use, including dual/poly use. This study also has findings for tobacco prevention efforts and interventions. To date, tobacco prevention programs have largely focused on combustible cigarettes 7 or e-cigarettes. 52,53 School-based interventions have been demonstrated to effectively reduce adolescent tobacco initiation by up to 12% per year. 54,55 As such, school-based interventions tailored to NHB youth and cigar smoking have the potential to address the 4:1 ratio in combustible tobacco declines observed in this study, provided these efforts receive appropriate investment and resources. Such interventions should be informed by population-based research through participatory community methods that incorporate the intervention stakeholders into the development, pre/pilot testing, implementation, dissemination, and evaluation of school-based interventions tailored to racially minor youth. It is important to note that the two most commonly used tobacco products in this study from 2014 to 2021 among allyouth are also two of the most popular modalities for cannabis use among youth. Specifically, e-cigarettes are the most used tobacco product and the fastest-growing modality of cannabis use among youth in the United States. 56 Similarly, blunts are uniquely popular as a modality for cannabis use among NHB youth. 57 The NYTS does not assess for cannabis use via blunts or e-cigarettes and, as a result, we cannot account for cannabis use in the observed trends. Future studies will need to explore the impact of cannabis use via blunt smoking and cannabis vaping on the trends reported in this study. Published data suggest that cigar products account for a sizable proportion of the disparities in declines of combustible tobacco smoking. However, future research will need to consider the complexities of multiple tobacco product use when further examining the trends observed in this study. In the United States, multiple tobacco product use is most commonly characterized by the use of e-cigarettes and one combustible tobacco products. 12,26 Our examination of trends in combustible tobacco smoking accounted for differences by e-cigarette use ; however, additional study will be needed to investigate trends and disparities in youth smoking of multiple combustible products . This study has several limitations. First, data on economic factors was not available for this analysis. In the United States, economic indicators are consistent predictors of tobacco use and nicotine dependence . 57 Youth from low-income backgrounds are also exposed to a greater proportion of risk factors for tobacco use, such as tobacco retail marketing, price promotions, and outlet density. 58 59 However, race and ethnicity are not inherently discrete categories but are, instead, social constructs created and shaped through political and economic considerations. 60 Our operationalization of race/ethnic category, based on federal guidelines, inhibits the findings of this study from informing on the nuances of racial and ethnic identities in the United States. Third, we could not account for tobacco and cannabis couse via e-cigarettes or cigars . As a result, it is plausible that a proportion of the combustible tobacco smokers were blunt smokers or e-cigarette users vaping cannabis . While this may bias the study by inflating the number of combustible tobacco users and/or e-cigarette users, cannabis users who abstain from nicotine remain relevant to understanding tobacco use patterns among youth. Specifically, adolescents who vape cannabis or smoke blunts are still obtaining and using a tobacco product modified for cannabis use . Fourth, our findings are nationally representative and may not necessarily generalize to small units . Fifth, this study did not account for smokeless tobacco use, given the low prevalence and potential for collinearity in a large, nationally representative dataset. Nuanced, regional studies should explore the relationships observed in this study for smokeless tobacco use among relevant populations. To summarize, this study has broad implications for public health intervention, research, and regulatory policy, despite the limitations of cross-sectional, observational data. The substantial declines in combustible tobacco smoking among adolescents from 2014 to 2020 were not observed among NHB youth. While combustible tobacco smoking did decline modestly for NHB youth who did not use e-cigarettes, combustible tobacco smoking was essentially cut in half for all-other youth independent of e-cigarette use, from 2014 to 2020. A direct, evidence-based intervention aimed at reducing combustible tobacco smoking among NHB youth is essential and should follow evidence-based methodologies that incorporate sustainable funding for school-based intervention, public health education, and adult cessation treatment. [4][5][6][7] --- Data availability The data underlying this article are publicly available from the Centers for Disease Control and Prevention . The datasets were derived from sources in the public domain: https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/ index.htm --- Supplementary material Supplementary material is available at Nicotine and Tobacco Research online. --- Declaration of Interests SK and DM are consultants in litigation against the vaping industry. This does not alter our adherence to NTR data and materials-sharing policies. ---

We quantified the linear trend in combustible tobacco smoking among adolescents in the United States from 2014 to 2020, and then compared these trends across racial and ethnic categories. We also tested the effect of e-cigarette use on these trends for all-youth and across racial and ethnic categories.We pooled and analyzed seven years of National Youth Tobacco Survey data for n = 124 151 middle and high school students from 2014 to 2020. Weighted logistic regression analyses calculated the annual change in combustible tobacco smoking (ie cigarettes, cigars, and hookah) from 2014 to 2020. Stratified analyses examined linear trends for non-Hispanic White (NHW), NH-Black (NHB), Hispanic/ Latino, and NH-Other (NHO) youth. All-models controlled for sex, grade level, and past 30-day e-cigarette use.Combustible tobacco smoking from 2014 to 2020 dropped by more than 50% for NHW youth, more than 40% for Latino and NHO youth, compared to just 16% among NHB youth. From 2014 to 2020, the odds of combustible tobacco smoking declined by 21.5% per year for NHWs, which was significantly greater than Hispanic/Latinos (17% per year; p = .025), NHOs (15.4% per year; p = .01), and NHBs (5.1% per year; p < .001), adjusting for sex, grade, and e-cigarette use. Trends and disparities in trends by race and ethnicity were observed independent of e-cigarette use.Combustible tobacco smoking declined for all-youth but at significantly different rates across races and ethnicities. Notably, declines in combustible tobacco smoking are lagging among NHB youth. Interventions are critically needed to address this disparity. Implications: A direct, evidence-based intervention to reduce combustible tobacco smoking among NHB youth is critically needed. Such tobacco control initiatives should follow the Best Practices for Comprehensive Tobacco Control Framework, incorporating sustainable funding for school-based intervention, public health education, and adult cessation.

introduction tobacco use among adolescents has evolved considerably over the past decade electronic cigarettes have been the most used tobacco product among nonhispanic white and hispaniclatino youth from 2014 1 to 2021 2 conversely combustible cigars were the most used tobacco product among nonhispanic black youth over this time 12 with the exception of 2019 3 over this time cigarette smoking declined significantly among youth across allracial and ethnic categories 12 combustible tobacco exposes the user to toxins and carcinogens as byproducts of combustion 45 that are not present in ecigarettes 4 5 6 7 8 additionally combustible tobacco smoking has greater odds of nicotine dependence than ecigarette use during adolescence 9 10 11 12 in other words the most popular tobacco product among nhb youth is significantly more dangerous and addictive than the most popular tobacco product among nhw and hispanic youth in the united states shifting patterns of tobacco use requires an understanding of the tobacco retail environment 13 and the commercial determinants of health 1415 in the united states the tobacco industry has a documented record of marketing its products to youth particularly nhb youth 16 17 18 19 as noted by garrett et al 16 the tobacco industry has attempted to link their products with black culture through direct advertisements of select brands of combustible cigarettes and cigars 2021 in print and online similarly price promotions have been found to target zip codes with higher concentrations of nhb residents 22 the historical and contemporary context of the tobacco industry targeting nhb youth necessitates extensive and quantitative investigation ecigarette use is an important consideration in understanding trends in combustible tobacco smoking among youth in the united states 68 while decades of epidemiological study are required to fully understand the direct health consequences of ecigarette use during adolescence 68 it is wellestablished that nicotine is an addictive psychoactive stimulant and neurotoxin for developing brains 23 24 25 further ecigarettes have been linked to current 1226 29 and future combustible tobacco smoking among youth 30 31 32 33 34 35 36 37 38 39 though the causal pathway from ecigarettes to combustible tobacco remains unclear 3440 evidencebased intervention and regulatory policy will be needed to address adolescent tobacco use particularly combustible tobacco smoking further research is required to explore racial and ethnic differences in combustible tobacco smoking and the cause of these disparities considering the rise in ecigarette use to inform evidencebased public health intervention and regulatory policy subsequently research on combustible tobacco smoking will need to account for ecigarette use given the prevalence of ecigarette use 12 and the substantial overlap of ecigarette use and combustible tobacco smoking 27 28 29 among youth study aims and hypotheses this study has three aims first we aim to examine combustible tobacco smoking trends among a nationally representative sample of middle and high school students from 2014 to 2020 second we aim to compare trends in combustible tobacco smoking across racial and ethnic categories nonhispanic white nonhispanic black hispaniclatino and nonhispanic other from 2014 to 2020 based on prior surveillance data we hypothesize that combustible tobacco smoking will decline slower among nonhispanic black youth relative to nonhispanic white youth from 2014 to 2020 findings will provide insights into changing tobacco product use among youth and evaluate the degree of racial and ethnic disparities in these trends finally we aim to examine the role of ecigarette use as a possible effect modifier on combustible tobacco smoking trends from 2014 to 2020 for the entire sample and stratified by the four racial and ethnic categories methods study sample and population we pooled and analyzed seven years of national youth tobacco survey data the nyts is an annual crosssectional survey of tobacco use behaviors among middle and high students in the united states we did not use data from the 2021 nyts surveys 41 given methodologic changes related to the covid19 pandemic and our focus on examining reliable trends the cdc explicitly states the 2021 nyts estimates should not be compared with previous nyts survey waves 41 a total of n 132 003 middle and high school students completed the ntys from 2014 to 2020 approximately 56 of the sample had missing data on one or more study variables and were not included in the analytic model the final sample was n 124 151 middle and high school students from 2014 to 2020 we conducted a complete case analysis given our datasets missingness rate and size 42 measures past 30day combustible tobacco smoking the study outcome was past 30day smoking of one or more combustible tobacco products cigarettes cigar products or hookah this study did not incorporate bidis pipe tobacco or rollyourown any value greater than 0 indicated any past 30day use the nyts methodology guide directed weighted estimates 43 applied to generate nationally representative prevalence data per year we did not incorporate lesserused tobacco products in order to isolate analyses to more prevalent tobacco products among youth annual trend the survey years were modeled as a continuous and independent variable years ranged from 2014 to 2020 and increased in units of one there were no gaps in the survey year race and ethnicity this study examined trends in combustible tobacco smoking across racial and ethnic categories per cdc recommendations 41 participants were classified as nonhispanic white nhw nonhispanic black hispaniclatino or nonhispanic other nho reflecting youth who identified as american indian or alaska native asian native hawaiian or other pacific islanders or any combination of race and ethnic categories covariates we controlled for sex males served as the referents we also controlled for grade level with middle school indicating sixtheighth grade students and high school indicating 9th 12th grade past 30day ecigarette use was incorporated as a covariate and possible effect modifier participants who reported using ecigarettes on one or more days were considered ecigarette users statistical analyses first we estimated the weighted prevalence of past 30day combustible tobacco smoking by year and raceethnicity for the total sample and stratified by past 30day ecigarette use study hypotheses were tested using a series of multivariate logistic regression models first we conducted weighted logistic regression models examining combustible tobacco smoking trends from 2014 to 2020 among middle and high school students controlling for sex grade level raceethnicity and past 30day ecigarette use next we modeled the interaction between year and raceethnicity to assess for differences in combustible tobacco smoking trends for nhb hispaniclatino and nho youth relative to nhw then weighted logistic regression analyses stratified by raceethnicity were conducted to quantify the trends in combustible tobacco smoking from 2014 to 2020 finally we replicated the above analyses among youth who did and did not report past 30day ecigarette use these analyses were conducted to account for the high rate of dualpoly tobacco product use among youth 27 28 29 analyses were performed using stata 142 sampling weights were applied in allmodels to generate nationally representative estimates nicotine and tobacco research 2024 vol xx no xx results descriptive statistics as seen in table 1 combustible tobacco smoking declined from 121 in 2014 to 66 in 2020 for the entire sample trends are also reported by raceethnic category demographic characteristics of the study sample are reported in table 2 trends in combustible tobacco smoking among youth we found that the odds of combustible tobacco smoking significantly declined each year from 2014 to 2020 among allmiddle and high school students in the united states adjusting for sex raceethnicity grade level and past 30day ecigarette use however these trends in combustible tobacco smoking differed significantly by raceethnicity stratified analyses found that the odds of combustible tobacco smoking significantly declined each year among nhw hispaniclatino nho and nhb each analysis controlled for sex grade level and past 30day ecigarette use analyses for the full sample and stratified by raceethnic category are provided in table 3 nonecigarette users as seen in table 4 we found that the odds of combustible tobacco smoking significantly declined each year among nonecigarette users adjusting for sex raceethnicity and grade level analyses of nonecigarette users stratified by raceethnicity found that the odds of combustible tobacco smoking significantly declined each year among nhw youth hispaniclatino and nho youth who did not use ecigarettes however no decline in combustible tobacco smoking was observed from 2014 to 2020 among nhb youth who did not use ecigarettes each analysis controlled for sex and grade level ecigarette users as seen in table 4 we found that the odds of combustible tobacco smoking significantly declined each year among current ecigarette users adjusting for sex raceethnicity and grade level analyses stratified by raceethnicity found that the odds of combustible tobacco smoking significantly declined each year among nhw youth hispaniclatino and nho youth who used ecigarettes however no decline in combustible tobacco smoking was observed from 2014 to 2020 among nhb youth who used ecigarettes each analysis controlled for sex and grade level discussion this study compared trends in combustible tobacco smoking by raceethnic category among middle and high school students in the united states we found odds of combustible tobacco smoking declined 215 per year among nhw youth from 2014 to 2020 which was 422 times greater than nhbs 139 times greater than nhos and 126 times greater than hispaniclatinos racial ethnic disparities in combustible tobacco smoking trends from 2014 to 2020 were observed independent of ecigarette use these figures show that the reductions in adolescent tobacco use observed since 2014 have not equitably reached communities of color particularly nonhispanicblack youth this study has several implications for public health research and practice from a regulatory perspective our findings indicate a need to address the commercial and social determinants of health that have resulted in disparate trends in combustible tobacco smoking among nhb youth in the united states for example adolescent tobacco use is heavily influenced by exposure to direct advertising of tobacco 5 6 7 there is an established racial and ethnic bias in tobacco marketing resulting in racial and ethnic differences in cigarette brand preferences 18 44 45 46 47 historically the tobacco industry has focused on cigarettes as the primary mode of nicotine delivery with marketing efforts designed to promote differing brands and product characteristics and tailored this marketing by race and ethnicity 18 44 45 46 47 at present less is known about the tactics and expenditures of tobacco industry marketing for noncigarette combustible tobacco products and ecigarettes 4849 our findings raise concerns about racial and ethnic biases in the marketing of combustible tobacco products that may require regulatory oversight these concerns are extended to the marketing of ecigarettes which is linked to ecigarette use 5051 and remains largely unregulated or systematically monitored 4849 the shifting behaviors in adolescent tobacco use suggest the need to research and if necessary address the marketing of specific tobacco products like cigars and ecigarettes in line with combustible cigarettes to address adolescent tobacco use including dualpoly use this study also has findings for tobacco prevention efforts and interventions to date tobacco prevention programs have largely focused on combustible cigarettes 7 or ecigarettes 5253 schoolbased interventions have been demonstrated to effectively reduce adolescent tobacco initiation by up to 12 per year 5455 as such schoolbased interventions tailored to nhb youth and cigar smoking have the potential to address the 41 ratio in combustible tobacco declines observed in this study provided these efforts receive appropriate investment and resources such interventions should be informed by populationbased research through participatory community methods that incorporate the intervention stakeholders into the development prepilot testing implementation dissemination and evaluation of schoolbased interventions tailored to racially minor youth it is important to note that the two most commonly used tobacco products in this study from 2014 to 2021 among allyouth are also two of the most popular modalities for cannabis use among youth specifically ecigarettes are the most used tobacco product and the fastestgrowing modality of cannabis use among youth in the united states 56 similarly blunts are uniquely popular as a modality for cannabis use among nhb youth 57 the nyts does not assess for cannabis use via blunts or ecigarettes and as a result we cannot account for cannabis use in the observed trends future studies will need to explore the impact of cannabis use via blunt smoking and cannabis vaping on the trends reported in this study published data suggest that cigar products account for a sizable proportion of the disparities in declines of combustible tobacco smoking however future research will need to consider the complexities of multiple tobacco product use when further examining the trends observed in this study in the united states multiple tobacco product use is most commonly characterized by the use of ecigarettes and one combustible tobacco products 1226 our examination of trends in combustible tobacco smoking accounted for differences by ecigarette use however additional study will be needed to investigate trends and disparities in youth smoking of multiple combustible products this study has several limitations first data on economic factors was not available for this analysis in the united states economic indicators are consistent predictors of tobacco use and nicotine dependence 57 youth from lowincome backgrounds are also exposed to a greater proportion of risk factors for tobacco use such as tobacco retail marketing price promotions and outlet density 58 59 however race and ethnicity are not inherently discrete categories but are instead social constructs created and shaped through political and economic considerations 60 our operationalization of raceethnic category based on federal guidelines inhibits the findings of this study from informing on the nuances of racial and ethnic identities in the united states third we could not account for tobacco and cannabis couse via ecigarettes or cigars as a result it is plausible that a proportion of the combustible tobacco smokers were blunt smokers or ecigarette users vaping cannabis while this may bias the study by inflating the number of combustible tobacco users andor ecigarette users cannabis users who abstain from nicotine remain relevant to understanding tobacco use patterns among youth specifically adolescents who vape cannabis or smoke blunts are still obtaining and using a tobacco product modified for cannabis use fourth our findings are nationally representative and may not necessarily generalize to small units fifth this study did not account for smokeless tobacco use given the low prevalence and potential for collinearity in a large nationally representative dataset nuanced regional studies should explore the relationships observed in this study for smokeless tobacco use among relevant populations to summarize this study has broad implications for public health intervention research and regulatory policy despite the limitations of crosssectional observational data the substantial declines in combustible tobacco smoking among adolescents from 2014 to 2020 were not observed among nhb youth while combustible tobacco smoking did decline modestly for nhb youth who did not use ecigarettes combustible tobacco smoking was essentially cut in half for allother youth independent of ecigarette use from 2014 to 2020 a direct evidencebased intervention aimed at reducing combustible tobacco smoking among nhb youth is essential and should follow evidencebased methodologies that incorporate sustainable funding for schoolbased intervention public health education and adult cessation treatment 4 5 6 7 data availability the data underlying this article are publicly available from the centers for disease control and prevention the datasets were derived from sources in the public domain indexhtm supplementary material supplementary material is available at nicotine and tobacco research online declaration of interests sk and dm are consultants in litigation against the vaping industry this does not alter our adherence to ntr data and materialssharing policies

we quantified the linear trend in combustible tobacco smoking among adolescents in the united states from 2014 to 2020 and then compared these trends across racial and ethnic categories we also tested the effect of ecigarette use on these trends for allyouth and across racial and ethnic categorieswe pooled and analyzed seven years of national youth tobacco survey data for n 124 151 middle and high school students from 2014 to 2020 weighted logistic regression analyses calculated the annual change in combustible tobacco smoking ie cigarettes cigars and hookah from 2014 to 2020 stratified analyses examined linear trends for nonhispanic white nhw nhblack nhb hispanic latino and nhother nho youth allmodels controlled for sex grade level and past 30day ecigarette usecombustible tobacco smoking from 2014 to 2020 dropped by more than 50 for nhw youth more than 40 for latino and nho youth compared to just 16 among nhb youth from 2014 to 2020 the odds of combustible tobacco smoking declined by 215 per year for nhws which was significantly greater than hispaniclatinos 17 per year p 025 nhos 154 per year p 01 and nhbs 51 per year p 001 adjusting for sex grade and ecigarette use trends and disparities in trends by race and ethnicity were observed independent of ecigarette usecombustible tobacco smoking declined for allyouth but at significantly different rates across races and ethnicities notably declines in combustible tobacco smoking are lagging among nhb youth interventions are critically needed to address this disparity implications a direct evidencebased intervention to reduce combustible tobacco smoking among nhb youth is critically needed such tobacco control initiatives should follow the best practices for comprehensive tobacco control framework incorporating sustainable funding for schoolbased intervention public health education and adult cessation

Introduction From governments and rulers to philosophers and academics, and even poets and artists, the concepts and challenges of conflict, peace, and rights have occupied human thinking and behaviour for millennia, shaping not only our history and our present but our future. Contemporary human rights discourse and models of conflict transformation and peacebuilding have been influenced by centuries old beliefs in universal rights and the pursuit of a set of moral standards to which all societies could be held accountable . Following the atrocities of the second World Caitriona Mackel/ Environmental Science and Sustainable Development pg. 2 War the field of conflict resolution moved away from the more traditional focus on conflict prevention towards a model of conflict transformation which pays more attention to: human rights; the underlying causes of conflict; the needs of victims; and a recognition of the complex challenges involved in making the transition from violence to sustainable peace . Nowhere is the relationship between human rights and conflict transformation more intertwined, nor the need to consider root causes more crucial, than in the field of transitional justice. One of the key questions that arises for post-conflict societies is whether and how the legacy of violence, oppression and human rights violations should be addressed during the course of a society's transition from violent conflict to sustainable peace and the rule of law and/or democracy. This question poses a number of dilemmas: should we confront the past? what wrongs do we need to address? who is to be held accountable? should those responsible be punished? and how do we ensure that wrongs are not repeated or violence refuelled? The concept of transitional justice was developed in order to address these dilemmas by recognising that enabling societies to transition and deal with the atrocities of the past requires more specialised mechanisms than can be provided by traditional judicial and non-judicial structures. Since it was coined in the early 1990's the term transitional justice has gained global significance as an umbrella term to describe an ever expanding range of mechanisms to 'redress past wrongs, vindicate the dignity of victims and provide justice in times of transition ' . The United Nations defines transitional justice as 'the full range of processes and mechanisms associated with a society's attempt to come to terms with a legacy of large-scale past abuses in order to ensure accountability, serve justice and achieve reconciliation' . Transitional justice is a set of practices, centred around truth, justice, reparation and guarantees of non-recurrence, that are not only desirable but necessary in order to make the transition from conflict or oppression to sustainable peace. A range of judicial and non-judicial mechanisms, often referred to as a 'toolkit', have evolved to fulfil the core obligations of the field of transitional justice. Conflict and oppression undermine the full range of civil, political, economic, social and cultural rights nonetheless, civil and political rights violations are often more clearly identifiable and therefore perceived as the most urgent and fundamental rights to be respected on the path to peace. However, ignoring economic, social and cultural rights in the post-settlement phase risks failing to respond to the immediate needs and expectation of those most directly affected . Human rights violations are both a symptom and a cause of violent conflict and the violation of economic, social and cultural rights often functions as an underlying cause creating the grievances and group identities that can motivate civil violence . Addressing the root causes of conflict, alongside redressing human rights abuses, is therefore essential if transitional justice measures are to prove successful. By focusing on root causes the longstanding question of how civil and political rights affect and are affected by economic, social and cultural rights is renewed and attention is placed on the relationship between violence and poverty, discrimination, marginalisation and social exclusion . Traditionally transitional justice has ignored economic, social and cultural rights instead prioritising violations of civil and political rights as the primary human rights violations to be addressed when seeking justice for past atrocities . Socio-economic issues often lie at the heart of conflict and are specifically articulated by affected populations in the transitional period, ignoring violations of socio-economic rights is a risk to both peace and the effectiveness of transitional justice mechanisms . If, as the universal human rights legal framework suggests, all rights are considered to be universal, indivisible, interdependent and interrelated why are socio-economic rights largely ignored within transitional justice processes? Cahill-Ripley and Robins suggest that the narrow legal scope of transitional justice has resulted in the field focusing on criminal justice and those grave violations which can be tried in a court of law. Socio-economic rights are often considered as secondary, non-justiciable and equated to policy development rather than as legal entitlements within the remit of transitional justice . By focusing on the use of a limited number of established legal mechanisms transitional justice is constrained by its own 'toolkit' preventing the emergence of practices that could deliver broader justice that includes tackling the socio-economic causes and consequences of conflict and ultimately addresses the needs of victims. . The big question for the field of transitional justice is how its mechanisms can take better account of socio-economic issues and whether these mechanisms are adequate or appropriate . Caitriona Mackel/ Environmental Science and Sustainable Development pg. 3 Addressing violations of civil and political rights without addressing violations of socio-economic rights actually undermines the indivisibility and interdependence of human rights . Transitional justice therefore must have the ambition to look beyond the civil and political rights violations which often trigger transition towards the structural socio-economic rights violations, such as discrimination and inequality, that are usually part of the root causes of conflict . Structural socio-economic violations cause both frustration and unrest and if there is no attempt to address these inequalities then the risk is that conflict and violence will resurface despite the best efforts of transitional justice mechanisms. If we consider that structural socio-economic inequalities are an important source of conflict, then we must also consider that correcting these inequalities is an integral aspect of postconflict policy. The transitional justice 'toolkit' must therefore be expanded in order to more effectively confront violations of socio-economic rights, address the needs of victims and assist in societal transformation . Cahill-Ripley suggests that what is required is a broader and more holistic definition of transitional justice that would include mechanisms that investigate and remedy violations of both socio-economic rights and civil and political rights. A broader approach to transitional justice could involve the use of mechanisms, which traditionally fall outside the remit of transitional justice and conflict transformation such as legal reforms, bills of rights or the establishment of new institutions and practices which monitor socio-economic rights. One recent proposition to broaden the scope of transitional justice in order to address structural socio-economic inequalities is Yuvraj Joshi's recommendation that affirmative action should be integrated into the transitional justice toolkit. Joshi suggests that by fixating on a finite and narrow set of mechanisms transitional justice scholars have overlooked the role that affirmative action measures could play in brining attention to structural inequalities, promoting the inclusion of excluded groups, and helping to delineate the boundaries of transitional justice. By focusing on a limited set of mechanisms transitional justice practitioners fail to capture the real-world complexities of transition and give the impression that these mechanisms constitute the complete range of responses available to transitional societies . My work, in progress, examines if and how affirmative action could be integrated into the transitional justice 'toolkit' to better address socio-economic inequalities in post-conflict societies. An in-depth investigation on the use of affirmative action to address one socio-economic inequality within one transitional setting is required. For the purposes of my study, the problem of new, existing and persistent housing inequalities in post-conflict Belfast has been selected as an illustrative case study to demonstrate the potential power of affirmative action in dealing with the past and re-shaping the future. The main objective of this study is to analyse the implementation and effectiveness of existing affirmative action programmes, to address socio-economic inequalities, in the United States , South Africa and Northern Ireland in order to produce a regulatory policy framework for addressing housing inequalities in post-conflict Belfast. --- Problem Statement Ireland, and in particular Northern Ireland , has a protracted history of violent conflict, segregation, discrimination and deep-rooted political and societal divisions, arising from complex disputes over ethno-national identity and the legitimacy of territorial control, which can be traced as far back as the 12 th century . The 16 th century plantation of Ireland radically altered the religious balance of the island creating a Protestant majority in the North who were loyal to British rule. The subsequent clashes between the Protestant settlers and the predominantly Catholic indigenous population coupled with their political, religious and social differences led to widespread segregation of the two communities. In order to exert British control, the Catholic population, along with Protestant dissenters, were suppressed and marginalised through a number of Penal laws which not only criminalised their religious practices but barred them from voting, owning land, exercising certain professions and from holding certain offices . Although the majority of these Penal laws were removed during the Catholic emancipation process in the 18 th and 19 th centuries, Catholics in the Protestant dominated North still faced extensive, overt religious discrimination. The 1921 partition of Ireland created a Protestant/Unionist controlled state, NI, which fastened religion firmly to political disputes over national identity, territory and inequality. In the decades that followed historical and persistent religious, political and social divisions, and the overt discrimination of the Catholic minority, increasingly reinforced the segregation of communities along some of the most institutionalised and embedded of structureshousing, pg. 4 education, social and religious life, sporting and cultural activities . The continued use of legislation as a tool of oppression coupled with acts of discrimination, such as the deliberate refusal of homes and jobs, and electoral gerrymandering throughout the first half of the 20 th century created a widespread sense of grievance among the Catholic/Nationalist community which could not be channelled through the existing political structures . Ultimately these historical and persistent human rights abuses, inequalities and discrimination, propelled the civil rights campaign of the 1960s and resulted in a slide into a violent conflict that spanned three decades and during which over three thousand people lost their lives. Housing is a particularly complex issue in NI. The discriminatory provision and allocation of social housing in NI was both a key theme of the civil rights campaign and a consistent feature of the conflict. Claims of discrimination in the allocation of social housing began to surface during the 1950s and the community response to these claims were at the forefront of the civil rights movement . It was in fact an act of deliberate discrimination in the allocation of social housing, and the subsequent protests against this, which led directly to the outbreak of widespread civil unrest from 1968 onwards . Against the backdrop of discriminatory practices and the exclusion of Catholics from social and political structures, occurrences of overt housing discrimination were a reminder of the institutional inequalities ingrained and dished out by the state . Throughout the conflict a series of housing reforms were introduced to not only increase and improve the social housing stock but to also de-politicise housing and correct unfair allocation practices . In 1998 the Good Friday Agreement brought an end to the 30-year conflict and established a new devolved power sharing Assembly. With the arrival of peace there was remarkable agreement among those involved in the formulation of housing policy that the time had come for locally accountable politicians to find local solutions to local problems however, many of the issues around discriminatory social housing provision in NI have never been addressed and significant differentials between Catholic and Protestant communities persist. Deprived communities and vulnerable people continue to face significant issues in relation to the limited provision of adequate and affordable social housing, homelessness, housing poverty and stress, segregation, social exclusion and the legacy of conflict. Despite an emphasis on the promotion of equality and human rights within the Good Friday Agreement inequality in housing remains, not only within predominantly Catholic communities, but across many of the nine identified equality categories here: religious belief; political opinion; gender; race; disability; age; marital status; dependents; and sexual orientation. This is due, in part, to the conplex challenge of power-sharing in a deeply divided society where politicians and policy-makers cannot easily agree on the progession of equality and human rights. In its 2017 'Statement on Inequalities in Housing and Communities' the Equality Commission for NI identified 7 key housing inequalities. 1 As the largest and most segregated city, Belfast is home to the highest number of individuals impacted by the most significant housing inequalities such as: unequal access to adequate housing; overcrowding; housing stress; homelessness; higher waiting lists and longer waiting times . One of the greatest contributing factors to housing inequalities, noted by ECNI , is the persistence of residential segregation. Deep political and societal divisions have not been effectively addressed on the road to peace and as a result when given a choice the vast majority of people chose to live in a single identity area in keeping with their own perceived identity . Although residential segregation has begun to decline the persistence of segregated residential patterns fragments and limits the operation of wider housing markets. ECNI argues that a wide variety of evidence demonstrates a huge demand and intense pressure for additional housing for Catholics, particularly in North Belfast, which cannot be filled by the properties left vacant by Protestants in the area as the peace line is not transgressed. This challenge is not unique to North Belfast but reflects the effect of residential segregation across the city where the 'lack of stock relative to demand for social housing in sometimes narrowly defined geographical areas may not easily be met by excess supply in other nearby areas' . Across Belfast, a collage of socalled peace walls and interface areas segregate Catholic and Protestant neighbourhoods creating economic, social and cultural equality barriers that result in: high levels of unemployment; high levels of educational underachievement; inadequacies and accessibility issues in the provision of housing; low levels of investment; and a lack of development and regeneration initiatives for communities . These physical barriers create the divided spaces in which inequalities prevail and reconciliation seems a world away. Belfast's so-called peace walls and the complex challenges they maintain are a bleak reminder that the most vulnerable have been neglected on NI's road to peace. Inequalities are exacerbated by the isolation, fear and sectarian violence that dictates the narrative of everyday life in the shadows of Belfast's defensive architecture. Being afforded the right to housing through a country's constitution, legislation or commitment to internationally binding treaties does not always result in adequate housing for all. NI is no exception. Housing policy, and in particular social housing policy, in NI has always been heavily influenced by political considerations. In 1990 the Standing Advisory Commission on Human Rights produced its second report on 'Religious and Political Discrimination and Equality of Opportunity in NI' focused solely on housing. Although the report highlighted that affirmative action measures, such as the official monitoring of religious backgrounds, deserved careful consideration political pressures and opposition from the NI Housing Executive, that such measures would cause a hostile public reaction, resulted in no express recommendation of regulatory measures to address discrimination and establish equality of opportunity in housing . This was in stark contrast to SACHR's first report on discrimination and equality of opportunity in employment, which embraced and expressly recommended a regulatory affirmative action framework to address inequality. These recommendations were taken forward and incorporated into the Fair Employment Act of 1989 and succeeded in reducing religious discrimination, creating greater employment of under-represented communities, and creating greater employment integration. Crucial to the success of this affirmative action measures framework was the implementation of SACHR's explicit recommendations for robust data monitoring which allowed for external scrutiny of Catholic and Protestant recruitment . The challenge of navigating housing in a politically and physically divided city has resulted in a failed opportunity to adopt a similar statutory framework which could have re-shaped policies and procedures to address historical housing inequalities and prevent new inequalities from arising over the course of the last three decades. --- Significance of the Work Joshi argues that affirmative action could reorientate transitioning societies towards a better understanding of socio-economic inequalities. By making affirmative action part of the transitional justice 'toolkit' transitioning societies benefit from the attention affirmative action brings to the socio-economic consequences of the past . Joshi proposes he is the first to offer an integrated approach of affirmative action as transitional justice filling a gap in the current literature by bridging two fields 'that share several conceptual and normative concerns yet until now have remained largely isolated from one another' . In proposing that affirmative action can bridge the divide between the field of transitional justice and the phenomenon of societal transition that it seeks to understand and facilitate Joshi compares the use of affirmative action in two societies transitioning along racial lines: the United States and South Africa. Although the US is largely excluded from transitional justice discourse Joshi argues that when placed in conversation with South Africa the US exhibits many characteristics of a transitional society recovering from the legacy of racial oppression and segregation . He argues that affirmative action has been a central means to pursue transition in both the US and South Africa with transitional concerns underpinning the discourse on affirmative action in both societies . Affirmative action is primarily designed to achieve equality and increase diversity through the deliberate use of race, gender, or other protected characteristics to the benefit of disadvantaged groups. Affirmative action therefore requires us to intentionally look at the realities of the differentials between the life chances of different races or genders etc. and implement policies that redress these. In both the US and South Africa affirmative action has been highly criticised for being race-conscious, for some 'affirmative action based on race impedes transition to a non-racial world and is akin to practices that have been historically used to oppress racialized groups' . However, Joshi argues that shift away from affirmative action practices based on race, or other characteristics, actually impedes transition. 'Affirmative action should therefore occupy a central place among the transitional justice measures implemented to address massive human rights abuses' . By taking an integrated approach Caitriona Mackel/ Environmental Science and Sustainable Development pg. 6 to affirmative action and transitional justice structural inequalities could be better addressed and transition better facilitated. A robust legal affirmative action framework currently exists in NI in the context of employment and empirical evidence demonstrates that the implementation of this framework through regulatory monitoring and enforcement has resulted in an increased employment share for previously under-represented groups and a significant shift towards workforce integration . In NI, an innovative programme of affirmative action utilises legal enforcement alongside voluntary action plans, to ensure that both Catholic and Protestant communities enjoy fair participation in employment . The inclusion of affirmative action within fair employment legislation and practices have proved successful in transforming what was once a highly discriminatory and segregated employment sphere. The implementation of statutory obligations on employers to: register with an enforcement body ; monitor and report on the religious composition of their workforce; and make changes to personnel policies and procedures, has led to both greater employment integration and greater employment of underrepresented communities. McCrudden, et al, suggest that the success of the NI approach to addressing employment inequalities through affirmative action could have far reaching implications; providing a model not only for other jurisdictions seeking to tackle issues of fair employment but also for other structural inequalities within society including within NI itself . A missed opportunity to develop similar affirmative action based legislation, despite its consideration, to tackle housing inequalities in Northern Ireland has resulted in the persistence of historical religious discrimination and the growth of new inequalities over the course of the last three decades. My research seeks to advance further on these arguments by examining the use of affirmative action to address socioeconomic inequalities, through an illustrative case study on housing inequalities in post-conflict Belfast, in order to investigate the potential integration of affirmative action into the transitional justice 'toolkit'. As recently as December 2021 the NI Human Rights Commission has noted that housing inequalities remains on their list of issues still requiring action. It is therefore timely to re-examine the capacity of affirmative action to address chronic housing inequalities as part of NI's continued transition to sustainable peace. --- Theoretical Approach My study utilises a theoretical framework that illustrates why transitioning societies need to prioritise socio-economic rights and how affirmative action could provide the necessary tools for tackling inequality, discrimination and disadvantage in post-conflict transition. By drawing upon the theories of transformative justice, substantive equality and new social movements my study illustrates how these concepts, and the relationships between them, reinforce the overall argument that affirmative action is a legitimate tool to address socio-economic inequalities, discrimination and disadvantage in post-conflict transition. As noted, by focusing predominantly on civil and political rights violations through a narrow set of legal remedies, transitional justice often overlooks violations of socio-economic rights and the impact of harms on victims and wider society. Although it may be a complex undertaking, addressing these injustices within post-conflict societies is essential. For transitional justice to be effective different kinds of justice are needed depending on the nature of the injustice, and the level at which the injustice occurred, in the particular society at the moment of transition . To modify post-conflict structures in ways that are more inclusive, equal and fair we must consider a concept of justice that is more transformative rather than transitional . Transformative justice allows us to look more closely at affected communities within a range of different political settings with the aim of creating communication and pursuing 'forms of justice that break with the structures that may have led to violence in the first place' . Transformative justice broadens 'the focus of measures aimed at promoting postconflict or post-authoritarian justice for human rights abuses beyond that of transitional justice' . Transformative justice therefore requires the development of a new, specifically focused 'toolkit' and as Evans suggests there is a case to be made for the use of existing tools designed to combat inequality, poverty and corruption. In particular, transitional justice mechanisms have thus far proved inadequate in dealing with violations relating to land, such as violations of the right to housing . Where the established 'toolkit' of transitional pg. 7 justice is considered inappropriate or inadequate for dealing with socio-economic inequalities then the processes through which we pursue transformative justice matters . Although transitional justice is primarily anchored in law, for many transitional societies, such as NI, greater attention must be paid to the issues which lie in the background of legal and human rights discourse such as religion, culture, politics, economics and local tradition . Dealing with socio-economic inequalities within transitional settings therefore requires the integration of knowledge, theories and tools from a variety of disciplines. Taking a more transformative justice approach to transition allows us to step away from the more normative scope of transitional justice, draw upon the insights that can be gained from other fields and give serious consideration to mechanisms which traditionally fall outside of the realm of transitional justice. Instead of aiming to treat all people alike substantive equality aims to correct disadvantage by focusing on the detrimental consequences attached to an individual's status or group identity . Fredman suggests that affirmative action advances substantive equality by actively taking steps to redress inequality, discrimination and disadvantage as well as prejudice within one concept. Barnard & Hepple suggest that under a substantive approach to equality special measures such as affirmative action can be used to overcome underrepresentation of disadvantaged groups in the workplace or ensure their fair share in the distribution of resources . There is no one single definition or model of affirmative action, even the term itself varies from jurisdiction to jurisdiction and may be referred to as 'positive action', 'employment equity' or 'special measures'. For the purposes of my research project the term affirmative action will be used as an umbrella term for the range of activities primarily designed to achieve equality and increase diversity through the deliberate use of race, gender, or other protected characteristics to the benefit of disadvantaged groups. A substantive equality framework provides the space for my research project to justify the consideration of affirmative action policies to address housing inequalities in NI. The development of specific targeted affirmative action policies focused on equitable outcomes and opportunities could address discrimination and unequal access. As a root cause of conflict the issue of addressing housing inequalities has been largely ignored as part of NI's transitional processes. The application of affirmative action as a tool for dealing with these inequalities can only be considered within a transformative justice approach to dealing with the consequences of NI's violent past. Utilising the existing tools of substantive equality, as part of a transformative justice 'toolkit', therefore strengthens the overall argument within my research project that affirmative action has a potential role to play in addressing new, existing and persistent housing inequalities in post-conflict Belfast. Because transitional justice remains normatively driven it has been fairly limited in addressing the particular social and political needs of those directly affected by violent conflict, oppression and human rights violations . Typically the externally driven, top-down, transitional justice agenda discourages the participation of affected populations, giving them little or no opportunity to engage in the process or goals of transitional mechanisms. A transformative justice approach on the other hand requires the inclusion of affected communities in shaping the agenda for law, policy and practice thus opening the door to actors typically exluded in transitional processes . Transformative justice encourages the voice of social movements and grassroots groups as opposed to the transitional justice approach of privileging elite actors. By giving agency and voice to affected populations and highlighting socio-economic rights, transformative justice could act as the catalyst for embedding these rights into transitioning societies. Participatory processes are therefore a vital component of transformative justice providing affected populations with the means to raise concerns and shape processes which increase the likelihood of legitimate outcomes. Social movements and community based organisations play a vital role in articulating the concerns of those most affected by issues such as housing inequalities. Evans in particular, notes that the social movement praxis is ultimately essential for understanding how a transformative justice agenda might be promoted. Urban social movements are increasingly considered an important part of urban governance processes with local activists influencing decision-making through participation practices and legal tools . Domaradzka argues that the global spread of successful Right to the City movements illustrates the power of collectives coming together under a common agenda to achieve social justice in the face of growing urban inequalities. The right to the city agenda can effect change by addressing: housing policies which ignore inequalities; property development practices which create housing shortages; and planning policies that create residential disadvantage . Furthermore, the right to the city implies co-responsibility on governments and populations to claim, defend and promote this right. The rationale for taking a more transformative approach to addressing housing inequalities in Belfast is thus further reinforced by the capacity of collective action to reshape policy and practice and effect lasting change across an urban agenda that is broader than just housing. Under a transformative justice framework participatory action could be encouraged in communities throughout Belfast to fully identify the housing inequalities and needs of those most at risk from the legacy of the past and effect lasting change that achieves housing equality for all. The theories of transformative justice, substantive equality and new social movements explored within my research project provides a unique framework which supports the overall research argument that affirmative action could play a vital role in addressing new, existing and persistent housing inequalities in post-conflict Belfast. Under a transformative justice agenda, that is driven by a bottom-up, context specific and participatory led approach to postconflict socio-economic justice and equality, affirmative action could be utilised to re-shape housing policy and address chronic housing inequalities in post-conflict Belfast. In doing so we could look to the future as well as deal with the past. --- Methodological Approach My research project takes the form of an illustrative case study conducted within an interdisciplinary, socio-legal framework using comparative analysis and semi-structured interviews to investigate how affirmative action could be used to address chronic housing inequalities in post-conflict Belfast. The purpose of this case study is to illustrate how, through an examination of existing examples, affirmative action could be integrated into the transitional justice 'toolkit' for addressing socio-economic inequalities. An illustrative case study approach enables the researcher to explore and understand complex issues through an empirical study of a contemporary phenomenon within its reallife context . 'As human rights problems are common to all countries, it is often useful to compare experiences in different countries and situations' . Utilising comparative analysis methods within my illustrative case study gives access to an extensive range of alternative solutions or ideas that may reveal a way out of NI's particular dilemma . Comparative analysis will therefore be conducted on the use of affirmative action and the role of social movements in addressing socio-economic inequalities, including housing, in the US, South Africa and NI. The purpose of this comparative analysis is to identify and draw upon the similarities and differences between the selected comparative subjects in order to investigate: how the implementation of affirmative action measures could address housing inequalities in post-conflict Belfast; and what role social movements, such as the Right to the City, could play in re-shaping housing policy and effecting lasting change. While there are significant legal, political, social and cultural differences between the three jurisdictions selected for comparison in my study, there are, several commonalities in relation to socio-economic inequalities and a deep history of societal division, residential segregation and violence. The issue of housing inequalities in particular is common across all three jurisdictions. Most importantly affirmative action policies and programmes have been utilised in each, with varying degrees of success, to address a range of socio-economic inequalities including housing. Social movements, particularly Right to the City movements, have also played an important role in influencing decisionmaking and shaping policy in relation to land and housing across all three jurisdictions. The comparative analysis will be conducted in three parts. The first part will explore: the impetus and legal framework for affirmative action; the implementation of affirmative action; and the impact of affirmative action in all three jurisdictions in relation to addressing socio-economic inequalities. The second part will follow a similar pattern of investigation to focus specifically on how affirmative action has been implemented to address the effects of housing discrimination and segregation in both the US and South Africa in order to identify similarities, differences and lessons learned that may provide insight into how affirmative action could be effectively applied to the context of housing in NI, where no current framework exists. The final part of this comparative analysis will examine the Right to the City campaigns which form an integral part of the continued fight against housing inequalities and segregation in all three jurisdictions to establish and evaluate the similarities and differences in the role of social movements in achieving social justice. Caitriona Mackel/ Environmental Science and Sustainable Development pg. 9 The comparative analysis will be conducted through desk-based research using a socio-legal examination of legislation, case law, policy documents, reports and academic literature to collect and analyse relevant data on the implementation, enforcement and effectiveness of affirmative action, and the role of social movements, to address socio-economic inequalities, including housing, in all three jurisdictions. By conducting a comparative analysis of legislation, policies, and administrative practices relating to affirmative action, alongside a comparison of the role of social actors in the housing sector, my research project aims to pinpoint potential limitations, implications and benefits for the development of a potential participatory led regulatory affirmative action framework that could be applied to the illustrative case study on new, existing and persistent housing inequalities in post-conflict Belfast. As Belfast has been selected as an illustrative case study semi-structured interviews to explore local participants' thoughts on the use of affirmative action in housing will be conducted within NI using a range of appropriate participants selected from the public, private and community sectors. Interview participants will include carefully selected representatives recruited from: government departments and agencies; public agencies and bodies; human rights organisations; NGOs; political parties; and community organisations. Participants who are directly involved in the provision of social housing, the development of housing policy, the monitoring of inequalities and those who represent community interests have been identified as the primary interview targets. A small number of private landlords and property developers who are directly involved in the development and provision of social housing will also be interviewed. Participants will include representatives from: the Department for Communities; the NI Housing Executive; semi-public and private social housing providers; ECNI; the Participation and Practice of Rights; the Market Development Association; and political parties. Approximately 20-25 interviews will be conducted using a set of predetermined, open-ended questions designed to encourage participants to openly discuss their views on how the implementation and enforcement of affirmative action could effectively address chronic housing inequalities in Belfast. Participants will also be asked about their thoughts and experiences of social movements and actors in shaping decision-making, policy development and community focused human rights indicators. --- Anticipated Findings, Conclusions & Implications As a work in progress there are as yet no definitive findings, conclusions or implications from my research. The comparative analysis process is currently underway and initial examinations of the data obtained to date indicate that there are a range of similarities and differences between the three jurisdictions being compared. Similarities are present in the justifications for the use of affirmative action; the legal foundations of affirmative action obligations; the beneficiaries and domains in which affirmative action is implemented; and in some respects the effectiveness of using these measures to address socio-economic inequalities. However, substantial differences in relation to the boundaries of affirmative action, the role of the judiciary, and the ways in which affirmative action is implemented and enforced cannot be ignored. Early data on the use of affirmative action to address housing discrimination and segregation in the US and South Africa suggests that despite a firm legal framework in both jurisdictions progress on these issues has been slow as a result of political controversies and failures in the implementation and enforcement of affirmative action obligations. For example in the US, the Affirmatively Furthering Fair Housing rule established under the Obama administration in 2015 set out a comprehensive statutory framework for states, local governments and public housing agencies to take meaningful actions to combat discrimination, overcome segregations, foster inclusive communities and promote fair housing choice . The AFFH rule showed considerable potential to increase inclusion, eliminate discrimination and improve equal access to opportunity . However, this potential could not be reached as implementation of the rule was delayed and eventually scrapped by the Trump administration in 2020. Similarly in South Africa, the Socio-Economic Rights Institute outlines that the persistence of discrimination does not stem from the legal and policy framework developed for housing but rather from political pressures and the manner in which this framework is implemented in practice . The preliminary findings indicate that an affirmative action framework for NI could have the potential to address housing inequalities but the success of such a framework is dependent on political cooperation and the effective implementation of robust monitoring and enforcement procedures. Caitriona Mackel/ Environmental Science and Sustainable Development pg. 10 Initial findings from the US and South Africa also demonstrate that the meaningful participation of affected populations is essential for the success of an affirmative action framework in housing. Affirmative action is designed to redress the specific needs of those most disadvantaged, marginalised, exluded or ignored in society . Early data indicates that affirmative action measures must be designed not only for, but in conjunction with, the participation of affected populations in order to be responsive to these needs and affect lasting change. A lack of participation implies limited power and voice to affect change in the attitudes, institutions and policies which have fuelled discrimination and exclusion in the first place . The challenge lies in the ability to incorporate participation in policy-making processes which are primarily conducted by political elites. Preliminary analysis of the work of social movements indicates that the solution could lie in their ability to overcome the barriers which exclude civil society from policy formulation .A comparative analysis of the Right to the City social movement in the US, South Africa and NI is due to commence and it is anticipated that the data will demonstrate ways in which this movement could be utilised in the policy-making process to create more legitimate, transparent, accountable, and equitable housing policies and practices in NI. Semi-structured interviews, for which full ethical approval has been granted, are currently underway in NI. Research participants from the NGO and community sector, in particular, noted how public policy, underwhich housing falls, is often obstructed by power sharing tensions and political deadlocks at the heart of government. Initial data gathered from these research participants indicates a strong desire for the development of a statutory framework which would place obligations on housing providers to monitor, report on and take action to address inequalities and on government to ensure effective implementation and enforcement. Data obtained from interview participants to date, including the NIHE and a number of NI's main political parties, regarding the commitment to effective implementation of statutory monitoring, reporting and enforcement procedures in NI's employment sector indiates that similar commitments and success could be achieved in the context of housing under a statutory framework. Interviews are ongoing and it is anticipated that the data obtained from future participants will not only shape the development of an affirmative action framework but also further demonstrate that the timing is now right to apply affirmative action in the context of housing, as suggested by SACHR, to secure the equitable provision and allocation of social housing in NI. It is anticipated that this work in progress while culminate in the development of an affirmative action framework which could be implemented into law and policy by the NI Assembly and could be monitored and enforced by the ECNI. This framework incorporate similar statutory monitoring, reporting and enforcement process to those which already exist in employment in NI with the addition of monitoring all equality categories in order to effectively address the range of housing inequalities experienced in NI. By considering the role of social movements in influencing public policy my research seeks to incorporate grassroots participation into NI policy processes to achieve reforms that address the needs of those most impacted by NI's chronic housing inequalities. Ultimately, while my research project is context specific it seeks to have wider significance and uncover the potential power of integrating affirmative action into the transitional justice 'toolkit' for addressing socio-economic inequalities far beyond the borders of NI's most politically, socially, economically and spatially divided city.

Belfast is a deeply divided and fragmented city not just politically, socially, and economically but physically. It is a city shaped by its history, its experiences of violent conflict and its post-conflict transition. A collage of so-called peace walls and interface areas segregate neighbourhoods across the city creating some of the most socially and economically deprived areas where inequalities are significantly exacerbated by the tension and sectarianism that segregation reinforces. Despite the peace process, historical and new inequalities in the provision and allocation of social housing affect many vulnerable individuals and communities resulting in unequal access to adequate housing; overcrowding; housing stress; homelessness; higher waiting lists and longer waiting times. The challenge of navigating housing in a politically and physically divided city has resulted in failed opportunities to shape policies and procedures to address existing, persistent, and new housing inequalities. Addressing the legacy of violence and human rights violations is central to building sustainable peace in transitioning societies. If we acknowledge that socio-economic inequalities are not only a consequence of violent conflict but also a root cause, then we must also acknowledge that correcting these inequalities is an essential component of postconflict policy. Transitional justice often overlooks violations of socio-economic rights and the impact of these on victims and wider society. A growing body of literature suggests transformative justice expands the traditional 'toolkit' to include measures, not typically employed in transitional justice, to confront violations of socio-economic rights, address the needs of victims and assist in societal transformation more effectively. Under a transformative justice approach, my research explores how affirmative action and the role of social movements, such as the Right to the City, could be used to address housing inequalities in post-conflict Belfast. In doing so we could look to the future as well as deal with the past.

introduction from governments and rulers to philosophers and academics and even poets and artists the concepts and challenges of conflict peace and rights have occupied human thinking and behaviour for millennia shaping not only our history and our present but our future contemporary human rights discourse and models of conflict transformation and peacebuilding have been influenced by centuries old beliefs in universal rights and the pursuit of a set of moral standards to which all societies could be held accountable following the atrocities of the second world caitriona mackel environmental science and sustainable development pg 2 war the field of conflict resolution moved away from the more traditional focus on conflict prevention towards a model of conflict transformation which pays more attention to human rights the underlying causes of conflict the needs of victims and a recognition of the complex challenges involved in making the transition from violence to sustainable peace nowhere is the relationship between human rights and conflict transformation more intertwined nor the need to consider root causes more crucial than in the field of transitional justice one of the key questions that arises for postconflict societies is whether and how the legacy of violence oppression and human rights violations should be addressed during the course of a societys transition from violent conflict to sustainable peace and the rule of law andor democracy this question poses a number of dilemmas should we confront the past what wrongs do we need to address who is to be held accountable should those responsible be punished and how do we ensure that wrongs are not repeated or violence refuelled the concept of transitional justice was developed in order to address these dilemmas by recognising that enabling societies to transition and deal with the atrocities of the past requires more specialised mechanisms than can be provided by traditional judicial and nonjudicial structures since it was coined in the early 1990s the term transitional justice has gained global significance as an umbrella term to describe an ever expanding range of mechanisms to redress past wrongs vindicate the dignity of victims and provide justice in times of transition the united nations defines transitional justice as the full range of processes and mechanisms associated with a societys attempt to come to terms with a legacy of largescale past abuses in order to ensure accountability serve justice and achieve reconciliation transitional justice is a set of practices centred around truth justice reparation and guarantees of nonrecurrence that are not only desirable but necessary in order to make the transition from conflict or oppression to sustainable peace a range of judicial and nonjudicial mechanisms often referred to as a toolkit have evolved to fulfil the core obligations of the field of transitional justice conflict and oppression undermine the full range of civil political economic social and cultural rights nonetheless civil and political rights violations are often more clearly identifiable and therefore perceived as the most urgent and fundamental rights to be respected on the path to peace however ignoring economic social and cultural rights in the postsettlement phase risks failing to respond to the immediate needs and expectation of those most directly affected human rights violations are both a symptom and a cause of violent conflict and the violation of economic social and cultural rights often functions as an underlying cause creating the grievances and group identities that can motivate civil violence addressing the root causes of conflict alongside redressing human rights abuses is therefore essential if transitional justice measures are to prove successful by focusing on root causes the longstanding question of how civil and political rights affect and are affected by economic social and cultural rights is renewed and attention is placed on the relationship between violence and poverty discrimination marginalisation and social exclusion traditionally transitional justice has ignored economic social and cultural rights instead prioritising violations of civil and political rights as the primary human rights violations to be addressed when seeking justice for past atrocities socioeconomic issues often lie at the heart of conflict and are specifically articulated by affected populations in the transitional period ignoring violations of socioeconomic rights is a risk to both peace and the effectiveness of transitional justice mechanisms if as the universal human rights legal framework suggests all rights are considered to be universal indivisible interdependent and interrelated why are socioeconomic rights largely ignored within transitional justice processes cahillripley and robins suggest that the narrow legal scope of transitional justice has resulted in the field focusing on criminal justice and those grave violations which can be tried in a court of law socioeconomic rights are often considered as secondary nonjusticiable and equated to policy development rather than as legal entitlements within the remit of transitional justice by focusing on the use of a limited number of established legal mechanisms transitional justice is constrained by its own toolkit preventing the emergence of practices that could deliver broader justice that includes tackling the socioeconomic causes and consequences of conflict and ultimately addresses the needs of victims the big question for the field of transitional justice is how its mechanisms can take better account of socioeconomic issues and whether these mechanisms are adequate or appropriate caitriona mackel environmental science and sustainable development pg 3 addressing violations of civil and political rights without addressing violations of socioeconomic rights actually undermines the indivisibility and interdependence of human rights transitional justice therefore must have the ambition to look beyond the civil and political rights violations which often trigger transition towards the structural socioeconomic rights violations such as discrimination and inequality that are usually part of the root causes of conflict structural socioeconomic violations cause both frustration and unrest and if there is no attempt to address these inequalities then the risk is that conflict and violence will resurface despite the best efforts of transitional justice mechanisms if we consider that structural socioeconomic inequalities are an important source of conflict then we must also consider that correcting these inequalities is an integral aspect of postconflict policy the transitional justice toolkit must therefore be expanded in order to more effectively confront violations of socioeconomic rights address the needs of victims and assist in societal transformation cahillripley suggests that what is required is a broader and more holistic definition of transitional justice that would include mechanisms that investigate and remedy violations of both socioeconomic rights and civil and political rights a broader approach to transitional justice could involve the use of mechanisms which traditionally fall outside the remit of transitional justice and conflict transformation such as legal reforms bills of rights or the establishment of new institutions and practices which monitor socioeconomic rights one recent proposition to broaden the scope of transitional justice in order to address structural socioeconomic inequalities is yuvraj joshis recommendation that affirmative action should be integrated into the transitional justice toolkit joshi suggests that by fixating on a finite and narrow set of mechanisms transitional justice scholars have overlooked the role that affirmative action measures could play in brining attention to structural inequalities promoting the inclusion of excluded groups and helping to delineate the boundaries of transitional justice by focusing on a limited set of mechanisms transitional justice practitioners fail to capture the realworld complexities of transition and give the impression that these mechanisms constitute the complete range of responses available to transitional societies my work in progress examines if and how affirmative action could be integrated into the transitional justice toolkit to better address socioeconomic inequalities in postconflict societies an indepth investigation on the use of affirmative action to address one socioeconomic inequality within one transitional setting is required for the purposes of my study the problem of new existing and persistent housing inequalities in postconflict belfast has been selected as an illustrative case study to demonstrate the potential power of affirmative action in dealing with the past and reshaping the future the main objective of this study is to analyse the implementation and effectiveness of existing affirmative action programmes to address socioeconomic inequalities in the united states south africa and northern ireland in order to produce a regulatory policy framework for addressing housing inequalities in postconflict belfast problem statement ireland and in particular northern ireland has a protracted history of violent conflict segregation discrimination and deeprooted political and societal divisions arising from complex disputes over ethnonational identity and the legitimacy of territorial control which can be traced as far back as the 12 th century the 16 th century plantation of ireland radically altered the religious balance of the island creating a protestant majority in the north who were loyal to british rule the subsequent clashes between the protestant settlers and the predominantly catholic indigenous population coupled with their political religious and social differences led to widespread segregation of the two communities in order to exert british control the catholic population along with protestant dissenters were suppressed and marginalised through a number of penal laws which not only criminalised their religious practices but barred them from voting owning land exercising certain professions and from holding certain offices although the majority of these penal laws were removed during the catholic emancipation process in the 18 th and 19 th centuries catholics in the protestant dominated north still faced extensive overt religious discrimination the 1921 partition of ireland created a protestantunionist controlled state ni which fastened religion firmly to political disputes over national identity territory and inequality in the decades that followed historical and persistent religious political and social divisions and the overt discrimination of the catholic minority increasingly reinforced the segregation of communities along some of the most institutionalised and embedded of structureshousing pg 4 education social and religious life sporting and cultural activities the continued use of legislation as a tool of oppression coupled with acts of discrimination such as the deliberate refusal of homes and jobs and electoral gerrymandering throughout the first half of the 20 th century created a widespread sense of grievance among the catholicnationalist community which could not be channelled through the existing political structures ultimately these historical and persistent human rights abuses inequalities and discrimination propelled the civil rights campaign of the 1960s and resulted in a slide into a violent conflict that spanned three decades and during which over three thousand people lost their lives housing is a particularly complex issue in ni the discriminatory provision and allocation of social housing in ni was both a key theme of the civil rights campaign and a consistent feature of the conflict claims of discrimination in the allocation of social housing began to surface during the 1950s and the community response to these claims were at the forefront of the civil rights movement it was in fact an act of deliberate discrimination in the allocation of social housing and the subsequent protests against this which led directly to the outbreak of widespread civil unrest from 1968 onwards against the backdrop of discriminatory practices and the exclusion of catholics from social and political structures occurrences of overt housing discrimination were a reminder of the institutional inequalities ingrained and dished out by the state throughout the conflict a series of housing reforms were introduced to not only increase and improve the social housing stock but to also depoliticise housing and correct unfair allocation practices in 1998 the good friday agreement brought an end to the 30year conflict and established a new devolved power sharing assembly with the arrival of peace there was remarkable agreement among those involved in the formulation of housing policy that the time had come for locally accountable politicians to find local solutions to local problems however many of the issues around discriminatory social housing provision in ni have never been addressed and significant differentials between catholic and protestant communities persist deprived communities and vulnerable people continue to face significant issues in relation to the limited provision of adequate and affordable social housing homelessness housing poverty and stress segregation social exclusion and the legacy of conflict despite an emphasis on the promotion of equality and human rights within the good friday agreement inequality in housing remains not only within predominantly catholic communities but across many of the nine identified equality categories here religious belief political opinion gender race disability age marital status dependents and sexual orientation this is due in part to the conplex challenge of powersharing in a deeply divided society where politicians and policymakers cannot easily agree on the progession of equality and human rights in its 2017 statement on inequalities in housing and communities the equality commission for ni identified 7 key housing inequalities 1 as the largest and most segregated city belfast is home to the highest number of individuals impacted by the most significant housing inequalities such as unequal access to adequate housing overcrowding housing stress homelessness higher waiting lists and longer waiting times one of the greatest contributing factors to housing inequalities noted by ecni is the persistence of residential segregation deep political and societal divisions have not been effectively addressed on the road to peace and as a result when given a choice the vast majority of people chose to live in a single identity area in keeping with their own perceived identity although residential segregation has begun to decline the persistence of segregated residential patterns fragments and limits the operation of wider housing markets ecni argues that a wide variety of evidence demonstrates a huge demand and intense pressure for additional housing for catholics particularly in north belfast which cannot be filled by the properties left vacant by protestants in the area as the peace line is not transgressed this challenge is not unique to north belfast but reflects the effect of residential segregation across the city where the lack of stock relative to demand for social housing in sometimes narrowly defined geographical areas may not easily be met by excess supply in other nearby areas across belfast a collage of socalled peace walls and interface areas segregate catholic and protestant neighbourhoods creating economic social and cultural equality barriers that result in high levels of unemployment high levels of educational underachievement inadequacies and accessibility issues in the provision of housing low levels of investment and a lack of development and regeneration initiatives for communities these physical barriers create the divided spaces in which inequalities prevail and reconciliation seems a world away belfasts socalled peace walls and the complex challenges they maintain are a bleak reminder that the most vulnerable have been neglected on nis road to peace inequalities are exacerbated by the isolation fear and sectarian violence that dictates the narrative of everyday life in the shadows of belfasts defensive architecture being afforded the right to housing through a countrys constitution legislation or commitment to internationally binding treaties does not always result in adequate housing for all ni is no exception housing policy and in particular social housing policy in ni has always been heavily influenced by political considerations in 1990 the standing advisory commission on human rights produced its second report on religious and political discrimination and equality of opportunity in ni focused solely on housing although the report highlighted that affirmative action measures such as the official monitoring of religious backgrounds deserved careful consideration political pressures and opposition from the ni housing executive that such measures would cause a hostile public reaction resulted in no express recommendation of regulatory measures to address discrimination and establish equality of opportunity in housing this was in stark contrast to sachrs first report on discrimination and equality of opportunity in employment which embraced and expressly recommended a regulatory affirmative action framework to address inequality these recommendations were taken forward and incorporated into the fair employment act of 1989 and succeeded in reducing religious discrimination creating greater employment of underrepresented communities and creating greater employment integration crucial to the success of this affirmative action measures framework was the implementation of sachrs explicit recommendations for robust data monitoring which allowed for external scrutiny of catholic and protestant recruitment the challenge of navigating housing in a politically and physically divided city has resulted in a failed opportunity to adopt a similar statutory framework which could have reshaped policies and procedures to address historical housing inequalities and prevent new inequalities from arising over the course of the last three decades significance of the work joshi argues that affirmative action could reorientate transitioning societies towards a better understanding of socioeconomic inequalities by making affirmative action part of the transitional justice toolkit transitioning societies benefit from the attention affirmative action brings to the socioeconomic consequences of the past joshi proposes he is the first to offer an integrated approach of affirmative action as transitional justice filling a gap in the current literature by bridging two fields that share several conceptual and normative concerns yet until now have remained largely isolated from one another in proposing that affirmative action can bridge the divide between the field of transitional justice and the phenomenon of societal transition that it seeks to understand and facilitate joshi compares the use of affirmative action in two societies transitioning along racial lines the united states and south africa although the us is largely excluded from transitional justice discourse joshi argues that when placed in conversation with south africa the us exhibits many characteristics of a transitional society recovering from the legacy of racial oppression and segregation he argues that affirmative action has been a central means to pursue transition in both the us and south africa with transitional concerns underpinning the discourse on affirmative action in both societies affirmative action is primarily designed to achieve equality and increase diversity through the deliberate use of race gender or other protected characteristics to the benefit of disadvantaged groups affirmative action therefore requires us to intentionally look at the realities of the differentials between the life chances of different races or genders etc and implement policies that redress these in both the us and south africa affirmative action has been highly criticised for being raceconscious for some affirmative action based on race impedes transition to a nonracial world and is akin to practices that have been historically used to oppress racialized groups however joshi argues that shift away from affirmative action practices based on race or other characteristics actually impedes transition affirmative action should therefore occupy a central place among the transitional justice measures implemented to address massive human rights abuses by taking an integrated approach caitriona mackel environmental science and sustainable development pg 6 to affirmative action and transitional justice structural inequalities could be better addressed and transition better facilitated a robust legal affirmative action framework currently exists in ni in the context of employment and empirical evidence demonstrates that the implementation of this framework through regulatory monitoring and enforcement has resulted in an increased employment share for previously underrepresented groups and a significant shift towards workforce integration in ni an innovative programme of affirmative action utilises legal enforcement alongside voluntary action plans to ensure that both catholic and protestant communities enjoy fair participation in employment the inclusion of affirmative action within fair employment legislation and practices have proved successful in transforming what was once a highly discriminatory and segregated employment sphere the implementation of statutory obligations on employers to register with an enforcement body monitor and report on the religious composition of their workforce and make changes to personnel policies and procedures has led to both greater employment integration and greater employment of underrepresented communities mccrudden et al suggest that the success of the ni approach to addressing employment inequalities through affirmative action could have far reaching implications providing a model not only for other jurisdictions seeking to tackle issues of fair employment but also for other structural inequalities within society including within ni itself a missed opportunity to develop similar affirmative action based legislation despite its consideration to tackle housing inequalities in northern ireland has resulted in the persistence of historical religious discrimination and the growth of new inequalities over the course of the last three decades my research seeks to advance further on these arguments by examining the use of affirmative action to address socioeconomic inequalities through an illustrative case study on housing inequalities in postconflict belfast in order to investigate the potential integration of affirmative action into the transitional justice toolkit as recently as december 2021 the ni human rights commission has noted that housing inequalities remains on their list of issues still requiring action it is therefore timely to reexamine the capacity of affirmative action to address chronic housing inequalities as part of nis continued transition to sustainable peace theoretical approach my study utilises a theoretical framework that illustrates why transitioning societies need to prioritise socioeconomic rights and how affirmative action could provide the necessary tools for tackling inequality discrimination and disadvantage in postconflict transition by drawing upon the theories of transformative justice substantive equality and new social movements my study illustrates how these concepts and the relationships between them reinforce the overall argument that affirmative action is a legitimate tool to address socioeconomic inequalities discrimination and disadvantage in postconflict transition as noted by focusing predominantly on civil and political rights violations through a narrow set of legal remedies transitional justice often overlooks violations of socioeconomic rights and the impact of harms on victims and wider society although it may be a complex undertaking addressing these injustices within postconflict societies is essential for transitional justice to be effective different kinds of justice are needed depending on the nature of the injustice and the level at which the injustice occurred in the particular society at the moment of transition to modify postconflict structures in ways that are more inclusive equal and fair we must consider a concept of justice that is more transformative rather than transitional transformative justice allows us to look more closely at affected communities within a range of different political settings with the aim of creating communication and pursuing forms of justice that break with the structures that may have led to violence in the first place transformative justice broadens the focus of measures aimed at promoting postconflict or postauthoritarian justice for human rights abuses beyond that of transitional justice transformative justice therefore requires the development of a new specifically focused toolkit and as evans suggests there is a case to be made for the use of existing tools designed to combat inequality poverty and corruption in particular transitional justice mechanisms have thus far proved inadequate in dealing with violations relating to land such as violations of the right to housing where the established toolkit of transitional pg 7 justice is considered inappropriate or inadequate for dealing with socioeconomic inequalities then the processes through which we pursue transformative justice matters although transitional justice is primarily anchored in law for many transitional societies such as ni greater attention must be paid to the issues which lie in the background of legal and human rights discourse such as religion culture politics economics and local tradition dealing with socioeconomic inequalities within transitional settings therefore requires the integration of knowledge theories and tools from a variety of disciplines taking a more transformative justice approach to transition allows us to step away from the more normative scope of transitional justice draw upon the insights that can be gained from other fields and give serious consideration to mechanisms which traditionally fall outside of the realm of transitional justice instead of aiming to treat all people alike substantive equality aims to correct disadvantage by focusing on the detrimental consequences attached to an individuals status or group identity fredman suggests that affirmative action advances substantive equality by actively taking steps to redress inequality discrimination and disadvantage as well as prejudice within one concept barnard hepple suggest that under a substantive approach to equality special measures such as affirmative action can be used to overcome underrepresentation of disadvantaged groups in the workplace or ensure their fair share in the distribution of resources there is no one single definition or model of affirmative action even the term itself varies from jurisdiction to jurisdiction and may be referred to as positive action employment equity or special measures for the purposes of my research project the term affirmative action will be used as an umbrella term for the range of activities primarily designed to achieve equality and increase diversity through the deliberate use of race gender or other protected characteristics to the benefit of disadvantaged groups a substantive equality framework provides the space for my research project to justify the consideration of affirmative action policies to address housing inequalities in ni the development of specific targeted affirmative action policies focused on equitable outcomes and opportunities could address discrimination and unequal access as a root cause of conflict the issue of addressing housing inequalities has been largely ignored as part of nis transitional processes the application of affirmative action as a tool for dealing with these inequalities can only be considered within a transformative justice approach to dealing with the consequences of nis violent past utilising the existing tools of substantive equality as part of a transformative justice toolkit therefore strengthens the overall argument within my research project that affirmative action has a potential role to play in addressing new existing and persistent housing inequalities in postconflict belfast because transitional justice remains normatively driven it has been fairly limited in addressing the particular social and political needs of those directly affected by violent conflict oppression and human rights violations typically the externally driven topdown transitional justice agenda discourages the participation of affected populations giving them little or no opportunity to engage in the process or goals of transitional mechanisms a transformative justice approach on the other hand requires the inclusion of affected communities in shaping the agenda for law policy and practice thus opening the door to actors typically exluded in transitional processes transformative justice encourages the voice of social movements and grassroots groups as opposed to the transitional justice approach of privileging elite actors by giving agency and voice to affected populations and highlighting socioeconomic rights transformative justice could act as the catalyst for embedding these rights into transitioning societies participatory processes are therefore a vital component of transformative justice providing affected populations with the means to raise concerns and shape processes which increase the likelihood of legitimate outcomes social movements and community based organisations play a vital role in articulating the concerns of those most affected by issues such as housing inequalities evans in particular notes that the social movement praxis is ultimately essential for understanding how a transformative justice agenda might be promoted urban social movements are increasingly considered an important part of urban governance processes with local activists influencing decisionmaking through participation practices and legal tools domaradzka argues that the global spread of successful right to the city movements illustrates the power of collectives coming together under a common agenda to achieve social justice in the face of growing urban inequalities the right to the city agenda can effect change by addressing housing policies which ignore inequalities property development practices which create housing shortages and planning policies that create residential disadvantage furthermore the right to the city implies coresponsibility on governments and populations to claim defend and promote this right the rationale for taking a more transformative approach to addressing housing inequalities in belfast is thus further reinforced by the capacity of collective action to reshape policy and practice and effect lasting change across an urban agenda that is broader than just housing under a transformative justice framework participatory action could be encouraged in communities throughout belfast to fully identify the housing inequalities and needs of those most at risk from the legacy of the past and effect lasting change that achieves housing equality for all the theories of transformative justice substantive equality and new social movements explored within my research project provides a unique framework which supports the overall research argument that affirmative action could play a vital role in addressing new existing and persistent housing inequalities in postconflict belfast under a transformative justice agenda that is driven by a bottomup context specific and participatory led approach to postconflict socioeconomic justice and equality affirmative action could be utilised to reshape housing policy and address chronic housing inequalities in postconflict belfast in doing so we could look to the future as well as deal with the past methodological approach my research project takes the form of an illustrative case study conducted within an interdisciplinary sociolegal framework using comparative analysis and semistructured interviews to investigate how affirmative action could be used to address chronic housing inequalities in postconflict belfast the purpose of this case study is to illustrate how through an examination of existing examples affirmative action could be integrated into the transitional justice toolkit for addressing socioeconomic inequalities an illustrative case study approach enables the researcher to explore and understand complex issues through an empirical study of a contemporary phenomenon within its reallife context as human rights problems are common to all countries it is often useful to compare experiences in different countries and situations utilising comparative analysis methods within my illustrative case study gives access to an extensive range of alternative solutions or ideas that may reveal a way out of nis particular dilemma comparative analysis will therefore be conducted on the use of affirmative action and the role of social movements in addressing socioeconomic inequalities including housing in the us south africa and ni the purpose of this comparative analysis is to identify and draw upon the similarities and differences between the selected comparative subjects in order to investigate how the implementation of affirmative action measures could address housing inequalities in postconflict belfast and what role social movements such as the right to the city could play in reshaping housing policy and effecting lasting change while there are significant legal political social and cultural differences between the three jurisdictions selected for comparison in my study there are several commonalities in relation to socioeconomic inequalities and a deep history of societal division residential segregation and violence the issue of housing inequalities in particular is common across all three jurisdictions most importantly affirmative action policies and programmes have been utilised in each with varying degrees of success to address a range of socioeconomic inequalities including housing social movements particularly right to the city movements have also played an important role in influencing decisionmaking and shaping policy in relation to land and housing across all three jurisdictions the comparative analysis will be conducted in three parts the first part will explore the impetus and legal framework for affirmative action the implementation of affirmative action and the impact of affirmative action in all three jurisdictions in relation to addressing socioeconomic inequalities the second part will follow a similar pattern of investigation to focus specifically on how affirmative action has been implemented to address the effects of housing discrimination and segregation in both the us and south africa in order to identify similarities differences and lessons learned that may provide insight into how affirmative action could be effectively applied to the context of housing in ni where no current framework exists the final part of this comparative analysis will examine the right to the city campaigns which form an integral part of the continued fight against housing inequalities and segregation in all three jurisdictions to establish and evaluate the similarities and differences in the role of social movements in achieving social justice caitriona mackel environmental science and sustainable development pg 9 the comparative analysis will be conducted through deskbased research using a sociolegal examination of legislation case law policy documents reports and academic literature to collect and analyse relevant data on the implementation enforcement and effectiveness of affirmative action and the role of social movements to address socioeconomic inequalities including housing in all three jurisdictions by conducting a comparative analysis of legislation policies and administrative practices relating to affirmative action alongside a comparison of the role of social actors in the housing sector my research project aims to pinpoint potential limitations implications and benefits for the development of a potential participatory led regulatory affirmative action framework that could be applied to the illustrative case study on new existing and persistent housing inequalities in postconflict belfast as belfast has been selected as an illustrative case study semistructured interviews to explore local participants thoughts on the use of affirmative action in housing will be conducted within ni using a range of appropriate participants selected from the public private and community sectors interview participants will include carefully selected representatives recruited from government departments and agencies public agencies and bodies human rights organisations ngos political parties and community organisations participants who are directly involved in the provision of social housing the development of housing policy the monitoring of inequalities and those who represent community interests have been identified as the primary interview targets a small number of private landlords and property developers who are directly involved in the development and provision of social housing will also be interviewed participants will include representatives from the department for communities the ni housing executive semipublic and private social housing providers ecni the participation and practice of rights the market development association and political parties approximately 2025 interviews will be conducted using a set of predetermined openended questions designed to encourage participants to openly discuss their views on how the implementation and enforcement of affirmative action could effectively address chronic housing inequalities in belfast participants will also be asked about their thoughts and experiences of social movements and actors in shaping decisionmaking policy development and community focused human rights indicators anticipated findings conclusions implications as a work in progress there are as yet no definitive findings conclusions or implications from my research the comparative analysis process is currently underway and initial examinations of the data obtained to date indicate that there are a range of similarities and differences between the three jurisdictions being compared similarities are present in the justifications for the use of affirmative action the legal foundations of affirmative action obligations the beneficiaries and domains in which affirmative action is implemented and in some respects the effectiveness of using these measures to address socioeconomic inequalities however substantial differences in relation to the boundaries of affirmative action the role of the judiciary and the ways in which affirmative action is implemented and enforced cannot be ignored early data on the use of affirmative action to address housing discrimination and segregation in the us and south africa suggests that despite a firm legal framework in both jurisdictions progress on these issues has been slow as a result of political controversies and failures in the implementation and enforcement of affirmative action obligations for example in the us the affirmatively furthering fair housing rule established under the obama administration in 2015 set out a comprehensive statutory framework for states local governments and public housing agencies to take meaningful actions to combat discrimination overcome segregations foster inclusive communities and promote fair housing choice the affh rule showed considerable potential to increase inclusion eliminate discrimination and improve equal access to opportunity however this potential could not be reached as implementation of the rule was delayed and eventually scrapped by the trump administration in 2020 similarly in south africa the socioeconomic rights institute outlines that the persistence of discrimination does not stem from the legal and policy framework developed for housing but rather from political pressures and the manner in which this framework is implemented in practice the preliminary findings indicate that an affirmative action framework for ni could have the potential to address housing inequalities but the success of such a framework is dependent on political cooperation and the effective implementation of robust monitoring and enforcement procedures caitriona mackel environmental science and sustainable development pg 10 initial findings from the us and south africa also demonstrate that the meaningful participation of affected populations is essential for the success of an affirmative action framework in housing affirmative action is designed to redress the specific needs of those most disadvantaged marginalised exluded or ignored in society early data indicates that affirmative action measures must be designed not only for but in conjunction with the participation of affected populations in order to be responsive to these needs and affect lasting change a lack of participation implies limited power and voice to affect change in the attitudes institutions and policies which have fuelled discrimination and exclusion in the first place the challenge lies in the ability to incorporate participation in policymaking processes which are primarily conducted by political elites preliminary analysis of the work of social movements indicates that the solution could lie in their ability to overcome the barriers which exclude civil society from policy formulation a comparative analysis of the right to the city social movement in the us south africa and ni is due to commence and it is anticipated that the data will demonstrate ways in which this movement could be utilised in the policymaking process to create more legitimate transparent accountable and equitable housing policies and practices in ni semistructured interviews for which full ethical approval has been granted are currently underway in ni research participants from the ngo and community sector in particular noted how public policy underwhich housing falls is often obstructed by power sharing tensions and political deadlocks at the heart of government initial data gathered from these research participants indicates a strong desire for the development of a statutory framework which would place obligations on housing providers to monitor report on and take action to address inequalities and on government to ensure effective implementation and enforcement data obtained from interview participants to date including the nihe and a number of nis main political parties regarding the commitment to effective implementation of statutory monitoring reporting and enforcement procedures in nis employment sector indiates that similar commitments and success could be achieved in the context of housing under a statutory framework interviews are ongoing and it is anticipated that the data obtained from future participants will not only shape the development of an affirmative action framework but also further demonstrate that the timing is now right to apply affirmative action in the context of housing as suggested by sachr to secure the equitable provision and allocation of social housing in ni it is anticipated that this work in progress while culminate in the development of an affirmative action framework which could be implemented into law and policy by the ni assembly and could be monitored and enforced by the ecni this framework incorporate similar statutory monitoring reporting and enforcement process to those which already exist in employment in ni with the addition of monitoring all equality categories in order to effectively address the range of housing inequalities experienced in ni by considering the role of social movements in influencing public policy my research seeks to incorporate grassroots participation into ni policy processes to achieve reforms that address the needs of those most impacted by nis chronic housing inequalities ultimately while my research project is context specific it seeks to have wider significance and uncover the potential power of integrating affirmative action into the transitional justice toolkit for addressing socioeconomic inequalities far beyond the borders of nis most politically socially economically and spatially divided city

belfast is a deeply divided and fragmented city not just politically socially and economically but physically it is a city shaped by its history its experiences of violent conflict and its postconflict transition a collage of socalled peace walls and interface areas segregate neighbourhoods across the city creating some of the most socially and economically deprived areas where inequalities are significantly exacerbated by the tension and sectarianism that segregation reinforces despite the peace process historical and new inequalities in the provision and allocation of social housing affect many vulnerable individuals and communities resulting in unequal access to adequate housing overcrowding housing stress homelessness higher waiting lists and longer waiting times the challenge of navigating housing in a politically and physically divided city has resulted in failed opportunities to shape policies and procedures to address existing persistent and new housing inequalities addressing the legacy of violence and human rights violations is central to building sustainable peace in transitioning societies if we acknowledge that socioeconomic inequalities are not only a consequence of violent conflict but also a root cause then we must also acknowledge that correcting these inequalities is an essential component of postconflict policy transitional justice often overlooks violations of socioeconomic rights and the impact of these on victims and wider society a growing body of literature suggests transformative justice expands the traditional toolkit to include measures not typically employed in transitional justice to confront violations of socioeconomic rights address the needs of victims and assist in societal transformation more effectively under a transformative justice approach my research explores how affirmative action and the role of social movements such as the right to the city could be used to address housing inequalities in postconflict belfast in doing so we could look to the future as well as deal with the past

Background The aging population in China has grown dramatically over the past several decades. Between 2000 and 2013, the number of Chinese aged 65 and older increased from 90 million to more than 200 million [1]. By 2050, this segment of the population is projected to increase to more than 300 million and will account for approximately 30% of the entire population [1]. As the number of older adults increases, so has the number of elderly living with some form of cognitive impairment. For example, a recent epidemiological study showed that the prevalence of mild cognitive impairment in China was 20.1% among older adults aged 60 or above [2]. In addition, it is estimated that around 6% of the older adults with MCI progress to dementia annually [3]. Such increase in cognitive impairment in aging populations have major societal and human implications [4]. Studies show that persons with cognitive impairment are at greater risk of physical disabilities, disease comorbidities, hospital admissions, and subsequent mortality than their cognitively normal counterparts [4][5][6][7]. Therefore, recent research has increasingly sought to understand the factors contributing to cognitive decline in older adults. In the context of an aging population, China has also undergone a rapid urbanization due to its significant economic growth and social mobility in recent decades [8]. The share number of urban population increased from 19.4% in 1980 to 54.4% in 2014 [9]. One of the key contributors to the growing urban population is internal migration among adult populations [8]. In 2010, the number of internal migrants in China reached 221 million-nearly 1/6 of the nation's total population-and is projected to double in the next 10 years [10]. The implications of these massive demographic changes are not without health consequences. Indeed, there is now increasing evidence to suggest significant health disparities among urban residents, rural residents, and internal migrants in China [11,12]. Although findings have been mixed, most studies have demonstrated a "healthy migrant effect"-the observed finding that people who migrate are often healthier than those who did not migrate [13,14]. Accordingly, research has shown that rural-tourban migrants in China report better self-rated health than their rural counterparts [13]. Those who migrate to urban areas also exhibit lower rates of acute illnesses and disabilities relative to native urban residents [15,16]. However, almost all these previous studies used crosssection data, research is lacking in our understanding of changes in health status, such as cognitive function, in relation to changes of residential status, as the results of urbanization and migration in China. Furthermore, we know surprisingly little about the potential factors associated with stability in urban-rural residence that may influence trajectories of cognitive function in later life. This study uses multiple waves of the Chinese Longitudinal Healthy Longevity Survey to examine agerelated trajectories of cognitive function among older adults living in urban and rural areas of China. We investigate whether and to what extent stability or change in residence-i.e., native urban residence, native rural residence, rural-to-urban residence, and urban-to-rural residence-is associated with changes in cognitive function over a period of a decade. We also examine a wide breadth of socioeconomic, family support, behavioral, and health-related factors that may be contributing to the associations. The public health and policy implications of the findings are discussed. Since the economic reforms in 1979, China has experienced significant economic growth and social changes [17]. During this period, an acceleration of urbanization occurred throughout eastern regions of the nation and the number of rural-to-urban migrants increased steadily through the beginning of the twenty-first century [18,19]. The demographic shift occurring from widespread geographic mobility in China has been described as one of most extensive migrations in the human history [20]. Furthermore, many of those residing in China also experienced varying degrees of hardship from World War II, the Cultural Revolution, periods of hunger or starvation, limited educational opportunities, and other consequences of dynamic changes in socio-political institutions [21]. Although the patterns and processes of migration have been well documented in the complex context of China, its association with cognitive function in later life is understudied. --- Migration and cognitive function A significant number of studies have focused on the relationship between international migration and cognitive function [22][23][24][25]. However, the results from this literature are often inconsistent and currently inconclusive-with some studies indicating that there is no association between migration and cognitive status [24,26,27]. Far fewer studies have focused exclusively on migration within a country and the evidence is similarly contradictory. From the limited research that exists, there is some support for the healthy migrant hypothesis [13,28]-which argues that migrants are typically healthier than those living in the receiving location . For example, research from India showed that adults who migrated from rural to urban areas had lower rates of dementia than adults who resided in urban areas for long periods of time [28]. However, this finding was not supported by another study that demonstrated no difference in cognitive function between migrants and nonmigrants [29]. Nevertheless, both studies were limited by cross-sectional designs and only studied participants from a small geographic area. To date, no existing studies have examined a longitudinal association between internal migration and changes in cognitive function among older adults in China. We argue that migration is an understudied social determinant of health that operates through complex and multifactorial pathways over time. From a life course perspective, migration is associated with a number of socioeconomic, occupation, environment, social support, behavioral, and health-related factors that can have a cumulative and lasting impact on later-life trajectories of cognitive health. An individual's socioeconomic status might change along with the migration process. For example, previous studies showed that in developing countries, a large amount of rural residents migrated to urban settings for better education and working opportunities [10,30]. These advantages in SES such as education and income are considered to be protective factors of cognitive decline [31][32][33][34]. However, there may be some disadvantages related to migration. For example, changes in an individual's health behaviors are often observed from a migrant population. Rural-to-urban migrants were more likely to adapt to westernized life styles: high calorie intake, physical inactivity, and sedentary employment [35,36]. These unhealthy life styles are considered as risk factors of cognitive impairment [37][38][39]. In addition, these factors not only directly affect an individual's cognitive function but also increase the likelihood of developing chronic diseases such as hypertension and diabetes that have been shown to produce negative effects on later life cognition [40,41]. Previous research reported that migrants often experienced various stressful life events, such as separating from their families, during and after the migration process [42]. In addition, a number of studies well documented the hostility and discrimination that migrants received. For example, rural-to-urban migrants are often denied access to many of the social welfare programs such as health insurance and unemployment benefits that are available to their urban counterparts, even if they are doing the same job [10]. The perceived discrimination and family separation may result in lack of social support, which has been found to have negative impact on an individual's cognitive function [43,44]. The change in residential status may also result in changes in living and working environments. Literature suggested that people work in agricultural settings are more likely to expose pesticide that was related to decline of cognitive function [45]. In addition, open fire cooking, a major source of indoor pollution, is still more common among rural households especially in developing countries [46][47][48]. Indoor pollution has been shown to be associated with poorer cognitive function [49]. Therefore, moving from a rural to an urban setting are likely to have improved living and working environments, which may yield a positive influence on cognitive function. Besides all the factors that might change during the change of residential status, other factors also determine an individual's cognitive function. For example, a growing body of literature has demonstrated the association between physical function and cognitive function [50,51]. Age is also a strong risk factor associated with cognitive decline [52]. Compared with male, female population reported a worse cognitive function especially in the oldest old age range [53,54]. Overall, individual's SES, psychological well-being, health status, and health behaviors influence cognitive function both directly and indirectly. The migration process might change some of these factors therefore influence an individual's cognitive function. --- Hypotheses To our knowledge, this is the first study that examines how migration contributes to the cognitive function trajectories over a specific period of time among the CLHLS study participants. We expect that migration will play an important role in the differences in cognitive function trajectories among Chinese older adults. Based on prior empirical evidence and a life course perspective we posited the following hypotheses for analysis: Hypothesis 1: Native rural residents will tend to exhibit worse cognitive function and a faster rate of cognitive decline than native urban residents. Hypothesis 2: Compared to urban residents, both rural-tourban residents and urban-to-rural residents will show similar cognitive function at baseline but a faster rate of cognitive decline than native urban residents. --- Methods --- Data We used multiple waves of data from the Chinese Longitudinal Healthy Longevity Survey for this study. The CLHLS was designed to collect information on factors related to health and longevity in older adults from 22 provinces in mainland China [55]. The survey was administered every two to three years between 1998 and 2014. Beginning in 2000, newly recruited samples were added to replenish and augment the sample of oldest-old adults; and a smaller comparative sample of adults aged 65-80 years was added starting in 2002. The details of the CLHLS sampling design, response rates, attrition, and data quality have been described extensively elsewhere [55]. The current study draws from data collected in 2002, 2005, 2008-2009, 2011-2012, and 2014. Participants who were 90 years or older at baseline were excluded to reduce possible selection bias and an additional 12 participants were excluded because of missing data on cognitive function. Therefore, the total analytic sample consisted of 17,333 participants aged 65-90 at baseline who contributed 39,900 observations over the study period. Figure 1 illustrates the structure of the analytic sample by survey year, initial interview year, and survival status across waves. [56,57]. The MMSE captured four dimensions of older adults' cognitive ability: cognitive orientation, calculation, recall, and language. As previously documented, several items in the Chinese version of MMSE were modified to improve their meaning and cultural acceptability [58]. The reliability and validity of the MMSE in the CLHLS has been established in prior study [58]. In particular, previous research showed that participants were more likely to be unable to answer relatively difficult tasks when they exhibited poor health and/or existing cognitive limitations [57]. Therefore, following prior research, we categorized responses of "unable to answer" as incorrect answers [33,59,60]. This approach is widely used in previous studies and will not introduce potential bias [33,60]. We also explored alternative approaches to handle the cases for "unable to answer," such as adding an additional variable in the analyses to indicate whether the participant was unable to answer any question. We found that this approach yielded very similar results as the approach used in this study. A total MMSE score was calculated and ranged from 0 to 30, with lower scores indicating poor cognitive ability. --- Measures --- Cognitive function --- The Chinese version of the Mini-Mental State Examination was used to measure cognitive function --- Residential status Residential status was ascertained by asking participants about their residential location in early life and in adult life at each wave. Categorical variables were used to indicate participants who were: 1) rural, 2) urban, 3) rural-tourban, and 4) urban-to-rural. Persons born in rural areas and are currently living in rural areas are considered "rural;" and persons born in urban areas and are currently living in urban areas are considered "urban." Participants who were born in rural areas and currently living in urban areas were defined as "rural-to-urban" residents. Finally, participants who were born in urban areas and currently living in rural areas were defined as "urban-to-rural" residents. The categorical variables are time-varying in the prospective analyses and account for changes in adult residential location during the study period. --- Covariates Based on existing literature, we included numerous covariates that are associated with residential status and/or cognitive function . Demographic characteristics included age , gender , and ethnicity . Socioeconomic factors included childhood SES, years of education , primary lifetime occupation , and whether the respondent is economically independent . Family support factors included the participants' marital status and proximity to their children . Behavioral factors included smoking , regular consumption of vegetables and fish , and routine exercise . Finally, covariates for health status included having any disability in activities of daily living and instrumental activities of daily living , and having any diagnosed chronic disease. Missing data on study measures was minimal in the CLHLS sample . Various strategies were assessed to address missing data and the results were very similar. Therefore, the current analysis uses listwise deletion to handle missing data. --- Analyses Baseline characteristics of study participants were examined across the four residence groups. Group differences were tested using one-way ANOVA for continuous variables and chi-square tests for categorical variables. To examine changes in older adults' cognitive function across age, we used two-level multilevel models with maximum likelihood estimation-using an xtmixed procedure in Stata for analyzing longitudinal data with attrition. First, we fit unconditional models with fixed and random linear and quadratic functions that were added to the intercept-only model. Tests of model fit in preliminary analyses based on BIC values indicated that a linear function best parameterized the pattern of cognitive decline in the data. At Level 1, we estimated a linear trajectory of individual-level changes in cognitive function as a function of increasing age. We estimated between-individual effects in the age trajectories of cognitive function at Level 2. All models also controlled for mortality and loss to follow-up. The multivariate analyses were conducted in several steps. First, demographic characteristics were included to adjust for the participants' background characteristics. Next, we included a series of models to assess how socioeconomic resources, family support, health behaviors, and health-related factors contributed to the associations. A final model was tested that included all study covariates. All of the covariates were included in the model at either level 1 or level 2 . We also estimated goodness of fit indices to compare fit across the non-nested models [61]. Sampling weights were not used in the analyses because previous research indicates that the CLHLS sampling strategy was not designed as a nationally representative sample [55]. In addition, all multivariate analyses included variables used in the sampling weights to produce unbiased estimates and avoid inflated standard errors [62]. Stata version 14.2 was used for all analyses. --- Results --- Descriptive statistics Baseline sample distributions are reported in Table 2 for the overall sample and by residential status. Overall, the average age of participants was approximately 78 years, the small majority were men , and most were non-Han ethnicity . More than half of the entire sample was rural residents and most of the respondents did not migrate during the study period. Compared with other residential groups, rural residents had significantly lower levels of education, were less likely to work in professional/administrative occupations, and were less financially independent. Rural residents were also less likely to consume vegetables and fish, less likely to engage in regular exercise, and more likely to smoke. Urban residents-and rural-to-urban residents-were younger, more likely to work in professional/administrative jobs, and were more independent financially. However, rural-to-urban residents showed the worst childhood SES among the 4 groups. Urban residents also reported the highest rates of diagnosed chronic disease and ADL disability; whereas urban-to-rural residents reported somewhat higher rates of having at least one IADL disability. Overall, the mean score of MMSE was 25.7 at baseline, with rural residents exhibited the lowest MMSE scores, followed by rural-to-urban residents, and urban residents exhibited the highest scores. and changes in cognitive function. Model 1 adjusted for demographic characteristics and showed that rural residents had significantly lower MMSE scores than urban residents. In addition, rural residents and rural-to-urban migrants had significantly faster declines in cognitive function than urban residents. These patterns were largely unchanged after adding participants' family support and health status into the models. Model 2 included socioeconomic factors and shows changes in the trajectories of cognitive function related to residential status. At baseline, rural residents exhibited significantly better cognitive function at baseline compared with urban residents when accounting for socioeconomic factors. However, the results also showed that the initially higher MMSE scores among rural and rural-to-urban migrants decline at a significantly faster rate with age compared with long-term urban residents. Model 4 included behavioral factors and further showed that there were no significant baseline differences in cognitive function related to residential status. Additional analyses indicated that engaging in routine exercise was the key behavioral factor contributing to the attenuation of MMSE differences among residence groups at baseline. Model 6 included all covariates and indicated significant differences in the initial levels and/or changes in MMSE scores for rural and rural-to-urban residence relative to urban residence. To better illustrate these findings, Fig. 2 presents the results from these analyses. In sum, we found that urban residents had the lowest MMSE scores at baseline; however, we also found that older adults who resided in rural areas, migrated from rural-to- Abbreviations: SD standard deviation urban, or from urban-to-rural areas had significantly greater reductions in cognitive function with increasing age. Several sensitivity analyses were also performed. First, the results were largely unchanged when including adults who were aged 90 and older at baseline-suggesting that selection bias at advanced ages did not play a significant role in the findings. Second, we also estimated three-level multilevel models to further include residential status as a random effect in the analyses . Third, we used baseline residential status as the predictor in the model and included a dummy variable that indicated whether the respondent moved or not during the course of the study. The results from these analyses were consistent with the findings reported here. Finally, we added a variable that indicated whether the current residential location is the same as their birthplace to account for potential urbanization in rural-to-urban resident group. The results were essentially similar to those we presented in this study. --- Multilevel models of change in cognitive decline --- Discussion The purpose of this study is to examine the association between early-life and adult residential status and changes in cognitive function over time. Using longitudinal data and a time-vary indicator of residential status for older adults in China, we found significant differences in the initial levels and rates of decline in cognitive function among older adults with different residential status. Furthermore, the relationships were not fully explained by older adults' demographic background, socioeconomic resources, family support, health behaviors, and health status. The current study extends previous findings by further demonstrating how current residence and past migration can have a lasting association on trajectories of cognitive function in older adulthood [60,63]. After adjusting for all covariates, we found that rural residents had better cognitive function at baseline but a faster rate of decline than urban residents, which partially supports our first hypothesis. The observed difference in the initial level of cognitive function may be related to selective survival; whereas, the faster rate of decline may be associated with the negative consequences of living in rural areas that have been documented in previous research [64]. We also found no difference in the initial levels nor rates of decline in cognitive function between urban-to-rural residents and urban residents. This finding is somewhat in contrast to our second hypothesis. However, based on the limited evidence of urban-to-rural residents in prior studies and the relatively small size of this group, more research is needed to explore whether moving from an urban residence to a rural one could have an impact on later-life cognitive function. The findings from this study provide only partial support to the healthy migrant hypothesis [13]. Consistent with research in India [28], we found that rural-to-urban residents had better baseline cognitive function than urban residents in China. Although this finding does not fully support our second hypothesis, the explanation for this association may be attributable in part to the selection of healthy individuals who may be more likely and/ or able to migrate [65]. Indeed, we found no difference in baseline MMSE scores between urban residents and rural-to-urban residents after taking into account the participants' health status. Contrary to the healthy migrant effect, however, we also found that rural-to-urban residents had more rapid declines in cognitive function than their urban counterparts. This finding partially supports our second hypothesis. Although adjustments for a variety of important confounders did not explain this association, it is possible that the cumulative toll of these risk factors at earlier ages may have precipitated an acceleration of cognitive decline at older ages. This argument is compatible with a large body of research on the life course which demonstrates that early-life and long-term exposure to disadvantage can have consequences across the adult life span [66][67][68][69]. In the context of China, previous research has shown that living in rural areas in early life is negatively associated with cognitive function [64]. In addition, it may be that migrating from rural to urban areas may limit an individual's social network and available sources of social support from friends and family members. Studies have also suggested that rural-to-urban residents may be denied access to some of the social benefits available to their urban counterparts , which may have important implications for access to health care and health maintenance [10]. An important area for future research will be to investigate the mechanisms underlying the findings from this study and to develop possible intervention strategies to reduce these risks. As expected, health status was the strongest correlate of cognitive function in our sample of older adult. Our analyses also suggested that socioeconomic and behavioral factors had among the greatest overall model fit for estimating the changes in cognitive function across age. Accordingly, we found that education, occupation, and economic independence were strongly associated with cognitive function among older adults in China. This finding is consistent with other studies showing that higher levels of SES were associated with higher overall levels of cognitive function [60,63]. We also found that regular exercise, and healthy diet were significantly associated with higher cognitive performance, as shown elsewhere [38,70] .However, our results suggest that health status, socioeconomic factors, and health behaviors appear to be operating largely independent of the migration variables. Therefore, we encourage additional quantitative and qualitative studies of the possible mechanisms at play. This study has several limitations that should be acknowledged. First, the measure of residential status in the CLHLS is relatively crude. In particular, we were unable to identify the respondent's age at migration, the reason that they migrated, and multiple migrations-factors that may be important for understanding the association with cognitive health. Second, because of China's urbanization in recent decades, we recognize that some urban areas may have been rural areas in the past. Therefore, it is possible that some of the findings related to change of residential status may be attributable to urbanization. Although we did a sensitivity analysis to account for potential urbanization, we are not able to fully differentiate rural-to-urban migrants from those whose residential status changed because of urbanization. It is possible that the underlying mechanisms for these two groups may be different. For example, those whose residential status changed because of urbanization might not experience separation from family or changes in their environment. However, they may also have similar experience in terms of raising living standard, change of lifestyle, and improved access to care. We encourage future studies to consider how these and other factors may contribute to changes in cognitive function related to residential status. Third, we acknowledge that the CLHLS includes the oldest-old adults in China and thus may include some degree of bias related to selective survival. However, this issue is largely unavoidable when studying cognitive decline at later ages. Overall, this study provided a better knowledge and understanding on the risks related to decline of cognition. Results from this study also provided guidance for future research that addresses health disparities. Future research should not only compare rural versus urban residents, but also take consideration of the migrants, a large segment of the population in developing countries, the study results are particularly useful for those countries that are undergoing a significant social transition and urbanization. In addition, this study provided insights that help us target these identified risk factors in future research, and ultimately develop effective programs and interventions to improve cognitive function. --- Conclusions In conclusion, the current study found a robust association between early-life and adult residential status and changes in cognitive function among older adults in China. These findings provide new evidence to a growing literature on the importance of social determinants in healthy aging. We encourage additional studies to corroborate the results from this study and further explore the factors that may be contributing to differential declines in cognitive health related to place of birth and adult living environments. --- Additional file Additional file 1: Table S1 --- --- Competing interests DG is a section editor of the Journal, and MED is an association editor of the Journal. --- --- --- Disclaimer Views expressed in the paper are solely of those authors and do not necessarily reflect those of Duke University, the United Nations, and New York University. ---

Background: Residential status has been linked to numerous determinants of health and well-being. However, the influence of residential status on cognitive decline remains unclear. The purpose of this research was to assess the changes of cognitive function among older adults with different residential status (urban residents, rural-to-urban residents, rural residents, and urban-to-rural residents), over a 12-year period.

background the aging population in china has grown dramatically over the past several decades between 2000 and 2013 the number of chinese aged 65 and older increased from 90 million to more than 200 million 1 by 2050 this segment of the population is projected to increase to more than 300 million and will account for approximately 30 of the entire population 1 as the number of older adults increases so has the number of elderly living with some form of cognitive impairment for example a recent epidemiological study showed that the prevalence of mild cognitive impairment in china was 201 among older adults aged 60 or above 2 in addition it is estimated that around 6 of the older adults with mci progress to dementia annually 3 such increase in cognitive impairment in aging populations have major societal and human implications 4 studies show that persons with cognitive impairment are at greater risk of physical disabilities disease comorbidities hospital admissions and subsequent mortality than their cognitively normal counterparts 4 5 6 7 therefore recent research has increasingly sought to understand the factors contributing to cognitive decline in older adults in the context of an aging population china has also undergone a rapid urbanization due to its significant economic growth and social mobility in recent decades 8 the share number of urban population increased from 194 in 1980 to 544 in 2014 9 one of the key contributors to the growing urban population is internal migration among adult populations 8 in 2010 the number of internal migrants in china reached 221 millionnearly 16 of the nations total populationand is projected to double in the next 10 years 10 the implications of these massive demographic changes are not without health consequences indeed there is now increasing evidence to suggest significant health disparities among urban residents rural residents and internal migrants in china 1112 although findings have been mixed most studies have demonstrated a healthy migrant effectthe observed finding that people who migrate are often healthier than those who did not migrate 1314 accordingly research has shown that ruraltourban migrants in china report better selfrated health than their rural counterparts 13 those who migrate to urban areas also exhibit lower rates of acute illnesses and disabilities relative to native urban residents 1516 however almost all these previous studies used crosssection data research is lacking in our understanding of changes in health status such as cognitive function in relation to changes of residential status as the results of urbanization and migration in china furthermore we know surprisingly little about the potential factors associated with stability in urbanrural residence that may influence trajectories of cognitive function in later life this study uses multiple waves of the chinese longitudinal healthy longevity survey to examine agerelated trajectories of cognitive function among older adults living in urban and rural areas of china we investigate whether and to what extent stability or change in residenceie native urban residence native rural residence ruraltourban residence and urbantorural residenceis associated with changes in cognitive function over a period of a decade we also examine a wide breadth of socioeconomic family support behavioral and healthrelated factors that may be contributing to the associations the public health and policy implications of the findings are discussed since the economic reforms in 1979 china has experienced significant economic growth and social changes 17 during this period an acceleration of urbanization occurred throughout eastern regions of the nation and the number of ruraltourban migrants increased steadily through the beginning of the twentyfirst century 1819 the demographic shift occurring from widespread geographic mobility in china has been described as one of most extensive migrations in the human history 20 furthermore many of those residing in china also experienced varying degrees of hardship from world war ii the cultural revolution periods of hunger or starvation limited educational opportunities and other consequences of dynamic changes in sociopolitical institutions 21 although the patterns and processes of migration have been well documented in the complex context of china its association with cognitive function in later life is understudied migration and cognitive function a significant number of studies have focused on the relationship between international migration and cognitive function 22 23 24 25 however the results from this literature are often inconsistent and currently inconclusivewith some studies indicating that there is no association between migration and cognitive status 242627 far fewer studies have focused exclusively on migration within a country and the evidence is similarly contradictory from the limited research that exists there is some support for the healthy migrant hypothesis 1328 which argues that migrants are typically healthier than those living in the receiving location for example research from india showed that adults who migrated from rural to urban areas had lower rates of dementia than adults who resided in urban areas for long periods of time 28 however this finding was not supported by another study that demonstrated no difference in cognitive function between migrants and nonmigrants 29 nevertheless both studies were limited by crosssectional designs and only studied participants from a small geographic area to date no existing studies have examined a longitudinal association between internal migration and changes in cognitive function among older adults in china we argue that migration is an understudied social determinant of health that operates through complex and multifactorial pathways over time from a life course perspective migration is associated with a number of socioeconomic occupation environment social support behavioral and healthrelated factors that can have a cumulative and lasting impact on laterlife trajectories of cognitive health an individuals socioeconomic status might change along with the migration process for example previous studies showed that in developing countries a large amount of rural residents migrated to urban settings for better education and working opportunities 1030 these advantages in ses such as education and income are considered to be protective factors of cognitive decline 31 32 33 34 however there may be some disadvantages related to migration for example changes in an individuals health behaviors are often observed from a migrant population ruraltourban migrants were more likely to adapt to westernized life styles high calorie intake physical inactivity and sedentary employment 3536 these unhealthy life styles are considered as risk factors of cognitive impairment 37 38 39 in addition these factors not only directly affect an individuals cognitive function but also increase the likelihood of developing chronic diseases such as hypertension and diabetes that have been shown to produce negative effects on later life cognition 4041 previous research reported that migrants often experienced various stressful life events such as separating from their families during and after the migration process 42 in addition a number of studies well documented the hostility and discrimination that migrants received for example ruraltourban migrants are often denied access to many of the social welfare programs such as health insurance and unemployment benefits that are available to their urban counterparts even if they are doing the same job 10 the perceived discrimination and family separation may result in lack of social support which has been found to have negative impact on an individuals cognitive function 4344 the change in residential status may also result in changes in living and working environments literature suggested that people work in agricultural settings are more likely to expose pesticide that was related to decline of cognitive function 45 in addition open fire cooking a major source of indoor pollution is still more common among rural households especially in developing countries 46 47 48 indoor pollution has been shown to be associated with poorer cognitive function 49 therefore moving from a rural to an urban setting are likely to have improved living and working environments which may yield a positive influence on cognitive function besides all the factors that might change during the change of residential status other factors also determine an individuals cognitive function for example a growing body of literature has demonstrated the association between physical function and cognitive function 5051 age is also a strong risk factor associated with cognitive decline 52 compared with male female population reported a worse cognitive function especially in the oldest old age range 5354 overall individuals ses psychological wellbeing health status and health behaviors influence cognitive function both directly and indirectly the migration process might change some of these factors therefore influence an individuals cognitive function hypotheses to our knowledge this is the first study that examines how migration contributes to the cognitive function trajectories over a specific period of time among the clhls study participants we expect that migration will play an important role in the differences in cognitive function trajectories among chinese older adults based on prior empirical evidence and a life course perspective we posited the following hypotheses for analysis hypothesis 1 native rural residents will tend to exhibit worse cognitive function and a faster rate of cognitive decline than native urban residents hypothesis 2 compared to urban residents both ruraltourban residents and urbantorural residents will show similar cognitive function at baseline but a faster rate of cognitive decline than native urban residents methods data we used multiple waves of data from the chinese longitudinal healthy longevity survey for this study the clhls was designed to collect information on factors related to health and longevity in older adults from 22 provinces in mainland china 55 the survey was administered every two to three years between 1998 and 2014 beginning in 2000 newly recruited samples were added to replenish and augment the sample of oldestold adults and a smaller comparative sample of adults aged 6580 years was added starting in 2002 the details of the clhls sampling design response rates attrition and data quality have been described extensively elsewhere 55 the current study draws from data collected in 2002 2005 20082009 20112012 and 2014 participants who were 90 years or older at baseline were excluded to reduce possible selection bias and an additional 12 participants were excluded because of missing data on cognitive function therefore the total analytic sample consisted of 17333 participants aged 6590 at baseline who contributed 39900 observations over the study period figure 1 illustrates the structure of the analytic sample by survey year initial interview year and survival status across waves 5657 the mmse captured four dimensions of older adults cognitive ability cognitive orientation calculation recall and language as previously documented several items in the chinese version of mmse were modified to improve their meaning and cultural acceptability 58 the reliability and validity of the mmse in the clhls has been established in prior study 58 in particular previous research showed that participants were more likely to be unable to answer relatively difficult tasks when they exhibited poor health andor existing cognitive limitations 57 therefore following prior research we categorized responses of unable to answer as incorrect answers 335960 this approach is widely used in previous studies and will not introduce potential bias 3360 we also explored alternative approaches to handle the cases for unable to answer such as adding an additional variable in the analyses to indicate whether the participant was unable to answer any question we found that this approach yielded very similar results as the approach used in this study a total mmse score was calculated and ranged from 0 to 30 with lower scores indicating poor cognitive ability measures cognitive function the chinese version of the minimental state examination was used to measure cognitive function residential status residential status was ascertained by asking participants about their residential location in early life and in adult life at each wave categorical variables were used to indicate participants who were 1 rural 2 urban 3 ruraltourban and 4 urbantorural persons born in rural areas and are currently living in rural areas are considered rural and persons born in urban areas and are currently living in urban areas are considered urban participants who were born in rural areas and currently living in urban areas were defined as ruraltourban residents finally participants who were born in urban areas and currently living in rural areas were defined as urbantorural residents the categorical variables are timevarying in the prospective analyses and account for changes in adult residential location during the study period covariates based on existing literature we included numerous covariates that are associated with residential status andor cognitive function demographic characteristics included age gender and ethnicity socioeconomic factors included childhood ses years of education primary lifetime occupation and whether the respondent is economically independent family support factors included the participants marital status and proximity to their children behavioral factors included smoking regular consumption of vegetables and fish and routine exercise finally covariates for health status included having any disability in activities of daily living and instrumental activities of daily living and having any diagnosed chronic disease missing data on study measures was minimal in the clhls sample various strategies were assessed to address missing data and the results were very similar therefore the current analysis uses listwise deletion to handle missing data analyses baseline characteristics of study participants were examined across the four residence groups group differences were tested using oneway anova for continuous variables and chisquare tests for categorical variables to examine changes in older adults cognitive function across age we used twolevel multilevel models with maximum likelihood estimationusing an xtmixed procedure in stata for analyzing longitudinal data with attrition first we fit unconditional models with fixed and random linear and quadratic functions that were added to the interceptonly model tests of model fit in preliminary analyses based on bic values indicated that a linear function best parameterized the pattern of cognitive decline in the data at level 1 we estimated a linear trajectory of individuallevel changes in cognitive function as a function of increasing age we estimated betweenindividual effects in the age trajectories of cognitive function at level 2 all models also controlled for mortality and loss to followup the multivariate analyses were conducted in several steps first demographic characteristics were included to adjust for the participants background characteristics next we included a series of models to assess how socioeconomic resources family support health behaviors and healthrelated factors contributed to the associations a final model was tested that included all study covariates all of the covariates were included in the model at either level 1 or level 2 we also estimated goodness of fit indices to compare fit across the nonnested models 61 sampling weights were not used in the analyses because previous research indicates that the clhls sampling strategy was not designed as a nationally representative sample 55 in addition all multivariate analyses included variables used in the sampling weights to produce unbiased estimates and avoid inflated standard errors 62 stata version 142 was used for all analyses results descriptive statistics baseline sample distributions are reported in table 2 for the overall sample and by residential status overall the average age of participants was approximately 78 years the small majority were men and most were nonhan ethnicity more than half of the entire sample was rural residents and most of the respondents did not migrate during the study period compared with other residential groups rural residents had significantly lower levels of education were less likely to work in professionaladministrative occupations and were less financially independent rural residents were also less likely to consume vegetables and fish less likely to engage in regular exercise and more likely to smoke urban residentsand ruraltourban residentswere younger more likely to work in professionaladministrative jobs and were more independent financially however ruraltourban residents showed the worst childhood ses among the 4 groups urban residents also reported the highest rates of diagnosed chronic disease and adl disability whereas urbantorural residents reported somewhat higher rates of having at least one iadl disability overall the mean score of mmse was 257 at baseline with rural residents exhibited the lowest mmse scores followed by ruraltourban residents and urban residents exhibited the highest scores and changes in cognitive function model 1 adjusted for demographic characteristics and showed that rural residents had significantly lower mmse scores than urban residents in addition rural residents and ruraltourban migrants had significantly faster declines in cognitive function than urban residents these patterns were largely unchanged after adding participants family support and health status into the models model 2 included socioeconomic factors and shows changes in the trajectories of cognitive function related to residential status at baseline rural residents exhibited significantly better cognitive function at baseline compared with urban residents when accounting for socioeconomic factors however the results also showed that the initially higher mmse scores among rural and ruraltourban migrants decline at a significantly faster rate with age compared with longterm urban residents model 4 included behavioral factors and further showed that there were no significant baseline differences in cognitive function related to residential status additional analyses indicated that engaging in routine exercise was the key behavioral factor contributing to the attenuation of mmse differences among residence groups at baseline model 6 included all covariates and indicated significant differences in the initial levels andor changes in mmse scores for rural and ruraltourban residence relative to urban residence to better illustrate these findings fig 2 presents the results from these analyses in sum we found that urban residents had the lowest mmse scores at baseline however we also found that older adults who resided in rural areas migrated from ruralto abbreviations sd standard deviation urban or from urbantorural areas had significantly greater reductions in cognitive function with increasing age several sensitivity analyses were also performed first the results were largely unchanged when including adults who were aged 90 and older at baselinesuggesting that selection bias at advanced ages did not play a significant role in the findings second we also estimated threelevel multilevel models to further include residential status as a random effect in the analyses third we used baseline residential status as the predictor in the model and included a dummy variable that indicated whether the respondent moved or not during the course of the study the results from these analyses were consistent with the findings reported here finally we added a variable that indicated whether the current residential location is the same as their birthplace to account for potential urbanization in ruraltourban resident group the results were essentially similar to those we presented in this study multilevel models of change in cognitive decline discussion the purpose of this study is to examine the association between earlylife and adult residential status and changes in cognitive function over time using longitudinal data and a timevary indicator of residential status for older adults in china we found significant differences in the initial levels and rates of decline in cognitive function among older adults with different residential status furthermore the relationships were not fully explained by older adults demographic background socioeconomic resources family support health behaviors and health status the current study extends previous findings by further demonstrating how current residence and past migration can have a lasting association on trajectories of cognitive function in older adulthood 6063 after adjusting for all covariates we found that rural residents had better cognitive function at baseline but a faster rate of decline than urban residents which partially supports our first hypothesis the observed difference in the initial level of cognitive function may be related to selective survival whereas the faster rate of decline may be associated with the negative consequences of living in rural areas that have been documented in previous research 64 we also found no difference in the initial levels nor rates of decline in cognitive function between urbantorural residents and urban residents this finding is somewhat in contrast to our second hypothesis however based on the limited evidence of urbantorural residents in prior studies and the relatively small size of this group more research is needed to explore whether moving from an urban residence to a rural one could have an impact on laterlife cognitive function the findings from this study provide only partial support to the healthy migrant hypothesis 13 consistent with research in india 28 we found that ruraltourban residents had better baseline cognitive function than urban residents in china although this finding does not fully support our second hypothesis the explanation for this association may be attributable in part to the selection of healthy individuals who may be more likely and or able to migrate 65 indeed we found no difference in baseline mmse scores between urban residents and ruraltourban residents after taking into account the participants health status contrary to the healthy migrant effect however we also found that ruraltourban residents had more rapid declines in cognitive function than their urban counterparts this finding partially supports our second hypothesis although adjustments for a variety of important confounders did not explain this association it is possible that the cumulative toll of these risk factors at earlier ages may have precipitated an acceleration of cognitive decline at older ages this argument is compatible with a large body of research on the life course which demonstrates that earlylife and longterm exposure to disadvantage can have consequences across the adult life span 66 67 68 69 in the context of china previous research has shown that living in rural areas in early life is negatively associated with cognitive function 64 in addition it may be that migrating from rural to urban areas may limit an individuals social network and available sources of social support from friends and family members studies have also suggested that ruraltourban residents may be denied access to some of the social benefits available to their urban counterparts which may have important implications for access to health care and health maintenance 10 an important area for future research will be to investigate the mechanisms underlying the findings from this study and to develop possible intervention strategies to reduce these risks as expected health status was the strongest correlate of cognitive function in our sample of older adult our analyses also suggested that socioeconomic and behavioral factors had among the greatest overall model fit for estimating the changes in cognitive function across age accordingly we found that education occupation and economic independence were strongly associated with cognitive function among older adults in china this finding is consistent with other studies showing that higher levels of ses were associated with higher overall levels of cognitive function 6063 we also found that regular exercise and healthy diet were significantly associated with higher cognitive performance as shown elsewhere 3870 however our results suggest that health status socioeconomic factors and health behaviors appear to be operating largely independent of the migration variables therefore we encourage additional quantitative and qualitative studies of the possible mechanisms at play this study has several limitations that should be acknowledged first the measure of residential status in the clhls is relatively crude in particular we were unable to identify the respondents age at migration the reason that they migrated and multiple migrationsfactors that may be important for understanding the association with cognitive health second because of chinas urbanization in recent decades we recognize that some urban areas may have been rural areas in the past therefore it is possible that some of the findings related to change of residential status may be attributable to urbanization although we did a sensitivity analysis to account for potential urbanization we are not able to fully differentiate ruraltourban migrants from those whose residential status changed because of urbanization it is possible that the underlying mechanisms for these two groups may be different for example those whose residential status changed because of urbanization might not experience separation from family or changes in their environment however they may also have similar experience in terms of raising living standard change of lifestyle and improved access to care we encourage future studies to consider how these and other factors may contribute to changes in cognitive function related to residential status third we acknowledge that the clhls includes the oldestold adults in china and thus may include some degree of bias related to selective survival however this issue is largely unavoidable when studying cognitive decline at later ages overall this study provided a better knowledge and understanding on the risks related to decline of cognition results from this study also provided guidance for future research that addresses health disparities future research should not only compare rural versus urban residents but also take consideration of the migrants a large segment of the population in developing countries the study results are particularly useful for those countries that are undergoing a significant social transition and urbanization in addition this study provided insights that help us target these identified risk factors in future research and ultimately develop effective programs and interventions to improve cognitive function conclusions in conclusion the current study found a robust association between earlylife and adult residential status and changes in cognitive function among older adults in china these findings provide new evidence to a growing literature on the importance of social determinants in healthy aging we encourage additional studies to corroborate the results from this study and further explore the factors that may be contributing to differential declines in cognitive health related to place of birth and adult living environments additional file additional file 1 table s1 competing interests dg is a section editor of the journal and med is an association editor of the journal disclaimer views expressed in the paper are solely of those authors and do not necessarily reflect those of duke university the united nations and new york university

background residential status has been linked to numerous determinants of health and wellbeing however the influence of residential status on cognitive decline remains unclear the purpose of this research was to assess the changes of cognitive function among older adults with different residential status urban residents ruraltourban residents rural residents and urbantorural residents over a 12year period

. However, many healthcare professionals attest to viewing cases of suspected elder abuse but fail to report them . One study revealed that physicians only report 2% of all suspected cases . In the same study, social workers and mental health professionals reported 25% of case and nurses reported 26% of suspected cases, a substantially larger number than reported by physicians. Even so, it is suspected that only 1 in 5 cases of abuse is reported . The reasons for lack of reporting have been identified by community health care providers and include clinicians reluctant to acknowledge abuse, lack of protocol to identify abuse, fear of liability and limited number of services available to implement for abuse . Reasons for lack of case detection decisions by healthcare professionals include lack of knowledge about elder abuse, its prevalence, signs and symptoms, risk factors, and information about perpetrators . While laws require reporting regardless of mitigating circumstances, most healthcare professionals consider the broader context of the patient before reporting, including patient autonomy and rights, patient-physician confidentiality, quality of life, and future patienthealthcare professional relationships. One study found that many physicians encounter three key realities when deciding to report; namely, they worry about future physician patient rapport and trust, patient quality of life, and physician control . Various reasons exist for having unreported cases of elder abuse, such as a lack of trust in the reporting system, difficulty in detecting abuse, and lack of time. Over 90% of emergency physicians felt that their state lacked the resources to meet the needs of victims . Just 11% of Iowa family physicians thought there were sufficient resources to address elder abuse . Although all adult protective services laws provide immunity from liability for those who report in good faith, some physicians cite that fear of liability keeps them from reporting except in cases of absolute evidence . Unreported cases exist also, as many physicians may not even broach the subject with their patients; one study showed that over 60% of physicians had never asked their elderly patients about abuse . Rodriguez and colleagues interviewed a convenience sample of 20 family and general internal medicine physicians to identify their perspectives on mandated reporting of elder abuse. This study expands that work by examining the perspectives of other healthcare professionals, as well as physicians, in primary care settings. Previous studies typically focus on the role of only physicians in reporting elder abuse, neglecting to fully reveal the multi-disciplinary approach within healthcare systems. An elder patient may encounter many mandatory reporters in their clinical visits. The purpose of this study was to explore healthcare professionals' perspectives on elder abuse to achieve a better understanding of the problems of detecting and reporting elder abuse. Then, ideas for improving the process can be generated. Specifically, this exploratory study sought to identify the barriers to elder abuse reporting and how perceptions of barriers vary depending on health care discipline. This qualitative approach using in-depth interviews is appropriate for exploring a complex domain that is not fully understood, in this case perspectives on and barriers to mandatory reporting of elder abuse, and is meant to be hypothesis-generating rather than hypothesis testing. --- METHODS The methods for this project were approved by the Institutional Review Board of the University of Iowa. Methods will be described for subject recruitment, instrument, interviews, and qualitative analyses. --- Subject Recruitment A combined convenience and purposive sample of nurses, physicians, and social workers was sought . All family physician names were obtained from the Iowa Board of Medical Examiners and all nurse names were obtained from the Iowa Board of Nursing. All family physicians were selected in two adjoining counties in Iowa to receive the mailing. The counties selected were convenient for the interviewer to have close proximity for the interviews. All nurses employed in an office setting except those employed at student health centers, as research assistants, or in pediatric specialties, were selected from the same two counties in Iowa. An office social worker provided a list of social worker names from one of these two counties. A cover letter with the list of interview questions was sent to all eligible 155 physicians, 221 nurses, and 19 social workers. Included in the envelope was a form to complete and return in a postage-paid envelope indicating the respondent would participate in the study interview. Returning a completed form indicated consent to participate. Contact information was provided on the form. After receipt of acceptance to participate, a researcher contacted the respondent and set up a time and place for interview. Sixty envelopes were returned as undeliverable. Six persons reported they felt unqualified or lacked time to participate. No further attempts were made to engage non-respondents after the initial invitation letter, as a sufficient sample size had been obtained. --- Data Collection An interview guide developed by Rodriguez and colleagues was used for this study. The guide had 13 open-ended interview questions and was developed from literature review and expert input. The questions were developed for physicians and were modified for nurses and social workers by replacing "physician" with "nurse" and "social worker." Demographic information was not collected from the subjects because of the topic. A respondent could indicate they were aware of an elder abuse incident and had not reported it, which would be against the law in Iowa. One interviewer was trained in ethnographic techniques by an investigator and she conducted all interviews. The interviewer held three practice sessions with two nurses and a physician prior to data collection and was critiqued by the three. The interviews were conducted in the respondent's or interviewer's office. At the beginning of the interview, the respondents were reminded not to indicate who they were or the names of any of the abuse victims. Interviews lasted from 10 to 60 minutes depending on the participants clinical experience with elder abuse, were all tape-recorded, and transcribed verbatim. --- Qualitative Analysis A multi-step process of thematic analysis was used to identify the core themes that represent the perceptions of nurses, physicians, and social workers about barriers to elder abuse reporting . All transcriptions were entered in N'Vivo , a qualitative software program that allows for coding and systematic searching of interview data. The analysis team was made up of a family physician geriatrician , a nurse researcher , a social worker , a medical student who served as primary investigator and interviewer for the study , and an anthropologist who oversaw the qualitative analysis of the data . To develop a preliminary codebook, each team member carefully read a sample of transcripts from all professions and assigned descriptive codes to segments of text. Team members met to reach consensus on codes and the interviewer applied these codes to the transcripts of responses of all persons interviewed. A second coding step entailed members of the research team representing each profession interactively reading through interview transcripts from subjects in their profession. Members of the research team developed discipline specific coding schemes and then met to reach consensus on overarching categories of barriers to elder abuse reporting that would capture individual differences and allow for generalizability to the perceptions of all practitioners. Codes were then grouped into these 5 primary categories and were analyzed by profession to reveal difference and similarities in discipline specific statements related to each of the five categories . --- RESULTS Nine nurses, 8 physicians, and 6 social workers participated in interviews resulting in a total of 23 participants. Nurse and physician participants worked in hospital-based outpatient clinics and stand-alone physician clinics. Social workers were employed in hospital-based outpatient clinics, a tertiary care hospital, an elder services organization, and a nursing home. --- Descriptions of Elder Abuse All professions reported emotional, financial, mental, neglect, physical, psychological, spousal, and verbal abuse as the kinds of abuse they may encounter. In addition, physicians reported isolation and sexual abuse. Social workers also mentioned self-neglect. Nurses tended to describe the abuse rather than label it, such as you might find a patient with suspicious injuries, perhaps on the forearm, some bruising or burns or a blackened eye. Physicians answered succinctly with labels, such as, physical abuse or financial exploitation. In contrast to nurses and physicians, social workers all focused on self-neglect. --- Barriers to Elder Abuse Detection and Reporting Analysis of participants' statements about barriers to detecting and reporting of elder abuse revealed five major categories under which the majority of statements could be grouped: professional orientation, assessment, interpretation, systems, and knowledge and education. The level of emphasis on each of these categories varied between each profession interviewed. --- Professional Orientation Nurses, physicians, and social workers each approach elder abuse with different values that they have developed over their years of practice. While individual experiences varied, trends emerged in the general disposition of groups of healthcare workers as they discussed their thoughts and approach to elder abuse. Nurses expressed passion about caring for their patients and preventing and detecting elder abuse. Nurses reported wanting to look for other explanations than elder abuse to explain why their patients are not doing well. As one nurse said, Concerns would be falls, which can be described as "I tripped and fell down the stairs." Does that raise a suspicion? Not typically. Nurses stated feeling uncomfortable asking about abuse, and were more task-oriented to getting things done quickly that they are assigned to do, such as taking vital signs and getting the medical record ready for the physician. One nurse explained this as, … are more concerned about "do we have the questions answered, to get the billing correct, do we have the blood pressure down, do we have all of the stuff that we need", there is not a lot of skill sometimes from the people that are actually in a position to find out much more before the seven or twelve minutes that the physician has. Nurses also looked to others to deal with abuse, noting that others were more likely to see it than they would in their practice. They thought that physicians and supervisors should be the ones dealing with the abuse, and that they should always direct any suspicions to them. Part of this stemmed from misconceptions about the laws; some nurses believed that protocol within the clinic prevented nurses from looking into reporting abuse, believing instead that the physician should look into and report it. No, I think just mainly getting social services involved and letting them take over, because that is their expertise and they will be able to get a hold of the situation. Most nurses thought they either should rarely or never report directly to the Iowa Department of Human Services , the regulatory agency for receiving reports and investigating elder abuse. One even noted explicitly that her experiences have changed how she deals with something like abuse, that she is now less likely to report every suspicion and more likely to validate her concerns first. While nurses clearly stated that all they need is a suspicion, they were unwilling to accuse people without very strong suspicions, and leave investigations into their suspicions to a physician or social worker. The doctor can do that, though, I don't know that my licensure really puts me that far. It makes me a mandatory reporter, but reporting what I see is one thing, but actually speaking directly to the person, that's totally different, unless, I was oneon-one with the patient. If the patient's telling me this stuff, then I'd say, "Ok, the doctor's going to be coming in, you need to talk this over with her." Physicians reported elder abuse as an important issue that they don't encounter enough in their practice to actively concern themselves with. One of their greatest barriers in disposition was the set of priorities with which they are otherwise concerned. Because of their limited time schedules, they prioritize with what they feel most concerned and comfortable dealing. I mean they die of heart disease, they die of high blood pressure, of cancer. So you go with what's going to kill them most likely, which is those common diseases, and elder abuse is probably too common, but it doesn't kill 400,000 people a year like heart disease does. So subconsciously, and maybe even consciously, you tend to suppress those suspicions. Physicians thought that other physicians or healthcare workers were more likely to see abused and neglected patients. If they did see it, they wanted to let social workers investigate and deal with it since they were the "experts." In addition, they respected their patients and wanted to trust and work with their patient rather than bring an outside party into the relationship. They were hesitant to upset the patient or label something as abuse. Physicians were reluctant to be incorrect, and looked for "high suspicion" and "enough information" in order to report. One physician said "doctors don't want to be wrong, they want to be 100% certain, and suspicion does not mean certainty." Social workers highly valued the safety and care of the elder, and were hesitant to talk to patients about abuse for fear of alienating caregivers and patients or bringing retaliation onto the patient. They also wanted sufficient evidence, for fear of identifying the wrong perpetrator, as well as having a strong enough case to be accepted. If a family member who was neglecting seemed to be amenable to additional services, the social worker instead attempted to manage the situation themselves instead of referring to IDHS. When they didn't feel like there was enough evidence, they would personally try to gather more information before reporting, or else they didn't report it at all and attempted to improve the possible abusive situation themselves. One social worker described her approach as, So if you don't feel like something's going to happen, it might be easier to say, "Looks like things are very good right now, but can we make this better? Can we just figure out a way to get you into a safe place, and if you're going to end up in a nursing home anyway, why go through all the rigmarole of the antagonism of making a report?" --- ASSESSMENT Many found difficulty in detecting abuse even if they were asking questions and looking for the possibility of it. Assessment for elder abuse was a major practical barrier that many found difficult to overcome with the resources available to them. A lack of time was one of the most commonly mentioned problems; both nurses and physicians felt that they had so many other tasks to deal with that there wasn't enough time to address elder abuse. Nurses felt they only had enough time to be concerned with tasks and questions to get the patient prepared to see the physician as quickly as possible. Physicians were more focused on known diseases or physical conditions that they could treat and with which they were more familiar. Both cited that they had to prioritize what could best fit into the limited time they had, and most often elder abuse didn't fall at the top of that priority list. In addition, physicians noted that elder abuse isn't a problem that you can quickly or cleanly ameliorate. The trouble is, you just can't say, "I'm going to order an EKG and a CBC, and I'm going to call a social worker because I think you're being abused." Many physicians believe that it is a "schedule buster." If they suspect the possibility of abuse, they don't have enough time to delve into the subject to gather sufficient evidence to support reporting. The assumption is that physicians are clueless and don't care… so physicians are bombarded by all these people who want us to do a better job, enthusiasts who have only that as their responsibility. Very little understanding of the realities of practice. In another pragmatic sense, obtaining privacy was a problem for all three groups. Social workers seemed most comfortable asking caretakers and family to leave the room, whereas nurses and physicians noted that it was sometimes difficult to find privacy in every visit. Nurses noted, And I think most of the time the doctor has them go out while the exam is going on, but while I'm interacting with the elderly person, that family member is in the room. Physicians thought it was fine to ask caretakers to leave, but didn't always follow through. They might ask different questions based on whether or not the caretaker was in the room, but few mentioned asking the caretaker to leave. General lack of sensitivity in detecting abuse is another factor in assessment challenges. The reasons to suspect abuse are often well hidden. One social worker said, You only see what's in front of you and do you know that someone hasn't been bathed or had their clothes put on or they're taken care of for the past month if they come to the office in their Sunday best smiling with their loving caregiver. You know, and then somebody goes into the home and finds the place is a shambles and the electricity doesn't work and the person's been freezing. All groups thought that the clinic was a controlled environment that allowed caretakers and elders to clean up before coming in. Elders seldom admitted to being abused because of fear of reprisal or being placed in a nursing home. Rarely did abuse present itself with easy physical evidence; the most common cases of financial abuse and neglect are far harder to find signs of within the clinic. In addition, social workers thought that even when they did suspect abuse, that it was difficult to obtain sufficient information to report it. Tied in with sensitivity is the problem of continuity of care. Several nurses thought that it was almost impossible to detect abuse in a one-time setting unless there were very obvious signs. One nurse said, I would have to have, for elder abuse, I'd have to see a pattern. Seeing them once wouldn't give me the feeling that I could report anything, unless you overheard. Social workers and physicians thought that seeing a person over time allowed you to understand their baseline and any deviations from it. --- INTERPRETATION While the laws surrounding elder abuse try to make it clear what constitutes elder abuse and who the law protects, interpreting and implementing the law in clinical practice proved to be more difficult for most nurses, physicians, and social workers. One social worker argued, It's not like we have universal agreement on what is abuse and what is violence in this society at all…I think that's part of what plays into this is that whole area of "What is abuse?" We don't agree. Nurses were most concerned with discerning whether something they observed actually adds up to elder abuse, or whether it was merely poor care decisions by caretakers. If you really did know someone well or felt like you understood their situation and you were on the fence, it might be reasonable in some cases to wait until the next time that you see them. Cases of abuse that were not clearly evident created challenges for others as well. One physician said, I think this is where it gets pretty complicated, because we're trying to determine probably from what is a continuum into a dichotomous state, which is suspicion: yes, no. And what do you do with all those gray areas in between? That makes it very hard. In these cases health care providers often approach the patient and family as needing more resources rather than viewing the case as purposeful abuse or neglect. One social worker said, I think for the reason that if you don't feel like something's going to happen, it's easier just to take whatever you can do in your own hands and try and fix it, and not in the light of elder abuse, just in the light of someone who has care needs that haven't been met that you can help them meet. The physicians' reasons for this seem to stem from personal values related to patient autonomy and respect, whereas social workers used their experience with the reporting system to IDHS as a gauge to determine whether something was "reportable" or not. I know for a lot of social workers, you just choose not to report because if you report, nothing's going to be done. Social workers wanted a large body of evidence available before they decide to make a report to IDHS. While they acknowledge that many cases of elder abuse are not obvious, their knowledge of the law and the reporting system made them confident in their suspicion when reporting. However, even when they feel they have well-documented abuse and dependence, many cases still were not accepted by IDHS. As said by one social worker, If we reported every case like that, that would be huge. And I don't see IDHS taking those cases. Their line of what is abuse and what they can take care of themselves tends to be drawn not on personal values, but on what the system will accept and substantiate. One of the other difficult issues for physicians and social workers was interpreting whether the patient who was being abused or neglected was a dependent adult. For an investigation to be conducted in Iowa, the alleged victim has to be dependent. A social worker noted the struggling with this determination, Whether a person chooses to live that way and they're just making those choices, or whether they actually have impaired decision-making and can't make those choices. Physicians were strong advocates of personal autonomy, but also did not want their patients to be hurt. While many contrasted elder abuse with child abuse, they expressed that it was far more difficult determining dependence in an elder than in a child. For example, one physician said, There often is question whether a 90-year old is totally dependent. It's not always black and white in elders, whereas the existence of dependence is very black and white in children. Determination of dependences factored into decisions of whether to report or to work with the elder to improve their own care. Every social worker said that dependence was an important consideration for them when reporting. Unlike determining whether abuse was occurring, social workers typically relied on physician expertise to help make the final determination of dependence. --- SYSTEM There were two major systems discussed in the interviews: the internal system of responsibility within a clinic or hospital, and the external system of reporting to IDHS. Most nurses seemed generally unaware of exact protocols for reporting elder abuse in their clinic, and some thought they didn't exist. They preferred to refer suspected abuse to the physician and/or to the social worker. Nurses also seemed generally unaware of dealing with the reporting system external to their clinic. While some claimed suspicions of abuse, only one described actually calling and reporting to DHS in another state. Physicians generally thought it best to report in their system to a social worker, but wished the internal system was easier to navigate. They preferred for the social worker to take over for them and tell them how best to proceed. It's not "call this number and we'll be right down," it's "this is what you should ask, and this is how you should investigate," and the trouble is, we don't have time to ask that or investigate that. Some physicians acknowledged that part of this came from lack of payment or compensation for the long time requirements that come with reporting. Most physicians' knowledge of reporting to IDHS came from hearsay that the system was frustrating. One who had tried to report was of the opinion that IDHS seems to be underfunded and overworked, and he'd had frustrating results from reporting. Social workers were by far the most dextrous at navigating both internal clinical and external IDHS systems. They thought that often physicians or nurses wanted the social worker to report for them. One commented that this was a poor choice; even though there might be a team approach to investigating the suspected abuse internally, everyone should take the burden upon themselves to report the abuse so that there are checks within the system to ensure cases get reported. I will say there have been a couple cases where I have known that there's been a report made, with patient's that I've seen, that I did not think it was a dependent adult, but somebody else felt they were and made a report. Which is, in a way, the system working. Because they had the most experience with reporting, social workers knew in detail the problems they encountered with reporting to IDHS. All except one social worker found the process "frustrating". Because of how the reporting system is legislated in Iowa, social workers often found that most of their reported cases of abuse were not even accepted by IDHS for investigation. I'm not aware that they have accepted more than one report in our county this year. Some social workers blamed the law as too prohibitive. What I mean by that is that if it's so stringent that there has to be a caretaker or if the definition of dependent is so stringent that adult protective services isn't taking referrals, then we have to do something about that to loosen that up or at least to have some kind of alternative so that person can still be brought into the system. Social workers felt that there needed to be something else in place to bring alleged victims into the system and obtain resources. When cases were accepted, they were often not substantiated, even when social workers had documented that abuse or neglect had occurred. I feel like the neglect rises to a level of self-neglect, but IDHS or the county hasn't agreed with that, and felt like the situation almost needed to worsen before they could step in or do anything. Some blamed this on parts of the law being unclear, leading to different interpretations by social workers and IDHS. Some explained that since IDHS is under such tight funding restrictions, they choose to interpret reports so that they don't have to investigate in order to stay within their budget. Because of this, some social workers believed that IDHS should not be responsible for investigating both child and adult abuse, and advocate bringing more resources toward investigating elder abuse. You're not going to get stronger laws, because IDHS is always going to argue against them, because a stronger law is going to be more people into the system, and that destroys their budget, and they can't do it, so they'll write fiscal notes all the time to block anything that's going to cost more money, even though it should help more people. Even when abuse is substantiated, social workers generally did not see changes occurring in those mistreated. The caretaker may be banned from professionally practicing, but the caretaker can still privately take care of family members. IDHS isn't regulated to obtain resources for the elder unless they have permission to, and for some dependent adults they don't receive that permission. If they do, they often do not have adequate funding to obtain needed resources or to pay guardians and conservators. Unlike child or domestic abuse, no institutional settings are available for placement. Because there is not a clear remedy to these situations, many social workers attempted to work inside the system, but often obtained far better results by working outside it, as one social worker explained, What we want is to continue to follow up if those rejections occur, because that doesn't take away the fact that they're still living in an avarice situation. So we want to work outside that if we have to, and to answer your question then what we want to do, what we can do is go in and do an assessment to try to work with the person to set up the services that they might benefit from, even if they are not a so called 'founded case' of dependent adult abuse. They report what they think they might be able to be substantiated with well-documented evidence or a paper trail. "I guess it's probably made me a little more argumentative, and when I call DHS, I feel like I have to have a really strong case and a lot of concrete evidence to provide them to insure that it gets accepted or to up the likelihood that it gets accepted. So I try to have all my information and to be able to defend it." --- KNOWLEDGE AND EDUCATION Overall, social workers were the most informed about the detection and reporting of elder abuse, likely because they had all undergone the process of trying to report cases. A few thought that education and awareness of elder abuse could be improved for clinicians. Nurses and physicians weren't nearly as comfortable with their knowledge of abuse as social workers. As one physician noted, I think because it's an infrequent thing that doctors think about, it falls away as far as things to remember. It's like any other medical issue, if you don't treat it or see it frequently, you're not going to remember how to treat it as much in the future. While Iowa is currently the only state with required education for mandatory reporters of abuse every five years, most found this training inadequate and unpractical for approaching an elder with suspicion of abuse. Many would like more case-based pragmatic training that they could actually use. One physician said, What exactly do you say? I mean, the education tends to be very vague. "Well, if you suspect elder abuse, you should inquire about X, Y, Z," without using the exact words that you would use. So what we need is the exact words. Nurses and physicians were typically unsure of a specific person or number to contact for reporting abuse and unsure how to proceed if abuse was suspected. Some physicians and nurses presented inaccuracies in their knowledge about elder abuse. Most physicians thought that elder abuse was rare. Most nurses were unaware of many of the laws surrounding confidentiality, anonymity, and personal liability for reporting, as well as who should specifically be the one to report. One nurse voiced her uncertainty, We're mandatory reporters, but I don't know what that includes. Something that they tell us here in the office, if that can be divulged. But if I am outside of the office, I wouldn't hesitate at all. --- DISCUSSION The purpose of this exploratory study was to elicit the perspectives of nurses, physicians, and social workers surrounding the detection and reporting of elder abuse in primary care settings. What emerged was a sequence of events that occur during elder abuse detection and reporting that detailed the barriers to reporting elder abuse: the professional orientation held even before entering a room with a possibly mistreated elder, the assessment of that elder for abuse, interpretation of the assessment, and reporting and managing the case of elder abuse both within internal institutional and external IDHS systems. An additional barrier to detection and reporting, cross-cutting the others was the lack of knowledge and adequate education for assessing and addressing elder abuse and neglect. As our study demonstrates, each group of health care providers has different perspectives on their role in the detection and reporting of elder abuse. Nurses tended to perceive elder abuse as uncommon and generally did not feel it was their role nor did they have time to assess patients for potential abuse. Rather they relied on physicians to detect and report elder abuse. Physicians felt that other patient care issues, time limitations and maintaining trust in the clinician-patient relationship outweighed the importance of detecting and pursuing suspected cases of elder abuse, and relied on social workers to approach these issues with patients. Social workers, although having the most knowledge and experience related to elder abuse, relied on nurses and physicians to detect potential abusive situations and to work with them in making appropriate referrals. While social workers were perceived by all groups as having a major role in reporting elder abuse, social workers reported major obstacles to reporting and achieving adequate results within the current system. All groups acknowledged the need for more and better education about elder abuse detection and reporting. While previous studies have tended to focus solely on physicians, the current study's focus on three different groups of healthcare professionals revealed both common and divergent perceptions of elder abuse detection and reporting. Physician-patient relationship, increase and decrease in patient quality of life, and presence and loss of physician control were themes identified by primary care physicians answering the same questions as the participants in this study . Even though concepts were labeled differently from this work and the earlier study, the same issues were evident, such as discerning that abuse occurred, deciding when to report, hurting the provider-patient relationship if a report is made, deciding to provide increased services than reporting , and determining who should report. Similar themes also evolved in this study as noted in the earlier work about reporting: reluctant to acknowledge abuse, lack of knowledge about reporting laws, protocol for reporting, and limited funding for services . In a recent focus group study to develop and validate an instrument, nurses, physicians, and social workers involved with elder abuse appeared to have similar thoughts as the respondents in this study . Nurses were practical and cognizant of time constraints in the clinic setting, physicians were holistic in their approach but were also constrained by practicality and time, and social workers were advocates for their clients. While Iowa is currently the only state with mandatory training on dependent adult abuse, confusion still persists as to the actual law surrounding both abuse and mandatory reporting, especially by nurses. Differing institutional requirements and chains of command may contribute to this confusion. When asked what changes or improvements could be made, many people from all groups suggested more frequent and more practical education. While education is currently mandated for every five years in Iowa for mandatory reporters of abuse, participants requested refreshers to be given as often as yearly. They also desired content to focus on specific cases and questions, as well as how to best respond. It is possible that such education could be helpful in providing a better base of knowledge for people to address both assessment and interpretation of elder abuse. While the realities of a busy clinic cannot be changed, giving clinicians the tools to function in that clinic and better assess patients for elder abuse in the short amount of time they have may begin to address practicality problems. While not as obvious as physical ailments, elder abuse is far more prevalent and impactful on health than most clinicians recognized. Consistently screening and watching for elder abuse needs to be done in a realistic manner that fits into a clinical context. The difficulty arises in that asking about elder abuse cannot be a mere box checked off while a nurse reads questions off a computer. Rather, it must be a question sensitively attended to throughout the clinical evaluation both in a patient's responses and interactions with caregivers. Pragmatic education on how to address elder abuse in the clinic is essential, and is a clear, more easily implementable initial route for change than beginning to address other systemic concerns. To improve detection of elder abuse, a 6-item questionnaire, the Elder Abuse Suspicion Index, is available for use in primary care clinics . Its sensitivity is 0.47, specificity is 0.75, and takes less than 2 minutes to complete. Proper case-based education also may begin to address some of the problems of interpretation encountered when addressing elder abuse by providing examples to which nurses, physicians, and social workers can compare their own personal experiences. Physicians and nurses who had experienced case-based education felt it was some of the most helpful for later actual possible abuse situations. Reviews of the continuing health care education interventions identify experiential, interactive and case-based educational approaches as more likely resulting in provider behavior change than relying solely on didactic lectures . Nonetheless, there is no absolute way to elucidate whether a particular patient actually meets the criteria for suspicion of abuse or neglect. Facts, values, and experience go into personally defining abuse, suspicion, and dependence for each individual healthcare professional. It is here, possibly, that the multi-disciplinary team of all of these groups focused on addressing a specific case can be most beneficial by both aggregating evidence as well as multiple interpretations of the possible abuse. This may be especially valuable in dealing with typically more difficult cases of neglect, which constitute the highest proportion of abuse but cause the most speculation on dependence and personal autonomy. The external systematic structure and funding of the reporting system within the Iowa Department of Human Services was obviously a far-reaching and major systematic barrier that cannot be easily changed. The lack of documented reports makes it difficult to quantify the number of reported cases of abuse versus those accepted for investigation. Working together, the three disciplines rely on each other to maneuver the system and meet the requirements for reporting. Because of their role in most systems, social workers most often have far more expertise in reporting. An obvious undercurrent was the abounding variety of items that hindered physicians, nurses, and social workers from reporting elder abuse. For example, a commonly held notion was the idea that strong suspicion, almost to the point of certainty, was needed to report elder abuse. Many identified in one thought that they would report any suspicion, but in another detailed how though they had been suspicious of elder abuse in a certain case, they didn't report because they lacked sufficient evidence. Most seemed to understand the general idea of the law; however, implementation and understanding of the definition of "suspicion" vacillated as each individual saw fit. In contrast to the other health professionals, social workers recognized elder abuse as a common and important problem. Their general disposition to approaching elder abuse is based on what experience has taught them. Many questioned the structure of the external system and felt that it wasn't efficient or even capable of handling elder abuse. They questioned whether they should report elder abuse initially detected by someone else and whether IDHS should be the body to whom they report. They viewed the reporting system as stressful and frustrating, and this tainted how they handled their reports. These results must be considered in the context of our study limitations. As an exploratory qualitative study, we interviewed only a limited number of health care providers about their perceptions of barriers to elder abuse detection and reporting. While our overall sample size was small, it was appropriate in order to fulfill our study purpose which was to identify the range and complexity of issues and barriers perceived by different health care disciplines in relation to elder abuse and within the sample size range for similar exploratory qualitative studies . However, it may limit the generalizability of findings from this study to understanding barriers to elder abuse reporting for all groups of health care providers. Further investigation of the categories of barriers among a larger sample size would be necessary to determine the validity of our findings. Also, as noted, this open-ended interview study did not allow for quantification of respondents perceptions, but rather only the identification of salient themes in addressing issues of elder abuse in the clinical context. This study, however, does provide a clearer foundation that could be used to develop more objective questions and surveys that would allow for assessment of whether similar perceptions and barriers are present among a larger sample of healthcare providers. In addition, our study is limited to the geographical sampling. All of those sampled were in a single Iowa Department of Human Services reporting site within Iowa. The results may not be indicative of reporting results and barriers at other sites and in other states, since there are no federal laws regarding domestic elder abuse reporting. --- CONCLUSION While not as obvious as diabetes or stroke, elder abuse and neglect can have deep and longterm effects on an older person's health. The impact by healthcare professionals in recognizing and reporting elder abuse and obtaining resources for those mistreated can be profound. While continuity in the external reporting system is needed, many changes also can be made within the clinical setting as well that may facilitate reporting elder mistreatment. More frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse in the minds of nurses and physicians. This education should stress maintaining personal responsibility and fulfilling one's personal role in reporting abuse within the use of an interdisciplinary medical team. --- 2. Please tell me about any patient situations in which, for whatever reason, made you think that there may be risk of or probable elder abuse? 3. What might make you suspicious that a patient of yours was experiencing elder abuse? 4. What would you do if you become suspicious? 5. Is there anything else that a primary care nurse might consider doing once there is suspicion of elder abuse? --- 6. Under what conditions if any would you report abuse? --- 7. Under what circumstances if any would you consider only monitoring? 8. Why do you think that patients who have been victims of elder abuse might be reluctant to bring this up with their primary care nurses at regularly scheduled visits? 9. Why do you think nurses may not address the topic of elder abuse, even if suspected during regularly scheduled visits? 10. How do you feel about the law that requires nurses to report suspected elder abuse? 11. What do you think could be done in your practice to help improve the effectiveness of nurse efforts to address elder abuse? 12. What changes can be made to the clinic setting or environment that will help improve the effectiveness of nurse efforts to address elder abuse? 13. Is there anything else that we haven't talked about that you would like to say about improving nurse effectiveness in addressing elder abuse? --- APPENDIX Open-Ended Interview Questions: Nurse Instructions: Remember, during the interview, I will be taping our conversation. Please provide no information that would identify yourself or any of your patients. We are interested in understanding nurse's thoughts on addressing elder abuse in the outpatient clinical setting. --- 1. Please tell me about the kinds of elder abuse that a primary care nurse might encounter in the outpatient setting?

The purpose of this study was to explore through interviews of healthcare professionals their perspectives on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process. Through a mailed survey, nurses, physicians, and social workers were invited to participate in an interview. Nine nurses, 8 physicians, and 6 social workers were interviewed and thematic analysis was used to identify the following core themes: professional orientation, assessment, interpretation, systems, and knowledge and education. The impact by healthcare professionals in recognizing and reporting elder abuse and obtaining resources for those mistreated can be profound. Nurses tended to perceive elder abuse as uncommon and generally did not feel it was their role nor did they have time to assess patients for potential abuse. Physicians felt that other patient care issues, time limitations and maintaining trust in the clinician-patient relationship outweighed the importance of detecting and pursuing suspected cases of elder abuse. Social workers, although having the most knowledge and experience related to elder abuse, relied on nurses and physicians to detect potential abusive situations and to work with them in making appropriate referrals. The three disciplines acknowledged the need for more and better education about elder abuse detection and reporting. Participants suggested a reorganization of the external reporting system. More frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse.elder abuse; elder mistreatment; primary care; reporting In the US, mandatory reporting laws for health care professionals exist in 44 states and the District of Columbia (Daly, Jogerst, Brinig, & Dawson, 2003). Guidelines from the American Medical Association note that a physician may be the only person outside the family that an elder sees regularly, and is therefore in a key position to report elder abuse

however many healthcare professionals attest to viewing cases of suspected elder abuse but fail to report them one study revealed that physicians only report 2 of all suspected cases in the same study social workers and mental health professionals reported 25 of case and nurses reported 26 of suspected cases a substantially larger number than reported by physicians even so it is suspected that only 1 in 5 cases of abuse is reported the reasons for lack of reporting have been identified by community health care providers and include clinicians reluctant to acknowledge abuse lack of protocol to identify abuse fear of liability and limited number of services available to implement for abuse reasons for lack of case detection decisions by healthcare professionals include lack of knowledge about elder abuse its prevalence signs and symptoms risk factors and information about perpetrators while laws require reporting regardless of mitigating circumstances most healthcare professionals consider the broader context of the patient before reporting including patient autonomy and rights patientphysician confidentiality quality of life and future patienthealthcare professional relationships one study found that many physicians encounter three key realities when deciding to report namely they worry about future physician patient rapport and trust patient quality of life and physician control various reasons exist for having unreported cases of elder abuse such as a lack of trust in the reporting system difficulty in detecting abuse and lack of time over 90 of emergency physicians felt that their state lacked the resources to meet the needs of victims just 11 of iowa family physicians thought there were sufficient resources to address elder abuse although all adult protective services laws provide immunity from liability for those who report in good faith some physicians cite that fear of liability keeps them from reporting except in cases of absolute evidence unreported cases exist also as many physicians may not even broach the subject with their patients one study showed that over 60 of physicians had never asked their elderly patients about abuse rodriguez and colleagues interviewed a convenience sample of 20 family and general internal medicine physicians to identify their perspectives on mandated reporting of elder abuse this study expands that work by examining the perspectives of other healthcare professionals as well as physicians in primary care settings previous studies typically focus on the role of only physicians in reporting elder abuse neglecting to fully reveal the multidisciplinary approach within healthcare systems an elder patient may encounter many mandatory reporters in their clinical visits the purpose of this study was to explore healthcare professionals perspectives on elder abuse to achieve a better understanding of the problems of detecting and reporting elder abuse then ideas for improving the process can be generated specifically this exploratory study sought to identify the barriers to elder abuse reporting and how perceptions of barriers vary depending on health care discipline this qualitative approach using indepth interviews is appropriate for exploring a complex domain that is not fully understood in this case perspectives on and barriers to mandatory reporting of elder abuse and is meant to be hypothesisgenerating rather than hypothesis testing methods the methods for this project were approved by the institutional review board of the university of iowa methods will be described for subject recruitment instrument interviews and qualitative analyses subject recruitment a combined convenience and purposive sample of nurses physicians and social workers was sought all family physician names were obtained from the iowa board of medical examiners and all nurse names were obtained from the iowa board of nursing all family physicians were selected in two adjoining counties in iowa to receive the mailing the counties selected were convenient for the interviewer to have close proximity for the interviews all nurses employed in an office setting except those employed at student health centers as research assistants or in pediatric specialties were selected from the same two counties in iowa an office social worker provided a list of social worker names from one of these two counties a cover letter with the list of interview questions was sent to all eligible 155 physicians 221 nurses and 19 social workers included in the envelope was a form to complete and return in a postagepaid envelope indicating the respondent would participate in the study interview returning a completed form indicated consent to participate contact information was provided on the form after receipt of acceptance to participate a researcher contacted the respondent and set up a time and place for interview sixty envelopes were returned as undeliverable six persons reported they felt unqualified or lacked time to participate no further attempts were made to engage nonrespondents after the initial invitation letter as a sufficient sample size had been obtained data collection an interview guide developed by rodriguez and colleagues was used for this study the guide had 13 openended interview questions and was developed from literature review and expert input the questions were developed for physicians and were modified for nurses and social workers by replacing physician with nurse and social worker demographic information was not collected from the subjects because of the topic a respondent could indicate they were aware of an elder abuse incident and had not reported it which would be against the law in iowa one interviewer was trained in ethnographic techniques by an investigator and she conducted all interviews the interviewer held three practice sessions with two nurses and a physician prior to data collection and was critiqued by the three the interviews were conducted in the respondents or interviewers office at the beginning of the interview the respondents were reminded not to indicate who they were or the names of any of the abuse victims interviews lasted from 10 to 60 minutes depending on the participants clinical experience with elder abuse were all taperecorded and transcribed verbatim qualitative analysis a multistep process of thematic analysis was used to identify the core themes that represent the perceptions of nurses physicians and social workers about barriers to elder abuse reporting all transcriptions were entered in nvivo a qualitative software program that allows for coding and systematic searching of interview data the analysis team was made up of a family physician geriatrician a nurse researcher a social worker a medical student who served as primary investigator and interviewer for the study and an anthropologist who oversaw the qualitative analysis of the data to develop a preliminary codebook each team member carefully read a sample of transcripts from all professions and assigned descriptive codes to segments of text team members met to reach consensus on codes and the interviewer applied these codes to the transcripts of responses of all persons interviewed a second coding step entailed members of the research team representing each profession interactively reading through interview transcripts from subjects in their profession members of the research team developed discipline specific coding schemes and then met to reach consensus on overarching categories of barriers to elder abuse reporting that would capture individual differences and allow for generalizability to the perceptions of all practitioners codes were then grouped into these 5 primary categories and were analyzed by profession to reveal difference and similarities in discipline specific statements related to each of the five categories results nine nurses 8 physicians and 6 social workers participated in interviews resulting in a total of 23 participants nurse and physician participants worked in hospitalbased outpatient clinics and standalone physician clinics social workers were employed in hospitalbased outpatient clinics a tertiary care hospital an elder services organization and a nursing home descriptions of elder abuse all professions reported emotional financial mental neglect physical psychological spousal and verbal abuse as the kinds of abuse they may encounter in addition physicians reported isolation and sexual abuse social workers also mentioned selfneglect nurses tended to describe the abuse rather than label it such as you might find a patient with suspicious injuries perhaps on the forearm some bruising or burns or a blackened eye physicians answered succinctly with labels such as physical abuse or financial exploitation in contrast to nurses and physicians social workers all focused on selfneglect barriers to elder abuse detection and reporting analysis of participants statements about barriers to detecting and reporting of elder abuse revealed five major categories under which the majority of statements could be grouped professional orientation assessment interpretation systems and knowledge and education the level of emphasis on each of these categories varied between each profession interviewed professional orientation nurses physicians and social workers each approach elder abuse with different values that they have developed over their years of practice while individual experiences varied trends emerged in the general disposition of groups of healthcare workers as they discussed their thoughts and approach to elder abuse nurses expressed passion about caring for their patients and preventing and detecting elder abuse nurses reported wanting to look for other explanations than elder abuse to explain why their patients are not doing well as one nurse said concerns would be falls which can be described as i tripped and fell down the stairs does that raise a suspicion not typically nurses stated feeling uncomfortable asking about abuse and were more taskoriented to getting things done quickly that they are assigned to do such as taking vital signs and getting the medical record ready for the physician one nurse explained this as … are more concerned about do we have the questions answered to get the billing correct do we have the blood pressure down do we have all of the stuff that we need there is not a lot of skill sometimes from the people that are actually in a position to find out much more before the seven or twelve minutes that the physician has nurses also looked to others to deal with abuse noting that others were more likely to see it than they would in their practice they thought that physicians and supervisors should be the ones dealing with the abuse and that they should always direct any suspicions to them part of this stemmed from misconceptions about the laws some nurses believed that protocol within the clinic prevented nurses from looking into reporting abuse believing instead that the physician should look into and report it no i think just mainly getting social services involved and letting them take over because that is their expertise and they will be able to get a hold of the situation most nurses thought they either should rarely or never report directly to the iowa department of human services the regulatory agency for receiving reports and investigating elder abuse one even noted explicitly that her experiences have changed how she deals with something like abuse that she is now less likely to report every suspicion and more likely to validate her concerns first while nurses clearly stated that all they need is a suspicion they were unwilling to accuse people without very strong suspicions and leave investigations into their suspicions to a physician or social worker the doctor can do that though i dont know that my licensure really puts me that far it makes me a mandatory reporter but reporting what i see is one thing but actually speaking directly to the person thats totally different unless i was oneonone with the patient if the patients telling me this stuff then id say ok the doctors going to be coming in you need to talk this over with her physicians reported elder abuse as an important issue that they dont encounter enough in their practice to actively concern themselves with one of their greatest barriers in disposition was the set of priorities with which they are otherwise concerned because of their limited time schedules they prioritize with what they feel most concerned and comfortable dealing i mean they die of heart disease they die of high blood pressure of cancer so you go with whats going to kill them most likely which is those common diseases and elder abuse is probably too common but it doesnt kill 400000 people a year like heart disease does so subconsciously and maybe even consciously you tend to suppress those suspicions physicians thought that other physicians or healthcare workers were more likely to see abused and neglected patients if they did see it they wanted to let social workers investigate and deal with it since they were the experts in addition they respected their patients and wanted to trust and work with their patient rather than bring an outside party into the relationship they were hesitant to upset the patient or label something as abuse physicians were reluctant to be incorrect and looked for high suspicion and enough information in order to report one physician said doctors dont want to be wrong they want to be 100 certain and suspicion does not mean certainty social workers highly valued the safety and care of the elder and were hesitant to talk to patients about abuse for fear of alienating caregivers and patients or bringing retaliation onto the patient they also wanted sufficient evidence for fear of identifying the wrong perpetrator as well as having a strong enough case to be accepted if a family member who was neglecting seemed to be amenable to additional services the social worker instead attempted to manage the situation themselves instead of referring to idhs when they didnt feel like there was enough evidence they would personally try to gather more information before reporting or else they didnt report it at all and attempted to improve the possible abusive situation themselves one social worker described her approach as so if you dont feel like somethings going to happen it might be easier to say looks like things are very good right now but can we make this better can we just figure out a way to get you into a safe place and if youre going to end up in a nursing home anyway why go through all the rigmarole of the antagonism of making a report assessment many found difficulty in detecting abuse even if they were asking questions and looking for the possibility of it assessment for elder abuse was a major practical barrier that many found difficult to overcome with the resources available to them a lack of time was one of the most commonly mentioned problems both nurses and physicians felt that they had so many other tasks to deal with that there wasnt enough time to address elder abuse nurses felt they only had enough time to be concerned with tasks and questions to get the patient prepared to see the physician as quickly as possible physicians were more focused on known diseases or physical conditions that they could treat and with which they were more familiar both cited that they had to prioritize what could best fit into the limited time they had and most often elder abuse didnt fall at the top of that priority list in addition physicians noted that elder abuse isnt a problem that you can quickly or cleanly ameliorate the trouble is you just cant say im going to order an ekg and a cbc and im going to call a social worker because i think youre being abused many physicians believe that it is a schedule buster if they suspect the possibility of abuse they dont have enough time to delve into the subject to gather sufficient evidence to support reporting the assumption is that physicians are clueless and dont care… so physicians are bombarded by all these people who want us to do a better job enthusiasts who have only that as their responsibility very little understanding of the realities of practice in another pragmatic sense obtaining privacy was a problem for all three groups social workers seemed most comfortable asking caretakers and family to leave the room whereas nurses and physicians noted that it was sometimes difficult to find privacy in every visit nurses noted and i think most of the time the doctor has them go out while the exam is going on but while im interacting with the elderly person that family member is in the room physicians thought it was fine to ask caretakers to leave but didnt always follow through they might ask different questions based on whether or not the caretaker was in the room but few mentioned asking the caretaker to leave general lack of sensitivity in detecting abuse is another factor in assessment challenges the reasons to suspect abuse are often well hidden one social worker said you only see whats in front of you and do you know that someone hasnt been bathed or had their clothes put on or theyre taken care of for the past month if they come to the office in their sunday best smiling with their loving caregiver you know and then somebody goes into the home and finds the place is a shambles and the electricity doesnt work and the persons been freezing all groups thought that the clinic was a controlled environment that allowed caretakers and elders to clean up before coming in elders seldom admitted to being abused because of fear of reprisal or being placed in a nursing home rarely did abuse present itself with easy physical evidence the most common cases of financial abuse and neglect are far harder to find signs of within the clinic in addition social workers thought that even when they did suspect abuse that it was difficult to obtain sufficient information to report it tied in with sensitivity is the problem of continuity of care several nurses thought that it was almost impossible to detect abuse in a onetime setting unless there were very obvious signs one nurse said i would have to have for elder abuse id have to see a pattern seeing them once wouldnt give me the feeling that i could report anything unless you overheard social workers and physicians thought that seeing a person over time allowed you to understand their baseline and any deviations from it interpretation while the laws surrounding elder abuse try to make it clear what constitutes elder abuse and who the law protects interpreting and implementing the law in clinical practice proved to be more difficult for most nurses physicians and social workers one social worker argued its not like we have universal agreement on what is abuse and what is violence in this society at all…i think thats part of what plays into this is that whole area of what is abuse we dont agree nurses were most concerned with discerning whether something they observed actually adds up to elder abuse or whether it was merely poor care decisions by caretakers if you really did know someone well or felt like you understood their situation and you were on the fence it might be reasonable in some cases to wait until the next time that you see them cases of abuse that were not clearly evident created challenges for others as well one physician said i think this is where it gets pretty complicated because were trying to determine probably from what is a continuum into a dichotomous state which is suspicion yes no and what do you do with all those gray areas in between that makes it very hard in these cases health care providers often approach the patient and family as needing more resources rather than viewing the case as purposeful abuse or neglect one social worker said i think for the reason that if you dont feel like somethings going to happen its easier just to take whatever you can do in your own hands and try and fix it and not in the light of elder abuse just in the light of someone who has care needs that havent been met that you can help them meet the physicians reasons for this seem to stem from personal values related to patient autonomy and respect whereas social workers used their experience with the reporting system to idhs as a gauge to determine whether something was reportable or not i know for a lot of social workers you just choose not to report because if you report nothings going to be done social workers wanted a large body of evidence available before they decide to make a report to idhs while they acknowledge that many cases of elder abuse are not obvious their knowledge of the law and the reporting system made them confident in their suspicion when reporting however even when they feel they have welldocumented abuse and dependence many cases still were not accepted by idhs as said by one social worker if we reported every case like that that would be huge and i dont see idhs taking those cases their line of what is abuse and what they can take care of themselves tends to be drawn not on personal values but on what the system will accept and substantiate one of the other difficult issues for physicians and social workers was interpreting whether the patient who was being abused or neglected was a dependent adult for an investigation to be conducted in iowa the alleged victim has to be dependent a social worker noted the struggling with this determination whether a person chooses to live that way and theyre just making those choices or whether they actually have impaired decisionmaking and cant make those choices physicians were strong advocates of personal autonomy but also did not want their patients to be hurt while many contrasted elder abuse with child abuse they expressed that it was far more difficult determining dependence in an elder than in a child for example one physician said there often is question whether a 90year old is totally dependent its not always black and white in elders whereas the existence of dependence is very black and white in children determination of dependences factored into decisions of whether to report or to work with the elder to improve their own care every social worker said that dependence was an important consideration for them when reporting unlike determining whether abuse was occurring social workers typically relied on physician expertise to help make the final determination of dependence system there were two major systems discussed in the interviews the internal system of responsibility within a clinic or hospital and the external system of reporting to idhs most nurses seemed generally unaware of exact protocols for reporting elder abuse in their clinic and some thought they didnt exist they preferred to refer suspected abuse to the physician andor to the social worker nurses also seemed generally unaware of dealing with the reporting system external to their clinic while some claimed suspicions of abuse only one described actually calling and reporting to dhs in another state physicians generally thought it best to report in their system to a social worker but wished the internal system was easier to navigate they preferred for the social worker to take over for them and tell them how best to proceed its not call this number and well be right down its this is what you should ask and this is how you should investigate and the trouble is we dont have time to ask that or investigate that some physicians acknowledged that part of this came from lack of payment or compensation for the long time requirements that come with reporting most physicians knowledge of reporting to idhs came from hearsay that the system was frustrating one who had tried to report was of the opinion that idhs seems to be underfunded and overworked and hed had frustrating results from reporting social workers were by far the most dextrous at navigating both internal clinical and external idhs systems they thought that often physicians or nurses wanted the social worker to report for them one commented that this was a poor choice even though there might be a team approach to investigating the suspected abuse internally everyone should take the burden upon themselves to report the abuse so that there are checks within the system to ensure cases get reported i will say there have been a couple cases where i have known that theres been a report made with patients that ive seen that i did not think it was a dependent adult but somebody else felt they were and made a report which is in a way the system working because they had the most experience with reporting social workers knew in detail the problems they encountered with reporting to idhs all except one social worker found the process frustrating because of how the reporting system is legislated in iowa social workers often found that most of their reported cases of abuse were not even accepted by idhs for investigation im not aware that they have accepted more than one report in our county this year some social workers blamed the law as too prohibitive what i mean by that is that if its so stringent that there has to be a caretaker or if the definition of dependent is so stringent that adult protective services isnt taking referrals then we have to do something about that to loosen that up or at least to have some kind of alternative so that person can still be brought into the system social workers felt that there needed to be something else in place to bring alleged victims into the system and obtain resources when cases were accepted they were often not substantiated even when social workers had documented that abuse or neglect had occurred i feel like the neglect rises to a level of selfneglect but idhs or the county hasnt agreed with that and felt like the situation almost needed to worsen before they could step in or do anything some blamed this on parts of the law being unclear leading to different interpretations by social workers and idhs some explained that since idhs is under such tight funding restrictions they choose to interpret reports so that they dont have to investigate in order to stay within their budget because of this some social workers believed that idhs should not be responsible for investigating both child and adult abuse and advocate bringing more resources toward investigating elder abuse youre not going to get stronger laws because idhs is always going to argue against them because a stronger law is going to be more people into the system and that destroys their budget and they cant do it so theyll write fiscal notes all the time to block anything thats going to cost more money even though it should help more people even when abuse is substantiated social workers generally did not see changes occurring in those mistreated the caretaker may be banned from professionally practicing but the caretaker can still privately take care of family members idhs isnt regulated to obtain resources for the elder unless they have permission to and for some dependent adults they dont receive that permission if they do they often do not have adequate funding to obtain needed resources or to pay guardians and conservators unlike child or domestic abuse no institutional settings are available for placement because there is not a clear remedy to these situations many social workers attempted to work inside the system but often obtained far better results by working outside it as one social worker explained what we want is to continue to follow up if those rejections occur because that doesnt take away the fact that theyre still living in an avarice situation so we want to work outside that if we have to and to answer your question then what we want to do what we can do is go in and do an assessment to try to work with the person to set up the services that they might benefit from even if they are not a so called founded case of dependent adult abuse they report what they think they might be able to be substantiated with welldocumented evidence or a paper trail i guess its probably made me a little more argumentative and when i call dhs i feel like i have to have a really strong case and a lot of concrete evidence to provide them to insure that it gets accepted or to up the likelihood that it gets accepted so i try to have all my information and to be able to defend it knowledge and education overall social workers were the most informed about the detection and reporting of elder abuse likely because they had all undergone the process of trying to report cases a few thought that education and awareness of elder abuse could be improved for clinicians nurses and physicians werent nearly as comfortable with their knowledge of abuse as social workers as one physician noted i think because its an infrequent thing that doctors think about it falls away as far as things to remember its like any other medical issue if you dont treat it or see it frequently youre not going to remember how to treat it as much in the future while iowa is currently the only state with required education for mandatory reporters of abuse every five years most found this training inadequate and unpractical for approaching an elder with suspicion of abuse many would like more casebased pragmatic training that they could actually use one physician said what exactly do you say i mean the education tends to be very vague well if you suspect elder abuse you should inquire about x y z without using the exact words that you would use so what we need is the exact words nurses and physicians were typically unsure of a specific person or number to contact for reporting abuse and unsure how to proceed if abuse was suspected some physicians and nurses presented inaccuracies in their knowledge about elder abuse most physicians thought that elder abuse was rare most nurses were unaware of many of the laws surrounding confidentiality anonymity and personal liability for reporting as well as who should specifically be the one to report one nurse voiced her uncertainty were mandatory reporters but i dont know what that includes something that they tell us here in the office if that can be divulged but if i am outside of the office i wouldnt hesitate at all discussion the purpose of this exploratory study was to elicit the perspectives of nurses physicians and social workers surrounding the detection and reporting of elder abuse in primary care settings what emerged was a sequence of events that occur during elder abuse detection and reporting that detailed the barriers to reporting elder abuse the professional orientation held even before entering a room with a possibly mistreated elder the assessment of that elder for abuse interpretation of the assessment and reporting and managing the case of elder abuse both within internal institutional and external idhs systems an additional barrier to detection and reporting crosscutting the others was the lack of knowledge and adequate education for assessing and addressing elder abuse and neglect as our study demonstrates each group of health care providers has different perspectives on their role in the detection and reporting of elder abuse nurses tended to perceive elder abuse as uncommon and generally did not feel it was their role nor did they have time to assess patients for potential abuse rather they relied on physicians to detect and report elder abuse physicians felt that other patient care issues time limitations and maintaining trust in the clinicianpatient relationship outweighed the importance of detecting and pursuing suspected cases of elder abuse and relied on social workers to approach these issues with patients social workers although having the most knowledge and experience related to elder abuse relied on nurses and physicians to detect potential abusive situations and to work with them in making appropriate referrals while social workers were perceived by all groups as having a major role in reporting elder abuse social workers reported major obstacles to reporting and achieving adequate results within the current system all groups acknowledged the need for more and better education about elder abuse detection and reporting while previous studies have tended to focus solely on physicians the current studys focus on three different groups of healthcare professionals revealed both common and divergent perceptions of elder abuse detection and reporting physicianpatient relationship increase and decrease in patient quality of life and presence and loss of physician control were themes identified by primary care physicians answering the same questions as the participants in this study even though concepts were labeled differently from this work and the earlier study the same issues were evident such as discerning that abuse occurred deciding when to report hurting the providerpatient relationship if a report is made deciding to provide increased services than reporting and determining who should report similar themes also evolved in this study as noted in the earlier work about reporting reluctant to acknowledge abuse lack of knowledge about reporting laws protocol for reporting and limited funding for services in a recent focus group study to develop and validate an instrument nurses physicians and social workers involved with elder abuse appeared to have similar thoughts as the respondents in this study nurses were practical and cognizant of time constraints in the clinic setting physicians were holistic in their approach but were also constrained by practicality and time and social workers were advocates for their clients while iowa is currently the only state with mandatory training on dependent adult abuse confusion still persists as to the actual law surrounding both abuse and mandatory reporting especially by nurses differing institutional requirements and chains of command may contribute to this confusion when asked what changes or improvements could be made many people from all groups suggested more frequent and more practical education while education is currently mandated for every five years in iowa for mandatory reporters of abuse participants requested refreshers to be given as often as yearly they also desired content to focus on specific cases and questions as well as how to best respond it is possible that such education could be helpful in providing a better base of knowledge for people to address both assessment and interpretation of elder abuse while the realities of a busy clinic cannot be changed giving clinicians the tools to function in that clinic and better assess patients for elder abuse in the short amount of time they have may begin to address practicality problems while not as obvious as physical ailments elder abuse is far more prevalent and impactful on health than most clinicians recognized consistently screening and watching for elder abuse needs to be done in a realistic manner that fits into a clinical context the difficulty arises in that asking about elder abuse cannot be a mere box checked off while a nurse reads questions off a computer rather it must be a question sensitively attended to throughout the clinical evaluation both in a patients responses and interactions with caregivers pragmatic education on how to address elder abuse in the clinic is essential and is a clear more easily implementable initial route for change than beginning to address other systemic concerns to improve detection of elder abuse a 6item questionnaire the elder abuse suspicion index is available for use in primary care clinics its sensitivity is 047 specificity is 075 and takes less than 2 minutes to complete proper casebased education also may begin to address some of the problems of interpretation encountered when addressing elder abuse by providing examples to which nurses physicians and social workers can compare their own personal experiences physicians and nurses who had experienced casebased education felt it was some of the most helpful for later actual possible abuse situations reviews of the continuing health care education interventions identify experiential interactive and casebased educational approaches as more likely resulting in provider behavior change than relying solely on didactic lectures nonetheless there is no absolute way to elucidate whether a particular patient actually meets the criteria for suspicion of abuse or neglect facts values and experience go into personally defining abuse suspicion and dependence for each individual healthcare professional it is here possibly that the multidisciplinary team of all of these groups focused on addressing a specific case can be most beneficial by both aggregating evidence as well as multiple interpretations of the possible abuse this may be especially valuable in dealing with typically more difficult cases of neglect which constitute the highest proportion of abuse but cause the most speculation on dependence and personal autonomy the external systematic structure and funding of the reporting system within the iowa department of human services was obviously a farreaching and major systematic barrier that cannot be easily changed the lack of documented reports makes it difficult to quantify the number of reported cases of abuse versus those accepted for investigation working together the three disciplines rely on each other to maneuver the system and meet the requirements for reporting because of their role in most systems social workers most often have far more expertise in reporting an obvious undercurrent was the abounding variety of items that hindered physicians nurses and social workers from reporting elder abuse for example a commonly held notion was the idea that strong suspicion almost to the point of certainty was needed to report elder abuse many identified in one thought that they would report any suspicion but in another detailed how though they had been suspicious of elder abuse in a certain case they didnt report because they lacked sufficient evidence most seemed to understand the general idea of the law however implementation and understanding of the definition of suspicion vacillated as each individual saw fit in contrast to the other health professionals social workers recognized elder abuse as a common and important problem their general disposition to approaching elder abuse is based on what experience has taught them many questioned the structure of the external system and felt that it wasnt efficient or even capable of handling elder abuse they questioned whether they should report elder abuse initially detected by someone else and whether idhs should be the body to whom they report they viewed the reporting system as stressful and frustrating and this tainted how they handled their reports these results must be considered in the context of our study limitations as an exploratory qualitative study we interviewed only a limited number of health care providers about their perceptions of barriers to elder abuse detection and reporting while our overall sample size was small it was appropriate in order to fulfill our study purpose which was to identify the range and complexity of issues and barriers perceived by different health care disciplines in relation to elder abuse and within the sample size range for similar exploratory qualitative studies however it may limit the generalizability of findings from this study to understanding barriers to elder abuse reporting for all groups of health care providers further investigation of the categories of barriers among a larger sample size would be necessary to determine the validity of our findings also as noted this openended interview study did not allow for quantification of respondents perceptions but rather only the identification of salient themes in addressing issues of elder abuse in the clinical context this study however does provide a clearer foundation that could be used to develop more objective questions and surveys that would allow for assessment of whether similar perceptions and barriers are present among a larger sample of healthcare providers in addition our study is limited to the geographical sampling all of those sampled were in a single iowa department of human services reporting site within iowa the results may not be indicative of reporting results and barriers at other sites and in other states since there are no federal laws regarding domestic elder abuse reporting conclusion while not as obvious as diabetes or stroke elder abuse and neglect can have deep and longterm effects on an older persons health the impact by healthcare professionals in recognizing and reporting elder abuse and obtaining resources for those mistreated can be profound while continuity in the external reporting system is needed many changes also can be made within the clinical setting as well that may facilitate reporting elder mistreatment more frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse in the minds of nurses and physicians this education should stress maintaining personal responsibility and fulfilling ones personal role in reporting abuse within the use of an interdisciplinary medical team 2 please tell me about any patient situations in which for whatever reason made you think that there may be risk of or probable elder abuse 3 what might make you suspicious that a patient of yours was experiencing elder abuse 4 what would you do if you become suspicious 5 is there anything else that a primary care nurse might consider doing once there is suspicion of elder abuse 6 under what conditions if any would you report abuse 7 under what circumstances if any would you consider only monitoring 8 why do you think that patients who have been victims of elder abuse might be reluctant to bring this up with their primary care nurses at regularly scheduled visits 9 why do you think nurses may not address the topic of elder abuse even if suspected during regularly scheduled visits 10 how do you feel about the law that requires nurses to report suspected elder abuse 11 what do you think could be done in your practice to help improve the effectiveness of nurse efforts to address elder abuse 12 what changes can be made to the clinic setting or environment that will help improve the effectiveness of nurse efforts to address elder abuse 13 is there anything else that we havent talked about that you would like to say about improving nurse effectiveness in addressing elder abuse appendix openended interview questions nurse instructions remember during the interview i will be taping our conversation please provide no information that would identify yourself or any of your patients we are interested in understanding nurses thoughts on addressing elder abuse in the outpatient clinical setting 1 please tell me about the kinds of elder abuse that a primary care nurse might encounter in the outpatient setting

the purpose of this study was to explore through interviews of healthcare professionals their perspectives on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process through a mailed survey nurses physicians and social workers were invited to participate in an interview nine nurses 8 physicians and 6 social workers were interviewed and thematic analysis was used to identify the following core themes professional orientation assessment interpretation systems and knowledge and education the impact by healthcare professionals in recognizing and reporting elder abuse and obtaining resources for those mistreated can be profound nurses tended to perceive elder abuse as uncommon and generally did not feel it was their role nor did they have time to assess patients for potential abuse physicians felt that other patient care issues time limitations and maintaining trust in the clinicianpatient relationship outweighed the importance of detecting and pursuing suspected cases of elder abuse social workers although having the most knowledge and experience related to elder abuse relied on nurses and physicians to detect potential abusive situations and to work with them in making appropriate referrals the three disciplines acknowledged the need for more and better education about elder abuse detection and reporting participants suggested a reorganization of the external reporting system more frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuseelder abuse elder mistreatment primary care reporting in the us mandatory reporting laws for health care professionals exist in 44 states and the district of columbia daly jogerst brinig dawson 2003 guidelines from the american medical association note that a physician may be the only person outside the family that an elder sees regularly and is therefore in a key position to report elder abuse

While women accounts for almost half of all medical students, problems encountered due to motherhood in the time of residency still remains an unresolved issue. We investigated the prevalent concerns among female Lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities. A cross sectional observational study on this research problem was conducted at a University Hospital in Beirut, Lebanon. Female residents and chief of departments were interviewed about their point of view regarding motherhood and maternity during residency. There were 89 residents and 22 head of department who agreed to participate in this study. During the interviews, 29 residents were directly asked about their family and motherhood plans, out of which 9% did not reveal their intention. Additionally, 35% of the residents thought that this subject could affect the program directors' selection of residency candidates. Furthermore, half of them felt that having pregnant colleagues would add to their workload, and believed that pregnant colleagues showed less productivity. 45% of program directors stated that it was an important factor taken into consideration during the interview, and 68% believed that residents tended to choose their specialty according to their life priorities. Pregnancy during residency training represents major challenges for female residents and their program directors. Rules and laws designed to set a balance between career and personal life are required to simplify decision-making in this critical period. --- Background The existing literature on the subject matter of pregnancy during residency reports that residents struggle with the conflicting identities and roles of a mother, a student, and a physician [1]. The imbalance between having a family life and a medical career was only a minor problem in the past, because the vast majority of doctors were men. In case of women, however, challenges are faced and resolved permanently to achieve this balance. The number of women pursuing a career in medicine is gradually increasing. Most data comes from North American centers. In 1997, women comprised 43% of the medical students in the United States and 22% of practicing physicians [2]. In 2001, those numbers amounted to 45.8% for female medical students and 28% for female academic medical faculty [3]. Women are expected to represent 50% of all practicing doctors by the year 2040 [4]. Other than their medical profession, women physicians remain responsible for the majority of domestic tasks and the upbringing of their children, making it difficult for them to devote the hours that a profession in medicine necessitates. Women students are hindered by family concerns, while male students are less influenced by them [5]. Pregnancies during residency do occur, and they can cause professional setbacks for many residents [6]. Long hours, unpredictable work demands, guilt induced by the possible workload increase for fellow colleagues, and the residents' high expectations of themselves can all result in severe stress for pregnant residents [7]. In 2012, a random survey was distributed among 600 female physicians who had graduated from medical school in 1995. Infertility issues occurred in 24% of the respondents, with the average age of diagnosis at 33.7 years. In these cases, when asked what they would have changed in hindsight, 29% stated that they could have considered attempting conception earlier, 17% felt that they should have opted for a different specialty, and 7% wished they had utilized cryopreservation to extend fertility [8]. Another issue frequently encountered by residents concerns the reaction of their colleagues. Fellow residents or practicing physicians may oppose any increase in work that they need to assume in the occasion where pregnant residents reduce their hours of work due to pregnancy or take maternity leaves. Pregnant residents found the physical demands sought by residency and lack of support from fellow residents and their departments to be the most taxing stressors. Feelings of anger and resentment toward the pregnant residents were common among the other residents [6]. This study aims to study the intricate relationship between the personal life and career of female doctors, and the way it impacts the selection into a residency program. --- Methods A cross sectional study was conducted in 2016 at the Hotel-Dieu de France University Hospital in Beirut, Lebanon, in order to evaluate how maternity and motherhood influence the specialty choice of residents. A 30-question survey was sent to 143 female residents. A separate 13-question survey was distributed electronically to program directors of all medical and surgical specialties at our University Hospital . There were no exclusion criteria pertaining to residents. The study protocol was approved by the institution's ethical committee and the study was registered under the number: tfem/2017/16. Following an informed consent to participate, the survey was completed anonymously. The consent form was independent from the questionnaire, making the questionnaire anonymous for authors who analyzed the results. Several questions were drafted to address key issues. The survey was pilot tested with a small group; and subsequently, a final check was performed. Residents were asked about their demographics . The survey focused on maternity and included questions designed to explore issues surrounding the timing of pregnancy during residency and perceptions regarding the impact of maternity and marriage on the residents' training as well as on their career and specialty choice. Head of departments were questioned about their demographics , their opinion concerning maternity during residency, and its impact on the resident's productivity, as well as the impact during the specialty interview. Questionnaires included closed-end items and open questions for mentioning particular comments. All the questionnaires were submitted over a period of 2 months. --- Results Among the 143 residents, 89 completed the survey . Among the 23 head of departments, 22 completed the survey . The mean age of the residents is 28 years . Among the 89 residents, only 14 were married and only 5 had kids . All of them had only one child, and the pregnancy occurred during their third or fourth year. The characteristics of resident respondents and program directors are summarized in Tables 1 and2 respectively. With regard to the timing and the opinion of our residents, at the end of their 7th year of medical school, 60/ 89 declared that maternity was not an influencing factor for their specialty choice. At the end of PGY1, 63 residents also declined that maternity was an influencing factor guiding their specialty choice. During interviews, 29 residents were asked questions pertaining to maternity and parenthood, and most of them declared that they were honest about their response, while 9% stated that they were not. Indeed, 35% thought that this subject could influence the program director's selection choice, 24% thought it would not, and 41% were unsure. Conversely, 45% of program directors revealed that it was an important factor to be taken into consideration during the interview, and 68.1% believed that residents chose their specialty according to their life priorities. When questioned about their actual priorities, 87.1% of residents confirmed that their education and career came first, and only 12.9% were found to be family-oriented at that stage. Moreover, 63.6% of doctors thought that residents can simultaneously manage both a career and a family. Although 17 program directors thought that the best time for a resident to have a child was after their subspecialty, 32% of them had their first child during residency. Despite all the difficulties and obstacles that female residents have to encounter during pregnancy, the motivating factors that lead to their pregnancy include the desire to start a family , encouragement from parents , fear of future infertility , financial independence , and flexible schedules in that order. An analysis of the impact of pregnancy on their work revealed that among the 7 residents who have children, during their first trimester, 4 did not leave work before 6 pm and 2 stayed back extra hours. During their second trimester, 5 did not leave work before 6 pm and the other 2 worked extra hours. During their last trimester, 3 could not stay until 6 pm and had to leave early. With respect to the point of view of their colleagues, 41 of 88 respondents felt that their pregnant colleagues increased their personal workloads and almost half of them believed that they were less productive. Program directors thought that marriage alone affects productivity and work and 91% thought motherhood affects their residents' productivity even further. Details of the effects of motherhood based on these perspectives are summarized in Table 3. --- Discussion This is the first descriptive study in Lebanon, the aim of which is to examine residents' and program directors' opinions on motherhood during residency. In our institution, the first specialty decision has to be taken toward the end of medical school, and the second specialty decision takes place at the end of the first year for surgical specialties or the second year for internal medicine specialties. One hypothesis explaining the reasons behind motherhood not being planned before the third year is the simple fact of postponing its stress and effect on career decisions and maybe the program directors' decision. In fact, it was found that 34.8% of residents thought that this subject could influence the program director's choice unfavorably, and 45.4% of program directors revealed that it was indeed an important factor during the interview. Trying hard to strike a balance between family life and medical career exerts an impact on future choices and education. Choosing the right time to start a family is a crucial decision for women pursuing medicine, especially considering that women's prime child-bearing years coincide with the peak of her medical studies and residency, when work constraints are considerable and finances are tight, with little disposable income to hire professional assistants . These are popular opinions in many parts of the world-70% of American physicians in their response to a national survey stated that the best time for a pregnancy would be after residency, although 44% of these respondents had been pregnant during residency [9]. A 1996 study revealed that 85% of female physicians make career changes because of their children and families [10]. The pressures presented by increasing age and decreasing fertility are a reality for female physicians. In this study, it was discovered that 36.8% feared future infertility. The dilemna between biological and professional clocks may be a particularly important issue that several female physicians face-one which may have critical implications in terms of professional advancement and potential career satisfaction; despite this fact, delayed child-bearing appears to be common among American female physicians [8]. On an average, female physicians have their first child 7.4 years later than the general population [11]. In this study, the age at which the respondent residents' first pregnancy occurred was between 28 and 29, which is lower than the average age of 30.4 found in Stentz et al.'s study; Additionally, in this study, 41 of 88 respondents felt that their pregnant colleagues increased their workloads; and almost half of them , believed that they were less productive-all of which correlates with our findings. We note that there is no clear evidence that pregnant residents are less productive , but we seeked approval or denial of this prevalent opinion among our study population. Lack of support and sometimes hostility from program directors, doctors, and other residents are also extensively reported in the literature [12] [13]. Residents sometimes report receiving less support from colleagues and supervisors upon resuming work post childbirth in a study published in 2005 [7]. Those who had their first pregnancy during medical school received lesser workplace support than those who had their first pregnancies after training [8]. All these problems can be solved by planning for residents' pregnancies and clear maternity/parental leave policies [6]. Stress reduction can be achieved by opting to live in an area close to work, home, children's school, and child care. With lesser time spent on traveling between different places or stuck in bottling, more time is available for a productive career and family activities. Managing the increased workloads for colleagues seems to be another challenging aspect of this problem and would impact the decision of faculty administrators regarding the adequate number of residents that would be accepted in a program. The authors are aware that the results of this pilot study are limited by the number of participants and also by the limited response rate among residents ; larger studies involving universities in various countries and societies would be necessary to have a clear view over this important aspect of female physicians. --- Conclusion The combination of a medical career and motherhood continues to pose challenges for women-a subject matter that warrants further investigation and targeted support. Lebanese training programs can successfully enhance the experience of motherhood during residency by providing policies or laws creating a healthy balance between the competing demands of family, work, and student life. This will certainly have a positive impact on the resident's productivity and will decrease the extra workload faced by the colleagues of pregnant residents. Authors hope that pointing out this issue will lead authorities in many countries to design targeted rules and laws to set a balance between career and personal life to reinforce women's ability to participate equally in the workforce during the female residency training period. --- --- Authors' contributions AK and EN designed the study and were involved in writing of the draft; SM and EA were responsible for project conception and development; CC and PA were responsible for data collection and statistics. SM and CC participated in coordinating the different steps and execution of the study. All authors read and approved the final manuscript. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Motherhood is a demanding part of any women's life. Female interns could encounter difficulties during selection for residency program according to their plans of conceiving. Our aim is to explore the influence of female gender on the selection process of residency programs. Method: A cross sectional study was conducted in 2016 at a University Hospital in Beirut, Lebanon. Female residents and chief of departments were interviewed about the impact of the timing of motherhood during residency on the interview for admission. The questionnaire reviewed concerns among female Lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities. Results: Eighty nine female residents and 22 head of department agreed to participate in this study. During the interviews for residency acceptance, 29 residents (34.5%) were directly asked about their family and motherhood plans; 9% of them did not reveal their intention. 35% of the residents thought that this subject could affect the program directors' decision. 47% of residents felt that having pregnant colleagues would add to their workload, and almost half of them (46%) believed that pregnant colleagues showed less productivity. 45% of program directors stated that it was an important factor taken into consideration during the interview, and 68% believed that residents tended to choose their specialty according to their life priorities. Conclusion: Pregnancy during residency training represents major challenges for female residents and their program directors. Rules and laws designed to set a balance between career and personal life are required to improve women's ability to participate equally in the workforce.

while women accounts for almost half of all medical students problems encountered due to motherhood in the time of residency still remains an unresolved issue we investigated the prevalent concerns among female lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities a cross sectional observational study on this research problem was conducted at a university hospital in beirut lebanon female residents and chief of departments were interviewed about their point of view regarding motherhood and maternity during residency there were 89 residents and 22 head of department who agreed to participate in this study during the interviews 29 residents were directly asked about their family and motherhood plans out of which 9 did not reveal their intention additionally 35 of the residents thought that this subject could affect the program directors selection of residency candidates furthermore half of them felt that having pregnant colleagues would add to their workload and believed that pregnant colleagues showed less productivity 45 of program directors stated that it was an important factor taken into consideration during the interview and 68 believed that residents tended to choose their specialty according to their life priorities pregnancy during residency training represents major challenges for female residents and their program directors rules and laws designed to set a balance between career and personal life are required to simplify decisionmaking in this critical period background the existing literature on the subject matter of pregnancy during residency reports that residents struggle with the conflicting identities and roles of a mother a student and a physician 1 the imbalance between having a family life and a medical career was only a minor problem in the past because the vast majority of doctors were men in case of women however challenges are faced and resolved permanently to achieve this balance the number of women pursuing a career in medicine is gradually increasing most data comes from north american centers in 1997 women comprised 43 of the medical students in the united states and 22 of practicing physicians 2 in 2001 those numbers amounted to 458 for female medical students and 28 for female academic medical faculty 3 women are expected to represent 50 of all practicing doctors by the year 2040 4 other than their medical profession women physicians remain responsible for the majority of domestic tasks and the upbringing of their children making it difficult for them to devote the hours that a profession in medicine necessitates women students are hindered by family concerns while male students are less influenced by them 5 pregnancies during residency do occur and they can cause professional setbacks for many residents 6 long hours unpredictable work demands guilt induced by the possible workload increase for fellow colleagues and the residents high expectations of themselves can all result in severe stress for pregnant residents 7 in 2012 a random survey was distributed among 600 female physicians who had graduated from medical school in 1995 infertility issues occurred in 24 of the respondents with the average age of diagnosis at 337 years in these cases when asked what they would have changed in hindsight 29 stated that they could have considered attempting conception earlier 17 felt that they should have opted for a different specialty and 7 wished they had utilized cryopreservation to extend fertility 8 another issue frequently encountered by residents concerns the reaction of their colleagues fellow residents or practicing physicians may oppose any increase in work that they need to assume in the occasion where pregnant residents reduce their hours of work due to pregnancy or take maternity leaves pregnant residents found the physical demands sought by residency and lack of support from fellow residents and their departments to be the most taxing stressors feelings of anger and resentment toward the pregnant residents were common among the other residents 6 this study aims to study the intricate relationship between the personal life and career of female doctors and the way it impacts the selection into a residency program methods a cross sectional study was conducted in 2016 at the hoteldieu de france university hospital in beirut lebanon in order to evaluate how maternity and motherhood influence the specialty choice of residents a 30question survey was sent to 143 female residents a separate 13question survey was distributed electronically to program directors of all medical and surgical specialties at our university hospital there were no exclusion criteria pertaining to residents the study protocol was approved by the institutions ethical committee and the study was registered under the number tfem201716 following an informed consent to participate the survey was completed anonymously the consent form was independent from the questionnaire making the questionnaire anonymous for authors who analyzed the results several questions were drafted to address key issues the survey was pilot tested with a small group and subsequently a final check was performed residents were asked about their demographics the survey focused on maternity and included questions designed to explore issues surrounding the timing of pregnancy during residency and perceptions regarding the impact of maternity and marriage on the residents training as well as on their career and specialty choice head of departments were questioned about their demographics their opinion concerning maternity during residency and its impact on the residents productivity as well as the impact during the specialty interview questionnaires included closedend items and open questions for mentioning particular comments all the questionnaires were submitted over a period of 2 months results among the 143 residents 89 completed the survey among the 23 head of departments 22 completed the survey the mean age of the residents is 28 years among the 89 residents only 14 were married and only 5 had kids all of them had only one child and the pregnancy occurred during their third or fourth year the characteristics of resident respondents and program directors are summarized in tables 1 and2 respectively with regard to the timing and the opinion of our residents at the end of their 7th year of medical school 60 89 declared that maternity was not an influencing factor for their specialty choice at the end of pgy1 63 residents also declined that maternity was an influencing factor guiding their specialty choice during interviews 29 residents were asked questions pertaining to maternity and parenthood and most of them declared that they were honest about their response while 9 stated that they were not indeed 35 thought that this subject could influence the program directors selection choice 24 thought it would not and 41 were unsure conversely 45 of program directors revealed that it was an important factor to be taken into consideration during the interview and 681 believed that residents chose their specialty according to their life priorities when questioned about their actual priorities 871 of residents confirmed that their education and career came first and only 129 were found to be familyoriented at that stage moreover 636 of doctors thought that residents can simultaneously manage both a career and a family although 17 program directors thought that the best time for a resident to have a child was after their subspecialty 32 of them had their first child during residency despite all the difficulties and obstacles that female residents have to encounter during pregnancy the motivating factors that lead to their pregnancy include the desire to start a family encouragement from parents fear of future infertility financial independence and flexible schedules in that order an analysis of the impact of pregnancy on their work revealed that among the 7 residents who have children during their first trimester 4 did not leave work before 6 pm and 2 stayed back extra hours during their second trimester 5 did not leave work before 6 pm and the other 2 worked extra hours during their last trimester 3 could not stay until 6 pm and had to leave early with respect to the point of view of their colleagues 41 of 88 respondents felt that their pregnant colleagues increased their personal workloads and almost half of them believed that they were less productive program directors thought that marriage alone affects productivity and work and 91 thought motherhood affects their residents productivity even further details of the effects of motherhood based on these perspectives are summarized in table 3 discussion this is the first descriptive study in lebanon the aim of which is to examine residents and program directors opinions on motherhood during residency in our institution the first specialty decision has to be taken toward the end of medical school and the second specialty decision takes place at the end of the first year for surgical specialties or the second year for internal medicine specialties one hypothesis explaining the reasons behind motherhood not being planned before the third year is the simple fact of postponing its stress and effect on career decisions and maybe the program directors decision in fact it was found that 348 of residents thought that this subject could influence the program directors choice unfavorably and 454 of program directors revealed that it was indeed an important factor during the interview trying hard to strike a balance between family life and medical career exerts an impact on future choices and education choosing the right time to start a family is a crucial decision for women pursuing medicine especially considering that womens prime childbearing years coincide with the peak of her medical studies and residency when work constraints are considerable and finances are tight with little disposable income to hire professional assistants these are popular opinions in many parts of the world70 of american physicians in their response to a national survey stated that the best time for a pregnancy would be after residency although 44 of these respondents had been pregnant during residency 9 a 1996 study revealed that 85 of female physicians make career changes because of their children and families 10 the pressures presented by increasing age and decreasing fertility are a reality for female physicians in this study it was discovered that 368 feared future infertility the dilemna between biological and professional clocks may be a particularly important issue that several female physicians faceone which may have critical implications in terms of professional advancement and potential career satisfaction despite this fact delayed childbearing appears to be common among american female physicians 8 on an average female physicians have their first child 74 years later than the general population 11 in this study the age at which the respondent residents first pregnancy occurred was between 28 and 29 which is lower than the average age of 304 found in stentz et als study additionally in this study 41 of 88 respondents felt that their pregnant colleagues increased their workloads and almost half of them believed that they were less productiveall of which correlates with our findings we note that there is no clear evidence that pregnant residents are less productive but we seeked approval or denial of this prevalent opinion among our study population lack of support and sometimes hostility from program directors doctors and other residents are also extensively reported in the literature 12 13 residents sometimes report receiving less support from colleagues and supervisors upon resuming work post childbirth in a study published in 2005 7 those who had their first pregnancy during medical school received lesser workplace support than those who had their first pregnancies after training 8 all these problems can be solved by planning for residents pregnancies and clear maternityparental leave policies 6 stress reduction can be achieved by opting to live in an area close to work home childrens school and child care with lesser time spent on traveling between different places or stuck in bottling more time is available for a productive career and family activities managing the increased workloads for colleagues seems to be another challenging aspect of this problem and would impact the decision of faculty administrators regarding the adequate number of residents that would be accepted in a program the authors are aware that the results of this pilot study are limited by the number of participants and also by the limited response rate among residents larger studies involving universities in various countries and societies would be necessary to have a clear view over this important aspect of female physicians conclusion the combination of a medical career and motherhood continues to pose challenges for womena subject matter that warrants further investigation and targeted support lebanese training programs can successfully enhance the experience of motherhood during residency by providing policies or laws creating a healthy balance between the competing demands of family work and student life this will certainly have a positive impact on the residents productivity and will decrease the extra workload faced by the colleagues of pregnant residents authors hope that pointing out this issue will lead authorities in many countries to design targeted rules and laws to set a balance between career and personal life to reinforce womens ability to participate equally in the workforce during the female residency training period authors contributions ak and en designed the study and were involved in writing of the draft sm and ea were responsible for project conception and development cc and pa were responsible for data collection and statistics sm and cc participated in coordinating the different steps and execution of the study all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background motherhood is a demanding part of any womens life female interns could encounter difficulties during selection for residency program according to their plans of conceiving our aim is to explore the influence of female gender on the selection process of residency programs method a cross sectional study was conducted in 2016 at a university hospital in beirut lebanon female residents and chief of departments were interviewed about the impact of the timing of motherhood during residency on the interview for admission the questionnaire reviewed concerns among female lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities results eighty nine female residents and 22 head of department agreed to participate in this study during the interviews for residency acceptance 29 residents 345 were directly asked about their family and motherhood plans 9 of them did not reveal their intention 35 of the residents thought that this subject could affect the program directors decision 47 of residents felt that having pregnant colleagues would add to their workload and almost half of them 46 believed that pregnant colleagues showed less productivity 45 of program directors stated that it was an important factor taken into consideration during the interview and 68 believed that residents tended to choose their specialty according to their life priorities conclusion pregnancy during residency training represents major challenges for female residents and their program directors rules and laws designed to set a balance between career and personal life are required to improve womens ability to participate equally in the workforce

Introduction Youths are in a state of rapid physical and psychological change. They have curiosity and urge to experience new phenomena [1]. Nevertheless, youths are exposed to different circumstance like fears, worries and different desires, they feel shame to get advice and guidance from their parents and elders [2]. Over a life cycle approach, youths and their communities need to know about reproductive health so that, they can make informed decisions about their reproductive health and sexuality [3,4]. Premarital sex, defined as voluntary sexual intercourse between unmarried persons, is increasing worldwide [5]. It is unsafe because, most youths have no enough awareness on how to prevent and how to get guidance services on reproductive anatomy, physiology, sexually transmitted infection , and Human Immunodeficiency Virus [6,7]. As a result, they are exposed to serious problems including premarital sex with its consequences and emotional scar [8,9]. Though, schools are institutions where sufficient information and formal educations are provided to youths, premarital sexual practice among high school youths have been increased worldwide [10]. Globally, 35.3 million people live with HIV/AIDS of which youths account 2.1 million. Among 2.3 million new HIV infections, youths account more than half [7]. Illegal abortions, risk of HIV infections and school dropout are the bad consequences of pre-marital sex in sub-Saharan Africa [11]. Up to 25% of 15-19 years, old youth's exercised sex before age 15. In Ethiopia, the prevalence of premarital sex is increasing [12][13][14]. A study conducted in Eastern part of Ethiopia and Lalibela Town reported that above one-fourth of the school youths were exposed to premarital sex [12,15]. Another study which is done in west Shoa Zone reported that about 60% of high school youths were exercised premarital sex [9]. Different scholars identified inconsistent factors which were positively or negatively associated with premarital sexual practice. Some of these factors includes age of students, sex, residence, educational level, peer pressure, having pocket money, substance use, alcohol drink, watching pornography movie, living arrangement, discussion with parents about sexual issues, having peers who are experienced sex and fall in love and access religious and life skill education [9,[12][13][14][15][16][17]. According to Debretabor district health office report sexually transmitted diseases, abortion and unwanted pregnancy are high in the study area among youths [18]. However, prevalence of premarital sexual practice and its associated factors among high school youths in the study area was not dealt yet. Thus, this study aimed to determine premarital sexual practices and associated factors among high school youths in Debretabor town, south Gondar, Ethiopia. --- Main text --- Methods --- Study design and setting School based cross-sectional study design was conducted from September 18 to October 16, 2017, among high school youths in Debretabor town, South Gondar zone, Ethiopia. Debretabor town is located at 667 km from Addis Ababa, capital city of Ethiopia and has three high schools. The total numbers of high school youths in the study area by the year 2017 were 8892 [18]. --- Source population The source population was all high school youths who were residing in Debretabor town and its surrounding rural Kebeles. --- Study population The study population was all high-school youths aged 15 to 24 years that were enrolled as a regular day-time student in 2017. --- Inclusion criteria All secondary school youths aged 15-24 attending regular class in Debretabor town during data collection period were included in the study. --- Exclusion criterion Married high school youths were excluded. --- Sample size determination Sample size was calculated using a single population proportion formula designated as n = p d 2 based on the assumptions of P-value = 0.25 which was the proportion of premarital sex among in-school youths in Jimma [19], a 95% confidence level, 4% margin of error and 10% non-response rate. Accordingly, the total sample size calculated was 497. --- Sampling procedure All the high schools in the town were included in the study, and total sample size was proportionally allocated to each school. The lists of youths were obtained from the respective school registrar. Then, the study participants from each school were selected by computer generated simple random sampling technique after proportional allocation to their grade level. --- Data collection Pre-tested, self-administered structured Amharic questionnaire was used to collect the data. The questionnaire was pre-tested on 10% of the study participants at Alem-ber high school, which has the same setup to the study area, found in South Gondar zone. The questionnaire was amended according to the finding in the pretest before the distributions of final questionnaires. Training was given for data collectors and supervisors. Before the participants filled the questionnaires, the trained data collector gave orientation to youths regarding the aim of the study, the content of the questionnaire, the issue of confidentiality and respondents rights. Moreover, trained data collectors were involved in taking consents from participants and gathering filled questionnaires. However, data collectors were not present when the participants were filling the questionnaire. The study used premarital sex practice as dependent variable and Socio-demographic Characteristics of youths and parents , risk behavior and peer pressure and history of partner hood, demand for condom utilization as independent variable. --- Data management and analysis The data were entered using Epi-info version 7.2.1 and exported to SPSS version 23 for analysis. Descriptive statistics like frequency, percentage and standard deviation was computed. Binary logistics regression model was applied to identify determinant factors related premarital sexual practice. Variables with P value less than 0.25 on bi-variate analysis were entered to multi-variate analysis. 95% confidence interval was used to identify associated factors in multi-variable binary logistic regression model. Hosmer-Lemeshow goodness of the model fit was checked and analysis was done by entering procedure. --- Result --- Socio-demographic characteristics of the respondents Four hundred eighty high school youths were filled the questionnaire making a response rate of 96.6%. From the total respondents, more than half of them were females. Majority youths age were from 15 to 19 years. The average age and standard deviation of respondents were 17 and 1.29 years respectively. Larger proportion of the participants were grade nine students. The majority of the respondents were Orthodox Christians. Only 23.3% of in school youths had pocket money, about 89% of youths were living with their parents and attending religious services. Moreover, above half of the youths didn't discuss about sexual issues with their parents . --- Sexual characteristics and risk behavior of respondents From all respondents, 22.5% have had premarital sexual intercourse at the time of the survey, of which 63.9% were males and 60.2% had their first sexual intercourse at the age of 15-19 years. The main reason for initiation of sexual intercourse was due to fell in love which accounts 48.1%, followed by sexual desire 22.2%. Concerning the number of sexual partners, majority of students have had sex with one partner and about 58% of the them were used condom during sexual intercourse. Coming to risky behavior, 28.1% of the youths drunk alcohol, 16.2% watched pornography and 2.7% chewed khat. About 61% of youths who watched pornography film were exposed to premarital sex . --- Factors associated with premarital sexual practice among high school youths in Debretabor town, 2017 The Logistic regression analysis showed that premarital sexual practice among youths who did not attend religious education was 7.4 times more likely exposed to premarital sex as compared to the counterpart [AOR = 7.4, 95% CI ]. Similarly, youths who had a boy or a girl friend were 9.66 times more likely to start premarital sex than those who didn't have a boy or a girl [AOR = 9.66, 95% CI ]. Youths who were drinking alcohol every day and less than twice a week were 9.43 times [AOR = 9.43, 95% CI ] and 2.52 times [AOR = 2.52, 95% CI ] more likely engaged in premarital sex practice respectively as compared to those who did not drink alcohol. Students who watched pornography film were 5.15 times more likely practiced premarital sex as compared to those who didn't watch pornography film [AOR = 5.15, 95% CI ]. But it was found to be less likely among urban youths resident family as compared with youths who came from rural resident families . --- Discussion Premarital sexual practice of high school youths in this study was 22.5% . This finding was in line with a study conducted in Nekemtie town [20], in Jimma [19] and school youths in Alamata [21]. However, it was higher than in Coast Province, Kenya youths [22], and Robit high school youths [10]. The difference might be as a result of sample size, coast province; Kenya used existing data available from Kenya Global School Based Health Survey which was national study. So it could be more precise as compared with this study. In addition, there might be sociocultural differences in community among study areas. But this finding was lower than in-school youths in Ghana [23], in Jimma [24] in Eastern Ethiopia [12] and in Debremarkos high school youths , showing a changing and improving trend in easiness of reporting sexual matters and increasing premarital sexual awareness from time to time [7,26]. The difference might also be due to variations on the prevalence of risky sexual behavior. This study also found that those youths who didn't attend religious education were more likely exposed to premarital sex as compared with their counter parts. It is in agreement with studies conducted in Bahir Dar City [14] and Mizan Aman [27]. The possible reason could be religious institutions strongly thought youths to be abstained until marriage. High School youths who have a boyfriend or girlfriend were more likely to have premarital sexual intercourse than those who don't. There were similar reports in Alamata [28], and Nekemt towns [20]. This could be due to the pressure from their boy/girl friend to have sexual practice. Youths who drunk alcohol were engaged in premarital sexual practice as compared to their counterparts. This finding is the same as the studies done in South West [27] and Western Ethiopia [29]. The possible explanation might be, when youths drink alcohol, his/her ability of self-controlling decrease and this may expose to premarital sex. Students who watched pornography film were more likely practiced premarital sex as compared to those who didn't. There is similar finding in Shendi Town [13] and Northern Ethiopia [7]. The possible reason could be pornography film leads youths physiological and psychological motive for sexual intercourse. Youths from rural family residents were more exposed to premarital sex urban youths. This is not in agreement with other studies [7,21,28,30,31]. This difference might be due to low parental control of rural youths as they lived with rented rooms, exposed to exercising sexual issues freely. --- Conclusions Significant numbers of high school youths were engaged in sexual practice before marriage. Not attending religious education, have a boy/girlfriend, watching pornography film, alcohol drinkers and came from rural residing families were identified risk factors. So, the school community and respective health sector need to establish and strengthen school health program and school clubs to give awareness about identified risks of premarital sex. In addition family should link their youths to religious education in parallel to formal school education. --- Limitation of the study Since the nature of this study is sensitive, reporting errors and biases can't be controlled. In addition as this study used only quantitative data, the behavioral related information might be missed. Since the questionnaire was self-administered, lack of control over the responses rate, no control over who filled the questionnaires and questions may be miss-understood so that the true impression of the participants may not be gathered. --- --- --- --- --- Competing interests The authors declare that they have no competing interests. ---

Objective: Premarital sex is voluntary sexual intercourse between unmarried persons. Prevalence and factors associated with premarital sexual practice in the study area are lacking. Thus, the aims of this study were to determine the prevalence and to identify factors associated with premarital sexual practice among Debretabor high school youths.The prevalence of premarital sex among Debretabor town high school youths was 22.5% of which 63.9% of them were males. Among those high school youths, the majority (60.2%) had their first sexual intercourse at the age of 15-19 years. The main reason for initiation of sexual intercourse was due to fell in love which accounts 48.1%, followed by sexual desire 22.2%. Predictors that are risk for premarital sex were youths who did not attend religious education [AOR = 7.4, 95% CI (3.32, 16.43)], having boy or girl friends [AOR = 9.66, 95% CI (4.80, 19.43)], drinking alcohol every day [AOR = 9.43, 95% CI (2.86, 31.14)] and less than twice a week [AOR = 2.52, 95% CI (1.22, 5.21)], watching pornography film [AOR = 5.15, 95% CI (2.56, 10.37)] and youths came from rural residing families [AOR = 0.51, 95% CI (0.27, 0.96)].

introduction youths are in a state of rapid physical and psychological change they have curiosity and urge to experience new phenomena 1 nevertheless youths are exposed to different circumstance like fears worries and different desires they feel shame to get advice and guidance from their parents and elders 2 over a life cycle approach youths and their communities need to know about reproductive health so that they can make informed decisions about their reproductive health and sexuality 34 premarital sex defined as voluntary sexual intercourse between unmarried persons is increasing worldwide 5 it is unsafe because most youths have no enough awareness on how to prevent and how to get guidance services on reproductive anatomy physiology sexually transmitted infection and human immunodeficiency virus 67 as a result they are exposed to serious problems including premarital sex with its consequences and emotional scar 89 though schools are institutions where sufficient information and formal educations are provided to youths premarital sexual practice among high school youths have been increased worldwide 10 globally 353 million people live with hivaids of which youths account 21 million among 23 million new hiv infections youths account more than half 7 illegal abortions risk of hiv infections and school dropout are the bad consequences of premarital sex in subsaharan africa 11 up to 25 of 1519 years old youths exercised sex before age 15 in ethiopia the prevalence of premarital sex is increasing 12 13 14 a study conducted in eastern part of ethiopia and lalibela town reported that above onefourth of the school youths were exposed to premarital sex 1215 another study which is done in west shoa zone reported that about 60 of high school youths were exercised premarital sex 9 different scholars identified inconsistent factors which were positively or negatively associated with premarital sexual practice some of these factors includes age of students sex residence educational level peer pressure having pocket money substance use alcohol drink watching pornography movie living arrangement discussion with parents about sexual issues having peers who are experienced sex and fall in love and access religious and life skill education 9 12 13 14 15 16 17 according to debretabor district health office report sexually transmitted diseases abortion and unwanted pregnancy are high in the study area among youths 18 however prevalence of premarital sexual practice and its associated factors among high school youths in the study area was not dealt yet thus this study aimed to determine premarital sexual practices and associated factors among high school youths in debretabor town south gondar ethiopia main text methods study design and setting school based crosssectional study design was conducted from september 18 to october 16 2017 among high school youths in debretabor town south gondar zone ethiopia debretabor town is located at 667 km from addis ababa capital city of ethiopia and has three high schools the total numbers of high school youths in the study area by the year 2017 were 8892 18 source population the source population was all high school youths who were residing in debretabor town and its surrounding rural kebeles study population the study population was all highschool youths aged 15 to 24 years that were enrolled as a regular daytime student in 2017 inclusion criteria all secondary school youths aged 1524 attending regular class in debretabor town during data collection period were included in the study exclusion criterion married high school youths were excluded sample size determination sample size was calculated using a single population proportion formula designated as n p d 2 based on the assumptions of pvalue 025 which was the proportion of premarital sex among inschool youths in jimma 19 a 95 confidence level 4 margin of error and 10 nonresponse rate accordingly the total sample size calculated was 497 sampling procedure all the high schools in the town were included in the study and total sample size was proportionally allocated to each school the lists of youths were obtained from the respective school registrar then the study participants from each school were selected by computer generated simple random sampling technique after proportional allocation to their grade level data collection pretested selfadministered structured amharic questionnaire was used to collect the data the questionnaire was pretested on 10 of the study participants at alember high school which has the same setup to the study area found in south gondar zone the questionnaire was amended according to the finding in the pretest before the distributions of final questionnaires training was given for data collectors and supervisors before the participants filled the questionnaires the trained data collector gave orientation to youths regarding the aim of the study the content of the questionnaire the issue of confidentiality and respondents rights moreover trained data collectors were involved in taking consents from participants and gathering filled questionnaires however data collectors were not present when the participants were filling the questionnaire the study used premarital sex practice as dependent variable and sociodemographic characteristics of youths and parents risk behavior and peer pressure and history of partner hood demand for condom utilization as independent variable data management and analysis the data were entered using epiinfo version 721 and exported to spss version 23 for analysis descriptive statistics like frequency percentage and standard deviation was computed binary logistics regression model was applied to identify determinant factors related premarital sexual practice variables with p value less than 025 on bivariate analysis were entered to multivariate analysis 95 confidence interval was used to identify associated factors in multivariable binary logistic regression model hosmerlemeshow goodness of the model fit was checked and analysis was done by entering procedure result sociodemographic characteristics of the respondents four hundred eighty high school youths were filled the questionnaire making a response rate of 966 from the total respondents more than half of them were females majority youths age were from 15 to 19 years the average age and standard deviation of respondents were 17 and 129 years respectively larger proportion of the participants were grade nine students the majority of the respondents were orthodox christians only 233 of in school youths had pocket money about 89 of youths were living with their parents and attending religious services moreover above half of the youths didnt discuss about sexual issues with their parents sexual characteristics and risk behavior of respondents from all respondents 225 have had premarital sexual intercourse at the time of the survey of which 639 were males and 602 had their first sexual intercourse at the age of 1519 years the main reason for initiation of sexual intercourse was due to fell in love which accounts 481 followed by sexual desire 222 concerning the number of sexual partners majority of students have had sex with one partner and about 58 of the them were used condom during sexual intercourse coming to risky behavior 281 of the youths drunk alcohol 162 watched pornography and 27 chewed khat about 61 of youths who watched pornography film were exposed to premarital sex factors associated with premarital sexual practice among high school youths in debretabor town 2017 the logistic regression analysis showed that premarital sexual practice among youths who did not attend religious education was 74 times more likely exposed to premarital sex as compared to the counterpart aor 74 95 ci similarly youths who had a boy or a girl friend were 966 times more likely to start premarital sex than those who didnt have a boy or a girl aor 966 95 ci youths who were drinking alcohol every day and less than twice a week were 943 times aor 943 95 ci and 252 times aor 252 95 ci more likely engaged in premarital sex practice respectively as compared to those who did not drink alcohol students who watched pornography film were 515 times more likely practiced premarital sex as compared to those who didnt watch pornography film aor 515 95 ci but it was found to be less likely among urban youths resident family as compared with youths who came from rural resident families discussion premarital sexual practice of high school youths in this study was 225 this finding was in line with a study conducted in nekemtie town 20 in jimma 19 and school youths in alamata 21 however it was higher than in coast province kenya youths 22 and robit high school youths 10 the difference might be as a result of sample size coast province kenya used existing data available from kenya global school based health survey which was national study so it could be more precise as compared with this study in addition there might be sociocultural differences in community among study areas but this finding was lower than inschool youths in ghana 23 in jimma 24 in eastern ethiopia 12 and in debremarkos high school youths showing a changing and improving trend in easiness of reporting sexual matters and increasing premarital sexual awareness from time to time 726 the difference might also be due to variations on the prevalence of risky sexual behavior this study also found that those youths who didnt attend religious education were more likely exposed to premarital sex as compared with their counter parts it is in agreement with studies conducted in bahir dar city 14 and mizan aman 27 the possible reason could be religious institutions strongly thought youths to be abstained until marriage high school youths who have a boyfriend or girlfriend were more likely to have premarital sexual intercourse than those who dont there were similar reports in alamata 28 and nekemt towns 20 this could be due to the pressure from their boygirl friend to have sexual practice youths who drunk alcohol were engaged in premarital sexual practice as compared to their counterparts this finding is the same as the studies done in south west 27 and western ethiopia 29 the possible explanation might be when youths drink alcohol hisher ability of selfcontrolling decrease and this may expose to premarital sex students who watched pornography film were more likely practiced premarital sex as compared to those who didnt there is similar finding in shendi town 13 and northern ethiopia 7 the possible reason could be pornography film leads youths physiological and psychological motive for sexual intercourse youths from rural family residents were more exposed to premarital sex urban youths this is not in agreement with other studies 721283031 this difference might be due to low parental control of rural youths as they lived with rented rooms exposed to exercising sexual issues freely conclusions significant numbers of high school youths were engaged in sexual practice before marriage not attending religious education have a boygirlfriend watching pornography film alcohol drinkers and came from rural residing families were identified risk factors so the school community and respective health sector need to establish and strengthen school health program and school clubs to give awareness about identified risks of premarital sex in addition family should link their youths to religious education in parallel to formal school education limitation of the study since the nature of this study is sensitive reporting errors and biases cant be controlled in addition as this study used only quantitative data the behavioral related information might be missed since the questionnaire was selfadministered lack of control over the responses rate no control over who filled the questionnaires and questions may be missunderstood so that the true impression of the participants may not be gathered competing interests the authors declare that they have no competing interests

objective premarital sex is voluntary sexual intercourse between unmarried persons prevalence and factors associated with premarital sexual practice in the study area are lacking thus the aims of this study were to determine the prevalence and to identify factors associated with premarital sexual practice among debretabor high school youthsthe prevalence of premarital sex among debretabor town high school youths was 225 of which 639 of them were males among those high school youths the majority 602 had their first sexual intercourse at the age of 1519 years the main reason for initiation of sexual intercourse was due to fell in love which accounts 481 followed by sexual desire 222 predictors that are risk for premarital sex were youths who did not attend religious education aor 74 95 ci 332 1643 having boy or girl friends aor 966 95 ci 480 1943 drinking alcohol every day aor 943 95 ci 286 3114 and less than twice a week aor 252 95 ci 122 521 watching pornography film aor 515 95 ci 256 1037 and youths came from rural residing families aor 051 95 ci 027 096

INTRODUCTION With the current paradigm shift of the game industry towards games as a service [9,36,61], player retention has become one of the most important design goals and metrics. Entertainment value is, in fact, measured in hours of playtime. To accommodate for these shifting values, commoditization strategies have begun revolving around subscription-based models, free to play games with premium content, free updates, premium DLC, and season passes. In an interview, Anne Blondel-Jouin, Vice President of Live Ops at Ubisoft, explained that: "...games as a service, or live games, refer to games that offer an evolving long-term, entertaining experience for our players. They often have a focus on online competitive multiplayer experiences such as Tom Clancy's The Division but they can also include other types of game experiences like The Crew. 'Live' refers to all the activities and interactions created for the game community including pre-and post-launch as well as regular updates, new content, and events both in-game and out-of-game, etc. throughout the game's lifespan" [63]. As shown by the longevity of games such as World of Warcraft or League of Legends, social connections foster prolonged retention. One of the most important tools that the industry uses to investigate social connections, especially in social and online games, is Social Network Analysis . Increasingly, social network analysis methods are being used in games [e.g., 3,19,23,42,43]. Similar to the literature on online communities [34], it suggests that there are key members who contribute to keeping the community alive. In this paper, we apply methods from SNA to the game Tom Clancy's The Division to identify potential influencers, here defined as players that engage with the multiplayer component of the game in a way that makes them highly centralized . Subsequently, we compare relevant features of influencers with two other populations, power users and random players, to investigate if there are other differences besides the way in which the three populations utilize multiplayer components. To gauge whether playing with influencers has an impact, we investigate changes in playtime and time spent playing in groups for the social circles of the influencers, power users, and random players. This work contributes to understanding the social dynamics and providing evidence for social contagion in online social game networks and provides a deeper understanding of the role and impact that influencers in these networks may have. This paper is organized as follows: We first ground and motivate this work within the existing literature by discussing influence in social networks, what has been done with SNA in games, what is known about social contagion in this context, and what we generally know about influencers and how to identify them. Then, we describe how we conducted our study using a sample of PC players from TCTD and SNA. The paper ends by presenting and discussing the results. --- BACKGROUND In the following sections, we will describe the work that is done on SNA and social contagion in the context of games. Then, we will turn to what we know about influencers in general before we discuss what our research involves. --- Influence in Social Networks Social Network Analysis is a family of methods for formally describing and analyzing relations between people as graphs with nodes and edges , with broad applications in offline and online social networks [40]. A major topic of SNA research is social influence, as expressed for instance in behavioral and social contagion theory [14,38,60]: behaviors and their consequences cluster and spread within networks [e.g., 6,14]. Methodologically, social influence is often hard to disentangle from homophily, namely where similarity is the primary cause for connections [14,39]. Still, there is now good evidence for contagion processes in social networks via social-psychological mechanisms such as modeling or norm-setting [16,17]. Put differently: Not only do similar behaviors attract connections; being connected causes more similar behavior. As online social networks have become major means of communication, social influence has become subject to intense interest in communication and marketing as well as computer science and human-computer interaction communities, especially computer-supported collaborative work and learning, Internet research, or informatics [15,47,52]. Practitioners have been chiefly concerned with finding ways to maximize the spread of desired information and behaviors through networks, and to reliably measure the impact of particular actions and actors [37]. --- Social Network Analysis in Games The volume of work in SNA is substantial, and due to limitations of space we here focus on previous work in games, directly related to the current project. Previous research on social behavior in games suggests that social interaction influence the user experience and forms an important motivational driver for play [19,62], giving the games industry a direct interest in social network analysis [2]. SNA has been employed as a method for investigating social interaction between players primarily since the introduction of social network games in the mid-late 2000s [30]. Social networks in games have been investigated using qualitative methods and ethnographic approaches [18], as well as using quantitative SNA [25,62]. The available SNA work is mainly focused on massively multiplayer online games , using in-game social features such as friend lists to construct networks. Ducheneaut et al. [19] and Shen [48] examined social interactions in these types of games. Surveys have also been used as a method for collecting information about the social connections of players, e.g. Shen and Chen [49]. Szell and Thurner [53], studied the structure of friend-, enemy-, and communication networks, noting that friend and enemy networks were different topologically. Player-generated structures such as guilds have also been investigated, e.g. by Ducheneaut et al. [20] and Chen et al. [13] who used SNA metrics such as density and centrality to map and characterize the properties of player guilds in World of Warcraft. More limited attention is given to other game genres. One exception is Iosup et al. [24] that looked at social networks in DOTA 2 and StarCraft II, using match-making as the baseline for building edges between players. Rattinger et al. [44] used similar connections between players in Destiny to build networks. The authors noted that the most engaged players were characterized by having large social networks. Following up, Schiller et al. [46] analyzed a social matchmaking service for Destiny players operating outside the game itself. Summarizing, SNA as applied to games has been focused on the associations that form between players during and around the playing activity [19,25,44]. There is more limited work on social structures formed around games [46], not only for external services, but also distribution platforms such as Steam and Uplay. The work presented here forms a concrete extension of previous work applying SNA in games contexts, not only by integrating information about social connections from the Ubisoft distribution platform Uplay, but also in its continuation of the work by e.g. Rattinger et al. [44] on using SNA to identify players with specific properties across in-game behavior and network behavior. --- Social Contagion in Games With respect to social contagion, there has been some evidence in online games, such as generosity [26,65], purchasing of in-game goods [22], and cheating such as bot usage [64], including initial exploratory attempts at identifying "spreaders" or influencers with an outsized impact on cheating behavior [28]. However, research suggests that online in-game interaction network structures and dynamics are context-sensitive, meaning different kinds of interactions and relations show different structures and dynamics [50]. Thus, the existence of social contagion for gift-giving does not immediately generalize to e.g. team play, as different kinds of interactions have different strategic and other utilities and thus bring in different considerations and social-psychological mechanisms [50]. --- Influencers There is no agreement on what is an influential person [45]. However, two types of influencers can be distinguished in previous work: an individual who impacts the spread of information or behavior, people who influence people [58]; and an individual who exhibits some combinations of desirable attributes such as trustworthiness and expertise or network attributes [27]. The first group of influencers are often referred to as opinion leaders [21], prestigious innovators [12], key-players [8] and spreaders [31]. The second group of influencers are often referred to as celebrities [51], evangelists [4] or experts [27]. Here we focus on measuring and quantifying the influence of an influencer of the first type, for two reasons. First, because they may touch a large scale of audience with a very small marketing cost [33,35,54]. Second, because their tendency to spread desirable behavior may be key to keep healthy communities alive for a longer time [12,31]. Centrality measures have been proven to be relevant indicators in the analysis and comprehension of influencers in a social network [5,32]. The most utilized measures of centrality are: in-and out-degree, betweenness, eigenvector and closeness; they are all measures of an actor's prominence in a network [57]. Valente et al. [55] investigated correlations between these most common measures of centrality. The researchers found that there are strong but varied correlations among the centrality measures presented here. The average of the correlations was 0.53 with a standard deviation of 0.14, indicating these measures are distinct, yet conceptually related. Since the centrality measures examined are not mutually excluding members but have slight different selection criteria, in order to identify the players with most influence we will utilize all the centrality measures and select only players that are ranked at the top for each measure. --- Research Question and Contribution To summarize, there is good evidence for social contagion and the existence of influencers in social networks more generally. Prior work in games has shown the existence of in-game social network structures similar to other domains. However, there is as of yet little data on social contagion or influencers in in-game social networks, which is the focus of the present study. Specifically, the question remains whether influencers in online games have an outsized influence not just in terms of the quantitative reach of their ego network, but also in terms of their qualitative impact on behavior. Since standard influencer definitions are based on social network features, reach-based claims are somewhat tautological: individuals with a large network by definition will touch a large network. Hence, instead of asking, "Do influencers influence more people?", we asked: "Do influencers influence people's behavior more strongly?" Given the game industry's interest in playtime as a major relevant design goal and prior work on influencers' specific social behaviors, we focused on these two aspects to measure the influence that influencers may have on other players. While operationalizing playtime is straightforward, social behaviors are less so. Because the clearest form of exhibiting social behaviors is playing together, we decided to operationalize this aspect as social play, specifically the percentage to which one plays a multiplayer game collaboratively with others versus alone. Put as a research question: Do influencers in online games affect connected players' playtime and social play more strongly than average? Given prior findings in the SNA literature, we hypothesized that: Social contagion effect: If a player joins the in-game network of an influencer, it will increase the player's playtime and social play . Impact of Influencers: If a player joins the in-game network of an influencer, it will increase the player's playtime and social play more than joining the in-game network of another player. The first hypotheses test if a social contagion effect occurs as a result of playing with an influencer; the second hypotheses seek to determine whether an influencer has more influence than other socially active players or, in other words, to rule out that playtime and/or social play can explain for the effect on other players. By testing these hypotheses, we are making a twofold contribution to the literature: We are establishing whether basic tenets of social contagion in offline social networks transfer to online, in-game networks, extending the evidence base from larger-sized, longer-lifetime guilds to short-term, small-sized pick-up groups. We are deepening the general understanding of influencers in online social networks by establishing to what extent their influence supersedes other network members not just in network reach, but also per-individual behavioral impact. --- METHOD Material To avoid potential confounds by homophily, we looked for instances where we could quasi-experimentally observe changes in player's playtime and social behaviors before and after joining another player's social network, and compare influencers to the average player population. We found such an instance in the group mechanic of TCTD. TCTD is an online-only open world RPG shooter, set in a near future New York City in the aftermath of a smallpox pandemic. The player, an agent of Strategic Homeland Division, must help the group rebuild its operations in Manhattan, investigate the nature of the outbreak, and combat criminal activity in its wake. Released March 2016, TCTD accumulated more than 20 million players to date, becoming the fastest selling new Ubisoft IP of all times. As of April 2017 , there were more than 2 million active monthly players. TCTD is structured with elements of role-playing games combined with collaborative Player versus Environment and Player versus Player online multiplayer activities. It is split in two zones: PvE, where players cannot kill each other , and PvP, where they can. We use the terms "competitive" and "cooperative" to indicate coop vs. PvP. It is possible to play and replay all the story missions and side missions with up to four real players in coop . Alternatively, it is possible to enter a PvP area called the Dark Zone and challenge other players. All activities, both in PvP and PvE, can be completed solo or in groups. Groups are composed of the group creator and up to three other players. Groups can be created through quickmatch with random players or with players already connected as friends to the profile through Xbox Live, PlayStation Network , or Uplay accounts. Players invite and accept friend invites by using Uplay IDs. Upon acceptance, players show up in each other's menus as someone they can add to a group play session. Uplay is a multiplayer and communications service for PC, used exclusively by first-party Ubisoft games. Groups can be created or joined at safe houses and social hubs scattered around the game area or right before beginning an activity. A playtime segmentation report showed that active players are spending more than 35% of their time in groups, while players that quit the game spent less than 30% of their time in groups. Based on that and the existing literature, we hypothesized that social dynamics have an impact on player retention. SNA was adopted as the tool to identify and isolate influential players. --- Dataset We had access to data collected by both the Uplay platform and the TCTD game. To reduce the computational time for this analysis, instead of working with the whole dataset from more than 14 million players , we polled an initial random sample of 200,000 PC players from TCTD, and then included all other players that the initial sample interacted with in the game either by being invited or by inviting to a group. This led to a sample of 246,041 players. This will be referred to as the initial sample. This initial sample was polled on April 24th, 2017. We chose PC players only because our access to account data was limited to the Uplay service. Including PS4 and Xbox players would have required special permission from Sony and Microsoft. In addition, we made sure to include individuals that players in the original sample interacted with since we were interested in exploring communities generated by group forming behavior and not including these last players would have imposed an incomplete network. The total population at the time of polling was 14,716,507 players. Therefore, the initial sample is 1.7 percent of the entire population at that time. The dataset consists of two tables. The first table has the IDs of the group creators, the time of group creation, the IDs of players invited to each group and their status . The second table has, for every player , various statistics, such as their total and daily playtime, number of friends, etc. --- Identifying Influencers We used conventional SNA techniques to identify influencers in our data set, a practice that has been done before in the context of both social networks at large [7,31] and multiplayer games specifically [29]. Given that there is no agreement on which individual measure to utilize when identifying influencers, we used six different measures of centrality: closeness, betweenness, eigenvector, in-degree, out-degree and pagerank. All the sets of players identified by each centrality measure are intersected with each other to identify the players that are considered central for each of the six measures. In this work, we define influencers as players that satisfy all these six conditions. We then plotted the resulting influencers onto a network graph where the nodes represent the players and the color of a node indicates the community the node belongs to. The resulting supergraph is depicted in Figure 1. The size of the nodes is proportional to the importance of a player, hence influencers display a much bigger size than normal players. Details of our method are described below. Identifying Most Central Influencers. We first computed centrality measures, which aim to quantify the "influence" of a particular node within a network. Our aim was to identify within each community which player may be influential. To accomplish this, we considered the following measures: Closeness centrality: how easily accessible a node is to all other players, represented as the length of the shortest path. The speed by which a player accesses all other players ranges between 0 and 1. We selected all nodes with values > 0, resulting in 182 players. Betweenness centrality: it represents the number of shortest paths to other players, or how likely a player is the most direct route between two other players. The range fell between 0 and 168. We selected all nodes with values > 0; resulting in 78 players. Eigenvector centrality: while degree centrality counts all connected nodes equally, eigenvector centrality treats connected nodes differently based on their "importance, " or how well a player is connected to others. The range is between 0 and 1. We selected all nodes with values > 0.05; resulting in 198 players. In-Degree : number of connections to a node from others. These are players invited most often to groups. Range is between 0 and 5 and we selected all nodes with values => 2, resulting in 371 players. Out-Degree: number of connections from a node to other nodes. These are group creators that frequently invite other players. Values range between 0 and 630 and we selected all nodes with values > 0, resulting in 165 players. In-and out-degree together tell us how many players a certain player can reach directly. Pagerank: what fraction of players can be reached via directed paths. It uses links as a measure of importance. Each node is assigned a score based on its number of incoming links . These links are also weighted depending on the relative score of its originating node. The result is that nodes with many incoming links are influential, and nodes to which they are connected share some of that influence. The scores range between 0.000063 and 0.000059. We selected all nodes with values > 0.00006, resulting in 178 players. Choosing Influencers. The intersection between the 182 players with highest closeness centrality, the 78 players with the highest betweenness centrality, the 198 players with the highest eigenvector centrality, the 371 players with the highest in-degree centrality, the 165 players with the highest out-degree centrality, and the 174 players with the highest pagerank score returned 49 players. These 49 players will be referred to as influencers from now on. It is important to note how intersecting across the six measures of centrality gives us a very conservative selection of players since in order to be considered influencers they must satisfy all six criteria. Furthermore, as Figure 1 shows, these 49 players map to a very large extent onto the sub-communities that form the heart of the network. --- Sampling Comparison Players After we identified the influential players, we sampled a group of comparison players to get a better understanding of who these influencers are. Because we hypothesized that playtime and/or social play alone cannot explain the effect on other players, for this comparison group we selected the most engaged players in the whole population-generally known as "power users. " It is important to note that power users is an already existing category of players; within Ubisoft they are known as "star players" [1]. Ubisoft routinely invites "power players" to special events and sees them as an important resource for community building. With this in mind, it is legitimate to wonder whether "power players" could count as another influencer type . There may be some overlap of these categories. However, as our data offers no good, easy indicator of popularity and status within the player community, we cannot test this assumption. In the context of TCTD, power users are defined as players with: At least 70 hours playtime. The whole player population has an average playtime of 67 hours and 20 minutes. At least 10 friends on Uplay. On average players have 8.60 friends. Gearscore in the top 5%. Gearscore is an indicator for how well-equipped players are. Every weapon or piece of gear found after reaching level 30 has a Gearscore value. The higher an item's Gearscore, the stronger the item is, making it a more valuable field asset. The overall Gear Score of players defines their progression after the "end-game" . We selected only the top 5 percent. At least played twice in groups in the week before we polled the sample. We added this criterion to ensure that the power users made extensive use of the multiplayer functionalities of the game. Applying these criteria to our initial sample led to 2,102 power users . It is interesting to compare infuencers to power users because we made no effort to remove influencers from the initial sample, yet no influencer was found amongst the power users. A third comparison was carried out with the total population. Additionally, we intended to compare longitudinally the impact that influencers, powers users, and random players from the general population may have on others. For that purpose, we needed to extend our samples. First we selected all players that engaged with the 49 influencers , all players that engaged with 49 power users randomly selected from the 2,102 initial power users sample , and all players that engaged with 49 random players from the initial sample . For the latter sampling, we excluded players with less than 1 week of total playtime and excluded all power and influential users. Lastly, we examined if there was behavior transfer from influencers to the players they interacted with by running again the influencer identification method from the section "Identifying Influencers." For this we needed to extend the three samples. We selected all players that interacted with the 49 influencers and that were still active a year later and added all players that interacted with them ; we also selected all players that interacted with the 49 power users and that were still active a year later and added all players that interacted with them ; and finally we selected all players that interacted with the 49 random players and that were still active a year later and added all players that interacted with them . --- Constructs and Measures As discussed before, to evaluate our hypotheses we focused on two constructs: playtime and social play. Playtime acts as a proxy for retention; social play will reveal a tendency to value the social dimension of play more, which, as we hypothesized based on the TCTD data and the existing literature, is a good indicator for how long a player will be engaged with a gameand is therefore another proxy measure of retention. Both constructs are measured as follows: Playtime . Average daily playtime calculated only for days of activity. Social Play . Ratio of solo and group play. Both measures were chosen in the context of TCTD. For example, we chose to use playtime and not days played because it fits better with the game's monetization model: players need to play "enough" every day to see value in and buy upgrades or subscriptions, and the longer they play in this active fashion, the more they pay over time. Days played would not offer this level of granular information. --- RESULTS --- Descriptive statistics Table 1 shows an overview of the three groups: influencers, powers users, and the total population. The comparison is based on the lifetime of players. On average, it turns out that the powers users are indeed the powers users we would expect with more sessions played, more daily playtime, but especially far more playtime, kills, skill kills , and items extracted compared to the influencers and the total population. For example, power users played almost four times more than the influencers and seven times more than the general population . The influencers, on the other hand, have on average far more friends compared to the power users and general population , but especially interact with others more in group play than power users and the general population . Interestingly, both influencers and power users spent about two-thirds of their time in group play, whereas this is the reverse for the general population. Another interesting observation is that for performative measures the influencers perform similar to the general population. As for group play, power users spent only marginally more time in group vs. solo play and competitive vs. cooperative play, but especially have created and joined many more groups compared to influencers and the average players. However, these numbers are somewhat deceiving. When we consider their total playtime, it turns out that on average power users create 0.45 and join 0.38 groups per hour; the average player creates 0.38 and joins 0.30 groups per hour; and influencers create 0.74 and join 0.39 groups per hour. Therefore, it shows that power users are only marginally more engaged per hour than the average player and that influencers take far more initiative in creating groups. In terms of group play, it is also interesting to consider with whom both influencers and powers have played with. On average, power users play with 27 other players in their lifetime. This is interesting because the number of players that power users interact with in groups is very close to the number of friends , indicating that power users tend to play almost exclusively with their friends. At the same time, each influencer plays on average with 342 other players, a larger number compared to the already large number of their friends , indicating that influencers play in groups with considerably more players than just their friends. Therefore, while power users spend on average about equal --- Testing Hypotheses To assess our hypotheses, we took the following three steps: We isolated all players that played with influencers , the selected power users , and the selected random players at least twice in the week before polling the data. We split data regarding their communities in two: data regarding play behavior corresponding to the two weeks before joining the community and data regarding play behavior for the two weeks after joining the community. We compared daily playtime and social play ratio two weeks before and two weeks after joining the communities of the influencers, power users, and random players, respectively. Results are shown in Table 2. There is a clear change and impact on the behavior of players that join the community of the influencers: the daily playtime increases considerably, from a number very close to the general population average to a number very close to the influencers themselves; the amount of time spent in groups increases from the total population average to almost the same amount of the influencers. For playing with power users, in contrast, both the daily playtime and social play do not change drastically. The numbers are also similar to the powers users themselves, suggesting that not only do power users play together with their group of friends , they are likely to play together with other power users. Engaging with random players does not change behavior and, as expected here, the statistics are similar compared to the total population. Paired-samples t-tests were conducted to compare daily playtime and social play in two weeks before joining a community and two weeks after . As for the playtime , there was a significant difference for the daily playtime of players interacting with influencers before and after they joined the influencers' community; t = 28.83, p = .001, r = .22. No significant effect on daily playtime was witnessed for players interacting with power users two weeks before and after joining their community; t =-0.26, p = .796, r = .007. For the random sample of players, there was also no significant effect on daily playtime, two weeks before and after joining their community; t = 0.14, p = .885, r = .005. These results support hypotheses H1a and H2a: joining a group with an influencer did, in fact, increase the daily playtime of players , at least in the first two weeks after joining, while the same could not be stated of power users or a random sample of players during the same period . As for social play, joining an influencers's community significantly changed the ratio from two weeks before to after ; t = 74.32, p = .001, r = .50. This ratio change was also significant for players joining a power user's community compared to their situation two weeks before and after joining them; t = 4.79, p = .001, r = .13. For a random sample of players, two weeks before and after joining groups, it did not significantly change their social play ratio; t = -0.54, Table 2: Changes in the influencers', power users', and random players' communities two weeks before and two weeks after engaging with influencers, power users, and random players. Social play ratio 41%-59% 59%-41% 60%-40% 65%-35% 39%-61% 38%-62% p = .588, r = .002. These results support hypotheses H1b and H2b: the ratio of playing in groups significantly increased for players joining an influencer's community , at least in the first two weeks after joining. While a significant increase in group play happens with joining power users as well, their impact is less. The effect size for influencers is large resulting in an average increase on of 18% in group play, whereas the effect size for power users is small resulting in an average increase of only 5% of group play . --- Influencers --- Retention and Influencer Conversion For testing our hypotheses, we limited our observations to two weeks before and after. A question remains what kind of influence influencers may have on other players beyond this period. For this analysis, we first considered if players are still actively playing TCTD. In our previous analyses we used playtime and social play as measures because these can indirectly tell us something about retention: more engaged players and players engaged in the multiplayer aspects of a game tend to stick around longer. To calculate retention here, we looked at which of the players who joined the communities of the influencers, power users, and random players were still active after one year. Table 3 shows the retention results. After 1 year, 23% of the influencers' community is still active, whereas this is 29% of the power users' community and only 5% of the random players' community. The second consideration is more ambitious. We considered which of the players from these communities may have become an influencer themselves. As we have demonstrated, influencers have an impact on other players and so if these players are converted into influencers they, on their turn, can influence others-and thereby keep the community alive, even if certain influencers decide to leave the game. For this analysis, we first applied the same method for identifying the original 49 influencers except a year later . Then, we considered which of the newly identified influencers mapped onto the players from the initial population that the original influencers, power users, and random players engaged with. Table 3 shows the conversion results, which are remarkable. From the community of the random players only 2 players were identified as an influencer a year later, which is a conversion rate of 1% based on the still active players in that community. The influence of power users is greater: from their community 22 players are identified as an influencer resulting in a rate of 6%. However, from the community of influencers we identified a staggering number of 1,002 influencers, which corresponds to a rate of 26%. --- DISCUSSION Using conventional Social Network Analysis techniques we identified key members that are very engaged with the game Tom Clancy's The Division but also with other players. The question that we investigated is whether these so-called influencers really influence other player's behavior, as measured in their playtime and social play , and if they do this more than other players . Our results provide supporting evidence that influencers do indeed impact other players and more so than others. We discuss here our findings on social contagion, retention, and player differences before explaining the limitations and implications of this study. --- Influencers are Socially Contagious Our results highlight that the identified influencers seem to have a very tangible impact on the people they play with: these other players begin playing longer and spend more time in groups. We observed a significant increase with a small to medium effect size on playtime and a large effect size on social play . Compared to interacting with an influencer two weeks before, players' daily playtime increased on average with 24% and their social play ratio completely reversed in favor of being more social two weeks after . We contrasted the impact of influencers with those of power users and average users and found that interacting with these users does not yield any significant differences in playtime and only a significant but with a smaller effect size on social play for power users. Therefore, a strong social contagion effect is unique to the influencers. Homophily is always a possible confound in social contagion work [14]. For this reason, we ran a quasi-experimental analysis comparing playtime and social play ratio pre/post joining the team of an influencer vs. power player vs. normal Table 3: Players interacting with influencers, power users, and random players that continue to be active and have become influencers themselves after 1 year. Note: conversion rate is based on active population after 1 year. player . Homophily would predict higher overall playtime and social play ratio among influencer team members, but not the significant changes that we observed. This makes us confident in claiming causality that influencers are socially contagious. --- Initial population --- Influencers are Important for Retention Retention is a key measure for success in the game industry. Our results suggest that not only are influencers socially contagious, they are also important for retention. We measured if players continue to be active players one year after interacting with influencers, power users, and random players and found that players who interacted with influencers and power users are more likely to be active compared to a random player . While the retention is higher for power users, it should be kept in mind that influencers are able to retain ten times the number of players and that power users tend to engage only with similar users, so their influence is more of a reinforcing feedback loop than having an impact on the community at large. What is most striking, however, is that players who have interacted with influencers may become influencers themselves after a year . Such influence is not as noticeable with power users or random players . This data suggests that the social contagion effect of influencers may go as far as converting a significant portion of the players they interact with into influencers. Because we did not experimentally test this, or observed whether these new influencers exhibit the same kind of impact, we cannot claim causality here neither can we fully illustrate what impact this has on the community. However, these results provide further evidence of the important role that influencers play in online game communities, especially with the issue of retention in mind. In fact, as the sustained lifetime of a game depends in large measure on a healthy, lively community of players engaged with the multiplayer aspects of the game, these players seem to form the invisible social backbone of a game community. --- Influencers are Different Players Our results show that influencers are different from other players . Influencers create groups much more than the average player. They play many more sessions , have many more friends , and spent relatively more time in group and coop play than the average player. More importantly, they seem to be the ones who initiate group play and invite others to join . Power users, on the other hand, spent many more hours playing , but while they engage considerably in group activities, even at a similar ratio as the influencers, they tend to start groups relatively less and seem to play mostly with their much more limited number of friends who are likely to be power users too and less so with strangers. Important to observe as well is that the selected power users are indeed power users: compared to the average player, they have far more kills , skill kills , and items extracted , and play more competitively . Interestingly, the statistics for influencers on these performative metrics are with the exception of competitive play fairly similar to the average player. Therefore, what defines influencers in contrast to power users is that they have a wide-reaching and solid network of friends and an active engagement with the multiplayer aspects of a game rather than an elite performance in the game. Influencers are the social butterflies. Although these metrics highlight the differences between influencers vs. power users vs. average players, it is important to note that these metrics are not sufficient to identify influencers. When applying one or a combination of metrics, it was impossible to achieve the same result. Therefore, SNA seems to be required to identify influencers. The approach we have taken here is to define influencers on the basis of combining six centrality measures and then inspecting the results visually for verification . Future research is needed to further refine this approach and examine how it generalizes to other contexts. Furthermore, neither the SNA or the metrics tell us really who these influencers are and how it is possible that they can convert others into influencers. Because explanations such as that influencers are inherently social, a suggestion supported by evidence that there are similarities between virtual and real world personalities and behavior [10,11,56,67], or are a different type of player, more into social play [41, 66, e.g.,], cannot fully explain the results we observe here. It may be that those converted are socially inclined people and that interacting with another socially inclined person but already socially active player activates how they can and want to play. Regardless, our quantitative, hypothesis-testing approach is inherently limited in generating detailed explanatory portraits of players and the dynamics we observed. Future qualitative and mixed-methods work, where influencers and the players they interact with are interviewed or closely followed over a period of time, can provide further evidence on understanding who these players are and why they have such influence on others beyond being socially active as described with the metrics here. --- Limitations and Generalization Our presented work has several limitations. First, the work focused on a single game. Although there are differences between TCTD and other online games, the type of game, its mechanics, and especially group play management is similar to other online multiplayer games. The most important difference in terms of group play compared to other online games is that it is limited to up to four players at a time, meaning that player ties may be closer than in other games and that there are more loosely connected communities than in other games. More importantly, influencers who initiate group play may be more influential as they are the ones who make connections across the network, whereas in games where guilds and factions play a role there are other mechanisms of how players join groups. Second, we sampled only one degree of ties after the initial sample of 200,000 PC players by including all the players the initial polled sample interacted with. This was a necessary step because we aimed to investigate their social networks based on who they play with. However, there is a question how representative the sample is in terms of the whole population. Depending on the study design and situation, different techniques for sample size estimation exists. Assuming normally distributed variables in the population, Z-scores can be used to define the confidence interval and sample size. In the current case, with a 1% margin of error and a 99% confidence level , the required sample size for the whole population would be about 9,600 players using random sampling. The sample used here is roughly 20 times larger. Nevertheless, aside from replicating the work in other game contexts, future work could operate with the entire network and/or samples that have up to three degrees of ties similar to what others have done while utilizing SNA on game communities [43,44]. Third, while we made deliberate decisions-based on literature, closely examining our data, and definitions used by Ubisoft-on how to identify influencers, define power users, and examine the impact of social contagion choosing a different set of criteria may have led to different results. As future work will consider this phenomenon more closely, more robust standards and definitions will be established and the results presented here can be affirmed. Fourth, in order to rule out the possibility that a particular metric can explain for the impact we observed, it would be necessary to perform a propensity sample where we compare the influencers to a sample with similar characteristics. --- Implications The current work has important implications for HCI researchers and industry. For HCI researchers, we have established here how social contagion or influence occurs in online, in-game networks, specifically in the context of shortterm, small-sized pick-up groups. While we need to be cognizant of this particular context, this work advances the field at large. Where previous SNA work on influencers in games and social media focused on network features only [e.g., 59], our work highlights how influencers act differently from others and the extent of their impact on others and the community over time. Additionally, as it remains an ongoing discussion on how to identify influencers in social networks using SNA metrics [45], our work suggests a combination is necessary and that measures of activity and popularity are not good metrics. This latter is relevant for the community management for every game or social media, which generally tend to be most interested in active users, as well "celebrities, evangelists, or experts" such as power users. Our data suggests that for TCTD at least, the "most central" users may be the most important for engaging, and retaining other users. Therefore, community managers should tap into SNA to identify such influential users, then leverage them for feedback or to reach a large part of the community. --- CONCLUSION In this paper, we studied if influencers in online games affect connected players' playtime and social play more strongly than average. We studied this in the context of Tom Clancy's The Division, a popular multiplayer online shooter. Our findings show that influencers do indeed impact other players and more so than power users or the average player, thus providing evidence for a social contagion effect and the important role influencers have in these online social networks.

In a wide range of social networks, people's behavior is influenced by social contagion: we do what our network does. Networks often feature particularly influential individuals, commonly called "influencers'. ' Existing work suggests that in-game social networks in online games are similar to reallife social networks in many respects. However, we do not know whether there are in-game equivalents to influencers. We therefore applied standard social network features used to identify influencers to the online multiplayer shooter Tom Clancy's The Division. Results show that network featuredefined influencers had indeed an outsized impact on playtime and social play of players joining their in-game network.• Human-centered computing → Empirical studies in HCI; Empirical studies in collaborative and social computing;

introduction with the current paradigm shift of the game industry towards games as a service 93661 player retention has become one of the most important design goals and metrics entertainment value is in fact measured in hours of playtime to accommodate for these shifting values commoditization strategies have begun revolving around subscriptionbased models free to play games with premium content free updates premium dlc and season passes in an interview anne blondeljouin vice president of live ops at ubisoft explained that games as a service or live games refer to games that offer an evolving longterm entertaining experience for our players they often have a focus on online competitive multiplayer experiences such as tom clancys the division but they can also include other types of game experiences like the crew live refers to all the activities and interactions created for the game community including preand postlaunch as well as regular updates new content and events both ingame and outofgame etc throughout the games lifespan 63 as shown by the longevity of games such as world of warcraft or league of legends social connections foster prolonged retention one of the most important tools that the industry uses to investigate social connections especially in social and online games is social network analysis increasingly social network analysis methods are being used in games eg 319234243 similar to the literature on online communities 34 it suggests that there are key members who contribute to keeping the community alive in this paper we apply methods from sna to the game tom clancys the division to identify potential influencers here defined as players that engage with the multiplayer component of the game in a way that makes them highly centralized subsequently we compare relevant features of influencers with two other populations power users and random players to investigate if there are other differences besides the way in which the three populations utilize multiplayer components to gauge whether playing with influencers has an impact we investigate changes in playtime and time spent playing in groups for the social circles of the influencers power users and random players this work contributes to understanding the social dynamics and providing evidence for social contagion in online social game networks and provides a deeper understanding of the role and impact that influencers in these networks may have this paper is organized as follows we first ground and motivate this work within the existing literature by discussing influence in social networks what has been done with sna in games what is known about social contagion in this context and what we generally know about influencers and how to identify them then we describe how we conducted our study using a sample of pc players from tctd and sna the paper ends by presenting and discussing the results background in the following sections we will describe the work that is done on sna and social contagion in the context of games then we will turn to what we know about influencers in general before we discuss what our research involves influence in social networks social network analysis is a family of methods for formally describing and analyzing relations between people as graphs with nodes and edges with broad applications in offline and online social networks 40 a major topic of sna research is social influence as expressed for instance in behavioral and social contagion theory 143860 behaviors and their consequences cluster and spread within networks eg 614 methodologically social influence is often hard to disentangle from homophily namely where similarity is the primary cause for connections 1439 still there is now good evidence for contagion processes in social networks via socialpsychological mechanisms such as modeling or normsetting 1617 put differently not only do similar behaviors attract connections being connected causes more similar behavior as online social networks have become major means of communication social influence has become subject to intense interest in communication and marketing as well as computer science and humancomputer interaction communities especially computersupported collaborative work and learning internet research or informatics 154752 practitioners have been chiefly concerned with finding ways to maximize the spread of desired information and behaviors through networks and to reliably measure the impact of particular actions and actors 37 social network analysis in games the volume of work in sna is substantial and due to limitations of space we here focus on previous work in games directly related to the current project previous research on social behavior in games suggests that social interaction influence the user experience and forms an important motivational driver for play 1962 giving the games industry a direct interest in social network analysis 2 sna has been employed as a method for investigating social interaction between players primarily since the introduction of social network games in the midlate 2000s 30 social networks in games have been investigated using qualitative methods and ethnographic approaches 18 as well as using quantitative sna 2562 the available sna work is mainly focused on massively multiplayer online games using ingame social features such as friend lists to construct networks ducheneaut et al 19 and shen 48 examined social interactions in these types of games surveys have also been used as a method for collecting information about the social connections of players eg shen and chen 49 szell and thurner 53 studied the structure of friend enemy and communication networks noting that friend and enemy networks were different topologically playergenerated structures such as guilds have also been investigated eg by ducheneaut et al 20 and chen et al 13 who used sna metrics such as density and centrality to map and characterize the properties of player guilds in world of warcraft more limited attention is given to other game genres one exception is iosup et al 24 that looked at social networks in dota 2 and starcraft ii using matchmaking as the baseline for building edges between players rattinger et al 44 used similar connections between players in destiny to build networks the authors noted that the most engaged players were characterized by having large social networks following up schiller et al 46 analyzed a social matchmaking service for destiny players operating outside the game itself summarizing sna as applied to games has been focused on the associations that form between players during and around the playing activity 192544 there is more limited work on social structures formed around games 46 not only for external services but also distribution platforms such as steam and uplay the work presented here forms a concrete extension of previous work applying sna in games contexts not only by integrating information about social connections from the ubisoft distribution platform uplay but also in its continuation of the work by eg rattinger et al 44 on using sna to identify players with specific properties across ingame behavior and network behavior social contagion in games with respect to social contagion there has been some evidence in online games such as generosity 2665 purchasing of ingame goods 22 and cheating such as bot usage 64 including initial exploratory attempts at identifying spreaders or influencers with an outsized impact on cheating behavior 28 however research suggests that online ingame interaction network structures and dynamics are contextsensitive meaning different kinds of interactions and relations show different structures and dynamics 50 thus the existence of social contagion for giftgiving does not immediately generalize to eg team play as different kinds of interactions have different strategic and other utilities and thus bring in different considerations and socialpsychological mechanisms 50 influencers there is no agreement on what is an influential person 45 however two types of influencers can be distinguished in previous work an individual who impacts the spread of information or behavior people who influence people 58 and an individual who exhibits some combinations of desirable attributes such as trustworthiness and expertise or network attributes 27 the first group of influencers are often referred to as opinion leaders 21 prestigious innovators 12 keyplayers 8 and spreaders 31 the second group of influencers are often referred to as celebrities 51 evangelists 4 or experts 27 here we focus on measuring and quantifying the influence of an influencer of the first type for two reasons first because they may touch a large scale of audience with a very small marketing cost 333554 second because their tendency to spread desirable behavior may be key to keep healthy communities alive for a longer time 1231 centrality measures have been proven to be relevant indicators in the analysis and comprehension of influencers in a social network 532 the most utilized measures of centrality are inand outdegree betweenness eigenvector and closeness they are all measures of an actors prominence in a network 57 valente et al 55 investigated correlations between these most common measures of centrality the researchers found that there are strong but varied correlations among the centrality measures presented here the average of the correlations was 053 with a standard deviation of 014 indicating these measures are distinct yet conceptually related since the centrality measures examined are not mutually excluding members but have slight different selection criteria in order to identify the players with most influence we will utilize all the centrality measures and select only players that are ranked at the top for each measure research question and contribution to summarize there is good evidence for social contagion and the existence of influencers in social networks more generally prior work in games has shown the existence of ingame social network structures similar to other domains however there is as of yet little data on social contagion or influencers in ingame social networks which is the focus of the present study specifically the question remains whether influencers in online games have an outsized influence not just in terms of the quantitative reach of their ego network but also in terms of their qualitative impact on behavior since standard influencer definitions are based on social network features reachbased claims are somewhat tautological individuals with a large network by definition will touch a large network hence instead of asking do influencers influence more people we asked do influencers influence peoples behavior more strongly given the game industrys interest in playtime as a major relevant design goal and prior work on influencers specific social behaviors we focused on these two aspects to measure the influence that influencers may have on other players while operationalizing playtime is straightforward social behaviors are less so because the clearest form of exhibiting social behaviors is playing together we decided to operationalize this aspect as social play specifically the percentage to which one plays a multiplayer game collaboratively with others versus alone put as a research question do influencers in online games affect connected players playtime and social play more strongly than average given prior findings in the sna literature we hypothesized that social contagion effect if a player joins the ingame network of an influencer it will increase the players playtime and social play impact of influencers if a player joins the ingame network of an influencer it will increase the players playtime and social play more than joining the ingame network of another player the first hypotheses test if a social contagion effect occurs as a result of playing with an influencer the second hypotheses seek to determine whether an influencer has more influence than other socially active players or in other words to rule out that playtime andor social play can explain for the effect on other players by testing these hypotheses we are making a twofold contribution to the literature we are establishing whether basic tenets of social contagion in offline social networks transfer to online ingame networks extending the evidence base from largersized longerlifetime guilds to shortterm smallsized pickup groups we are deepening the general understanding of influencers in online social networks by establishing to what extent their influence supersedes other network members not just in network reach but also perindividual behavioral impact method material to avoid potential confounds by homophily we looked for instances where we could quasiexperimentally observe changes in players playtime and social behaviors before and after joining another players social network and compare influencers to the average player population we found such an instance in the group mechanic of tctd tctd is an onlineonly open world rpg shooter set in a near future new york city in the aftermath of a smallpox pandemic the player an agent of strategic homeland division must help the group rebuild its operations in manhattan investigate the nature of the outbreak and combat criminal activity in its wake released march 2016 tctd accumulated more than 20 million players to date becoming the fastest selling new ubisoft ip of all times as of april 2017 there were more than 2 million active monthly players tctd is structured with elements of roleplaying games combined with collaborative player versus environment and player versus player online multiplayer activities it is split in two zones pve where players cannot kill each other and pvp where they can we use the terms competitive and cooperative to indicate coop vs pvp it is possible to play and replay all the story missions and side missions with up to four real players in coop alternatively it is possible to enter a pvp area called the dark zone and challenge other players all activities both in pvp and pve can be completed solo or in groups groups are composed of the group creator and up to three other players groups can be created through quickmatch with random players or with players already connected as friends to the profile through xbox live playstation network or uplay accounts players invite and accept friend invites by using uplay ids upon acceptance players show up in each others menus as someone they can add to a group play session uplay is a multiplayer and communications service for pc used exclusively by firstparty ubisoft games groups can be created or joined at safe houses and social hubs scattered around the game area or right before beginning an activity a playtime segmentation report showed that active players are spending more than 35 of their time in groups while players that quit the game spent less than 30 of their time in groups based on that and the existing literature we hypothesized that social dynamics have an impact on player retention sna was adopted as the tool to identify and isolate influential players dataset we had access to data collected by both the uplay platform and the tctd game to reduce the computational time for this analysis instead of working with the whole dataset from more than 14 million players we polled an initial random sample of 200000 pc players from tctd and then included all other players that the initial sample interacted with in the game either by being invited or by inviting to a group this led to a sample of 246041 players this will be referred to as the initial sample this initial sample was polled on april 24th 2017 we chose pc players only because our access to account data was limited to the uplay service including ps4 and xbox players would have required special permission from sony and microsoft in addition we made sure to include individuals that players in the original sample interacted with since we were interested in exploring communities generated by group forming behavior and not including these last players would have imposed an incomplete network the total population at the time of polling was 14716507 players therefore the initial sample is 17 percent of the entire population at that time the dataset consists of two tables the first table has the ids of the group creators the time of group creation the ids of players invited to each group and their status the second table has for every player various statistics such as their total and daily playtime number of friends etc identifying influencers we used conventional sna techniques to identify influencers in our data set a practice that has been done before in the context of both social networks at large 731 and multiplayer games specifically 29 given that there is no agreement on which individual measure to utilize when identifying influencers we used six different measures of centrality closeness betweenness eigenvector indegree outdegree and pagerank all the sets of players identified by each centrality measure are intersected with each other to identify the players that are considered central for each of the six measures in this work we define influencers as players that satisfy all these six conditions we then plotted the resulting influencers onto a network graph where the nodes represent the players and the color of a node indicates the community the node belongs to the resulting supergraph is depicted in figure 1 the size of the nodes is proportional to the importance of a player hence influencers display a much bigger size than normal players details of our method are described below identifying most central influencers we first computed centrality measures which aim to quantify the influence of a particular node within a network our aim was to identify within each community which player may be influential to accomplish this we considered the following measures closeness centrality how easily accessible a node is to all other players represented as the length of the shortest path the speed by which a player accesses all other players ranges between 0 and 1 we selected all nodes with values 0 resulting in 182 players betweenness centrality it represents the number of shortest paths to other players or how likely a player is the most direct route between two other players the range fell between 0 and 168 we selected all nodes with values 0 resulting in 78 players eigenvector centrality while degree centrality counts all connected nodes equally eigenvector centrality treats connected nodes differently based on their importance or how well a player is connected to others the range is between 0 and 1 we selected all nodes with values 005 resulting in 198 players indegree number of connections to a node from others these are players invited most often to groups range is between 0 and 5 and we selected all nodes with values 2 resulting in 371 players outdegree number of connections from a node to other nodes these are group creators that frequently invite other players values range between 0 and 630 and we selected all nodes with values 0 resulting in 165 players inand outdegree together tell us how many players a certain player can reach directly pagerank what fraction of players can be reached via directed paths it uses links as a measure of importance each node is assigned a score based on its number of incoming links these links are also weighted depending on the relative score of its originating node the result is that nodes with many incoming links are influential and nodes to which they are connected share some of that influence the scores range between 0000063 and 0000059 we selected all nodes with values 000006 resulting in 178 players choosing influencers the intersection between the 182 players with highest closeness centrality the 78 players with the highest betweenness centrality the 198 players with the highest eigenvector centrality the 371 players with the highest indegree centrality the 165 players with the highest outdegree centrality and the 174 players with the highest pagerank score returned 49 players these 49 players will be referred to as influencers from now on it is important to note how intersecting across the six measures of centrality gives us a very conservative selection of players since in order to be considered influencers they must satisfy all six criteria furthermore as figure 1 shows these 49 players map to a very large extent onto the subcommunities that form the heart of the network sampling comparison players after we identified the influential players we sampled a group of comparison players to get a better understanding of who these influencers are because we hypothesized that playtime andor social play alone cannot explain the effect on other players for this comparison group we selected the most engaged players in the whole populationgenerally known as power users it is important to note that power users is an already existing category of players within ubisoft they are known as star players 1 ubisoft routinely invites power players to special events and sees them as an important resource for community building with this in mind it is legitimate to wonder whether power players could count as another influencer type there may be some overlap of these categories however as our data offers no good easy indicator of popularity and status within the player community we cannot test this assumption in the context of tctd power users are defined as players with at least 70 hours playtime the whole player population has an average playtime of 67 hours and 20 minutes at least 10 friends on uplay on average players have 860 friends gearscore in the top 5 gearscore is an indicator for how wellequipped players are every weapon or piece of gear found after reaching level 30 has a gearscore value the higher an items gearscore the stronger the item is making it a more valuable field asset the overall gear score of players defines their progression after the endgame we selected only the top 5 percent at least played twice in groups in the week before we polled the sample we added this criterion to ensure that the power users made extensive use of the multiplayer functionalities of the game applying these criteria to our initial sample led to 2102 power users it is interesting to compare infuencers to power users because we made no effort to remove influencers from the initial sample yet no influencer was found amongst the power users a third comparison was carried out with the total population additionally we intended to compare longitudinally the impact that influencers powers users and random players from the general population may have on others for that purpose we needed to extend our samples first we selected all players that engaged with the 49 influencers all players that engaged with 49 power users randomly selected from the 2102 initial power users sample and all players that engaged with 49 random players from the initial sample for the latter sampling we excluded players with less than 1 week of total playtime and excluded all power and influential users lastly we examined if there was behavior transfer from influencers to the players they interacted with by running again the influencer identification method from the section identifying influencers for this we needed to extend the three samples we selected all players that interacted with the 49 influencers and that were still active a year later and added all players that interacted with them we also selected all players that interacted with the 49 power users and that were still active a year later and added all players that interacted with them and finally we selected all players that interacted with the 49 random players and that were still active a year later and added all players that interacted with them constructs and measures as discussed before to evaluate our hypotheses we focused on two constructs playtime and social play playtime acts as a proxy for retention social play will reveal a tendency to value the social dimension of play more which as we hypothesized based on the tctd data and the existing literature is a good indicator for how long a player will be engaged with a gameand is therefore another proxy measure of retention both constructs are measured as follows playtime average daily playtime calculated only for days of activity social play ratio of solo and group play both measures were chosen in the context of tctd for example we chose to use playtime and not days played because it fits better with the games monetization model players need to play enough every day to see value in and buy upgrades or subscriptions and the longer they play in this active fashion the more they pay over time days played would not offer this level of granular information results descriptive statistics table 1 shows an overview of the three groups influencers powers users and the total population the comparison is based on the lifetime of players on average it turns out that the powers users are indeed the powers users we would expect with more sessions played more daily playtime but especially far more playtime kills skill kills and items extracted compared to the influencers and the total population for example power users played almost four times more than the influencers and seven times more than the general population the influencers on the other hand have on average far more friends compared to the power users and general population but especially interact with others more in group play than power users and the general population interestingly both influencers and power users spent about twothirds of their time in group play whereas this is the reverse for the general population another interesting observation is that for performative measures the influencers perform similar to the general population as for group play power users spent only marginally more time in group vs solo play and competitive vs cooperative play but especially have created and joined many more groups compared to influencers and the average players however these numbers are somewhat deceiving when we consider their total playtime it turns out that on average power users create 045 and join 038 groups per hour the average player creates 038 and joins 030 groups per hour and influencers create 074 and join 039 groups per hour therefore it shows that power users are only marginally more engaged per hour than the average player and that influencers take far more initiative in creating groups in terms of group play it is also interesting to consider with whom both influencers and powers have played with on average power users play with 27 other players in their lifetime this is interesting because the number of players that power users interact with in groups is very close to the number of friends indicating that power users tend to play almost exclusively with their friends at the same time each influencer plays on average with 342 other players a larger number compared to the already large number of their friends indicating that influencers play in groups with considerably more players than just their friends therefore while power users spend on average about equal testing hypotheses to assess our hypotheses we took the following three steps we isolated all players that played with influencers the selected power users and the selected random players at least twice in the week before polling the data we split data regarding their communities in two data regarding play behavior corresponding to the two weeks before joining the community and data regarding play behavior for the two weeks after joining the community we compared daily playtime and social play ratio two weeks before and two weeks after joining the communities of the influencers power users and random players respectively results are shown in table 2 there is a clear change and impact on the behavior of players that join the community of the influencers the daily playtime increases considerably from a number very close to the general population average to a number very close to the influencers themselves the amount of time spent in groups increases from the total population average to almost the same amount of the influencers for playing with power users in contrast both the daily playtime and social play do not change drastically the numbers are also similar to the powers users themselves suggesting that not only do power users play together with their group of friends they are likely to play together with other power users engaging with random players does not change behavior and as expected here the statistics are similar compared to the total population pairedsamples ttests were conducted to compare daily playtime and social play in two weeks before joining a community and two weeks after as for the playtime there was a significant difference for the daily playtime of players interacting with influencers before and after they joined the influencers community t 2883 p 001 r 22 no significant effect on daily playtime was witnessed for players interacting with power users two weeks before and after joining their community t 026 p 796 r 007 for the random sample of players there was also no significant effect on daily playtime two weeks before and after joining their community t 014 p 885 r 005 these results support hypotheses h1a and h2a joining a group with an influencer did in fact increase the daily playtime of players at least in the first two weeks after joining while the same could not be stated of power users or a random sample of players during the same period as for social play joining an influencerss community significantly changed the ratio from two weeks before to after t 7432 p 001 r 50 this ratio change was also significant for players joining a power users community compared to their situation two weeks before and after joining them t 479 p 001 r 13 for a random sample of players two weeks before and after joining groups it did not significantly change their social play ratio t 054 table 2 changes in the influencers power users and random players communities two weeks before and two weeks after engaging with influencers power users and random players social play ratio 41 59 59 41 60 40 65 35 39 61 38 62 p 588 r 002 these results support hypotheses h1b and h2b the ratio of playing in groups significantly increased for players joining an influencers community at least in the first two weeks after joining while a significant increase in group play happens with joining power users as well their impact is less the effect size for influencers is large resulting in an average increase on of 18 in group play whereas the effect size for power users is small resulting in an average increase of only 5 of group play influencers retention and influencer conversion for testing our hypotheses we limited our observations to two weeks before and after a question remains what kind of influence influencers may have on other players beyond this period for this analysis we first considered if players are still actively playing tctd in our previous analyses we used playtime and social play as measures because these can indirectly tell us something about retention more engaged players and players engaged in the multiplayer aspects of a game tend to stick around longer to calculate retention here we looked at which of the players who joined the communities of the influencers power users and random players were still active after one year table 3 shows the retention results after 1 year 23 of the influencers community is still active whereas this is 29 of the power users community and only 5 of the random players community the second consideration is more ambitious we considered which of the players from these communities may have become an influencer themselves as we have demonstrated influencers have an impact on other players and so if these players are converted into influencers they on their turn can influence othersand thereby keep the community alive even if certain influencers decide to leave the game for this analysis we first applied the same method for identifying the original 49 influencers except a year later then we considered which of the newly identified influencers mapped onto the players from the initial population that the original influencers power users and random players engaged with table 3 shows the conversion results which are remarkable from the community of the random players only 2 players were identified as an influencer a year later which is a conversion rate of 1 based on the still active players in that community the influence of power users is greater from their community 22 players are identified as an influencer resulting in a rate of 6 however from the community of influencers we identified a staggering number of 1002 influencers which corresponds to a rate of 26 discussion using conventional social network analysis techniques we identified key members that are very engaged with the game tom clancys the division but also with other players the question that we investigated is whether these socalled influencers really influence other players behavior as measured in their playtime and social play and if they do this more than other players our results provide supporting evidence that influencers do indeed impact other players and more so than others we discuss here our findings on social contagion retention and player differences before explaining the limitations and implications of this study influencers are socially contagious our results highlight that the identified influencers seem to have a very tangible impact on the people they play with these other players begin playing longer and spend more time in groups we observed a significant increase with a small to medium effect size on playtime and a large effect size on social play compared to interacting with an influencer two weeks before players daily playtime increased on average with 24 and their social play ratio completely reversed in favor of being more social two weeks after we contrasted the impact of influencers with those of power users and average users and found that interacting with these users does not yield any significant differences in playtime and only a significant but with a smaller effect size on social play for power users therefore a strong social contagion effect is unique to the influencers homophily is always a possible confound in social contagion work 14 for this reason we ran a quasiexperimental analysis comparing playtime and social play ratio prepost joining the team of an influencer vs power player vs normal table 3 players interacting with influencers power users and random players that continue to be active and have become influencers themselves after 1 year note conversion rate is based on active population after 1 year player homophily would predict higher overall playtime and social play ratio among influencer team members but not the significant changes that we observed this makes us confident in claiming causality that influencers are socially contagious initial population influencers are important for retention retention is a key measure for success in the game industry our results suggest that not only are influencers socially contagious they are also important for retention we measured if players continue to be active players one year after interacting with influencers power users and random players and found that players who interacted with influencers and power users are more likely to be active compared to a random player while the retention is higher for power users it should be kept in mind that influencers are able to retain ten times the number of players and that power users tend to engage only with similar users so their influence is more of a reinforcing feedback loop than having an impact on the community at large what is most striking however is that players who have interacted with influencers may become influencers themselves after a year such influence is not as noticeable with power users or random players this data suggests that the social contagion effect of influencers may go as far as converting a significant portion of the players they interact with into influencers because we did not experimentally test this or observed whether these new influencers exhibit the same kind of impact we cannot claim causality here neither can we fully illustrate what impact this has on the community however these results provide further evidence of the important role that influencers play in online game communities especially with the issue of retention in mind in fact as the sustained lifetime of a game depends in large measure on a healthy lively community of players engaged with the multiplayer aspects of the game these players seem to form the invisible social backbone of a game community influencers are different players our results show that influencers are different from other players influencers create groups much more than the average player they play many more sessions have many more friends and spent relatively more time in group and coop play than the average player more importantly they seem to be the ones who initiate group play and invite others to join power users on the other hand spent many more hours playing but while they engage considerably in group activities even at a similar ratio as the influencers they tend to start groups relatively less and seem to play mostly with their much more limited number of friends who are likely to be power users too and less so with strangers important to observe as well is that the selected power users are indeed power users compared to the average player they have far more kills skill kills and items extracted and play more competitively interestingly the statistics for influencers on these performative metrics are with the exception of competitive play fairly similar to the average player therefore what defines influencers in contrast to power users is that they have a widereaching and solid network of friends and an active engagement with the multiplayer aspects of a game rather than an elite performance in the game influencers are the social butterflies although these metrics highlight the differences between influencers vs power users vs average players it is important to note that these metrics are not sufficient to identify influencers when applying one or a combination of metrics it was impossible to achieve the same result therefore sna seems to be required to identify influencers the approach we have taken here is to define influencers on the basis of combining six centrality measures and then inspecting the results visually for verification future research is needed to further refine this approach and examine how it generalizes to other contexts furthermore neither the sna or the metrics tell us really who these influencers are and how it is possible that they can convert others into influencers because explanations such as that influencers are inherently social a suggestion supported by evidence that there are similarities between virtual and real world personalities and behavior 10115667 or are a different type of player more into social play 41 66 eg cannot fully explain the results we observe here it may be that those converted are socially inclined people and that interacting with another socially inclined person but already socially active player activates how they can and want to play regardless our quantitative hypothesistesting approach is inherently limited in generating detailed explanatory portraits of players and the dynamics we observed future qualitative and mixedmethods work where influencers and the players they interact with are interviewed or closely followed over a period of time can provide further evidence on understanding who these players are and why they have such influence on others beyond being socially active as described with the metrics here limitations and generalization our presented work has several limitations first the work focused on a single game although there are differences between tctd and other online games the type of game its mechanics and especially group play management is similar to other online multiplayer games the most important difference in terms of group play compared to other online games is that it is limited to up to four players at a time meaning that player ties may be closer than in other games and that there are more loosely connected communities than in other games more importantly influencers who initiate group play may be more influential as they are the ones who make connections across the network whereas in games where guilds and factions play a role there are other mechanisms of how players join groups second we sampled only one degree of ties after the initial sample of 200000 pc players by including all the players the initial polled sample interacted with this was a necessary step because we aimed to investigate their social networks based on who they play with however there is a question how representative the sample is in terms of the whole population depending on the study design and situation different techniques for sample size estimation exists assuming normally distributed variables in the population zscores can be used to define the confidence interval and sample size in the current case with a 1 margin of error and a 99 confidence level the required sample size for the whole population would be about 9600 players using random sampling the sample used here is roughly 20 times larger nevertheless aside from replicating the work in other game contexts future work could operate with the entire network andor samples that have up to three degrees of ties similar to what others have done while utilizing sna on game communities 4344 third while we made deliberate decisionsbased on literature closely examining our data and definitions used by ubisofton how to identify influencers define power users and examine the impact of social contagion choosing a different set of criteria may have led to different results as future work will consider this phenomenon more closely more robust standards and definitions will be established and the results presented here can be affirmed fourth in order to rule out the possibility that a particular metric can explain for the impact we observed it would be necessary to perform a propensity sample where we compare the influencers to a sample with similar characteristics implications the current work has important implications for hci researchers and industry for hci researchers we have established here how social contagion or influence occurs in online ingame networks specifically in the context of shortterm smallsized pickup groups while we need to be cognizant of this particular context this work advances the field at large where previous sna work on influencers in games and social media focused on network features only eg 59 our work highlights how influencers act differently from others and the extent of their impact on others and the community over time additionally as it remains an ongoing discussion on how to identify influencers in social networks using sna metrics 45 our work suggests a combination is necessary and that measures of activity and popularity are not good metrics this latter is relevant for the community management for every game or social media which generally tend to be most interested in active users as well celebrities evangelists or experts such as power users our data suggests that for tctd at least the most central users may be the most important for engaging and retaining other users therefore community managers should tap into sna to identify such influential users then leverage them for feedback or to reach a large part of the community conclusion in this paper we studied if influencers in online games affect connected players playtime and social play more strongly than average we studied this in the context of tom clancys the division a popular multiplayer online shooter our findings show that influencers do indeed impact other players and more so than power users or the average player thus providing evidence for a social contagion effect and the important role influencers have in these online social networks

in a wide range of social networks peoples behavior is influenced by social contagion we do what our network does networks often feature particularly influential individuals commonly called influencers existing work suggests that ingame social networks in online games are similar to reallife social networks in many respects however we do not know whether there are ingame equivalents to influencers we therefore applied standard social network features used to identify influencers to the online multiplayer shooter tom clancys the division results show that network featuredefined influencers had indeed an outsized impact on playtime and social play of players joining their ingame network• humancentered computing → empirical studies in hci empirical studies in collaborative and social computing

Introduction Children who pose a sexual threat to other children raise major practice and policy issues , however, most recent research in this field comes from North America . While there is a limited body of recent empirical research concerning Youths-Who-Pose-Sexual-Risk from continental Europe , there is relatively little recent empirical work from the UK. As Riser states, practitioners need a better understanding of YWPSR, because they represent a potentially important intervention point to prevent future abuse, as these young people are at the full flood of their hormonal drive, and the earlier the unchecked inappropriate sexual behaviour the more likely they are to become confirmed paedophiles . Thus there is every incentive for social workers to confront the issues and understand what leads them to this situation, as this may be the optimum, or even the last opportunity for effective prevention. Aetiological research identifies two key themes. First, studies showing associations with various biological and neurological links ; however, whether this is causal or reactive is problematic. A `biological' element seems to have a place, as illustrated in a recent twinstudy that found monozygotic twins having higher concordance rates for child sex abuse than did dizygotic twins . The authors' model of human behaviour is of a constant bio-psycho-social interaction. Such a model acknowledges the possibility of biological interactional influence upon psychosocial factors that in turn influences biological development . This does not exonerate the abusers, nor diminish the vital importance of the psychosocial and environmental features, but the interaction of the two needs to be better understood. Recent work by the Children's Commissioner for England has highlighted that a proportion of young people who sexually offend have a degree of neuro-disability, opening up the possibility of another complex interaction that may underpin offending behaviour but offers a possible better opportunity for preventative intervention by taking an integrated view earlier . Most psychosocial research emanates mainly from North America and continental Europe and its complexity is highlighted by Whitaker et al This suggests there are different types of young people who offend against children , but what all agree upon is that the earlier the offending starts, the more likely it is that the child sex abuse will continue for longer . A major issue is the degree to which current child sex abusers were themselves victims of sex abuse as children, as there is research pointing in this direction , but of course not all abused children become abusers, and, not all CSA were abused when a child. Consequently, the more we can know about this early stage the better. This study emerged following a request from front-line child protection social workers who sought the guidance of the Local Safeguarding Children Board , which oversees child protection in their area, about their clients who appeared to be Youths-Who-Pose-Sexual-Risk to other children, which led to this descriptive case analysis. Two important groups of young people to consider, who might be amongst YWPSR are those with known severe psychosocial problems. The first are children who have formally been taken into public care and are `Looked-After' under the supervision of the Local Authority, designated `Looked-After-Children' . The second group are children who have formally been Excluded-from-School by the Head Teacher because of behaviour that either disrupts other children's education or they are unable to be educated within mainstream education which is associated with serious psychosocial difficulties . There are four main research questions, based upon anonymised information from the Youth's social workers. 1) were these Youths who appear to be YWPSR more likely to have been Looked-After-Children or not? 2] were these Youths who appear to be YWPSR more likely to be or have been Excludedfrom-School children than not? 3] are there significant differences between the Youths known to have been sexually abused compared with those not known to be abused? 4] are there significant differences between those who have already been Formally Charged with a child sex related offence and those who have not been charged? --- Methodology Team leaders from an English Local Safeguarding Children's Board reported that their front-line colleagues were expressing concerns about possible YWPSR. Because of related work in this field of risk assessment , the LSCB confidentially and anonymously invited the authors to undertake an audit of the cases to determine whether there were any discernible patterns of behaviour in the background of these young people. It was not possible to examine actual case-records because of the need to protect the anonymity of the Youths, their social workers and the LSCB. Ethical approval for the project was given by the LSCB as they were satisfied that clients and their social workers confidentiality were maintained. To ensure total anonymity we agreed that the LSCB would remain anonymous in any subsequent publication. Consequently the data we used came from a social history protocol we designed based upon international research that identified a range of factors that was associated with Youths who later became adult Child-Sex-Abusers, to determine whether these Youths had similar characteristics . We could not find a standardised questionnaire or protocol that was indicative of youths who posed a potential sexual risk to children. Consequently, from current research literature, referred to throughout this paper, we extrapolated what appeared to be the strongest statistical association of factors related to those who became a child sex abuser. Thus the protocol, although not standardised, is of original design and proved to be internally consistent as demonstrated by the results obtained. Nonetheless, we recognise this is a limitation to be born in mind when considering the findings. The questionnaires were distributed by the LSCB to the social workers and because of the perceived sensitivity of the material, only one author had direct contact with the LSCB and none with the social workers thus maintaining total confidentiality. A confidential report went to the LSCB but as the results appear to have wider relevance in an area of relative paucity of British empirical data, the outcomes are reported here. There are a number of inevitable limitations to the study, in part due to the small sample size. The reliability of the data is influenced by the individual social worker's knowledge of factor present to a specific youth. Hence, a negative score about a particular piece of behaviour or background does not necessarily mean that it did not apply to that youth, but simply that the social worker did not know about it. These limitations are explored in greater detail in the discussion. Data covered the Youths' demographics and the problems they faced, broadly categorised as psychological, educational and family. The total data was then separately analysed in subgroups to compare: 1. Youths who were known to have been Sexually Abused, with those who were not 2. Youths were either former or current Looked-After-Child , or former Excludedfrom-School with those who were not 3. Youths who had been Formally Charged with a sex offence against another child versus those who had not been charged This last comparison is undertaken because a formal charge of a sex offence against a child within the general population is statistically extremely rare and consequently might be considered as a serious indication that the young person is already at risk of recidivism .The subgroups were statistically tested using the non-parametric chi square test, which is appropriate for relatively small numbers. --- Findings We first report on the total sample in regard to the YWPSR demographics, their behaviour and family background. Frequency scores are given in Table [1] on every item for the whole cohort. However, rather than swamp the reader with masses of data on each identified factor, only those showing a statistically significant difference will be commented in each of the four comparative sub-groups. --- Sample The sample consists of a cohort of cases of young men aged 13-18 who came to the attention of child protection social workers over the course of one year. In each case the case-responsible social workers had expressed concern that the young people appeared to be YWPSR to other children because of reported inappropriate sexual behaviour, invariably against much younger children. Fifty-five young males and one female were initially considered and 37 questionnaires were finally completed. The main reasons for the non-return of 18 questionnaires were because the social workers were either concerned not to inadvertently stigmatise their client, or, because the problem appeared to have been resolved. As only one case was female , it was decided that little could comparatively be said about her, other than she had a highly disturbed background. Consequently, the following findings refer to the 36 males for whom we have completed case-history protocols, giving a 67% response rate. --- Age Table [1] give the demographics of the cohort and their current situation. Of the thirty-six cases at the time of the offence 47% were aged 14 years and under, 20% between 15-16 years, and 33% were 17-18 years old. A key aspect of YWPSR is their age. Nearly a third had their first inappropriate sexual behaviour aged eleven and under, more than half were aged between 12-14 and the remaining 5 were aged 15 years and over. Twenty of the Youths had been formally charged with a sexual offence, 25% were aged <14 and 31% were aged 15+. --- Links with Children's Services Seventeen of the YWPSR were known to the Social Services, 20% who had been LAC whilst 28% are still LAC. The youths' problems fall naturally into Psychological, Educational and Familial factors. Psychological: Major themes were: more than two-thirds had low self-esteem, 67% were socially isolated, 61% lacked appropriate peer relationships, 31% were described as having attachment difficulties and 17% had expressed confusion about their sexual identity. Behaviours linked to fewer than 10%, i.e. only two or less cases, are not discussed, but are noted in the table. Educational: Almost half had experienced bullying at school, 25% had bullied others, 25% were frequent truants, 36% had learning difficulties 33% had Special Educational Needs and 14% had a formal diagnosis of Attention Deficit Hyperactivity Disorder .Whilst fifteen of the Youths had been Excluded-from-School at some time, forming a separate sub-group for analysis. Familial: The Youths came from families experiencing multiple disruption; 56% were reported to have suffered emotional abuse, 39% neglect and 31% physical abuse. There was a high level, 53%, of reported domestic violence and 31% within-family sexual abuse of other children by a parent figure. 28% of families had a history of parental mental illness, but a relatively low level of reported parental alcohol misuse and substance abuse . However, the parents had reported 39% of the youths being violent and abusive in the home, with 22% reporting them as violent/abusive outside the home. 17% were reported as having run away either from home or care and 11% as being involved in fire-setting at home. Self-evidently, with such profiles these YWPSR have a multiplicity of problems. Insert Table [1] The Sub-Groups Each sub-group is compared against the rest of the cohort to determine any themes that might emerge. Rather than give each item, only those that were statistically significant or a trend are shown. Youths who themselves were Sexually Abused 25% were known to have been Sexually Abused in the home, though it must be remembered that the referring social worker would not always know of any abuse. Despite the small numbers, Table [2] shows that there were some statistically significant differences between these two groups, which indicate the particularly adverse experience of these YWPSR in the context of their having experienced sexual abuse themselves. Whilst it was not statistically significant, six of the nine abused Youths were also Excluded-from-School , which of course is of practical significance and would add to any social isolation. The `abused' group had greater contact with social services, 8 of the 9 were either currently or previously LAC. There was a trend of witnessing more family violence; significantly more emotional abuse, physical abuse and neglect; and six had a history of running away from home/care. All were said to be socially isolated, lacked peer relationships and had greater contact with mental health services. --- Insert Table [2] Previous or Current LAC Table [3] lists the statistically significant differences between those 17 youths who were or are currently LAC, compared with those who were not. Of the 35 factors related to the YWPSR backgrounds and behaviour, the LAC subgroup had significantly greater scores or showed trends on 25 of the items, indicating that LAC young men were frequently involved in problematic situations. However, in regard to deliberate-self-harm, violence in the home and contact with mental health services, it was the non-LAC youths who were significantly more often involved than the LAC youths. It is noteworthy that the LAC sub-group tended to start age-inappropriate sexual behaviour at a much younger age; half were eleven and under. The main differences between the two sub-groups were that the LAC youths had greater exposure to domestic violence and were more likely to be victims of emotional and physical abuse and neglect. They were also considerably more socially isolated, had lower self-esteem, comparatively lacked social skills and had attachment difficulties. As would be expected with LAC young people, social services were significantly more often involved in their supervision and they attended group sessions. Interestingly, there was little difference in terms of victim awareness training. Inset Table [3] Excluded-from-School Table [4] lists the significant differences between the 42% of YWPSR who had also been Excluded-from-School compared to the non-EFS youths. Of the 35 items regarding background and behaviour, the EFS sub-group differed significantly on 19 items from the non-EFS. The EFS group contained more 15-year old YWPSR whose inappropriate sexual behaviour started after 12 years old. Interestingly the EFS had a greater history of parental alcohol abuse, substance abuse and mental health problems than the non-EFS. As might be expected the EFS had significantly more school-related problems such as truancy, bullying and being bullied. Linked to this was a lack of peer relationships. The EFS group were more violently abusive at home, had more consensual sex and four out of the 15 had been involved in deliberate-self-harm, which when compared to their age peers in the general population was more than a thousand times that of the general population. The EFS group had less contact with social services, a finding to which we shall return. Finally, 40% of the 15 EFS were either previously or currently in care. --- Insert Table [4] YWPSR & Charged with a Sex Offence More than half of the cohort had formally been charged with a sex offence against a child. This is a remarkable statistic as such charges are amongst the rarest in the criminal field, because the authorities find the offence so hard to prove. However, against expectations, we found relatively few significant differences between the `charged' and 'noncharged'; indeed there were only four significant items. Crucially, the `charged' group were older, and 14 out of the 20 were 15+ and were relatively later in terms of age at inappropriate sex. None had parents involved in substance abuse, but half the group had been involved in victim awareness sessions. It would seem the only notable difference of this sub-group was their age, suggesting the police only become involved when YWPSR are older. --- Key Findings First, there were statistically significant differences between the Youths who themselves had been abused and those who were not known to have been abused. Second, of the current or former LAC, 47% had far worse backgrounds, in terms of emotional, physical and sexual abuse, domestic violence etc. than those who had never been LAC. Third, the majority of these youths experienced low self-esteem, social isolation and poor peer relationships. This suggests that achieving age-appropriate relationships may be especially challenging, especially in view of their problems at school. Fourth, the over-lap with the learning difficulties spills over into educational problems and this may further impair young people's ability to relate appropriately to their age peers. Furthermore, many had begun their depredations very early and there is evidence that the earlier this starts, the greater likelihood this becomes a repetitive pattern of behaviour . The above psychosocial environmental factors reflect recent studies from continental Europe and North America , which gives the authors some confidence in the validity of the findings of this small British study. Fifth, against our expectations, the twenty youths formally charged with sexual offences had few significant differences when compared to those who were not charged, other than their age. This strongly suggests that when the police intervene the youths are a little further along the cusp to becoming child sex abusers. Conversely, it may be they were charged because they were more visible to children's services and it may be their being known that makes them more readily identified. Finally, after accounting for the 17 LAC and the 11 EFS, there are a further 8 YMPSR for whom biological factors, namely ADHD, might be an issue. There are studies that link biological and environmental factors as possibly multi-causal of CSA . Indeed the Children's Commissioner Report reminds us that those on the autistic / learning difficulties spectrum may be more prone to be YWPSR , possibly in part due to their inability to maintain appropriate agerelated relationships, with the resulting social isolation . --- Discussion and Conclusions. Limitations 1] There was only one female in the cohort so her case was excluded from the general analysis as little could be comparatively said about a single protocol other than her profile indicated a highly disturbed person. 3] Conversely, the absence of a risk factor does not necessarily mean it was not part of the individual's behaviour or background, but simply because it is unknown to their social worker. 4] There is the problem of age-span in these cases. Whilst age is a chronological fact, in practice it is highly variable in individuals, as some 12 year olds can hormonally be virtually a young adult. 5] A major problem in assessing this children's and adolescent's sexual behaviour is that we do not know the boundaries of normal child and adolescent sexual behaviour 6] Finally, these findings could be misunderstood or misinterpreted, especially in relation to the LAC group, indicative of `failure' of the child care system, hence the need for the greatest caution in interpreting the data. Despite the small numbers, it was possible to demonstrate some significant differences between the various sub-groups, which were internally consistent. For example in relation to those who had been abused themselves, it was possible to confirm earlier research on former LAC and EFS young men aged 16-24, in relation to a comparatively high rate of sex offences against children, although former LAC males had a significantly better outcome than another disadvantaged group, former EFS young men . So despite these qualifications, the authors believe this study is worth pursuing because of the relative paucity of British based empirical research in this area and the need for better informed practice and policy. --- Policy & Practice Implications When informally discussing our findings with experienced front-line child protection social workers, a frequent response was that none of the findings surprised them. Indeed, it was felt that the problems posed by YWPSR were well known, but rarely formally discussed or acknowledged. So, despite the earlier reports from National Children's Home and the Dept. of Health and the Home Office , there appears to be relatively little debate, which highlights the first key issue as, by implication, the social workers themselves are aware that there are youths who potentially pose a sexual risk to children on their case load. Clearly, until a formal assessment and consequent identification has been undertaken, we do not know the numbers or the scale of the problem at a national level. This leads to the second key issue and this relates to the 'deservedness' of the YWPSR. We would invite the reader to consider the factors that underpin the lack of discussion, assessment and identification of YWPSR. It might be that, with such a high link with current or former LAC young men being YWPSR, we might be ignoring what might be happening in the young people's care situation. We need to confront the issue of how services treat the sexually inappropriate behaviours of their LAC charges before the young person has left the care of the local authority. The third issue we highlight relates to the treatment and care of the YWPSR. The social worker's duty is to maintain the focus upon the paramount interest of the child, which also includes when the child poses a sexual risk to other children. This needs to achieved, by skilfully balancing risk with the key legislative principle that the best place for children is for them to be looked-after in their own homes. This confronts us with the need to make a judgement of whether the child's removal from their family is necessary to ensure their safety and well-being. Overall, this requires balancing the ethical dilemma of how best to assist the individual whilst ensuring the safety of other children. To maintain the highest proportion of YWPSR in their home requires effective local provision. We are aware of local authorities that are developing their own specialist provision and, crucially, building the capacity and confidence of their child care social workers to practice in this context. This fits the agenda for professional development clearly laid out so helpfully in the Professional Capabilities Framework . Perhaps the key practice implication is the fact that the majority of these young people were socially isolated, with low self-esteem and few peer relationships. This core sense of their psychosocial `inadequacy' might largely account for their inappropriate targeting of younger children, as they are unable sustain a peer-age relationship. We need to remember that these youths are at the first full flood of their sex drives, so it is a matter of helping them to handle it appropriately. Hence, the practice aim should be to improve their social skills, equipping them to better develop more mature and age appropriate social and sexual relationships. Whilst the authors acknowledge the limitations of this study, they believe it has the potential to contribute a wider debate that is required so that we are better able to respond to the reality of YWPSR. The priority is for the victim-abuser to develop an acceptable sexual behaviour and thereby avoid joining the next generation of child sex abusers. Perhaps the most salient feature of this study is that social workers already know about young people who pose a sexual risk to other children. They currently manage the risk that they young people pose in their different placement settings e.g. residential homes, foster homes, or is quietly ignored in case we inadvertently stigmatise these young people or hope they will develop more mature age-appropriate relationships. For practitioners and policy makers, evidence can and should encourage betterinformed decision-making. In the context of youths who pose a sexual risk to children. The evidence highlighted in this study suggests that the optimal outcomes for these youths will be by the earliest possible intervention. For these youths already on the case-load of child care social workers a skilled assessment will identify those in greatest need of diverting as early as possible from the path of child sexual abuse i.e. before becoming too fixated along the road of becoming a child sex abuser. The authors hope this study may strengthen the argument in favour of providing for these vulnerable young people while the statutory services retain the duty of care and the power to provide effective intervention.

Social workers had expressed concern to their Local Safeguarding Children Board (LSCB) about male Youths (13-18)-Who-Pose-Sexual-Risk (YWPSR) to children, leading to this study of 36 social-history protocols, completed by the youths' social workers, that identified the presence of research-based factors of YWPSR who then go on to become adult child sex offenders. To ensure total confidentiality, no actual case-record data were available to the authors, ensuring the LSCB, social workers and their clients remain totally anonymous. While a small sample poses methodological difficulties, the authors believe the data is worthy of consideration as a pilot study for a larger project that might highlight the potential areas for early intervention. Findings: Key findings were: Twenty-nine (80%) of thirty-six YWPSR were <14 when first showing inappropriate sexual behaviour, whilst 25% were known to have been sexually abused themselves, mostly <11yrs and 47% were either currently or had been, Looked-After-Children, with 42% having been Excluded-from-School of who 36% had learning difficulties. Their level of disturbance is shown by 11% having made a suicide attempt and they being formally charges for sex offences against children, which was significantly higher than that found in the adult general population. Finally 66% suffered from low self-esteem, were socially isolated and had poor peer relationships; reflected in the high level of problems at school. Application: Such young people pose a challenge for all concerned and an evidence-based debate is required to explore how to prevent further unacceptable behaviour and thereby protect vulnerable children.

introduction children who pose a sexual threat to other children raise major practice and policy issues however most recent research in this field comes from north america while there is a limited body of recent empirical research concerning youthswhoposesexualrisk from continental europe there is relatively little recent empirical work from the uk as riser states practitioners need a better understanding of ywpsr because they represent a potentially important intervention point to prevent future abuse as these young people are at the full flood of their hormonal drive and the earlier the unchecked inappropriate sexual behaviour the more likely they are to become confirmed paedophiles thus there is every incentive for social workers to confront the issues and understand what leads them to this situation as this may be the optimum or even the last opportunity for effective prevention aetiological research identifies two key themes first studies showing associations with various biological and neurological links however whether this is causal or reactive is problematic a biological element seems to have a place as illustrated in a recent twinstudy that found monozygotic twins having higher concordance rates for child sex abuse than did dizygotic twins the authors model of human behaviour is of a constant biopsychosocial interaction such a model acknowledges the possibility of biological interactional influence upon psychosocial factors that in turn influences biological development this does not exonerate the abusers nor diminish the vital importance of the psychosocial and environmental features but the interaction of the two needs to be better understood recent work by the childrens commissioner for england has highlighted that a proportion of young people who sexually offend have a degree of neurodisability opening up the possibility of another complex interaction that may underpin offending behaviour but offers a possible better opportunity for preventative intervention by taking an integrated view earlier most psychosocial research emanates mainly from north america and continental europe and its complexity is highlighted by whitaker et al this suggests there are different types of young people who offend against children but what all agree upon is that the earlier the offending starts the more likely it is that the child sex abuse will continue for longer a major issue is the degree to which current child sex abusers were themselves victims of sex abuse as children as there is research pointing in this direction but of course not all abused children become abusers and not all csa were abused when a child consequently the more we can know about this early stage the better this study emerged following a request from frontline child protection social workers who sought the guidance of the local safeguarding children board which oversees child protection in their area about their clients who appeared to be youthswhoposesexualrisk to other children which led to this descriptive case analysis two important groups of young people to consider who might be amongst ywpsr are those with known severe psychosocial problems the first are children who have formally been taken into public care and are lookedafter under the supervision of the local authority designated lookedafterchildren the second group are children who have formally been excludedfromschool by the head teacher because of behaviour that either disrupts other childrens education or they are unable to be educated within mainstream education which is associated with serious psychosocial difficulties there are four main research questions based upon anonymised information from the youths social workers 1 were these youths who appear to be ywpsr more likely to have been lookedafterchildren or not 2 were these youths who appear to be ywpsr more likely to be or have been excludedfromschool children than not 3 are there significant differences between the youths known to have been sexually abused compared with those not known to be abused 4 are there significant differences between those who have already been formally charged with a child sex related offence and those who have not been charged methodology team leaders from an english local safeguarding childrens board reported that their frontline colleagues were expressing concerns about possible ywpsr because of related work in this field of risk assessment the lscb confidentially and anonymously invited the authors to undertake an audit of the cases to determine whether there were any discernible patterns of behaviour in the background of these young people it was not possible to examine actual caserecords because of the need to protect the anonymity of the youths their social workers and the lscb ethical approval for the project was given by the lscb as they were satisfied that clients and their social workers confidentiality were maintained to ensure total anonymity we agreed that the lscb would remain anonymous in any subsequent publication consequently the data we used came from a social history protocol we designed based upon international research that identified a range of factors that was associated with youths who later became adult childsexabusers to determine whether these youths had similar characteristics we could not find a standardised questionnaire or protocol that was indicative of youths who posed a potential sexual risk to children consequently from current research literature referred to throughout this paper we extrapolated what appeared to be the strongest statistical association of factors related to those who became a child sex abuser thus the protocol although not standardised is of original design and proved to be internally consistent as demonstrated by the results obtained nonetheless we recognise this is a limitation to be born in mind when considering the findings the questionnaires were distributed by the lscb to the social workers and because of the perceived sensitivity of the material only one author had direct contact with the lscb and none with the social workers thus maintaining total confidentiality a confidential report went to the lscb but as the results appear to have wider relevance in an area of relative paucity of british empirical data the outcomes are reported here there are a number of inevitable limitations to the study in part due to the small sample size the reliability of the data is influenced by the individual social workers knowledge of factor present to a specific youth hence a negative score about a particular piece of behaviour or background does not necessarily mean that it did not apply to that youth but simply that the social worker did not know about it these limitations are explored in greater detail in the discussion data covered the youths demographics and the problems they faced broadly categorised as psychological educational and family the total data was then separately analysed in subgroups to compare 1 youths who were known to have been sexually abused with those who were not 2 youths were either former or current lookedafterchild or former excludedfromschool with those who were not 3 youths who had been formally charged with a sex offence against another child versus those who had not been charged this last comparison is undertaken because a formal charge of a sex offence against a child within the general population is statistically extremely rare and consequently might be considered as a serious indication that the young person is already at risk of recidivism the subgroups were statistically tested using the nonparametric chi square test which is appropriate for relatively small numbers findings we first report on the total sample in regard to the ywpsr demographics their behaviour and family background frequency scores are given in table 1 on every item for the whole cohort however rather than swamp the reader with masses of data on each identified factor only those showing a statistically significant difference will be commented in each of the four comparative subgroups sample the sample consists of a cohort of cases of young men aged 1318 who came to the attention of child protection social workers over the course of one year in each case the caseresponsible social workers had expressed concern that the young people appeared to be ywpsr to other children because of reported inappropriate sexual behaviour invariably against much younger children fiftyfive young males and one female were initially considered and 37 questionnaires were finally completed the main reasons for the nonreturn of 18 questionnaires were because the social workers were either concerned not to inadvertently stigmatise their client or because the problem appeared to have been resolved as only one case was female it was decided that little could comparatively be said about her other than she had a highly disturbed background consequently the following findings refer to the 36 males for whom we have completed casehistory protocols giving a 67 response rate age table 1 give the demographics of the cohort and their current situation of the thirtysix cases at the time of the offence 47 were aged 14 years and under 20 between 1516 years and 33 were 1718 years old a key aspect of ywpsr is their age nearly a third had their first inappropriate sexual behaviour aged eleven and under more than half were aged between 1214 and the remaining 5 were aged 15 years and over twenty of the youths had been formally charged with a sexual offence 25 were aged 14 and 31 were aged 15 links with childrens services seventeen of the ywpsr were known to the social services 20 who had been lac whilst 28 are still lac the youths problems fall naturally into psychological educational and familial factors psychological major themes were more than twothirds had low selfesteem 67 were socially isolated 61 lacked appropriate peer relationships 31 were described as having attachment difficulties and 17 had expressed confusion about their sexual identity behaviours linked to fewer than 10 ie only two or less cases are not discussed but are noted in the table educational almost half had experienced bullying at school 25 had bullied others 25 were frequent truants 36 had learning difficulties 33 had special educational needs and 14 had a formal diagnosis of attention deficit hyperactivity disorder whilst fifteen of the youths had been excludedfromschool at some time forming a separate subgroup for analysis familial the youths came from families experiencing multiple disruption 56 were reported to have suffered emotional abuse 39 neglect and 31 physical abuse there was a high level 53 of reported domestic violence and 31 withinfamily sexual abuse of other children by a parent figure 28 of families had a history of parental mental illness but a relatively low level of reported parental alcohol misuse and substance abuse however the parents had reported 39 of the youths being violent and abusive in the home with 22 reporting them as violentabusive outside the home 17 were reported as having run away either from home or care and 11 as being involved in firesetting at home selfevidently with such profiles these ywpsr have a multiplicity of problems insert table 1 the subgroups each subgroup is compared against the rest of the cohort to determine any themes that might emerge rather than give each item only those that were statistically significant or a trend are shown youths who themselves were sexually abused 25 were known to have been sexually abused in the home though it must be remembered that the referring social worker would not always know of any abuse despite the small numbers table 2 shows that there were some statistically significant differences between these two groups which indicate the particularly adverse experience of these ywpsr in the context of their having experienced sexual abuse themselves whilst it was not statistically significant six of the nine abused youths were also excludedfromschool which of course is of practical significance and would add to any social isolation the abused group had greater contact with social services 8 of the 9 were either currently or previously lac there was a trend of witnessing more family violence significantly more emotional abuse physical abuse and neglect and six had a history of running away from homecare all were said to be socially isolated lacked peer relationships and had greater contact with mental health services insert table 2 previous or current lac table 3 lists the statistically significant differences between those 17 youths who were or are currently lac compared with those who were not of the 35 factors related to the ywpsr backgrounds and behaviour the lac subgroup had significantly greater scores or showed trends on 25 of the items indicating that lac young men were frequently involved in problematic situations however in regard to deliberateselfharm violence in the home and contact with mental health services it was the nonlac youths who were significantly more often involved than the lac youths it is noteworthy that the lac subgroup tended to start ageinappropriate sexual behaviour at a much younger age half were eleven and under the main differences between the two subgroups were that the lac youths had greater exposure to domestic violence and were more likely to be victims of emotional and physical abuse and neglect they were also considerably more socially isolated had lower selfesteem comparatively lacked social skills and had attachment difficulties as would be expected with lac young people social services were significantly more often involved in their supervision and they attended group sessions interestingly there was little difference in terms of victim awareness training inset table 3 excludedfromschool table 4 lists the significant differences between the 42 of ywpsr who had also been excludedfromschool compared to the nonefs youths of the 35 items regarding background and behaviour the efs subgroup differed significantly on 19 items from the nonefs the efs group contained more 15year old ywpsr whose inappropriate sexual behaviour started after 12 years old interestingly the efs had a greater history of parental alcohol abuse substance abuse and mental health problems than the nonefs as might be expected the efs had significantly more schoolrelated problems such as truancy bullying and being bullied linked to this was a lack of peer relationships the efs group were more violently abusive at home had more consensual sex and four out of the 15 had been involved in deliberateselfharm which when compared to their age peers in the general population was more than a thousand times that of the general population the efs group had less contact with social services a finding to which we shall return finally 40 of the 15 efs were either previously or currently in care insert table 4 ywpsr charged with a sex offence more than half of the cohort had formally been charged with a sex offence against a child this is a remarkable statistic as such charges are amongst the rarest in the criminal field because the authorities find the offence so hard to prove however against expectations we found relatively few significant differences between the charged and noncharged indeed there were only four significant items crucially the charged group were older and 14 out of the 20 were 15 and were relatively later in terms of age at inappropriate sex none had parents involved in substance abuse but half the group had been involved in victim awareness sessions it would seem the only notable difference of this subgroup was their age suggesting the police only become involved when ywpsr are older key findings first there were statistically significant differences between the youths who themselves had been abused and those who were not known to have been abused second of the current or former lac 47 had far worse backgrounds in terms of emotional physical and sexual abuse domestic violence etc than those who had never been lac third the majority of these youths experienced low selfesteem social isolation and poor peer relationships this suggests that achieving ageappropriate relationships may be especially challenging especially in view of their problems at school fourth the overlap with the learning difficulties spills over into educational problems and this may further impair young peoples ability to relate appropriately to their age peers furthermore many had begun their depredations very early and there is evidence that the earlier this starts the greater likelihood this becomes a repetitive pattern of behaviour the above psychosocial environmental factors reflect recent studies from continental europe and north america which gives the authors some confidence in the validity of the findings of this small british study fifth against our expectations the twenty youths formally charged with sexual offences had few significant differences when compared to those who were not charged other than their age this strongly suggests that when the police intervene the youths are a little further along the cusp to becoming child sex abusers conversely it may be they were charged because they were more visible to childrens services and it may be their being known that makes them more readily identified finally after accounting for the 17 lac and the 11 efs there are a further 8 ympsr for whom biological factors namely adhd might be an issue there are studies that link biological and environmental factors as possibly multicausal of csa indeed the childrens commissioner report reminds us that those on the autistic learning difficulties spectrum may be more prone to be ywpsr possibly in part due to their inability to maintain appropriate agerelated relationships with the resulting social isolation discussion and conclusions limitations 1 there was only one female in the cohort so her case was excluded from the general analysis as little could be comparatively said about a single protocol other than her profile indicated a highly disturbed person 3 conversely the absence of a risk factor does not necessarily mean it was not part of the individuals behaviour or background but simply because it is unknown to their social worker 4 there is the problem of agespan in these cases whilst age is a chronological fact in practice it is highly variable in individuals as some 12 year olds can hormonally be virtually a young adult 5 a major problem in assessing this childrens and adolescents sexual behaviour is that we do not know the boundaries of normal child and adolescent sexual behaviour 6 finally these findings could be misunderstood or misinterpreted especially in relation to the lac group indicative of failure of the child care system hence the need for the greatest caution in interpreting the data despite the small numbers it was possible to demonstrate some significant differences between the various subgroups which were internally consistent for example in relation to those who had been abused themselves it was possible to confirm earlier research on former lac and efs young men aged 1624 in relation to a comparatively high rate of sex offences against children although former lac males had a significantly better outcome than another disadvantaged group former efs young men so despite these qualifications the authors believe this study is worth pursuing because of the relative paucity of british based empirical research in this area and the need for better informed practice and policy policy practice implications when informally discussing our findings with experienced frontline child protection social workers a frequent response was that none of the findings surprised them indeed it was felt that the problems posed by ywpsr were well known but rarely formally discussed or acknowledged so despite the earlier reports from national childrens home and the dept of health and the home office there appears to be relatively little debate which highlights the first key issue as by implication the social workers themselves are aware that there are youths who potentially pose a sexual risk to children on their case load clearly until a formal assessment and consequent identification has been undertaken we do not know the numbers or the scale of the problem at a national level this leads to the second key issue and this relates to the deservedness of the ywpsr we would invite the reader to consider the factors that underpin the lack of discussion assessment and identification of ywpsr it might be that with such a high link with current or former lac young men being ywpsr we might be ignoring what might be happening in the young peoples care situation we need to confront the issue of how services treat the sexually inappropriate behaviours of their lac charges before the young person has left the care of the local authority the third issue we highlight relates to the treatment and care of the ywpsr the social workers duty is to maintain the focus upon the paramount interest of the child which also includes when the child poses a sexual risk to other children this needs to achieved by skilfully balancing risk with the key legislative principle that the best place for children is for them to be lookedafter in their own homes this confronts us with the need to make a judgement of whether the childs removal from their family is necessary to ensure their safety and wellbeing overall this requires balancing the ethical dilemma of how best to assist the individual whilst ensuring the safety of other children to maintain the highest proportion of ywpsr in their home requires effective local provision we are aware of local authorities that are developing their own specialist provision and crucially building the capacity and confidence of their child care social workers to practice in this context this fits the agenda for professional development clearly laid out so helpfully in the professional capabilities framework perhaps the key practice implication is the fact that the majority of these young people were socially isolated with low selfesteem and few peer relationships this core sense of their psychosocial inadequacy might largely account for their inappropriate targeting of younger children as they are unable sustain a peerage relationship we need to remember that these youths are at the first full flood of their sex drives so it is a matter of helping them to handle it appropriately hence the practice aim should be to improve their social skills equipping them to better develop more mature and age appropriate social and sexual relationships whilst the authors acknowledge the limitations of this study they believe it has the potential to contribute a wider debate that is required so that we are better able to respond to the reality of ywpsr the priority is for the victimabuser to develop an acceptable sexual behaviour and thereby avoid joining the next generation of child sex abusers perhaps the most salient feature of this study is that social workers already know about young people who pose a sexual risk to other children they currently manage the risk that they young people pose in their different placement settings eg residential homes foster homes or is quietly ignored in case we inadvertently stigmatise these young people or hope they will develop more mature ageappropriate relationships for practitioners and policy makers evidence can and should encourage betterinformed decisionmaking in the context of youths who pose a sexual risk to children the evidence highlighted in this study suggests that the optimal outcomes for these youths will be by the earliest possible intervention for these youths already on the caseload of child care social workers a skilled assessment will identify those in greatest need of diverting as early as possible from the path of child sexual abuse ie before becoming too fixated along the road of becoming a child sex abuser the authors hope this study may strengthen the argument in favour of providing for these vulnerable young people while the statutory services retain the duty of care and the power to provide effective intervention

social workers had expressed concern to their local safeguarding children board lscb about male youths 1318 whoposesexualrisk ywpsr to children leading to this study of 36 socialhistory protocols completed by the youths social workers that identified the presence of researchbased factors of ywpsr who then go on to become adult child sex offenders to ensure total confidentiality no actual caserecord data were available to the authors ensuring the lscb social workers and their clients remain totally anonymous while a small sample poses methodological difficulties the authors believe the data is worthy of consideration as a pilot study for a larger project that might highlight the potential areas for early intervention findings key findings were twentynine 80 of thirtysix ywpsr were 14 when first showing inappropriate sexual behaviour whilst 25 were known to have been sexually abused themselves mostly 11yrs and 47 were either currently or had been lookedafterchildren with 42 having been excludedfromschool of who 36 had learning difficulties their level of disturbance is shown by 11 having made a suicide attempt and they being formally charges for sex offences against children which was significantly higher than that found in the adult general population finally 66 suffered from low selfesteem were socially isolated and had poor peer relationships reflected in the high level of problems at school application such young people pose a challenge for all concerned and an evidencebased debate is required to explore how to prevent further unacceptable behaviour and thereby protect vulnerable children

Introduction *The exponential growth and prevalence of Social Media Platforms have played a pivotal role in driving transformative changes within modern societies since the onset of the 21 st century. These platforms have engendered profound shifts in various aspects of individuals' lifestyles, significantly shaping the way people interact, communicate, and conduct their daily activities . SMPs enhanced the potential of communication between individuals and altered the function, areas, forms, and impacts of communication, reflecting the nature of social connections within the modern family . Suppose we observe that the Smartphone has replaced the laptop as the most widely used technology. In that case, we should understand that this is not because the Smartphone is an upgraded version of the laptop but rather because it has brought the individual closer and closer to the technology or rather individualized or personalized communication technology . When Social Media Platforms came into existence, they affected the family's social relationships and ability to carry out activities related to child-rearing, supervision, and assistance that require communicative behavior to ensure positive actions in the community . This phenomenon has also had adverse effects on Saudi families. Notably, the increasing education and employment opportunities for Saudi women outside their homes have brought about significant changes in family dynamics and functions. In addition to this, the widespread adoption of social media sites represents another major transformation, impacting relationships within Saudi families and their ability to maintain effectiveness in the face of "Globalized Culture," which competes with their inherent "cultural construction." Research exploring the utilization of SMPs among Saudi youth indicates a substantial surge in smartphone ownership, and some individuals have developed a dependence on these platforms . The rising use of SMPs is not unique to the Kingdom of Saudi Arabia, despite the significant growth relative to other developed nations. Most research concurs that there is excessive use of SMPs, particularly among children and adolescents . The development observed by the Kingdom of Saudi Arabia in the sphere of the Internet, particularly social communication platforms, has allowed the Kingdom to open up to many cultures and societies, particularly the youth. This tendency challenges the Saudi family due to the traditional and conservative nature of the culture that permeates sectors of Saudi society. The significance of the research lies in the fact that the population of the study carries the duality mentioned above, as all segments of the society, especially students , quickly adapted to modern communication technology on the one hand, and the spread of Bedouin traditional culture, in which conservative religious ideology occupies the central position on the other. Consequently, gender segregation is still an established regulation in the various phases of education. Family and tribal affiliation are still powerful factors in forming social interactions and producing stakes in the local community. In addition, Christian culture remains a primary organizing principle for daily life. The questions we pose in this paper are: 1. What are the effects of SMPs on students' relationships with their families? 2. Did using SMPs reduce the functions of the Saudi family and weaken its connections? Or it contributed to strengthening and maintaining it? --- Research problem The advent of the internet was accompanied by qualitative changes to the many types of social relationships . Numerous researchers concurred that the advent of SMPs directly weakened social bonds and steadily increased the importance of the individual at the price of society, social life, family life, and social institutions . If individualism is one of the tenets of modernity, then rapid industrialization and the proliferation of SMPs have transformed 'individualism' into a narcissistic inclination, as evidenced by Exhibitionists, Self-Presentation, Managing Impressions , Selfies, and Self-Extension . Undoubtedly, the SMPs provided limitless communication, expression, and entertainment opportunities. Still, it weakened the authority of social control and monitoring of social institutions, especially the family, thereby affecting the formation of identities and giving rise to the term "Fluid Identities." In addition, pathological phenomena related to the excessive use of the Internet and social media platforms have emerged, which have a bearing on the quality of family interactions, such as Internet Addiction, Feelings of Loneliness, and Familial Selective Mutism. Familial selective mutism is an indicator, along with Depression and Internet Addiction , for the weakness of relationships between family members as a result of their use of SMPs. It is reflected in the fact that one family member has no interest in communicating with certain family members in certain situations. The studies revealed that selective mutism is not caused by a lack of knowledge, perception, ability to communicate and talk, physical disability, autism, or a communication disorder . It is by excessive internet use or shyness or depressed mood, or reclusive behavior or the nature of family relations , or socialization . Despite the various causes, mutism is characterized as a reluctance and unwillingness to communicate with specific individuals in certain social situations in which communication is delayed. In contrast, the individual speaks and interacts in other contexts. Mutism is also defined as reluctance and unwillingness to talk with some family members in specific social contexts. The studies that examined the relationships of youth with the internet concurred that there is excessive use of SMPs. Still, they differed regarding the effects of the uses on the relationships within the family and its relation to the absence of communication within the family and the areas of uses. The SMPs are prevalent in diverse countries, distinguished by their culture, values, and social systems . SMPs are utilized differently not only by societies but also by individuals within those communities. As a result, the excessive use of SMPs has varying repercussions at the level of familial selective mutism. This is because a society's culture affects the uses and gratifications based on its network of values, standards, symbols, and weight of the family, which limit the severity of these repercussions . The studies that hypothesized a relationship between excessive Internet use, particularly by SMPs, and addiction, social isolation, or familial mutism, relied on causal interpretation and quantitative indicators for Internet use by individuals , which are expressed in the number of daily hours allocated. It serves as evidence to demonstrate the connection. The uses, motives, and expected gratifications were not analyzed qualitatively to determine the degree of exacerbation of the "familial selective mutism" phenomenon. Or it was to determine whether the uses themselves may be a means to reduce the phenomenon of mutism within the family and to enhance communication among its members . In this study, we will not adopt the liberal concept of the relationship between the Internet and individuals, which states that the Internet is a market full of consumer goods. A rational consumer chooses from this market the stuff that can fulfill his needs , even though it leads him to adopt satisfying behaviors at the expense of his psychological and social health, as well as at the expense of his culture and family. Instead, we hypothesize that SMPs use is governed by limited rationality . By that, we mean that the uses of SMPs by the students do not interpret their narrow personal motives which may lead them to selective mutism. Still, they specify the values and standards of cultural patterns they belong to and refer to when identifying and evaluating their uses . The earliest studies overlooked this critical approach for the use of SMPs by the public since they focused on the use of SMPs by individuals, their individual opinions and selections, which the theory assumes are conscious and free . However, the aforementioned is the theoretical position followed by this study. The inclusion of variable of cultural pattern in the interpretation of behaviors and, in our case, the motivations of the students to use SMPs and their gratifications necessitates the approval of the position of the family in these uses, as the family represents a standard pattern, monitoring system, controlling, and a reference for social affiliation, all of which contribute to a degree to defining the phenomenon of familial selective mutism. Regardless of their position, it is impossible to understand students' behaviors without referring to their selves as if they were disconnected from the social system and cultural pattern they belong to Astleitner et al. . Additionally, familial selective mutism cannot be diagnosed without an investigation of uses and gratifications and the presence of the family. Therefore, the indicator of many hours spent communicating with family members, which may be correlated with the degree of familial selective mutism, does not disclose any correlation between the young and their parents. This is impacted by selective mutism and selective mutism severity . Therefore, the diagnosis and evaluation of the phenomena of family selective mutism must be based on analyzing uses and expected gratifications for adolescents and not on quantifying time spent surfing the internet and using SMPs. Therefore, users are faced with two motivations: To be independent of the family and to belong to it and communicate with its members . In reality, it falls under the influence of traditional and cultural values on the one hand and rapid modernization accelerated by communication technology on the other. The youth attempt to strike a balance between his sense of independence and his relationship with the family, which operates as a social institution that provides life functions and reproduces social systems and cultural values . In the oscillation between the individual, self, and personal on the one hand and the familial, institutional, and cultural on the other, "familial selective mutism" is explained as a phenomenon that is not caused by the excessive use of SMPs, but instead reflects the duality that the Saudi student experiences. --- Research objectives This study aims to determine the association between the uses and gratifications of SMPs for students and the prevalence of selective mutism within Saudi families. To reach this target, the following objectives must be attained:  To determine the type of student usage of SMPs.  To determine the level of family influence on student use of SMPs.  To determine the extent to which the family influences students' use of SMPs and their satisfaction.  To determine the extent to which the use of SMPs affects the frequency of communication between students and their parents. --- Methodology and statistical treatment This study employed a descriptive statistical analysis to investigate the usage of social communication sites and satisfaction levels among students of the College of Literature and Arts at the University of Hail. The data was collected through an online questionnaire distributed to a sample of 384 students, consisting of both male and female participants, during the first three months of 2022. The questionnaire encompassed four distinct components. The first part aimed to gather information about the general characteristics of the students and their families. The second part sought to understand the students' motivations, usage patterns of social communication sites, and the satisfaction derived from their usage. The third segment focused on assessing the influence of the students' families on their motivations and engagement with social communication sites. Finally, the fourth part was designed to explore the consequences and gratifications arising from students' use of social media in their family relationships. The study population comprised male and female students from the College of Literature and Arts at the University of Hail, totaling 9,788 students. The sample size of 384 students was selected from this population through randomization, representing approximately 25 percent of the sampling frame, which is an acceptable percentage for descriptive research. The researchers used "Statistical Package for the Social Sciences " for statistical analysis, employing various techniques such as frequencies, percentages, means, standard deviations, and the chi-square test. Regarding family characteristics in the study sample, it was observed that the families exhibited conventional traits in terms of structure, with features such as polygamy, a large number of children, and low educational levels. Moreover, the distribution of labor within the families showed gender-based segregation of duties, with women's work being comparatively weaker, and their educational levels relatively lower. These factors were found to influence how students utilized SMPs and affected the patterns of family communication. A significant proportion of student respondents belonged to families with average monthly incomes between 5,000 and less than 10,000 Saudi Riyals, while 28.1% came from families with incomes ranging from 10,000 to 20,000 Saudi Riyals. Only 5.7% of respondents reported a monthly family income exceeding 20,000 Saudi Riyals. The low economic capital of respondent families, as indicated by their monthly income, could be attributed to two primary factors. First, a small percentage of fathers and mothers possessed advanced degrees compared to a higher rate of literacy . Additionally, cultural factors played a significant role, reflecting social and religious traditions that continue to impact segments of Saudi society, leading to reservations about women's education and employment based on conservative religious values. Consequently, a substantial majority of respondents' mothers did not work, while 52.8% of fathers were retired, and 43.5% were employed. Traditional culture also influenced family structure, with approximately 32.3% of respondents' fathers having more than one wife. Family size was also found to be relatively large among the respondents, reflecting the prevalence of extended families in traditionally conservative societies. Specifically, 35.4% of respondents had four to six siblings, 29.2% had seven to nine siblings, and 22.9% had more than nine siblings. --- Results This research investigates the utilization patterns and ramifications of SMPs within the student population at the College of Literature and Arts, University of Hail. The findings shed light on the age of initial SMP usage among students and the diverse motivations driving their engagement, encompassing recreational purposes, information-seeking behaviors, and social networking activities. Additionally, the study delves into the influence of the family in shaping the students' adoption of SMPs and their preferred communication channels. Furthermore, the study provides a comprehensive examination of the implications arising from excessive SMP usage, addressing potential negative effects in considerable depth. --- Possibilities and uses The examination of data in this study reveals that students enrolled in the College of Literature and Arts at the University of Hail commenced their engagement with SMPs at an early stage of their lives. Evidently, approximately half of the study's population, represented by the sample under consideration, initiated their use of the Internet between the ages of 10 and 15, while an intriguing 29% adopted this technology before reaching the age of 10. An analysis of the survey findings, presented in Table 1, provides valuable insights into the internet infrastructure and device ownership among the respondents and their families. Specifically, it is deduced that a considerable proportion of the respondents' families, accounting for 77.1%, possess access to WiFi within their households. This observation also suggests that a substantial majority of respondents, amounting to 72.4%, hail from urban localities within the Hail region, while the remaining 27.6% reside in rural areas. Moreover, the prevalence of smartphone ownership among Saudi Arabian students emerges as a noteworthy trend. As evidenced by the research sample, 33.1% of the respondents possess multiple smartphones, while a significant 30.7% have multiple SIM cards. This reflects the widespread utilization and reliance on smartphones as a primary means of accessing SMPs. Additionally, financial patterns concerning internet usage are discernible among the participants. A notable 44.8% of the respondents reported monthly expenditures ranging from 100 to 200 Saudi Riyals on the internet. Furthermore, 26.9% indicated lower expenses, allocating less than 100 SR, while 28.4% reported expenditures below 200 SR. These findings collectively provide a comprehensive portrait of the students' early adoption of SMPs, the prevalence of internet access within households, the dominance of smartphone ownership, and the financial aspects pertaining to internet usage among the surveyed population. --- Platforms and uses As per the latest data provided by CITC , WhatsApp holds the distinction of being the most prevalent social networking site in Saudi Arabia, boasting a remarkable usage rate of 89.9%. Following closely behind is Snapchat, which garners a usage rate of 64.9%. However, when examining the specific research sample under consideration, the dynamics appear to differ. Surprisingly, Snapchat emerges as the most favored social networking site among the participants, commanding a substantial usage rate of 75.5%. Twitter secures the second position with a notable prevalence of 43.6%, while YouTube and TikTok share a close percentage of 41.7%. Instagram also commands a usage rate of 41.7%. Intriguingly, both Facebook and WhatsApp find themselves in the sixth position, with an equal usage rate of 1.8%. This fact merits further exploration and consideration in the context of the research findings. On the contrary, the data uncovered a substantial presence of students across multiple SMPs, with 60.4% maintaining between one and three accounts, and 28.6% possessing four to six accounts. Remarkably, the time dedicated to SMPs varies significantly, yet it is particularly striking that a considerable proportion of students expend a substantial amount of time on social networking sites. Specifically, 50.5% of the respondents disclosed spending a minimum of 5 hours daily on SMPs, while 31.5% reported allocating 3 to 5 hours each day to these platforms. These findings corroborate previous research highlighting the extensive utilization of social networking sites by Saudi students . --- Pursuit of entertainment As per the students' responses, the primary reason for utilizing SMPs is for leisure and entertainment, as indicated by the highest preference rate of 60.1% for watching movies and videos, followed by 38.7% for sports viewing, and 25.2% for sharing photos and videos. The secondary purpose is information seeking, with a preference rate of 46.0%. Notably, seeking friendships and romantic relationships had a relatively low rate of 9.2%. Table 2. According to the rates of students' penetration of the specialized websites of SMPs, the expected gratifications of students rank in the order of their motivations. The preference rate for entertainment websites was 73%. For sports websites, it was 35.6%; for religious websites, it was 40.5%; for scientific websites, it was 36.3%. Regarding online dating websites, just 9.2% of students responded. The majority of the students' responses indicate a preference for "negative" interactions, as reflected in the prevalent trend toward such behavior in the following chart. Table 3 clearly illustrates that the most prevalent behavior among students is passive viewing of content, with a rate of 68.75%. Conversely, the act of presenting oneself in daily life on SMPs is expected to have a much lower rate of 21.5%, as is the case with sharing videos , leaving comments , and using emojis Table 3. --- Impact of family on the uses of students The personal choices of students regarding the use of SMPs are not only determined by their individual preferences but also by the influence and status of their family. Table 4 depicts the position of the family concerning other areas of affiliation. The study concluded that students' early usage of social communication platforms and the number of hours they spent was not detrimental to their family relationships. In reality, the family occupies a significant social and emotional position among students, reflecting the program's efficiency. Regarding the feeling of belonging, it ranks first with a relative weight of 0.92 percent, followed by friendships with a relative importance of 0.71 percent, and the tribe with a relative weight of 0.61 percent . The study does not interpret the significant influence of the family among students solely based on emotional attachment. The responses suggest that the family plays a crucial role in fulfilling traditional functions, especially concerning wealth and resources, as indicated in Table 5. The results of the study unveil that parents play a pivotal role as the second most substantial source of financial support, carrying a relative weight of 0.74. Their contribution is of utmost importance, as they offer essential assistance and monetary aid to students who benefit from scholarships. However, it is noteworthy that parents are not the sole providers of financial support, as siblings also play a significant role with a relative weight of 0.55. Intriguingly, when considering the combined relative weights of parents and siblings, the family unit emerges as the predominant source of financial support, surpassing the influence of scholarships in this context . --- Family's position in the uses of SMPs by students The salience of the family unit among students becomes apparent in the communication channels they uphold with their family members via SMPs. As demonstrated in Table 6, there exists a notable presence of parents within the students' social groups, with mothers exhibiting a higher representation percentage of 49.1% as compared to fathers with 41.1%. Furthermore, the respondent's roster of friends displays a greater proportion of brothers, amounting to 68.1%, in contrast to sisters, which accounts for 59.5% . The significance of the family in shaping students' usage of SMPs is underscored by compelling evidence, revealing that a substantial majority of groups formed on SMPs are family-oriented, with a noteworthy preference rate of 42.3%. This preference surpasses that of leisure groups , sports groups , and religious groups . Evidently, students express a clear inclination to employ these platforms as a means to disseminate information, particularly in the form of pictures and videos, among their family members, irrespective of the specific channel employed for parental-child communication. The research results vividly illustrate the extensive nature of this practice, as it is evident that mothers are more actively engaged in such exchanges with their children compared to fathers, with percentages of 38% and 23.3%, respectively. Moreover, the frequency of exchanges between students and their siblings exceeds that with their parents. This holds true for other relatives as well, as evidenced by a substantial preference percentage of 41.7%. These findings collectively highlight the salience of family interactions in driving students' engagement with SMPs, emphasizing the pivotal role of such platforms as channels for sharing information within the familial context. --- Effect of uses on the family relationships The present study seeks to assess the influence of the internet on familial communication by employing two prevalent indicators: the duration of internet usage and the age of initiation into internet usage. As evident from the data presented in Table 7, an examination of the responses provided by the sample members concerning the manifestations of selective mutism in family dynamics, based on the variable of the number of hours spent by students using SMPs, reveals that no statistically significant differences are observed. This conclusion is substantiated by the calculated F-value of 2.009, which does not achieve statistical significance, as indicated in Table 7. In addition, the study indicated that the age at which SMPs were first used, which is regarded as an early age, is not among the causes of family selective mutism. As the value of F reaches .880, which is not statistically significant, there are no statistically significant variations between the responses of sample members regarding the manifestations of selective mutism in the family life according to the variable of the age of beginning to use SMPs . There are no statistically significant variations between male and female pupils regarding their communicative relationship with their father, indicating that the gender variable has a bearing on identifying the communication trends between parents and children. In contrast, the results revealed statistically significant gender disparities in the communicative interaction between male and female students and their mothers in favor of male students, as indicated in the following Table 9. The statistical analysis in Table 9 indicates that there are no statistically significant differences between the genders at the significance level of 0.05 regarding the use of SMPs to communicate with the father, as the value of Chi-Square reached 2=4.53, which is not statistically significant. In addition, the statistical analysis in Table 9 indicates that there are statistically significant differences between the genders at the significance level of 0.05 in terms of communication with the mother using SMPs, as the Chi-Square value reached 2=11.12, which is statistically significant . --- Outcomes and discussions This study aimed to investigate the presence of "selective mutism" within Saudi families by examining the usage patterns of SMPs among students in the Hail region of the Kingdom of Saudi Arabia. The choice of this location was strategic, as it allowed exploration of the hypothesis that students' utilization of SMPs is influenced by their cultural background. Hence, cultural characteristics, particularly those rooted in traditional family structures and functions, exert an impact on students' engagement with SMPs. The study sought to ascertain whether excessive SMP usage inevitably leads to selective mutism within the family context. Given the conservative, traditional, and deeply ingrained cultural environment prevalent in the Hail region, juxtaposed with the increasing integration of modern communication technologies, it served as an apt research population for examining the interplay and mutual influence between contemporary and traditional cultures. This was achieved by analyzing the students' SMP usage patterns, gratifications derived from their usage, the family's role, and its overall impact on the phenomenon. The results concerning the nature of students' SMP usage indicated that their patterns align with the general trends observed in numerous countries regarding internet usage and engagement with SMPs, characteristic of the so-called "Generation Z" or "Internet Generation." Furthermore, the research revealed that over two-thirds of respondents have Wi-Fi access in their homes, and a significant portion of students allocate additional funds for internet subscriptions on their smartphones . More than sixty percent of students have at least three accounts, and almost one-third of respondents have more than three. The percentage of internet penetration has increased, as demonstrated by the findings of the present study and confirmed by other studies conducted on Saudi youth or in other parts of the world . Also, the research found that students received Smartphones and the chance for internet penetration and SMPs at a relatively young age , as one-third of them began using them before age 10 and the other half after the age of 10. Internet penetration at a young age, that is, since childhood, creates a consequence supported by a study comparing five Arab nations. This survey was done in 2013, and its findings represented the varied uses of mobile phones and the Internet by youngsters aged eight to ten. In addition, a United Nations Children's Fund research comparing European nations validated the result . The excessive and improper use of SMPs is among the fundamental findings about family mutism uncovered by the research of Savci et al. . For Saudi youth entertainment and communication. Previous research conducted on Saudi youth has documented an increase in the number of hours spent on Internet use and its prevalence . The study that evaluated the youth's use of SMPs determined that they do so for four reasons: Filling free time, obtaining information, finding enjoyment, and searching for friends . Consistent with the conclusion, examining the respondents' motivations showed that amusement is the first anticipated reward from students . However, the study of Jung et al. , considered that building friendships and keeping them is the first purpose behind the use of Facebook by students. This survey revealed that University of Hail students had a low propensity for online dating and that establishing friendships is less relevant to them. The kids enjoy the "negative interaction" that occurs when using the SMPs and retaining positive relationships . In their examination of women's Facebook usage; Boyd and Ellison reached this conclusion. The pursuit of social capital and the creation of independent worlds through investment in diversifying and expanding friendships are not among the respondents' anticipated gratifications. Therefore, social connection and communication with others outside of restricted circles are not essential for students. The conservative tendency is reflected in the responses of the participants answers to the question, "How do they justify this order of social communication platforms for their uses?" The primary argument for their selection of other communication platforms is that the general population in the Kingdom utilizes these platforms more frequently than others. The kids' use of Snapchat, Twitter, YouTube, and TikTok is driven by the need to be associated with the subscriber through simulation, which facilitates communication and interaction with others. It appears that "social media culture" encompasses the prevalent use of social media platforms, their representations and information, and attitudes toward them. These are the factors that determine how social segments utilize social media sites. It is a culture that emphasizes the necessity of including everyone in the group. The affirmation by respondents that they use Snapchat because other people use it results in a self-fulfilling prophecy, i.e., the students accept it because other students accept it. In contrast to the situation in the Kingdom of Saudi Arabia, whether among students or the general population of Saudis ), numerous studies have shown that Facebook is more popular than other platforms in many countries around the world . This demonstrates that using SMPs to fulfill the demand for belonging through the stimulation of others is a significant element in determining the supremacy of this platform over other platforms in any country. Additionally, research demonstrates that students perceive group membership as one of their desired rewards. Students' use of SMPs and their gratifications are influenced by their social and cultural traits, as determined by the second purpose of the study, which was to assess the influence of family on the students' use of SMPs . The research found that students are affected by SMPs in terms of their relationships, values, and standards of traditional family culture, which plays a crucial role in molding the uses and defining the gratifications . In the same context, it is posited that students' motivations for using Facebook exhibit variation based on their cultural backgrounds. The families of these students continue to fulfill social functions , economic functions , and anthropological functions . Religious culture confers "sanctification" upon the family and its kinship ties. All these factors contribute to family cohesion, bestowing it with significance and safeguarding it against communication breakdown between children and their parents, thereby mitigating the occurrence of "familial selective mutism." The value attributed to family cohesion, as evidenced by respondents' answers, underscores the importance of the family within a culture of conservatism. When asked about the significance of adhering to customs and traditions, 54.2% of students deemed it "very much necessary," while 26.8% considered it "necessary." Only 7.7% expressed negative views regarding adherence to customs and traditions. Religion and customs and traditions appear interconnected, with 80.7% of students performing prayers permanently, 16.9% doing so occasionally, and 2.3% not performing prayers. This linkage strengthens the traditional culture, imparting religious value to the family and establishing it as a vital resource in the lives of students, serving as their primary sphere of belonging. The emotional capital of the family among students is evident in their interactions on SMPs. The family ranks second, with a relative weight of 0.89%, as a topic that provokes reactions and engagement from students, surpassed only by the Islamic religion and preceding the tribe, favorite sports teams, and Saudi society. Despite a relatively low frequency of interaction, the family's influence is a potent motivator for engagement. Families develop within the context of the dominant culture, making them institutions for perpetuating that culture. In the selection of a spouse, family kinship carries the most significant influence , followed by tribal kinship . Mothers play a primary role in marriage matters, acting as a bridge between families, surpassing fathers by a relative weight of 44.5% to 6%. Despite the omnipresence of SMPs in students' daily lives and the hours they spend using them, students still turn to their families for information and seek advice and opinions on various matters, including religious , academic , health-related , and purchasing decisions . The students prioritize seeking information from their mothers , followed by their fathers , brothers , and sisters . Regarding the study's third objective, the results indicate that excessive SMP usage may have negative consequences. Contrary to a form of "selective mutism" or estrangement between children and parents, SMP usage may, in fact, enhance or at least maintain actual communication levels between them. This finding is consistent with numerous international studies that have highlighted the role of SMPs in fostering and sustaining parent-child connections because they enable parallel communication with direct communication and integrate with it. The responses from students indicate that the relationship with parents is not only enriched by communication through various social media platforms, but the percentage of students whose father or mother is on their friends' list on social networks is relatively high. It is when it is compared to the findings of other studies that examined communication between parents and youth via SMPs . The presence of family members with different percentages, as it reached more than half for brothers and slightly less than half for parents in the list of students' friends on SMPs , may strengthen the relationships between them if those relationships were good beforehand and the context of communication and its circumstances were also good so that the students and their families can use SMPs to communicate with each other. Additionally, the results indicate that 78% of respondents utilize social networking sites to communicate with their fathers, while 85.4% do so with their moms, according to the findings of this study. This conclusion is comparable to the results of Ball et al. and Child et al. , which are high percentages compared to the findings of Padilla-Walker et al. , which found that 40 percent of youngsters use SMPs to interact with their parents. In a similar approach, Child and Westermann concluded that such ratios indicate that the relationships between family members are already promising. The conclusion is verified by this research also as the percentages of students' membership to the family groups on SMPs is more significant than their belonging to the other groups of various peculiarity. If the more significant number of student responses relates to an average percentage of communication with the father and mother, then this average percentage favors moms more than fathers . This trend favors the father when students refrain from communicating with their parents via social media. So, 21.9% of kids did not use SMPs for communication with their parents, compared to 14.6% who did not use SMPs for communication with their mothers. The nature of a traditional family with a patriarchal structure and the mother's availability in the house interprets this trend towards communication with the mother more than the father. Regarding determining the effect of students' use of SMPs by adopting the variable of the number of hours of use and the age at which they began using the Internet and SMPs, the study's results indicated that the number of hours students spent using SMPs did not affect the desire to communicate or have a conversation with family members, particularly children, and parents. There were no statistically significant variations between respondents' statements about 'familial selective mutism' and the number of hours they spent using SMPs. This result is consistent with the conclusion of Ling and Li that there is no significant association between children's excessive use of SMPs and their family's communicative ties. However, these results differ from previous studies that were conducted on the relationship between SMPs and the Saudi family. It concluded that there is a negative effect of SMPs on communication and conversation between family members and established a correlation between the number of hours allocated daily for SMP use . The research that examined the usage of SMPs in family interactions could not reach a single conclusion about their danger or utility . This study indicated that the amount of time youth spend using SMPs has no effect on selective mutism manifestations within the family. Even though all students began utilizing SMPs at different ages during childhood, this does not influence the interpretation of selective mutism within the family. According to the analysis of the results , there were no statistically significant variations between the responses received from respondents regarding the symptoms of "selective mutism" in family life based on the variable of the age at which SMPs were first employed. This finding is consistent with the results of other studies, which found that children's early Internet use is not a factor in interpreting poor or interrupted communication between children and parents . The primary objective of this study was to investigate the impact of SMPs usage on the expression of "selective mutism" by analyzing the communication patterns within respondents' families concerning the utilization of SMPs. As a result, the study aimed to ascertain that family communication and interactions are subject to variations influenced predominantly by pre-existing family connections rather than being significantly affected by the presence of SMPs. The data indicate an increase in the proportion of persons who speak with their moms, with the average communication degree reaching 28.9% among boys compared to 12.9% among girls. This can be due to the gender-based division of roles and opportunities within the family, which forces female students to remain at home after school hours in contrast to male students who enjoy greater freedom of movement and possess the means for this movement . In addition, kids are permitted to be outside for a limited time, during which they must communicate with their mothers for information, supervision, and guidance. The results demonstrated that the mother is the axis of communication within the family for both sons and daughters, as they communicate with their mothers via SMPs more frequently than with their fathers. Additionally, male students interact with their parents more frequently than female classmates. This phenomenon is due to the patriarchal, traditional Arab family structure to which the families of the respondents belong , the presence of the mother in the house despite the weak functions of the mothers of the respondents, and the gender-based division of roles. In this arrangement, communication with the mother is more than with the father, and communication with brothers and sisters is more excellent than communication with the mother. The predicted gratifications of respondents' use of SMPs appear to be the maintenance of existing relationships rather than the establishment of new ones. They are compelled to communicate within the context of their current social ties. Chen also discovered the need to preserve contact with the family through SMPs, based on the necessity of communication within the context of their existing social relationships. Several studies similar to this one have indicated that the usage of SMPs has no negative impact on communication within the family, notably between children and parents . Instead, the research indicates that these platforms deepen the bond between them or at least serve as a communication bridge in situations where direct communication is difficult. Similarly, the study concluded that the students' use of SMPs was intended to maintain family ties, as evidenced in the respondents' families based on the structure of the distribution of relationships within the traditional family, as these families have no desire or intention to eliminate relationships. The family is still functional in carrying out essential functions such as belonging, providing, caring, solidarity, and procreating kinship. These conclusions present a departure from prior studies conducted on youth and children in the Kingdom of Saudi Arabia, which posited a "zero-sum game" scenario in the relationship between SMPs and family connections. These earlier studies suggested that SMPs weaken family bonds and contribute to the emergence of selective mutism within the family. To validate the generalizability of our findings, further investigation is required in other regions of the Kingdom, especially in major urban centers such as Riyadh and Jeddah. This necessitates the incorporation of multiple sociological variables that were not explicitly considered in the present study. --- Recommendations The study advocates for a comprehensive consideration of cultural, historical, and social factors when interpreting and analyzing the impacts of uses and gratifications associated with SMPs on family relationships, particularly with regard to communication patterns within the family. To achieve this, it is imperative to conduct comparative research both within different regions of the Kingdom of Saudi Arabia and between the Kingdom and other nations. Furthermore, the study's findings indicate that excessive use of SMPs does not necessarily lead to "selective mutism" within families. The research aims to corroborate this discovery through further investigations. Additionally, the study seeks to conduct analyses that challenge the hypotheses presented in previous studies, exploring the possibility that adopting SMPs may result in contrasting consequences. Specifically, the investigation delves into the theory that families' experiences of "mutism," sadness, and social anxiety disorder may contribute to excessive reliance on SMPs. To address these aspects, the study advocates for a systematic approach to examining how families engage with SMPs. While existing research has primarily focused on "selective mutism" as a psychological condition among school-aged children, the study emphasizes the significance of investigating this phenomenon within the family context, spanning across different age groups, including children, adolescents, and the elderly. This exploration of "familial selective mutism" becomes particularly crucial given the transformations that families undergo in diverse civilizations due to scientific and technological advancements. Hence, the study recommends indepth research to shed light on this aspect of family dynamics and its implications in the context of contemporary societal changes. ---

This study aims to investigate the influence of social media platforms (SMPs) on communication patterns within Saudi families. The research adopts an analytical description methodology employing a questionnaire tool administered to a sample of 384 male and female students from the University of Hail in the Kingdom of Saudi Arabia. The statistical treatment utilized the Statistical Package for Social Sciences (SPSS-V26) and included methods such as frequencies, percentages, arithmetic mean, standard deviation, and the chi-square test. Distinguished from prior studies, especially those employing quantitative indicators, this research embraces the theory of uses and gratifications to map communication between family members using SMPs. This approach allows for the determination of the prevalence of selective mutism within the family, considering the patriarchal family structure. The findings indicate that students generally communicate more with their mothers than with their fathers via SMPs. Additionally, male students exhibit higher levels of communication with their parents compared to female students, who tend to communicate more with their mothers than with their fathers. Moreover, the study reveals that the number of hours dedicated to using SMPs and family selective mutism did not display significant differences. Likewise, there were no significant variations between the age of SMP usage onset and family mutism. The study recommends conducting comparative analyses based on a similar approach to unveil communication dynamics in families with varying sociological, cultural, and geographical characteristics. Such research would enable the diagnosis of SMPs' impact on different family structures.

introduction the exponential growth and prevalence of social media platforms have played a pivotal role in driving transformative changes within modern societies since the onset of the 21 st century these platforms have engendered profound shifts in various aspects of individuals lifestyles significantly shaping the way people interact communicate and conduct their daily activities smps enhanced the potential of communication between individuals and altered the function areas forms and impacts of communication reflecting the nature of social connections within the modern family suppose we observe that the smartphone has replaced the laptop as the most widely used technology in that case we should understand that this is not because the smartphone is an upgraded version of the laptop but rather because it has brought the individual closer and closer to the technology or rather individualized or personalized communication technology when social media platforms came into existence they affected the familys social relationships and ability to carry out activities related to childrearing supervision and assistance that require communicative behavior to ensure positive actions in the community this phenomenon has also had adverse effects on saudi families notably the increasing education and employment opportunities for saudi women outside their homes have brought about significant changes in family dynamics and functions in addition to this the widespread adoption of social media sites represents another major transformation impacting relationships within saudi families and their ability to maintain effectiveness in the face of globalized culture which competes with their inherent cultural construction research exploring the utilization of smps among saudi youth indicates a substantial surge in smartphone ownership and some individuals have developed a dependence on these platforms the rising use of smps is not unique to the kingdom of saudi arabia despite the significant growth relative to other developed nations most research concurs that there is excessive use of smps particularly among children and adolescents the development observed by the kingdom of saudi arabia in the sphere of the internet particularly social communication platforms has allowed the kingdom to open up to many cultures and societies particularly the youth this tendency challenges the saudi family due to the traditional and conservative nature of the culture that permeates sectors of saudi society the significance of the research lies in the fact that the population of the study carries the duality mentioned above as all segments of the society especially students quickly adapted to modern communication technology on the one hand and the spread of bedouin traditional culture in which conservative religious ideology occupies the central position on the other consequently gender segregation is still an established regulation in the various phases of education family and tribal affiliation are still powerful factors in forming social interactions and producing stakes in the local community in addition christian culture remains a primary organizing principle for daily life the questions we pose in this paper are 1 what are the effects of smps on students relationships with their families 2 did using smps reduce the functions of the saudi family and weaken its connections or it contributed to strengthening and maintaining it research problem the advent of the internet was accompanied by qualitative changes to the many types of social relationships numerous researchers concurred that the advent of smps directly weakened social bonds and steadily increased the importance of the individual at the price of society social life family life and social institutions if individualism is one of the tenets of modernity then rapid industrialization and the proliferation of smps have transformed individualism into a narcissistic inclination as evidenced by exhibitionists selfpresentation managing impressions selfies and selfextension undoubtedly the smps provided limitless communication expression and entertainment opportunities still it weakened the authority of social control and monitoring of social institutions especially the family thereby affecting the formation of identities and giving rise to the term fluid identities in addition pathological phenomena related to the excessive use of the internet and social media platforms have emerged which have a bearing on the quality of family interactions such as internet addiction feelings of loneliness and familial selective mutism familial selective mutism is an indicator along with depression and internet addiction for the weakness of relationships between family members as a result of their use of smps it is reflected in the fact that one family member has no interest in communicating with certain family members in certain situations the studies revealed that selective mutism is not caused by a lack of knowledge perception ability to communicate and talk physical disability autism or a communication disorder it is by excessive internet use or shyness or depressed mood or reclusive behavior or the nature of family relations or socialization despite the various causes mutism is characterized as a reluctance and unwillingness to communicate with specific individuals in certain social situations in which communication is delayed in contrast the individual speaks and interacts in other contexts mutism is also defined as reluctance and unwillingness to talk with some family members in specific social contexts the studies that examined the relationships of youth with the internet concurred that there is excessive use of smps still they differed regarding the effects of the uses on the relationships within the family and its relation to the absence of communication within the family and the areas of uses the smps are prevalent in diverse countries distinguished by their culture values and social systems smps are utilized differently not only by societies but also by individuals within those communities as a result the excessive use of smps has varying repercussions at the level of familial selective mutism this is because a societys culture affects the uses and gratifications based on its network of values standards symbols and weight of the family which limit the severity of these repercussions the studies that hypothesized a relationship between excessive internet use particularly by smps and addiction social isolation or familial mutism relied on causal interpretation and quantitative indicators for internet use by individuals which are expressed in the number of daily hours allocated it serves as evidence to demonstrate the connection the uses motives and expected gratifications were not analyzed qualitatively to determine the degree of exacerbation of the familial selective mutism phenomenon or it was to determine whether the uses themselves may be a means to reduce the phenomenon of mutism within the family and to enhance communication among its members in this study we will not adopt the liberal concept of the relationship between the internet and individuals which states that the internet is a market full of consumer goods a rational consumer chooses from this market the stuff that can fulfill his needs even though it leads him to adopt satisfying behaviors at the expense of his psychological and social health as well as at the expense of his culture and family instead we hypothesize that smps use is governed by limited rationality by that we mean that the uses of smps by the students do not interpret their narrow personal motives which may lead them to selective mutism still they specify the values and standards of cultural patterns they belong to and refer to when identifying and evaluating their uses the earliest studies overlooked this critical approach for the use of smps by the public since they focused on the use of smps by individuals their individual opinions and selections which the theory assumes are conscious and free however the aforementioned is the theoretical position followed by this study the inclusion of variable of cultural pattern in the interpretation of behaviors and in our case the motivations of the students to use smps and their gratifications necessitates the approval of the position of the family in these uses as the family represents a standard pattern monitoring system controlling and a reference for social affiliation all of which contribute to a degree to defining the phenomenon of familial selective mutism regardless of their position it is impossible to understand students behaviors without referring to their selves as if they were disconnected from the social system and cultural pattern they belong to astleitner et al additionally familial selective mutism cannot be diagnosed without an investigation of uses and gratifications and the presence of the family therefore the indicator of many hours spent communicating with family members which may be correlated with the degree of familial selective mutism does not disclose any correlation between the young and their parents this is impacted by selective mutism and selective mutism severity therefore the diagnosis and evaluation of the phenomena of family selective mutism must be based on analyzing uses and expected gratifications for adolescents and not on quantifying time spent surfing the internet and using smps therefore users are faced with two motivations to be independent of the family and to belong to it and communicate with its members in reality it falls under the influence of traditional and cultural values on the one hand and rapid modernization accelerated by communication technology on the other the youth attempt to strike a balance between his sense of independence and his relationship with the family which operates as a social institution that provides life functions and reproduces social systems and cultural values in the oscillation between the individual self and personal on the one hand and the familial institutional and cultural on the other familial selective mutism is explained as a phenomenon that is not caused by the excessive use of smps but instead reflects the duality that the saudi student experiences research objectives this study aims to determine the association between the uses and gratifications of smps for students and the prevalence of selective mutism within saudi families to reach this target the following objectives must be attained  to determine the type of student usage of smps  to determine the level of family influence on student use of smps  to determine the extent to which the family influences students use of smps and their satisfaction  to determine the extent to which the use of smps affects the frequency of communication between students and their parents methodology and statistical treatment this study employed a descriptive statistical analysis to investigate the usage of social communication sites and satisfaction levels among students of the college of literature and arts at the university of hail the data was collected through an online questionnaire distributed to a sample of 384 students consisting of both male and female participants during the first three months of 2022 the questionnaire encompassed four distinct components the first part aimed to gather information about the general characteristics of the students and their families the second part sought to understand the students motivations usage patterns of social communication sites and the satisfaction derived from their usage the third segment focused on assessing the influence of the students families on their motivations and engagement with social communication sites finally the fourth part was designed to explore the consequences and gratifications arising from students use of social media in their family relationships the study population comprised male and female students from the college of literature and arts at the university of hail totaling 9788 students the sample size of 384 students was selected from this population through randomization representing approximately 25 percent of the sampling frame which is an acceptable percentage for descriptive research the researchers used statistical package for the social sciences for statistical analysis employing various techniques such as frequencies percentages means standard deviations and the chisquare test regarding family characteristics in the study sample it was observed that the families exhibited conventional traits in terms of structure with features such as polygamy a large number of children and low educational levels moreover the distribution of labor within the families showed genderbased segregation of duties with womens work being comparatively weaker and their educational levels relatively lower these factors were found to influence how students utilized smps and affected the patterns of family communication a significant proportion of student respondents belonged to families with average monthly incomes between 5000 and less than 10000 saudi riyals while 281 came from families with incomes ranging from 10000 to 20000 saudi riyals only 57 of respondents reported a monthly family income exceeding 20000 saudi riyals the low economic capital of respondent families as indicated by their monthly income could be attributed to two primary factors first a small percentage of fathers and mothers possessed advanced degrees compared to a higher rate of literacy additionally cultural factors played a significant role reflecting social and religious traditions that continue to impact segments of saudi society leading to reservations about womens education and employment based on conservative religious values consequently a substantial majority of respondents mothers did not work while 528 of fathers were retired and 435 were employed traditional culture also influenced family structure with approximately 323 of respondents fathers having more than one wife family size was also found to be relatively large among the respondents reflecting the prevalence of extended families in traditionally conservative societies specifically 354 of respondents had four to six siblings 292 had seven to nine siblings and 229 had more than nine siblings results this research investigates the utilization patterns and ramifications of smps within the student population at the college of literature and arts university of hail the findings shed light on the age of initial smp usage among students and the diverse motivations driving their engagement encompassing recreational purposes informationseeking behaviors and social networking activities additionally the study delves into the influence of the family in shaping the students adoption of smps and their preferred communication channels furthermore the study provides a comprehensive examination of the implications arising from excessive smp usage addressing potential negative effects in considerable depth possibilities and uses the examination of data in this study reveals that students enrolled in the college of literature and arts at the university of hail commenced their engagement with smps at an early stage of their lives evidently approximately half of the studys population represented by the sample under consideration initiated their use of the internet between the ages of 10 and 15 while an intriguing 29 adopted this technology before reaching the age of 10 an analysis of the survey findings presented in table 1 provides valuable insights into the internet infrastructure and device ownership among the respondents and their families specifically it is deduced that a considerable proportion of the respondents families accounting for 771 possess access to wifi within their households this observation also suggests that a substantial majority of respondents amounting to 724 hail from urban localities within the hail region while the remaining 276 reside in rural areas moreover the prevalence of smartphone ownership among saudi arabian students emerges as a noteworthy trend as evidenced by the research sample 331 of the respondents possess multiple smartphones while a significant 307 have multiple sim cards this reflects the widespread utilization and reliance on smartphones as a primary means of accessing smps additionally financial patterns concerning internet usage are discernible among the participants a notable 448 of the respondents reported monthly expenditures ranging from 100 to 200 saudi riyals on the internet furthermore 269 indicated lower expenses allocating less than 100 sr while 284 reported expenditures below 200 sr these findings collectively provide a comprehensive portrait of the students early adoption of smps the prevalence of internet access within households the dominance of smartphone ownership and the financial aspects pertaining to internet usage among the surveyed population platforms and uses as per the latest data provided by citc whatsapp holds the distinction of being the most prevalent social networking site in saudi arabia boasting a remarkable usage rate of 899 following closely behind is snapchat which garners a usage rate of 649 however when examining the specific research sample under consideration the dynamics appear to differ surprisingly snapchat emerges as the most favored social networking site among the participants commanding a substantial usage rate of 755 twitter secures the second position with a notable prevalence of 436 while youtube and tiktok share a close percentage of 417 instagram also commands a usage rate of 417 intriguingly both facebook and whatsapp find themselves in the sixth position with an equal usage rate of 18 this fact merits further exploration and consideration in the context of the research findings on the contrary the data uncovered a substantial presence of students across multiple smps with 604 maintaining between one and three accounts and 286 possessing four to six accounts remarkably the time dedicated to smps varies significantly yet it is particularly striking that a considerable proportion of students expend a substantial amount of time on social networking sites specifically 505 of the respondents disclosed spending a minimum of 5 hours daily on smps while 315 reported allocating 3 to 5 hours each day to these platforms these findings corroborate previous research highlighting the extensive utilization of social networking sites by saudi students pursuit of entertainment as per the students responses the primary reason for utilizing smps is for leisure and entertainment as indicated by the highest preference rate of 601 for watching movies and videos followed by 387 for sports viewing and 252 for sharing photos and videos the secondary purpose is information seeking with a preference rate of 460 notably seeking friendships and romantic relationships had a relatively low rate of 92 table 2 according to the rates of students penetration of the specialized websites of smps the expected gratifications of students rank in the order of their motivations the preference rate for entertainment websites was 73 for sports websites it was 356 for religious websites it was 405 for scientific websites it was 363 regarding online dating websites just 92 of students responded the majority of the students responses indicate a preference for negative interactions as reflected in the prevalent trend toward such behavior in the following chart table 3 clearly illustrates that the most prevalent behavior among students is passive viewing of content with a rate of 6875 conversely the act of presenting oneself in daily life on smps is expected to have a much lower rate of 215 as is the case with sharing videos leaving comments and using emojis table 3 impact of family on the uses of students the personal choices of students regarding the use of smps are not only determined by their individual preferences but also by the influence and status of their family table 4 depicts the position of the family concerning other areas of affiliation the study concluded that students early usage of social communication platforms and the number of hours they spent was not detrimental to their family relationships in reality the family occupies a significant social and emotional position among students reflecting the programs efficiency regarding the feeling of belonging it ranks first with a relative weight of 092 percent followed by friendships with a relative importance of 071 percent and the tribe with a relative weight of 061 percent the study does not interpret the significant influence of the family among students solely based on emotional attachment the responses suggest that the family plays a crucial role in fulfilling traditional functions especially concerning wealth and resources as indicated in table 5 the results of the study unveil that parents play a pivotal role as the second most substantial source of financial support carrying a relative weight of 074 their contribution is of utmost importance as they offer essential assistance and monetary aid to students who benefit from scholarships however it is noteworthy that parents are not the sole providers of financial support as siblings also play a significant role with a relative weight of 055 intriguingly when considering the combined relative weights of parents and siblings the family unit emerges as the predominant source of financial support surpassing the influence of scholarships in this context familys position in the uses of smps by students the salience of the family unit among students becomes apparent in the communication channels they uphold with their family members via smps as demonstrated in table 6 there exists a notable presence of parents within the students social groups with mothers exhibiting a higher representation percentage of 491 as compared to fathers with 411 furthermore the respondents roster of friends displays a greater proportion of brothers amounting to 681 in contrast to sisters which accounts for 595 the significance of the family in shaping students usage of smps is underscored by compelling evidence revealing that a substantial majority of groups formed on smps are familyoriented with a noteworthy preference rate of 423 this preference surpasses that of leisure groups sports groups and religious groups evidently students express a clear inclination to employ these platforms as a means to disseminate information particularly in the form of pictures and videos among their family members irrespective of the specific channel employed for parentalchild communication the research results vividly illustrate the extensive nature of this practice as it is evident that mothers are more actively engaged in such exchanges with their children compared to fathers with percentages of 38 and 233 respectively moreover the frequency of exchanges between students and their siblings exceeds that with their parents this holds true for other relatives as well as evidenced by a substantial preference percentage of 417 these findings collectively highlight the salience of family interactions in driving students engagement with smps emphasizing the pivotal role of such platforms as channels for sharing information within the familial context effect of uses on the family relationships the present study seeks to assess the influence of the internet on familial communication by employing two prevalent indicators the duration of internet usage and the age of initiation into internet usage as evident from the data presented in table 7 an examination of the responses provided by the sample members concerning the manifestations of selective mutism in family dynamics based on the variable of the number of hours spent by students using smps reveals that no statistically significant differences are observed this conclusion is substantiated by the calculated fvalue of 2009 which does not achieve statistical significance as indicated in table 7 in addition the study indicated that the age at which smps were first used which is regarded as an early age is not among the causes of family selective mutism as the value of f reaches 880 which is not statistically significant there are no statistically significant variations between the responses of sample members regarding the manifestations of selective mutism in the family life according to the variable of the age of beginning to use smps there are no statistically significant variations between male and female pupils regarding their communicative relationship with their father indicating that the gender variable has a bearing on identifying the communication trends between parents and children in contrast the results revealed statistically significant gender disparities in the communicative interaction between male and female students and their mothers in favor of male students as indicated in the following table 9 the statistical analysis in table 9 indicates that there are no statistically significant differences between the genders at the significance level of 005 regarding the use of smps to communicate with the father as the value of chisquare reached 2453 which is not statistically significant in addition the statistical analysis in table 9 indicates that there are statistically significant differences between the genders at the significance level of 005 in terms of communication with the mother using smps as the chisquare value reached 21112 which is statistically significant outcomes and discussions this study aimed to investigate the presence of selective mutism within saudi families by examining the usage patterns of smps among students in the hail region of the kingdom of saudi arabia the choice of this location was strategic as it allowed exploration of the hypothesis that students utilization of smps is influenced by their cultural background hence cultural characteristics particularly those rooted in traditional family structures and functions exert an impact on students engagement with smps the study sought to ascertain whether excessive smp usage inevitably leads to selective mutism within the family context given the conservative traditional and deeply ingrained cultural environment prevalent in the hail region juxtaposed with the increasing integration of modern communication technologies it served as an apt research population for examining the interplay and mutual influence between contemporary and traditional cultures this was achieved by analyzing the students smp usage patterns gratifications derived from their usage the familys role and its overall impact on the phenomenon the results concerning the nature of students smp usage indicated that their patterns align with the general trends observed in numerous countries regarding internet usage and engagement with smps characteristic of the socalled generation z or internet generation furthermore the research revealed that over twothirds of respondents have wifi access in their homes and a significant portion of students allocate additional funds for internet subscriptions on their smartphones more than sixty percent of students have at least three accounts and almost onethird of respondents have more than three the percentage of internet penetration has increased as demonstrated by the findings of the present study and confirmed by other studies conducted on saudi youth or in other parts of the world also the research found that students received smartphones and the chance for internet penetration and smps at a relatively young age as onethird of them began using them before age 10 and the other half after the age of 10 internet penetration at a young age that is since childhood creates a consequence supported by a study comparing five arab nations this survey was done in 2013 and its findings represented the varied uses of mobile phones and the internet by youngsters aged eight to ten in addition a united nations childrens fund research comparing european nations validated the result the excessive and improper use of smps is among the fundamental findings about family mutism uncovered by the research of savci et al for saudi youth entertainment and communication previous research conducted on saudi youth has documented an increase in the number of hours spent on internet use and its prevalence the study that evaluated the youths use of smps determined that they do so for four reasons filling free time obtaining information finding enjoyment and searching for friends consistent with the conclusion examining the respondents motivations showed that amusement is the first anticipated reward from students however the study of jung et al considered that building friendships and keeping them is the first purpose behind the use of facebook by students this survey revealed that university of hail students had a low propensity for online dating and that establishing friendships is less relevant to them the kids enjoy the negative interaction that occurs when using the smps and retaining positive relationships in their examination of womens facebook usage boyd and ellison reached this conclusion the pursuit of social capital and the creation of independent worlds through investment in diversifying and expanding friendships are not among the respondents anticipated gratifications therefore social connection and communication with others outside of restricted circles are not essential for students the conservative tendency is reflected in the responses of the participants answers to the question how do they justify this order of social communication platforms for their uses the primary argument for their selection of other communication platforms is that the general population in the kingdom utilizes these platforms more frequently than others the kids use of snapchat twitter youtube and tiktok is driven by the need to be associated with the subscriber through simulation which facilitates communication and interaction with others it appears that social media culture encompasses the prevalent use of social media platforms their representations and information and attitudes toward them these are the factors that determine how social segments utilize social media sites it is a culture that emphasizes the necessity of including everyone in the group the affirmation by respondents that they use snapchat because other people use it results in a selffulfilling prophecy ie the students accept it because other students accept it in contrast to the situation in the kingdom of saudi arabia whether among students or the general population of saudis numerous studies have shown that facebook is more popular than other platforms in many countries around the world this demonstrates that using smps to fulfill the demand for belonging through the stimulation of others is a significant element in determining the supremacy of this platform over other platforms in any country additionally research demonstrates that students perceive group membership as one of their desired rewards students use of smps and their gratifications are influenced by their social and cultural traits as determined by the second purpose of the study which was to assess the influence of family on the students use of smps the research found that students are affected by smps in terms of their relationships values and standards of traditional family culture which plays a crucial role in molding the uses and defining the gratifications in the same context it is posited that students motivations for using facebook exhibit variation based on their cultural backgrounds the families of these students continue to fulfill social functions economic functions and anthropological functions religious culture confers sanctification upon the family and its kinship ties all these factors contribute to family cohesion bestowing it with significance and safeguarding it against communication breakdown between children and their parents thereby mitigating the occurrence of familial selective mutism the value attributed to family cohesion as evidenced by respondents answers underscores the importance of the family within a culture of conservatism when asked about the significance of adhering to customs and traditions 542 of students deemed it very much necessary while 268 considered it necessary only 77 expressed negative views regarding adherence to customs and traditions religion and customs and traditions appear interconnected with 807 of students performing prayers permanently 169 doing so occasionally and 23 not performing prayers this linkage strengthens the traditional culture imparting religious value to the family and establishing it as a vital resource in the lives of students serving as their primary sphere of belonging the emotional capital of the family among students is evident in their interactions on smps the family ranks second with a relative weight of 089 as a topic that provokes reactions and engagement from students surpassed only by the islamic religion and preceding the tribe favorite sports teams and saudi society despite a relatively low frequency of interaction the familys influence is a potent motivator for engagement families develop within the context of the dominant culture making them institutions for perpetuating that culture in the selection of a spouse family kinship carries the most significant influence followed by tribal kinship mothers play a primary role in marriage matters acting as a bridge between families surpassing fathers by a relative weight of 445 to 6 despite the omnipresence of smps in students daily lives and the hours they spend using them students still turn to their families for information and seek advice and opinions on various matters including religious academic healthrelated and purchasing decisions the students prioritize seeking information from their mothers followed by their fathers brothers and sisters regarding the studys third objective the results indicate that excessive smp usage may have negative consequences contrary to a form of selective mutism or estrangement between children and parents smp usage may in fact enhance or at least maintain actual communication levels between them this finding is consistent with numerous international studies that have highlighted the role of smps in fostering and sustaining parentchild connections because they enable parallel communication with direct communication and integrate with it the responses from students indicate that the relationship with parents is not only enriched by communication through various social media platforms but the percentage of students whose father or mother is on their friends list on social networks is relatively high it is when it is compared to the findings of other studies that examined communication between parents and youth via smps the presence of family members with different percentages as it reached more than half for brothers and slightly less than half for parents in the list of students friends on smps may strengthen the relationships between them if those relationships were good beforehand and the context of communication and its circumstances were also good so that the students and their families can use smps to communicate with each other additionally the results indicate that 78 of respondents utilize social networking sites to communicate with their fathers while 854 do so with their moms according to the findings of this study this conclusion is comparable to the results of ball et al and child et al which are high percentages compared to the findings of padillawalker et al which found that 40 percent of youngsters use smps to interact with their parents in a similar approach child and westermann concluded that such ratios indicate that the relationships between family members are already promising the conclusion is verified by this research also as the percentages of students membership to the family groups on smps is more significant than their belonging to the other groups of various peculiarity if the more significant number of student responses relates to an average percentage of communication with the father and mother then this average percentage favors moms more than fathers this trend favors the father when students refrain from communicating with their parents via social media so 219 of kids did not use smps for communication with their parents compared to 146 who did not use smps for communication with their mothers the nature of a traditional family with a patriarchal structure and the mothers availability in the house interprets this trend towards communication with the mother more than the father regarding determining the effect of students use of smps by adopting the variable of the number of hours of use and the age at which they began using the internet and smps the studys results indicated that the number of hours students spent using smps did not affect the desire to communicate or have a conversation with family members particularly children and parents there were no statistically significant variations between respondents statements about familial selective mutism and the number of hours they spent using smps this result is consistent with the conclusion of ling and li that there is no significant association between childrens excessive use of smps and their familys communicative ties however these results differ from previous studies that were conducted on the relationship between smps and the saudi family it concluded that there is a negative effect of smps on communication and conversation between family members and established a correlation between the number of hours allocated daily for smp use the research that examined the usage of smps in family interactions could not reach a single conclusion about their danger or utility this study indicated that the amount of time youth spend using smps has no effect on selective mutism manifestations within the family even though all students began utilizing smps at different ages during childhood this does not influence the interpretation of selective mutism within the family according to the analysis of the results there were no statistically significant variations between the responses received from respondents regarding the symptoms of selective mutism in family life based on the variable of the age at which smps were first employed this finding is consistent with the results of other studies which found that childrens early internet use is not a factor in interpreting poor or interrupted communication between children and parents the primary objective of this study was to investigate the impact of smps usage on the expression of selective mutism by analyzing the communication patterns within respondents families concerning the utilization of smps as a result the study aimed to ascertain that family communication and interactions are subject to variations influenced predominantly by preexisting family connections rather than being significantly affected by the presence of smps the data indicate an increase in the proportion of persons who speak with their moms with the average communication degree reaching 289 among boys compared to 129 among girls this can be due to the genderbased division of roles and opportunities within the family which forces female students to remain at home after school hours in contrast to male students who enjoy greater freedom of movement and possess the means for this movement in addition kids are permitted to be outside for a limited time during which they must communicate with their mothers for information supervision and guidance the results demonstrated that the mother is the axis of communication within the family for both sons and daughters as they communicate with their mothers via smps more frequently than with their fathers additionally male students interact with their parents more frequently than female classmates this phenomenon is due to the patriarchal traditional arab family structure to which the families of the respondents belong the presence of the mother in the house despite the weak functions of the mothers of the respondents and the genderbased division of roles in this arrangement communication with the mother is more than with the father and communication with brothers and sisters is more excellent than communication with the mother the predicted gratifications of respondents use of smps appear to be the maintenance of existing relationships rather than the establishment of new ones they are compelled to communicate within the context of their current social ties chen also discovered the need to preserve contact with the family through smps based on the necessity of communication within the context of their existing social relationships several studies similar to this one have indicated that the usage of smps has no negative impact on communication within the family notably between children and parents instead the research indicates that these platforms deepen the bond between them or at least serve as a communication bridge in situations where direct communication is difficult similarly the study concluded that the students use of smps was intended to maintain family ties as evidenced in the respondents families based on the structure of the distribution of relationships within the traditional family as these families have no desire or intention to eliminate relationships the family is still functional in carrying out essential functions such as belonging providing caring solidarity and procreating kinship these conclusions present a departure from prior studies conducted on youth and children in the kingdom of saudi arabia which posited a zerosum game scenario in the relationship between smps and family connections these earlier studies suggested that smps weaken family bonds and contribute to the emergence of selective mutism within the family to validate the generalizability of our findings further investigation is required in other regions of the kingdom especially in major urban centers such as riyadh and jeddah this necessitates the incorporation of multiple sociological variables that were not explicitly considered in the present study recommendations the study advocates for a comprehensive consideration of cultural historical and social factors when interpreting and analyzing the impacts of uses and gratifications associated with smps on family relationships particularly with regard to communication patterns within the family to achieve this it is imperative to conduct comparative research both within different regions of the kingdom of saudi arabia and between the kingdom and other nations furthermore the studys findings indicate that excessive use of smps does not necessarily lead to selective mutism within families the research aims to corroborate this discovery through further investigations additionally the study seeks to conduct analyses that challenge the hypotheses presented in previous studies exploring the possibility that adopting smps may result in contrasting consequences specifically the investigation delves into the theory that families experiences of mutism sadness and social anxiety disorder may contribute to excessive reliance on smps to address these aspects the study advocates for a systematic approach to examining how families engage with smps while existing research has primarily focused on selective mutism as a psychological condition among schoolaged children the study emphasizes the significance of investigating this phenomenon within the family context spanning across different age groups including children adolescents and the elderly this exploration of familial selective mutism becomes particularly crucial given the transformations that families undergo in diverse civilizations due to scientific and technological advancements hence the study recommends indepth research to shed light on this aspect of family dynamics and its implications in the context of contemporary societal changes

this study aims to investigate the influence of social media platforms smps on communication patterns within saudi families the research adopts an analytical description methodology employing a questionnaire tool administered to a sample of 384 male and female students from the university of hail in the kingdom of saudi arabia the statistical treatment utilized the statistical package for social sciences spssv26 and included methods such as frequencies percentages arithmetic mean standard deviation and the chisquare test distinguished from prior studies especially those employing quantitative indicators this research embraces the theory of uses and gratifications to map communication between family members using smps this approach allows for the determination of the prevalence of selective mutism within the family considering the patriarchal family structure the findings indicate that students generally communicate more with their mothers than with their fathers via smps additionally male students exhibit higher levels of communication with their parents compared to female students who tend to communicate more with their mothers than with their fathers moreover the study reveals that the number of hours dedicated to using smps and family selective mutism did not display significant differences likewise there were no significant variations between the age of smp usage onset and family mutism the study recommends conducting comparative analyses based on a similar approach to unveil communication dynamics in families with varying sociological cultural and geographical characteristics such research would enable the diagnosis of smps impact on different family structures

INTRODUCTION Mating preferences are determined by a host of interrelated psychological, sociological, cultural and economic factors. In most societies, men marry younger women and women marry older men. Women are more likely to have mates with similar or higher educational attainment. These patterns reflect the stylized fact that men usually desire younger partners with higher reproductive capacity and women usually desire men with more resources and higher status [1]. From an evolutionary perspective, it is of interest to determine whether preferences regarding age and educational differences enhance fitness as measured by offspring count and whether the relationships persist in modern societies with access to social income support and modern birth-control methods. An early study by Bereczkei & Csanaky [2], using county survey data from Hungary, found that men marrying younger women had significantly more children than men who married older women. Using English data, Manning & Anderton [3] reported a maximum offspring count when the husband was 2-3 years older than his wife. Two more-recent studies also found an inverted U relationship. Using data for the seventeenth-through nineteenth-century Sami population in northern Finland, Helle et al. [4] found that men maximized their offspring count by marrying women approximately 15 years younger. Fieder & Huber [5], using contemporary Swedish data, found offspring count was maximized for men marrying women 4 years younger, and for women marrying men 6 years older. Lindqvist et al. [6] criticized this study for failing to control for a potentially important confounder, reproductive value. By including 'woman's age at marriage', they concluded that the relationship between parental age difference and offspring count is spurious. In reply, Fieder et al. [7] confirmed that their results were robust to including 'woman's age at first birth' in their model, a variable they claimed is a better measure of reproductive value than age at marriage. With regard to parental education, Mascie-Taylor [8] found that the education difference between husband and wife is positively associated with offspring in British data. For American women, Huber et al. [9] found that husband's income is related to offspring count for highly educated women, suggesting that resources are important for increasing modern female reproduction. Given the absence of studies on contemporary developing countries, we examine the relationship between parental age difference and offspring count in Taiwan. We also investigate the relationships between education, income and fertility. After adjustment for women's reproductive value, we find that marrying an older man or a less educated man is associated with fewer offspring. Resource availability, measured by husband's income, is associated with more offspring among highly educated women. Recognizing that the optimal age difference cannot differ by sex [10], we fit a quadratic model of woman's and man's age at first birth [11] and find that offspring count declines with woman's age and exhibits an inverted U-shaped relationship with man's age. --- MATERIAL AND METHODS We used 1978-2006 national birth register data to derive fertility histories for Taiwanese women born in 1961-1966. For each birth, the register contains parents' ages and years of education. We used the unique parents' personal identifiers to link birth records and calculated the number of children produced by each couple. Our analysis was restricted to women aged 40-45 years in 2006, who had largely completed childbearing. We included only women who bore children with the same father. Information on parental income was obtained from the 2005 government-employee and labour-insurance files that cover the vast majority of public-and private-sector employees. Our large national dataset, combining highly accurate offspring counts with parental education and income, allows us to assess the relationship between socio-economic status and offspring count. Our analysis is limited to couples producing at least one child. Parental age difference is father's age minus mother's age. Completed schooling is categorized as elementary, junior high, senior high, college and graduate school. After excluding observations missing father's income, 680 526 couples remain for analysis. Mothers absent from the insurance files for whom spousal income was available were assumed to have no market income. Mean age and education differences are 3.0 and 0.4 years, respectively. Mothers average 25.3 years at first birth and fathers average 28.3 years . Offspring count averages 2.3. --- RESULTS For comparability, we begin by replicating the specifications proposed by Fieder & Huber [5] and Lindqvist et al. [6]. Offspring count is regressed on parental age difference, parental age difference squared and woman's age at first birth. We examine effects of educationally assortative mating and resource availability by adding parental income, education and differences in education. Without controlling for female reproductive capacity, the linear model in column 1 of table 1 implies that a same-age couple averages 2.21 children and a 1 year increase in age differential is associated with 0.02 additional children. The quadratic model in column 2 implies that offspring count is maximized when the husband is 8 years older than his wife, 5 years more than the mean age difference. The relationship between parental age difference and offspring count is displayed in figure 1. Controlling for woman's age at first birth increases goodness of fit and substantially affects the estimated relationship between parental age difference and offspring count. In the linear model , the coefficient on age difference is much smaller and significantly less than zero. One possible explanation for the drastic change is that reproductive value is correlated with age difference. Indeed, the correlation between age difference and woman's age at first birth is 20.35. Women who married before 30 average 3 years younger than their husbands, significantly more than the 1 year difference among those who married after 30. This pattern accords with propositions on mate selection in evolutionary models and is similar to patterns found in most cultures [12]. Consistent with expectations, women who first gave birth at younger ages have higher offspring counts. A 1 year increase in age at first birth is associated with 0.07 fewer children. Note that the magnitude of this coefficient is much larger than the coefficient of age difference, suggesting that female reproductive capacity is more important in determining offspring count. The quadratic model that controls for reproductive value suggests that offspring count declines monotonically over positive age differences. Controlling for reproductive value, an older husband is associated with smaller offspring count. These results provide little support for the hypothesis that age difference per se entails a fitness advantage. They are consistent with evidence for pre-modern Swedish populations [6] but contrast with those for Hungary [2], England [3], Sami populations of pre-industrial Finland [4] and contemporary Swedish populations . It is well recognized that socio-economic status is associated with fertility timing and offspring count. We use educational attainment and income as measures of socio-economic status. As shown in column 5, offspring count is strongly negatively related to woman's education and income. To assess the relationship between educationally assortative mating and offspring count, we interacted a woman's education with dummy variables for differences in spousal education: same indicating the spouses have equal education and higher indicating the husband has more education. In our sample, only 22.3 per cent of women marry men with less education, whereas 42.5 and 35.2 per cent marry men with the same and higher educational attainment, respectively. Spousal education interactions are included in column 6. The reference group is couples in which the woman completed junior high school and the husband has less education. To examine whether the association between husband's resources and offspring count varies by woman's education, we include interactions of woman's education level and husband's income. Women marrying men with less education have fewer offspring than those marrying men with comparable or more education. Average offspring count is largest for couples in which both spouses have only elementary-school education. The association between educational difference and offspring count is consistent with evidence found for Britain [8] and Hungary [2]. Offspring count is significantly positively associated with husband's income among women in the higher education categories . This coincides with evidence for the USA [9], suggesting that financial resources are important for increasing modern female reproduction. Note that controlling for educationally assortative mating and husband's income has virtually no effect on our primary result that parental age difference is negatively associated with offspring count. Boyko [10] notes that the age difference at which offspring count is maximized in a population cannot differ between women and men . Kokko [11] illustrates how, despite the Fisher condition, optimal mate choice can differ between sexes and regressions of offspring count on parental age difference may fail to identify these conditions. We extend Kokko's quadratic model to include an interaction between mother's and father's age at first birth. As shown in table 2, offspring count declines with woman's age at first birth. Offspring count is a humpshaped function of man's age with a maximum that depends on the woman's age and is decreasing for positive age differences and observed woman's ages. --- DISCUSSION Our study differs from previous work in several important dimensions. First, our national population dataset provides a large sample with high-quality data. Second, we provide evidence for a recent cohort in a developing Asian country. We examine the relationships between reproductive consequences and mate choice considering not only spousal age difference but also educational differences and resource availability. Finally, we estimate a model that describes offspring count as a richer function of woman's and man's ages at first birth, not simply their age difference. We find assortative-mating patterns by age and educational attainment in Taiwan that are similar to those in many societies. On average, women who married before age 30 were 3 years younger than their husbands, whereas those who married later were only 1 year younger. More than 40 per cent of husbands and wives have the same educational attainment. Parental age, education and offspring M.-W. Our empirical results indicate that the positive relationship between parental age difference and offspring count can be largely attributed to the higher reproductive success of women who give birth at younger ages. After controlling for a woman's reproductive value , an older husband is associated with fewer offspring. Therefore, our results strongly support the view that it is reproductive value rather than age difference per se that is associated with offspring count. This result is supported by modelling offspring count as a function of parental ages at first birth, which implies that offspring count decreases with woman's age at first birth. Moreover, we find that educationally assortative mating is strongly associated with offspring count. Women who married men with less education have fewer children than those who married men with equal or more education. In the contemporary Taiwanese setting, with access to social support programmes and modern birthcontrol methods, increases in women's educational attainment, workforce participation and income are associated with lower fertility. To compensate for trade-offs between education, income generation and childbearing, women may increase their reproductive output by seeking mates with more resources.

Using contemporary population data from Taiwan, we examine the relationships between parental age difference, educationally assortative mating, income and offspring count. Controlling for women's reproductive value (measured by age at first birth), we find that an older husband is associated with fewer offspring, whereas a husband with similar or higher education is associated with more offspring. Concerning resources, we find that women's income is negatively associated with fertility and husband's income is positively associated with fertility among highly educated women. These results are consistent with the view that women compensate for trade-offs between education, income generation and childbearing by seeking mates with a higher status.

introduction mating preferences are determined by a host of interrelated psychological sociological cultural and economic factors in most societies men marry younger women and women marry older men women are more likely to have mates with similar or higher educational attainment these patterns reflect the stylized fact that men usually desire younger partners with higher reproductive capacity and women usually desire men with more resources and higher status 1 from an evolutionary perspective it is of interest to determine whether preferences regarding age and educational differences enhance fitness as measured by offspring count and whether the relationships persist in modern societies with access to social income support and modern birthcontrol methods an early study by bereczkei csanaky 2 using county survey data from hungary found that men marrying younger women had significantly more children than men who married older women using english data manning anderton 3 reported a maximum offspring count when the husband was 23 years older than his wife two morerecent studies also found an inverted u relationship using data for the seventeenththrough nineteenthcentury sami population in northern finland helle et al 4 found that men maximized their offspring count by marrying women approximately 15 years younger fieder huber 5 using contemporary swedish data found offspring count was maximized for men marrying women 4 years younger and for women marrying men 6 years older lindqvist et al 6 criticized this study for failing to control for a potentially important confounder reproductive value by including womans age at marriage they concluded that the relationship between parental age difference and offspring count is spurious in reply fieder et al 7 confirmed that their results were robust to including womans age at first birth in their model a variable they claimed is a better measure of reproductive value than age at marriage with regard to parental education mascietaylor 8 found that the education difference between husband and wife is positively associated with offspring in british data for american women huber et al 9 found that husbands income is related to offspring count for highly educated women suggesting that resources are important for increasing modern female reproduction given the absence of studies on contemporary developing countries we examine the relationship between parental age difference and offspring count in taiwan we also investigate the relationships between education income and fertility after adjustment for womens reproductive value we find that marrying an older man or a less educated man is associated with fewer offspring resource availability measured by husbands income is associated with more offspring among highly educated women recognizing that the optimal age difference cannot differ by sex 10 we fit a quadratic model of womans and mans age at first birth 11 and find that offspring count declines with womans age and exhibits an inverted ushaped relationship with mans age material and methods we used 19782006 national birth register data to derive fertility histories for taiwanese women born in 19611966 for each birth the register contains parents ages and years of education we used the unique parents personal identifiers to link birth records and calculated the number of children produced by each couple our analysis was restricted to women aged 4045 years in 2006 who had largely completed childbearing we included only women who bore children with the same father information on parental income was obtained from the 2005 governmentemployee and labourinsurance files that cover the vast majority of publicand privatesector employees our large national dataset combining highly accurate offspring counts with parental education and income allows us to assess the relationship between socioeconomic status and offspring count our analysis is limited to couples producing at least one child parental age difference is fathers age minus mothers age completed schooling is categorized as elementary junior high senior high college and graduate school after excluding observations missing fathers income 680 526 couples remain for analysis mothers absent from the insurance files for whom spousal income was available were assumed to have no market income mean age and education differences are 30 and 04 years respectively mothers average 253 years at first birth and fathers average 283 years offspring count averages 23 results for comparability we begin by replicating the specifications proposed by fieder huber 5 and lindqvist et al 6 offspring count is regressed on parental age difference parental age difference squared and womans age at first birth we examine effects of educationally assortative mating and resource availability by adding parental income education and differences in education without controlling for female reproductive capacity the linear model in column 1 of table 1 implies that a sameage couple averages 221 children and a 1 year increase in age differential is associated with 002 additional children the quadratic model in column 2 implies that offspring count is maximized when the husband is 8 years older than his wife 5 years more than the mean age difference the relationship between parental age difference and offspring count is displayed in figure 1 controlling for womans age at first birth increases goodness of fit and substantially affects the estimated relationship between parental age difference and offspring count in the linear model the coefficient on age difference is much smaller and significantly less than zero one possible explanation for the drastic change is that reproductive value is correlated with age difference indeed the correlation between age difference and womans age at first birth is 2035 women who married before 30 average 3 years younger than their husbands significantly more than the 1 year difference among those who married after 30 this pattern accords with propositions on mate selection in evolutionary models and is similar to patterns found in most cultures 12 consistent with expectations women who first gave birth at younger ages have higher offspring counts a 1 year increase in age at first birth is associated with 007 fewer children note that the magnitude of this coefficient is much larger than the coefficient of age difference suggesting that female reproductive capacity is more important in determining offspring count the quadratic model that controls for reproductive value suggests that offspring count declines monotonically over positive age differences controlling for reproductive value an older husband is associated with smaller offspring count these results provide little support for the hypothesis that age difference per se entails a fitness advantage they are consistent with evidence for premodern swedish populations 6 but contrast with those for hungary 2 england 3 sami populations of preindustrial finland 4 and contemporary swedish populations it is well recognized that socioeconomic status is associated with fertility timing and offspring count we use educational attainment and income as measures of socioeconomic status as shown in column 5 offspring count is strongly negatively related to womans education and income to assess the relationship between educationally assortative mating and offspring count we interacted a womans education with dummy variables for differences in spousal education same indicating the spouses have equal education and higher indicating the husband has more education in our sample only 223 per cent of women marry men with less education whereas 425 and 352 per cent marry men with the same and higher educational attainment respectively spousal education interactions are included in column 6 the reference group is couples in which the woman completed junior high school and the husband has less education to examine whether the association between husbands resources and offspring count varies by womans education we include interactions of womans education level and husbands income women marrying men with less education have fewer offspring than those marrying men with comparable or more education average offspring count is largest for couples in which both spouses have only elementaryschool education the association between educational difference and offspring count is consistent with evidence found for britain 8 and hungary 2 offspring count is significantly positively associated with husbands income among women in the higher education categories this coincides with evidence for the usa 9 suggesting that financial resources are important for increasing modern female reproduction note that controlling for educationally assortative mating and husbands income has virtually no effect on our primary result that parental age difference is negatively associated with offspring count boyko 10 notes that the age difference at which offspring count is maximized in a population cannot differ between women and men kokko 11 illustrates how despite the fisher condition optimal mate choice can differ between sexes and regressions of offspring count on parental age difference may fail to identify these conditions we extend kokkos quadratic model to include an interaction between mothers and fathers age at first birth as shown in table 2 offspring count declines with womans age at first birth offspring count is a humpshaped function of mans age with a maximum that depends on the womans age and is decreasing for positive age differences and observed womans ages discussion our study differs from previous work in several important dimensions first our national population dataset provides a large sample with highquality data second we provide evidence for a recent cohort in a developing asian country we examine the relationships between reproductive consequences and mate choice considering not only spousal age difference but also educational differences and resource availability finally we estimate a model that describes offspring count as a richer function of womans and mans ages at first birth not simply their age difference we find assortativemating patterns by age and educational attainment in taiwan that are similar to those in many societies on average women who married before age 30 were 3 years younger than their husbands whereas those who married later were only 1 year younger more than 40 per cent of husbands and wives have the same educational attainment parental age education and offspring mw our empirical results indicate that the positive relationship between parental age difference and offspring count can be largely attributed to the higher reproductive success of women who give birth at younger ages after controlling for a womans reproductive value an older husband is associated with fewer offspring therefore our results strongly support the view that it is reproductive value rather than age difference per se that is associated with offspring count this result is supported by modelling offspring count as a function of parental ages at first birth which implies that offspring count decreases with womans age at first birth moreover we find that educationally assortative mating is strongly associated with offspring count women who married men with less education have fewer children than those who married men with equal or more education in the contemporary taiwanese setting with access to social support programmes and modern birthcontrol methods increases in womens educational attainment workforce participation and income are associated with lower fertility to compensate for tradeoffs between education income generation and childbearing women may increase their reproductive output by seeking mates with more resources

using contemporary population data from taiwan we examine the relationships between parental age difference educationally assortative mating income and offspring count controlling for womens reproductive value measured by age at first birth we find that an older husband is associated with fewer offspring whereas a husband with similar or higher education is associated with more offspring concerning resources we find that womens income is negatively associated with fertility and husbands income is positively associated with fertility among highly educated women these results are consistent with the view that women compensate for tradeoffs between education income generation and childbearing by seeking mates with a higher status

INTRODUCTION Divorce among couples is increasingly becoming a critical issue, garnering attention from professionals in family dynamics and child development. In the United States, the divorce rate ranks as the sixth highest globally, with approximately 50% of marriages ending in divorce each year, as reported by the World Population Review [1]. This statistic is further substantiated by the National Center for Health Statistics [2], which indicates that of the 4-5 million people marrying annually in the United States, 42-53% of these marriages ultimately dissolve. The divorce process is a significant life event and a catalyst for family unity and connectedness disruption. This disruption extends profoundly to parents and children, instigating a cascade of psychological, physiological, mental, and emotional challenges. Research by Al Gharaibeh [3], Bastaits et al. [4], and DeAnda et al. [5] highlights the multifaceted impact of divorce on family members, especially children. Divorce can influence how well children do in school and affect their cognitive, physical, and social development as they interact with peers in the classroom. For some kids, the emotional strain of their parents' separation can lead to them becoming more reserved and distant from others, which could lead to dropping out of school. Parental divorce leads to more frequent changes in relationships, which can disrupt children's lives and their education [6]. Children from divorced households may encounter difficulties in adapting to frequent changes, including one parent establishing a new residence, enrolling in a different school, and forming new social connections. These circumstances may lead to instability in the children's lives. The concept of divorce and how it affects children were discussed in this paper, along with an overview of the divorce process. Children are the most vulnerable family members; therefore, we are particularly interested in learning how they may deal with the adverse effects of divorce when there is a marriage disruption and how divorce affects their physical and psychological health. The ways by which divorce rates can be minimized are also discussed. More importantly, there would be the examination of previous studies done by researchers in coping with change in family structure because of divorce and possible intervention and prevention that can be of help to families, which will help us to provide a comprehensive synopsis of future research direction. It is essential to investigate this area of family internal dynamics and help to provide a guide to coping or alleviating the stress of divorce in families, most especially for children. The significance of the topic and the detrimental effects of divorce on children's lives led to four research questions aimed at guiding this paper: The profound impact of divorce on children's lives is a significant area of concern, with extensive literature underscoring its effects on mental health, emotional stability, and physical well-being. Studies such as Anderson [7] have shown that children of divorced parents often face heightened levels of stress, anxiety, and depressive symptoms, alongside physiological impacts like sleep disturbances and altered eating patterns. Furthermore, the detrimental influence of divorce on academic performance is well-documented, with factors like emotional distress, decreased parental involvement, and instability in living arrangements leading to declines in grades, school attendance, and academic motivation, as evidenced by Brand et al. [6]. However, while a rich body of research addresses these consequences, a notable gap exists regarding proactive measures and resources aimed at reducing divorce rates. Much of the existing literature focuses on coping mechanisms following divorce rather than on prevention strategies. Our literature review finds that this gap is only partially addressed by existing programs. For instance, in collaboration with the CDC, a program developed by Niolon et al. [8] offers a framework for strengthening family relationships and enhancing parental support, indirectly benefiting children in families undergoing marital challenges. Yet, the limited focus of this program on directly targeting divorce rates and enhancing children's well-being postdivorce highlights the need for more comprehensive research and intervention development. This gap in the literature, particularly in terms of preventive measures and resources to lower divorce rates and improve children's well-being amid marital dissolution, emphasizes the crucial need for this study. Our research aims to explore and develop comprehensive strategies that address the aftermath of divorce and proactively work towards reducing its incidence and mitigating its impact on children. In doing so, we hope to fill a significant void in current research and interventions, emphasizing the importance of understanding and preventing the negative effects of divorce on children. --- DEFINING DIVORCE AND ITS EFFECT ON CHILDREN Divorce is the legal procedure through which the obligations and roles within a marriage are rearranged or terminated, resulting in the formal dissolution of the marital union, as governed by the laws of a specific state or nation [9]. Divorce, legally recognized as the dissolution of marriage, significantly alters the familial landscape, with profound effects that reverberate through the lives of the children involved. As Carlson & Magnuson [10] noted, the family unit is foundational to a child's development, providing the essential psychological, emotional, and social scaffolding necessary for healthy growth. Yet, when the structure of a family is compromised through a divorce, the resulting disruption can lead to a noticeable void in parental availability and support [11]. This reduced parental engagement can have cascading effects on a child's ability to navigate social complexities and form stable, secure relationships. The ramifications of divorce extend well beyond the immediate emotional turmoil. They encompass a spectrum of psychological disturbances, including increased risks for anxiety, depression, and behavioral issues [3]. Physiologically, children may experience stress-related health issues, with research pointing to potential disruptions in normal growth and development patterns [4]. The emotional upheaval often associated with divorce can manifest in children as mood instability, withdrawal from social interactions, or aggression, further complicating their ability to cope with the seismic shifts in their family dynamics. Academically, the impact of divorce is equally significant. Studies have correlated parental separation with a decline in academic performance, noting that emotional distraction and potential instability in living situations can detract from a child's focus and engagement with educational pursuits [5]. The effects of divorce may also permeate into other life spheres, influencing children's peer relationships, self-esteem, and even future romantic partnerships [12]. Moreover, the consequences of divorce on children can persist into adulthood. Longitudinal studies have observed that children of divorced parents may carry the weight of their childhood experiences into their own adult relationships, employment stability, and mental health outcomes. These long-term effects' societal and economic implications are substantial, warranting a deeper exploration into preventative strategies and support mechanisms that can mitigate these outcomes. Additionally, divorce can often lead to a socioeconomic decline for the custodial parent, usually the mother, which further exacerbates the challenges faced by children. Financial instability can limit access to resources and opportunities, potentially widening the gap in educational and social equity for these children compared to their peers from intact families. In understanding the multi-dimensional impact of divorce on children, it becomes crucial to adopt a holistic approach to their care. Interdisciplinary collaboration between educators, healthcare providers, and mental health professionals is essential to address the full scope of children's needs post-divorce. Stakeholders must recognize these children's nuanced challenges and work collectively to create support systems that foster resilience and provide stability in all areas of their lives. The repercussions of divorce on children's health can be profound and long-lasting, often exacerbated by the reduced availability of parents to tend to their children's medical needs. The disruption caused by spousal separation can create a gap in the care and attention required for maintaining children's health. Al Gharaibeh [3] suggests that during and after divorce, the focus of parents might shift away from the day-to-day necessities of their children's health, leading to potential neglect of medical issues. Children's cognitive development can be significantly impacted by nutritional deficiencies that arise from changes in household dynamics. Essential nutrients, crucial for brain development and function, may be less prioritized, and as a result, children might face cognitive delays or impairments. This nutritional neglect can also increase the likelihood of academic setbacks, including the need to repeat grades, as proper diet and nutrition play a critical role in children's ability to learn and retain information. The research of Wallerstein and Lewis [13] further illustrates the health implications of divorce on children, highlighting that the psychological stress associated with parental separation can manifest in unhealthy eating and sleeping patterns. These disruptions are not merely inconveniences but determinants of a child's overall health and well-being. Chronic stress, a common byproduct of divorce, is known to compromise immune function and can lead to a host of physical health issues. Nyaradi et al. [14] draw attention to the specific impact of iron deficiency, a common nutritional shortfall among children experiencing the upheaval of divorce. Iron is a vital mineral for cognitive development, and its deficiency is linked to various health concerns. Children lacking adequate iron in their diets are at a higher risk for developing respiratory conditions like asthma, suffering from frequent headaches, and encountering speech and pronunciation difficulties. Moreover, iron deficiency can affect a child's energy levels and mood, leading to fatigue and a predisposition toward irritability or depression. In addition to direct health effects, the indirect consequences of divorce on children's health can include a lack of consistent health care monitoring and followup. Regular pediatric appointments and health screenings may become less frequent, causing early signs of health issues to go unnoticed. The psychological toll of divorce can also lead children to engage in risky behaviors in adolescence, potentially leading to adverse health outcomes that could extend into adulthood. Given these significant health concerns, the impact of divorce on children requires a multidimensional approach to care. This approach should integrate nutritional counseling, mental health support, and educational assistance to ensure that children facing the challenges of divorce receive the holistic care they need. Through such comprehensive support, it is possible to mitigate some of the adverse effects divorce can have on a child's physical and mental health, thereby promoting more positive developmental outcomes. --- SIGNIFICANCE OF THE STUDY The significance of this research transcends academic interest, addressing a pressing social issue with real-world implications. Divorce, while a personal family matter, has the potential to reverberate through the educational system and community at large, manifesting in behavioral and academic challenges within the classroom. This study aims to rigorously investigate the impact of divorce on children's psychological and physiological well-being, an area that, despite its critical importance, remains under-explored. The repercussions of marital dissolution on children are multifaceted and enduring. These children may face emotional upheaval that can manifest in a variety of behaviors, ranging from subtle withdrawal to overt aggression. The resulting disturbances not only disrupt their own learning experiences but can also affect the classroom environment. Understanding these reactions' psychological and physiological nuances is vital for developing effective support systems within educational and community settings. Teachers, school officials, and religious leaders who serve as important figures in children's lives will find this study's outcomes particularly beneficial. These influencers can tailor their approaches to meet the needs of affected children more effectively. In addition, the study will offer insights into how school counselors, educators, and parents can collaboratively foster environments that support the academic and emotional needs of children navigating the complexities of a changed family landscape. Moreover, the findings of this study have the potential to initiate a much-needed dialogue among stakeholders, including curriculum developers and policymakers. There is an urgent need for comprehensive strategies that address the holistic well-being of children from divorced families. With a significant number of students experiencing divorce as a part of their childhood, it is paramount for educational policies and curricula to reflect supportive measures that can mitigate the negative impacts identified by researchers like Nisivoccia [15]. The study will also contribute to a broader understanding of how shifts in family dynamics influence students' academic outcomes at a time when educational institutions are under increasing scrutiny for their role in student performance. This paper will inform policy and practice, ultimately leading to more resilient educational systems that are responsive to the needs of all students, particularly those facing the challenges of divorce. In essence, this study not only seeks to add to the academic discourse on the effects of divorce on children but also to catalyze change in how society, and specifically educational systems, respond to and support children affected by divorce. It is an imperative step towards ensuring that the next generation receives the empathetic support and comprehensive education necessary to thrive, regardless of their family circumstances. --- IMPACT OF DIVORCE ON THE PSYCHOLOGICAL AND PHYSIOLOGICAL WELLBEING OF CHILDREN Children tend to be affected psychologically when there is a disruption in the family's connectedness and togetherness [5]. Researchers have examined if there is a relationship between children's behavior and psychological imbalances following a divorce. In a longitudinal study involving 319 divorcing mothers and their children, DeAnda et al. [5] found that a mother's separation distress was significantly associated with increased children's externalizing behaviors. Findings showed that children became unhappy, sullen, irritable, fearful, anxious, and strong-tempered and did not get involved following their parents' divorce. Similarly, Guinart et al. [12] also found out that children struggled with sleep problems, mental confusion, anger, behavioral issues, low grades in school, animosity, and feelings of abandonment. Additionally, children who suffered from parental separation when they were adolescents and in early adulthood have a higher propensity to suffer from depression. The psychological and mental well-being of children from divorced families is at stake. Using a sample of Spanish single parents, Guinart et al. [12] conducted a qualitative study to investigate the immediate and long-term effects of family disruption on children. Their findings revealed that the children involved in the divorce process had behavioral issues, severe emotional disruptions, and subpar academic performance. Although this finding seems limited due to having just one participant's view and opinion, it can still help to support other related findings from other researchers who have done a quantitative survey in this direction. Guinart et al. [12] further asserted that children are affected physiologically and psychologically due to the high level of psychological strain their parents go through. The essential needs for children to develop and grow properly, including a healthy diet and adequate intake of vitamins and minerals, are often overlooked due to marital disruption and the stress that comes with it [3]. Hence, the children's physiological health is being affected. Huurre et al. [16] also examined the long-term effect of spousal separation on a range of adult outcomes, including social relationship issues and unforeseen life contingencies. The sample included 2269 ninthgrade students in Tampere, Finland, in the year 1983. The study participants were examined at the age of 16 and 32 years old. The results showed that participants from divorced households had a higher risk of smoking daily and drinking often, which can affect them physiologically over time. The impact of parental separation on the psychological well-being of their offspring can be measured through clinical assessment. In recent days, there seems to be an increase in family instability-related consultations, which can be linked to elements that increase the likelihood of psychopathological disorders in children. Divorce has a negative psychological and physiological impact on the well-being of children. Much has not been done on the physiological impact of divorce compared to the psychological impact, which is a potential research pathway to venture into. --- MITIGATING THE NEGATIVE EFFECTS OF DIVORCE AND FAMILY STRUCTURE DYNAMICS: COPING STRATEGIES AND RESILIENCE Coping with the negative effects of divorce and dynamics in family structure can be tough, but a direct relationship between the offspring and one of the parents after the divorce can assist in mediating the negative influence on the children [4]. Based on Bastaits et al. [4] findings in a study conducted making use of 618 parent-child pairs who took part in the divorce research, it can be inferred that the provision of parental care, even amid divorce, has been recognized as a crucial safeguard for children's welfare. It should be noted, nevertheless, that parents and other members of the family frequently find it difficult to help their children during the challenging period following a divorce. In essence, divorce is a painful and heartbreaking life experience in which adults have a tough time adjusting to life afterward and may have a negative impact on how they interact with their children. Helping to provide a means of escape from the effect of divorce and to cope appropriately with the adjusting process leads to examining the possible intervention and preventive measures that could mitigate the alarming rate of divorce in society. De Anda et al. [5] carried out a qualitative study on children's postdivorce adjustment. The study revealed that residential mothers' postdivorce separation distress has both direct and indirect implications for children's postdivorce adjustment. Through a longitudinal study involving 319 mother-child dyads, it was found that higher levels of separation distress in mothers were associated with increased internalizing and externalizing behaviors in their children. These findings highlight the interdependent associations between parents and children's postdivorce adjustment and emphasize the importance of addressing separation distress and co-parenting conflict for positive outcomes in children. In a quantitative study carried out by Al Gharaibeh [3] on the effect of divorce on children, the researchers discovered a correlation between divorce and a higher prevalence of several effects of divorce, including financial stress, inability to focus on class, sleeping disorders, and stubbornness. However, the study failed to consider the children's perspective regarding the divorce process, focusing solely on the viewpoint of their mothers. Examining the children's perception would be of great importance. Similarly, Jackson et al. [11] examined the connection between the social support of persons affected by parental divorce, their expectations for their careers, and their confidence in their ability to find true love in a romantic relationship. The findings show that professional expectations and confidence in romantic relationships were considerably positively correlated with the level of social support. The study was based solely on quantitative data, which will not allow the participants to express themselves fully; qualitative data can be added to supplement the findings and will give the participants a voice in the research process. --- INTERVENTION AND MEASURES FOR PREVENTING DIVORCE Guinart et al. [12] proposed that there must be an adequate and balanced development of the mind as a treatment strategy that can lessen the chance of developing psychosocial adjustment issues or perhaps a psychopathological issue in the future. It is of no value to analyze the impact of divorce on children's wellness if an appropriate methodology to curb the menace of its havoc in the lives of individuals is not proffered. A careful review of all selected literature did not proffer enough substantial possible intervention and prevention programs for families and children involved in a divorce. However, research on divorce education is found in the literature, such as Geasler and Blaisure [17], whom both asserted that an all-embracing purpose of divorce education is to assist parents and children in adjusting to divorce. Divorce education has not been proven to mitigate the rate of divorce but to manage the victims of divorce, especially the children. This paper aims to project divorce issues as a menace that can be mitigated. Hence, Niolon et al. [8] of the Division of Violence Prevention at the Centers for Disease Control and Prevention , Atlanta, Georgia, developed a program titled Preventing Intimate Partner Violence across the lifespan. The Centers for Disease Control and Prevention developed a technical package aimed at preventing child abuse and neglect by implementing measures to counter Intimate Partner Violence . This approach involves introducing youth to these preventive measures at an early age before they encounter such situations [8]. The technical packages include policies that focus on recognizing and addressing the links between various types of violence, which could result in a reduction in divorce rates among married couples. When young people are educated on the warning signs in dating relationships, they can make better choices and potentially avoid marriages that might end in divorce, thereby preventing the psychological and physiological impacts such as divorces could have on their children. The program explained that IPV begins in adolescence and can be prevented. It is logical to state that if this program, as explained in Fig. 1, is introduced early to adolescents and younger children, it has the tendency to furnish those exposed to it with information that will make them have a successful marriage in the future. --- PROPOSED RESEARCH APPROACHES TO ADDRESS THE NEGATIVE IMPACT OF DIVORCE ON CHILDREN It is important that the government takes proactive measures to allocate funds for conducting an extensive study on the profound effects of divorce on children's academic achievement. This critical research is essential to overcome the current limitations of practical solutions available to educators, who face an increasing need to provide effective support to children of divorced families. Because many families have experienced divorce, it is imperative that our educational systems understand the unique challenges these families face. Upon securing funding, it is imperative to prioritize teacher retraining, so that they are equipped with valuable insights and practical tips for supporting children from divorced backgrounds. To ensure that instructors are aware of the negative consequences divorce can have on children, it is essential to provide them with practical ideas for creating classes that respond to their specific needs. School boards should develop a rule mandating that each school or group of schools hire one or two instructors with the necessary training to facilitate this process. To create and implement comprehensive programs to support children whose parents have divorced, educators should engage with school counselors and social workers. By encouraging a collaborative approach, these programs can offer the essential direction and tools to ease the difficulties and worries faced by classroom instructors who interact with children from divorced families. Furthermore, it is critical to acknowledge the inherent challenges classroom teachers encounter while trying to satisfy the requirements of all the students in the class while also giving children of divorced parents the particular attention they require. The burden on classroom teachers can be significantly reduced by ensuring that schools have adequately trained teachers who can plan and implement schooland classroom-based intervention programs. These trained professionals can better address the specific needs of children from divorced backgrounds, fostering an inclusive and supportive learning environment for all students. Furthermore, it is advised that the parents of children going through a divorce work closely with social workers, school counselors, and trained instructors. It has been established that partnerships and frequent contact between schools, instructors, and parents are essential for pupils to succeed. To ensure that the children's academic performance is prioritized even throughout the trying divorce transition, the qualified teachers and other counselors would work with the parents to provide them with counseling, techniques, and programs they could continue participating in with their children. Finally, we recommend that divorce education be incorporated into the school curriculum. If the mindset of children and adolescents is changed about divorce through the intervention of specially trained teachers/instructors and school counselors, they will grow up to appreciate the sanctity of marriage and strive to make their marriages work. Men will respect their wives at home, and this will reduce the rate at which spouses abuse each other in the family. --- LIMITATIONS OF THE STUDY While this study endeavors to provide comprehensive insights into the effects of divorce on children's psychological and physiological well-being, it recognizes several limitations that must be acknowledged. Firstly, the scope of the literature reviewed may not encompass all existing research on the topic due to the vastness of the field. Consequently, some relevant studies might not have been included, which could influence the comprehensiveness of the findings presented. Secondly, the study relies heavily on secondary data from previously published research. While this methodology allows for an extensive overview of available literature, it also means that the conclusions drawn are limited to the perspectives and data of those studies. Primary research, such as direct interviews or surveys with affected children and their families, would provide valuable firsthand accounts that are not included in this study. Additionally, the cross-sectional nature of most divorce research, including that cited in this study, does not allow for the observation of longterm effects over time. Longitudinal studies would be beneficial to understand the enduring consequences of divorce on children's wellbeing. The research also focuses predominantly on the negative impacts of divorce, potentially overlooking any resilience or positive adaptation strategies that children might develop. Furthermore, there may be a variation in the effects of divorce based on factors such as age, socioeconomic status, and cultural background, which are not extensively explored in this study. Lastly, the study acknowledges the potential for publication bias in the literature reviewed, as studies with significant findings are more likely to be published than those with null or negative results. This bias could skew the representation of the impact of divorce on children. Recognizing these limitations is crucial for interpreting the study's findings accurately and for guiding future research to build on the knowledge base with a more nuanced understanding of the effects of divorce on children. --- CONCLUSION The review of the current literature reveals a significant amount of research focused on understanding the psychological impacts of divorce on children. These studies have shed light on the myriad ways in which divorce affects children's mental health, ranging from increased anxiety and depression to behavioral changes and academic challenges. However, there is a notable gap in research regarding effective intervention and prevention strategies. While the adverse effects on children's psychological and physiological well-being are well-documented, efforts to develop comprehensive programs that address these issues are comparatively limited. This lack of focused research on interventions and preventive measures indicates a crucial area for future studies. More in-depth research is needed to explore and develop targeted strategies that can effectively support children and families navigating the complexities of divorce. This could include the design and evaluation of counseling programs, support groups, and educational initiatives aimed at helping children cope with the emotional and psychological stress of parental separation. Furthermore, there is a pressing need for studies that employ qualitative methods to gain deeper insights into the personal experiences and needs of children from divorced families. Such research could provide valuable information on the specific challenges these children face and the types of support that would be most beneficial to them. Additionally, expanding the scope of research to include larger and more diverse samples is essential for a more comprehensive understanding of the varying impacts of divorce across different communities and cultural backgrounds. When these gaps in the literature is addressed, future research has the potential to significantly enhance our understanding of the effects of divorce on children. This, in turn, would inform the development of more effective intervention and prevention programs, ultimately aiding in mitigating the negative impacts of divorce and promoting the long-term well-being of affected children and their families. --- COMPETING INTERESTS Authors have declared that no competing interests exist.

This paper examines the multifaceted effects of divorce on children, focusing on their psychological and physiological well-being. It highlights the significant disruption divorce causes in family dynamics, leading to profound changes in children's emotional states, behaviors, and academic performance. The paper notes a substantial body of research documenting the psychological consequences of divorce, such as increased anxiety, depression, and behavioral issues. However, it identifies a notable gap in studies concentrating on intervention and prevention strategies. Additionally, the physiological impacts of divorce, such as health problems and developmental challenges, are not as comprehensively studied. The paper advocates for qualitative research to delve into the personal experiences of affected children and suggests expanding the scope of research to larger and more diverse population samples. It highlights the need for developing comprehensive strategies to mitigate the adverse effects of divorce on children, emphasizing a

introduction divorce among couples is increasingly becoming a critical issue garnering attention from professionals in family dynamics and child development in the united states the divorce rate ranks as the sixth highest globally with approximately 50 of marriages ending in divorce each year as reported by the world population review 1 this statistic is further substantiated by the national center for health statistics 2 which indicates that of the 45 million people marrying annually in the united states 4253 of these marriages ultimately dissolve the divorce process is a significant life event and a catalyst for family unity and connectedness disruption this disruption extends profoundly to parents and children instigating a cascade of psychological physiological mental and emotional challenges research by al gharaibeh 3 bastaits et al 4 and deanda et al 5 highlights the multifaceted impact of divorce on family members especially children divorce can influence how well children do in school and affect their cognitive physical and social development as they interact with peers in the classroom for some kids the emotional strain of their parents separation can lead to them becoming more reserved and distant from others which could lead to dropping out of school parental divorce leads to more frequent changes in relationships which can disrupt childrens lives and their education 6 children from divorced households may encounter difficulties in adapting to frequent changes including one parent establishing a new residence enrolling in a different school and forming new social connections these circumstances may lead to instability in the childrens lives the concept of divorce and how it affects children were discussed in this paper along with an overview of the divorce process children are the most vulnerable family members therefore we are particularly interested in learning how they may deal with the adverse effects of divorce when there is a marriage disruption and how divorce affects their physical and psychological health the ways by which divorce rates can be minimized are also discussed more importantly there would be the examination of previous studies done by researchers in coping with change in family structure because of divorce and possible intervention and prevention that can be of help to families which will help us to provide a comprehensive synopsis of future research direction it is essential to investigate this area of family internal dynamics and help to provide a guide to coping or alleviating the stress of divorce in families most especially for children the significance of the topic and the detrimental effects of divorce on childrens lives led to four research questions aimed at guiding this paper the profound impact of divorce on childrens lives is a significant area of concern with extensive literature underscoring its effects on mental health emotional stability and physical wellbeing studies such as anderson 7 have shown that children of divorced parents often face heightened levels of stress anxiety and depressive symptoms alongside physiological impacts like sleep disturbances and altered eating patterns furthermore the detrimental influence of divorce on academic performance is welldocumented with factors like emotional distress decreased parental involvement and instability in living arrangements leading to declines in grades school attendance and academic motivation as evidenced by brand et al 6 however while a rich body of research addresses these consequences a notable gap exists regarding proactive measures and resources aimed at reducing divorce rates much of the existing literature focuses on coping mechanisms following divorce rather than on prevention strategies our literature review finds that this gap is only partially addressed by existing programs for instance in collaboration with the cdc a program developed by niolon et al 8 offers a framework for strengthening family relationships and enhancing parental support indirectly benefiting children in families undergoing marital challenges yet the limited focus of this program on directly targeting divorce rates and enhancing childrens wellbeing postdivorce highlights the need for more comprehensive research and intervention development this gap in the literature particularly in terms of preventive measures and resources to lower divorce rates and improve childrens wellbeing amid marital dissolution emphasizes the crucial need for this study our research aims to explore and develop comprehensive strategies that address the aftermath of divorce and proactively work towards reducing its incidence and mitigating its impact on children in doing so we hope to fill a significant void in current research and interventions emphasizing the importance of understanding and preventing the negative effects of divorce on children defining divorce and its effect on children divorce is the legal procedure through which the obligations and roles within a marriage are rearranged or terminated resulting in the formal dissolution of the marital union as governed by the laws of a specific state or nation 9 divorce legally recognized as the dissolution of marriage significantly alters the familial landscape with profound effects that reverberate through the lives of the children involved as carlson magnuson 10 noted the family unit is foundational to a childs development providing the essential psychological emotional and social scaffolding necessary for healthy growth yet when the structure of a family is compromised through a divorce the resulting disruption can lead to a noticeable void in parental availability and support 11 this reduced parental engagement can have cascading effects on a childs ability to navigate social complexities and form stable secure relationships the ramifications of divorce extend well beyond the immediate emotional turmoil they encompass a spectrum of psychological disturbances including increased risks for anxiety depression and behavioral issues 3 physiologically children may experience stressrelated health issues with research pointing to potential disruptions in normal growth and development patterns 4 the emotional upheaval often associated with divorce can manifest in children as mood instability withdrawal from social interactions or aggression further complicating their ability to cope with the seismic shifts in their family dynamics academically the impact of divorce is equally significant studies have correlated parental separation with a decline in academic performance noting that emotional distraction and potential instability in living situations can detract from a childs focus and engagement with educational pursuits 5 the effects of divorce may also permeate into other life spheres influencing childrens peer relationships selfesteem and even future romantic partnerships 12 moreover the consequences of divorce on children can persist into adulthood longitudinal studies have observed that children of divorced parents may carry the weight of their childhood experiences into their own adult relationships employment stability and mental health outcomes these longterm effects societal and economic implications are substantial warranting a deeper exploration into preventative strategies and support mechanisms that can mitigate these outcomes additionally divorce can often lead to a socioeconomic decline for the custodial parent usually the mother which further exacerbates the challenges faced by children financial instability can limit access to resources and opportunities potentially widening the gap in educational and social equity for these children compared to their peers from intact families in understanding the multidimensional impact of divorce on children it becomes crucial to adopt a holistic approach to their care interdisciplinary collaboration between educators healthcare providers and mental health professionals is essential to address the full scope of childrens needs postdivorce stakeholders must recognize these childrens nuanced challenges and work collectively to create support systems that foster resilience and provide stability in all areas of their lives the repercussions of divorce on childrens health can be profound and longlasting often exacerbated by the reduced availability of parents to tend to their childrens medical needs the disruption caused by spousal separation can create a gap in the care and attention required for maintaining childrens health al gharaibeh 3 suggests that during and after divorce the focus of parents might shift away from the daytoday necessities of their childrens health leading to potential neglect of medical issues childrens cognitive development can be significantly impacted by nutritional deficiencies that arise from changes in household dynamics essential nutrients crucial for brain development and function may be less prioritized and as a result children might face cognitive delays or impairments this nutritional neglect can also increase the likelihood of academic setbacks including the need to repeat grades as proper diet and nutrition play a critical role in childrens ability to learn and retain information the research of wallerstein and lewis 13 further illustrates the health implications of divorce on children highlighting that the psychological stress associated with parental separation can manifest in unhealthy eating and sleeping patterns these disruptions are not merely inconveniences but determinants of a childs overall health and wellbeing chronic stress a common byproduct of divorce is known to compromise immune function and can lead to a host of physical health issues nyaradi et al 14 draw attention to the specific impact of iron deficiency a common nutritional shortfall among children experiencing the upheaval of divorce iron is a vital mineral for cognitive development and its deficiency is linked to various health concerns children lacking adequate iron in their diets are at a higher risk for developing respiratory conditions like asthma suffering from frequent headaches and encountering speech and pronunciation difficulties moreover iron deficiency can affect a childs energy levels and mood leading to fatigue and a predisposition toward irritability or depression in addition to direct health effects the indirect consequences of divorce on childrens health can include a lack of consistent health care monitoring and followup regular pediatric appointments and health screenings may become less frequent causing early signs of health issues to go unnoticed the psychological toll of divorce can also lead children to engage in risky behaviors in adolescence potentially leading to adverse health outcomes that could extend into adulthood given these significant health concerns the impact of divorce on children requires a multidimensional approach to care this approach should integrate nutritional counseling mental health support and educational assistance to ensure that children facing the challenges of divorce receive the holistic care they need through such comprehensive support it is possible to mitigate some of the adverse effects divorce can have on a childs physical and mental health thereby promoting more positive developmental outcomes significance of the study the significance of this research transcends academic interest addressing a pressing social issue with realworld implications divorce while a personal family matter has the potential to reverberate through the educational system and community at large manifesting in behavioral and academic challenges within the classroom this study aims to rigorously investigate the impact of divorce on childrens psychological and physiological wellbeing an area that despite its critical importance remains underexplored the repercussions of marital dissolution on children are multifaceted and enduring these children may face emotional upheaval that can manifest in a variety of behaviors ranging from subtle withdrawal to overt aggression the resulting disturbances not only disrupt their own learning experiences but can also affect the classroom environment understanding these reactions psychological and physiological nuances is vital for developing effective support systems within educational and community settings teachers school officials and religious leaders who serve as important figures in childrens lives will find this studys outcomes particularly beneficial these influencers can tailor their approaches to meet the needs of affected children more effectively in addition the study will offer insights into how school counselors educators and parents can collaboratively foster environments that support the academic and emotional needs of children navigating the complexities of a changed family landscape moreover the findings of this study have the potential to initiate a muchneeded dialogue among stakeholders including curriculum developers and policymakers there is an urgent need for comprehensive strategies that address the holistic wellbeing of children from divorced families with a significant number of students experiencing divorce as a part of their childhood it is paramount for educational policies and curricula to reflect supportive measures that can mitigate the negative impacts identified by researchers like nisivoccia 15 the study will also contribute to a broader understanding of how shifts in family dynamics influence students academic outcomes at a time when educational institutions are under increasing scrutiny for their role in student performance this paper will inform policy and practice ultimately leading to more resilient educational systems that are responsive to the needs of all students particularly those facing the challenges of divorce in essence this study not only seeks to add to the academic discourse on the effects of divorce on children but also to catalyze change in how society and specifically educational systems respond to and support children affected by divorce it is an imperative step towards ensuring that the next generation receives the empathetic support and comprehensive education necessary to thrive regardless of their family circumstances impact of divorce on the psychological and physiological wellbeing of children children tend to be affected psychologically when there is a disruption in the familys connectedness and togetherness 5 researchers have examined if there is a relationship between childrens behavior and psychological imbalances following a divorce in a longitudinal study involving 319 divorcing mothers and their children deanda et al 5 found that a mothers separation distress was significantly associated with increased childrens externalizing behaviors findings showed that children became unhappy sullen irritable fearful anxious and strongtempered and did not get involved following their parents divorce similarly guinart et al 12 also found out that children struggled with sleep problems mental confusion anger behavioral issues low grades in school animosity and feelings of abandonment additionally children who suffered from parental separation when they were adolescents and in early adulthood have a higher propensity to suffer from depression the psychological and mental wellbeing of children from divorced families is at stake using a sample of spanish single parents guinart et al 12 conducted a qualitative study to investigate the immediate and longterm effects of family disruption on children their findings revealed that the children involved in the divorce process had behavioral issues severe emotional disruptions and subpar academic performance although this finding seems limited due to having just one participants view and opinion it can still help to support other related findings from other researchers who have done a quantitative survey in this direction guinart et al 12 further asserted that children are affected physiologically and psychologically due to the high level of psychological strain their parents go through the essential needs for children to develop and grow properly including a healthy diet and adequate intake of vitamins and minerals are often overlooked due to marital disruption and the stress that comes with it 3 hence the childrens physiological health is being affected huurre et al 16 also examined the longterm effect of spousal separation on a range of adult outcomes including social relationship issues and unforeseen life contingencies the sample included 2269 ninthgrade students in tampere finland in the year 1983 the study participants were examined at the age of 16 and 32 years old the results showed that participants from divorced households had a higher risk of smoking daily and drinking often which can affect them physiologically over time the impact of parental separation on the psychological wellbeing of their offspring can be measured through clinical assessment in recent days there seems to be an increase in family instabilityrelated consultations which can be linked to elements that increase the likelihood of psychopathological disorders in children divorce has a negative psychological and physiological impact on the wellbeing of children much has not been done on the physiological impact of divorce compared to the psychological impact which is a potential research pathway to venture into mitigating the negative effects of divorce and family structure dynamics coping strategies and resilience coping with the negative effects of divorce and dynamics in family structure can be tough but a direct relationship between the offspring and one of the parents after the divorce can assist in mediating the negative influence on the children 4 based on bastaits et al 4 findings in a study conducted making use of 618 parentchild pairs who took part in the divorce research it can be inferred that the provision of parental care even amid divorce has been recognized as a crucial safeguard for childrens welfare it should be noted nevertheless that parents and other members of the family frequently find it difficult to help their children during the challenging period following a divorce in essence divorce is a painful and heartbreaking life experience in which adults have a tough time adjusting to life afterward and may have a negative impact on how they interact with their children helping to provide a means of escape from the effect of divorce and to cope appropriately with the adjusting process leads to examining the possible intervention and preventive measures that could mitigate the alarming rate of divorce in society de anda et al 5 carried out a qualitative study on childrens postdivorce adjustment the study revealed that residential mothers postdivorce separation distress has both direct and indirect implications for childrens postdivorce adjustment through a longitudinal study involving 319 motherchild dyads it was found that higher levels of separation distress in mothers were associated with increased internalizing and externalizing behaviors in their children these findings highlight the interdependent associations between parents and childrens postdivorce adjustment and emphasize the importance of addressing separation distress and coparenting conflict for positive outcomes in children in a quantitative study carried out by al gharaibeh 3 on the effect of divorce on children the researchers discovered a correlation between divorce and a higher prevalence of several effects of divorce including financial stress inability to focus on class sleeping disorders and stubbornness however the study failed to consider the childrens perspective regarding the divorce process focusing solely on the viewpoint of their mothers examining the childrens perception would be of great importance similarly jackson et al 11 examined the connection between the social support of persons affected by parental divorce their expectations for their careers and their confidence in their ability to find true love in a romantic relationship the findings show that professional expectations and confidence in romantic relationships were considerably positively correlated with the level of social support the study was based solely on quantitative data which will not allow the participants to express themselves fully qualitative data can be added to supplement the findings and will give the participants a voice in the research process intervention and measures for preventing divorce guinart et al 12 proposed that there must be an adequate and balanced development of the mind as a treatment strategy that can lessen the chance of developing psychosocial adjustment issues or perhaps a psychopathological issue in the future it is of no value to analyze the impact of divorce on childrens wellness if an appropriate methodology to curb the menace of its havoc in the lives of individuals is not proffered a careful review of all selected literature did not proffer enough substantial possible intervention and prevention programs for families and children involved in a divorce however research on divorce education is found in the literature such as geasler and blaisure 17 whom both asserted that an allembracing purpose of divorce education is to assist parents and children in adjusting to divorce divorce education has not been proven to mitigate the rate of divorce but to manage the victims of divorce especially the children this paper aims to project divorce issues as a menace that can be mitigated hence niolon et al 8 of the division of violence prevention at the centers for disease control and prevention atlanta georgia developed a program titled preventing intimate partner violence across the lifespan the centers for disease control and prevention developed a technical package aimed at preventing child abuse and neglect by implementing measures to counter intimate partner violence this approach involves introducing youth to these preventive measures at an early age before they encounter such situations 8 the technical packages include policies that focus on recognizing and addressing the links between various types of violence which could result in a reduction in divorce rates among married couples when young people are educated on the warning signs in dating relationships they can make better choices and potentially avoid marriages that might end in divorce thereby preventing the psychological and physiological impacts such as divorces could have on their children the program explained that ipv begins in adolescence and can be prevented it is logical to state that if this program as explained in fig 1 is introduced early to adolescents and younger children it has the tendency to furnish those exposed to it with information that will make them have a successful marriage in the future proposed research approaches to address the negative impact of divorce on children it is important that the government takes proactive measures to allocate funds for conducting an extensive study on the profound effects of divorce on childrens academic achievement this critical research is essential to overcome the current limitations of practical solutions available to educators who face an increasing need to provide effective support to children of divorced families because many families have experienced divorce it is imperative that our educational systems understand the unique challenges these families face upon securing funding it is imperative to prioritize teacher retraining so that they are equipped with valuable insights and practical tips for supporting children from divorced backgrounds to ensure that instructors are aware of the negative consequences divorce can have on children it is essential to provide them with practical ideas for creating classes that respond to their specific needs school boards should develop a rule mandating that each school or group of schools hire one or two instructors with the necessary training to facilitate this process to create and implement comprehensive programs to support children whose parents have divorced educators should engage with school counselors and social workers by encouraging a collaborative approach these programs can offer the essential direction and tools to ease the difficulties and worries faced by classroom instructors who interact with children from divorced families furthermore it is critical to acknowledge the inherent challenges classroom teachers encounter while trying to satisfy the requirements of all the students in the class while also giving children of divorced parents the particular attention they require the burden on classroom teachers can be significantly reduced by ensuring that schools have adequately trained teachers who can plan and implement schooland classroombased intervention programs these trained professionals can better address the specific needs of children from divorced backgrounds fostering an inclusive and supportive learning environment for all students furthermore it is advised that the parents of children going through a divorce work closely with social workers school counselors and trained instructors it has been established that partnerships and frequent contact between schools instructors and parents are essential for pupils to succeed to ensure that the childrens academic performance is prioritized even throughout the trying divorce transition the qualified teachers and other counselors would work with the parents to provide them with counseling techniques and programs they could continue participating in with their children finally we recommend that divorce education be incorporated into the school curriculum if the mindset of children and adolescents is changed about divorce through the intervention of specially trained teachersinstructors and school counselors they will grow up to appreciate the sanctity of marriage and strive to make their marriages work men will respect their wives at home and this will reduce the rate at which spouses abuse each other in the family limitations of the study while this study endeavors to provide comprehensive insights into the effects of divorce on childrens psychological and physiological wellbeing it recognizes several limitations that must be acknowledged firstly the scope of the literature reviewed may not encompass all existing research on the topic due to the vastness of the field consequently some relevant studies might not have been included which could influence the comprehensiveness of the findings presented secondly the study relies heavily on secondary data from previously published research while this methodology allows for an extensive overview of available literature it also means that the conclusions drawn are limited to the perspectives and data of those studies primary research such as direct interviews or surveys with affected children and their families would provide valuable firsthand accounts that are not included in this study additionally the crosssectional nature of most divorce research including that cited in this study does not allow for the observation of longterm effects over time longitudinal studies would be beneficial to understand the enduring consequences of divorce on childrens wellbeing the research also focuses predominantly on the negative impacts of divorce potentially overlooking any resilience or positive adaptation strategies that children might develop furthermore there may be a variation in the effects of divorce based on factors such as age socioeconomic status and cultural background which are not extensively explored in this study lastly the study acknowledges the potential for publication bias in the literature reviewed as studies with significant findings are more likely to be published than those with null or negative results this bias could skew the representation of the impact of divorce on children recognizing these limitations is crucial for interpreting the studys findings accurately and for guiding future research to build on the knowledge base with a more nuanced understanding of the effects of divorce on children conclusion the review of the current literature reveals a significant amount of research focused on understanding the psychological impacts of divorce on children these studies have shed light on the myriad ways in which divorce affects childrens mental health ranging from increased anxiety and depression to behavioral changes and academic challenges however there is a notable gap in research regarding effective intervention and prevention strategies while the adverse effects on childrens psychological and physiological wellbeing are welldocumented efforts to develop comprehensive programs that address these issues are comparatively limited this lack of focused research on interventions and preventive measures indicates a crucial area for future studies more indepth research is needed to explore and develop targeted strategies that can effectively support children and families navigating the complexities of divorce this could include the design and evaluation of counseling programs support groups and educational initiatives aimed at helping children cope with the emotional and psychological stress of parental separation furthermore there is a pressing need for studies that employ qualitative methods to gain deeper insights into the personal experiences and needs of children from divorced families such research could provide valuable information on the specific challenges these children face and the types of support that would be most beneficial to them additionally expanding the scope of research to include larger and more diverse samples is essential for a more comprehensive understanding of the varying impacts of divorce across different communities and cultural backgrounds when these gaps in the literature is addressed future research has the potential to significantly enhance our understanding of the effects of divorce on children this in turn would inform the development of more effective intervention and prevention programs ultimately aiding in mitigating the negative impacts of divorce and promoting the longterm wellbeing of affected children and their families competing interests authors have declared that no competing interests exist

this paper examines the multifaceted effects of divorce on children focusing on their psychological and physiological wellbeing it highlights the significant disruption divorce causes in family dynamics leading to profound changes in childrens emotional states behaviors and academic performance the paper notes a substantial body of research documenting the psychological consequences of divorce such as increased anxiety depression and behavioral issues however it identifies a notable gap in studies concentrating on intervention and prevention strategies additionally the physiological impacts of divorce such as health problems and developmental challenges are not as comprehensively studied the paper advocates for qualitative research to delve into the personal experiences of affected children and suggests expanding the scope of research to larger and more diverse population samples it highlights the need for developing comprehensive strategies to mitigate the adverse effects of divorce on children emphasizing a

Bisexual men are at increased risk for depression, anxiety, and problematic substance use compared to both heterosexual and gay men , and they are also at increased risk for HIV compared to heterosexual men . As such, there is a critical need to develop interventions to improve their health and wellbeing. Many interventions are labeled as being for "gay and bisexual men," but they are typically designed for gay men and few bisexual men are included in efficacy trials . In recent years, HIV prevention programs have been developed for behaviorally bisexual men , but these programs are not tailored to the unique needs of self-identified bisexual men. This parallels the general trend in research on bisexual men, most of which has focused on their sexual behavior more so than their identity . However, bisexual identity is highly stigmatized, especially among men , and bisexual individuals face discrimination from both heterosexual and gay/lesbian individuals . These stigmarelated experiences not only contribute to negative health outcomes , they also present barriers to accessing healthcare . Developing tailored interventions for self-identified bisexual men has the potential to improve their health while affirming their identities and preparing them to cope with stigma and discrimination. In order to inform the development of interventions for self-identified bisexual men, it is important to understand their preferences for different intervention components. This is consistent with the Institute of Medicine's recommendation for healthcare to be able to respond to individual preferences, which first requires assessing them. Previous research has found that most behaviorally bisexual men prefer individual interventions due to privacy concerns, but some prefer group interventions to meet other bisexual men . To our knowledge, no previous studies have examined intervention preferences among self-identified bisexual men, and there is reason to believe that their preferences may be different than those of behaviorally bisexual men. First, in samples of youth and adults, large proportions of self-identified bisexual men do not report bisexual behavior . As such, findings from previous studies that have focused on behaviorally bisexual men may not generalize to self-identified bisexual men who have not engaged in bisexual behavior. Second, it has been suggested that sexual identity is the dimension of sexual orientation that is most relevant to experiences of disadvantage and discrimination , and that the often public nature of sexual identity may contribute to being targeted for victimization . In fact, accumulating evidence suggests that being more open about one's bisexual identity is associated with increases in depression and substance use , highlighting the relevance of bisexual identity to health. Finally, there is some evidence that self-identified bisexual men differ from behaviorally bisexual men who do not self-identify as bisexual in important ways. Specifically, compared to behaviorally bisexual men who do not self-identify as bisexual, self-identified bisexual men are less likely to be married, less likely to have children, more likely to have ever had anal sex, and more likely to describe their sexual behavior as "predominately homosexual" . These findings suggest that self-identified bisexual men may be embedded in different social communities than behaviorally bisexual men who do not self-identify as bisexual, which may affect their access to and engagement with healthcare as well as their needs and preferences for interventions. Interventions may need to address different topics and be delivered in different formats to meet the unique needs of self-identified bisexual men. For example, given the invisibility of bisexuality , men who identify as bisexual may be particularly likely to prefer interventions that connect them to other bisexual men in the interest of building community. In sum, the lack of research on intervention preferences among self-identified bisexual men represents a critical barrier to developing tailored interventions to improve their health and wellbeing. To address this gap, we examined preferences for different intervention components in a subset of cisgender men who identified as bisexual who participated in a larger longitudinal cohort study. We focused exclusively on cisgender men because the broader cohort only included individuals who were assigned male at birth and, as such, there were no transgender men in the cohort. In addition to examining intervention preferences, we also examined their associations with stigma-related experiences, outness, and recent sexual behavior. --- Methods --- Participants and Procedures We used data from a subset of 128 cisgender men who identified as bisexual who participated in RADAR-a longitudinal cohort study examining influences on HIV and substance use among young men who have sex with men. In order to enroll in the broader cohort, participants were required to be 16-29 years old, assigned male at birth, Englishspeaking, and to report a sexual minority identity or sex with a man in the past year. The subset of participants included in the current analyses were required to identify as bisexual and male. Given that the broader cohort only included individuals who were assigned male at birth, there were no transgender men in the cohort. Cohort members completed a psychosocial survey, a network interview, and biomedical specimen collection every six months and were compensated $50. Data collection began in February 2015, but the intervention preference measure was added after data collection had begun; it was administered to all participants who identified as bisexual and male who completed a visit between December 2016 and June 2017. The current analyses used data from the study visit during which each participant completed the intervention preference measure. All procedures were approved by the Institutional Review Board. The analytic sample ranged in age from 18 to 32 years and was racially/ethnically diverse . Most participants were HIV-negative, whereas 15.6% were HIV-positive. --- Measures Intervention preferences.-Participants were asked four questions: "Which of the following topics are important to address to improve the health and wellbeing of bisexual men?" Response options included: mental health; drug/alcohol use; HIV/STI; coping with discrimination/victimization; dating/relationships; other . Participants could select multiple response options. "What type of program would you be most comfortable with?" Response options included: a program for bisexual men only; a program for gay and bisexual men together; I don't have a preference. "Would you want the program to be one-on-one or in a group?" Response options included: one-on-one; group; I don't have a preference. "Would you want the program to be online or in-person?" Response options included: online; in-person; I don't have a preference. Anti-bisexual discrimination.-The Anti-Bisexual Experiences Scale is a 17-item measure that is administered twice . It measures three types of anti-bisexual discrimination, including sexual orientation instability assumptions , sexual irresponsibility assumptions , and hostility . Items were rated on a scale of 1 to 6 and means were calculated for discrimination from heterosexual and gay/lesbian individuals . Internalized binegativity.-The 5-item internalized binegativity subscale from the Bisexual Identity Inventory measures a negative affective response to being bisexual . Items were rated on a scale of 1 to 7 and their mean was calculated . Outness.-Participants were asked, "How out are you to people around you?" Response options included: 0 = not out to anyone; 1 = only out to a few select people; 2 = out to most people; and 3 = out to everyone. Recent sexual behavior.-The HIV-Risk Assessment for Sexual Partnerships is a self-administered, computerized interview designed to assess sexual behavior and associated situational/contextual variables at the level of the sexual partnership. In the current study, participants reported on up to four sexual partnerships during the preceding six months. For analyses, a dichotomous variable was created to reflect whether or not participants reported vaginal or anal sex with any female partners in the preceding six months. --- Results First, we examined the proportion of participants who endorsed each intervention preference. Then, we used chi-square tests, independent-samples t-tests, and one-way analysis of variance tests to examine the associations between intervention preferences and stigma-related experiences , outness, and reports of recent female sexual partners. --- Topics. The largest proportions of participants endorsed mental health and HIV/STI as important to address, but the majority also endorsed dating/relationships , drug/alcohol use , and coping with discrimination/victimization . Six participants identified additional topics . Topic endorsement was not associated with discrimination, internalized binegativity, outness, or reports of recent female sexual partners. --- Target population. Results are presented in Table 1. Approximately one-quarter of participants preferred an intervention for gay and bisexual men together, 18.8% preferred an intervention for bisexual men only, and 53.9% did not have a preference. Participants who preferred an intervention for bisexual men only reported more discrimination from gay/lesbian individuals and more discrimination from gay/lesbian and heterosexual individuals . Participants who preferred an intervention for bisexual men only were also more likely to report recent female sexual partners compared to those who preferred an intervention for gay and bisexual men together. Similarly, participants who did not have a preference were also more likely to report recent female sexual partners compared to those who preferred an intervention for gay and bisexual men together. Target population preference was not associated with internalized binegativity or outness. --- Format. Results are presented in Table 2. Approximately one-third of participants preferred a group intervention, 21.1% preferred an individual intervention, and 42.2% did not have a preference. Format preference was not associated with discrimination, internalized binegativity, outness, or reports of recent female sexual partners. --- Delivery. Results are presented in Table 3. Approximately half of participants preferred an inperson intervention, 10.2% preferred an online intervention, and 34.4% did not have a preference. Participants who preferred an in-person intervention and participants who preferred an online intervention both reported more discrimination from heterosexual individuals compared to those who did not have a preference. Delivery preference was not associated with discrimination from gay/lesbian individuals, internalized binegativity, outness, or reports of recent sexual partners. --- Discussion The cisgender men who identified as bisexual in our study endorsed a range of topics as important to address in programs aimed at improving their health. Although mental health was most commonly endorsed, all of the topics were endorsed by the majority of participants. These findings highlight the need for interventions for self-identified bisexual men to address multiple health issues and to attend to psychosocial issues . The importance of attending to dating/relationships is consistent with efforts to integrate HIV prevention and relationship education for young male couples . Although interventions have been developed to address the impact of discrimination on sexual minorities' health , none have been developed to address the unique challenges facing self-identified bisexual men. Preferences for other intervention components varied. A slightly larger proportion of participants preferred an intervention for gay and bisexual together compared to an intervention for bisexual men only; these men may believe the health needs of gay and bisexual men are more similar than different. However, those who reported more discrimination, especially from gay/lesbian individuals, were more likely to prefer an intervention for bisexual men only. These men may recognize the unique challenges facing bisexual individuals and may not feel comfortable discussing their concerns with gay men. Participants who reported recent female sexual partners were also more likely to prefer an intervention for bisexual men only. Given that bisexual men are often blamed for transmitting HIV to women , those who have had recent female sexual partners may be particularly aware of the unique challenges facing bisexual men and, as such, interested in discussing their concerns with other bisexual men who may have had similar experiences. In contrast to research on behaviorally bisexual men , a larger proportion of participants preferred a group intervention compared to an individual intervention. Meeting other bisexual men and being part of a community that shares the same identity may be more important to selfidentified bisexual men than to behaviorally bisexual men . Self-identified bisexual men may also feel more comfortable participating in a group intervention with other bisexual men. Finally, participants reported a preference for an in-person intervention compared to an online intervention, which may also reflect the importance of being part of a community that shares the same identity. Participants who preferred an in-person intervention and participants who preferred an online intervention both reported more discrimination from heterosexual individuals compared to those who did not have a preference. We did not assess whether discrimination occurred in-person or online, but it is possible that those who experienced in-person discrimination preferred an online intervention, whereas those who experienced online discrimination preferred an in-person intervention. Of note, a sizeable proportion of participants did not report intervention preferences . Given the lack of interventions for self-identified bisexual men, they may simply be interested in an intervention tailored to their unique needs regardless of the format. The current findings should be considered in light of several limitations. First, given that all of our participants were cisgender men living in Chicago, it will be important to examine intervention preferences among transgender men and in different geographic regions. Transgender people are particularly likely to use labels that reflect attractions to more than one gender/sex , and transgender people who identify as bisexual or pansexual tend to face greater hardships than those who identify as gay, lesbian, or heterosexual . As such, transgender people who identify as bisexual or pansexual may have unique needs and preferences for interventions. Further, there is some evidence that the experiences of people who identify as bisexual differ from those of people who identify as pansexual, queer, or fluid. For example, Mitchell, Davis, and Galupo found that people who identified as bisexual reported experiencing more interpersonal hostility from gay/lesbian people and feeling less connected to the LGBT community than did people who identified as pansexual, queer, or fluid. For that reason, it will be important to examine intervention preferences among people who use labels other than bisexual to describe their attractions to more than one gender/sex. Of note, cisgender men are more likely to use the label bisexual to describe their attractions to more than one gender/sex than they are to use other labels , and cisgender men are less likely than cisgender women and gender minorities to identify as pansexual or queer . Therefore, it may be particularly important to consider the range of labels used to describe attractions to more than one gender/sex in samples of cisgender women and gender minorities. Additionally, preferences for different intervention components may depend on the focus of the intervention . Finally, we did not ask participants why they preferred different intervention components, which future qualitative research could address. Limitations aside, the current study is the first to examine self-identified bisexual men's intervention preferences and findings will help inform the development of tailored interventions to address their unique needs. In sum, interventions for self-identified bisexual men would benefit from addressing a range of health and psychosocial issues. While in-person and group interventions may appeal to larger proportions of self-identified bisexual men, the appeal of an intervention for gay and bisexual men together compared to an intervention for bisexual men only may depend on individual and social/contextual factors. Our findings also highlight the importance of attending to the needs of self-identified bisexual men as their intervention preferences differed from those of behaviorally bisexual men in prior research. As noted, there are no evidence-based interventions tailored to the unique needs of self-identified bisexual men. The lack of funding available for research focused on bisexual men's health presents a major barrier to developing such interventions. From 1989 through 2011, less than 1% of all studies funded by the National Institutes of Health focused on LGBT health and, of those, only 14.8% involved bisexual men . Additionally, while foundation funding for research on LGBT populations reached a record high in 2016, less than 1% specifically focused on bisexual individuals . The recently established NIH Sexual and Gender Minority Research Office has and will continue to play a critical role in advancing research on SGM health, but there is still a need for increased attention to the health disparities affecting bisexual men. Policy makers can also help to reduce these disparities by enacting laws and allocating funding dedicated to this population. Identity and minority stress as a function of preferred intervention format. Table 3. Identity and minority stress as a function of preferred intervention modality.

Self-identified bisexual men are at increased risk for negative health outcomes, but there are no interventions tailored to their unique needs. In order to develop interventions for this population, it is first necessary to understand their preferences. As part of a larger study, 128 cisgender men who identified as bisexual reported on their preferences for different intervention components. Large proportions of participants prioritized addressing both health (e.g., mental health, HIV/STI) and psychosocial experiences (e.g., dating/relationships, discrimination/victimization). A slightly larger proportion of participants preferred an intervention for gay and bisexual men together compared to an intervention for bisexual men only. However, those who reported more discrimination and recent female sexual partners were more likely to prefer an intervention for bisexual men only. Larger proportions of participants preferred a group intervention compared to an individual intervention and an in-person intervention compared to an online intervention. These findings highlight the importance of addressing both health and psychosocial experiences in tailored interventions for self-identified bisexual men. Further, while in-person and group interventions may appeal to larger proportions of self-identified bisexual men, the appeal of an intervention for gay and bisexual men together compared to an intervention for bisexual men only may depend on individual and social/contextual factors.

bisexual men are at increased risk for depression anxiety and problematic substance use compared to both heterosexual and gay men and they are also at increased risk for hiv compared to heterosexual men as such there is a critical need to develop interventions to improve their health and wellbeing many interventions are labeled as being for gay and bisexual men but they are typically designed for gay men and few bisexual men are included in efficacy trials in recent years hiv prevention programs have been developed for behaviorally bisexual men but these programs are not tailored to the unique needs of selfidentified bisexual men this parallels the general trend in research on bisexual men most of which has focused on their sexual behavior more so than their identity however bisexual identity is highly stigmatized especially among men and bisexual individuals face discrimination from both heterosexual and gaylesbian individuals these stigmarelated experiences not only contribute to negative health outcomes they also present barriers to accessing healthcare developing tailored interventions for selfidentified bisexual men has the potential to improve their health while affirming their identities and preparing them to cope with stigma and discrimination in order to inform the development of interventions for selfidentified bisexual men it is important to understand their preferences for different intervention components this is consistent with the institute of medicines recommendation for healthcare to be able to respond to individual preferences which first requires assessing them previous research has found that most behaviorally bisexual men prefer individual interventions due to privacy concerns but some prefer group interventions to meet other bisexual men to our knowledge no previous studies have examined intervention preferences among selfidentified bisexual men and there is reason to believe that their preferences may be different than those of behaviorally bisexual men first in samples of youth and adults large proportions of selfidentified bisexual men do not report bisexual behavior as such findings from previous studies that have focused on behaviorally bisexual men may not generalize to selfidentified bisexual men who have not engaged in bisexual behavior second it has been suggested that sexual identity is the dimension of sexual orientation that is most relevant to experiences of disadvantage and discrimination and that the often public nature of sexual identity may contribute to being targeted for victimization in fact accumulating evidence suggests that being more open about ones bisexual identity is associated with increases in depression and substance use highlighting the relevance of bisexual identity to health finally there is some evidence that selfidentified bisexual men differ from behaviorally bisexual men who do not selfidentify as bisexual in important ways specifically compared to behaviorally bisexual men who do not selfidentify as bisexual selfidentified bisexual men are less likely to be married less likely to have children more likely to have ever had anal sex and more likely to describe their sexual behavior as predominately homosexual these findings suggest that selfidentified bisexual men may be embedded in different social communities than behaviorally bisexual men who do not selfidentify as bisexual which may affect their access to and engagement with healthcare as well as their needs and preferences for interventions interventions may need to address different topics and be delivered in different formats to meet the unique needs of selfidentified bisexual men for example given the invisibility of bisexuality men who identify as bisexual may be particularly likely to prefer interventions that connect them to other bisexual men in the interest of building community in sum the lack of research on intervention preferences among selfidentified bisexual men represents a critical barrier to developing tailored interventions to improve their health and wellbeing to address this gap we examined preferences for different intervention components in a subset of cisgender men who identified as bisexual who participated in a larger longitudinal cohort study we focused exclusively on cisgender men because the broader cohort only included individuals who were assigned male at birth and as such there were no transgender men in the cohort in addition to examining intervention preferences we also examined their associations with stigmarelated experiences outness and recent sexual behavior methods participants and procedures we used data from a subset of 128 cisgender men who identified as bisexual who participated in radara longitudinal cohort study examining influences on hiv and substance use among young men who have sex with men in order to enroll in the broader cohort participants were required to be 1629 years old assigned male at birth englishspeaking and to report a sexual minority identity or sex with a man in the past year the subset of participants included in the current analyses were required to identify as bisexual and male given that the broader cohort only included individuals who were assigned male at birth there were no transgender men in the cohort cohort members completed a psychosocial survey a network interview and biomedical specimen collection every six months and were compensated 50 data collection began in february 2015 but the intervention preference measure was added after data collection had begun it was administered to all participants who identified as bisexual and male who completed a visit between december 2016 and june 2017 the current analyses used data from the study visit during which each participant completed the intervention preference measure all procedures were approved by the institutional review board the analytic sample ranged in age from 18 to 32 years and was raciallyethnically diverse most participants were hivnegative whereas 156 were hivpositive measures intervention preferencesparticipants were asked four questions which of the following topics are important to address to improve the health and wellbeing of bisexual men response options included mental health drugalcohol use hivsti coping with discriminationvictimization datingrelationships other participants could select multiple response options what type of program would you be most comfortable with response options included a program for bisexual men only a program for gay and bisexual men together i dont have a preference would you want the program to be oneonone or in a group response options included oneonone group i dont have a preference would you want the program to be online or inperson response options included online inperson i dont have a preference antibisexual discriminationthe antibisexual experiences scale is a 17item measure that is administered twice it measures three types of antibisexual discrimination including sexual orientation instability assumptions sexual irresponsibility assumptions and hostility items were rated on a scale of 1 to 6 and means were calculated for discrimination from heterosexual and gaylesbian individuals internalized binegativitythe 5item internalized binegativity subscale from the bisexual identity inventory measures a negative affective response to being bisexual items were rated on a scale of 1 to 7 and their mean was calculated outnessparticipants were asked how out are you to people around you response options included 0 not out to anyone 1 only out to a few select people 2 out to most people and 3 out to everyone recent sexual behaviorthe hivrisk assessment for sexual partnerships is a selfadministered computerized interview designed to assess sexual behavior and associated situationalcontextual variables at the level of the sexual partnership in the current study participants reported on up to four sexual partnerships during the preceding six months for analyses a dichotomous variable was created to reflect whether or not participants reported vaginal or anal sex with any female partners in the preceding six months results first we examined the proportion of participants who endorsed each intervention preference then we used chisquare tests independentsamples ttests and oneway analysis of variance tests to examine the associations between intervention preferences and stigmarelated experiences outness and reports of recent female sexual partners topics the largest proportions of participants endorsed mental health and hivsti as important to address but the majority also endorsed datingrelationships drugalcohol use and coping with discriminationvictimization six participants identified additional topics topic endorsement was not associated with discrimination internalized binegativity outness or reports of recent female sexual partners target population results are presented in table 1 approximately onequarter of participants preferred an intervention for gay and bisexual men together 188 preferred an intervention for bisexual men only and 539 did not have a preference participants who preferred an intervention for bisexual men only reported more discrimination from gaylesbian individuals and more discrimination from gaylesbian and heterosexual individuals participants who preferred an intervention for bisexual men only were also more likely to report recent female sexual partners compared to those who preferred an intervention for gay and bisexual men together similarly participants who did not have a preference were also more likely to report recent female sexual partners compared to those who preferred an intervention for gay and bisexual men together target population preference was not associated with internalized binegativity or outness format results are presented in table 2 approximately onethird of participants preferred a group intervention 211 preferred an individual intervention and 422 did not have a preference format preference was not associated with discrimination internalized binegativity outness or reports of recent female sexual partners delivery results are presented in table 3 approximately half of participants preferred an inperson intervention 102 preferred an online intervention and 344 did not have a preference participants who preferred an inperson intervention and participants who preferred an online intervention both reported more discrimination from heterosexual individuals compared to those who did not have a preference delivery preference was not associated with discrimination from gaylesbian individuals internalized binegativity outness or reports of recent sexual partners discussion the cisgender men who identified as bisexual in our study endorsed a range of topics as important to address in programs aimed at improving their health although mental health was most commonly endorsed all of the topics were endorsed by the majority of participants these findings highlight the need for interventions for selfidentified bisexual men to address multiple health issues and to attend to psychosocial issues the importance of attending to datingrelationships is consistent with efforts to integrate hiv prevention and relationship education for young male couples although interventions have been developed to address the impact of discrimination on sexual minorities health none have been developed to address the unique challenges facing selfidentified bisexual men preferences for other intervention components varied a slightly larger proportion of participants preferred an intervention for gay and bisexual together compared to an intervention for bisexual men only these men may believe the health needs of gay and bisexual men are more similar than different however those who reported more discrimination especially from gaylesbian individuals were more likely to prefer an intervention for bisexual men only these men may recognize the unique challenges facing bisexual individuals and may not feel comfortable discussing their concerns with gay men participants who reported recent female sexual partners were also more likely to prefer an intervention for bisexual men only given that bisexual men are often blamed for transmitting hiv to women those who have had recent female sexual partners may be particularly aware of the unique challenges facing bisexual men and as such interested in discussing their concerns with other bisexual men who may have had similar experiences in contrast to research on behaviorally bisexual men a larger proportion of participants preferred a group intervention compared to an individual intervention meeting other bisexual men and being part of a community that shares the same identity may be more important to selfidentified bisexual men than to behaviorally bisexual men selfidentified bisexual men may also feel more comfortable participating in a group intervention with other bisexual men finally participants reported a preference for an inperson intervention compared to an online intervention which may also reflect the importance of being part of a community that shares the same identity participants who preferred an inperson intervention and participants who preferred an online intervention both reported more discrimination from heterosexual individuals compared to those who did not have a preference we did not assess whether discrimination occurred inperson or online but it is possible that those who experienced inperson discrimination preferred an online intervention whereas those who experienced online discrimination preferred an inperson intervention of note a sizeable proportion of participants did not report intervention preferences given the lack of interventions for selfidentified bisexual men they may simply be interested in an intervention tailored to their unique needs regardless of the format the current findings should be considered in light of several limitations first given that all of our participants were cisgender men living in chicago it will be important to examine intervention preferences among transgender men and in different geographic regions transgender people are particularly likely to use labels that reflect attractions to more than one gendersex and transgender people who identify as bisexual or pansexual tend to face greater hardships than those who identify as gay lesbian or heterosexual as such transgender people who identify as bisexual or pansexual may have unique needs and preferences for interventions further there is some evidence that the experiences of people who identify as bisexual differ from those of people who identify as pansexual queer or fluid for example mitchell davis and galupo found that people who identified as bisexual reported experiencing more interpersonal hostility from gaylesbian people and feeling less connected to the lgbt community than did people who identified as pansexual queer or fluid for that reason it will be important to examine intervention preferences among people who use labels other than bisexual to describe their attractions to more than one gendersex of note cisgender men are more likely to use the label bisexual to describe their attractions to more than one gendersex than they are to use other labels and cisgender men are less likely than cisgender women and gender minorities to identify as pansexual or queer therefore it may be particularly important to consider the range of labels used to describe attractions to more than one gendersex in samples of cisgender women and gender minorities additionally preferences for different intervention components may depend on the focus of the intervention finally we did not ask participants why they preferred different intervention components which future qualitative research could address limitations aside the current study is the first to examine selfidentified bisexual mens intervention preferences and findings will help inform the development of tailored interventions to address their unique needs in sum interventions for selfidentified bisexual men would benefit from addressing a range of health and psychosocial issues while inperson and group interventions may appeal to larger proportions of selfidentified bisexual men the appeal of an intervention for gay and bisexual men together compared to an intervention for bisexual men only may depend on individual and socialcontextual factors our findings also highlight the importance of attending to the needs of selfidentified bisexual men as their intervention preferences differed from those of behaviorally bisexual men in prior research as noted there are no evidencebased interventions tailored to the unique needs of selfidentified bisexual men the lack of funding available for research focused on bisexual mens health presents a major barrier to developing such interventions from 1989 through 2011 less than 1 of all studies funded by the national institutes of health focused on lgbt health and of those only 148 involved bisexual men additionally while foundation funding for research on lgbt populations reached a record high in 2016 less than 1 specifically focused on bisexual individuals the recently established nih sexual and gender minority research office has and will continue to play a critical role in advancing research on sgm health but there is still a need for increased attention to the health disparities affecting bisexual men policy makers can also help to reduce these disparities by enacting laws and allocating funding dedicated to this population identity and minority stress as a function of preferred intervention format table 3 identity and minority stress as a function of preferred intervention modality

selfidentified bisexual men are at increased risk for negative health outcomes but there are no interventions tailored to their unique needs in order to develop interventions for this population it is first necessary to understand their preferences as part of a larger study 128 cisgender men who identified as bisexual reported on their preferences for different intervention components large proportions of participants prioritized addressing both health eg mental health hivsti and psychosocial experiences eg datingrelationships discriminationvictimization a slightly larger proportion of participants preferred an intervention for gay and bisexual men together compared to an intervention for bisexual men only however those who reported more discrimination and recent female sexual partners were more likely to prefer an intervention for bisexual men only larger proportions of participants preferred a group intervention compared to an individual intervention and an inperson intervention compared to an online intervention these findings highlight the importance of addressing both health and psychosocial experiences in tailored interventions for selfidentified bisexual men further while inperson and group interventions may appeal to larger proportions of selfidentified bisexual men the appeal of an intervention for gay and bisexual men together compared to an intervention for bisexual men only may depend on individual and socialcontextual factors

The Importance of Social Relationships During and After Widowhood Widowhood is generally viewed as one of the most stressful life events and has been associated with substantial declines in well-being of the bereaved spouse . An important finding from previous research is that widows and widowers continue to experience lower average levels of subjective well-being compared to their preloss levels many years after the death of the spouse . Indeed, widows and widowers report grieving for their spouse and experiencing distress when thinking about their spouse even decades after the death . However, past studies have also identified substantial individual differences in the extent to which people react and adapt to the experience of widowhood . Whereas some individuals' well-being is deeply affected by the death of spouse, others show remarkable resilience when faced with this difficult life transition. A critical goal of widowhood research is to identify individual-difference factors that might promote more successful adaptation in the face of this stressful event. One potential factor that may play a role is the extent to which people have strong and supportive social relationships in their lives. Social relationships and social support have long been associated with physical and psychological well-being . Indeed, the need for social relationships has been deemed to be one of the fundamental human needs . Close relationships are thought by most people to be a necessary ingredient for happiness and meaning . Past research has shown that people are happier when spending time with others than when alone , that people with larger social networks are happier than those with smaller networks, and that people who have more contact with friends and family are happier than those who have less contact . Thus, there is a consensus in the literature that the relationships we have with others have an important impact on our well-being. It is often argued that people with more social contact and greater social support are not only happier, but also more resilient to the effects of stress ). This reasoning would suggest that it is important to establish and maintain strong and supportive social networks because they could help ease difficult situations that people may face throughout their lives . It is reasonable to think that access to supportive social relationships may be especially important for coping with the stress of widowhood, since widowhood inherently entails loss of an important relationship. Supportive network members may provide social companionship to widows and widowers, they may help with household chores or provide financial assistance, as well as offer advice and understanding that may help cope with the stress of widowhood . Thus, social relationships appear to be an excellent candidate for explaining individual differences in reaction and adaptation to widowhood. --- Main Effect Models Versus Buffering Effects Although support from close others may be beneficial for a number of reasons, the primary issue that we address in the current studies concerns the extent to which these relationships serve as a protective buffer against stress . Buffering effects occur when the protective factor becomes particularly important during times of stress. Buffering can take place during the initial reactions to the stressful event or during adaptation to the event. Social contacts may provide security and resources necessary to moderate the initial appraisal of the event, attenuating or eliminating negative reactions to the stressor. In the long-term, social contacts may provide emotional or tangible resources that an individual needs to cope with the stressful event. In this case, a strong network of people who provide social support would enable individuals to adapt from the initially negative response to the stressful event . The buffering model can be contrasted with a simpler main-effects model of social support. Whereas buffering effects are inherently interactive, main effects of supportive others are constant over time and across situations. In other words, it may simply be that people with more support report higher levels of well-being regardless of the stressors to which they have been exposed. That is, any differences in well being between people with varying amounts of social support are equal before, during, and after the stressful event. In contrast to the main effects model, the buffering model predicts that supportive others provide a protective function primarily in the times of stress. It is also important to note that some types of evidence for interactive buffering effects can provide greater support for the causal priority of social support in the social support/wellbeing association. If only main effects exist, then it is difficult to determine whether social support plays a causal role in the association because it may simply be that those who have high levels of well-being seek out, attract, or even just perceive more support. If, on the other hand, pre-existing social support variables predict future changes in well-being after the experience of a major life event, then this would provide stronger support for the causal role of social support in determining well-being . --- Evidence Regarding the Buffering Effects of Social Relationships After --- Widowhood Despite the influence of the buffering model in literature, there is little agreement across studies that have evaluated this model in context of widowhood. Small sample sizes, lack of long-term prospective studies, and inconsistencies in analytic methods likely contribute to lack of coherence across studies. Most early studies were based on cross-sectional design that have evaluated interactions between marital status and social support in predicting wellbeing of married and widowed groups. Although these studies are limited in what they can tell us about change over time, they have suggested that the extent to which social support moderates the impact of widowhood on well-being may depend on how long a person has been widowed prior to participating the in the study. For example, Bankoff surveyed widows who had lost their spouse within previous three years and found no association between affect and the extent to which friends and family provided companionship and intimacy for recent widows, yet there was a modest relationship for women who were widowed for longer time periods. Similarly, Greene and Feld found buffering effects of social support on positive affect for women who had been widowed for longer than five years, but not for more recent widows. These studies suggest that timing of assessment matters for understanding the role that social relationships may have for widowed individuals. Longitudinal studies can evaluate the impact of social relationships on the experience of stress at different points of time, yet they have generally failed to take full advantage of the longitudinal nature of their data. Indeed, the most common method of analysis is to perform a number of regression analyses, predicting well-being at each wave from baseline wellbeing and social support. This leads to results that are difficult to interpret. For example, Dimond, Lund, and Caserta tested whether size of social network, perceived closeness with friends and family, or quality of interactions with supportive others predicted change in depression, coping, stress, and life satisfaction over the first 2 years of widowhood . They found that network size predicted better coping at 6 months and higher life satisfaction at 1 year , perceived closeness predicted higher life satisfaction after the first and second year of widowhood only, and quality of interaction predicted less depression at 8 weeks . The difficulty in making conclusions from these lies in the inconsistencies of findings across different waves. For instance, how do we interpret the finding that network size predicts change in life satisfaction 1 year, but not 6 months or 18 months into widowhood? Other studies have also arrived at mixed results. Ha found that receiving support from children 6 months after loss was associated with less depressive symptoms in the first, but not the second year of widowhood. Norris and Murrell found that structural support at 3 months post-loss buffered depression 9 months into widowhood. Similarly, a study by Okabayashi et al. assessed social contact after widowhood and found that it predicted short-term reactions to widowhood , but not more long-term effects of widowhood. Finally, two studies found no buffering effects of support in widowhood . Stroebe et al. found main effects, but no buffering, of perceived availability of support on loneliness. Similarly, Stroebe et al. assessed a group of women prior to widowhood, and also followed them during the first four years of widowhood. This study also included a group of married women at each wave to serve as controls. The authors found main effects perceived social support on depression, but no interactions of support and marital status at any wave. According to these results, people who report more support from their friends and families tend to be generally less depressed than people with less support regardless of stress, but social support does not buffer against the negative effects of widowhood. In addition to small samples sizes , and less than ideal analytic methods, existing studies are also limited in the conclusions they can reach about the role that support may play in widowhood because they generally only follow individuals for relatively short time periods after loss . These studies can give us insight about the buffering role of social support for immediate reactions to widowhood, but they are not informative about the long-term effects that support may have for widows and widowers. Longer studies are necessary for study of individual differences in adaptation to widowhood. --- The Present Study In this paper, we explore the importance of a variety of social relationship variables for wellbeing of individuals as they experience widowhood. The literature on social relationships is vast and the construct of social relationships multifaceted. Different aspects of social relationships may have different associations with well-being. In this paper we primarily focus on positive aspects of social support, and in particular we examine frequency of social contact, perceived access to supportive relationships, and perceived quality of relationships, all of which have been emphasized as important in the well-being literature ). In addition, arguments have been made about the distinction between measures of structural and perceived support and their role in stress buffering. Structural measures of support tend to assess size of social network and frequency of contact. Measures of perceived support generally assess perceptions that supportive others will be available in need. Cohen and Wills suggested that structural support measures should be associated with main effects, whereas measures of perceived support should also show buffering against stress. Our study provides an opportunity to evaluate these claims because we include different types of support measures. We use prospective longitudinal design with data from three large-sample nationally representative panel surveys, one from Germany, one from Great Britain, and one from Australia to examine the extent to which social support buffers the adverse effects of widowhood. Using this strategy, we can address two questions about the relation between social support and well-being in widowed individuals that are relevant to the buffering hypothesis. First, we can examine whether social support protects from immediate negative effects of widowhood by looking at the extent to which individuals' well-being levels change from their baselines around the time that they become widowed. Second, we can test whether social support helps individuals adapt to widowhood by comparing the extent to which individuals with different levels of support recover from the immediate negative effects of widowhood over longer periods of time. If social support facilitates adaptation to widowhood, we expect that individuals with more support would adapt better to loss of spouse over time. --- Method Samples We obtained data for the analyses from three large longitudinal studies that used scientific sampling methods to approximate nationally representative samples: the German Socio-Economic Panel Study , the British Household Panel Survey , and the Household, Income and Labour Dynamics in Australia Survey . Data for these studies are collected annually, starting in 1984 for the GSOEP, 1991 for the BHPS, and 2001 for the HILDA, with the latest waves available for our analyses occurring in 2009 for the GSOEP, 2008 for the BHPS, and 2010 for the HILDA. All three surveys used multistage random sampling technique to select their samples, by first randomly selecting various locations within a country, and then randomly selecting household within these locations. All members of the household were asked to participate if they were at least 16 years old in the GSOEP and the BHPS, and at least 15 years old in the HILDA. Average annual attrition rates in the three panel studies were relatively low: 6% in the GSOEP, 4% in the BHPS, and 7% in the HILDA. Additional subsamples were added over the years in the GSOEP and the BHPS in order to maintain size and representativeness of the samples. The majority of the data in the surveys were collected in face-to-face interviews, including the questions used in this study. One exception is that the questions about social support were included in the paper and pencil questionnaire in the HILDA. Additional information about sampling and data collection is provided by Haisken-DeNew and Frick for GSOEP, Taylor, Brice, Buck, and Prentice-Lane for BHPS, and Summerfield for HILDA. From each of these three datasets we selected a sample of individuals who were already married at the first wave in which life satisfaction ratings were obtained, became widowed at some point during the data collection, and did not remarry afterwards. In order to obtain a more accurate estimate of pre-loss life satisfaction and avoid confounding different types of spousal losses, we excluded from our sample any individuals who separated or divorced prior to becoming widowed. We further reduced our sample by including only individuals who provided life satisfaction data for at least one wave prior to widowhood and at least one wave afterwards, rated their social support at least once, and provided information about their gender and age. The final GSOEP sample included 1,195 individuals , who became widowed at an average age of 66.8 years of age . For BHPS, the final sample comprised 562 individuals , who were widowed at 71.0 years of age, on average . In the HILDA, the final sample consisted of 298 participants , who were widowed at an average age of 72.0 years . --- Life Satisfaction GSOEP-Each year, starting with the first wave of data collection, participants rated the degree to which they were satisfied with their life as a whole, on a scale from 0 to 10 . Previous research has shown that there is a GSOEPspecific trend for individual's life satisfaction scores to decrease by .03 points per year, irrespective of age or cohort . This apparent panel conditioning effect can be dealt with in various ways, including adjusting the scores before analysis or by adding a linear trend based on the length of time in the study at the time of the assessment. Both approaches result in similar estimates, but we decided to adjust individual scores in this dataset by adding .03 points to each person's life satisfaction for each year of involvement in the study. We chose this approach because the .03 estimate at which Baird et al. arrived is based on an analysis of the full GSOEP sample, including detailed comparisons of participants who entered the study in different years but who participated for the same length of time. If we relied solely on the inclusion of the linear trend variable, this additional information about the size of the panel conditioning effect would not be included in the estimate. BHPS-A single question that asked participants to rate how dissatisfied or satisfied they were with their life overall on a scale from 1 to 7 was introduced in 1996, and has been included in all subsequent years except in 2001. Thus our analyses included data from 12 waves of study, taken over 13 years . HILDA-All available waves of the HILDA dataset included a single item measure of life satisfaction. Participants were asked to answer the question "All things considered, how satisfied are you with your life?" on a scale that ranged from 0 to 10 . --- Social Support Measures of social support differed across studies. The measures included an assessment of wide range of relationships characteristics, including: frequency of social contact, availability of tangible and emotional support from the social network, and the perceived satisfaction with supportive social relationships. Our aim was to examine whether there are consistencies in the effects of the different types of variables that are available in the three datasets. Results that replicate across studies that use different measures of social support can give us confidence that the findings are not simply due to idiosyncrasies of any particular operationalization. Results that differ across measures might provide insight into the role that different types of support may play in adaptation . GSOEP-The measure of support that was available in the GSOEP focuses on social contact. The measure, which was included in 13 of the 26 waves, asked participants a single question about how often they engaged in social activities with friends, relatives, or neighbours. Participants indicated whether they did so once per week, once per month, less often, or never. This variable was reverse coded so that higher score represented more social contact. --- BHPS- The measure included in the BHPS tapped into availability of different types of support from the social network. Waves 1, 3, 5, 7, 13, 15, and 17 included five items that asked participants whether they had no one, one person, or more than one person who could fulfill specific relationship roles . The items were coded on a three-point scale . We used the mean of these items as a measure of social support at each wave . HILDA-The HILDA dataset included a measure of perceived satisfaction with supportive social relationships at each wave. The measure consisted of 10 items and asked people to report their level of agreement with each item on a 7-point scale . 1 We averaged these items at each wave to create wave-specific indices of social relationships . Baseline, reaction, and adaptation support-In all three datasets we created three social support indices that corresponded to three phases of widowhood experience described below. In particular, we averaged the scores across all waves prior to loss of spouse to create an index of baseline support, or support that has been garnered before onset of widowhood. We used support reported in the first year of widowhood as an index of social support during the reaction period. Finally, we averaged social support variables across all other years of widowhood to obtain an index of support during the adaptation period. --- Analytic Approach To model life satisfaction over time, from before spousal loss into widowhood, we fit a series of multilevel nonlinear models to each dataset using the lme4 package of the R Statistical Software . We created the nonlinear models to describe life satisfaction trajectories that are typically observed as people experience important life events . The nonlinear model, which is depicted in Figure 1, assumes that life satisfaction begins to change from its stable level in the years leading up to loss of spouse, reaches the lowest point in the year in which spouse died, and then changes again until it reaches a new stable level some years into widowhood. Thus, the model estimates five parameters at the within-person level: baseline level of life satisfaction prior to widowhood, total change from baseline in the year of loss , total change from year of loss in subsequent years , and rates of change before and after loss of spouse. Baseline, reaction, and adaptation parameters were also modelled as random effects. At the betweenperson level we included grand-mean-centered social support variables and age at widowhood, and effect-coded gender as moderators of baseline, reaction, and adaptation. 2 1 The items were: "People don't come to visit me as often as I would like," "I often need help from other people but can't get it," "I seem to have a lot of friends," "I don't have anyone I can confide in," "I have no one to lean on in times of trouble," "There is someone who can always cheer me up when I'm down," "I often feel very lonely," "I enjoy the time I spend with the people who are important to me," "When something's on my mind, just talking with the people I know can make me feel better," and "When I need someone to help me out, I can usually find someone." 2 We also tested whether the effects of social support differed across gender and age and found no consistent significant effects. Our results were virtually unchanged when social support × gender or social support × age interactions were included in the analyses. One issue with studying social relationships in context of widowhood is that the size and composition of one's social network is likely to change with onset of widowhood . Because of this, we used separate indices of social support at three distinct periods that are relevant to widowhood . Our approach was to fit three models, each testing the moderating effects of one of the three sources of support, to each of the three datasets. The first model included the average of support during the pre-loss years, which would ideally provide the best test of the buffering theory. With this model we could examine whether the support people garner prior to experiencing the stress of widowhood would protect them from immediate adverse effects of spousal loss or help them recover in the following years . However, baseline support that was assessed in all three studies likely included one's spouse. Although the question of whether good marital relationships may buffer against negative effects of widowhood is interesting, the crucial test of the buffering hypothesis concerns the supportive relationships that are still there after the spouse dies. For this purpose we also tested buffering of the supportive relationships that are around during the year in which the spouse died . Unlike baseline support, social support during the reaction period does not include one's spouse, but it still allows us to test the buffering theory prospectively. That is, we can test whether people who receive most support during this difficult time are able to recover from the initial negative stress of widowhood. In order to fully understand the relationship between different sources of support and change in life satisfaction following widowhood, we also tested the third model that included social support reported during the adaptation phase. This model allows us to test for association between recovery from widowhood and support received during this period, but is limited because the two variables are measured concurrently. Without the temporal precedence any causal interpretation of the association between the two variables becomes more ambiguous. A significant association between support and recovery during the adaptation period could be evidence for the buffering hypothesis, but could also simply reflect the tendency of those who are able to recover to attract or perceive more supportive relationships. --- Results To get a better sense of how different measures of social relationships compared across studies, we correlated each measure with important characteristics such as age, gender, selfreported health, and relationship satisfaction for all participants across the three studies. As Table 1 shows, correlations with gender were generally quite low across studies, with men scoring slightly lower on measures of social relationships than women. Social relationship measures were also negatively correlated with age and positively correlated with selfreported health and relationship satisfaction across the three studies. Descriptive statistics for measures of social relationships at three phases of widowhood are shown in Table 2. Next, we ran three models for each dataset; results for each model are presented in Table 3. 3 The first model included baseline social support as a moderator of baseline life satisfaction, reaction, and adaptation, which enabled us to test prospective effects of social support on reaction and adaptation to widowhood. Associations between this variable and baseline life satisfaction were consistent across studies -people who reported more support in the years preceding the death of their spouse were also those who were most satisfied during this period. This finding is in agreement with the vast literature that finds a positive relationship between social support and subjective well-being. The more important test of the buffering hypothesis comes from examining the association between baseline support and change during the reaction and adaptation periods. In Table 3, this can be seen as a moderating effect of social support for the reaction and adaptation parameters in columns labelled "Model 1". This association was not significant in any of the datasets. In fact, it was typically negative in sign, even though not significantly different from zero. The negative direction of this association may reflect the contribution of spouse to one's support network. That is, it is possible that people whose spouse provided important support would be the ones that are most affected by widowhood. We next tested a second model that included social support during the reaction period as a moderator of baseline life satisfaction, and the extent of reaction and adaptation to widowhood. An important advantage of using reaction-period social support is that it does not include one's spouse but it still enables us to examine prospective effects of support that is available during a difficult period on subsequent adaptation. That is, we can test whether support once receives during the most difficult time may help people bounce back from the initial adverse effects of widowhood. As can be seen in columns labelled "Model 2" in Table 3, the association between support during the reaction year and baseline life satisfaction was consistently positive, although it reached significance only in the HILDA. This positive association likely reflects the continuity of support, such that those who were receiving the most support prior to widowhood are also those who are receiving most support during the reaction period. Indeed, if both support during baseline and reaction periods are included in the model, this association is reduced to nearly zero in all three datasets. Importantly, we found no consistent moderating effects of support received in the year of loss on change in life satisfaction, either in year in which the spouse died or the years after. The positive association between support and change in the year of loss reached statistical significance in the HILDA but was negligible in the other two datasets. Our data provided no evidence that support received during the most difficult time helped people recover from the negative impact of widowhood. The third model examined the moderating effects of support during the adaptation phase on life satisfaction prior to widowhood and the extent of reaction and adaptation to widowhood. For support during adaptation, we found a positive association with baseline life satisfaction, again reflecting consistency in support received over time. People who were happiest at baseline likely had more support to begin with, and were also more likely to have more support later on in widowhood. We found no consistent association between support during the adaptation phase and the extent of life satisfaction change in the year of loss . On the other hand, association between support and change during the adaptation period was consistently positive, although it only reached statistical significance in the BHPS. Thus, people who reported more support in the years that followed widowhood also showed most adaptation to this difficult event in one of the three studies. However, as both support and life satisfaction in this case were measured concurrently, the causal direction of this relationship is more ambiguous. It may be the case that people who receive more support in widowhood are able to bounce back more. However, it is also possible that those who do adapt the most are the ones who can attract, maintain, or perceive more supportive social relationships. --- Discussion Past research has shown that subjective well-being can and does change following the experience of major life events. However, why some people are more deeply affected than others by such events is still unclear. In this paper, we evaluated the role that social relationships and social support play in adjustment to widowhood. Social support and social relationships are often described as some of the most important predictors of subjective well-being . In particular, social support has been hypothesized to have a protective buffering effect, such that those with more support fare better than those with less support when misfortune occurs. This interaction between individual level characteristics and external events could substantially alter individuals' set-points of wellbeing. However, limitations in previous work have made it difficult to separate true buffering effects from simpler main effects. Prospective longitudinal designs are required to accomplish this goal. The current studies addressed this question using three very large, prospective samples-and three very different types of social support measures-to examine the extent to which social support buffers against declines in life satisfaction that follow widowhood. Results were generally consistent across the datasets, and two main conclusions emerged. First, consistent with past research , we observed a positive association between ratings of social support before the loss of spouse and life satisfaction during this period. People who report having more support before widowhood also have higher levels of life satisfaction. This consistent association may reflect a broad and general positive influence of social support on well-being, or it may reflect a tendency for happy people to seek out, acquire, or simply perceive supportive social networks. More importantly, our prospective design allowed us to test whether social support that one acquires when times are good is ultimately protective when faced with a particularly stressful life event -widowhood. Such analyses help to clarify whether social support has a buffering effect, and they provide more support than a simple main-effect finding for the causal role of social relationships in well-being. Our analyses showed absolutely no evidence of these protective effects of pre-loss social support on either initial reaction or long-term adaptation to widowhood. In fact, the association between baseline support and reaction to widowhood tended to be negative, such that people who reported more support at baseline actually reacted more negatively to widowhood. This result was consistent across all three studies, even though different measures of social support and social relationships were used. This trend stands in contrast to predictions of both buffering and main effect hypotheses of the effects of social support on stress, and it seems quite counter-intuitive at first glance. However, the effects need to be interpreted in the context of the fact that those with stronger pre-loss relationships tend to be happier than those with weaker pre-loss relationships. Thus, it may simply be the case that ratings of pre-loss relationships reflects the extent to which one's life is going very well before the widowhood occurs . If so, then this would be consistent with previous findings showing that people who are the happiest at baseline are most affected by negative events . In other words, it may be that happy people have the most to lose when bad things happen. An alternative explanation of this counter-intuitive pattern is that ratings of pre-loss relationships may reflect the extent to which the person's spouse was an important part of her or his social network. In the BHPS and the HILDA, the spouse may have been the person who provided different aspects of support . In the GSOEP, the spouse may have been instrumental to the participant's social activity, spending time with friends and family. In this case, to the extent that social relationships are important for well-being, people who considered their spouse as an integral part of their social networks would be more negatively affected by the loss of their spouse and would have more difficulty adapting to such loss. Consistent with this explanation are findings that widowed individuals who report more emotional warmth and instrumental dependence in marriage have a more difficult time adjusting to widowhood , and that support from spouse during marriage predicts higher depression for the widowed individuals years after the loss . Ideally, to test the buffering hypothesis, the social support measure would not include one's spouse. Indeed, one drawback of using pre-existing data is that we have no control over the variables that are included in the surveys. However, because we had so much longitudinal data available, we were able to use reports of support available during the most difficult time -the year of spousal loss -and still use prospective design to test for buffering. In this case, we tested whether social support that is present during an especially stressful period can help widows and widowers recover from the initial impact of widowhood. Again, however, we found no evidence that this was the case in any of our datasets. In only one dataset the direction of the effect was consistent with the buffering hypothesis, but it did not reach significance. However, even this evidence is in contrast with the idea that only measures of perceived support would show buffering effects, as it is the HILDA measure that most closely corresponds with perceived support. Thus, across three large datasets with different measures of social support, we failed to find evidence of buffering effects of support on widowhood. We also found a consistent positive association between social support during the adaptation phase and adaptation to loss of spouse, although this association reached significance in only one dataset . In other words, those who reported developing more positive social relationships after the loss of their spouse coped especially well in widowhood. The finding that post-loss social relationships are associated with adaptation to widowhood is consistent with the meta-analysis of studies on the effects of social relationships on post-traumatic stress disorder . Ozer et al. found that lack of social support after the stressful event negatively predicted adaptation, and that this was especially important several years after the stressful event. It is important to note that although the pattern of associations with support during the adaptation phase is consistent with a buffering model, this pattern tells us less about the causal priority of the effects of social relationships than an effect of baseline support or support in the year of loss would have. These latter measures of support at least have temporal priority over the changes that occur during and after widowhood, but the same cannot be said about support that is reported after death of spouse. So although the pattern of associations with adaptation-period support is consistent with a buffering hypothesis, it is also possible that those who recovered quickly from the initial negative effect of widowhood were better able to return to a normal level of social activity or simply perceive better social relationships. This issue highlights the importance of prospective studies when testing for buffering against stress. --- Strengths and Limitations The complex pattern of association between widowhood, life satisfaction, and social support obtained in our data could not be easily gleaned without the use of prospective longitudinal design. For example, comparisons of married and widowed individuals in cross-sectional studies would likely yield different results depending on whether the data were collected within the first year of widowhood or in the subsequent years. Another advantage of using prospective designs is that it is not necessary to include a separate control group because each participant's well-being level during baseline or reaction periods is known and can be used as a comparison point for reaction and adaptation to widowhood. Alternative designs that use separate matched controls may inadvertently confound additional variables with experience of widowhood. For example, important differences may exist between people who become widowed and those who do not in health behaviours or personality . Another important strength of this study is that our data spanned long periods of time both before and after death of spouse. This allows us to more accurately estimate baseline levels of well-being, and also to distinguish between short-term reactions and long-term adaptation to widowhood so that we can test whether social support offers a buffer at each of these bereavement periods. This is one of the major differences between our study and the previous studies that examined the buffering effects of social support in widowhood. Since most other studies were restricted to the first two years of widowhood, they were essentially testing buffering effects on short-term reactions to the experience of loss. As we see in this study, such effects are likely to be small and unreliable, and perhaps more sensitive to a particular measure of social relationships. On the other hand, social support seems to be more consistently associated with adaptation to widowhood, although even these associations tend to be small and were not statistically significant in all datasets. In addition, our study demonstrated the importance of distinguishing between support available at different phases of bereavement. Previous studies have used either pre-or postloss relationships without prior rationale for the selection of one over the other. As our study shows, the timing of social support measurement matters. Pre-loss support can include the spouse and efforts should be taken to avoid this confound if support is measured at this time. Support available during the first year of widowhood also has different associations with adaptation than support measured later in widowhood. Although early support does not seem to help with recovery from spousal loss, later support tends to be positively associated with adaptation to this difficult event. Future research should focus on understanding the causal direction of this association in order to gain insight into the role that social support has for our well-being. One limitation of our study is that we were not able to select what types of measures about social relationships were included in the surveys. The GSOEP assessed the extent of social contact, the BHPS asked people about availability of different types of support, and the HILDA used a measure of satisfaction with the social relationships. Thus, each measure assessed slightly different aspects of social relationships. In the existing well-being literature, all aspects of relationships have been considered important for well-being, but these claims have never been tested in the context of buffering effects of relationships on widowhood. In the social support literature, distinction is often made between received and perceived support, with perceived support being more often associated with buffering against stress. In this study, our strategy was to compare the results obtained from different measures. The general consistency of the results across the three datasets is important because it suggests that our findings are not specific to a particular measure but are more broadly informative about the role that social relationships may have in coping with widowhood. At least three different aspects of relationships -frequency of social contact, perceived access to social support, and perceived relationship quality -appear to provide no buffering against widowhood. However, other components of social relationships or social support may show different effects on the association between widowhood and well-being. --- Take-Home Message Widowhood is a stressful life transition that a large percentage of the general population will eventually have to face. However, there are marked individual differences in how well people adapt to death of the spouse. In this study, we evaluated whether social relationships can account for differences in reaction and adaptation to this important event. Neither social relationships that had been established prior to the loss of the spouse nor those that were around in the year of loss had a protective effect on post-loss changes in well-being. However, we observed positive albeit not always significant associations between post-loss support and adaptation to widowhood. As social networks are likely to change after loss of a spouse, distinguishing between social networks garnered before and after widowhood may be particularly important in widowhood research. Future research should examine reasons for variation in ratings of social relationships in widowhood across individuals and their possible association with adaptation to widowhood. The within-person parameters of the nonlinear model. On the x-axis is time from onset of widowhood, in years. Year 0 is the year of spousal death. Model predicted life satisfaction trajectories at different levels of social support during baseline, reaction, and adaptation periods from the GSOEP , the BHPS , and the HILDA . Year 0 is the year of spousal death. Correlations between measures of social relationships and important outcomes across the three studies. Descriptive statistics for measures of social relationships at three phases of widowhood. Baseline period includes all years prior to widowhood, reaction period includes the year of spousal loss, and adaptation period includes all subsequent years. Unstandardized coefficients for the nonlinear models. Model 1 included social support during the baseline period. Model 2 included support during the reaction period . Model 3 included support during the adaptation period . Gender: -1 = female; 1 = male. Age and social support ratings were grand-mean-centered. --- Acknowledgments --- Author Note: The data used in this paper were made available by the German Institute of EconomicResearch,the UK Data Archive, and the Melbourne Institute of Applied Economics and Social Research. Preparation of this article was supported by a SSHRC Doctoral Fellowship awarded to Ivana Anusic and NIA grant AG032001 awarded to Richard E. Lucas.

Objective-The idea that strong social relationships can buffer the negative effects of stresson well-being has received much attention in existing literature. However, previous studies have used less than ideal research designs to test this hypothesis, making it difficult to draw firm conclusions regarding these buffering effects. In this study we examined the buffering hypothesis in the context of reaction and adaptation to widowhood in three large longitudinal datasets. Method-We tested whether social relationships moderated reaction and adaptation to widowhood in samples of people who experienced loss of spouse from three longitudinal datasets of nationally representative samples from Germany (N = 1,195), Britain (N = 562), and Australia (N = 298). Results-We found no evidence that social relationships established before widowhood buffered either reaction or adaptation to death of one's spouse. Similarly, social relationships that were in place during the first year of widowhood did not help widows and widowers recover from this difficult event.

the importance of social relationships during and after widowhood widowhood is generally viewed as one of the most stressful life events and has been associated with substantial declines in wellbeing of the bereaved spouse an important finding from previous research is that widows and widowers continue to experience lower average levels of subjective wellbeing compared to their preloss levels many years after the death of the spouse indeed widows and widowers report grieving for their spouse and experiencing distress when thinking about their spouse even decades after the death however past studies have also identified substantial individual differences in the extent to which people react and adapt to the experience of widowhood whereas some individuals wellbeing is deeply affected by the death of spouse others show remarkable resilience when faced with this difficult life transition a critical goal of widowhood research is to identify individualdifference factors that might promote more successful adaptation in the face of this stressful event one potential factor that may play a role is the extent to which people have strong and supportive social relationships in their lives social relationships and social support have long been associated with physical and psychological wellbeing indeed the need for social relationships has been deemed to be one of the fundamental human needs close relationships are thought by most people to be a necessary ingredient for happiness and meaning past research has shown that people are happier when spending time with others than when alone that people with larger social networks are happier than those with smaller networks and that people who have more contact with friends and family are happier than those who have less contact thus there is a consensus in the literature that the relationships we have with others have an important impact on our wellbeing it is often argued that people with more social contact and greater social support are not only happier but also more resilient to the effects of stress this reasoning would suggest that it is important to establish and maintain strong and supportive social networks because they could help ease difficult situations that people may face throughout their lives it is reasonable to think that access to supportive social relationships may be especially important for coping with the stress of widowhood since widowhood inherently entails loss of an important relationship supportive network members may provide social companionship to widows and widowers they may help with household chores or provide financial assistance as well as offer advice and understanding that may help cope with the stress of widowhood thus social relationships appear to be an excellent candidate for explaining individual differences in reaction and adaptation to widowhood main effect models versus buffering effects although support from close others may be beneficial for a number of reasons the primary issue that we address in the current studies concerns the extent to which these relationships serve as a protective buffer against stress buffering effects occur when the protective factor becomes particularly important during times of stress buffering can take place during the initial reactions to the stressful event or during adaptation to the event social contacts may provide security and resources necessary to moderate the initial appraisal of the event attenuating or eliminating negative reactions to the stressor in the longterm social contacts may provide emotional or tangible resources that an individual needs to cope with the stressful event in this case a strong network of people who provide social support would enable individuals to adapt from the initially negative response to the stressful event the buffering model can be contrasted with a simpler maineffects model of social support whereas buffering effects are inherently interactive main effects of supportive others are constant over time and across situations in other words it may simply be that people with more support report higher levels of wellbeing regardless of the stressors to which they have been exposed that is any differences in well being between people with varying amounts of social support are equal before during and after the stressful event in contrast to the main effects model the buffering model predicts that supportive others provide a protective function primarily in the times of stress it is also important to note that some types of evidence for interactive buffering effects can provide greater support for the causal priority of social support in the social supportwellbeing association if only main effects exist then it is difficult to determine whether social support plays a causal role in the association because it may simply be that those who have high levels of wellbeing seek out attract or even just perceive more support if on the other hand preexisting social support variables predict future changes in wellbeing after the experience of a major life event then this would provide stronger support for the causal role of social support in determining wellbeing evidence regarding the buffering effects of social relationships after widowhood despite the influence of the buffering model in literature there is little agreement across studies that have evaluated this model in context of widowhood small sample sizes lack of longterm prospective studies and inconsistencies in analytic methods likely contribute to lack of coherence across studies most early studies were based on crosssectional design that have evaluated interactions between marital status and social support in predicting wellbeing of married and widowed groups although these studies are limited in what they can tell us about change over time they have suggested that the extent to which social support moderates the impact of widowhood on wellbeing may depend on how long a person has been widowed prior to participating the in the study for example bankoff surveyed widows who had lost their spouse within previous three years and found no association between affect and the extent to which friends and family provided companionship and intimacy for recent widows yet there was a modest relationship for women who were widowed for longer time periods similarly greene and feld found buffering effects of social support on positive affect for women who had been widowed for longer than five years but not for more recent widows these studies suggest that timing of assessment matters for understanding the role that social relationships may have for widowed individuals longitudinal studies can evaluate the impact of social relationships on the experience of stress at different points of time yet they have generally failed to take full advantage of the longitudinal nature of their data indeed the most common method of analysis is to perform a number of regression analyses predicting wellbeing at each wave from baseline wellbeing and social support this leads to results that are difficult to interpret for example dimond lund and caserta tested whether size of social network perceived closeness with friends and family or quality of interactions with supportive others predicted change in depression coping stress and life satisfaction over the first 2 years of widowhood they found that network size predicted better coping at 6 months and higher life satisfaction at 1 year perceived closeness predicted higher life satisfaction after the first and second year of widowhood only and quality of interaction predicted less depression at 8 weeks the difficulty in making conclusions from these lies in the inconsistencies of findings across different waves for instance how do we interpret the finding that network size predicts change in life satisfaction 1 year but not 6 months or 18 months into widowhood other studies have also arrived at mixed results ha found that receiving support from children 6 months after loss was associated with less depressive symptoms in the first but not the second year of widowhood norris and murrell found that structural support at 3 months postloss buffered depression 9 months into widowhood similarly a study by okabayashi et al assessed social contact after widowhood and found that it predicted shortterm reactions to widowhood but not more longterm effects of widowhood finally two studies found no buffering effects of support in widowhood stroebe et al found main effects but no buffering of perceived availability of support on loneliness similarly stroebe et al assessed a group of women prior to widowhood and also followed them during the first four years of widowhood this study also included a group of married women at each wave to serve as controls the authors found main effects perceived social support on depression but no interactions of support and marital status at any wave according to these results people who report more support from their friends and families tend to be generally less depressed than people with less support regardless of stress but social support does not buffer against the negative effects of widowhood in addition to small samples sizes and less than ideal analytic methods existing studies are also limited in the conclusions they can reach about the role that support may play in widowhood because they generally only follow individuals for relatively short time periods after loss these studies can give us insight about the buffering role of social support for immediate reactions to widowhood but they are not informative about the longterm effects that support may have for widows and widowers longer studies are necessary for study of individual differences in adaptation to widowhood the present study in this paper we explore the importance of a variety of social relationship variables for wellbeing of individuals as they experience widowhood the literature on social relationships is vast and the construct of social relationships multifaceted different aspects of social relationships may have different associations with wellbeing in this paper we primarily focus on positive aspects of social support and in particular we examine frequency of social contact perceived access to supportive relationships and perceived quality of relationships all of which have been emphasized as important in the wellbeing literature in addition arguments have been made about the distinction between measures of structural and perceived support and their role in stress buffering structural measures of support tend to assess size of social network and frequency of contact measures of perceived support generally assess perceptions that supportive others will be available in need cohen and wills suggested that structural support measures should be associated with main effects whereas measures of perceived support should also show buffering against stress our study provides an opportunity to evaluate these claims because we include different types of support measures we use prospective longitudinal design with data from three largesample nationally representative panel surveys one from germany one from great britain and one from australia to examine the extent to which social support buffers the adverse effects of widowhood using this strategy we can address two questions about the relation between social support and wellbeing in widowed individuals that are relevant to the buffering hypothesis first we can examine whether social support protects from immediate negative effects of widowhood by looking at the extent to which individuals wellbeing levels change from their baselines around the time that they become widowed second we can test whether social support helps individuals adapt to widowhood by comparing the extent to which individuals with different levels of support recover from the immediate negative effects of widowhood over longer periods of time if social support facilitates adaptation to widowhood we expect that individuals with more support would adapt better to loss of spouse over time method samples we obtained data for the analyses from three large longitudinal studies that used scientific sampling methods to approximate nationally representative samples the german socioeconomic panel study the british household panel survey and the household income and labour dynamics in australia survey data for these studies are collected annually starting in 1984 for the gsoep 1991 for the bhps and 2001 for the hilda with the latest waves available for our analyses occurring in 2009 for the gsoep 2008 for the bhps and 2010 for the hilda all three surveys used multistage random sampling technique to select their samples by first randomly selecting various locations within a country and then randomly selecting household within these locations all members of the household were asked to participate if they were at least 16 years old in the gsoep and the bhps and at least 15 years old in the hilda average annual attrition rates in the three panel studies were relatively low 6 in the gsoep 4 in the bhps and 7 in the hilda additional subsamples were added over the years in the gsoep and the bhps in order to maintain size and representativeness of the samples the majority of the data in the surveys were collected in facetoface interviews including the questions used in this study one exception is that the questions about social support were included in the paper and pencil questionnaire in the hilda additional information about sampling and data collection is provided by haiskendenew and frick for gsoep taylor brice buck and prenticelane for bhps and summerfield for hilda from each of these three datasets we selected a sample of individuals who were already married at the first wave in which life satisfaction ratings were obtained became widowed at some point during the data collection and did not remarry afterwards in order to obtain a more accurate estimate of preloss life satisfaction and avoid confounding different types of spousal losses we excluded from our sample any individuals who separated or divorced prior to becoming widowed we further reduced our sample by including only individuals who provided life satisfaction data for at least one wave prior to widowhood and at least one wave afterwards rated their social support at least once and provided information about their gender and age the final gsoep sample included 1195 individuals who became widowed at an average age of 668 years of age for bhps the final sample comprised 562 individuals who were widowed at 710 years of age on average in the hilda the final sample consisted of 298 participants who were widowed at an average age of 720 years life satisfaction gsoepeach year starting with the first wave of data collection participants rated the degree to which they were satisfied with their life as a whole on a scale from 0 to 10 previous research has shown that there is a gsoepspecific trend for individuals life satisfaction scores to decrease by 03 points per year irrespective of age or cohort this apparent panel conditioning effect can be dealt with in various ways including adjusting the scores before analysis or by adding a linear trend based on the length of time in the study at the time of the assessment both approaches result in similar estimates but we decided to adjust individual scores in this dataset by adding 03 points to each persons life satisfaction for each year of involvement in the study we chose this approach because the 03 estimate at which baird et al arrived is based on an analysis of the full gsoep sample including detailed comparisons of participants who entered the study in different years but who participated for the same length of time if we relied solely on the inclusion of the linear trend variable this additional information about the size of the panel conditioning effect would not be included in the estimate bhpsa single question that asked participants to rate how dissatisfied or satisfied they were with their life overall on a scale from 1 to 7 was introduced in 1996 and has been included in all subsequent years except in 2001 thus our analyses included data from 12 waves of study taken over 13 years hildaall available waves of the hilda dataset included a single item measure of life satisfaction participants were asked to answer the question all things considered how satisfied are you with your life on a scale that ranged from 0 to 10 social support measures of social support differed across studies the measures included an assessment of wide range of relationships characteristics including frequency of social contact availability of tangible and emotional support from the social network and the perceived satisfaction with supportive social relationships our aim was to examine whether there are consistencies in the effects of the different types of variables that are available in the three datasets results that replicate across studies that use different measures of social support can give us confidence that the findings are not simply due to idiosyncrasies of any particular operationalization results that differ across measures might provide insight into the role that different types of support may play in adaptation gsoepthe measure of support that was available in the gsoep focuses on social contact the measure which was included in 13 of the 26 waves asked participants a single question about how often they engaged in social activities with friends relatives or neighbours participants indicated whether they did so once per week once per month less often or never this variable was reverse coded so that higher score represented more social contact bhps the measure included in the bhps tapped into availability of different types of support from the social network waves 1 3 5 7 13 15 and 17 included five items that asked participants whether they had no one one person or more than one person who could fulfill specific relationship roles the items were coded on a threepoint scale we used the mean of these items as a measure of social support at each wave hildathe hilda dataset included a measure of perceived satisfaction with supportive social relationships at each wave the measure consisted of 10 items and asked people to report their level of agreement with each item on a 7point scale 1 we averaged these items at each wave to create wavespecific indices of social relationships baseline reaction and adaptation supportin all three datasets we created three social support indices that corresponded to three phases of widowhood experience described below in particular we averaged the scores across all waves prior to loss of spouse to create an index of baseline support or support that has been garnered before onset of widowhood we used support reported in the first year of widowhood as an index of social support during the reaction period finally we averaged social support variables across all other years of widowhood to obtain an index of support during the adaptation period analytic approach to model life satisfaction over time from before spousal loss into widowhood we fit a series of multilevel nonlinear models to each dataset using the lme4 package of the r statistical software we created the nonlinear models to describe life satisfaction trajectories that are typically observed as people experience important life events the nonlinear model which is depicted in figure 1 assumes that life satisfaction begins to change from its stable level in the years leading up to loss of spouse reaches the lowest point in the year in which spouse died and then changes again until it reaches a new stable level some years into widowhood thus the model estimates five parameters at the withinperson level baseline level of life satisfaction prior to widowhood total change from baseline in the year of loss total change from year of loss in subsequent years and rates of change before and after loss of spouse baseline reaction and adaptation parameters were also modelled as random effects at the betweenperson level we included grandmeancentered social support variables and age at widowhood and effectcoded gender as moderators of baseline reaction and adaptation 2 1 the items were people dont come to visit me as often as i would like i often need help from other people but cant get it i seem to have a lot of friends i dont have anyone i can confide in i have no one to lean on in times of trouble there is someone who can always cheer me up when im down i often feel very lonely i enjoy the time i spend with the people who are important to me when somethings on my mind just talking with the people i know can make me feel better and when i need someone to help me out i can usually find someone 2 we also tested whether the effects of social support differed across gender and age and found no consistent significant effects our results were virtually unchanged when social support × gender or social support × age interactions were included in the analyses one issue with studying social relationships in context of widowhood is that the size and composition of ones social network is likely to change with onset of widowhood because of this we used separate indices of social support at three distinct periods that are relevant to widowhood our approach was to fit three models each testing the moderating effects of one of the three sources of support to each of the three datasets the first model included the average of support during the preloss years which would ideally provide the best test of the buffering theory with this model we could examine whether the support people garner prior to experiencing the stress of widowhood would protect them from immediate adverse effects of spousal loss or help them recover in the following years however baseline support that was assessed in all three studies likely included ones spouse although the question of whether good marital relationships may buffer against negative effects of widowhood is interesting the crucial test of the buffering hypothesis concerns the supportive relationships that are still there after the spouse dies for this purpose we also tested buffering of the supportive relationships that are around during the year in which the spouse died unlike baseline support social support during the reaction period does not include ones spouse but it still allows us to test the buffering theory prospectively that is we can test whether people who receive most support during this difficult time are able to recover from the initial negative stress of widowhood in order to fully understand the relationship between different sources of support and change in life satisfaction following widowhood we also tested the third model that included social support reported during the adaptation phase this model allows us to test for association between recovery from widowhood and support received during this period but is limited because the two variables are measured concurrently without the temporal precedence any causal interpretation of the association between the two variables becomes more ambiguous a significant association between support and recovery during the adaptation period could be evidence for the buffering hypothesis but could also simply reflect the tendency of those who are able to recover to attract or perceive more supportive relationships results to get a better sense of how different measures of social relationships compared across studies we correlated each measure with important characteristics such as age gender selfreported health and relationship satisfaction for all participants across the three studies as table 1 shows correlations with gender were generally quite low across studies with men scoring slightly lower on measures of social relationships than women social relationship measures were also negatively correlated with age and positively correlated with selfreported health and relationship satisfaction across the three studies descriptive statistics for measures of social relationships at three phases of widowhood are shown in table 2 next we ran three models for each dataset results for each model are presented in table 3 3 the first model included baseline social support as a moderator of baseline life satisfaction reaction and adaptation which enabled us to test prospective effects of social support on reaction and adaptation to widowhood associations between this variable and baseline life satisfaction were consistent across studies people who reported more support in the years preceding the death of their spouse were also those who were most satisfied during this period this finding is in agreement with the vast literature that finds a positive relationship between social support and subjective wellbeing the more important test of the buffering hypothesis comes from examining the association between baseline support and change during the reaction and adaptation periods in table 3 this can be seen as a moderating effect of social support for the reaction and adaptation parameters in columns labelled model 1 this association was not significant in any of the datasets in fact it was typically negative in sign even though not significantly different from zero the negative direction of this association may reflect the contribution of spouse to ones support network that is it is possible that people whose spouse provided important support would be the ones that are most affected by widowhood we next tested a second model that included social support during the reaction period as a moderator of baseline life satisfaction and the extent of reaction and adaptation to widowhood an important advantage of using reactionperiod social support is that it does not include ones spouse but it still enables us to examine prospective effects of support that is available during a difficult period on subsequent adaptation that is we can test whether support once receives during the most difficult time may help people bounce back from the initial adverse effects of widowhood as can be seen in columns labelled model 2 in table 3 the association between support during the reaction year and baseline life satisfaction was consistently positive although it reached significance only in the hilda this positive association likely reflects the continuity of support such that those who were receiving the most support prior to widowhood are also those who are receiving most support during the reaction period indeed if both support during baseline and reaction periods are included in the model this association is reduced to nearly zero in all three datasets importantly we found no consistent moderating effects of support received in the year of loss on change in life satisfaction either in year in which the spouse died or the years after the positive association between support and change in the year of loss reached statistical significance in the hilda but was negligible in the other two datasets our data provided no evidence that support received during the most difficult time helped people recover from the negative impact of widowhood the third model examined the moderating effects of support during the adaptation phase on life satisfaction prior to widowhood and the extent of reaction and adaptation to widowhood for support during adaptation we found a positive association with baseline life satisfaction again reflecting consistency in support received over time people who were happiest at baseline likely had more support to begin with and were also more likely to have more support later on in widowhood we found no consistent association between support during the adaptation phase and the extent of life satisfaction change in the year of loss on the other hand association between support and change during the adaptation period was consistently positive although it only reached statistical significance in the bhps thus people who reported more support in the years that followed widowhood also showed most adaptation to this difficult event in one of the three studies however as both support and life satisfaction in this case were measured concurrently the causal direction of this relationship is more ambiguous it may be the case that people who receive more support in widowhood are able to bounce back more however it is also possible that those who do adapt the most are the ones who can attract maintain or perceive more supportive social relationships discussion past research has shown that subjective wellbeing can and does change following the experience of major life events however why some people are more deeply affected than others by such events is still unclear in this paper we evaluated the role that social relationships and social support play in adjustment to widowhood social support and social relationships are often described as some of the most important predictors of subjective wellbeing in particular social support has been hypothesized to have a protective buffering effect such that those with more support fare better than those with less support when misfortune occurs this interaction between individual level characteristics and external events could substantially alter individuals setpoints of wellbeing however limitations in previous work have made it difficult to separate true buffering effects from simpler main effects prospective longitudinal designs are required to accomplish this goal the current studies addressed this question using three very large prospective samplesand three very different types of social support measuresto examine the extent to which social support buffers against declines in life satisfaction that follow widowhood results were generally consistent across the datasets and two main conclusions emerged first consistent with past research we observed a positive association between ratings of social support before the loss of spouse and life satisfaction during this period people who report having more support before widowhood also have higher levels of life satisfaction this consistent association may reflect a broad and general positive influence of social support on wellbeing or it may reflect a tendency for happy people to seek out acquire or simply perceive supportive social networks more importantly our prospective design allowed us to test whether social support that one acquires when times are good is ultimately protective when faced with a particularly stressful life event widowhood such analyses help to clarify whether social support has a buffering effect and they provide more support than a simple maineffect finding for the causal role of social relationships in wellbeing our analyses showed absolutely no evidence of these protective effects of preloss social support on either initial reaction or longterm adaptation to widowhood in fact the association between baseline support and reaction to widowhood tended to be negative such that people who reported more support at baseline actually reacted more negatively to widowhood this result was consistent across all three studies even though different measures of social support and social relationships were used this trend stands in contrast to predictions of both buffering and main effect hypotheses of the effects of social support on stress and it seems quite counterintuitive at first glance however the effects need to be interpreted in the context of the fact that those with stronger preloss relationships tend to be happier than those with weaker preloss relationships thus it may simply be the case that ratings of preloss relationships reflects the extent to which ones life is going very well before the widowhood occurs if so then this would be consistent with previous findings showing that people who are the happiest at baseline are most affected by negative events in other words it may be that happy people have the most to lose when bad things happen an alternative explanation of this counterintuitive pattern is that ratings of preloss relationships may reflect the extent to which the persons spouse was an important part of her or his social network in the bhps and the hilda the spouse may have been the person who provided different aspects of support in the gsoep the spouse may have been instrumental to the participants social activity spending time with friends and family in this case to the extent that social relationships are important for wellbeing people who considered their spouse as an integral part of their social networks would be more negatively affected by the loss of their spouse and would have more difficulty adapting to such loss consistent with this explanation are findings that widowed individuals who report more emotional warmth and instrumental dependence in marriage have a more difficult time adjusting to widowhood and that support from spouse during marriage predicts higher depression for the widowed individuals years after the loss ideally to test the buffering hypothesis the social support measure would not include ones spouse indeed one drawback of using preexisting data is that we have no control over the variables that are included in the surveys however because we had so much longitudinal data available we were able to use reports of support available during the most difficult time the year of spousal loss and still use prospective design to test for buffering in this case we tested whether social support that is present during an especially stressful period can help widows and widowers recover from the initial impact of widowhood again however we found no evidence that this was the case in any of our datasets in only one dataset the direction of the effect was consistent with the buffering hypothesis but it did not reach significance however even this evidence is in contrast with the idea that only measures of perceived support would show buffering effects as it is the hilda measure that most closely corresponds with perceived support thus across three large datasets with different measures of social support we failed to find evidence of buffering effects of support on widowhood we also found a consistent positive association between social support during the adaptation phase and adaptation to loss of spouse although this association reached significance in only one dataset in other words those who reported developing more positive social relationships after the loss of their spouse coped especially well in widowhood the finding that postloss social relationships are associated with adaptation to widowhood is consistent with the metaanalysis of studies on the effects of social relationships on posttraumatic stress disorder ozer et al found that lack of social support after the stressful event negatively predicted adaptation and that this was especially important several years after the stressful event it is important to note that although the pattern of associations with support during the adaptation phase is consistent with a buffering model this pattern tells us less about the causal priority of the effects of social relationships than an effect of baseline support or support in the year of loss would have these latter measures of support at least have temporal priority over the changes that occur during and after widowhood but the same cannot be said about support that is reported after death of spouse so although the pattern of associations with adaptationperiod support is consistent with a buffering hypothesis it is also possible that those who recovered quickly from the initial negative effect of widowhood were better able to return to a normal level of social activity or simply perceive better social relationships this issue highlights the importance of prospective studies when testing for buffering against stress strengths and limitations the complex pattern of association between widowhood life satisfaction and social support obtained in our data could not be easily gleaned without the use of prospective longitudinal design for example comparisons of married and widowed individuals in crosssectional studies would likely yield different results depending on whether the data were collected within the first year of widowhood or in the subsequent years another advantage of using prospective designs is that it is not necessary to include a separate control group because each participants wellbeing level during baseline or reaction periods is known and can be used as a comparison point for reaction and adaptation to widowhood alternative designs that use separate matched controls may inadvertently confound additional variables with experience of widowhood for example important differences may exist between people who become widowed and those who do not in health behaviours or personality another important strength of this study is that our data spanned long periods of time both before and after death of spouse this allows us to more accurately estimate baseline levels of wellbeing and also to distinguish between shortterm reactions and longterm adaptation to widowhood so that we can test whether social support offers a buffer at each of these bereavement periods this is one of the major differences between our study and the previous studies that examined the buffering effects of social support in widowhood since most other studies were restricted to the first two years of widowhood they were essentially testing buffering effects on shortterm reactions to the experience of loss as we see in this study such effects are likely to be small and unreliable and perhaps more sensitive to a particular measure of social relationships on the other hand social support seems to be more consistently associated with adaptation to widowhood although even these associations tend to be small and were not statistically significant in all datasets in addition our study demonstrated the importance of distinguishing between support available at different phases of bereavement previous studies have used either preor postloss relationships without prior rationale for the selection of one over the other as our study shows the timing of social support measurement matters preloss support can include the spouse and efforts should be taken to avoid this confound if support is measured at this time support available during the first year of widowhood also has different associations with adaptation than support measured later in widowhood although early support does not seem to help with recovery from spousal loss later support tends to be positively associated with adaptation to this difficult event future research should focus on understanding the causal direction of this association in order to gain insight into the role that social support has for our wellbeing one limitation of our study is that we were not able to select what types of measures about social relationships were included in the surveys the gsoep assessed the extent of social contact the bhps asked people about availability of different types of support and the hilda used a measure of satisfaction with the social relationships thus each measure assessed slightly different aspects of social relationships in the existing wellbeing literature all aspects of relationships have been considered important for wellbeing but these claims have never been tested in the context of buffering effects of relationships on widowhood in the social support literature distinction is often made between received and perceived support with perceived support being more often associated with buffering against stress in this study our strategy was to compare the results obtained from different measures the general consistency of the results across the three datasets is important because it suggests that our findings are not specific to a particular measure but are more broadly informative about the role that social relationships may have in coping with widowhood at least three different aspects of relationships frequency of social contact perceived access to social support and perceived relationship quality appear to provide no buffering against widowhood however other components of social relationships or social support may show different effects on the association between widowhood and wellbeing takehome message widowhood is a stressful life transition that a large percentage of the general population will eventually have to face however there are marked individual differences in how well people adapt to death of the spouse in this study we evaluated whether social relationships can account for differences in reaction and adaptation to this important event neither social relationships that had been established prior to the loss of the spouse nor those that were around in the year of loss had a protective effect on postloss changes in wellbeing however we observed positive albeit not always significant associations between postloss support and adaptation to widowhood as social networks are likely to change after loss of a spouse distinguishing between social networks garnered before and after widowhood may be particularly important in widowhood research future research should examine reasons for variation in ratings of social relationships in widowhood across individuals and their possible association with adaptation to widowhood the withinperson parameters of the nonlinear model on the xaxis is time from onset of widowhood in years year 0 is the year of spousal death model predicted life satisfaction trajectories at different levels of social support during baseline reaction and adaptation periods from the gsoep the bhps and the hilda year 0 is the year of spousal death correlations between measures of social relationships and important outcomes across the three studies descriptive statistics for measures of social relationships at three phases of widowhood baseline period includes all years prior to widowhood reaction period includes the year of spousal loss and adaptation period includes all subsequent years unstandardized coefficients for the nonlinear models model 1 included social support during the baseline period model 2 included support during the reaction period model 3 included support during the adaptation period gender 1 female 1 male age and social support ratings were grandmeancentered acknowledgments author note the data used in this paper were made available by the german institute of economicresearchthe uk data archive and the melbourne institute of applied economics and social research preparation of this article was supported by a sshrc doctoral fellowship awarded to ivana anusic and nia grant ag032001 awarded to richard e lucas

objectivethe idea that strong social relationships can buffer the negative effects of stresson wellbeing has received much attention in existing literature however previous studies have used less than ideal research designs to test this hypothesis making it difficult to draw firm conclusions regarding these buffering effects in this study we examined the buffering hypothesis in the context of reaction and adaptation to widowhood in three large longitudinal datasets methodwe tested whether social relationships moderated reaction and adaptation to widowhood in samples of people who experienced loss of spouse from three longitudinal datasets of nationally representative samples from germany n 1195 britain n 562 and australia n 298 resultswe found no evidence that social relationships established before widowhood buffered either reaction or adaptation to death of ones spouse similarly social relationships that were in place during the first year of widowhood did not help widows and widowers recover from this difficult event

Family doctors practice at the crossroads of medicine and the social determinants of health. Our focus is not on an illness but on a person. We need to hear the stories of our patients' lives so that we can provide patient-centered care. We care about issues such as empowerment and education, compassion and a safe place for our patients to call home. We are advocates -a challenging role for most physicians. 1 As a medical educator, I must find ways of teaching advocacy and, hopefully, motivating learners to put it into practice, wherever they may be. In April 2016, I took my family to Nepal to establish some working relationships and, hopefully, gain some perspective for my teaching. My most memorable encounter on this trip was with Indira Ghale, an independent woman who does not live a traditional Nepali life. A colleague told me about this woman, who rescues girls from abusive situations in rural villages and from human trafficking in Kathmandu, so I gratefully accepted a dinner invitation and soon we were warmly welcomed into her home. Indira says it all began with her own mother, "When I look back on my mother's life, she got married at the age of fifteen, and she had no opportunity to say, 'No, I don't want to get married to a man who's already got women.'" Indira's mother married and had her first child at sixteen. Because her husband wanted a son, she went on to give birth to eight more children without resting. But Indira's mother had a vision for something better for her daughters. "My mother started thinking and educated us. And every time she said, 'You have to go to school. You have to study hard…. You can get opportunity…. You will have choice.'" e89 Indira has followed in her mother's footsteps, becoming a woman of strength who invests in the education of young women in need. She shares her home with seven abandoned and abused young women and offers them love, support, and education. She has lived through discrimination in many forms, but she doesn't view herself or her daughters as weak. "I still have some kind of energy, power," Indira says. "That power comes from my education." As Indira talks, my own daughters interrupt, raising their voices to complain that they're hungry. "Hush, we'll eat soon. Don't cause a fuss." "No," Indira says. "I want my girls to see. Your children speak so frankly…. Mine must learn to speak for themselves too. In our society we have very less opportunity to say 'no.'" There is much discrimination throughout the world. In Nepal, gender, caste, and wealth allow some to take advantage; society's blind eye can be a cruel response of wilful ignorance. In Kathmandu, Indira has friends from women's rights organizations who see the invisible and reach out to the untouchable; those deemed worthless and discarded by society. The joy and beauty of Nepal and its people are evident in the faces of our hosts. However, Indira goes on to explain that these young girls have also faced many challenges in their rural villages or upon moving to Kathmandu. Because these girls are under the age of sixteen, and without paperwork, they easily gain employment in restaurants. The restaurant owners are waiting to take advantage of their vulnerability. "And they cannot [say], 'No I don't want to do, I don't want to sit together with the customer and be together [so that] the customer can do whatever he wants to do [and] touch my body.' …They have to have sex with the customer, and the benefit always goes to the owner. …For some time they resists, but what the owner do is they give alcohol and also the drug to make them [cooperate]." This was the very life two of Indira's daughters were rescued from. I watch the older girls as they experiment with different toys to see which will hold the interest of my three year-old. They laugh, so happy now. I would never have guessed what they've suffered. But now I can see the strength in their smiles. Indira goes on to relate the stories of her other three daughters, who came to her when they were just seven, nine and ten years old. Two girls were raped by their grandfather, and one by her brother. These girls were then rejected, not only by their family members, but also from Nepalese society. "They don't want to see the girl's face within their community…. The society blamed them, 'it's your fault'. Never blame to the man." I look at my own daughters, so innocent, playing with these girls. Sometimes I am shocked by the world we live in. I want to raise my own children to understand these things, and yet I want to protect them too. Indira tells me that the girls are beginning to win back societal acceptance and recognize for themselves that they are not at fault for the abuse they've endured. "They are very strong daughters," she tells me. Three of the rapists are now in jail because these girls had the courage to speak up. One remains free because of his wealth and connections, but the girl he raped is not giving up. She tells Indira, "I want to be lawyer and I will provide the justice for girls who are suffering like me." --- Empowerment and education. Compassion and a safe place to call home. Indira's story tells of a woman who was willing to hear the pain of others and respond in her life, with a story of her own. Hearing, however, requires listening. How do we do that? Our own cultural assumptions filter another's life in a way that makes sense to us, and always there is the risk that we misunderstand or respond in well-intentioned but harmful ways. Even as I tell the story, why have I focused on some parts of Indira's story more than others? The fact that I am making such decisions reflects a power imbalance that I find distasteful. However, even as Indira reviews this manuscript for her approval, I see my fingerprints on her story like smudges on a window, partially obstructing the reader's view. Perhaps by acknowledging those smudges I can write, with a little more integrity, not only her story, but also our story: where two stories intersect and a new relationship, a new narrative begins. --- e89 The social determinants of health, including the issues of education, gender, finance, and ethnicity seen in Indira's story, represent power. We may lack an objective metric to assess the inequity here, but when we hear a story we begin to see, albeit through our own tainted lens, the complex ways health is impacted. However, knowledge -even of a complex concept -is not enough. Medical educators must help learners make the leap from learning to application . It is relatively easy to state things we accept as correct. E.g., living in a rural village can make education difficult; financial need can lead to abusive employment circumstances; and the victims of abuse are often blamed or even shunned. Propositional truths like these are useful at times, but as Andy Goodman once said, "nobody ever marched on Washington because of a pie chart." 2 If our lives are not impacted by the stories we hear, then perhaps we would be better off ignorant rather than steeling ourselves against compassion. Inaction leaves us voyeurs, consuming stories for interest but not shaping our own lives in response. 3 However, when we let the lives of others influence how we live, we can follow Indira's example and become advocates. Indira demonstrates great courage in the face of tremendous adversity, working outside of social norms to break down gender barriers and effect social change. As a medical educator, if narratives like this will help me teach advocacy, I consider the above risks, although real, worth taking. Indira tells the story of one woman's struggle for education and a home. Once she obtained these, she did not keep them to herself but was moved by the stories of those around her to join them in their struggle. Her own relative power was not wasted on inaction, but compelled her to reach out. Empowerment and education. Compassion and a safe place to call home. I suspect Indira's commitment to meeting these needs has done more for the health of her daughters than any doctor's prescription.

Indira is an independent woman who does not live a traditional Nepali life. She rescues abandoned and abused young women from sexual exploitation and provides them with love, support, and education. Her story highlights the key role of the social determinants of health in caring for marginalized populations. Challenges and benefits of attempting to learn from another's personal narrative are also considered.

family doctors practice at the crossroads of medicine and the social determinants of health our focus is not on an illness but on a person we need to hear the stories of our patients lives so that we can provide patientcentered care we care about issues such as empowerment and education compassion and a safe place for our patients to call home we are advocates a challenging role for most physicians 1 as a medical educator i must find ways of teaching advocacy and hopefully motivating learners to put it into practice wherever they may be in april 2016 i took my family to nepal to establish some working relationships and hopefully gain some perspective for my teaching my most memorable encounter on this trip was with indira ghale an independent woman who does not live a traditional nepali life a colleague told me about this woman who rescues girls from abusive situations in rural villages and from human trafficking in kathmandu so i gratefully accepted a dinner invitation and soon we were warmly welcomed into her home indira says it all began with her own mother when i look back on my mothers life she got married at the age of fifteen and she had no opportunity to say no i dont want to get married to a man whos already got women indiras mother married and had her first child at sixteen because her husband wanted a son she went on to give birth to eight more children without resting but indiras mother had a vision for something better for her daughters my mother started thinking and educated us and every time she said you have to go to school you have to study hard… you can get opportunity… you will have choice e89 indira has followed in her mothers footsteps becoming a woman of strength who invests in the education of young women in need she shares her home with seven abandoned and abused young women and offers them love support and education she has lived through discrimination in many forms but she doesnt view herself or her daughters as weak i still have some kind of energy power indira says that power comes from my education as indira talks my own daughters interrupt raising their voices to complain that theyre hungry hush well eat soon dont cause a fuss no indira says i want my girls to see your children speak so frankly… mine must learn to speak for themselves too in our society we have very less opportunity to say no there is much discrimination throughout the world in nepal gender caste and wealth allow some to take advantage societys blind eye can be a cruel response of wilful ignorance in kathmandu indira has friends from womens rights organizations who see the invisible and reach out to the untouchable those deemed worthless and discarded by society the joy and beauty of nepal and its people are evident in the faces of our hosts however indira goes on to explain that these young girls have also faced many challenges in their rural villages or upon moving to kathmandu because these girls are under the age of sixteen and without paperwork they easily gain employment in restaurants the restaurant owners are waiting to take advantage of their vulnerability and they cannot say no i dont want to do i dont want to sit together with the customer and be together so that the customer can do whatever he wants to do and touch my body …they have to have sex with the customer and the benefit always goes to the owner …for some time they resists but what the owner do is they give alcohol and also the drug to make them cooperate this was the very life two of indiras daughters were rescued from i watch the older girls as they experiment with different toys to see which will hold the interest of my three yearold they laugh so happy now i would never have guessed what theyve suffered but now i can see the strength in their smiles indira goes on to relate the stories of her other three daughters who came to her when they were just seven nine and ten years old two girls were raped by their grandfather and one by her brother these girls were then rejected not only by their family members but also from nepalese society they dont want to see the girls face within their community… the society blamed them its your fault never blame to the man i look at my own daughters so innocent playing with these girls sometimes i am shocked by the world we live in i want to raise my own children to understand these things and yet i want to protect them too indira tells me that the girls are beginning to win back societal acceptance and recognize for themselves that they are not at fault for the abuse theyve endured they are very strong daughters she tells me three of the rapists are now in jail because these girls had the courage to speak up one remains free because of his wealth and connections but the girl he raped is not giving up she tells indira i want to be lawyer and i will provide the justice for girls who are suffering like me empowerment and education compassion and a safe place to call home indiras story tells of a woman who was willing to hear the pain of others and respond in her life with a story of her own hearing however requires listening how do we do that our own cultural assumptions filter anothers life in a way that makes sense to us and always there is the risk that we misunderstand or respond in wellintentioned but harmful ways even as i tell the story why have i focused on some parts of indiras story more than others the fact that i am making such decisions reflects a power imbalance that i find distasteful however even as indira reviews this manuscript for her approval i see my fingerprints on her story like smudges on a window partially obstructing the readers view perhaps by acknowledging those smudges i can write with a little more integrity not only her story but also our story where two stories intersect and a new relationship a new narrative begins e89 the social determinants of health including the issues of education gender finance and ethnicity seen in indiras story represent power we may lack an objective metric to assess the inequity here but when we hear a story we begin to see albeit through our own tainted lens the complex ways health is impacted however knowledge even of a complex concept is not enough medical educators must help learners make the leap from learning to application it is relatively easy to state things we accept as correct eg living in a rural village can make education difficult financial need can lead to abusive employment circumstances and the victims of abuse are often blamed or even shunned propositional truths like these are useful at times but as andy goodman once said nobody ever marched on washington because of a pie chart 2 if our lives are not impacted by the stories we hear then perhaps we would be better off ignorant rather than steeling ourselves against compassion inaction leaves us voyeurs consuming stories for interest but not shaping our own lives in response 3 however when we let the lives of others influence how we live we can follow indiras example and become advocates indira demonstrates great courage in the face of tremendous adversity working outside of social norms to break down gender barriers and effect social change as a medical educator if narratives like this will help me teach advocacy i consider the above risks although real worth taking indira tells the story of one womans struggle for education and a home once she obtained these she did not keep them to herself but was moved by the stories of those around her to join them in their struggle her own relative power was not wasted on inaction but compelled her to reach out empowerment and education compassion and a safe place to call home i suspect indiras commitment to meeting these needs has done more for the health of her daughters than any doctors prescription

indira is an independent woman who does not live a traditional nepali life she rescues abandoned and abused young women from sexual exploitation and provides them with love support and education her story highlights the key role of the social determinants of health in caring for marginalized populations challenges and benefits of attempting to learn from anothers personal narrative are also considered

Introduction Nurses face ongoing challenges as they try to handle a growing number of complex tasks and demanding work conditions within the constraints of limited time [1]. In a mixed-methods study conducted in Palestine, [2], a nurse captured the challenges they encounter while endeavoring to address the requirements of all their patients: "You cannot give quality when you are overwhelmed with quantity. When I have 15 patients on a ward to take care of on a night shift, I barely have time to distribute the medications, leaving little time to care for patients" other needs." According to Saintsing et al. [3], nurses indicated that time limitations constrained their capacity to conduct thorough patient assessments. Around 80% of entry-level nurses acknowledged making errors due to time pressure. Managing time efciently and avoiding time-wasting activities are therefore essential in the nursing work environment. Te lack of time management and organizational skills was also related to inequities in health service provision and distribution [4]. Causes of time-wasting behaviors among nurses include a lack of efective time management skills. Tis includes not setting short-and long-term goals, failing to organize tasks, engaging in activities that waste time, and lacking knowledge and experience in setting priorities [5,6]. Consequences of time-wasting behaviors include inefective work performance, decreased productivity, and the potential for missing essential nursing care tasks [5]. Nurses who wasted their time and energy on social media and lowpriority tasks were found to signifcantly lower their work performance [7]. Not knowing how to set priorities by giving equal attention to major and minor problems can have dire consequences on patients' health and overall nursing outcomes [8]. Numerous studies have consistently demonstrated a detrimental impact of inefective time management on job performance [9,10]. Tang and Vandenberghe [11] explained that demands that exceed an individual's available resources contribute to a decline in overall work performance and well-being. Others found that work overload negatively afects performance through increasing stress [10]. A crosssectional study from Brazil revealed that work-related stresses had the greatest negative impact on job performance while social networks and job autonomy had the greatest positive impact [12]. A study by Knezevic et al. [13] investigated the efects of time management skills on job satisfaction for nurses. Te study found that poor time management skills were signifcantly associated with lower job satisfaction levels among nurses. In a related study, Ozkan & Timbil [14] found that nurses with poor time management skills made more medication errors and missed nursing care activities more frequently than those with good time management skills. Te authors recommended that time management training should be included in nursing education to improve patient safety and quality of care. Similarly, a study by Cleland Woods et al. [15] found that poor time management skills were associated with higher levels of job-related stress among nurses. Te authors recommended incorporating time management training into workplace wellness programs to help nurses manage their time more efectively and reduce job-related stress. In conclusion, poor time management skills can have negative efects on nurses' capacity to provide optimal patient care. It is, therefore, essential that time management skills are included as a critical component of nursing education and workplace wellness programs. Numerous studies, including those conducted by Hamzehkola and Naderi [16], Higazee et al. [17], Ebrahim et al. [18], and Elsabahy et al. [19], have presented sound evidence that time management interventions can enhance the organizational skills of nurses, mitigate work-related stress levels, and ultimately elevate the overall quality of their work. A time management educational program for head nurses in Iran assessed improvements in fve essential time management skills . Te results showed dramatic improvements in these basic skills after the educational intervention [20]. Another quasi-experimental experiment of 60 nurses from all hospital wards in Tehran examined the psychological and social impacts of a one-day educational workshop on strategies to improve time management and avoid wasting nursing time [16]. A pretest was followed by a posttest one month after the workshop. Results showed signifcant improvements in psychological well-being and trust among staf. Setting priorities has been defned as the action of assigning precedence in rank with regard to the importance or time for some activities over others [8]. In addition to delaying activities of less importance, prioritization can also eliminate unnecessary tasks which allow nurses to allocate more precious time for patients [16]. Tese fndings underscore the importance of time management skills for nurses. Prioritizing tasks and activities are crucial aspects of time management skills. It has been noted that new nurses struggle with managing their time and that their abilities to prioritize tasks and minimize time-wasting activities improve with experience [21]. Te degree to which this relationship is a function of experience, age, education, or other variables that evolve with time has not been extensively investigated in previous research [22]. Many studies show that time-wasting activities decrease with age, education, experience, and attending time-management courses. Most of the previous research, however, did not adjust for confounding efects in multivariate analyses [23]. Te current study aims at exploring the relationships between these background variables and time-wasting behaviors in multivariate models to distinguish the most important factors contributing to time-wasting behaviors. 1.1. Principles of Setting Priorities. Te fundamental question is how can nurses determine the priority, importance, and urgency of the multitude of tasks they are tasked with? Several time management theories and models can help nurses in managing their time and minimizing time-wasting activities. Te items used in the time-wasting scale of this study such as appreciating planning, distinguishing important tasks, and understanding time-wasting activities refect those principles. Tose principles include Te Pareto 80/20 rule notes that 80% of outcomes result from 20% of eforts [24]. Tis principle calls for identifying and focusing on the most impactful tasks, i.e., the ones that yield the highest returns. Te 80/20 rule therefore prioritizes the 20% of tasks that produce the best results. Te two-minute rule recommends completing small tasks frst before embarking on tasks that are complicated or require long durations [25]. Tis rule helps minimize the accumulation of small tasks and fosters a sense of progress. Te efort impact matrix, also known as the PICK Chart, prioritizes tasks based on impact and efort [26]. Te impact can be assessed based on fnancial gain, patient satisfaction, or health improvement. Te impact or yield of a task ranges from low to high. Te ABC method involves categorizing tasks based on their priority and then completing the highest priority tasks while less urgent tasks can be delayed or delegated [27]. Eisenhower matrix categorizes tasks based on their urgency and importance into four quadrants: urgent and important, important but not urgent, urgent but not important, and not urgent and not important. Te model helps prioritize tasks and focus on the most critical ones. Nursing time management skills are essential for delivering efcient and efective patient care. Poor time management skills can lead to decreased patient satisfaction, inefcient use of resources, and ultimately compromised patient care [14]. Terefore, this study aimed to investigate sociodemographic and institution-level factors associated with time-wasting behaviors among nurses in Palestine. Specifcally, the research questions were whether time-wasting behaviors vary by nurses' age, gender, place of residence, and educational levels. Of interest were the efects of institutional-level factors such as type of healthcare institution , facility size , and teaching status on time-wasting activities. Te impact of attending a time-management course on time-wasting behaviors was also investigated. --- Methods Te surveys were collected in the period between March and August 2019 from 714 nurses working in 17 hospitals and multiple primary health care clinics in the North of the West Bank of Palestine. Approval was obtained from the Palestinian Ministry of Health. Te researcher contacted the nursing directors of each hospital and primary healthcare center, inquiring about the number of nurses employed within their respective organizations. Subsequently, the researcher prepared questionnaires based on the gathered information, met with each nursing director in person, delivered the questionnaires, and explained the data collection process, including its content, objectives, and the process of obtaining consent. Te nursing directors were then tasked with distributing the questionnaires to all nurses in their organizations and collecting the completed questionnaires within a week. Te researcher personally collected the completed questionnaires from the nursing directors. All nurses completed the questionnaires except those who were sick or on leave. Inclusion criteria: all male and female staf and practical nurses who were available at the time of the data collection. Exclusion criteria: nurses who were on a sabbatical leave, a sick leave, nurse volunteers, and internship student nurses. Te entire process was completed within a span of six months, and the researcher, along with the assistance of two experienced data entry personnel, entered the data into SPSS version 25. Te collected data were analyzed using t-tests and ANOVA. To account for confounding efects, multivariate linear regression was employed. --- Study Instrument. Te study examined various sociodemographic variables including gender, age, residence, educational level, and years of experience. Time-wasting behaviors were evaluated using an 11-item scale developed based on prior research [28]. Tis scale measures diferent aspects of time-wasting behaviors, such as excessive grooming, poor planning, failing to distinguish between important and unimportant tasks, underestimating task completion time, excessive use of social media, and excessive socialization. Responses were recorded on a 5-point scale ranging from "never � 1" to "always � 5" and a summative score was computed. Scores could range from a minimum of 11 to a maximum of 55, with higher scores indicating more frequent engagement in time-wasting activities. Te face and content validity of the study were ensured through consultations with 10 experts in nursing and time management. Tese experts were briefed on the study's objectives and the construct of the scale. Tey were then asked to assess whether the items clearly and efectively measured their intended concepts . Additionally, the experts provided feedback on the relevance of the items and their representation of the content domains within the intended construct. Te author carefully analyzed the feedback received from the experts and made necessary adjustments to the wording and number of items. Subsequently, the revised questionnaire was pilot-tested with a group of 5 staf nurses. Construct validity was evaluated through factor analysis, and reliability was assessed using Cronbach's alpha. --- Results Cronbach's alpha of the entire sample was 0.862, indicating good internal consistency. Factor analysis identifed three distinct factors, as detailed in Table 1. Te Kaiser-Meyer-Olkin measure of sampling adequacy was 0.845, indicating strong partial correlations among the variables and justifying the use of factor analysis. Bartlett's test of sphericity returned a p value of less than 0.001, which rejects the null hypothesis that the variables are unrelated. Tis indicates that the correlation matrix is not an identity matrix, afrming the appropriateness of factor analysis. None of the items had a commonality value above 0.4, indicating the appropriateness of factor analysis for exploring the data. Overall, the threefactor structure accounted for a substantial 76.77% of the variance in the nursing time management scale. Te divergent validity of the scale was assessed by correlating it with another scale which is theoretically intended to measure good time management behaviors among nurses. Te time nursing wasting scale correlated negatively with the nursing time managements scale , correlation coefcient � -0.162, p < 0.001. Te NTMS is a scale that measures positive time management skills among nurses such as planning, goal setting, and coordination of activity . Te factor loadings, means, and standard deviations for each item within the time-wasting scale are displayed in Table 2. Higher mean values indicate more frequent engagement in time-wasting behaviors among the participants. Among the various behaviors, grooming appeared to be the least time-consuming activity, with a mean score of 2.14. In contrast, work interruptions, such as being overly accessible, ranked as the most signifcant time-wasting factor, with a mean score of 3.15. Following closely were behaviors like not having specifc time to respond to emails and phone calls and continuously checking emails and other communication media . Te factor analysis unveiled a three-factor model, categorizing time-wasting behaviors into three dimensions: Inability to plan and organize tasks Improper use of technology and social media Excessive socialization Table 3 shows the frequencies and means of the timewasting scores by background variables. Of the 714 Regarding workplace, the table shows that the mean time-wasting score was signifcantly higher for participants working in a hospital compared to those working in a patient community clinic . For this type of organization, the mean time-wasting score was signifcantly higher for participants working in a private organization compared to those working in a government organization . Regarding the current job position, the table shows that 631 participants were nurses, while 82 participants were nurse supervisors. Te mean time-wasting score was similar across the two job positions, with no statistically signifcant diference . Participants who worked in teaching hospitals/clinics had a lower mean time-wasting score than those who did not work in teaching hospitals/clinics , and those who attended a time management course had a slightly lower mean timewasting score than those who did not attend a time management course . Te multivariate linear regression in Table 4 shows no signifcant relationship between time wasting and gender, age, place of residence, educational level, and job experience. On the other hand, place of work emerged as a signifcant predictor of the time-wasting score when other background variables were considered. Individuals working in community clinics have lower time-wasting average scores compared to those working in hospitals . Te type of organization was also a signifcant predictor of time management skills. Individuals working in private organizations engaged in more time-wasting activities compared to those working in government organizations . Nurses in nonteaching hospitals are more likely to engage in time-wasting activities than nurses in teaching hospitals . Nurses who had not attended a time management course obtained a higher score on the time-wasting scale compared to nurses who had attended a time management course . --- Discussion Tis research sought to examine the predictors of timewasting behaviors among nurses. Te results indicate that time-wasting behaviors are infuenced by individual-level and organizational-level factors. Te fnding that attending a time management course is efective in reducing timewasting activities and improving time management skills corroborates numerous previous studies that have provided evidence for the positive impact of time management training [19,22,[29][30][31]. Prior studies have demonstrated that time-wasting activities decrease with age [22]. In the current study, older age was associated with lower time-wasting scores in the bivariate analysis, but this association did not hold in the multivariate analysis, most likely due to adjustments for confounding variables such as seniority or job experience. Similarly, job experience was associated with lower timewasting scores in the bivariate analysis, but this relationship did not persist in the multivariate analysis. Tis fnding contradicts previous research, which found signifcant correlations between years of experience and improved time management skills [23]. Educational level, however, was not associated with time-wasting behavior in this study. Tis result aligns with fndings from a study in Bangladesh that failed to establish a relationship between educational level and time management skills [32]. In contrast, a study in Iran found signifcant positive correlations between time management skills and age, education, job experience, and managerial experience, probably because this study did not adjust for potential confounding efects [16]. Organizational types, such as hospital vs. community clinic or government vs. private, were strongly statistically related to time-wasting scores in this study. Tis suggests that organizational-level factors could infuence timemanagement behaviors. Elsayed et al. [23] reported that organizational factors, such as understafng, work overload due to a large number of visitors, and the absence of clear management plans, strongly infuence employees' time management behaviors. Others have found that poor organizational and policy factors, such as frequent staf meetings, inefcient and unclear communications, and excessive administrative work, such as writing attendance records or tasks unrelated to their specialty, can result in signifcant time wastage among employees [33]. Time-wasting activities, as reported by nurses in this and previous studies, include spending too much time on lowpriority tasks; treating everything as urgent; inability to say "no" to extra work; and excessive interruptions by people and colleagues [34]. Meetings that are inefective, with no clear purpose, agenda, or follow-ups are a waste of time as well as arriving at meetings late. Other time-wasters include excessive socializing, phone calls, and phone interruptions; inefcient and unclear communications with patients and colleagues; insufciently detailed policies and procedures; reluctance to delegate tasks; and an overload of paperwork [34]. Not knowing how to prioritize, plan, and handle interruptions can lead to increased errors and work inefciencies [35,36]. Te fndings from this study concur with previous research, which shows the inability of nurses to say "no" as one of the most important factors negatively infuencing nurses' workfow [19,35]. It is known that in Arab culture, saying "no" or "I do not know" is not commonly used, probably because such terms are thought of as impolite. Nevertheless, nurses should learn to refuse additional tasks that they cannot perform or tasks that interrupt their workfow. Other major time-wasters mentioned in previous research include not knowing how to delegate. Figure 1 illustrates a theoretical framework of the types, causes, and consequences of time wasting in the nursing profession. Te fgure summarizes the fndings from this article and previous studies. --- 4.1. Limitations. While this study was carried out on a representative sample within the northern regions of Palestine, it is important to note that generalizing the fndings to other contexts may not be fully established. To strengthen the generalizability of the fndings, it is necessary to conduct further research in various other contexts. Moreover, as a cross-sectional study, causal inferences are constrained. Nevertheless, one strength of this study lies in its high sample size, addressing the constraints associated with smaller sample sizes in earlier research. Although having the nursing directors distribute and collect the surveys has increased response rates and motivation to complete the questionnaires with precision, it cannot be ruled out that some respondents may have been unduly infuenced to participate despite the fact that it was explained to them that participation is voluntary. --- Conclusions According to the results of this research, providing time management courses to nurses can be an efective strategy to reduce time waste and improve work quality. However, in addition to providing time management courses, hospitals and clinics should also consider implementing organizational policies and strategies to reduce time-wasting activities. 5.1. Recommendations. Hospitals and clinics should conduct regular time management courses for their employees, with an emphasis on providing practical instructions and exercises on how to avoid and eliminate time-wasting activities such as interruptions, distractions, and procrastinations. In addition, organizations should design policies that minimize time-wasting activities, such as requiring excessive reporting, vague communications, and unnecessary meetings. Such policies should be clearly communicated to all employees. In addition to time management courses, organizations should also provide their employees with the necessary tools and resources to manage their time efectively, such as timetracking software or prioritization frameworks. By following these recommendations, hospitals and clinics can create a more productive work environment and improve the quality of care they provide to their patients. --- Data Availability Te dataset examined in the present study can be obtained from the corresponding author upon a reasonable request. --- Ethical Approval Nurses were informed that participation in the questionnaire is optional and that no adverse consequences will arise from choosing not to participate. Tey were assured that their names would not be gathered and data confdentiality would be maintained by securely storing the questionnaires solely for research purposes. --- Consent Informed consent was acquired from all participants, including staf nurses and nursing directors. Ethical approval to conduct this study was obtained from the IRB of the American Arab University, Palestine IRB #13.P.E/22. --- Conflicts of Interest Te author declares that there are no conficts of interest. --- Authors' Contributions RZ completed this article.

Background. Nurses face signifcant challenges as they attempt to manage an increasing number of complex responsibilities within limited time frames. Tis article explores the factors contributing to time-wasting behaviors among nurses in Palestine and emphasizes the signifcance of efective time-management skills in nursing practice. Methods. Surveys were collected from a total of 714 nurses working in multiple healthcare facilities located in the north of the West Bank, Palestine. An 11-item time-wasting scale was developed and validated. Factors infuencing time-wasting behaviors among nurses were then investigated using multiple linear regression in SPSS version 25. Results. Attending time management courses signifcantly reduced time-wasting behaviors. Additionally, factors such as age, gender, and educational level did not appear to correlate with time-wasting behaviors. However, workplace, type of organization, and attendance of time management courses did impact nurses' time management skills. Conclusion. Tis article underscores the importance of time management skills in nursing practice. Inefcient time management can have detrimental efects on patient care and nursing outcomes. To mitigate these challenges, healthcare institutions and nursing education programs should prioritize time management training for nurses.

introduction nurses face ongoing challenges as they try to handle a growing number of complex tasks and demanding work conditions within the constraints of limited time 1 in a mixedmethods study conducted in palestine 2 a nurse captured the challenges they encounter while endeavoring to address the requirements of all their patients you cannot give quality when you are overwhelmed with quantity when i have 15 patients on a ward to take care of on a night shift i barely have time to distribute the medications leaving little time to care for patients other needs according to saintsing et al 3 nurses indicated that time limitations constrained their capacity to conduct thorough patient assessments around 80 of entrylevel nurses acknowledged making errors due to time pressure managing time efciently and avoiding timewasting activities are therefore essential in the nursing work environment te lack of time management and organizational skills was also related to inequities in health service provision and distribution 4 causes of timewasting behaviors among nurses include a lack of efective time management skills tis includes not setting shortand longterm goals failing to organize tasks engaging in activities that waste time and lacking knowledge and experience in setting priorities 56 consequences of timewasting behaviors include inefective work performance decreased productivity and the potential for missing essential nursing care tasks 5 nurses who wasted their time and energy on social media and lowpriority tasks were found to signifcantly lower their work performance 7 not knowing how to set priorities by giving equal attention to major and minor problems can have dire consequences on patients health and overall nursing outcomes 8 numerous studies have consistently demonstrated a detrimental impact of inefective time management on job performance 910 tang and vandenberghe 11 explained that demands that exceed an individuals available resources contribute to a decline in overall work performance and wellbeing others found that work overload negatively afects performance through increasing stress 10 a crosssectional study from brazil revealed that workrelated stresses had the greatest negative impact on job performance while social networks and job autonomy had the greatest positive impact 12 a study by knezevic et al 13 investigated the efects of time management skills on job satisfaction for nurses te study found that poor time management skills were signifcantly associated with lower job satisfaction levels among nurses in a related study ozkan timbil 14 found that nurses with poor time management skills made more medication errors and missed nursing care activities more frequently than those with good time management skills te authors recommended that time management training should be included in nursing education to improve patient safety and quality of care similarly a study by cleland woods et al 15 found that poor time management skills were associated with higher levels of jobrelated stress among nurses te authors recommended incorporating time management training into workplace wellness programs to help nurses manage their time more efectively and reduce jobrelated stress in conclusion poor time management skills can have negative efects on nurses capacity to provide optimal patient care it is therefore essential that time management skills are included as a critical component of nursing education and workplace wellness programs numerous studies including those conducted by hamzehkola and naderi 16 higazee et al 17 ebrahim et al 18 and elsabahy et al 19 have presented sound evidence that time management interventions can enhance the organizational skills of nurses mitigate workrelated stress levels and ultimately elevate the overall quality of their work a time management educational program for head nurses in iran assessed improvements in fve essential time management skills te results showed dramatic improvements in these basic skills after the educational intervention 20 another quasiexperimental experiment of 60 nurses from all hospital wards in tehran examined the psychological and social impacts of a oneday educational workshop on strategies to improve time management and avoid wasting nursing time 16 a pretest was followed by a posttest one month after the workshop results showed signifcant improvements in psychological wellbeing and trust among staf setting priorities has been defned as the action of assigning precedence in rank with regard to the importance or time for some activities over others 8 in addition to delaying activities of less importance prioritization can also eliminate unnecessary tasks which allow nurses to allocate more precious time for patients 16 tese fndings underscore the importance of time management skills for nurses prioritizing tasks and activities are crucial aspects of time management skills it has been noted that new nurses struggle with managing their time and that their abilities to prioritize tasks and minimize timewasting activities improve with experience 21 te degree to which this relationship is a function of experience age education or other variables that evolve with time has not been extensively investigated in previous research 22 many studies show that timewasting activities decrease with age education experience and attending timemanagement courses most of the previous research however did not adjust for confounding efects in multivariate analyses 23 te current study aims at exploring the relationships between these background variables and timewasting behaviors in multivariate models to distinguish the most important factors contributing to timewasting behaviors 11 principles of setting priorities te fundamental question is how can nurses determine the priority importance and urgency of the multitude of tasks they are tasked with several time management theories and models can help nurses in managing their time and minimizing timewasting activities te items used in the timewasting scale of this study such as appreciating planning distinguishing important tasks and understanding timewasting activities refect those principles tose principles include te pareto 8020 rule notes that 80 of outcomes result from 20 of eforts 24 tis principle calls for identifying and focusing on the most impactful tasks ie the ones that yield the highest returns te 8020 rule therefore prioritizes the 20 of tasks that produce the best results te twominute rule recommends completing small tasks frst before embarking on tasks that are complicated or require long durations 25 tis rule helps minimize the accumulation of small tasks and fosters a sense of progress te efort impact matrix also known as the pick chart prioritizes tasks based on impact and efort 26 te impact can be assessed based on fnancial gain patient satisfaction or health improvement te impact or yield of a task ranges from low to high te abc method involves categorizing tasks based on their priority and then completing the highest priority tasks while less urgent tasks can be delayed or delegated 27 eisenhower matrix categorizes tasks based on their urgency and importance into four quadrants urgent and important important but not urgent urgent but not important and not urgent and not important te model helps prioritize tasks and focus on the most critical ones nursing time management skills are essential for delivering efcient and efective patient care poor time management skills can lead to decreased patient satisfaction inefcient use of resources and ultimately compromised patient care 14 terefore this study aimed to investigate sociodemographic and institutionlevel factors associated with timewasting behaviors among nurses in palestine specifcally the research questions were whether timewasting behaviors vary by nurses age gender place of residence and educational levels of interest were the efects of institutionallevel factors such as type of healthcare institution facility size and teaching status on timewasting activities te impact of attending a timemanagement course on timewasting behaviors was also investigated methods te surveys were collected in the period between march and august 2019 from 714 nurses working in 17 hospitals and multiple primary health care clinics in the north of the west bank of palestine approval was obtained from the palestinian ministry of health te researcher contacted the nursing directors of each hospital and primary healthcare center inquiring about the number of nurses employed within their respective organizations subsequently the researcher prepared questionnaires based on the gathered information met with each nursing director in person delivered the questionnaires and explained the data collection process including its content objectives and the process of obtaining consent te nursing directors were then tasked with distributing the questionnaires to all nurses in their organizations and collecting the completed questionnaires within a week te researcher personally collected the completed questionnaires from the nursing directors all nurses completed the questionnaires except those who were sick or on leave inclusion criteria all male and female staf and practical nurses who were available at the time of the data collection exclusion criteria nurses who were on a sabbatical leave a sick leave nurse volunteers and internship student nurses te entire process was completed within a span of six months and the researcher along with the assistance of two experienced data entry personnel entered the data into spss version 25 te collected data were analyzed using ttests and anova to account for confounding efects multivariate linear regression was employed study instrument te study examined various sociodemographic variables including gender age residence educational level and years of experience timewasting behaviors were evaluated using an 11item scale developed based on prior research 28 tis scale measures diferent aspects of timewasting behaviors such as excessive grooming poor planning failing to distinguish between important and unimportant tasks underestimating task completion time excessive use of social media and excessive socialization responses were recorded on a 5point scale ranging from never � 1 to always � 5 and a summative score was computed scores could range from a minimum of 11 to a maximum of 55 with higher scores indicating more frequent engagement in timewasting activities te face and content validity of the study were ensured through consultations with 10 experts in nursing and time management tese experts were briefed on the studys objectives and the construct of the scale tey were then asked to assess whether the items clearly and efectively measured their intended concepts additionally the experts provided feedback on the relevance of the items and their representation of the content domains within the intended construct te author carefully analyzed the feedback received from the experts and made necessary adjustments to the wording and number of items subsequently the revised questionnaire was pilottested with a group of 5 staf nurses construct validity was evaluated through factor analysis and reliability was assessed using cronbachs alpha results cronbachs alpha of the entire sample was 0862 indicating good internal consistency factor analysis identifed three distinct factors as detailed in table 1 te kaisermeyerolkin measure of sampling adequacy was 0845 indicating strong partial correlations among the variables and justifying the use of factor analysis bartletts test of sphericity returned a p value of less than 0001 which rejects the null hypothesis that the variables are unrelated tis indicates that the correlation matrix is not an identity matrix afrming the appropriateness of factor analysis none of the items had a commonality value above 04 indicating the appropriateness of factor analysis for exploring the data overall the threefactor structure accounted for a substantial 7677 of the variance in the nursing time management scale te divergent validity of the scale was assessed by correlating it with another scale which is theoretically intended to measure good time management behaviors among nurses te time nursing wasting scale correlated negatively with the nursing time managements scale correlation coefcient � 0162 p 0001 te ntms is a scale that measures positive time management skills among nurses such as planning goal setting and coordination of activity te factor loadings means and standard deviations for each item within the timewasting scale are displayed in table 2 higher mean values indicate more frequent engagement in timewasting behaviors among the participants among the various behaviors grooming appeared to be the least timeconsuming activity with a mean score of 214 in contrast work interruptions such as being overly accessible ranked as the most signifcant timewasting factor with a mean score of 315 following closely were behaviors like not having specifc time to respond to emails and phone calls and continuously checking emails and other communication media te factor analysis unveiled a threefactor model categorizing timewasting behaviors into three dimensions inability to plan and organize tasks improper use of technology and social media excessive socialization table 3 shows the frequencies and means of the timewasting scores by background variables of the 714 regarding workplace the table shows that the mean timewasting score was signifcantly higher for participants working in a hospital compared to those working in a patient community clinic for this type of organization the mean timewasting score was signifcantly higher for participants working in a private organization compared to those working in a government organization regarding the current job position the table shows that 631 participants were nurses while 82 participants were nurse supervisors te mean timewasting score was similar across the two job positions with no statistically signifcant diference participants who worked in teaching hospitalsclinics had a lower mean timewasting score than those who did not work in teaching hospitalsclinics and those who attended a time management course had a slightly lower mean timewasting score than those who did not attend a time management course te multivariate linear regression in table 4 shows no signifcant relationship between time wasting and gender age place of residence educational level and job experience on the other hand place of work emerged as a signifcant predictor of the timewasting score when other background variables were considered individuals working in community clinics have lower timewasting average scores compared to those working in hospitals te type of organization was also a signifcant predictor of time management skills individuals working in private organizations engaged in more timewasting activities compared to those working in government organizations nurses in nonteaching hospitals are more likely to engage in timewasting activities than nurses in teaching hospitals nurses who had not attended a time management course obtained a higher score on the timewasting scale compared to nurses who had attended a time management course discussion tis research sought to examine the predictors of timewasting behaviors among nurses te results indicate that timewasting behaviors are infuenced by individuallevel and organizationallevel factors te fnding that attending a time management course is efective in reducing timewasting activities and improving time management skills corroborates numerous previous studies that have provided evidence for the positive impact of time management training 1922 29 30 31 prior studies have demonstrated that timewasting activities decrease with age 22 in the current study older age was associated with lower timewasting scores in the bivariate analysis but this association did not hold in the multivariate analysis most likely due to adjustments for confounding variables such as seniority or job experience similarly job experience was associated with lower timewasting scores in the bivariate analysis but this relationship did not persist in the multivariate analysis tis fnding contradicts previous research which found signifcant correlations between years of experience and improved time management skills 23 educational level however was not associated with timewasting behavior in this study tis result aligns with fndings from a study in bangladesh that failed to establish a relationship between educational level and time management skills 32 in contrast a study in iran found signifcant positive correlations between time management skills and age education job experience and managerial experience probably because this study did not adjust for potential confounding efects 16 organizational types such as hospital vs community clinic or government vs private were strongly statistically related to timewasting scores in this study tis suggests that organizationallevel factors could infuence timemanagement behaviors elsayed et al 23 reported that organizational factors such as understafng work overload due to a large number of visitors and the absence of clear management plans strongly infuence employees time management behaviors others have found that poor organizational and policy factors such as frequent staf meetings inefcient and unclear communications and excessive administrative work such as writing attendance records or tasks unrelated to their specialty can result in signifcant time wastage among employees 33 timewasting activities as reported by nurses in this and previous studies include spending too much time on lowpriority tasks treating everything as urgent inability to say no to extra work and excessive interruptions by people and colleagues 34 meetings that are inefective with no clear purpose agenda or followups are a waste of time as well as arriving at meetings late other timewasters include excessive socializing phone calls and phone interruptions inefcient and unclear communications with patients and colleagues insufciently detailed policies and procedures reluctance to delegate tasks and an overload of paperwork 34 not knowing how to prioritize plan and handle interruptions can lead to increased errors and work inefciencies 3536 te fndings from this study concur with previous research which shows the inability of nurses to say no as one of the most important factors negatively infuencing nurses workfow 1935 it is known that in arab culture saying no or i do not know is not commonly used probably because such terms are thought of as impolite nevertheless nurses should learn to refuse additional tasks that they cannot perform or tasks that interrupt their workfow other major timewasters mentioned in previous research include not knowing how to delegate figure 1 illustrates a theoretical framework of the types causes and consequences of time wasting in the nursing profession te fgure summarizes the fndings from this article and previous studies 41 limitations while this study was carried out on a representative sample within the northern regions of palestine it is important to note that generalizing the fndings to other contexts may not be fully established to strengthen the generalizability of the fndings it is necessary to conduct further research in various other contexts moreover as a crosssectional study causal inferences are constrained nevertheless one strength of this study lies in its high sample size addressing the constraints associated with smaller sample sizes in earlier research although having the nursing directors distribute and collect the surveys has increased response rates and motivation to complete the questionnaires with precision it cannot be ruled out that some respondents may have been unduly infuenced to participate despite the fact that it was explained to them that participation is voluntary conclusions according to the results of this research providing time management courses to nurses can be an efective strategy to reduce time waste and improve work quality however in addition to providing time management courses hospitals and clinics should also consider implementing organizational policies and strategies to reduce timewasting activities 51 recommendations hospitals and clinics should conduct regular time management courses for their employees with an emphasis on providing practical instructions and exercises on how to avoid and eliminate timewasting activities such as interruptions distractions and procrastinations in addition organizations should design policies that minimize timewasting activities such as requiring excessive reporting vague communications and unnecessary meetings such policies should be clearly communicated to all employees in addition to time management courses organizations should also provide their employees with the necessary tools and resources to manage their time efectively such as timetracking software or prioritization frameworks by following these recommendations hospitals and clinics can create a more productive work environment and improve the quality of care they provide to their patients data availability te dataset examined in the present study can be obtained from the corresponding author upon a reasonable request ethical approval nurses were informed that participation in the questionnaire is optional and that no adverse consequences will arise from choosing not to participate tey were assured that their names would not be gathered and data confdentiality would be maintained by securely storing the questionnaires solely for research purposes consent informed consent was acquired from all participants including staf nurses and nursing directors ethical approval to conduct this study was obtained from the irb of the american arab university palestine irb 13pe22 conflicts of interest te author declares that there are no conficts of interest authors contributions rz completed this article

background nurses face signifcant challenges as they attempt to manage an increasing number of complex responsibilities within limited time frames tis article explores the factors contributing to timewasting behaviors among nurses in palestine and emphasizes the signifcance of efective timemanagement skills in nursing practice methods surveys were collected from a total of 714 nurses working in multiple healthcare facilities located in the north of the west bank palestine an 11item timewasting scale was developed and validated factors infuencing timewasting behaviors among nurses were then investigated using multiple linear regression in spss version 25 results attending time management courses signifcantly reduced timewasting behaviors additionally factors such as age gender and educational level did not appear to correlate with timewasting behaviors however workplace type of organization and attendance of time management courses did impact nurses time management skills conclusion tis article underscores the importance of time management skills in nursing practice inefcient time management can have detrimental efects on patient care and nursing outcomes to mitigate these challenges healthcare institutions and nursing education programs should prioritize time management training for nurses

Introduction India is experiencing a rapid economic boom due in part to the opening of its markets in the 1990s and the emergence of a knowledge-based economy [1]. However, this prosperity has not translated into well-being among the country's young children. The prevalence of underweight among children under age five in India is one of the highest in the world-43% in 2006-surpassed only by Bangladesh, Yemen and Timor-Leste [2]. India is home to 55 million of the world's underweight children under age five-about one-third of the global burden of underweight in this age group [3]. During the prosperous 1990s, the average rate of decline in prevalence of underweight has been around 0.9% per year among Indian children aged below five years [3] whereas in China, another Asian country with a rapidly growing economy, it declined by approximately 5% per year [4]. The nutritional status of young children is an important indicator of health and development-it is not only a reflection of past health insults but an important indicator of future health trajectories [5]. Children under age three are particularly vulnerable to undernutrition, and because the growth rate in this period is greater than any other age period, it increases the risk of growth retardation [6]. Furthermore, undernutrition among young children captures the extent of development in a society [5] and is thus a marker for the overall well being of a population. It is well established that socioeconomic factors such as lower levels of household wealth and maternal education are important causes of childhood undernutrition [5]. Few studies have analyzed patterns of distribution of childhood undernutrition in India, across social factors such as household wealth and maternal education, using nationally representative data [7][8][9]. However, these were all cross sectional analyses and we did not find any published study that has evaluated the pattern of social disparities in childhood undernutrition in India across time. Studying the trend in social inequalities in childhood undernutrition over a period of economic growth sheds light on the potential benefits and adverse effects of such growth on this vulnerable population, thereby allowing us to review economic policies and their implementation from a public health perspective. We therefore examined trends in social disparities in undernutrition among Indian children under age three over the period of 1992-2005, using national-level data on child nutritional status from three cross-sectional surveys conducted in 1992, 1998 and 2005. --- Methods --- Ethics statement The data were analyzed anonymously, using publicly available secondary data, therefore no ethics statement is required for this work. --- Data We analyzed data from the three cross-sectional rounds of National Family Health Survey of India held in 1992, 1998 and 2005 to examine the trends in social disparities in undernutrition among children less than three years of age. These surveys used a multi-stage cluster sampling design to collect data on fertility, mortality, family planning, and important aspects of nutrition, health, and health care. The NFHS is the Indian version of the Demographic and Health Surveys which use standard model questionnaires designed for, and widely used in, developing countries [10]. Details of these nationally representative surveys have been described elsewhere [11]. We used data from the interviews with women of reproductive age which includes information about their children. As the 1992 and 1998 surveys included only those children who were under age three and born to those women in the household who were interviewed, the 2005 data were restricted to children meeting these two criteria. Data on Sikkim were missing in 1992 and data from Tripura were missing in 1998, therefore we excluded these states from our analytic sample. The original sample size from the three surveys, inclusion and exclusion criteria, and the resulting analytic sample size for each survey are shown in Figure 1. The individual response rate for women was 96.1% in 1992, 95.5% in 1998 and 94.5% in 2005. Following convention, we operationalized undernutrition as four binary variables denoting underweight, severely underweight, stunted and severely stunted. We used the World Health organization standards to compute the Z scores for weight-for-age and height-for-age [12]. Following WHO guidelines, children with a Z score of less than 22 on these variables were classified as underweight and stunted, respectively. Children whose Z scores were less than 23 were classified as severely underweight and severely stunted. Typically, weight-for-height and its binary equivalent wasting are also used to report the nutritional status of a population. However, wasting is highly influenced by seasonality, and not appropriate for use as an indicator to compare undernutrition rates in a population over time [13]. We therefore did not include wasting in our analysis. The height and weight of the children were measured by one researcher on each survey team. Height was measured to the nearest 0.1 cm using a measuring board, taking care to measure length for children less than 2 years of age. Weight was measured using the UNICEF Uniscale to the nearest 100 grams. --- Predictor Variables The predictors of interest in this study were: household wealth, maternal education, caste, and urban residence. We chose these variables because social epidemiological theories [5], as well as previous studies [7][8][9] indicate that they are important determinants of undernutrition among young children in India. Household wealth was operationalized as possession of household assets e.g., television, mattress, cattle. The dataset contained an index of household assets that had been created by ORC Macro using principal components analysis on items related to possession of assets [14]. This method was developed by Filmer and Pritchett and the index has been found to correlate highly with income data in developing countries [15]. We weighted the PCA scores in the dataset by the household sampling weights to ensure that the distribution was representative of all the households in India and then divided the households into quintiles. Since we were interested in the relative disparity among different wealth quintiles in each year, the quintiles were created separately for each survey. We constructed the maternal education variable using data on the number of years of schooling with the following categories: no education , primary education , secondary education and greater than secondary . We operationalized the caste variable as having the following categories: Scheduled caste, Scheduled tribe, ''Other'' caste and ''missing/no'' caste. This classification focuses more on the socially disadvantaged castes, and all privileged caste groups are represented in the ''Others'' group [16]. The census of India definition of urban/rural [17] was used to classify a household as urban or not. --- Covariates The association between undernutrition and the predictor variables of interest was assessed after accounting for the following covariates: age in months, gender, birth order of child, religion, and age of mother --- Analysis Plan Prevalence of underweight, severe underweight, stunted, and severely stunted were calculated for each survey period using survey analysis methods that account for sampling design. In order to account for the multilevel structure of the data and to account for clustering, we used a logistic multilevel modeling approach, with random effects specified for households, clusters and states. Specifically, we modeled the log odds of undernutrition for child i in household j, cluster k, nested in state l. In order to measure the trend in social disparities over time, we assessed whether the association between predictor of interest and undernutrition varied by survey year. This assessment required us to pool the data from all three years and test for interactions between the predictor of interest and the survey year in the pooled dataset using Wald tests. We additionally fit our final models stratified by survey year. The final models for all four outcomes included household wealth, maternal education, caste, and urban residence , as well as age in months, gender, birth order of child, religion, and age of mother. For presentation, we report the estimates and standard errors as model-based predicted probabilities , along with their 95% confidence intervals We also present disparities in undernutrition using the prevalence ratio [18], which is a better estimate than the odds ratio when the outcome is not a rare event. All analyses were conducted using SAS 9.1 and MLwiN 2.10 [19]. --- Results The overall prevalence of underweight was 49. 14, 43.82 and 40.26 in 1992, 1998 and 2005 respectively. The corresponding prevalence of stunting was 52.43, 50.65, and 44.73. The bivariate distributions of the prevalence of underweight, severe underweight, stunting and severe stunting are given in Table 1. --- Results of stratified multivariable multilevel analyses Household wealth, caste, and maternal education were significant predictors of all four undernutrition outcomes. There was no evidence to suggest that urban residence was associated with undernutrition once household wealth, maternal education and caste were included in the model. Predicted probabilities of being underweight, severely underweight, stunted or severely stunted are shown in Tables 2 and3. Figures 2345display the trends in the disparities in severe underweight and severe stunting across categories of wealth and maternal education. These results are from models accounting for household wealth, maternal education, caste, and urban residence , as well as age in months, gender, birth order of child, religion, and age of mother. All tests of interactions refer to interactions of the particular social factor with the survey year. --- Trends in disparities by wealth There was a clear gradient in the association between wealth quintiles and the probability of being undernourished, greater household wealth was associated with lower probabilities of all four outcomes. This pattern was seen for all survey years. Figure 2 displays the prevalence ratio of severe underweight across wealth quintiles over time Figure 4 displays prevalence ratios for severe stunting As can be seen from Table 2, while the probability of being severely underweight has decreased for all wealth groups between 1992 and 1998, this decrease was of smaller magnitude between 1998 and 2005. However, Figure 2 shows that wealth-based disparities on the ratio scale increased over time. The ratio of predicted probability in the poorest quintile to that in the richest quintile was 2 in 1992, 2.5 in 1998 and 2.8 in 2005. A similar pattern was seen for severely stunted , underweight and stunting . --- Trends in disparities by maternal education Just as observed with wealth quintiles, there was a clear gradient in the association between maternal education and the probability of being undernourished. Children of mothers with greater education had lower likelihood of being undernourished. Figure 3 displays the trends in the prevalence ratio of being severely underweight across categories of maternal education over the three survey years The probability of being severely underweight decreased for children of all maternal education groups between 1992 and 1998; however the rates appear static between 1998 and 2005 . The disparities on a ratio scale did not change much across the survey years. For severe stunting, however, the pattern was different-there was a decrease in predicted probability and a slight widening of disparities over time , with the prevalence ratios of 1.5 in 1992, 1.9 in 1998 and 1.9 in 2005 --- Trends in disparities by caste Children belonging to Scheduled Castes and Scheduled Tribes were statistically more likely to be undernourished as compared to children from the socially privileged Other caste in each of the three periods, however the effect size was small. The general trend was of decreasing probability of being severely underweight and severely stunted for all caste groups over the three periods. There was no significant trend in the disparities on a ratio scale by caste. --- Discussion This examination of social disparities in undernutrition among Indian children aged less than three years using nationally represen-tative survey data from 1992, 1998 and 2005 presented a complex picture. We discuss three major findings. First, the overall prevalence rates of undernutrition in India decreased over the 1992-2005 period; second, social disparities in undernutrition over these years either widened or stayed the same, however the absolute rates of undernutrition have decreased for everyone regardless of their social status; and third, the disparities by household wealth were greater than the disparities by maternal education. --- Trends in undernutrition This study found that there was a steady decrease in the rates of stunting in the 1992-2005 period, while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005. Numerous factors might have influenced this decline in stunting including, for example, the rapid economic growth India has experienced between 1990 and 2007, the provision of primary health care at the national level resulting in improved health of girl children over generations and implementation of preventive nutrition programs such as the Integrated Child Development Services Scheme [2]. Although the declining trend is a positive Figure 2. Prevalence ratio of being severely underweight by quintiles of household wealth. X axis = survey year. Y axis = prevalence ratio. Blue rhomboid = richest quintile, reference group . Pink square = second quintile. Green triangle = third quintile. Orange square = fourth quintile. Purple square = poorest quintile. PR from model adjusting for age in months, gender, birth order of child, age of mother, religion, household wealth, maternal education, caste, and urban residence. P value for Wald test of interaction between survey year and wealth quintiles = 0.015. doi:10.1371/journal.pone.0011392.g002 Figure 3. Prevalence ratio of being severely underweight by maternal education. X axis = survey year. Y axis = prevalence ratio. Blue rhomboid = .secondary education , reference group . Pink square = secondary education . Green triangle = primary education . Orange square = no schooling . PR from model adjusting for age in months, gender, birth order of child, age of mother, religion, household wealth, maternal education, caste, and urban residence. P value for Wald test of interaction between survey year and maternal education was .0.05. doi:10.1371/journal.pone.0011392.g003 finding, it needs to be tempered by the fact that the absolute rates of undernutrition in India continue to be higher than the majority of developing countries [2]. One study compared the trends in stunting among underfives in China and India during the 1990s and found that the rate of stunting in India remained almost unchanged while it halved between 1992 and 1998 in China [4]. A simple calculation using UNICEF data for 1994 and 2000-2006 allows us to compare the decline in undernutrition among underfives among various countries . India appears to lag behind comparable countries in reducing underweight, but has experienced some success, relative to others, in decreasing stunting over the years. Blue rhomboid = richest quintile, reference group . Pink square = second quintile. Green triangle = third quintile. Orange square = fourth quintile. Purple square = poorest quintile. PR from model adjusting for age in months, gender, birth order of child, age of mother, religion, household wealth, maternal education, caste, and urban residence. P value for Wald test of interaction between survey year and wealth quintiles = 0.053. doi:10.1371/journal.pone.0011392.g004 Figure 5. Prevalence ratio of being severely stunted maternal education. X axis = survey year. Y axis = prevalence ratio. Blue rhomboid = .secondary education , reference group . Pink square = secondary education . Green triangle = primary education . Orange square = no schooling . PR from model adjusting for age in months, gender, birth order of child, age of mother, religion, household wealth, maternal education, caste, and urban residence. P value for Wald test of interaction between survey year and maternal education = 0.022. doi:10.1371/journal.pone.0011392.g005 --- Trends in social disparities in undernutrition We found that social disparities in undernutrition either widened or were static, but never narrowed, against a background of national economic growth. Disparities in underweight and stunting by household wealth were progressively wider when we compared surveys over the 1992-2005 period. Even as we saw a lowering of undernutrition among all wealth groups, children from better-off families experienced a greater decline in undernutrition between 1992 and 2005 compared to children from households in the lowest wealth quintile, and these disparities widened over time. When viewed in a context of decreasing poverty but increasing income inequality [20], these findings suggest that children from better-off families have benefited from the economic growth to a greater extent than children from poor families. Rising income inequality has been linked to underinvestment in human capital because it leads to lack of attention and resources towards programs that benefit the poor and a greater focus on policies that benefit the well-off, and this adversely affects the health status of the poor [21]. Disparities in undernutrition by levels of maternal education were generally similar to wealth based disparities. Although slightly widened for stunting, disparities have stayed the same for underweight. The period of 1992-2005 has seen a rapid spread in the reach of mass media as well as a broadening in the content of media messages [22] and given the reach of satellite television [23] and mobile telephones in India [24], we might expect greater health dividends at every level of education. Notably, disparities in stunting, a marker of chronic undernutrition, appeared to widen over time. However, the rates of stunting have decreased at all levels of maternal education. We can conclude that the advantages of economic growth might be reaching children irrespective of their mother's education, although children of better-educated mothers appear to have benefited to a greater extent. There was no change in the pattern of the caste based disparities in undernutrition between 1992 and 2005. Additionally, the association between caste and undernutrition in each year, while statistically significant, was of extremely small magnitude once household wealth and maternal education were accounted for. This implies that inequalities by wealth and education account for most of the caste-based disparities in undernutrition. While Bharati et al [9] report that children from historically disadvantaged caste groups had, on average, lower levels of weight-for-age and height-for-age, our findings are not directly comparable to their study because they pool all disadvantaged caste groups together while we look at them as separate categories. Remarkably, we did not find any evidence for differential rates of undernutrition based on urban residence or gender after accounting for household wealth, maternal education, caste and other factors. These findings correspond with the results reported by Bharati et al [9], even though their operationalization of nutritional status differs from ours. A review of literature revealed only one study that examined trends in social disparities in child undernutrition in a developing country setting. This study used nationally representative data from Cameroon from 1991 and 1998 [25] and found that household economic status and maternal education were positively associated with weight-for-age and height-for-age Z scores among children less than 3 years of age. The study also found that, between 1991 and 1998, the beneficial effect of maternal education strengthened and the gap between the richest and the poorest groups increased, although these results did not attain statistical significance. Our results correspond with those of the Cameroon study, though they used Z scores to assess nutritional status while we used binary variables. --- Household wealth versus maternal education A comparison of the trend in inequalities over time shows us that disparities by household wealth were greater than those by maternal education The trend was of increasing wealth based inequalities in both underweight and stunting whereas maternal education based disparities widened slightly for stunting. Additionally, the differentials on the ratio scale as well as the absolute difference in probabilities show that increasing wealth-based disparities are of greater magnitude than maternal education based disparities. This suggests that a reduction in economic disparities might lead to a great reduction in social disparities in undernutrition. This comparison underscores the need to critically examine the manner in which economic growth at the national level is affecting the economic status of various groups in the population. --- Limitations A few limitations need to borne in mind while interpreting the results of this study. First, our interpretations frequently refer to the economic growth in India as a proximal determinant of social disparities in undernutrition, though our study is not designed to examine the effects of economic growth on these disparities. However, to our knowledge, this is the first study to describe the trends in social disparities in undernutrition in this population in the background of rapid economic growth. Second, we acknowledge the large amount of missing data on undernutrition outcomes in our study. However, a comparison of the sociodemographic distribution among those missing and not missing data showed that our analytic sample is very similar to those missing data. We therefore believe that our findings are not affected to a great extent by the missingness; however, this remains an issue and needs to borne in mind while interpreting the results. Given that this is the only nationally representative source of data on undernutrition among young children, and is used by national and international agencies [2], we are using the best data that are available. Therefore, we think that the results of this study are generalizable to all children under age three across India. Another limitation is that we were unable to explore differences, if any, between the Other Backward Classes caste group and the privileged ''Other'' caste group. Since the 1992 data contained only three caste groupings-SC, ST and Other, we were forced to pool OBC and the Other group in the 1998 and 2005 data. Similarly, data limitations prevented us from using a finer classification of the urban residence variable, such as large cities, smaller towns and villages. Fourth, education was measured as years of schooling, and might not be comparable over time. For example, a high school education in 1992 might be very different from a high school education in 2005. However such differences, if any, would have resulted in a non-differential bias. Also, we were able to compare how children from wealthier families differed from less wealthy families but unable to study the relationship between absolute levels of wealth and undernutrition. While trends in disparities by absolute levels of wealth are important, the NFHS is not the best source of data for such an analysis. However, we believe that the trends presented in this study raise important questions about the underlying causes for the widening wealth based disparities in undernutrition during a period of rapid economic growth. --- Conclusion This study displayed trends in social disparities in childhood undernutrition in India using data from a time when India began experiencing major economic growth. We would expect this growth to have increased household income, decreased food insecurity and improved the quality of nutrients available to Indians. Supporting this argument, we see that rates of undernutrition decrease over the 14 years, across all social groups. However, this decrease was unequal across categories of household wealth and maternal education. Notably, no narrowing of social disparities was observed in this study, despite using underweight and stunting, two indicators that capture both acute and chronic effects of undernutrition. The high rates of undernutrition and the persistent social disparities need to be addressed in an urgent and comprehensive manner. --- Supporting Information

Background: India experienced a rapid economic boom between 1991 and 2007. However, this economic growth has not translated into improved nutritional status among young Indian children. Additionally, no study has assessed the trends in social disparities in childhood undernutrition in the Indian context. We examined the trends in social disparities in underweight and stunting among Indian children aged less than three years using nationally representative data.We analyzed data from the three cross-sectional rounds of National Family Health Survey of India from 1992, 1998 and 2005. The social factors of interest were: household wealth, maternal education, caste, and urban residence. Using multilevel modeling to account for the nested structure and clustering of data, we fit multivariable logistic regression models to quantify the association between the social factors and the binary outcome variables. The final models additionally included age, gender, birth order of child, religion, and age of mother. We analyzed the trend by testing for interaction of the social factor and survey year in a dataset pooled from all three surveys. Results: While the overall prevalence rates of undernutrition among Indian children less than three decreased over the 1992-2005 period, social disparities in undernutrition over these 14 years either widened or stayed the same. The absolute rates of undernutrition decreased for everyone regardless of their social status. The disparities by household wealth were greater than the disparities by maternal education. There were no disparities in undernutrition by caste, gender or rural residence. Conclusions: There was a steady decrease in the rates of stunting in the 1992-2005 period, while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005. Social disparities in childhood undernutrition in India either widened or stayed the same during a time of major economic growth. While the advantages of economic growth might be reaching everyone, children from better-off households, with better educated mothers appear to have benefited to a greater extent than less privileged children. The high rates of undernutrition (even among the socially advantaged groups) and the persistent social disparities need to be addressed in an urgent and comprehensive manner.

introduction india is experiencing a rapid economic boom due in part to the opening of its markets in the 1990s and the emergence of a knowledgebased economy 1 however this prosperity has not translated into wellbeing among the countrys young children the prevalence of underweight among children under age five in india is one of the highest in the world43 in 2006surpassed only by bangladesh yemen and timorleste 2 india is home to 55 million of the worlds underweight children under age fiveabout onethird of the global burden of underweight in this age group 3 during the prosperous 1990s the average rate of decline in prevalence of underweight has been around 09 per year among indian children aged below five years 3 whereas in china another asian country with a rapidly growing economy it declined by approximately 5 per year 4 the nutritional status of young children is an important indicator of health and developmentit is not only a reflection of past health insults but an important indicator of future health trajectories 5 children under age three are particularly vulnerable to undernutrition and because the growth rate in this period is greater than any other age period it increases the risk of growth retardation 6 furthermore undernutrition among young children captures the extent of development in a society 5 and is thus a marker for the overall well being of a population it is well established that socioeconomic factors such as lower levels of household wealth and maternal education are important causes of childhood undernutrition 5 few studies have analyzed patterns of distribution of childhood undernutrition in india across social factors such as household wealth and maternal education using nationally representative data 7 8 9 however these were all cross sectional analyses and we did not find any published study that has evaluated the pattern of social disparities in childhood undernutrition in india across time studying the trend in social inequalities in childhood undernutrition over a period of economic growth sheds light on the potential benefits and adverse effects of such growth on this vulnerable population thereby allowing us to review economic policies and their implementation from a public health perspective we therefore examined trends in social disparities in undernutrition among indian children under age three over the period of 19922005 using nationallevel data on child nutritional status from three crosssectional surveys conducted in 1992 1998 and 2005 methods ethics statement the data were analyzed anonymously using publicly available secondary data therefore no ethics statement is required for this work data we analyzed data from the three crosssectional rounds of national family health survey of india held in 1992 1998 and 2005 to examine the trends in social disparities in undernutrition among children less than three years of age these surveys used a multistage cluster sampling design to collect data on fertility mortality family planning and important aspects of nutrition health and health care the nfhs is the indian version of the demographic and health surveys which use standard model questionnaires designed for and widely used in developing countries 10 details of these nationally representative surveys have been described elsewhere 11 we used data from the interviews with women of reproductive age which includes information about their children as the 1992 and 1998 surveys included only those children who were under age three and born to those women in the household who were interviewed the 2005 data were restricted to children meeting these two criteria data on sikkim were missing in 1992 and data from tripura were missing in 1998 therefore we excluded these states from our analytic sample the original sample size from the three surveys inclusion and exclusion criteria and the resulting analytic sample size for each survey are shown in figure 1 the individual response rate for women was 961 in 1992 955 in 1998 and 945 in 2005 following convention we operationalized undernutrition as four binary variables denoting underweight severely underweight stunted and severely stunted we used the world health organization standards to compute the z scores for weightforage and heightforage 12 following who guidelines children with a z score of less than 22 on these variables were classified as underweight and stunted respectively children whose z scores were less than 23 were classified as severely underweight and severely stunted typically weightforheight and its binary equivalent wasting are also used to report the nutritional status of a population however wasting is highly influenced by seasonality and not appropriate for use as an indicator to compare undernutrition rates in a population over time 13 we therefore did not include wasting in our analysis the height and weight of the children were measured by one researcher on each survey team height was measured to the nearest 01 cm using a measuring board taking care to measure length for children less than 2 years of age weight was measured using the unicef uniscale to the nearest 100 grams predictor variables the predictors of interest in this study were household wealth maternal education caste and urban residence we chose these variables because social epidemiological theories 5 as well as previous studies 7 8 9 indicate that they are important determinants of undernutrition among young children in india household wealth was operationalized as possession of household assets eg television mattress cattle the dataset contained an index of household assets that had been created by orc macro using principal components analysis on items related to possession of assets 14 this method was developed by filmer and pritchett and the index has been found to correlate highly with income data in developing countries 15 we weighted the pca scores in the dataset by the household sampling weights to ensure that the distribution was representative of all the households in india and then divided the households into quintiles since we were interested in the relative disparity among different wealth quintiles in each year the quintiles were created separately for each survey we constructed the maternal education variable using data on the number of years of schooling with the following categories no education primary education secondary education and greater than secondary we operationalized the caste variable as having the following categories scheduled caste scheduled tribe other caste and missingno caste this classification focuses more on the socially disadvantaged castes and all privileged caste groups are represented in the others group 16 the census of india definition of urbanrural 17 was used to classify a household as urban or not covariates the association between undernutrition and the predictor variables of interest was assessed after accounting for the following covariates age in months gender birth order of child religion and age of mother analysis plan prevalence of underweight severe underweight stunted and severely stunted were calculated for each survey period using survey analysis methods that account for sampling design in order to account for the multilevel structure of the data and to account for clustering we used a logistic multilevel modeling approach with random effects specified for households clusters and states specifically we modeled the log odds of undernutrition for child i in household j cluster k nested in state l in order to measure the trend in social disparities over time we assessed whether the association between predictor of interest and undernutrition varied by survey year this assessment required us to pool the data from all three years and test for interactions between the predictor of interest and the survey year in the pooled dataset using wald tests we additionally fit our final models stratified by survey year the final models for all four outcomes included household wealth maternal education caste and urban residence as well as age in months gender birth order of child religion and age of mother for presentation we report the estimates and standard errors as modelbased predicted probabilities along with their 95 confidence intervals we also present disparities in undernutrition using the prevalence ratio 18 which is a better estimate than the odds ratio when the outcome is not a rare event all analyses were conducted using sas 91 and mlwin 210 19 results the overall prevalence of underweight was 49 14 4382 and 4026 in 1992 1998 and 2005 respectively the corresponding prevalence of stunting was 5243 5065 and 4473 the bivariate distributions of the prevalence of underweight severe underweight stunting and severe stunting are given in table 1 results of stratified multivariable multilevel analyses household wealth caste and maternal education were significant predictors of all four undernutrition outcomes there was no evidence to suggest that urban residence was associated with undernutrition once household wealth maternal education and caste were included in the model predicted probabilities of being underweight severely underweight stunted or severely stunted are shown in tables 2 and3 figures 2345display the trends in the disparities in severe underweight and severe stunting across categories of wealth and maternal education these results are from models accounting for household wealth maternal education caste and urban residence as well as age in months gender birth order of child religion and age of mother all tests of interactions refer to interactions of the particular social factor with the survey year trends in disparities by wealth there was a clear gradient in the association between wealth quintiles and the probability of being undernourished greater household wealth was associated with lower probabilities of all four outcomes this pattern was seen for all survey years figure 2 displays the prevalence ratio of severe underweight across wealth quintiles over time figure 4 displays prevalence ratios for severe stunting as can be seen from table 2 while the probability of being severely underweight has decreased for all wealth groups between 1992 and 1998 this decrease was of smaller magnitude between 1998 and 2005 however figure 2 shows that wealthbased disparities on the ratio scale increased over time the ratio of predicted probability in the poorest quintile to that in the richest quintile was 2 in 1992 25 in 1998 and 28 in 2005 a similar pattern was seen for severely stunted underweight and stunting trends in disparities by maternal education just as observed with wealth quintiles there was a clear gradient in the association between maternal education and the probability of being undernourished children of mothers with greater education had lower likelihood of being undernourished figure 3 displays the trends in the prevalence ratio of being severely underweight across categories of maternal education over the three survey years the probability of being severely underweight decreased for children of all maternal education groups between 1992 and 1998 however the rates appear static between 1998 and 2005 the disparities on a ratio scale did not change much across the survey years for severe stunting however the pattern was differentthere was a decrease in predicted probability and a slight widening of disparities over time with the prevalence ratios of 15 in 1992 19 in 1998 and 19 in 2005 trends in disparities by caste children belonging to scheduled castes and scheduled tribes were statistically more likely to be undernourished as compared to children from the socially privileged other caste in each of the three periods however the effect size was small the general trend was of decreasing probability of being severely underweight and severely stunted for all caste groups over the three periods there was no significant trend in the disparities on a ratio scale by caste discussion this examination of social disparities in undernutrition among indian children aged less than three years using nationally representative survey data from 1992 1998 and 2005 presented a complex picture we discuss three major findings first the overall prevalence rates of undernutrition in india decreased over the 19922005 period second social disparities in undernutrition over these years either widened or stayed the same however the absolute rates of undernutrition have decreased for everyone regardless of their social status and third the disparities by household wealth were greater than the disparities by maternal education trends in undernutrition this study found that there was a steady decrease in the rates of stunting in the 19922005 period while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005 numerous factors might have influenced this decline in stunting including for example the rapid economic growth india has experienced between 1990 and 2007 the provision of primary health care at the national level resulting in improved health of girl children over generations and implementation of preventive nutrition programs such as the integrated child development services scheme 2 although the declining trend is a positive figure 2 prevalence ratio of being severely underweight by quintiles of household wealth x axis survey year y axis prevalence ratio blue rhomboid richest quintile reference group pink square second quintile green triangle third quintile orange square fourth quintile purple square poorest quintile pr from model adjusting for age in months gender birth order of child age of mother religion household wealth maternal education caste and urban residence p value for wald test of interaction between survey year and wealth quintiles 0015 doi101371journalpone0011392g002 figure 3 prevalence ratio of being severely underweight by maternal education x axis survey year y axis prevalence ratio blue rhomboid secondary education reference group pink square secondary education green triangle primary education orange square no schooling pr from model adjusting for age in months gender birth order of child age of mother religion household wealth maternal education caste and urban residence p value for wald test of interaction between survey year and maternal education was 005 doi101371journalpone0011392g003 finding it needs to be tempered by the fact that the absolute rates of undernutrition in india continue to be higher than the majority of developing countries 2 one study compared the trends in stunting among underfives in china and india during the 1990s and found that the rate of stunting in india remained almost unchanged while it halved between 1992 and 1998 in china 4 a simple calculation using unicef data for 1994 and 20002006 allows us to compare the decline in undernutrition among underfives among various countries india appears to lag behind comparable countries in reducing underweight but has experienced some success relative to others in decreasing stunting over the years blue rhomboid richest quintile reference group pink square second quintile green triangle third quintile orange square fourth quintile purple square poorest quintile pr from model adjusting for age in months gender birth order of child age of mother religion household wealth maternal education caste and urban residence p value for wald test of interaction between survey year and wealth quintiles 0053 doi101371journalpone0011392g004 figure 5 prevalence ratio of being severely stunted maternal education x axis survey year y axis prevalence ratio blue rhomboid secondary education reference group pink square secondary education green triangle primary education orange square no schooling pr from model adjusting for age in months gender birth order of child age of mother religion household wealth maternal education caste and urban residence p value for wald test of interaction between survey year and maternal education 0022 doi101371journalpone0011392g005 trends in social disparities in undernutrition we found that social disparities in undernutrition either widened or were static but never narrowed against a background of national economic growth disparities in underweight and stunting by household wealth were progressively wider when we compared surveys over the 19922005 period even as we saw a lowering of undernutrition among all wealth groups children from betteroff families experienced a greater decline in undernutrition between 1992 and 2005 compared to children from households in the lowest wealth quintile and these disparities widened over time when viewed in a context of decreasing poverty but increasing income inequality 20 these findings suggest that children from betteroff families have benefited from the economic growth to a greater extent than children from poor families rising income inequality has been linked to underinvestment in human capital because it leads to lack of attention and resources towards programs that benefit the poor and a greater focus on policies that benefit the welloff and this adversely affects the health status of the poor 21 disparities in undernutrition by levels of maternal education were generally similar to wealth based disparities although slightly widened for stunting disparities have stayed the same for underweight the period of 19922005 has seen a rapid spread in the reach of mass media as well as a broadening in the content of media messages 22 and given the reach of satellite television 23 and mobile telephones in india 24 we might expect greater health dividends at every level of education notably disparities in stunting a marker of chronic undernutrition appeared to widen over time however the rates of stunting have decreased at all levels of maternal education we can conclude that the advantages of economic growth might be reaching children irrespective of their mothers education although children of bettereducated mothers appear to have benefited to a greater extent there was no change in the pattern of the caste based disparities in undernutrition between 1992 and 2005 additionally the association between caste and undernutrition in each year while statistically significant was of extremely small magnitude once household wealth and maternal education were accounted for this implies that inequalities by wealth and education account for most of the castebased disparities in undernutrition while bharati et al 9 report that children from historically disadvantaged caste groups had on average lower levels of weightforage and heightforage our findings are not directly comparable to their study because they pool all disadvantaged caste groups together while we look at them as separate categories remarkably we did not find any evidence for differential rates of undernutrition based on urban residence or gender after accounting for household wealth maternal education caste and other factors these findings correspond with the results reported by bharati et al 9 even though their operationalization of nutritional status differs from ours a review of literature revealed only one study that examined trends in social disparities in child undernutrition in a developing country setting this study used nationally representative data from cameroon from 1991 and 1998 25 and found that household economic status and maternal education were positively associated with weightforage and heightforage z scores among children less than 3 years of age the study also found that between 1991 and 1998 the beneficial effect of maternal education strengthened and the gap between the richest and the poorest groups increased although these results did not attain statistical significance our results correspond with those of the cameroon study though they used z scores to assess nutritional status while we used binary variables household wealth versus maternal education a comparison of the trend in inequalities over time shows us that disparities by household wealth were greater than those by maternal education the trend was of increasing wealth based inequalities in both underweight and stunting whereas maternal education based disparities widened slightly for stunting additionally the differentials on the ratio scale as well as the absolute difference in probabilities show that increasing wealthbased disparities are of greater magnitude than maternal education based disparities this suggests that a reduction in economic disparities might lead to a great reduction in social disparities in undernutrition this comparison underscores the need to critically examine the manner in which economic growth at the national level is affecting the economic status of various groups in the population limitations a few limitations need to borne in mind while interpreting the results of this study first our interpretations frequently refer to the economic growth in india as a proximal determinant of social disparities in undernutrition though our study is not designed to examine the effects of economic growth on these disparities however to our knowledge this is the first study to describe the trends in social disparities in undernutrition in this population in the background of rapid economic growth second we acknowledge the large amount of missing data on undernutrition outcomes in our study however a comparison of the sociodemographic distribution among those missing and not missing data showed that our analytic sample is very similar to those missing data we therefore believe that our findings are not affected to a great extent by the missingness however this remains an issue and needs to borne in mind while interpreting the results given that this is the only nationally representative source of data on undernutrition among young children and is used by national and international agencies 2 we are using the best data that are available therefore we think that the results of this study are generalizable to all children under age three across india another limitation is that we were unable to explore differences if any between the other backward classes caste group and the privileged other caste group since the 1992 data contained only three caste groupingssc st and other we were forced to pool obc and the other group in the 1998 and 2005 data similarly data limitations prevented us from using a finer classification of the urban residence variable such as large cities smaller towns and villages fourth education was measured as years of schooling and might not be comparable over time for example a high school education in 1992 might be very different from a high school education in 2005 however such differences if any would have resulted in a nondifferential bias also we were able to compare how children from wealthier families differed from less wealthy families but unable to study the relationship between absolute levels of wealth and undernutrition while trends in disparities by absolute levels of wealth are important the nfhs is not the best source of data for such an analysis however we believe that the trends presented in this study raise important questions about the underlying causes for the widening wealth based disparities in undernutrition during a period of rapid economic growth conclusion this study displayed trends in social disparities in childhood undernutrition in india using data from a time when india began experiencing major economic growth we would expect this growth to have increased household income decreased food insecurity and improved the quality of nutrients available to indians supporting this argument we see that rates of undernutrition decrease over the 14 years across all social groups however this decrease was unequal across categories of household wealth and maternal education notably no narrowing of social disparities was observed in this study despite using underweight and stunting two indicators that capture both acute and chronic effects of undernutrition the high rates of undernutrition and the persistent social disparities need to be addressed in an urgent and comprehensive manner supporting information

background india experienced a rapid economic boom between 1991 and 2007 however this economic growth has not translated into improved nutritional status among young indian children additionally no study has assessed the trends in social disparities in childhood undernutrition in the indian context we examined the trends in social disparities in underweight and stunting among indian children aged less than three years using nationally representative datawe analyzed data from the three crosssectional rounds of national family health survey of india from 1992 1998 and 2005 the social factors of interest were household wealth maternal education caste and urban residence using multilevel modeling to account for the nested structure and clustering of data we fit multivariable logistic regression models to quantify the association between the social factors and the binary outcome variables the final models additionally included age gender birth order of child religion and age of mother we analyzed the trend by testing for interaction of the social factor and survey year in a dataset pooled from all three surveys results while the overall prevalence rates of undernutrition among indian children less than three decreased over the 19922005 period social disparities in undernutrition over these 14 years either widened or stayed the same the absolute rates of undernutrition decreased for everyone regardless of their social status the disparities by household wealth were greater than the disparities by maternal education there were no disparities in undernutrition by caste gender or rural residence conclusions there was a steady decrease in the rates of stunting in the 19922005 period while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005 social disparities in childhood undernutrition in india either widened or stayed the same during a time of major economic growth while the advantages of economic growth might be reaching everyone children from betteroff households with better educated mothers appear to have benefited to a greater extent than less privileged children the high rates of undernutrition even among the socially advantaged groups and the persistent social disparities need to be addressed in an urgent and comprehensive manner

INTRODUCTION Generativity, "the concern in establishing and guiding the next generation, " is the main task of development in mid-adulthood, and its acquisition and development are included in the activities of nurturing, production, and creation, which are the further development of ego-identity and the creation and extension of self-worth, and the goal of generativity is to promote individual development . Generativity involves both the motive and the behavior to support and guide younger people and to benefit "future generations" and generativity is adaptive, contributing positively to personality development and wellbeing . Building on Erikson's work, Kotre maintained that generativity is not attached to a certain age per se, but rather differently expressed across the adult lifespan. Furthermore, he distinguished four types of generativity: biological , parental , technical , and cultural generativity . With the recent development of China's aging population and the introduction of a nationwide two-child policy, the study of generativity sense, which is important for social and individual development, has received widespread attention from researchers . For example, researchers have found that generativity sense has an impact on individual career development, that fathers tend to benefit more than mothers from child-rearing activities, and that their commitment to family and child-rearing does not conflict with their social affairs and career development and success, but rather enhances men's self-efficacy . Peterson and Duncan found that generativity sense positively predicts positive female personality traits, marital and maternal satisfaction. As the research progressed, researchers, not content with Erikson's theories that emphasized only the positive dimensions of generativity sense for the middle-aged themselves and the subjects of generativity sense, began to explore the negative dimensions of generativity sense and developed an integrative theoretical framework of generativity sense . They explained generativity sense as a structural model of transformation that encompasses individual, interindividual, and social dynamics and includes seven components, of which generativity concern is central. Researchers have found a significant correlation between generativity concern and job burnout , but the mechanisms by which this occurs are unclear. Therefore, this study tends to explore the impact of job burnout on generativity concern. Job burnout is the physical, emotional, behavioral and mental exhaustion that occurs when an individual is unable to cope with the excessive demands of the external world beyond his or her energy and resources . Job burnout is manifested in three main areas: emotional exhaustion, dehumanization, and decreased personal fulfillment. Researchers have found that job burnout affects an individual's generativity concern . Both emotional exhaustion and depersonalization in burnout were significantly correlated with family-work conflict, and excessive family-work conflict significantly reduced an individual's generativity focus . On the one hand, mid-adulthood is an important period in an individual's career development, with heavy workloads that make the individual more prone to burnout . While on the other hand, mid-adulthood is also a time when the family is faced with a number of issues, whether it be peer development or child rearing, that stretch an already overburdened individual's time and energy . Job burnout has been shown to be positively correlated with affective problems such as anxiety, which affects an individual's focus on children as well as developmental themes, i.e., generativity concerns . The socio-emotional selectivity theory has been used to explain the changes in work motivation as individuals age . The theory posits that as the time horizon of a person's life course shortens, the priority of different goals changes. Individuals become more critical and devote more resources to emotionally meaningful goals and activities. In midadulthood, burnout leaving individuals with less energy to devote to events relevant to their sense of reproduction and, naturally, less concern for the positive aspects of themselves and the objects of their generativity. At the same time, the lack of positive feedback from generativity makes it difficult for individuals who are burned out to devote resources to people and events related to the sense of reproduction, thus reducing their attention to the generativity concern. On the other hand, the family is a social unit whose internal climate has a moderated effect on emotional stability and motivation . It has been found that family members with higher family intimacy and better adaptability are less affected by the negative effects of job burnout . Family members with high family intimacy and adaptability can derive emotional and material support from their family and social relationships, resulting in greater attention to things related to generativity concern . Therefore, this study explores the "how" and "under what conditions" burnout affects policemen's generativity concern, using subjective well-being as a mediator and family intimacy and adaptability as moderating variables. --- The Mediating Role of Subjective Well-Being Between Job Burnout and Generativity Concerns It is a comprehensive psychological indicator of an individual's quality of life and reflects the individual's state of social functioning and adjustment . Conservation of resources theory suggests that individuals tend to strive for, preserve, and maintain their precious resources, which include limited time, wealth, psychological comfort, optimism, and support factors. In the workplace, when individuals perceive a threat to their resources and find it difficult to adapt to work, there is a spiral of loss of resources and eventually burnout, which undermines their happiness . Research has found that burnout is an effective predictor of their subjective wellbeing , due to the fact that individuals who are burned out severely deplete physiological and psychological resources and disrupt the work-family balance. Burnout increases an individual's unhealthy behaviors , which in turn leads to a variety of physiological symptoms; burnout leads to increased negative emotions and symptoms such as anxiety and depression ; the depletion of physiological and psychological resources caused by job burnout, which in turn leads to the individual's inability to devote sufficient time and energy to other roles , and interference and conflict between different roles, which affects the individual's work-family balance . Subjective well-being is closely related to generativity , and subjective well-being effectively predicts generativity concerns, with individuals with high life satisfaction and physical and psychological well-being paying more attention to generativity and wanting satisfaction from multifaceted developmental tasks . Peterson and Duncan also found that women's satisfaction with motherhood positively predicted their generativity concern. These studies suggest that subjective well-being may mediate between job burnout and generativity concern, therefore, the current study examines the effect of job burnout, mediated by subjective wellbeing, on generativity concern. --- The Moderating Role of Family Intimacy and Adaptability on the Generativity Concerns of Job Burnout Effects Family intimacy and adaptability refers to the emotional ties between family members and the ability of the family system to change in response to problems that arise in family situations and at different stages of family development . Family intimacy and adjustment have been shown to be significantly positively correlated with positive factors such as an individual's interpersonal trust and significantly negatively correlated with negative factors such as depression . It has also been found that family intimacy is also positively correlated with adjustment and social support . Thus, individuals with higher family intimacy and adaptability tend to receive support and understanding from family and social relationships when experiencing job burnout, thereby reducing depression and the negative impact on reduced subjective well-being. Families with lower family intimacy and adaptability also have lower levels of trust among members. When experiencing job burnout, individuals tend to experience greater stress and negative emotions, as well as reduced generativity concerns ). In summary, the moderating effects of family intimacy and adaptability may exist between job burnout and generativity concern. On the one hand, good family intimacy and adaptability can protect individuals from the negative effects of job burnout, thus reducing generativity concern; on the other hand, there is a joint effect between job burnout and low family intimacy and adaptability, thus increasing the reduction of generativity concern. Therefore, this study focuses on the local policemen to investigate the effect of job burnout on the generativity concern of individuals. An important mechanism by which job burnout affects reproductive concern is that individuals with lower subjective well-being are more likely to have negative experiences after job burnout, and thus exhibit lower generativity concern. Therefore, this study hypothesizes that H1: Subjective well-being play a mediating role between job burnout and the generativity concern of policemen. On the other hand, family intimacy and adaptability play a mitigating role in the effect of job burnout on generativity concern, and this study hypothesizes that H2: the mediating role of subjective well-being is moderated by family intimacy and adaptability, i.e., subjective well-being is a moderating mediating variable between job burnout and generativity concern, see Figure 1. --- METHODS --- --- Measures The Loyola Generativity Scale was developed by McAdams and de St Aubin . The LGS consists of 20 items, each of which is self-rated from 0 "not at all for me" to 3 "often or always for me, " with 6 items being reverse scored. In the present study, the Cronbach's alpha coefficient for the entire scale was 0.80. Satisfaction with life scale was designed by Diener et al. . The scale consists of five items scored on a 7point Richter scale, with l indicating "strongly disagree" and 2 indicating "strongly agree." The total score of the scale is the sum of the scores for each question, and the range of scores is from 5 to 35. Studies have shown that the scale is a valid and reliable tool for measuring life satisfaction. Family Intimacy and Adaptation Scale was developed by Olson . The FACES II contain 30 items, 5 of which are reverse scoring items. In this study, the Cronbach's alpha coefficients for the two subscales were 0.920 and 0.904, respectively. Maslach Burnout Inventory was developed by Maslach and Jackson . The whole questionnaire consisted of 16 questions, which was later revised to 15 questions by Chinese researchers. In this study, the Cronbach's alpha coefficient for the whole questionnaire was 0.92, and the Cronbach's alpha coefficients for the three subscales were 0.94, respectively. --- Procedure The general demographic questionnaire and the official scale were bound in a booklet, and the sampling and distribution of the questionnaires were done with the assistance of postgraduate students, using the same instructions, and collected through onsite distribution, which took ∼30 min to complete. Statistical analysis of the collected data was performed using SPSS 20.0. --- RESULTS --- Control and Testing of Common Method Deviations The data collected in this study were collected from the selfreports of the respondents, and thus common method bias may exist. To reduce the impact of this bias on the results of the study, in terms of procedural control, this study set different response statements for each measurement questionnaire item, either in terms of degree of compliance or frequency. Statistically, the degree of common method bias of the data was tested using the Harman one-factor model method . The results showed that there were 22 factors with eigenvalues greater than one, and the first factor explained only 7.06% of the variance, which was much less than the critical value of 40%, indicating that there was no serious homoscedasticity bias for each variable in this study. --- Descriptive Statistics The mean, standard deviation and Pearson Correlation Coefficient for each variable are presented in Table 1. The results showed that the variables of subjective well-being, generativity concern, family intimacy and adaptability were both significantly positively correlated and job burnout was significantly negatively correlated ; and most of the correlations between demographic variables such as age, gender, with or without of child, marital status, and income, and the above-mentioned research variables have reached a statistically significant level, so it is necessary to control for them in the following analysis. --- Test for Moderated Mediation Effect Following the recommendations of Muller et al. , testing a moderated mediating model requires the estimation of three equations: Equation 1 estimates the moderating effect of the moderating variable on the relationship between the independent variable and the dependent variable . Equation 2estimates the moderating effect of the moderating variable on the relationship between the independent variable and the mediating variable . Equation 3estimates the moderating effect of the moderating variable on the relationship between the mediating variable and the dependent variable . All predictor variables were standardized in each equation, controlling for demographic variables such as age and gender. As shown in Table 2, job burnout significantly negatively predicted generativity concern in Equation 1 , but the interaction term for job burnout and intimacy was not a significant predictor of generativity concern . Job burnout negatively predicted subjective well-being in Equation 2 , but the interaction term for job burnout and intimacy was not significant in predicting subjective well-being . Subjective well-being in Equation 3 positively predicted generativity concern , while the interaction terms of subjective well-being and intimacy were also significant in predicting generativity concern . Thus, the four variables of job burnout, subjective well-being, intimacy, and generativity concern constituted a moderated mediation model, and the moderating effect occurred only in the second half of the mediating effect, i.e., the effect of subjective well-being on generativity concern was moderated by intimacy. To reveal how intimacy modulates the effect of subjective well-being on generativity concern, we grouped high and low according to the score of intimacy and plotted the interaction as shown in Figure 2. The simple slope test showed that when the level of intimacy was high , the degree of subjective well-being on generativity concern showed a more obvious upward trend ; when the level of intimacy was low , the degree of subjective well-being on generativity concern showed an upward trend with a signs of leveling off . Thus, intimacy can play a facilitating role in the positive predictive effect of subjective well-being on generativity concerns. The same procedure was used to test for the moderating effect of adaptation. As shown in Table 3, job burnout significantly negatively predicted generativity concern in Equation 1 , but the interaction term of job burnout and adaptability was not a significant predictor of generativity concern . Job burnout negatively predicted subjective well-being in Equation 2 , but the interaction term for job burnout and adaptability was not significant in predicting subjective well-being . In Equation 3subjective well-being positively predicted generativity concern , while the interaction term of subjective well-being and adaptability was also significant in predicting generativity concern . Thus, the four variables of job burnout, subjective well-being, adaptability, and generativity concern also constituted a moderated mediation model, and the moderating effect occurred only in the second half of the mediation effect, i.e., the effect of subjective well-being on generativity concern was moderated by adaptability. To reveal how adaptation modulates the effect of subjective well-being on generativity concern, the interaction diagrams shown in Figure 3 are plotted by grouping high and low according to the score of adaptation. A simple slope test showed that when the level of adaptation was high , the degree of influence of subjective well-being on generativity concern showed a more pronounced upward trend ; when the level of adaptation was low , the upward trend of the degree of influence of subjective well-being on generativity concern showed signs of flattening . Thus, adaptation can play a facilitating role in the positive predictive role of subjective well-being on generativity concerns. --- DISCUSSION This study found that job burnout negatively influenced generativity concern, which is consistent with previous findings that the higher the level of job burnout, the lower the generativity concern . The current findings also show that subjective well-being mediates between job burnout and generativity concern, which confirms our hypothesis. Poor wellbeing and moderate to high levels of burnout are associated . Adults' satisfaction in work and life can extend to a broader range of concerns, such as concern for their own achievements, concern for the growth and well-being of the next generation, caring for others, and caring for the community, i.e., generativity concern . When job burnout occurs, adults' physiological and psychological resource depletion and work-family balance are disrupted, which negatively affects an individual's subjective well-being and may even produce anxiety and depression , all of which are detrimental to an individual's of productive and creative activities. Adult subjective well-being is closely related to generativity concern, and a decrease in well-being affects an individual's generativity concern, i.e., a decrease in concern, care, and concern for the next generation, others, and society ). The current study provides supportive evidence for this hypothesis. The present study found that there was a moderating effect of family intimacy and adaptability on the indirect effect between job burnout and generativity concern. Work-family conflict can predict greater levels of emotional exhaustion, the multi-group path models test suggest that the type and level of job resource moderates the relationship between job burnout and job satisfaction . For different levels of family intimacy and adaptability, the magnitude of the mediating effect of job burnout through subjective well-being on generativity sense concern varied. The indirect effect was more pronounced for adults with lower family intimacy and adaptation than for adults with higher family intimacy and adaptation. Specifically, the moderating effect of family intimacy and adaptability occurs in the second half of the mediating chain pathway, where the relationship between subjective well-being and generativity concern depends on the level of family intimacy and adaptability. As shown in Figures 2,3, low levels of family intimacy and adaptability can significantly reduce the positive effect of subjective wellbeing on generativity concern, while high levels of family intimacy and adaptability can enhance this effect. Thus, for adults who are burned out, low levels of family intimacy and adaptability and high levels of family intimacy and adaptability play the roles of "adding insult to injury" and "give timely assistance, " respectively. Family intimacy and adaptability, as important family relationship indicators that measure the degree of emotional and material support available to adults in the family environment , play an extremely important role in adults' social relationships. Good family intimacy and adaptability allows family members to enjoy a warm and supportive family environment, prompting the psychological --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- experience of their productive and creative activities to extend into a wider space, resulting in a higher willingness to care for others and for the community. The psychological processes resulting from subjective well-being can be weakened or enhanced in the important environment of the family. --- CONCLUSION Subjective well-being mediates between burnout and generativity concern, i.e., burnout has an indirect effect on generativity concern by influencing the subjective well-being of adults. The relationship between subjective well-being and generativity concern is moderated by family intimacy and adaptation, both of which enhance the positive effect of subjective well-being on generativity concern. --- STUDY LIMITATIONS Though this study makes several contributions to the literature on job burnout and affective well-being, its limitation is worthy of note. The sample used, study design , lack of adjustment for possible confounders and was conducted only in H city from China are significant limitations of the study. In using an availability sample of police officers, there is a risk of potentially having a biased sample. --- ETHICS STATEMENT The studies involving human participants were reviewed and approved by The study protocol was approved by Hezhou University Ethnics Committee, and has been executed consistent with ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.. The patients/participants provided their written informed consent to participate in this study. --- --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background: Policemen all over the world are tasked with the heavy work of maintaining social security. With the imbalance in mentality brought about by high population density and social transformation, the work of the Chinese police is particularly hard. As the window of demographic dividend is closing and the number of newborns is insufficient, China has started to adjust its established fertility policy to encourage a family to have two children. However, the results have not met the expectations of the policy adjustment. It is generally believed that factors such as high work pressure, high parenting costs, and low levels of happiness may be the main reasons for low fertility intentions. Studying this typical population of police officers may explore the relationship between work stress, happiness, and reproductive concerns, and provide evidence of Chinese sample. Objectives: To explore the relations between job burnout, subjective well-being, and generativity concern in Chinese police officers.The study used a cross-sectional survey to collect data from 494 police officers from H city in China. The participants completed the Maslach Burnout Inventory (MBI), the Family Adaptability and Cohesion Scale (FACESII), the Loyola Generativity Scale (LGS), and the Satisfaction with life scale (SWLS). Moderated mediation effect models assessed the association between job burnout, subjective well-being, and generativity concern. Results: Job burnout had a significant negative predictive effect on both subjective well-being and generativity concern, and subjective well-being played a mediating role between job burnout and generativity concern. In addition, family intimacy and adaptability had a significant negative moderating effect between subjective well-being and generativity concern. In a conclusion, there is a moderated mediating effect between job burnout and generativity concern.Subjective well-being played a mediating role between job burnout and generativity concern.

introduction generativity the concern in establishing and guiding the next generation is the main task of development in midadulthood and its acquisition and development are included in the activities of nurturing production and creation which are the further development of egoidentity and the creation and extension of selfworth and the goal of generativity is to promote individual development generativity involves both the motive and the behavior to support and guide younger people and to benefit future generations and generativity is adaptive contributing positively to personality development and wellbeing building on eriksons work kotre maintained that generativity is not attached to a certain age per se but rather differently expressed across the adult lifespan furthermore he distinguished four types of generativity biological parental technical and cultural generativity with the recent development of chinas aging population and the introduction of a nationwide twochild policy the study of generativity sense which is important for social and individual development has received widespread attention from researchers for example researchers have found that generativity sense has an impact on individual career development that fathers tend to benefit more than mothers from childrearing activities and that their commitment to family and childrearing does not conflict with their social affairs and career development and success but rather enhances mens selfefficacy peterson and duncan found that generativity sense positively predicts positive female personality traits marital and maternal satisfaction as the research progressed researchers not content with eriksons theories that emphasized only the positive dimensions of generativity sense for the middleaged themselves and the subjects of generativity sense began to explore the negative dimensions of generativity sense and developed an integrative theoretical framework of generativity sense they explained generativity sense as a structural model of transformation that encompasses individual interindividual and social dynamics and includes seven components of which generativity concern is central researchers have found a significant correlation between generativity concern and job burnout but the mechanisms by which this occurs are unclear therefore this study tends to explore the impact of job burnout on generativity concern job burnout is the physical emotional behavioral and mental exhaustion that occurs when an individual is unable to cope with the excessive demands of the external world beyond his or her energy and resources job burnout is manifested in three main areas emotional exhaustion dehumanization and decreased personal fulfillment researchers have found that job burnout affects an individuals generativity concern both emotional exhaustion and depersonalization in burnout were significantly correlated with familywork conflict and excessive familywork conflict significantly reduced an individuals generativity focus on the one hand midadulthood is an important period in an individuals career development with heavy workloads that make the individual more prone to burnout while on the other hand midadulthood is also a time when the family is faced with a number of issues whether it be peer development or child rearing that stretch an already overburdened individuals time and energy job burnout has been shown to be positively correlated with affective problems such as anxiety which affects an individuals focus on children as well as developmental themes ie generativity concerns the socioemotional selectivity theory has been used to explain the changes in work motivation as individuals age the theory posits that as the time horizon of a persons life course shortens the priority of different goals changes individuals become more critical and devote more resources to emotionally meaningful goals and activities in midadulthood burnout leaving individuals with less energy to devote to events relevant to their sense of reproduction and naturally less concern for the positive aspects of themselves and the objects of their generativity at the same time the lack of positive feedback from generativity makes it difficult for individuals who are burned out to devote resources to people and events related to the sense of reproduction thus reducing their attention to the generativity concern on the other hand the family is a social unit whose internal climate has a moderated effect on emotional stability and motivation it has been found that family members with higher family intimacy and better adaptability are less affected by the negative effects of job burnout family members with high family intimacy and adaptability can derive emotional and material support from their family and social relationships resulting in greater attention to things related to generativity concern therefore this study explores the how and under what conditions burnout affects policemens generativity concern using subjective wellbeing as a mediator and family intimacy and adaptability as moderating variables the mediating role of subjective wellbeing between job burnout and generativity concerns it is a comprehensive psychological indicator of an individuals quality of life and reflects the individuals state of social functioning and adjustment conservation of resources theory suggests that individuals tend to strive for preserve and maintain their precious resources which include limited time wealth psychological comfort optimism and support factors in the workplace when individuals perceive a threat to their resources and find it difficult to adapt to work there is a spiral of loss of resources and eventually burnout which undermines their happiness research has found that burnout is an effective predictor of their subjective wellbeing due to the fact that individuals who are burned out severely deplete physiological and psychological resources and disrupt the workfamily balance burnout increases an individuals unhealthy behaviors which in turn leads to a variety of physiological symptoms burnout leads to increased negative emotions and symptoms such as anxiety and depression the depletion of physiological and psychological resources caused by job burnout which in turn leads to the individuals inability to devote sufficient time and energy to other roles and interference and conflict between different roles which affects the individuals workfamily balance subjective wellbeing is closely related to generativity and subjective wellbeing effectively predicts generativity concerns with individuals with high life satisfaction and physical and psychological wellbeing paying more attention to generativity and wanting satisfaction from multifaceted developmental tasks peterson and duncan also found that womens satisfaction with motherhood positively predicted their generativity concern these studies suggest that subjective wellbeing may mediate between job burnout and generativity concern therefore the current study examines the effect of job burnout mediated by subjective wellbeing on generativity concern the moderating role of family intimacy and adaptability on the generativity concerns of job burnout effects family intimacy and adaptability refers to the emotional ties between family members and the ability of the family system to change in response to problems that arise in family situations and at different stages of family development family intimacy and adjustment have been shown to be significantly positively correlated with positive factors such as an individuals interpersonal trust and significantly negatively correlated with negative factors such as depression it has also been found that family intimacy is also positively correlated with adjustment and social support thus individuals with higher family intimacy and adaptability tend to receive support and understanding from family and social relationships when experiencing job burnout thereby reducing depression and the negative impact on reduced subjective wellbeing families with lower family intimacy and adaptability also have lower levels of trust among members when experiencing job burnout individuals tend to experience greater stress and negative emotions as well as reduced generativity concerns in summary the moderating effects of family intimacy and adaptability may exist between job burnout and generativity concern on the one hand good family intimacy and adaptability can protect individuals from the negative effects of job burnout thus reducing generativity concern on the other hand there is a joint effect between job burnout and low family intimacy and adaptability thus increasing the reduction of generativity concern therefore this study focuses on the local policemen to investigate the effect of job burnout on the generativity concern of individuals an important mechanism by which job burnout affects reproductive concern is that individuals with lower subjective wellbeing are more likely to have negative experiences after job burnout and thus exhibit lower generativity concern therefore this study hypothesizes that h1 subjective wellbeing play a mediating role between job burnout and the generativity concern of policemen on the other hand family intimacy and adaptability play a mitigating role in the effect of job burnout on generativity concern and this study hypothesizes that h2 the mediating role of subjective wellbeing is moderated by family intimacy and adaptability ie subjective wellbeing is a moderating mediating variable between job burnout and generativity concern see figure 1 methods measures the loyola generativity scale was developed by mcadams and de st aubin the lgs consists of 20 items each of which is selfrated from 0 not at all for me to 3 often or always for me with 6 items being reverse scored in the present study the cronbachs alpha coefficient for the entire scale was 080 satisfaction with life scale was designed by diener et al the scale consists of five items scored on a 7point richter scale with l indicating strongly disagree and 2 indicating strongly agree the total score of the scale is the sum of the scores for each question and the range of scores is from 5 to 35 studies have shown that the scale is a valid and reliable tool for measuring life satisfaction family intimacy and adaptation scale was developed by olson the faces ii contain 30 items 5 of which are reverse scoring items in this study the cronbachs alpha coefficients for the two subscales were 0920 and 0904 respectively maslach burnout inventory was developed by maslach and jackson the whole questionnaire consisted of 16 questions which was later revised to 15 questions by chinese researchers in this study the cronbachs alpha coefficient for the whole questionnaire was 092 and the cronbachs alpha coefficients for the three subscales were 094 respectively procedure the general demographic questionnaire and the official scale were bound in a booklet and the sampling and distribution of the questionnaires were done with the assistance of postgraduate students using the same instructions and collected through onsite distribution which took ∼30 min to complete statistical analysis of the collected data was performed using spss 200 results control and testing of common method deviations the data collected in this study were collected from the selfreports of the respondents and thus common method bias may exist to reduce the impact of this bias on the results of the study in terms of procedural control this study set different response statements for each measurement questionnaire item either in terms of degree of compliance or frequency statistically the degree of common method bias of the data was tested using the harman onefactor model method the results showed that there were 22 factors with eigenvalues greater than one and the first factor explained only 706 of the variance which was much less than the critical value of 40 indicating that there was no serious homoscedasticity bias for each variable in this study descriptive statistics the mean standard deviation and pearson correlation coefficient for each variable are presented in table 1 the results showed that the variables of subjective wellbeing generativity concern family intimacy and adaptability were both significantly positively correlated and job burnout was significantly negatively correlated and most of the correlations between demographic variables such as age gender with or without of child marital status and income and the abovementioned research variables have reached a statistically significant level so it is necessary to control for them in the following analysis test for moderated mediation effect following the recommendations of muller et al testing a moderated mediating model requires the estimation of three equations equation 1 estimates the moderating effect of the moderating variable on the relationship between the independent variable and the dependent variable equation 2estimates the moderating effect of the moderating variable on the relationship between the independent variable and the mediating variable equation 3estimates the moderating effect of the moderating variable on the relationship between the mediating variable and the dependent variable all predictor variables were standardized in each equation controlling for demographic variables such as age and gender as shown in table 2 job burnout significantly negatively predicted generativity concern in equation 1 but the interaction term for job burnout and intimacy was not a significant predictor of generativity concern job burnout negatively predicted subjective wellbeing in equation 2 but the interaction term for job burnout and intimacy was not significant in predicting subjective wellbeing subjective wellbeing in equation 3 positively predicted generativity concern while the interaction terms of subjective wellbeing and intimacy were also significant in predicting generativity concern thus the four variables of job burnout subjective wellbeing intimacy and generativity concern constituted a moderated mediation model and the moderating effect occurred only in the second half of the mediating effect ie the effect of subjective wellbeing on generativity concern was moderated by intimacy to reveal how intimacy modulates the effect of subjective wellbeing on generativity concern we grouped high and low according to the score of intimacy and plotted the interaction as shown in figure 2 the simple slope test showed that when the level of intimacy was high the degree of subjective wellbeing on generativity concern showed a more obvious upward trend when the level of intimacy was low the degree of subjective wellbeing on generativity concern showed an upward trend with a signs of leveling off thus intimacy can play a facilitating role in the positive predictive effect of subjective wellbeing on generativity concerns the same procedure was used to test for the moderating effect of adaptation as shown in table 3 job burnout significantly negatively predicted generativity concern in equation 1 but the interaction term of job burnout and adaptability was not a significant predictor of generativity concern job burnout negatively predicted subjective wellbeing in equation 2 but the interaction term for job burnout and adaptability was not significant in predicting subjective wellbeing in equation 3subjective wellbeing positively predicted generativity concern while the interaction term of subjective wellbeing and adaptability was also significant in predicting generativity concern thus the four variables of job burnout subjective wellbeing adaptability and generativity concern also constituted a moderated mediation model and the moderating effect occurred only in the second half of the mediation effect ie the effect of subjective wellbeing on generativity concern was moderated by adaptability to reveal how adaptation modulates the effect of subjective wellbeing on generativity concern the interaction diagrams shown in figure 3 are plotted by grouping high and low according to the score of adaptation a simple slope test showed that when the level of adaptation was high the degree of influence of subjective wellbeing on generativity concern showed a more pronounced upward trend when the level of adaptation was low the upward trend of the degree of influence of subjective wellbeing on generativity concern showed signs of flattening thus adaptation can play a facilitating role in the positive predictive role of subjective wellbeing on generativity concerns discussion this study found that job burnout negatively influenced generativity concern which is consistent with previous findings that the higher the level of job burnout the lower the generativity concern the current findings also show that subjective wellbeing mediates between job burnout and generativity concern which confirms our hypothesis poor wellbeing and moderate to high levels of burnout are associated adults satisfaction in work and life can extend to a broader range of concerns such as concern for their own achievements concern for the growth and wellbeing of the next generation caring for others and caring for the community ie generativity concern when job burnout occurs adults physiological and psychological resource depletion and workfamily balance are disrupted which negatively affects an individuals subjective wellbeing and may even produce anxiety and depression all of which are detrimental to an individuals of productive and creative activities adult subjective wellbeing is closely related to generativity concern and a decrease in wellbeing affects an individuals generativity concern ie a decrease in concern care and concern for the next generation others and society the current study provides supportive evidence for this hypothesis the present study found that there was a moderating effect of family intimacy and adaptability on the indirect effect between job burnout and generativity concern workfamily conflict can predict greater levels of emotional exhaustion the multigroup path models test suggest that the type and level of job resource moderates the relationship between job burnout and job satisfaction for different levels of family intimacy and adaptability the magnitude of the mediating effect of job burnout through subjective wellbeing on generativity sense concern varied the indirect effect was more pronounced for adults with lower family intimacy and adaptation than for adults with higher family intimacy and adaptation specifically the moderating effect of family intimacy and adaptability occurs in the second half of the mediating chain pathway where the relationship between subjective wellbeing and generativity concern depends on the level of family intimacy and adaptability as shown in figures 23 low levels of family intimacy and adaptability can significantly reduce the positive effect of subjective wellbeing on generativity concern while high levels of family intimacy and adaptability can enhance this effect thus for adults who are burned out low levels of family intimacy and adaptability and high levels of family intimacy and adaptability play the roles of adding insult to injury and give timely assistance respectively family intimacy and adaptability as important family relationship indicators that measure the degree of emotional and material support available to adults in the family environment play an extremely important role in adults social relationships good family intimacy and adaptability allows family members to enjoy a warm and supportive family environment prompting the psychological data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation experience of their productive and creative activities to extend into a wider space resulting in a higher willingness to care for others and for the community the psychological processes resulting from subjective wellbeing can be weakened or enhanced in the important environment of the family conclusion subjective wellbeing mediates between burnout and generativity concern ie burnout has an indirect effect on generativity concern by influencing the subjective wellbeing of adults the relationship between subjective wellbeing and generativity concern is moderated by family intimacy and adaptation both of which enhance the positive effect of subjective wellbeing on generativity concern study limitations though this study makes several contributions to the literature on job burnout and affective wellbeing its limitation is worthy of note the sample used study design lack of adjustment for possible confounders and was conducted only in h city from china are significant limitations of the study in using an availability sample of police officers there is a risk of potentially having a biased sample ethics statement the studies involving human participants were reviewed and approved by the study protocol was approved by hezhou university ethnics committee and has been executed consistent with ethical standards laid down in the 1964 declaration of helsinki and its later amendments the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

background policemen all over the world are tasked with the heavy work of maintaining social security with the imbalance in mentality brought about by high population density and social transformation the work of the chinese police is particularly hard as the window of demographic dividend is closing and the number of newborns is insufficient china has started to adjust its established fertility policy to encourage a family to have two children however the results have not met the expectations of the policy adjustment it is generally believed that factors such as high work pressure high parenting costs and low levels of happiness may be the main reasons for low fertility intentions studying this typical population of police officers may explore the relationship between work stress happiness and reproductive concerns and provide evidence of chinese sample objectives to explore the relations between job burnout subjective wellbeing and generativity concern in chinese police officersthe study used a crosssectional survey to collect data from 494 police officers from h city in china the participants completed the maslach burnout inventory mbi the family adaptability and cohesion scale facesii the loyola generativity scale lgs and the satisfaction with life scale swls moderated mediation effect models assessed the association between job burnout subjective wellbeing and generativity concern results job burnout had a significant negative predictive effect on both subjective wellbeing and generativity concern and subjective wellbeing played a mediating role between job burnout and generativity concern in addition family intimacy and adaptability had a significant negative moderating effect between subjective wellbeing and generativity concern in a conclusion there is a moderated mediating effect between job burnout and generativity concernsubjective wellbeing played a mediating role between job burnout and generativity concern

Background There remains an underappreciation for the seriousness of myopia amongst the general public. In 2010, uncorrected refractive error was responsible for one in five cases of blindness and the leading cause of moderate or severe visual impairment [1]. From an economic perspective, according to an estimation by Fricke et al. [2], distance vision impairment caused by uncorrected refractive error, either directly or indirectly, leads to global productivity losses equivalent to USD 202 billion annually. At the same time, the global prevalence of myopia has increased notably in recent decades. A meta-analysis by Holden et al. included 145 studies published since 1995 and found a worldwide increase in the prevalence of myopia from 25.6% in 2000 to 32.3% in 2010 [3]. This trend has been most pronounced in East Asian populations, and particularly in countries with 'high-pressure educational systems' such as South Korea, China, Taiwan and Singapore [3], leading to children spending more time indoors out of the sunlight and engaged in near work as part of their studies. A remarkable study from Taiwan estimated an increase in the prevalence of myopia in 12-year-old children from 36.7% in 1983 to 60.7% in 2000, while for young people aged 16-18 in 2000, prevalence had reached 84% [4]. Globally, myopia prevalence is projected to reach approximately 49.8% in 2050 with as many as 5 billion people affected [3]. At birth, children tend to be hyperopic with positive spherical equivalents [5,6]. The human eye grows and modifications of the cornea, lens and the axial length of the eye determine refractive status in adulthood. In most cases, these modifications lead to good visual acuity. However, if the process of axial elongation is accelerated, children are more likely to develop myopia. Why do some eyes grow too fast? The rapid increase in the prevalence [3] and national differences in the progression of myopia [7,8] suggest that this type of growth cannot be explained by genetic factors. Based on animal experiments finding that intraocular dopamine antagonizes stimuli for eye growth [9] and Jones et al. finding an association of time outdoors with myopia [10], Rose et al. developed the hypothesis that the protective effect of time outdoors is caused by a light-triggered dopamine release in brighter light [11]. Following experiments with vertebrates such as chickens [12] and rhesus monkeys [13] have shown that ambient illuminance has a significant influence on eye growth, although the level of brightness required to have an impact usually only originates in natural sunlight. As such, numerous studies have analyzed the association of sunlight exposuremeasured as time spent outdoors -with the prevalence of myopia [10,11,[14][15][16][17][18][19]. The suspected association of near work activities with myopia originates from studies from the 19th century, e.g., by Hermann Cohn in 1867. Cohn found that there was a greater prevalence of myopia in children who worked in dark classrooms, and an association between myopia and higher levels of schooling. As students in dark classrooms are required to work at closer distances, and a higher school level demands more studying and reading, he concluded that near work activities were responsible for myopia onset [20]. To date, this hypothesis has been tested in numerous studies examining the correlation of self-reported quantities of near work and myopia [16,19,21,22]. What characteristics tend to be present in children who are at equal risk of becoming myopic? One way to define social class is with the socioeconomic status . SES, or the three associated components education, income and occupational status have been found to be significantly associated with myopia in various studies [15,[23][24][25][26]. Myopia prevalence has been reported to be 41.3% among German adults aged 18-35 [5]. However, as this study assessed myopia based on self-reported noncycloplegic measurements, it might overestimate the real value. Although this prevalence remains lower than in some Asian countries, understanding the factors involved in myopia onset is crucial if we hope to appropriately respond to future shifts in prevalence or even reduce the current incidence of myopia. The KiGGS survey, a multicenter study in Germany, explored the relationship of leisure activities with myopia in a large German cohort based on questionnaires in which parents reported whether their children were myopic or not [27]. The research discussed in this paper is intended to supplement this data analysis by determining the relationship between child myopia , time spent outdoors and in near work as well as the role of SES. --- Methods --- LIFE child and study population The LIFE Child study is part of LIFE, a large-scale research program implemented by the Leipzig University, Germany. LIFE Child is a prospective cohort study carried out at the Leipzig Research Center for Civilization Diseases, which seeks to assess the factors involved in the development of health and non-communicable diseases in young people from the prenatal stage to adulthood. The study launched in July 2011; participants are invited to attend annual followups over a period of 10 years. The population is drawn from the city of Leipzig and its immediate surroundings. Recruitment is conducted in a range of settings, such as schools, kindergartens, local clinics, primary care practices, public health centers and partner studies. The data are collected by a trained multidisciplinary team following standard operating procedures. The majority of participating children have no migratory background . --- Eye examination The data used in this paper were produced in the eye examinations carried out on study participants between the ages 3 and 18 years inclusive. For each subject, three refraction measurements were carried out for both eyes using noncycloplegic autorefraction . The use of cycloplegics in the measurement of refractive status was not approved by the local Ethics Committee. For further analysis, each participant was classified for the eye's refractive error. The refractive error was defined as follows: First the SE was calculated as SE = sphere + cylinder/2; out of the three SE values calculated for each participant, the median value was selected. This practice is suggested by Rauscher et al. who showed that the true refractive error can be approximated by employing the median of repeated measurement in case measurement under cycloplegia is not an option [28]. Myopia was defined as ≤ -0.75 D. --- Questionnaire data As part of the basic examination and eye examination, parents and children were asked to answer age-dependent questionnaires. To assess SES, parents reported their highest occupational and educational status and their total household income. Each of these pieces of data was subsequently converted to a score between 1 and 7 inclusive, with the sum of these scores used as a total SES index score for the family. The SES index scores therefore ranged from 3 to 21, with a higher score indicating higher SES. To explore differences in children's leisure behavior between social classes, we defined three SES groups using the SES index as suggested by Lampert et al. in the context of the KiGGS study [29]. Questions about the child's leisure activities were designed by researchers of the LIFE Child study team. They were answered by parents or, if the child was 10 years old or older, by children themselves. These items produce information about frequency per week and duration per day of reading/writing/drawing tasks and outdoor playtime. With regard to reading/writing/drawing, the activity with the highest frequency or duration was recorded. Possible responses for the frequency question were "once per week", "two days a week", "every two days" and "every day", while the answer options for duration were "< 1 h", "1-2 h", "3-4 h" and "> 4 h". --- Data analysis For all data analysis, we utilized the open source application R, version 3.5.3 . From the 4820 eye examinations conducted to date, each participant's most recent visit was filtered. This produced a more equal age distribution. Siblings and twins were excluded to prevent genetic bias in our results. After these steps, a total of 1416 examined children remained. A population characteristics table was subdivided into two age groups for comparison purposes as suggested by Schuster et al. [27]. Group differences in the SE of both eyes were tested using t-tests. Using logistic regression models with myopia as the dependent variable, the associations between questionnaire parameters and myopia were analyzed. These models were then adjusted for age, sex and SES as continuous measure. Finally, we examined whether children from different SES groups showed significantly different leisure time activity patterns with a chi-squared test. The level of significance was set to α = 0.05. --- Results --- Study population 1416 children and adolescents between the ages of 3 and 18 inclusive were included in this study. Table 1 shows the population characteristics. Based on the median SE per eye, the mean SE of all children was -0.12 ± 0.07 D in the right eye and -0.11 ± 0.07 D in the left; the median SE values were 0.025 D and 0.018 D, respectively. The t-test revealed no significant difference in the refraction values between left and right eyes . Therefore, the following analysis will refer to refraction data for the right eye only. Out of 1416 children, 195 children were myopic with a SE ≤ -0.75 D, and 1221 had a SE > -0.75 D. --- Myopia and leisure time activities The results of the univariate logistic regression analysis are displayed in Table 2. It shows significant associations of myopia with low outdoor activity frequency, high near work duration and low near work frequency. Outdoor activity duration was not significantly associated with myopia. Table 3 shows the results of the multiple logistic regression analysis. The models from the univariate analysis were complemented by the parameters age, sex and SES of the study participants. Outdoor activity frequency and near work duration maintained a significant association with myopia after this adjustment while near work frequency was no longer significantly associated with myopia. Outdoor activity duration continued to display no significant association with myopia. Finally, the two parameters outdoor activity frequency and near work duration were included simultaneously in the same model. Both remained significantly associated with myopia after adjustment. Since outdoor activity frequencies of twice a week or more showed no significant association with myopia , subjects who were reported to spend time outdoors "every day", "every two days" and "two days a week" were grouped in one group, which was designated "twice a week or more". This was performed in the same manner with near work durations of "3-4 hours" and "> 4 hours", merging these response groups into one designated "> 3 h". The relationships between myopia and outdoor activity frequency and near work duration in this final model are illustrated in Figures 1 and 2, respectively. These show that both low outdoor activity frequency and long near work duration are significantly associated with myopia, even after adjusting for each other as well as for age, sex and SES. Expressed in terms of probability, children who spend time outdoors once a week were more than four times as likely to be myopic than children who go outside twice a week or more . Children who engage in near work for longer periods each day were two to four times as likely to be myopic as those who engage in near work for shorter lengths of time . It was then checked whether the associations between myopia and the various leisure time activity parameters varied with the age of the participant, but interactions of age with outdoor activity frequency and near work duration all failed to reach significance . This was the case both when the subjects were divided into age groups -preschool , elementary school and high school -and when the interactions with age were tested as a continuous variable. Interactions of sex and SES with outdoor activity frequency and near work duration were not significant either. --- Myopia and socioeconomic status The distribution of children between SES groups is displayed in Table 1. In univariate logistic regression analysis, higher SES was significantly associated with a lower likelihood of myopia . However, after correcting for age and sex , this association was no longer significant. Figure 3 illustrates the relationship between the SES index and myopia in the afore mentioned final model with adjustment for age, sex, outdoor time frequency and near work duration. The rate of myopia decreased with higher SES values, although this association did not reach significance . Children with a low SES played outside on fewer days per week , but for longer time periods than children with a high SES. Furthermore, children with a low SES were engaged in near work activities on fewer days per week , but for greater amounts of time than children with a high SES. Although these relationships are comprehensible, the differences between the SES groups were not significant for the parameters "near work frequency" and "near work duration". --- Discussion The LIFE Child study is the first study in Germany to work with refraction data in a cohort of children and adolescents aged 3-18 years. A detailed analysis of the refractive status of children in the LIFE Child cohort is described elsewhere [30]. The prevalence of myopia in this cohort is similar to the findings of Schuster et al. in another German cohort, which estimated that 5.4% of 3-to 10-year-olds and 21.1% of 11to 17-year-old children were myopic [27]. Compared to Schuster et al., children with a high SES are overrepresented in our population , and children with a low SES are underrepresented [27]. However, we were still able to include more than 120 children with a low SES for robust data analysis. Myopia prevalence was higher in older than in younger children. Less frequent time outdoors, shorter time outdoors durations and longer near work activities in older children, probably due to a growing amount of school hours and homework as well as a change in the way older children spend their remaining leisure time, might be possible reasons for this effect. While young children like to play outside, adolescents tend to be more involved in media. The findings that outdoor time becomes shorter and less frequent in older children is in line with several other studies, e.g. Gao et al. [31], Shah et al. [32] and Enthoven et al. [19]. A higher near work frequency of younger children is rather puzzling as we defined near work as reading, writing and drawing and children only learn to read at the age of six years. A social desirability With regard to time spent outdoors or engaged in near work, we distinguished between the length per day and the frequency per week of leisure time activity, which enabled us to investigate more precisely which aspect of leisure time behavior is more important with respect to myopia. --- Time outdoors Since Jones et al. found that an increased amount of time spent outdoors was negatively associated with myopia [10], many other studies followed, mostly detecting the same relationship of myopia and time outdoors, regardless of whether a cross-sectional [11] or longitudinal [14] study design was chosen. The results are consistent for different populations, e.g., Dutch [19], Spanish [17] or Chinese [15,16]. A global meta-analysis by Xiong et al. in 2017 included 25 studies with 34420 subjects and found negative associations between the amount of time spent outdoors and the incidence and prevalence of myopia [18]. In multivariate analyses, our data suggest that the frequency of daylight exposure is more important than the duration concerning myopia onset. The total time spent outdoors throughout a day was not significantly associated with myopia. Based on our data, we cannot tell whether time outdoors was spent in sunlight or not. Especially in winter, children might spend time outdoors without being exposed to sunlight. At the same time, children who played outside multiple times per week were less likely to be myopic than children who only played outside once a week. This finding indicates that, when achieved on a daily basis, even a short stimulus of sunlight might inhibit eye growth and go along with a reduced myopic shift. Based on animal experiments [33,34], Wallman and Winawer reported in a review that short, but intermittent eye-growth-inhibiting signals in between lasting periods of growth-inducing signals have a disproportionately high protective effect with regard to myopic shift [35]. A frequent daylight exposure operates as this intermittent growth-inhibiting signal. An experiment on chicks by Lan et al. supports this hypothesis, finding that low frequency cycles of bright light provide a stronger inhibiting effect against deprivation myopia than exposures to bright light for 5 h or more [36]. The dominant association of outdoor frequency compared to outdoor duration with myopia in our study does not contradict but rather complement current literature as it offers a more distinguished insight into the underlying mechanisms responsible for the significant association of time outdoors with myopia in the studies mentioned above [10,11,[14][15][16][17][18][19]. Based on evidence from observational studies like these, He et al. explored the effect of prevention measures in 6-year-old Chinese primary school children in a cluster-randomized intervention-controlled trial. The intervention group was assigned one additional 40-minute class each school day and parents were encouraged to engage their children in more outdoor activities after school. The control group followed their usual activity pattern. After three years, the intervention group showed a significantly lower cumulative incidence rate of myopia and change in the SE refraction than the control group [37], leading to the conclusion that onset and progression of myopia can be controlled through such interventions. Comparable intervention studies from Taiwan also found a protective effect of increased outdoor activity time against myopia onset [38,39]. --- Near work An inconsistent definition of near work among authors complicates the process of comparing results and drawing a final conclusion on the association between near work and myopia. Even if we exclude studies that include mid-distance activities as part of their near work investigated, such as watching TV or computer time, and those that examined preschool children, there is still no clear picture. A longitudinal study from the United Kingdom [40] and a cross-sectional study from the Netherlands [19] both defined near work as "reading" and found a positive association between near work and myopia. A cross-sectional study from Beijing, on the other hand, could not find an association between near work and myopia [16]. A study by Ip et al. is notable for the examination of intensive near work: Longer time periods spent on reading for pleasure and a close reading distance were significantly associated with a more myopic refraction [21]. We defined near work as "reading, drawing or writing". In multivariate analyses, a greater amount of near work per day was positively associated with myopia, but a greater frequency of near work activity per week was not. As suggested by Ip et al., the intensity of near work with constant accommodation seems to have a larger effect on myopia genesis than the frequency with which such near work takes place. This is concordant with the assertion by Wallman and Winawer, as mentioned above [35]. The interruption of near work activities is a signal that slows down eye growth. In our data, this is demonstrated by significant differences in the effect, in terms of myopic shift, of longer near work periods compared to shorter periods. Huang et al. from Taiwan reported similar results, finding that taking breaks to interrupt near work activities lasting 30 min or more led to significantly less myopia after 6 months than was the case with children who did not interrupt long sessions of near work [22]. Intervention-controlled studies with school classes of varying durations could be used to confirm whether there is a causal effect. As such, these insights may result in the development of measures to prevent myopia in children. --- Socioeconomic status In the present study, the SES measure is composed of three variables: household income, parental education and parental occupation. Irrespective of what combinations of these variables have been used in previous studies, a high SES has usually been associated with a higher prevalence of myopia. In a study with 1st-and 4th-grade children from Beijing, those with a higher SES had a significantly higher risk of being myopic [15]. Saw et al. share similar results in 7-to 9-year-old children from Singapore [23]. One of the only exceptions to this association was found in 5711 6-year-old children from Rotterdam. Tideman et al. found that a low family income and a low educational level on the part of the mother was significantly associated with a higher prevalence of myopia in children [24]. In all three mentioned studies, the associations did not remain significant after adjusting for outdoor activity and near work time [15,23,24], indicating that the effect of SES might be explained by differences in near work behavior and outdoor activity in different SES groups. Many other studies, which were unable to adjust for near work and outdoor time, retained a significant association in multivariate analyses [25,26]. Our analyses indicate the same relationship between SES and myopia as did the findings of Tideman et al.: the lower the parents' SES index score, the greater the risk that their children will be myopic. As in previous studies [15,23,24], the association was no longer significant after adjusting for the frequency of outdoor activity and the duration of near work. In our cohort, children with a higher SES tended to play outside more often and to spend shorter periods of time engaged in near work than children with a lower SES. These relationships are indicative of healthier leisure time habits, with regard to eye health, among children from a higher social class. A greater awareness of lifestyle risks among families with a higher SES may be responsible for this. Tideman et al. reported -in reference to the Rotterdam-based cohort -that children with a low SES spend more time engaged in indoor activities with less compensation provided by outdoor exposure and that lifestyle factors explained 71% of the increased risk for myopia in children with a lower SES [24]. Most other studies indicate that children with a higher SES spend less time playing outside and more time in near work activities, explaining the comparatively inverse association of myopia with SES. --- Limitations The major limitation of this study is that we were unable to use cycloplegics during eye examination. To reduce an overestimation of the prevalence of myopia, we set the cutoff for myopia as -0.75 D and used the median value out of three measurements per eye. Although myopia prevalence is comparable to the German KiGGS study cohort [27], it is unclear whether these measures exclude some genuine myopic children and whether they effectively eliminate the number of pseudo-myopes in our cohort, so the true cycloplegic value remains unknown. Another parameter reflecting near work activity is smartphone use, which was included as a separate question in our assessment. However, to date, we do not have a sufficient amount of data to investigate smartphone use, and regrettably, this shift in near work behavior in children in the past 10-15 years is not represented in the present results. A further limitation is the large age range of the included children. Even if all associations were adjusted by child age, confounding cannot be completely excluded. Although recruitment of study participants was conducted with diverse methods, a recruitment bias remains an issue. Citizens who do not speak German as well as families with a low SES are underrepresented in our study cohort. The questionnaires used to assess near work and time outdoors were designed by our researchers and were not validated. Furthermore, depending on the age of the participant, questionnaires were completed either by the parent or, for young people aged 10 and upwards, by children themselves. Parents and the young participants may have different perspectives and estimate leisure time activity differently. In addition to questionnaire bias in general, we should consider the potential for a recall bias as well as a social desirability bias [41], especially concerning questions about outdoor time. --- Conclusion Given the rapid increase in myopia prevalence in East Asian countries, it is likely that environmental factors contribute to the genesis of myopia to a large degree. Our findings suggest that a daily exposure to sunlight and restricting the duration of uninterrupted near work might protect against pathological eye growth. Furthermore, in our cohort, children from a higher social class tended to be less myopic. Considering the vast economic burden caused by myopia, and the apparent cost-effectiveness of intervention, prevention strategies should be established for children at all ages. --- Data availability The datasets generated and/or analyzed during the current study are not publicly available due to ethical restrictions. The LIFE Child study is a study collecting potentially sensitive information. Publishing data sets is not covered by the informed consent provided by the study participants. Furthermore, the data protection concept of LIFE requests that all researchers interested in accessing data sign a project agreement. Researchers that are interested in accessing and analyzing data collected in the LIFE Child study may contact the data use and access committee . --- Abbreviations --- SE spherical equivalent SES socioeconomic status OR odds ratio CI confidence interval --- --- --- --- Competing interests The authors declare no competing interests. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. ---

Background To investigate environmental and social risk factors for myopia in children and adolescents in Germany. Methods 1437 children aged between 3 and 18 inclusive were examined as part of the LIFE Child study based in Leipzig, Germany. Information about leisure time activities and social status was ascertained by parents and children in a questionnaire. Refractive status was attained by measuring noncycloplegic autorefraction. Myopia was defined as spherical equivalent (SE) ≤ -0.75 D. Risk factors were identified using multiple logistic regression analysis.In multiple logistic regression analysis, myopia was significantly associated with less frequent outdoor activity ("once a week" vs. "twice a week or more": odds ratio (OR) 4.35, 95% confidence interval (CI) 1.89-9.98, p<0.01) and longer near work sessions (1-2 h vs. < 1 h: OR 1.83, CI 1.10-3.04, p=0.02; > 3 h vs. < 1 h: OR 3.71, CI 1.43-9.61, p<0.01) after adjustment for age, sex and socioeconomic status (SES). Duration of outdoor activity, near work frequency and SES showed no significant association with myopia (p > 0.05). Children with a lower SES were involved in longer periods of outdoor and near work activities but on fewer occasions over the course of the week, although this connection was not significant.Myopia is associated with environmental factors. The present findings suggest that daily exposure to sunlight and a restriction of long-duration near work activities might protect against pathological eye growth. Prevention strategies should be implemented for children at all ages.

background there remains an underappreciation for the seriousness of myopia amongst the general public in 2010 uncorrected refractive error was responsible for one in five cases of blindness and the leading cause of moderate or severe visual impairment 1 from an economic perspective according to an estimation by fricke et al 2 distance vision impairment caused by uncorrected refractive error either directly or indirectly leads to global productivity losses equivalent to usd 202 billion annually at the same time the global prevalence of myopia has increased notably in recent decades a metaanalysis by holden et al included 145 studies published since 1995 and found a worldwide increase in the prevalence of myopia from 256 in 2000 to 323 in 2010 3 this trend has been most pronounced in east asian populations and particularly in countries with highpressure educational systems such as south korea china taiwan and singapore 3 leading to children spending more time indoors out of the sunlight and engaged in near work as part of their studies a remarkable study from taiwan estimated an increase in the prevalence of myopia in 12yearold children from 367 in 1983 to 607 in 2000 while for young people aged 1618 in 2000 prevalence had reached 84 4 globally myopia prevalence is projected to reach approximately 498 in 2050 with as many as 5 billion people affected 3 at birth children tend to be hyperopic with positive spherical equivalents 56 the human eye grows and modifications of the cornea lens and the axial length of the eye determine refractive status in adulthood in most cases these modifications lead to good visual acuity however if the process of axial elongation is accelerated children are more likely to develop myopia why do some eyes grow too fast the rapid increase in the prevalence 3 and national differences in the progression of myopia 78 suggest that this type of growth cannot be explained by genetic factors based on animal experiments finding that intraocular dopamine antagonizes stimuli for eye growth 9 and jones et al finding an association of time outdoors with myopia 10 rose et al developed the hypothesis that the protective effect of time outdoors is caused by a lighttriggered dopamine release in brighter light 11 following experiments with vertebrates such as chickens 12 and rhesus monkeys 13 have shown that ambient illuminance has a significant influence on eye growth although the level of brightness required to have an impact usually only originates in natural sunlight as such numerous studies have analyzed the association of sunlight exposuremeasured as time spent outdoors with the prevalence of myopia 1011 14 15 16 17 18 19 the suspected association of near work activities with myopia originates from studies from the 19th century eg by hermann cohn in 1867 cohn found that there was a greater prevalence of myopia in children who worked in dark classrooms and an association between myopia and higher levels of schooling as students in dark classrooms are required to work at closer distances and a higher school level demands more studying and reading he concluded that near work activities were responsible for myopia onset 20 to date this hypothesis has been tested in numerous studies examining the correlation of selfreported quantities of near work and myopia 16192122 what characteristics tend to be present in children who are at equal risk of becoming myopic one way to define social class is with the socioeconomic status ses or the three associated components education income and occupational status have been found to be significantly associated with myopia in various studies 15 23 24 25 26 myopia prevalence has been reported to be 413 among german adults aged 1835 5 however as this study assessed myopia based on selfreported noncycloplegic measurements it might overestimate the real value although this prevalence remains lower than in some asian countries understanding the factors involved in myopia onset is crucial if we hope to appropriately respond to future shifts in prevalence or even reduce the current incidence of myopia the kiggs survey a multicenter study in germany explored the relationship of leisure activities with myopia in a large german cohort based on questionnaires in which parents reported whether their children were myopic or not 27 the research discussed in this paper is intended to supplement this data analysis by determining the relationship between child myopia time spent outdoors and in near work as well as the role of ses methods life child and study population the life child study is part of life a largescale research program implemented by the leipzig university germany life child is a prospective cohort study carried out at the leipzig research center for civilization diseases which seeks to assess the factors involved in the development of health and noncommunicable diseases in young people from the prenatal stage to adulthood the study launched in july 2011 participants are invited to attend annual followups over a period of 10 years the population is drawn from the city of leipzig and its immediate surroundings recruitment is conducted in a range of settings such as schools kindergartens local clinics primary care practices public health centers and partner studies the data are collected by a trained multidisciplinary team following standard operating procedures the majority of participating children have no migratory background eye examination the data used in this paper were produced in the eye examinations carried out on study participants between the ages 3 and 18 years inclusive for each subject three refraction measurements were carried out for both eyes using noncycloplegic autorefraction the use of cycloplegics in the measurement of refractive status was not approved by the local ethics committee for further analysis each participant was classified for the eyes refractive error the refractive error was defined as follows first the se was calculated as se sphere cylinder2 out of the three se values calculated for each participant the median value was selected this practice is suggested by rauscher et al who showed that the true refractive error can be approximated by employing the median of repeated measurement in case measurement under cycloplegia is not an option 28 myopia was defined as ≤ 075 d questionnaire data as part of the basic examination and eye examination parents and children were asked to answer agedependent questionnaires to assess ses parents reported their highest occupational and educational status and their total household income each of these pieces of data was subsequently converted to a score between 1 and 7 inclusive with the sum of these scores used as a total ses index score for the family the ses index scores therefore ranged from 3 to 21 with a higher score indicating higher ses to explore differences in childrens leisure behavior between social classes we defined three ses groups using the ses index as suggested by lampert et al in the context of the kiggs study 29 questions about the childs leisure activities were designed by researchers of the life child study team they were answered by parents or if the child was 10 years old or older by children themselves these items produce information about frequency per week and duration per day of readingwritingdrawing tasks and outdoor playtime with regard to readingwritingdrawing the activity with the highest frequency or duration was recorded possible responses for the frequency question were once per week two days a week every two days and every day while the answer options for duration were 1 h 12 h 34 h and 4 h data analysis for all data analysis we utilized the open source application r version 353 from the 4820 eye examinations conducted to date each participants most recent visit was filtered this produced a more equal age distribution siblings and twins were excluded to prevent genetic bias in our results after these steps a total of 1416 examined children remained a population characteristics table was subdivided into two age groups for comparison purposes as suggested by schuster et al 27 group differences in the se of both eyes were tested using ttests using logistic regression models with myopia as the dependent variable the associations between questionnaire parameters and myopia were analyzed these models were then adjusted for age sex and ses as continuous measure finally we examined whether children from different ses groups showed significantly different leisure time activity patterns with a chisquared test the level of significance was set to α 005 results study population 1416 children and adolescents between the ages of 3 and 18 inclusive were included in this study table 1 shows the population characteristics based on the median se per eye the mean se of all children was 012 ± 007 d in the right eye and 011 ± 007 d in the left the median se values were 0025 d and 0018 d respectively the ttest revealed no significant difference in the refraction values between left and right eyes therefore the following analysis will refer to refraction data for the right eye only out of 1416 children 195 children were myopic with a se ≤ 075 d and 1221 had a se 075 d myopia and leisure time activities the results of the univariate logistic regression analysis are displayed in table 2 it shows significant associations of myopia with low outdoor activity frequency high near work duration and low near work frequency outdoor activity duration was not significantly associated with myopia table 3 shows the results of the multiple logistic regression analysis the models from the univariate analysis were complemented by the parameters age sex and ses of the study participants outdoor activity frequency and near work duration maintained a significant association with myopia after this adjustment while near work frequency was no longer significantly associated with myopia outdoor activity duration continued to display no significant association with myopia finally the two parameters outdoor activity frequency and near work duration were included simultaneously in the same model both remained significantly associated with myopia after adjustment since outdoor activity frequencies of twice a week or more showed no significant association with myopia subjects who were reported to spend time outdoors every day every two days and two days a week were grouped in one group which was designated twice a week or more this was performed in the same manner with near work durations of 34 hours and 4 hours merging these response groups into one designated 3 h the relationships between myopia and outdoor activity frequency and near work duration in this final model are illustrated in figures 1 and 2 respectively these show that both low outdoor activity frequency and long near work duration are significantly associated with myopia even after adjusting for each other as well as for age sex and ses expressed in terms of probability children who spend time outdoors once a week were more than four times as likely to be myopic than children who go outside twice a week or more children who engage in near work for longer periods each day were two to four times as likely to be myopic as those who engage in near work for shorter lengths of time it was then checked whether the associations between myopia and the various leisure time activity parameters varied with the age of the participant but interactions of age with outdoor activity frequency and near work duration all failed to reach significance this was the case both when the subjects were divided into age groups preschool elementary school and high school and when the interactions with age were tested as a continuous variable interactions of sex and ses with outdoor activity frequency and near work duration were not significant either myopia and socioeconomic status the distribution of children between ses groups is displayed in table 1 in univariate logistic regression analysis higher ses was significantly associated with a lower likelihood of myopia however after correcting for age and sex this association was no longer significant figure 3 illustrates the relationship between the ses index and myopia in the afore mentioned final model with adjustment for age sex outdoor time frequency and near work duration the rate of myopia decreased with higher ses values although this association did not reach significance children with a low ses played outside on fewer days per week but for longer time periods than children with a high ses furthermore children with a low ses were engaged in near work activities on fewer days per week but for greater amounts of time than children with a high ses although these relationships are comprehensible the differences between the ses groups were not significant for the parameters near work frequency and near work duration discussion the life child study is the first study in germany to work with refraction data in a cohort of children and adolescents aged 318 years a detailed analysis of the refractive status of children in the life child cohort is described elsewhere 30 the prevalence of myopia in this cohort is similar to the findings of schuster et al in another german cohort which estimated that 54 of 3to 10yearolds and 211 of 11to 17yearold children were myopic 27 compared to schuster et al children with a high ses are overrepresented in our population and children with a low ses are underrepresented 27 however we were still able to include more than 120 children with a low ses for robust data analysis myopia prevalence was higher in older than in younger children less frequent time outdoors shorter time outdoors durations and longer near work activities in older children probably due to a growing amount of school hours and homework as well as a change in the way older children spend their remaining leisure time might be possible reasons for this effect while young children like to play outside adolescents tend to be more involved in media the findings that outdoor time becomes shorter and less frequent in older children is in line with several other studies eg gao et al 31 shah et al 32 and enthoven et al 19 a higher near work frequency of younger children is rather puzzling as we defined near work as reading writing and drawing and children only learn to read at the age of six years a social desirability with regard to time spent outdoors or engaged in near work we distinguished between the length per day and the frequency per week of leisure time activity which enabled us to investigate more precisely which aspect of leisure time behavior is more important with respect to myopia time outdoors since jones et al found that an increased amount of time spent outdoors was negatively associated with myopia 10 many other studies followed mostly detecting the same relationship of myopia and time outdoors regardless of whether a crosssectional 11 or longitudinal 14 study design was chosen the results are consistent for different populations eg dutch 19 spanish 17 or chinese 1516 a global metaanalysis by xiong et al in 2017 included 25 studies with 34420 subjects and found negative associations between the amount of time spent outdoors and the incidence and prevalence of myopia 18 in multivariate analyses our data suggest that the frequency of daylight exposure is more important than the duration concerning myopia onset the total time spent outdoors throughout a day was not significantly associated with myopia based on our data we cannot tell whether time outdoors was spent in sunlight or not especially in winter children might spend time outdoors without being exposed to sunlight at the same time children who played outside multiple times per week were less likely to be myopic than children who only played outside once a week this finding indicates that when achieved on a daily basis even a short stimulus of sunlight might inhibit eye growth and go along with a reduced myopic shift based on animal experiments 3334 wallman and winawer reported in a review that short but intermittent eyegrowthinhibiting signals in between lasting periods of growthinducing signals have a disproportionately high protective effect with regard to myopic shift 35 a frequent daylight exposure operates as this intermittent growthinhibiting signal an experiment on chicks by lan et al supports this hypothesis finding that low frequency cycles of bright light provide a stronger inhibiting effect against deprivation myopia than exposures to bright light for 5 h or more 36 the dominant association of outdoor frequency compared to outdoor duration with myopia in our study does not contradict but rather complement current literature as it offers a more distinguished insight into the underlying mechanisms responsible for the significant association of time outdoors with myopia in the studies mentioned above 1011 14 15 16 17 18 19 based on evidence from observational studies like these he et al explored the effect of prevention measures in 6yearold chinese primary school children in a clusterrandomized interventioncontrolled trial the intervention group was assigned one additional 40minute class each school day and parents were encouraged to engage their children in more outdoor activities after school the control group followed their usual activity pattern after three years the intervention group showed a significantly lower cumulative incidence rate of myopia and change in the se refraction than the control group 37 leading to the conclusion that onset and progression of myopia can be controlled through such interventions comparable intervention studies from taiwan also found a protective effect of increased outdoor activity time against myopia onset 3839 near work an inconsistent definition of near work among authors complicates the process of comparing results and drawing a final conclusion on the association between near work and myopia even if we exclude studies that include middistance activities as part of their near work investigated such as watching tv or computer time and those that examined preschool children there is still no clear picture a longitudinal study from the united kingdom 40 and a crosssectional study from the netherlands 19 both defined near work as reading and found a positive association between near work and myopia a crosssectional study from beijing on the other hand could not find an association between near work and myopia 16 a study by ip et al is notable for the examination of intensive near work longer time periods spent on reading for pleasure and a close reading distance were significantly associated with a more myopic refraction 21 we defined near work as reading drawing or writing in multivariate analyses a greater amount of near work per day was positively associated with myopia but a greater frequency of near work activity per week was not as suggested by ip et al the intensity of near work with constant accommodation seems to have a larger effect on myopia genesis than the frequency with which such near work takes place this is concordant with the assertion by wallman and winawer as mentioned above 35 the interruption of near work activities is a signal that slows down eye growth in our data this is demonstrated by significant differences in the effect in terms of myopic shift of longer near work periods compared to shorter periods huang et al from taiwan reported similar results finding that taking breaks to interrupt near work activities lasting 30 min or more led to significantly less myopia after 6 months than was the case with children who did not interrupt long sessions of near work 22 interventioncontrolled studies with school classes of varying durations could be used to confirm whether there is a causal effect as such these insights may result in the development of measures to prevent myopia in children socioeconomic status in the present study the ses measure is composed of three variables household income parental education and parental occupation irrespective of what combinations of these variables have been used in previous studies a high ses has usually been associated with a higher prevalence of myopia in a study with 1stand 4thgrade children from beijing those with a higher ses had a significantly higher risk of being myopic 15 saw et al share similar results in 7to 9yearold children from singapore 23 one of the only exceptions to this association was found in 5711 6yearold children from rotterdam tideman et al found that a low family income and a low educational level on the part of the mother was significantly associated with a higher prevalence of myopia in children 24 in all three mentioned studies the associations did not remain significant after adjusting for outdoor activity and near work time 152324 indicating that the effect of ses might be explained by differences in near work behavior and outdoor activity in different ses groups many other studies which were unable to adjust for near work and outdoor time retained a significant association in multivariate analyses 2526 our analyses indicate the same relationship between ses and myopia as did the findings of tideman et al the lower the parents ses index score the greater the risk that their children will be myopic as in previous studies 152324 the association was no longer significant after adjusting for the frequency of outdoor activity and the duration of near work in our cohort children with a higher ses tended to play outside more often and to spend shorter periods of time engaged in near work than children with a lower ses these relationships are indicative of healthier leisure time habits with regard to eye health among children from a higher social class a greater awareness of lifestyle risks among families with a higher ses may be responsible for this tideman et al reported in reference to the rotterdambased cohort that children with a low ses spend more time engaged in indoor activities with less compensation provided by outdoor exposure and that lifestyle factors explained 71 of the increased risk for myopia in children with a lower ses 24 most other studies indicate that children with a higher ses spend less time playing outside and more time in near work activities explaining the comparatively inverse association of myopia with ses limitations the major limitation of this study is that we were unable to use cycloplegics during eye examination to reduce an overestimation of the prevalence of myopia we set the cutoff for myopia as 075 d and used the median value out of three measurements per eye although myopia prevalence is comparable to the german kiggs study cohort 27 it is unclear whether these measures exclude some genuine myopic children and whether they effectively eliminate the number of pseudomyopes in our cohort so the true cycloplegic value remains unknown another parameter reflecting near work activity is smartphone use which was included as a separate question in our assessment however to date we do not have a sufficient amount of data to investigate smartphone use and regrettably this shift in near work behavior in children in the past 1015 years is not represented in the present results a further limitation is the large age range of the included children even if all associations were adjusted by child age confounding cannot be completely excluded although recruitment of study participants was conducted with diverse methods a recruitment bias remains an issue citizens who do not speak german as well as families with a low ses are underrepresented in our study cohort the questionnaires used to assess near work and time outdoors were designed by our researchers and were not validated furthermore depending on the age of the participant questionnaires were completed either by the parent or for young people aged 10 and upwards by children themselves parents and the young participants may have different perspectives and estimate leisure time activity differently in addition to questionnaire bias in general we should consider the potential for a recall bias as well as a social desirability bias 41 especially concerning questions about outdoor time conclusion given the rapid increase in myopia prevalence in east asian countries it is likely that environmental factors contribute to the genesis of myopia to a large degree our findings suggest that a daily exposure to sunlight and restricting the duration of uninterrupted near work might protect against pathological eye growth furthermore in our cohort children from a higher social class tended to be less myopic considering the vast economic burden caused by myopia and the apparent costeffectiveness of intervention prevention strategies should be established for children at all ages data availability the datasets generated andor analyzed during the current study are not publicly available due to ethical restrictions the life child study is a study collecting potentially sensitive information publishing data sets is not covered by the informed consent provided by the study participants furthermore the data protection concept of life requests that all researchers interested in accessing data sign a project agreement researchers that are interested in accessing and analyzing data collected in the life child study may contact the data use and access committee abbreviations se spherical equivalent ses socioeconomic status or odds ratio ci confidence interval competing interests the authors declare no competing interests the funders had no role in the design of the study in the collection analyses or interpretation of data in the writing of the manuscript or in the decision to publish the results

background to investigate environmental and social risk factors for myopia in children and adolescents in germany methods 1437 children aged between 3 and 18 inclusive were examined as part of the life child study based in leipzig germany information about leisure time activities and social status was ascertained by parents and children in a questionnaire refractive status was attained by measuring noncycloplegic autorefraction myopia was defined as spherical equivalent se ≤ 075 d risk factors were identified using multiple logistic regression analysisin multiple logistic regression analysis myopia was significantly associated with less frequent outdoor activity once a week vs twice a week or more odds ratio or 435 95 confidence interval ci 189998 p 001 and longer near work sessions 12 h vs 1 h or 183 ci 110304 p002 3 h vs 1 h or 371 ci 143961 p 001 after adjustment for age sex and socioeconomic status ses duration of outdoor activity near work frequency and ses showed no significant association with myopia p 005 children with a lower ses were involved in longer periods of outdoor and near work activities but on fewer occasions over the course of the week although this connection was not significantmyopia is associated with environmental factors the present findings suggest that daily exposure to sunlight and a restriction of longduration near work activities might protect against pathological eye growth prevention strategies should be implemented for children at all ages

Introduction With the wide application of the Internet technology, the Internet has gradually transformed to the dynamic platform for information sharing and interactive communication. e 43 rd statistical report indicated that China had 854 million Internet users, and 99.1 percent of them access the Internet via mobile phones [1]. Social networks of a smart city have become the mainstream platform for information exchange and opinion expression. e users are not only the receivers of information, but also the creators to publish text comments in social networks. e hot events of public opinion refer that personal opinions are released on upcoming or already happened events by online communication tools and network platforms [2]. e spread of public opinion will snowball and expand by social networks, and emergent events may develop in an uncontrollable direction. Chain events caused by inadequate supervision on social networks can bring about the bad influence, and the frequency and harmfulness have shown an obvious rising trend in recent years [3]. Previous research has been studied from the qualitative aspects, such as the evolution mechanism of public opinion, information element classification, and influence judgment. However, the above research cannot meet the needs of online public opinion supervision, and the monitoring and management of hot events in social networks of a smart city need to implement quantitative judgment. For public opinion monitoring and management, Steyvers and Griffiths [4] proposed a topic model for public opinion detection in the social network. Yeh et al. [5] proposed a conceptually dynamic latent Dirichlet allocation model for topic content detection and tracking. e studies on probabilistic topic models for extracting hot topics from long texts have achieved good results [6], but these models are not suited to extract hot topics from short texts, such as Twitter and Facebook [7]. Kim et al. [8] introduced the sentiment scoring based on topics through the n-gram LDA topic modeling technology and investigated the topic reports and sentiment dynamics in news about Ebola virus. Subeno et al. [9] proposed a collapsed Gibbs sampling method based on the latent Dirichlet allocation model widely used on Spark. Park et al. [10] used partially collapsed Gibbs sampling for latent Dirichlet allocation and proposed a reasoning LDA method, which effectively obtained unbiased estimation under flexible modeling of heterogeneous text corpus by partially collapsed and Dirichlet mixed processing. However, there are still some problems in the detection of public opinion for events in social networks of a smart city. Firstly, the detection and analysis of public opinions for hot events in social networks mostly remain in the qualitative analysis or empirical research, lacking quantitative research. Secondly, there is a lack of public opinion analysis method combining with the characteristics of the microblog in social networks. irdly, for the sentiment analysis of public opinion events, most research adopts the two-stage method. at is to detect the event firstly and then conduct sentiment analysis and judgment, which is likely to lead to the separation between the event and sentiment. Fourthly, the dissemination for public opinions of hot events is time sensitive, so it is necessary to involve the time factor in comment text analysis. us, this paper proposes a mixed model with dynamic topic-sentiment for short texts in the social network, which comprehensively incorporates the topics, sentiment, and time factor of events to detect the public opinion. By quantitative analysis of real experiment data, the model can not only show the quantitative evolution trend of public opinion, but also provide the propagation rule of sudden events. e main contributions of this paper are reflected in two aspects. Firstly, the TSTS model is proposed by extending the topic model, which can not only extract both topic and sentiment polarity words, but also integrate the time factor to realize dynamic analysis of short texts. Secondly, this paper studies the detection and evolution analysis of Internet public opinion by the dynamic topic-sentiment model. e real datasets are used to conduct experimental analysis of the proposed model, which can reflect the evolution trend of public opinion diffusion. --- Related Research --- Research on Relevant Topic Models. e traditional opinion mining is to analyze the sentiment orientations based on the level of document and sentence. e traditional topic model was mainly used to compare the similarity among articles by comparing the number of repeated words in different articles. Blei et al. [11] proposed the latent Dirichlet allocation topic model to mine the hidden semantics of the text. LDA is a three-layer Bayesian model involving the document, topic, and word. e document is composed of a mixed distribution of topics, and each topic follows a polynomial distribution. And, Dirichlet distribution is introduced as the prior information of the polynomial distribution. e schematic diagram of the LDA topic model is shown in Figure 1. --- Research on Topic Model of Short Text. For most topic models, the topic is the word that appears in the document and has some connection. In previous studies, the topic model of short texts was expanded by introducing relevant background or author information, which weakened the topic and produced meaningless word contributions. Similarly, if co-occurrence words are extended to the whole corpus in the experiment, the occurrence frequency of each word will be greatly increased, and the connection between words will be closer. en, the modeling on documents will be easier. Based on the above hypotheses, Cheng et al. [12] proposed the biterm topic model , which is another way to explain the relationship between words, and text modeling of documents can be conducted based on the word co-occurrence model of the whole corpus. Rashid et al. [13] proposed the fuzzy topic modeling for short texts from the fuzzy perspective to solve the sparsity problem. Based on BTM, Lu et al. [14] introduced the RIBS-Bigrams model by learning the usage relationship, which showed topics with two-letter groups. Zhu et al. [15] proposed a joint model based on the latent Dirichlet allocation and BTM, which not only alleviates the sparsity of the BTM algorithm in processing short texts, but also preserves topic information of the document through the extended LDA. --- Research on Mixed Model Integrating Topic Sentiment. To evaluate the sentiment tendency of documents, the joint sentiment topic model added the sentiment layer based on the LDA model, forming a four-layer Bayesian network [16]. In this structure, the sentiment polarity label is related to the document, and the word generation is also influenced by both topic and sentiment. In the traditional LDA model, the generation of the document and words is determined by the topic. But in the JST model, the word of the document is determined by the topic and the sentiment. Amplayo et al. [17] proposed the aspect and sentiment unification model with sentiment level. e difference between JST and ASUM is that words in a sentence come from different topics in the JST model, while all words of a sentence belong to one topic in the ASUM model. In terms of event evolution, the associative topic model is proposed [19], and the recognized cluster is represented as the word distribution of the cluster with the corresponding event. In addition, Topic Over Time was proposed to integrate the time factor into the LDA model [20]. In the TOT model, word co-occurrence can affect the discovery of subject words, and time information can also affect the extraction of topic words. Unlike other models, each topic is subject to a continuous distribution of time and not rely on Markov models to discretize time in the TOT model. For each document generation, the mixed distribution of topics is determined by word co-occurrence and timestamp [21], which allows the TOT model to maintain independence in the time dimension and can predict the time for the document without any time information. --- Gibbs Sampling. e derivation of the experimental model in the paper is a variant form of the Markov Chain, so the Markov Chain Monte Carlo method is used for sampling in the experiment. Gibbs sampling, as one of the MCMC methods, has been widely used in prior research. Gibbs sampling is used to obtain a set of observations that approximate a specified multidimensional probability distribution, such as the probability distribution of two random variables. e Gibbs sampling method used for the latent Dirichlet allocation model can significantly improve the speed of the real-text corpus [22]. Papanikolaou et al. [23] estimated latent Dirichlet allocation parameters from Gibbs sampling by using all conditional distributions of potential variable assignments to effectively average multiple samples. Zhou et al. [24] proposed two kinds of Gibbs sampling inference methods, such as Sparse BTM and ESparse BTM, to achieve BTM by weighing space and time. Bhuyan [25] proposed the correlation random effect model based on potential variables and an algorithm to estimate correlation parameters based on Gibbs sampling. --- Model Constructing --- Topic-Sentiment Mixture Model with Time Factor . Based on prior research, this paper mainly improves the topic model from three aspects. Firstly, the sparse matrix caused by short texts in the social network is solved. Secondly, the topic and sentiment distribution of the same word pair are controlled. irdly, the problem of text homogeneity is solved by incorporating the time factor into the topic model. erefore, the TSTS model proposed in this paper is used to constrain the word pairs in the same document, which greatly reduces the complexity of time and space and makes up for the sparse matrix of short texts to some extent. Moreover, the sentiment layer is integrated into TSTS by extending the hypotheses of ASUM and restrains word pairs generated by constraining sentences to follow the same topic-sentiment distribution. Finally, the TSTS model incorporating the time factor does not rely on the Markov model to discretize time, and each topic is subject to the continuous temporal distribution. For each document generation, the mixed distribution of topics is determined by the words co-occurrence and timestamps. TSTS model is shown in Figure 2. e TSTS model simulates the generating process of online comments. Generally, the online comments from users can be regarded as a document, which is short, pithy, and highly emotional. e word co-occurrence from BTM is the most effective solution for the short-text topic model. In addition, the TSTS model with the time layer can continuously sample users' evaluation of hot events, as well as the dynamic changes of users' sentiment. erefore, the hypotheses of the TSTS model are proposed as follows: e probability distribution of the time factor is not directly equal to the joint distribution of the topic and sentiment e topic-sentiment distribution of each document is independent [26] Similar topics of different sentiment polarity are not automatically categorized [27] Combined with the probability graph of Bayesian's network, the TSTS model proposed in the paper has four characteristics. First, a word pair is used to replace a single word to carry out the sampling model. Second, each timestamp is related by topic and sentiment. ird, the extraction of thematic characteristic and sentiment words is for the whole corpus. Fourth, in the derivation process of the TSTS model, it is not necessary to correspond between thematic feature and affective polarity words. at is because every topic and sentiment have the corresponding polynomial word pair distribution. In addition, the text modeling process of the TSTS model also follows the assumption that there is a connection between the sentimental polarity words of the topic features, which also changes with the time factor. So, the documents used to train the model must have a specific timestamp, such as the publishing time of the microblog. --- Generation of a Text in TSTS Model. In the TSTS model, we assumed that a corpus is composed of several texts. For instance, a microblog is a text containing two dimensions of topic and sentiment. Considering the effectiveness of public opinions and related parameters of the microblog text, word distribution is determined by the topic, sentiment, and time. So, TSTS is an unsupervised topic-sentiment mixed model. e generation process of the document is as follows: Extract a polynomial distribution θ d on a topic from the Dirichlet prior distribution α, that is, θ d ∼ Dir z i ∼ θ d z i ∼ θ d Choose an emotional label l i ∼ π z i Choose a pair of words b i ∼ φ z i ,l i Choose a timestamp t i ∼ ψ z i ,l i As shown in Figure 2, word pairs in a document may belong to different timestamps in the text generation process of the TSTS topic model. In theory, all the content of an article such as words and topics should belong to the same timestamp. Also, the introduction of the time factor into the topic model will affect the topic homogeneity of an article. However, the default time factor of the TSTS model in the topic model will not affect the homogeneity of the text. So, it is assumed that the time factor in the paper has no weight. Based on the TOT and the group topic model, the superparameter μ is introduced into TSTS to balance the interaction of time and words in document generation. e parameters' explanation of the TSTS model is shown in Table 1. --- Model Deduction. According to the Bayesian network structure diagram of the TSTS model, the polynomial distribution θ of the topic, the distribution π of sentiment with the topic, the correlation distribution φ of word pairs with <topic, sentiment>, and the correlation distribution ψ of time with <topic, sentiment> can be calculated according to the superparameters α, β, c, and μ. en, Gibbs sampling is done that can ensure the convergence of the TSTS model under enough iteration times. And, each word in the document is assigned the topic and sentiment that are most suitable for the facts. According to the principle of Bayesian independence, the joint probability of word pair, topic, sentimental polarity, and timestamp is given as follows: p � p • p • p • p, (1 ) where the parameters are independent such as word pairs b and parameters α, c, and μ, timestamps t and parameters α, c, and β, sentiment polarity l and parameters α, μ, and β, and topic words z and parameters β, c, and μ. erefore, the joint distribution in the equation can be obtained by calculating the four parts on the right side of the equation. Given the sentiment polarity label of specific topic features, the distribution of b can be regarded as a polynomial distribution. Based on the premise of topic words z i and l i , b i is generated by N times with the probability p at each time. Given that word pairs are independent of each other, we can obtain p � 􏽙 N i�1 p b i z i , l i 􏼌 􏼌 􏼌 􏼌 􏼐 􏼑 � 􏽙 N i β • b i . (2 ) Superparameters are the representation parameters of the framework in the machine learning model [28], such as the number of classes in the clustering method or the number of topics in the topic model. In the Bayesian network, the distribution and density function of θ are denoted as H and h, respectively. ey are regarded as the prior distribution function and the prior density function, respectively, which are collectively referred to as the prior distribution. If the distribution of θ is obtained after sampling, it is called the posterior distribution. Based on the conjugate property of Dirichlet∼multinomial, when the Dir + Mult � Dir. For the general text model, the discretized Dirichlet distribution and multinational distribution are as follows: Dir � Γ 􏽐 T j�1 β 􏼐 􏼑 􏽑 T j�1 Γ 􏽙 T j�1 n j , (4 ) Mult � N n 􏼠 􏼡 􏽙 T j�1 n j , (5 ) where i, j, k, and h represent the iteration times of word pairs, topic, sentiment, and timestamp in the modeling process, respectively. Since the distribution of p follows the Dirichlet distribution, this paper introduces φ for p. It can be obtained by integrating φ: p � 􏽚 p • pdφ � Γ Γ V 􏼠 􏼡 T•S 􏽙 j 􏽙 k 􏽑 i Γ n i,j,k + β 􏼐 􏼑 Γ n j,k + Vβ 􏼐 􏼑 . (6 ) To estimate the posterior parameters φ in the formula, we can combine with the Bayes formula and the conjugate property of Dirichlet∼multinomial. e distribution of the posterior parameters can be obtained as follows: p) ∝ Dir φ n i,j,k + β 􏼌 􏼌 􏼌 􏼌 􏼌 􏼒 􏼓. Given that the expectation of the Dirichlet distribution is E) � ε i /􏽐 i ε i , so the calculated parameters are estimated by the known posterior parameter distribution expectation. e estimated results are shown in equation . Similarly, for p, ψ is introduced. By integrating ψ, it can be obtained as follows: p � Γ Γ H 􏼠 􏼡 T•S 􏽙 j 􏽙 k 􏽑 h Γ n j,k,h + μ 􏼐 􏼑 Γ n j,k + Hμ 􏼐 􏼑 . (8 ) For p, π is introduced. By integrating π, it can be obtained as follows: p � Γ 􏽐 k c k 􏼁 􏽑 k Γ c k 􏼁 􏼠 􏼡 T 􏽙 j 􏽑 k Γ n j,k + c k 􏼐 􏼑 Γ n j + 􏽐 k α k 􏼐 􏼑 . (9 ) For p, θ is introduced. By integrating θ, it can be obtained as follows: p � Γ 􏽐 j α j 􏼐 􏼑 􏽑 j Γ α j 􏼐 􏼑 ⎛ ⎝ ⎞ ⎠ D 􏽙 d 􏽑 j Γ n d,j + α j 􏼐 􏼑 Γ n d + 􏽐 j α j 􏼐 􏼑 . (10 ) e TSTS model can estimate the posterior distribution after estimated values z and s have been obtained by sampling calculations. en, the calculated equations - are brought into equation . Combining with the nature of Gamma function, the conditional distribution probability in Gibbs sampling can be obtained: p s p � k, z p � j b, t, l -p 􏼌 􏼌 􏼌 􏼌 , z -p , α, β, c, μ 􏼐 􏼑 ∝ n -p d,j + α j n -p d + 􏽐 j α j • n -p w p ,j,k + β n -p j,k + Vβ • n -p j,k + c k n -p j + 􏽐 k c k • n -p j,k,t p + μ n -p j,k + Hμ . (11 ) In order to simplify equation , the superparameter μ � 1/n d is introduced. When the superparameters α, β, μ, and c are given, the set B of the word pair, the corresponding topic z, and sentiment label l can be used to infer the parameters φ, θ, π, and ψ based on Bayes' rule and Dirichlet conjugate properties: φ j,k,i � n i,j,k + β n j,k + Vβ , θ d,j � n d,j + α j n d + 􏽐 j α j , π j,k � n j,k + c k n j + 􏽐 k c k , ψ j,k,h � n j,k,h + μ n j,k + Hμ . (12 ) --- Experiment Analysis 4.1. Data Collection. In order to verify the TSTS model proposed in this paper, the four hot events are randomly selected from the trending searches of Sina Weibo in 2019. And, the comments of four events are regarded as the experimental datasets. e four datasets selected are "Military parade in National Day," " e assault on a doctor," "Hong Kong's event," and "Garbage sorting in Shanghai." e comments are extracted from the Sina social network platform. In the original datasets, there are some meaningless words in the microblog text, such as stop words, interjections in tone, punctuation marks, and numeric expressions. Before text modeling, the word segmentation package in Python is used to process the experimental initial dataset. In addition, considering that comments on social networks are relatively new, the fashionable expressions in the social network are collected and added to the customized dictionary. So, these emerging words can be identified as far as possible and replaced with normal expressions. In addition, there are some useless words in the text, such as URL links and numbers, which can be filtered by regular expressions. Finally, a total of 14288 experimental data in four events are obtained. e description of four datasets is shown in Table 2. --- Sentiment Dictionary. e words or phrases in the sentiment dictionary have obvious sentiment tendency, Complexity which can be divided into positive and negative words. e sentiment dictionary in this paper has two major roles. On the one hand, we can identify sentiment polarity words and distinguish topic features and sentiment words. On the other hand, combining with sentiment prior information to make the model more accurate in judging the sentiment polarity of the text. Given that sentiment polarity words can reflect users' sentiment tendency, it is of great significance to analyze the sentiment orientation of the text. At present, there are two major Chinese sentiment dictionaries: NTU and HowNet. e former dictionary contains 2812 positive words and 8276 negative words. e latter contains about 5,000 positive words and 5,000 negative words. Based on HowNet and the classification of sentiment polarity [29,30], this paper constitutes the sentiment dictionary of the TSTS model evaluation experiment, as shown in Table 3. --- Parameter Setting. In this paper, the Gibbs algorithm is used to sample the TSTS model and estimate four posterior parameters. According to the parameter setting in the traditional topic model, the superparameters are set as follows. First, the superparameter α is set as 50/K, and K is the number of topics extracted. Second, β is set as 0.01. ird, c is set as /S. AVE stands for the average length of articles, that is, the average number of words in the microblog in this experiment, and S stands for the total number of polar tags. Finally, μ is set as 1/n d . --- Evaluation Indicator. For the extraction of topic features, perplexity is used as an evaluation indicator to measure the predictive power of unknown data in the process of model modeling. Also, the lower perplexity means better efficiency. e calculation formula of the perplexity is as follows: perplexity � P 􏽥 D t | M 􏼁 � exp - 􏽐 D t d�1 log P 􏽥 b t d | M 􏼒 􏼓 􏽐 D t d�1 􏽥 N t d ⎧ ⎪ ⎪ ⎨ ⎪ ⎪ ⎩ ⎫ ⎪ ⎪ ⎬ ⎪ ⎪ ⎭ , (13 ) where 􏽥 D t � 􏽥 b t d 􏼚 􏼛 D t d�1 represents an unknown dataset with the timestamp t. P 􏽥 b t d | M 􏼒 􏼓 � 􏽙 􏽥 N t d n�1 􏽙 L l�1 􏽙 T t�1 P 􏽥 b d,n | l, z 􏼐 􏼑PP, (14 ) where P 􏽥 b t d | M 􏼒 􏼓 � 􏽙 V i�1 􏽘 l l�1 􏽘 T z�1 φ l,z,i • θ d,l,z • π d,l ) 􏽥 N t d,i . ⎛ ⎝ (15 ) For sentiment segmentation, the sentiment judgment from the perspective of the document is used as the evaluation index, which is based on the sentim ent polarity label in the sentiment dictionary. For the documents in this experiment, the positive and negative sentiment of a document can be judged. is paper adopts the consistency test method to mark the sentiment labels [31]. --- Results --- Extraction of Topics. e primary task of the TSTS model is to extract topic features. As an extension of the topic-sentiment mixed model, the assessment is to judge whether the extracted topic features are reasonable and accurate. Before extracting topic features from text modeling, it is necessary to determine the number of topics to be extracted and the iteration times of Gibbs sampling. For the effective evaluation of topic discovery, the degree of perplexity is used as the measurement index in the paper. e lower the perplexity is, the better the fitting effect of the model is. Taking dataset 1 as an example, the simulation results are shown in Figure 3. Based on the experimental results shown in Figure 3, the number of topics was set 20 in the subsequent experiments. In addition, we can calculate the perplexity of three models with the change of the iterations. By comparing the experimental results of TSTS and LDA, it can be found that the effect of TSTS is always better than LDA, and the degree of perplexity decreases with the increase of iteration. at indicates that the topic discovery ability of TSTS gradually improves, mainly because the TSTS model incorporates the word pairs to alleviate the sparse matrix of LDA for short texts. By comparing the experimental results of TSTS and BTM, it can be found that TSTS was better than BTM when the number of iterations increases. However, as the number 6 Complexity of iterations increased, the gap of both models became smaller. is is because the word pair of BTM is used for the whole corpus. When the number of iterations is small, the proportion of noise words is relatively large, resulting in poor quality of topic words. In addition, the sentiment layer is integrated into TSTS, and the error generated in the sentiment estimation will affect the next iteration. Although TSTS is worse than BTM when there are more iterations, the effect of TSTS can still be balanced with BTM. erefore, during the extraction of topic features, the number of topics and iterations can be set as 20 and 600. --- Sentiment Polarity. e information related to sentiment polarity is provided in accordance with the topic and sentiment polarity of words. e sentiment distribution of topics extracted from the TSTS model is shown in Figure 4. In addition, JST and ASUM are introduced as the comparison to measure the effect of sentiment recognition of the TSTS model. Each document has a binary sentiment label, such as positive or negative sentiment. Taking dataset 2 " e attack on the doctor" as an example, the result is shown in Figure 4. e number of topics is set to 5 at the beginning of the experiment. With the refinement of granularity, the performance of the TSTS model increases. Compared with JST and ASUM, the curve of the TSTS model changes greatly considering the topic and sentiment relationship among word pairs of the document. e change curve of the JST model shows a steady upward trend, and the identification efficiency of ASUM is low. at is because ASUM has strict assumptions, and the increase in the number of topics will cause the decentralization of topics and sentiments, which has a great negative impact on the overall performance of the model. e overall effect of the TSTS model was slightly better than JST and ASUM, but the effect decreased slightly after the number of topics increased to 20. is is because the data collected in the dataset are limited, and the number of topics has been set to discretize the word distribution. us, the judgment of sentiment polarity is affected. e sentiment label classification of documents is compared under different topics, and the result of the TSTS model is better than JST and ASUM. With the increase of topics, the recognition performance of the topic model has some fluctuations. But, the TSTS model was always better than JST and ASUM. When the number of obtained topics and iterations is set as 20 and 600, the TSTS is the best model in topic detection. When the number of topics in the four datasets was set as 20, the accuracy of sentiment polarity judgment is shown in Table 4. From Table 4, the TSTS model is better than JST and ASUM in judging the sentiment polarity of documents. is Complexity is because sentiment polarity depends on the performance of topic discovery in the previous stage. In this experiment, the effect of JST and ASUM was exactly opposite. e difference was caused by the length of the original document, which also indirectly verified the effectiveness of the TSTS model. From Figure 5, it can be seen that the proportion of positive sentiment is significantly higher than the other sentiments in the dataset "Military parade in National Day" and the dataset "Garbage sorting in Shanghai," which is consistent with the sentiment tendency of users in the social network. For the second dataset " e assault on a doctor," the two kinds of negative sentiment polarities of topic #1 and topic #2 were compared. Topic #1 is more likely to be sad sentiment, while topic #2 is more likely to be angry sentiment. Topic #1 reflects the statement of the event, and topic #2 represents the follow-up discussion of the event. --- Topic and Sentiment Evolution. e curves of topic features extracted from four datasets through the TSTS model are shown in Figure 6. Taking dataset 2 as an example, the topic curve conforms to the evolution law of social and abrupt events. e two curves represent the trend of feature words over time in topic #1 and topic #2. Topic #1 is the 8 Complexity statement about the case itself. From the beginning of the event, the amount of discussion about the event on the social network rose sharply and then gradually declined. Topic #2 is a discussion on the development of the case, which has caused the second hot discussion again. e time is not consistent when two curves reach the high peak. e peak value of topic #2 curve is lower than that of topic #1, which reflects the discussion of the same event will fade over time. Even if there is a new topic, discussion of a new topic is far lower than the beginning of the event. Meanwhile, similar results can be verified in other three datasets. e proportion of the sentiment polarity in the four datasets is shown in Figure 7. Since the sentiment polarity proportion is measured, the four sentiment polarities are balanced distributed before the occurrence of the events. After the event occurred, the polarity of positive and negative sentiment began to change toward the two extremes. Among the four datasets, the positive sentiment was higher than the negative sentiment in the first dataset "National Day military parade event" and the fourth dataset "Shanghai garbage classification event," which also conforms to the social sentiment of events. In addition, it can be found that the difference among the four sentiment labels is large in the initial stage, and the distribution of sentiment labels becomes stable in the later stage. It has proved that the second report of social events does not cause the heat for the first time. But, the sentiment tendency judgment in social networks will not decline sharply with the reduction of discussion, which can be proved in topic #2 of the second dataset " e assault on a doctor." Given that the topic features come from the background of a corpus and contain a lot of noise words, the relative position of four curves is closer in terms of sentiment polarity evolution. However, there is still a gap between government feelings, which is different from the average distribution of sentiment polarity at the beginning of the event. --- Discussion From the perspective of theoretical significance, this paper extends the LDA model to some extent. First, in view of the sparse matrix caused by the short text, word pairs are introduced to replace a single word for text generation according to BTM. Based on the hypotheses of JST and ASUM, the sentiment layer is introduced to form the Bayesian network structure, and the word pair is limited to the same sentiment polarity distribution. Second, in order to realize dynamic analysis and text homogeneity, the timestamp and the corresponding superparameter are introduced to alleviate the problem of the word order in the text generation. ird, this research combines behavioral experiments, big data mining, mathematical modeling, and imitating to promote the research expansion of new situations and new methods. From the perspective of practical significance, this paper is of great value in tracking and monitoring topics of public opinion in social networks. e online public opinions of hot events can be monitored, which contributes to accurately judge social events and make emergency decisions for government or departments. In addition, this paper analyzed the evolution, response, and governance of public opinion, which is conducive to understand the formation mechanism and the collaborative evolution of public opinion. Meanwhile, the use of public opinion information can detect and screen information, prevent the spread of rumor, and scientifically formulate the mechanism of utilization to effectively reduce the loss risk. --- Conclusions In the context of the mobile social network, the number of short texts is growing explosively. In order to extract information from massive short texts quickly and monitor public opinions, the TSTS model is proposed in the study based on LDA, BTM, JST, ASUM, and TOT. From the experimental results, the TSTS model achieves good performance. In terms of topic feature extraction, the degree of perplexity of TSTS is always lower than LDA. Moreover, although the degree of perplexity is slightly higher than BTM with the increase of iteration times, it can maintain the balance with BTM. In the sentiment analysis, the effect of TSTS was significantly better than JST and ASUM. Finally, the TSTS model incorporating the time factor can determine the change trend of the topic and sentiment. ere are still some shortcomings in this paper. Firstly, for the extraction of topic feature words, the global topic level can be added to the topic layer of the TSTS model to filter the common topic words. Secondly, in sentiment polarity judgment, the sentiment labels are manually marked based on prior knowledge. However, the sentiments are extremely rich and changeable. In the future research, the Bayesian network and entity theory can be used to judge sentiment bias. --- Data Availability e data used to support the findings of this study are available from the corresponding author upon request. --- Conflicts of Interest e authors declare that they have no conflicts of interest.

With the rapid development of mobile Internet, the social network has become an important platform for users to receive, release, and disseminate information. In order to get more valuable information and implement effective supervision on public opinions, it is necessary to study the public opinions, sentiment tendency, and the evolution of the hot events in social networks of a smart city. In view of social networks' characteristics such as short text, rich topics, diverse sentiments, and timeliness, this paper conducts text modeling with words co-occurrence based on the topic model. Besides, the sentiment computing and the time factor are incorporated to construct the dynamic topic-sentiment mixture model (TSTS). en, four hot events were randomly selected from the microblog as datasets to evaluate the TSTS model in terms of topic feature extraction, sentiment analysis, and time change. e results show that the TSTS model is better than the traditional models in topic extraction and sentiment analysis. Meanwhile, by fitting the time curve of hot events, the change rules of comments in the social network is obtained.

introduction with the wide application of the internet technology the internet has gradually transformed to the dynamic platform for information sharing and interactive communication e 43 rd statistical report indicated that china had 854 million internet users and 991 percent of them access the internet via mobile phones 1 social networks of a smart city have become the mainstream platform for information exchange and opinion expression e users are not only the receivers of information but also the creators to publish text comments in social networks e hot events of public opinion refer that personal opinions are released on upcoming or already happened events by online communication tools and network platforms 2 e spread of public opinion will snowball and expand by social networks and emergent events may develop in an uncontrollable direction chain events caused by inadequate supervision on social networks can bring about the bad influence and the frequency and harmfulness have shown an obvious rising trend in recent years 3 previous research has been studied from the qualitative aspects such as the evolution mechanism of public opinion information element classification and influence judgment however the above research cannot meet the needs of online public opinion supervision and the monitoring and management of hot events in social networks of a smart city need to implement quantitative judgment for public opinion monitoring and management steyvers and griffiths 4 proposed a topic model for public opinion detection in the social network yeh et al 5 proposed a conceptually dynamic latent dirichlet allocation model for topic content detection and tracking e studies on probabilistic topic models for extracting hot topics from long texts have achieved good results 6 but these models are not suited to extract hot topics from short texts such as twitter and facebook 7 kim et al 8 introduced the sentiment scoring based on topics through the ngram lda topic modeling technology and investigated the topic reports and sentiment dynamics in news about ebola virus subeno et al 9 proposed a collapsed gibbs sampling method based on the latent dirichlet allocation model widely used on spark park et al 10 used partially collapsed gibbs sampling for latent dirichlet allocation and proposed a reasoning lda method which effectively obtained unbiased estimation under flexible modeling of heterogeneous text corpus by partially collapsed and dirichlet mixed processing however there are still some problems in the detection of public opinion for events in social networks of a smart city firstly the detection and analysis of public opinions for hot events in social networks mostly remain in the qualitative analysis or empirical research lacking quantitative research secondly there is a lack of public opinion analysis method combining with the characteristics of the microblog in social networks irdly for the sentiment analysis of public opinion events most research adopts the twostage method at is to detect the event firstly and then conduct sentiment analysis and judgment which is likely to lead to the separation between the event and sentiment fourthly the dissemination for public opinions of hot events is time sensitive so it is necessary to involve the time factor in comment text analysis us this paper proposes a mixed model with dynamic topicsentiment for short texts in the social network which comprehensively incorporates the topics sentiment and time factor of events to detect the public opinion by quantitative analysis of real experiment data the model can not only show the quantitative evolution trend of public opinion but also provide the propagation rule of sudden events e main contributions of this paper are reflected in two aspects firstly the tsts model is proposed by extending the topic model which can not only extract both topic and sentiment polarity words but also integrate the time factor to realize dynamic analysis of short texts secondly this paper studies the detection and evolution analysis of internet public opinion by the dynamic topicsentiment model e real datasets are used to conduct experimental analysis of the proposed model which can reflect the evolution trend of public opinion diffusion related research research on relevant topic models e traditional opinion mining is to analyze the sentiment orientations based on the level of document and sentence e traditional topic model was mainly used to compare the similarity among articles by comparing the number of repeated words in different articles blei et al 11 proposed the latent dirichlet allocation topic model to mine the hidden semantics of the text lda is a threelayer bayesian model involving the document topic and word e document is composed of a mixed distribution of topics and each topic follows a polynomial distribution and dirichlet distribution is introduced as the prior information of the polynomial distribution e schematic diagram of the lda topic model is shown in figure 1 research on topic model of short text for most topic models the topic is the word that appears in the document and has some connection in previous studies the topic model of short texts was expanded by introducing relevant background or author information which weakened the topic and produced meaningless word contributions similarly if cooccurrence words are extended to the whole corpus in the experiment the occurrence frequency of each word will be greatly increased and the connection between words will be closer en the modeling on documents will be easier based on the above hypotheses cheng et al 12 proposed the biterm topic model which is another way to explain the relationship between words and text modeling of documents can be conducted based on the word cooccurrence model of the whole corpus rashid et al 13 proposed the fuzzy topic modeling for short texts from the fuzzy perspective to solve the sparsity problem based on btm lu et al 14 introduced the ribsbigrams model by learning the usage relationship which showed topics with twoletter groups zhu et al 15 proposed a joint model based on the latent dirichlet allocation and btm which not only alleviates the sparsity of the btm algorithm in processing short texts but also preserves topic information of the document through the extended lda research on mixed model integrating topic sentiment to evaluate the sentiment tendency of documents the joint sentiment topic model added the sentiment layer based on the lda model forming a fourlayer bayesian network 16 in this structure the sentiment polarity label is related to the document and the word generation is also influenced by both topic and sentiment in the traditional lda model the generation of the document and words is determined by the topic but in the jst model the word of the document is determined by the topic and the sentiment amplayo et al 17 proposed the aspect and sentiment unification model with sentiment level e difference between jst and asum is that words in a sentence come from different topics in the jst model while all words of a sentence belong to one topic in the asum model in terms of event evolution the associative topic model is proposed 19 and the recognized cluster is represented as the word distribution of the cluster with the corresponding event in addition topic over time was proposed to integrate the time factor into the lda model 20 in the tot model word cooccurrence can affect the discovery of subject words and time information can also affect the extraction of topic words unlike other models each topic is subject to a continuous distribution of time and not rely on markov models to discretize time in the tot model for each document generation the mixed distribution of topics is determined by word cooccurrence and timestamp 21 which allows the tot model to maintain independence in the time dimension and can predict the time for the document without any time information gibbs sampling e derivation of the experimental model in the paper is a variant form of the markov chain so the markov chain monte carlo method is used for sampling in the experiment gibbs sampling as one of the mcmc methods has been widely used in prior research gibbs sampling is used to obtain a set of observations that approximate a specified multidimensional probability distribution such as the probability distribution of two random variables e gibbs sampling method used for the latent dirichlet allocation model can significantly improve the speed of the realtext corpus 22 papanikolaou et al 23 estimated latent dirichlet allocation parameters from gibbs sampling by using all conditional distributions of potential variable assignments to effectively average multiple samples zhou et al 24 proposed two kinds of gibbs sampling inference methods such as sparse btm and esparse btm to achieve btm by weighing space and time bhuyan 25 proposed the correlation random effect model based on potential variables and an algorithm to estimate correlation parameters based on gibbs sampling model constructing topicsentiment mixture model with time factor based on prior research this paper mainly improves the topic model from three aspects firstly the sparse matrix caused by short texts in the social network is solved secondly the topic and sentiment distribution of the same word pair are controlled irdly the problem of text homogeneity is solved by incorporating the time factor into the topic model erefore the tsts model proposed in this paper is used to constrain the word pairs in the same document which greatly reduces the complexity of time and space and makes up for the sparse matrix of short texts to some extent moreover the sentiment layer is integrated into tsts by extending the hypotheses of asum and restrains word pairs generated by constraining sentences to follow the same topicsentiment distribution finally the tsts model incorporating the time factor does not rely on the markov model to discretize time and each topic is subject to the continuous temporal distribution for each document generation the mixed distribution of topics is determined by the words cooccurrence and timestamps tsts model is shown in figure 2 e tsts model simulates the generating process of online comments generally the online comments from users can be regarded as a document which is short pithy and highly emotional e word cooccurrence from btm is the most effective solution for the shorttext topic model in addition the tsts model with the time layer can continuously sample users evaluation of hot events as well as the dynamic changes of users sentiment erefore the hypotheses of the tsts model are proposed as follows e probability distribution of the time factor is not directly equal to the joint distribution of the topic and sentiment e topicsentiment distribution of each document is independent 26 similar topics of different sentiment polarity are not automatically categorized 27 combined with the probability graph of bayesians network the tsts model proposed in the paper has four characteristics first a word pair is used to replace a single word to carry out the sampling model second each timestamp is related by topic and sentiment ird the extraction of thematic characteristic and sentiment words is for the whole corpus fourth in the derivation process of the tsts model it is not necessary to correspond between thematic feature and affective polarity words at is because every topic and sentiment have the corresponding polynomial word pair distribution in addition the text modeling process of the tsts model also follows the assumption that there is a connection between the sentimental polarity words of the topic features which also changes with the time factor so the documents used to train the model must have a specific timestamp such as the publishing time of the microblog generation of a text in tsts model in the tsts model we assumed that a corpus is composed of several texts for instance a microblog is a text containing two dimensions of topic and sentiment considering the effectiveness of public opinions and related parameters of the microblog text word distribution is determined by the topic sentiment and time so tsts is an unsupervised topicsentiment mixed model e generation process of the document is as follows extract a polynomial distribution θ d on a topic from the dirichlet prior distribution α that is θ d ∼ dir z i ∼ θ d z i ∼ θ d choose an emotional label l i ∼ π z i choose a pair of words b i ∼ φ z i l i choose a timestamp t i ∼ ψ z i l i as shown in figure 2 word pairs in a document may belong to different timestamps in the text generation process of the tsts topic model in theory all the content of an article such as words and topics should belong to the same timestamp also the introduction of the time factor into the topic model will affect the topic homogeneity of an article however the default time factor of the tsts model in the topic model will not affect the homogeneity of the text so it is assumed that the time factor in the paper has no weight based on the tot and the group topic model the superparameter μ is introduced into tsts to balance the interaction of time and words in document generation e parameters explanation of the tsts model is shown in table 1 model deduction according to the bayesian network structure diagram of the tsts model the polynomial distribution θ of the topic the distribution π of sentiment with the topic the correlation distribution φ of word pairs with and the correlation distribution ψ of time with can be calculated according to the superparameters α β c and μ en gibbs sampling is done that can ensure the convergence of the tsts model under enough iteration times and each word in the document is assigned the topic and sentiment that are most suitable for the facts according to the principle of bayesian independence the joint probability of word pair topic sentimental polarity and timestamp is given as follows p � p • p • p • p 1 where the parameters are independent such as word pairs b and parameters α c and μ timestamps t and parameters α c and β sentiment polarity l and parameters α μ and β and topic words z and parameters β c and μ erefore the joint distribution in the equation can be obtained by calculating the four parts on the right side of the equation given the sentiment polarity label of specific topic features the distribution of b can be regarded as a polynomial distribution based on the premise of topic words z i and l i b i is generated by n times with the probability p at each time given that word pairs are independent of each other we can obtain p � 􏽙 n i�1 p b i z i l i 􏼌 􏼌 􏼌 􏼌 􏼐 􏼑 � 􏽙 n i β • b i 2 superparameters are the representation parameters of the framework in the machine learning model 28 such as the number of classes in the clustering method or the number of topics in the topic model in the bayesian network the distribution and density function of θ are denoted as h and h respectively ey are regarded as the prior distribution function and the prior density function respectively which are collectively referred to as the prior distribution if the distribution of θ is obtained after sampling it is called the posterior distribution based on the conjugate property of dirichlet∼multinomial when the dir mult � dir for the general text model the discretized dirichlet distribution and multinational distribution are as follows dir � γ 􏽐 t j�1 β 􏼐 􏼑 􏽑 t j�1 γ 􏽙 t j�1 n j 4 mult � n n 􏼠 􏼡 􏽙 t j�1 n j 5 where i j k and h represent the iteration times of word pairs topic sentiment and timestamp in the modeling process respectively since the distribution of p follows the dirichlet distribution this paper introduces φ for p it can be obtained by integrating φ p � 􏽚 p • pdφ � γ γ v 􏼠 􏼡 t•s 􏽙 j 􏽙 k 􏽑 i γ n ijk β 􏼐 􏼑 γ n jk vβ 􏼐 􏼑 6 to estimate the posterior parameters φ in the formula we can combine with the bayes formula and the conjugate property of dirichlet∼multinomial e distribution of the posterior parameters can be obtained as follows p ∝ dir φ n ijk β 􏼌 􏼌 􏼌 􏼌 􏼌 􏼒 􏼓 given that the expectation of the dirichlet distribution is e � ε i 􏽐 i ε i so the calculated parameters are estimated by the known posterior parameter distribution expectation e estimated results are shown in equation similarly for p ψ is introduced by integrating ψ it can be obtained as follows p � γ γ h 􏼠 􏼡 t•s 􏽙 j 􏽙 k 􏽑 h γ n jkh μ 􏼐 􏼑 γ n jk hμ 􏼐 􏼑 8 for p π is introduced by integrating π it can be obtained as follows p � γ 􏽐 k c k 􏼁 􏽑 k γ c k 􏼁 􏼠 􏼡 t 􏽙 j 􏽑 k γ n jk c k 􏼐 􏼑 γ n j 􏽐 k α k 􏼐 􏼑 9 for p θ is introduced by integrating θ it can be obtained as follows p � γ 􏽐 j α j 􏼐 􏼑 􏽑 j γ α j 􏼐 􏼑 ⎛ ⎝ ⎞ ⎠ d 􏽙 d 􏽑 j γ n dj α j 􏼐 􏼑 γ n d 􏽐 j α j 􏼐 􏼑 10 e tsts model can estimate the posterior distribution after estimated values z and s have been obtained by sampling calculations en the calculated equations are brought into equation combining with the nature of gamma function the conditional distribution probability in gibbs sampling can be obtained p s p � k z p � j b t l p 􏼌 􏼌 􏼌 􏼌 z p α β c μ 􏼐 􏼑 ∝ n p dj α j n p d 􏽐 j α j • n p w p jk β n p jk vβ • n p jk c k n p j 􏽐 k c k • n p jkt p μ n p jk hμ 11 in order to simplify equation the superparameter μ � 1n d is introduced when the superparameters α β μ and c are given the set b of the word pair the corresponding topic z and sentiment label l can be used to infer the parameters φ θ π and ψ based on bayes rule and dirichlet conjugate properties φ jki � n ijk β n jk vβ θ dj � n dj α j n d 􏽐 j α j π jk � n jk c k n j 􏽐 k c k ψ jkh � n jkh μ n jk hμ 12 experiment analysis 41 data collection in order to verify the tsts model proposed in this paper the four hot events are randomly selected from the trending searches of sina weibo in 2019 and the comments of four events are regarded as the experimental datasets e four datasets selected are military parade in national day e assault on a doctor hong kongs event and garbage sorting in shanghai e comments are extracted from the sina social network platform in the original datasets there are some meaningless words in the microblog text such as stop words interjections in tone punctuation marks and numeric expressions before text modeling the word segmentation package in python is used to process the experimental initial dataset in addition considering that comments on social networks are relatively new the fashionable expressions in the social network are collected and added to the customized dictionary so these emerging words can be identified as far as possible and replaced with normal expressions in addition there are some useless words in the text such as url links and numbers which can be filtered by regular expressions finally a total of 14288 experimental data in four events are obtained e description of four datasets is shown in table 2 sentiment dictionary e words or phrases in the sentiment dictionary have obvious sentiment tendency complexity which can be divided into positive and negative words e sentiment dictionary in this paper has two major roles on the one hand we can identify sentiment polarity words and distinguish topic features and sentiment words on the other hand combining with sentiment prior information to make the model more accurate in judging the sentiment polarity of the text given that sentiment polarity words can reflect users sentiment tendency it is of great significance to analyze the sentiment orientation of the text at present there are two major chinese sentiment dictionaries ntu and hownet e former dictionary contains 2812 positive words and 8276 negative words e latter contains about 5000 positive words and 5000 negative words based on hownet and the classification of sentiment polarity 2930 this paper constitutes the sentiment dictionary of the tsts model evaluation experiment as shown in table 3 parameter setting in this paper the gibbs algorithm is used to sample the tsts model and estimate four posterior parameters according to the parameter setting in the traditional topic model the superparameters are set as follows first the superparameter α is set as 50k and k is the number of topics extracted second β is set as 001 ird c is set as s ave stands for the average length of articles that is the average number of words in the microblog in this experiment and s stands for the total number of polar tags finally μ is set as 1n d evaluation indicator for the extraction of topic features perplexity is used as an evaluation indicator to measure the predictive power of unknown data in the process of model modeling also the lower perplexity means better efficiency e calculation formula of the perplexity is as follows perplexity � p 􏽥 d t m 􏼁 � exp 􏽐 d t d�1 log p 􏽥 b t d m 􏼒 􏼓 􏽐 d t d�1 􏽥 n t d ⎧ ⎪ ⎪ ⎨ ⎪ ⎪ ⎩ ⎫ ⎪ ⎪ ⎬ ⎪ ⎪ ⎭ 13 where 􏽥 d t � 􏽥 b t d 􏼚 􏼛 d t d�1 represents an unknown dataset with the timestamp t p 􏽥 b t d m 􏼒 􏼓 � 􏽙 􏽥 n t d n�1 􏽙 l l�1 􏽙 t t�1 p 􏽥 b dn l z 􏼐 􏼑pp 14 where p 􏽥 b t d m 􏼒 􏼓 � 􏽙 v i�1 􏽘 l l�1 􏽘 t z�1 φ lzi • θ dlz • π dl 􏽥 n t di ⎛ ⎝ 15 for sentiment segmentation the sentiment judgment from the perspective of the document is used as the evaluation index which is based on the sentim ent polarity label in the sentiment dictionary for the documents in this experiment the positive and negative sentiment of a document can be judged is paper adopts the consistency test method to mark the sentiment labels 31 results extraction of topics e primary task of the tsts model is to extract topic features as an extension of the topicsentiment mixed model the assessment is to judge whether the extracted topic features are reasonable and accurate before extracting topic features from text modeling it is necessary to determine the number of topics to be extracted and the iteration times of gibbs sampling for the effective evaluation of topic discovery the degree of perplexity is used as the measurement index in the paper e lower the perplexity is the better the fitting effect of the model is taking dataset 1 as an example the simulation results are shown in figure 3 based on the experimental results shown in figure 3 the number of topics was set 20 in the subsequent experiments in addition we can calculate the perplexity of three models with the change of the iterations by comparing the experimental results of tsts and lda it can be found that the effect of tsts is always better than lda and the degree of perplexity decreases with the increase of iteration at indicates that the topic discovery ability of tsts gradually improves mainly because the tsts model incorporates the word pairs to alleviate the sparse matrix of lda for short texts by comparing the experimental results of tsts and btm it can be found that tsts was better than btm when the number of iterations increases however as the number 6 complexity of iterations increased the gap of both models became smaller is is because the word pair of btm is used for the whole corpus when the number of iterations is small the proportion of noise words is relatively large resulting in poor quality of topic words in addition the sentiment layer is integrated into tsts and the error generated in the sentiment estimation will affect the next iteration although tsts is worse than btm when there are more iterations the effect of tsts can still be balanced with btm erefore during the extraction of topic features the number of topics and iterations can be set as 20 and 600 sentiment polarity e information related to sentiment polarity is provided in accordance with the topic and sentiment polarity of words e sentiment distribution of topics extracted from the tsts model is shown in figure 4 in addition jst and asum are introduced as the comparison to measure the effect of sentiment recognition of the tsts model each document has a binary sentiment label such as positive or negative sentiment taking dataset 2 e attack on the doctor as an example the result is shown in figure 4 e number of topics is set to 5 at the beginning of the experiment with the refinement of granularity the performance of the tsts model increases compared with jst and asum the curve of the tsts model changes greatly considering the topic and sentiment relationship among word pairs of the document e change curve of the jst model shows a steady upward trend and the identification efficiency of asum is low at is because asum has strict assumptions and the increase in the number of topics will cause the decentralization of topics and sentiments which has a great negative impact on the overall performance of the model e overall effect of the tsts model was slightly better than jst and asum but the effect decreased slightly after the number of topics increased to 20 is is because the data collected in the dataset are limited and the number of topics has been set to discretize the word distribution us the judgment of sentiment polarity is affected e sentiment label classification of documents is compared under different topics and the result of the tsts model is better than jst and asum with the increase of topics the recognition performance of the topic model has some fluctuations but the tsts model was always better than jst and asum when the number of obtained topics and iterations is set as 20 and 600 the tsts is the best model in topic detection when the number of topics in the four datasets was set as 20 the accuracy of sentiment polarity judgment is shown in table 4 from table 4 the tsts model is better than jst and asum in judging the sentiment polarity of documents is complexity is because sentiment polarity depends on the performance of topic discovery in the previous stage in this experiment the effect of jst and asum was exactly opposite e difference was caused by the length of the original document which also indirectly verified the effectiveness of the tsts model from figure 5 it can be seen that the proportion of positive sentiment is significantly higher than the other sentiments in the dataset military parade in national day and the dataset garbage sorting in shanghai which is consistent with the sentiment tendency of users in the social network for the second dataset e assault on a doctor the two kinds of negative sentiment polarities of topic 1 and topic 2 were compared topic 1 is more likely to be sad sentiment while topic 2 is more likely to be angry sentiment topic 1 reflects the statement of the event and topic 2 represents the followup discussion of the event topic and sentiment evolution e curves of topic features extracted from four datasets through the tsts model are shown in figure 6 taking dataset 2 as an example the topic curve conforms to the evolution law of social and abrupt events e two curves represent the trend of feature words over time in topic 1 and topic 2 topic 1 is the 8 complexity statement about the case itself from the beginning of the event the amount of discussion about the event on the social network rose sharply and then gradually declined topic 2 is a discussion on the development of the case which has caused the second hot discussion again e time is not consistent when two curves reach the high peak e peak value of topic 2 curve is lower than that of topic 1 which reflects the discussion of the same event will fade over time even if there is a new topic discussion of a new topic is far lower than the beginning of the event meanwhile similar results can be verified in other three datasets e proportion of the sentiment polarity in the four datasets is shown in figure 7 since the sentiment polarity proportion is measured the four sentiment polarities are balanced distributed before the occurrence of the events after the event occurred the polarity of positive and negative sentiment began to change toward the two extremes among the four datasets the positive sentiment was higher than the negative sentiment in the first dataset national day military parade event and the fourth dataset shanghai garbage classification event which also conforms to the social sentiment of events in addition it can be found that the difference among the four sentiment labels is large in the initial stage and the distribution of sentiment labels becomes stable in the later stage it has proved that the second report of social events does not cause the heat for the first time but the sentiment tendency judgment in social networks will not decline sharply with the reduction of discussion which can be proved in topic 2 of the second dataset e assault on a doctor given that the topic features come from the background of a corpus and contain a lot of noise words the relative position of four curves is closer in terms of sentiment polarity evolution however there is still a gap between government feelings which is different from the average distribution of sentiment polarity at the beginning of the event discussion from the perspective of theoretical significance this paper extends the lda model to some extent first in view of the sparse matrix caused by the short text word pairs are introduced to replace a single word for text generation according to btm based on the hypotheses of jst and asum the sentiment layer is introduced to form the bayesian network structure and the word pair is limited to the same sentiment polarity distribution second in order to realize dynamic analysis and text homogeneity the timestamp and the corresponding superparameter are introduced to alleviate the problem of the word order in the text generation ird this research combines behavioral experiments big data mining mathematical modeling and imitating to promote the research expansion of new situations and new methods from the perspective of practical significance this paper is of great value in tracking and monitoring topics of public opinion in social networks e online public opinions of hot events can be monitored which contributes to accurately judge social events and make emergency decisions for government or departments in addition this paper analyzed the evolution response and governance of public opinion which is conducive to understand the formation mechanism and the collaborative evolution of public opinion meanwhile the use of public opinion information can detect and screen information prevent the spread of rumor and scientifically formulate the mechanism of utilization to effectively reduce the loss risk conclusions in the context of the mobile social network the number of short texts is growing explosively in order to extract information from massive short texts quickly and monitor public opinions the tsts model is proposed in the study based on lda btm jst asum and tot from the experimental results the tsts model achieves good performance in terms of topic feature extraction the degree of perplexity of tsts is always lower than lda moreover although the degree of perplexity is slightly higher than btm with the increase of iteration times it can maintain the balance with btm in the sentiment analysis the effect of tsts was significantly better than jst and asum finally the tsts model incorporating the time factor can determine the change trend of the topic and sentiment ere are still some shortcomings in this paper firstly for the extraction of topic feature words the global topic level can be added to the topic layer of the tsts model to filter the common topic words secondly in sentiment polarity judgment the sentiment labels are manually marked based on prior knowledge however the sentiments are extremely rich and changeable in the future research the bayesian network and entity theory can be used to judge sentiment bias data availability e data used to support the findings of this study are available from the corresponding author upon request conflicts of interest e authors declare that they have no conflicts of interest

with the rapid development of mobile internet the social network has become an important platform for users to receive release and disseminate information in order to get more valuable information and implement effective supervision on public opinions it is necessary to study the public opinions sentiment tendency and the evolution of the hot events in social networks of a smart city in view of social networks characteristics such as short text rich topics diverse sentiments and timeliness this paper conducts text modeling with words cooccurrence based on the topic model besides the sentiment computing and the time factor are incorporated to construct the dynamic topicsentiment mixture model tsts en four hot events were randomly selected from the microblog as datasets to evaluate the tsts model in terms of topic feature extraction sentiment analysis and time change e results show that the tsts model is better than the traditional models in topic extraction and sentiment analysis meanwhile by fitting the time curve of hot events the change rules of comments in the social network is obtained

Objective: Recently, severe period poverty has had a dramatic spread throughout Lebanon as a result of several crises: the COVID-pandemic, the Beirut explosion, and the economic collapse. Period poverty is the lack of access to menstrual hygiene materials, comfortable environments, and adequate education about menstrual health. Due to the great implications of period poverty on Lebanese women's health, our study aims to explore stakeholder's perspective on the Lebanese public health policy regarding menstrual health, the evolving challenges it faces in the context of the current economic collapse, and to suggest recommendations for solutions. Methods: Our study is qualitative in nature, where data collection was done via online semi-structured interviews with stakeholders from the public and private sectors of the Lebanese healthcare system in addition to non-governmental organizations and physicians. Data were then analyzed based on themes and subthemes that emerged from the interviews. Results: Nine stakeholders were interviewed: five from NGOs, two obstetrics and gynecology physicians, and two public sector representatives. The challenges to menstrual health were subcategorized into previously existing and new ones. The consequences of poor menstrual health were tackled on the mental, physical, and social levels. Stakeholders suggested both short-term and long-term recommendations. Short-term recommendations included decreasing the monetary burden by subsidizing menstrual products or via a coupon system. Long-term recommendations included proper education on multiple levels, cooperation between key players in the private and public sectors, and encouragement of local production to ensure future sustainability. --- Introduction Menstruation is a biological process that is charged with social and economic significance . The World Health Organization 1948 constitution defines health as the "state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity" . In recent efforts to improve equitable women's health, menstrual health has been receiving more importance in public health policy . Effective MH, as defined by the Global menstrual Collective, is not merely the absence of disease, but it also entails a state of complete physical, mental, and social welfare, in relation to menstruation . Adequate and hygienic MH is a human rights issue and should be treated as such . Ineffective MH has implications across health, education, work, and social status . Furthermore, the availability of appropriate products and adequate menstrual hygiene settings are unequal across various socioeconomic and geographical levels, further complicating MH . Numerous publications and recent international conferences highlight how MH is a crucial yet often neglected dimension of global sanitation, which is further amplified in low and low-middle-income countries . Every day, an estimated 200 million menstruating girls and women in low-income countries suffer from the lack of access to adequate sanitary products . High costs and decreased availability lead to the decreased use of disposable and reusable sanitary napkins/pads, further contributing to the problem in low and low-middle-income countries . Since 2019, Lebanon has been dealing with a worsening economic collapse and crumbling banking sector, leading to hyperinflation and the Lebanese currency losing more than 93% of its value . Subsidization efforts of essential goods like fuel and medications failed to include menstrual products . Sanitary pads and other menstrual products now cost at least four to 10 times the original prices before the financial downturn . The situation forced women to seek alternatives, either by compromising quality and using cheaper brands or by repurposing other products, like diapers and rugs . Problems with MH are not new in Lebanon; however, they have been previously mostly confined to individuals from lower socioeconomic backgrounds, such as refugees . The current economic collapse has caused period poverty to become a concern to women and girls all over the country. A recent survey in Lebanon showed that 76.5% of women have difficulty accessing menstrual products . Among the surveyed women, 57.6% report using the same pad for longer, while 56.9% of women are opting for cheaper alternatives . Poor MH among women and girls in Lebanon during the crisis has demonstrated significant repercussions: 43% report anxiety and stress about MH, 36% suffer from physical symptoms and 35.9% avoid engaging in daily activities due to poor period management . Inadequate MH nowadays is also leading to psychological and social problems. Moreover, 46.5% of the surveyed women report feeling ashamed of their periods and 47% of the participants are afraid that other people would know that they are menstruating . In this project, we aim to explore the Lebanese public health policy regarding menstrual health in the context of the current economic collapse. Specifically, we will address the lack of policies and identify recommendations aimed at accessing menstrual health materials, education, and dealing with potential outcomes in the education and labor sectors. --- Materials and methodology --- Study design Our study is a qualitative study where data collection was done via semi-structured questions with nine stakeholders. The methodological approach used is the framework method of interpretive research . This study is a primary descriptive study exploring the topic using open-ended interview questions and drawing conclusions based on findings. Participants' selection was purposive. Interviewees were chosen to encompass the public and private sectors of the Lebanese healthcare system, in addition to non-governmental organizations involved with women's health, particularly menstrual health. An interview guide with four main questions was developed in English since all interviewees can understand and express themselves in English. Additional probing questions were added as follow-up based on the interviewee's role and area of expertise . All interviews, except one, were conducted via online Zoom/Webex meetings as per the interviewees' preference. The one in-person interview was conducted in-office. Oral consent was obtained at the beginning of each meeting. Two medical students conducted each interview, both male and female. One student asked the questions, while the other typed the responses to ensure a smooth, uninterrupted flow of the interview. No one other than the interviewers and interviewees was present during the interview process. The duration of the meetings averaged around 20 min. The interviews were conducted from August to September 2021. No changes or modifications were made to the transcripts after the interviews. Participants were not provided the analysis for feedback or editing. --- Recruited stakeholders Recruitment of the following stakeholders was based on their expertise and experience in menstrual health management in Lebanon, be it through work in the public sector or at a ministry level, physicians practicing as obstetrics and gynecology specialists, or in non-governmental organizations dealing with women's health. The participants were approached via email and were told the subject matter of the research and asked if they were interested in participation before the interviews were conducted. Oral consent was obtained at the beginning of every interview and approval to record their answers in writing was secured. The interviewees could withdraw at any point during the interview. They also received a copy of the question guide by email prior to the interview. --- Data analysis Data were collected through the verbatim transcription of the interviews. Microsoft Excel was used to tabulate the responses per the questions asked. The interviewees' answers were tabulated in separate columns. Framework analysis was used to analyze the results based on themes . A deductive approach was used to organize the data into four main categories, following the organization of our questionnaire. Afterward, an inductive approach was implemented to add categories based on quotes that did not fit the data-driven categories. The coding process identified concepts based on existence, meaning the concept would be counted if it appeared at least once. Major and minor themes were derived for analysis that was consequently summarized. --- Results --- Current menstrual health policy No current policy on menstrual health in Lebanon was found to exist. --- Pre-existing challenges In responding to the main challenges facing women's menstrual health in Lebanon that predated the current economic crisis, respondents stated that menstrual cycle knowledge is very limited, there is a lot of confusion regarding what a normal menstrual pattern vs. an abnormal one is, and what is related to fertility vs. what is not. "Period poverty is the lack of access to menstrual products, a bathroom where women can change, and a safe place where women can freely talk about their issues."-Local NGO cofounder. As for MH challenges affecting marginalized communities, such as refugees and domestic workers, interviewees highlighted poor living conditions, lack of access to proper infrastructure within camps, and low salaries. Possible solutions to mitigate these challenges are awareness campaigns offering boxes with tissues, pads, hygienic lotions, and soap designed by the UNFPA. According to a local NGO, reports showed that girls within these marginalized communities did not know what the kit was used for, and they wanted cosmetics instead, which highlights the "menstrual knowledge" challenge being at the core of the problem. Although dignity kits are not distributed anymore because of their cost, awareness campaigns are still being held by the UNFPA. --- Emerging challenges related to the economic crisis The stakeholders described women's menstrual health in Lebanon in the context of the current economic crisis as a disaster. Due to the exponentially increasing expenses of pads, women are resorting to makeshift ways of handling their periods like old clothes or cotton and nylon coverings. Several initiatives and organizations had shifted their efforts toward focusing on the distribution of MH kits, rather than awareness campaigns. "Women right now do not care about learning; they just want their products so that they can survive in their daily life."-Founder of another local NGO. Another problem is the government's lack of funding and support toward women's products even though other sanitary products, like razor blades, are supported. Thus, the financial decisions can be described as "patriarchal." The respondent from the Ministry of Public Health stated that there was no government budget allocated for women's health. The respondent recommended the focus be shifted toward getting the support of NGOs and the UN, seeing how the government is overwhelmed during this critical time dealing with the lack of access to medications and vaccines in the country. Moreover, there is only one domestic producer of sanitary products in Lebanon, with the rest being imported. Additionally, only five out of 15 raw materials needed to produce sanitary products are subsidized in Lebanon. Hence, locally produced sanitary products are currently not cheaper than their imported counterparts for domestic use. Another emerging challenge addressed was water scarcity. So, even if the issue of educating women on reusable pads and menstrual cups is addressed, the lack of proper access to water, soap, and adequate temperatures for washing renders these alternatives ineffective and potentially dangerous due to an increased risk of infections. --- Main consequences identified Furthermore, when asked about the various consequences arising from poor MHM in Lebanon, most of the responders believed that what women are currently experiencing is a combination of physical, social, and mental challenges. Responders considered mental and social consequences as the most overwhelming, specifically the humiliation women are suffering from on daily basis. Women and girls are experiencing significant distress and anxiety, negatively impacting their social life. Period poverty is hindering women's empowerment, as many tend to conceal psychological outcomes and not seek medical support. Women are also being less productive: missing school/workdays and trapping themselves throughout menses. Regarding physical health, there was an increase in skin and genital infections from resorting to makeshift and sub-optimal methods during menses. Some of the reported conditions include perineal dermatitis, sexually transmitted infections, and dermatopathies. Most patients delay seeking treatment, resulting in significant medical morbidities which are also greatly attributed to lack of education. In addition to this, the restriction on mobility female experience, as a consequence of poor menstrual management, amplifies the social consequences mentioned before. --- Stakeholder's recommendations for action After exploring the various outcomes and consequences associated with poor MH, interviewees were asked about possible solutions and recommendations. All responders agreed that immediate measures must be taken to alleviate the burden on women. Regarding short-term recommendations, the interviewees suggested providing and advertising free healthcare clinics and gathering donations to offer disposable pads or washable pads which are more cost-effective. Additionally, it was suggested that local production companies decrease their exports to increase local availability. Another proposed solution is a voucher system that can guarantee access to sanitary products exclusively, which will ensure fair distribution by removing money from the equation. Furthermore, a stakeholder suggested creating a chain that links the Center for Social Services, primary care centers, NGOs, municipalities, and schools to regulate the acquisition and distribution of pads, particularly to those who need them the most. Moving on to long-term solutions, most responders suggested education and issuing governmental policies as the main pillars. To tackle the lack of education, the Ministry of Higher Education must implement menstrual health education as a fixed part of middle school curricula which aids in raising awareness among both males and females, thus normalizing and de-stigmatizing the topic. This school education programs should be comprehensive and aimed at girls, boys, and teachers because everyone has a role to play in solving the problem. These formal education programs can be supplemented by independent awareness campaigns organized by local NGOs. Some stakeholders believed that environmentally sustainable menstrual products are the future; however, others warned that the current infrastructure and stigma in Lebanon prohibit this. For example, some unmarried women and girls may fear that menstrual cups may compromise their virginity and are thus taboo to use. It was stressed that high levels of advocacy by the public are required to cause change, and this can only be done with a high level of public awareness. Interviewees also believed that local production needs to be increased substantially and to that end, policy and legislative amendments need to be undertaken. This can be best achieved by conducting feasibility studies with the Investment and Development Authority in Lebanon which proposes solutions such as offering fast-track construction permits, reduction in land registration fees, and tax exemption on raw materials to interested investors. Other solutions included diverting the production of some factories, like diaper-producing factories, into sanitary pad production. There was a consensus among responders that the cooperation of many parties is necessary to cause change, and everyone particularly highlighted the government's role. The ministries of industry, health, and education were mentioned. The role of the ministry of the industry includes subsidizing raw materials for the local production of menstrual hygiene products and removing taxes on finished products. They believed that the government should play an active role because "pads are not a luxury like razors or shaving creams"-they should be available and affordable to all. Moreover, the government could be the key to organizing efforts coming from different sources under one umbrella that will maximize impact. Combining the organization of a governmental body, funding of the private sector, expertise of the healthcare professionals, and initiative of the NGOs, will create a clear plan to solve the problem. --- Discussion Experiencing menstruation safely and cleanly is a human rights issue . In Lebanon, attaining proper MH has always been a struggle, especially in marginalized communities. The three crises, namely, the devaluation of the Lebanese Lira, the COVID-19 pandemic, and the August 4th Beirut explosion have made period poverty a more widespread problem. Before the economic crisis, lack of education and cultural taboos were cited as the main source of MH mismanagement. Additional challenges faced by more vulnerable populations, like domestic workers and refugees, include financial issues, poor infrastructure, and the lack of private and safe places. A 2018 report by Concern Worldwide showed that many refugees used baby diapers or tissue papers during their menses . The deteriorating situation in Lebanon has multiplied the number of women facing MH-related problems. A wave of crises hit Lebanon almost simultaneously; starting with the October 17, 2019 revolution, followed by the globally devastating COVID-19 pandemic in 2020, and finally the Beirut port blast of August 4, 2020. These factors led to the devaluation of the Lebanese Lira by more than 90% , which is still on a downhill spiral. Consequently, problems arose in every sector and industry, including MH. According to our responders, three main challenges became clear in the aftermath. First, as the price of menstrual pads skyrocketed , most Lebanese women started using fewer pads and other MH-related products . This was reflected in a study conducted by Plan International Lebanon which showed that 79.2% of women changed their consumption habits of menstrual health products, either by using the same pad for a long time or using cheaper alternatives . Some women resort to alternative measures such as "using old clothes, reusable cotton pads, and even newspapers." These methods are used by women and girls in resource-poor countries such as Kenya, Northern Ethiopia, Pakistan, and Uganda among others . Second, because of these makeshift methods, the interviewed physicians are reporting an increase in clinic visits regarding previously "rare" and "not-often seen" diseases, such as advanced-stage vulvar dermatitis. This is in concordance with the literature, as a study conducted by Majed, R. showed that poor menstrual hygiene was associated with an increased risk of infections and morbidity . Similarly, a study in Ethiopia used a self-administered questionnaire to identify women with a high risk of reproductive tract infections . Women who changed blood-absorbent material and washed their genital area only once per day were associated with higher rates of reproductive tract infections . Another study in India reports an increase in RTIs among women adopting unhygienic menstrual management methods, with Candida and Bacterial vaginosis being the most common infections . Finally, responders agree that cultural taboo and lack of education act as the scaffold for the exacerbation of these difficulties during the current economic crisis. During the collapse of the Lebanese currency, the Lebanese government subsidized men's health products like shaving creams and razor blades, while women's health products, such as menstrual pads, were not . The government even subsidized snacking nuts, but not menstrual pads . This is just one example of the Lebanese society's dismissal of women's health, and consequently, women's rights. This leads to a variety of consequences in the lives of women in Lebanon. Interestingly, there are no publications on this type of discrimination in Lebanon and no articles were described Lebanon as a "patriarchal society, " as described by a respondent. Further investigations about this are warranted. According to the results, poor MH has physical, social, and mental repercussions. In terms of mental and social outcomes, the results indicate that females are suffering from humiliation, anxiety, and distress; they are less productive and missing school/workdays. This is in accordance with the study conducted in Uganda by Miiro et al. in 2018 which found that 20% of female adolescents report missing at least 1 or more school days each month due to menses, in addition to experiencing substantial feelings of embarrassment . To alleviate the burden of the embarrassment and distress that women have already gone through, it may be beneficial to create support groups for girls and women who have faced difficulties or have been bullied because they were menstruating. These would provide affected women and girls with a safe space to share and, in turn, would help them better cope with their experiences and allow them a chance to restructure their perspective about the natural process their body experiences. The proposed long-term solutions focused on effecting change at multiple societal levels. The focus of these changes would include but are not limited to government, schools, home, and the workplace. Many responders replied that longterm solutions are in the hands of the government; however, a powerful change in societal discourse and behavior can also influence policymakers. The main culprit is, at its root, societal values and stigma. A way of changing society is through education. Without it, myths perpetuate and stigma strengthens. This is consistent with the literature as a study by Sommer et al. described that the lack of proper menstrual health education for both boys and girls was associated with exacerbated cultural stigma about menstruation . Education, especially in schools, will help shift the narrative surrounding menstruation from its stigma and associated myths to something much more positive and inclusive. The Ministry of Education can work on implementing updated curricula to include MH, especially at the middle school level for all children. At the level of the community, NGOs, and civil society have a huge important role to play when it comes to educating the public regarding menstrual health. Nation-wide campaigns aimed toward destigmatizing periods are key. It can also serve as advertising for relevant NGOs that are currently working on acquiring and dispersing MH kits in underserved communities to acquire donations for their cause. Another potential solution is the creation of dedicated public affordable/free clinics sponsored by the MoPH for women's health. These clinics could act as hubs for providing medical care but also places where underprivileged girls and women can go receive MH materials and relevant education. Additionally, NGOs can also work hand-in-hand with the government in an attempt to secure appropriate alternatives to disposable menstrual pads and tampons, seeing as the price of these products continues to skyrocket. It is not just important to educate about menstrual health in isolation, women's rights as a general concept should be bolstered in education. Empowering women to be in decision-making positions would allow for women's issues to be addressed in a more knowledgeable fashion. This in turn would encompass fixing the gaps in menstrual health and a variety of other overlooked issues regarding women's health. This is exemplified by Sommer's observation that the WASH community, which was dominated by men, did not know how to handle menstrual health management and consequently did not prioritize it . Another theme addressed in the long-term recommendations is that of sustainability. There is a debate among respondents about finding alternatives for disposable menstrual pads vs. making them more accessible. On the one hand, making disposable pads more accessible requires financial and industrial frameworks to be placed to boost local production, subsidize, or cheapen the products. The results show that currently, local production is not a sustainable choice as most raw materials for menstrual pads are not subsidized. This is consistent with findings that show that local production is not necessarily always a cheaper alternative. For example, homemade pad-producing machines in India cost at least 723 GBP, without the cost of materials . Though Japan has begun to fund pad production in the Lebanese city of Tripoli, it is unsustainable to depend solely on foreign aid . Hence, subsidizing and lowering taxes on imported products and raw materials for local production in Lebanon may make these products much more affordable to consumers and may play an important role in rejuvenating, even if to a small extent, the local industries that work directly or indirectly in manufacturing them. On the other hand, it is arguable that Lebanon in its current state cannot financially support businesses by subsidizing raw materials for disposable pads or finished products, as there is concern whether subsidization, as a band-aid solution for the crisis, will even continue to exist. Hence, the proposed solution is to encourage the use of alternative products. Regarding the cost of various menstrual hygiene products, UNICEF calculated in 2019 that disposable pads cost 0.10-0.30 USD per pad with an accumulating cost for replenishment; reusable pads come at a higher initial cost of 1.50-3 USD per pad but are cheaper long term due to lower replenishment requirements; and menstrual cups have a high initial investment cost of 10 to 40 USD as a one-time purchase without recurring costs . Even at the lower rates that the UNFPA provides these products, there are still other non-fiscal considerations . The issue with alternative products is that not all women may be comfortable with them or know how to use them. Cultural context is an important consideration when advocating for certain alternatives, such as the menstrual cup. Lebanon's culture is intertwined with religious values and the concept of virginity is highly regarded in many communities. A device such as the menstrual cup may be seen as taboo due to its application inside the vagina, thereby compromising the currently held beliefs about virginity . Therefore, it may not be the right choice to offer religious unmarried women or girls in certain communities. Moreover, a pilot study in Uganda supporting the use of menstrual cups showed that uptake was 87% among participants. Women reported satisfactory experiences while using the cup and that they needed 2-6 months to get accustomed to it . Another population that requires special consideration is refugees in Lebanon. Access to clean water is shamefully limited in refugee camps-if these women were given washable pads, the water they use to wash them would not clean them . More information about the water quality and quantity requirements of different menstrual hygiene products is necessary to tailor recommendations for resource-poor populations. Nonetheless, a UNEP report identified menstrual cups as the most ecofriendly menstrual product. However, this report did not outline the associated water need for the cups . Therefore, a one-fits-all solution regarding disposable pad substitutes is not pragmatic and context should be heavily considered for many sub-populations of women in Lebanon. Solutions should include giving women the tools to make informed decisions through education and empowering them by giving them options, instead of enforcing a solution that they may not understand or be comfortable with. In this way, their rights can be protected. --- Limitations Our stakeholders were limited in number. We managed to interview nine individuals whose roles included NGO representatives, and OBGYN doctors, with only two representing governmental authorities-one parliament member and one MoPH representative. However, no representatives from relevant manufacturing industries were interviewed, which would have offered valuable insight. Also, all interviews, except one, were done via WebEx/Zoom online meetings which might have limited some interviewees' ability to express themselves. Another limitation of this study is that it explored the views of a few policy stakeholders without including firsthand insight from women in Lebanon who are experiencing period poverty. More studies are needed to explore the impact of the unmet menstrual needs of women and girls in Lebanon. These studies should also include a molecular investigation to quantify the medical risks to support the observations of the interviewers in this study. Additionally, more studies are needed to test the stakeholder's insight about the effectiveness of the proposed interventions and the feasibility of implementing them. --- Conclusion In Lebanon, challenges regarding MH were historically limited to vulnerable populations, such as migrant domestic workers and refugees. However, the devaluation of the Lebanese Lira, the COVID-19 pandemic, and the August 4th Beirut explosion have placed Lebanon in a seemingly endless state of crisis. The crises have decreased the Lebanese population's purchasing power, leaving women in the country with an unexpected dilemma: to spend their money on menstrual hygiene products or other necessities. Consequently, with the new onset of mass financial poverty, period poverty has spread throughout Lebanon as well. Women in Lebanon are resorting to unsafe practices that compromise their physical and mental health to a larger degree than ever before. To rectify this, three main challenges must be tackled: alleviating financial burden, protecting women's health, and fighting social stigma. It is necessary to take steps to address these issues to protect women's right to safe, clean, and accessible MH. While some measures must be implemented immediately, the fruits of many initiatives may not be seen for some time. While women in Lebanon navigate the turmoil of the ongoing crises, seeds can be sown today so that the newer generation is better equipped to handle gaps in women's health in general, including but not limited to MH. --- Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s. --- Ethics statement Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Ezzedin O and Fouad FM ( ) Menstrual health and period poverty in Lebanon during economic crisis: A qualitative analysis of the challenges and recommendations.

objective recently severe period poverty has had a dramatic spread throughout lebanon as a result of several crises the covidpandemic the beirut explosion and the economic collapse period poverty is the lack of access to menstrual hygiene materials comfortable environments and adequate education about menstrual health due to the great implications of period poverty on lebanese womens health our study aims to explore stakeholders perspective on the lebanese public health policy regarding menstrual health the evolving challenges it faces in the context of the current economic collapse and to suggest recommendations for solutions methods our study is qualitative in nature where data collection was done via online semistructured interviews with stakeholders from the public and private sectors of the lebanese healthcare system in addition to nongovernmental organizations and physicians data were then analyzed based on themes and subthemes that emerged from the interviews results nine stakeholders were interviewed five from ngos two obstetrics and gynecology physicians and two public sector representatives the challenges to menstrual health were subcategorized into previously existing and new ones the consequences of poor menstrual health were tackled on the mental physical and social levels stakeholders suggested both shortterm and longterm recommendations shortterm recommendations included decreasing the monetary burden by subsidizing menstrual products or via a coupon system longterm recommendations included proper education on multiple levels cooperation between key players in the private and public sectors and encouragement of local production to ensure future sustainability introduction menstruation is a biological process that is charged with social and economic significance the world health organization 1948 constitution defines health as the state of complete physical mental and social wellbeing and not merely the absence of disease or infirmity in recent efforts to improve equitable womens health menstrual health has been receiving more importance in public health policy effective mh as defined by the global menstrual collective is not merely the absence of disease but it also entails a state of complete physical mental and social welfare in relation to menstruation adequate and hygienic mh is a human rights issue and should be treated as such ineffective mh has implications across health education work and social status furthermore the availability of appropriate products and adequate menstrual hygiene settings are unequal across various socioeconomic and geographical levels further complicating mh numerous publications and recent international conferences highlight how mh is a crucial yet often neglected dimension of global sanitation which is further amplified in low and lowmiddleincome countries every day an estimated 200 million menstruating girls and women in lowincome countries suffer from the lack of access to adequate sanitary products high costs and decreased availability lead to the decreased use of disposable and reusable sanitary napkinspads further contributing to the problem in low and lowmiddleincome countries since 2019 lebanon has been dealing with a worsening economic collapse and crumbling banking sector leading to hyperinflation and the lebanese currency losing more than 93 of its value subsidization efforts of essential goods like fuel and medications failed to include menstrual products sanitary pads and other menstrual products now cost at least four to 10 times the original prices before the financial downturn the situation forced women to seek alternatives either by compromising quality and using cheaper brands or by repurposing other products like diapers and rugs problems with mh are not new in lebanon however they have been previously mostly confined to individuals from lower socioeconomic backgrounds such as refugees the current economic collapse has caused period poverty to become a concern to women and girls all over the country a recent survey in lebanon showed that 765 of women have difficulty accessing menstrual products among the surveyed women 576 report using the same pad for longer while 569 of women are opting for cheaper alternatives poor mh among women and girls in lebanon during the crisis has demonstrated significant repercussions 43 report anxiety and stress about mh 36 suffer from physical symptoms and 359 avoid engaging in daily activities due to poor period management inadequate mh nowadays is also leading to psychological and social problems moreover 465 of the surveyed women report feeling ashamed of their periods and 47 of the participants are afraid that other people would know that they are menstruating in this project we aim to explore the lebanese public health policy regarding menstrual health in the context of the current economic collapse specifically we will address the lack of policies and identify recommendations aimed at accessing menstrual health materials education and dealing with potential outcomes in the education and labor sectors materials and methodology study design our study is a qualitative study where data collection was done via semistructured questions with nine stakeholders the methodological approach used is the framework method of interpretive research this study is a primary descriptive study exploring the topic using openended interview questions and drawing conclusions based on findings participants selection was purposive interviewees were chosen to encompass the public and private sectors of the lebanese healthcare system in addition to nongovernmental organizations involved with womens health particularly menstrual health an interview guide with four main questions was developed in english since all interviewees can understand and express themselves in english additional probing questions were added as followup based on the interviewees role and area of expertise all interviews except one were conducted via online zoomwebex meetings as per the interviewees preference the one inperson interview was conducted inoffice oral consent was obtained at the beginning of each meeting two medical students conducted each interview both male and female one student asked the questions while the other typed the responses to ensure a smooth uninterrupted flow of the interview no one other than the interviewers and interviewees was present during the interview process the duration of the meetings averaged around 20 min the interviews were conducted from august to september 2021 no changes or modifications were made to the transcripts after the interviews participants were not provided the analysis for feedback or editing recruited stakeholders recruitment of the following stakeholders was based on their expertise and experience in menstrual health management in lebanon be it through work in the public sector or at a ministry level physicians practicing as obstetrics and gynecology specialists or in nongovernmental organizations dealing with womens health the participants were approached via email and were told the subject matter of the research and asked if they were interested in participation before the interviews were conducted oral consent was obtained at the beginning of every interview and approval to record their answers in writing was secured the interviewees could withdraw at any point during the interview they also received a copy of the question guide by email prior to the interview data analysis data were collected through the verbatim transcription of the interviews microsoft excel was used to tabulate the responses per the questions asked the interviewees answers were tabulated in separate columns framework analysis was used to analyze the results based on themes a deductive approach was used to organize the data into four main categories following the organization of our questionnaire afterward an inductive approach was implemented to add categories based on quotes that did not fit the datadriven categories the coding process identified concepts based on existence meaning the concept would be counted if it appeared at least once major and minor themes were derived for analysis that was consequently summarized results current menstrual health policy no current policy on menstrual health in lebanon was found to exist preexisting challenges in responding to the main challenges facing womens menstrual health in lebanon that predated the current economic crisis respondents stated that menstrual cycle knowledge is very limited there is a lot of confusion regarding what a normal menstrual pattern vs an abnormal one is and what is related to fertility vs what is not period poverty is the lack of access to menstrual products a bathroom where women can change and a safe place where women can freely talk about their issueslocal ngo cofounder as for mh challenges affecting marginalized communities such as refugees and domestic workers interviewees highlighted poor living conditions lack of access to proper infrastructure within camps and low salaries possible solutions to mitigate these challenges are awareness campaigns offering boxes with tissues pads hygienic lotions and soap designed by the unfpa according to a local ngo reports showed that girls within these marginalized communities did not know what the kit was used for and they wanted cosmetics instead which highlights the menstrual knowledge challenge being at the core of the problem although dignity kits are not distributed anymore because of their cost awareness campaigns are still being held by the unfpa emerging challenges related to the economic crisis the stakeholders described womens menstrual health in lebanon in the context of the current economic crisis as a disaster due to the exponentially increasing expenses of pads women are resorting to makeshift ways of handling their periods like old clothes or cotton and nylon coverings several initiatives and organizations had shifted their efforts toward focusing on the distribution of mh kits rather than awareness campaigns women right now do not care about learning they just want their products so that they can survive in their daily lifefounder of another local ngo another problem is the governments lack of funding and support toward womens products even though other sanitary products like razor blades are supported thus the financial decisions can be described as patriarchal the respondent from the ministry of public health stated that there was no government budget allocated for womens health the respondent recommended the focus be shifted toward getting the support of ngos and the un seeing how the government is overwhelmed during this critical time dealing with the lack of access to medications and vaccines in the country moreover there is only one domestic producer of sanitary products in lebanon with the rest being imported additionally only five out of 15 raw materials needed to produce sanitary products are subsidized in lebanon hence locally produced sanitary products are currently not cheaper than their imported counterparts for domestic use another emerging challenge addressed was water scarcity so even if the issue of educating women on reusable pads and menstrual cups is addressed the lack of proper access to water soap and adequate temperatures for washing renders these alternatives ineffective and potentially dangerous due to an increased risk of infections main consequences identified furthermore when asked about the various consequences arising from poor mhm in lebanon most of the responders believed that what women are currently experiencing is a combination of physical social and mental challenges responders considered mental and social consequences as the most overwhelming specifically the humiliation women are suffering from on daily basis women and girls are experiencing significant distress and anxiety negatively impacting their social life period poverty is hindering womens empowerment as many tend to conceal psychological outcomes and not seek medical support women are also being less productive missing schoolworkdays and trapping themselves throughout menses regarding physical health there was an increase in skin and genital infections from resorting to makeshift and suboptimal methods during menses some of the reported conditions include perineal dermatitis sexually transmitted infections and dermatopathies most patients delay seeking treatment resulting in significant medical morbidities which are also greatly attributed to lack of education in addition to this the restriction on mobility female experience as a consequence of poor menstrual management amplifies the social consequences mentioned before stakeholders recommendations for action after exploring the various outcomes and consequences associated with poor mh interviewees were asked about possible solutions and recommendations all responders agreed that immediate measures must be taken to alleviate the burden on women regarding shortterm recommendations the interviewees suggested providing and advertising free healthcare clinics and gathering donations to offer disposable pads or washable pads which are more costeffective additionally it was suggested that local production companies decrease their exports to increase local availability another proposed solution is a voucher system that can guarantee access to sanitary products exclusively which will ensure fair distribution by removing money from the equation furthermore a stakeholder suggested creating a chain that links the center for social services primary care centers ngos municipalities and schools to regulate the acquisition and distribution of pads particularly to those who need them the most moving on to longterm solutions most responders suggested education and issuing governmental policies as the main pillars to tackle the lack of education the ministry of higher education must implement menstrual health education as a fixed part of middle school curricula which aids in raising awareness among both males and females thus normalizing and destigmatizing the topic this school education programs should be comprehensive and aimed at girls boys and teachers because everyone has a role to play in solving the problem these formal education programs can be supplemented by independent awareness campaigns organized by local ngos some stakeholders believed that environmentally sustainable menstrual products are the future however others warned that the current infrastructure and stigma in lebanon prohibit this for example some unmarried women and girls may fear that menstrual cups may compromise their virginity and are thus taboo to use it was stressed that high levels of advocacy by the public are required to cause change and this can only be done with a high level of public awareness interviewees also believed that local production needs to be increased substantially and to that end policy and legislative amendments need to be undertaken this can be best achieved by conducting feasibility studies with the investment and development authority in lebanon which proposes solutions such as offering fasttrack construction permits reduction in land registration fees and tax exemption on raw materials to interested investors other solutions included diverting the production of some factories like diaperproducing factories into sanitary pad production there was a consensus among responders that the cooperation of many parties is necessary to cause change and everyone particularly highlighted the governments role the ministries of industry health and education were mentioned the role of the ministry of the industry includes subsidizing raw materials for the local production of menstrual hygiene products and removing taxes on finished products they believed that the government should play an active role because pads are not a luxury like razors or shaving creamsthey should be available and affordable to all moreover the government could be the key to organizing efforts coming from different sources under one umbrella that will maximize impact combining the organization of a governmental body funding of the private sector expertise of the healthcare professionals and initiative of the ngos will create a clear plan to solve the problem discussion experiencing menstruation safely and cleanly is a human rights issue in lebanon attaining proper mh has always been a struggle especially in marginalized communities the three crises namely the devaluation of the lebanese lira the covid19 pandemic and the august 4th beirut explosion have made period poverty a more widespread problem before the economic crisis lack of education and cultural taboos were cited as the main source of mh mismanagement additional challenges faced by more vulnerable populations like domestic workers and refugees include financial issues poor infrastructure and the lack of private and safe places a 2018 report by concern worldwide showed that many refugees used baby diapers or tissue papers during their menses the deteriorating situation in lebanon has multiplied the number of women facing mhrelated problems a wave of crises hit lebanon almost simultaneously starting with the october 17 2019 revolution followed by the globally devastating covid19 pandemic in 2020 and finally the beirut port blast of august 4 2020 these factors led to the devaluation of the lebanese lira by more than 90 which is still on a downhill spiral consequently problems arose in every sector and industry including mh according to our responders three main challenges became clear in the aftermath first as the price of menstrual pads skyrocketed most lebanese women started using fewer pads and other mhrelated products this was reflected in a study conducted by plan international lebanon which showed that 792 of women changed their consumption habits of menstrual health products either by using the same pad for a long time or using cheaper alternatives some women resort to alternative measures such as using old clothes reusable cotton pads and even newspapers these methods are used by women and girls in resourcepoor countries such as kenya northern ethiopia pakistan and uganda among others second because of these makeshift methods the interviewed physicians are reporting an increase in clinic visits regarding previously rare and notoften seen diseases such as advancedstage vulvar dermatitis this is in concordance with the literature as a study conducted by majed r showed that poor menstrual hygiene was associated with an increased risk of infections and morbidity similarly a study in ethiopia used a selfadministered questionnaire to identify women with a high risk of reproductive tract infections women who changed bloodabsorbent material and washed their genital area only once per day were associated with higher rates of reproductive tract infections another study in india reports an increase in rtis among women adopting unhygienic menstrual management methods with candida and bacterial vaginosis being the most common infections finally responders agree that cultural taboo and lack of education act as the scaffold for the exacerbation of these difficulties during the current economic crisis during the collapse of the lebanese currency the lebanese government subsidized mens health products like shaving creams and razor blades while womens health products such as menstrual pads were not the government even subsidized snacking nuts but not menstrual pads this is just one example of the lebanese societys dismissal of womens health and consequently womens rights this leads to a variety of consequences in the lives of women in lebanon interestingly there are no publications on this type of discrimination in lebanon and no articles were described lebanon as a patriarchal society as described by a respondent further investigations about this are warranted according to the results poor mh has physical social and mental repercussions in terms of mental and social outcomes the results indicate that females are suffering from humiliation anxiety and distress they are less productive and missing schoolworkdays this is in accordance with the study conducted in uganda by miiro et al in 2018 which found that 20 of female adolescents report missing at least 1 or more school days each month due to menses in addition to experiencing substantial feelings of embarrassment to alleviate the burden of the embarrassment and distress that women have already gone through it may be beneficial to create support groups for girls and women who have faced difficulties or have been bullied because they were menstruating these would provide affected women and girls with a safe space to share and in turn would help them better cope with their experiences and allow them a chance to restructure their perspective about the natural process their body experiences the proposed longterm solutions focused on effecting change at multiple societal levels the focus of these changes would include but are not limited to government schools home and the workplace many responders replied that longterm solutions are in the hands of the government however a powerful change in societal discourse and behavior can also influence policymakers the main culprit is at its root societal values and stigma a way of changing society is through education without it myths perpetuate and stigma strengthens this is consistent with the literature as a study by sommer et al described that the lack of proper menstrual health education for both boys and girls was associated with exacerbated cultural stigma about menstruation education especially in schools will help shift the narrative surrounding menstruation from its stigma and associated myths to something much more positive and inclusive the ministry of education can work on implementing updated curricula to include mh especially at the middle school level for all children at the level of the community ngos and civil society have a huge important role to play when it comes to educating the public regarding menstrual health nationwide campaigns aimed toward destigmatizing periods are key it can also serve as advertising for relevant ngos that are currently working on acquiring and dispersing mh kits in underserved communities to acquire donations for their cause another potential solution is the creation of dedicated public affordablefree clinics sponsored by the moph for womens health these clinics could act as hubs for providing medical care but also places where underprivileged girls and women can go receive mh materials and relevant education additionally ngos can also work handinhand with the government in an attempt to secure appropriate alternatives to disposable menstrual pads and tampons seeing as the price of these products continues to skyrocket it is not just important to educate about menstrual health in isolation womens rights as a general concept should be bolstered in education empowering women to be in decisionmaking positions would allow for womens issues to be addressed in a more knowledgeable fashion this in turn would encompass fixing the gaps in menstrual health and a variety of other overlooked issues regarding womens health this is exemplified by sommers observation that the wash community which was dominated by men did not know how to handle menstrual health management and consequently did not prioritize it another theme addressed in the longterm recommendations is that of sustainability there is a debate among respondents about finding alternatives for disposable menstrual pads vs making them more accessible on the one hand making disposable pads more accessible requires financial and industrial frameworks to be placed to boost local production subsidize or cheapen the products the results show that currently local production is not a sustainable choice as most raw materials for menstrual pads are not subsidized this is consistent with findings that show that local production is not necessarily always a cheaper alternative for example homemade padproducing machines in india cost at least 723 gbp without the cost of materials though japan has begun to fund pad production in the lebanese city of tripoli it is unsustainable to depend solely on foreign aid hence subsidizing and lowering taxes on imported products and raw materials for local production in lebanon may make these products much more affordable to consumers and may play an important role in rejuvenating even if to a small extent the local industries that work directly or indirectly in manufacturing them on the other hand it is arguable that lebanon in its current state cannot financially support businesses by subsidizing raw materials for disposable pads or finished products as there is concern whether subsidization as a bandaid solution for the crisis will even continue to exist hence the proposed solution is to encourage the use of alternative products regarding the cost of various menstrual hygiene products unicef calculated in 2019 that disposable pads cost 010030 usd per pad with an accumulating cost for replenishment reusable pads come at a higher initial cost of 1503 usd per pad but are cheaper long term due to lower replenishment requirements and menstrual cups have a high initial investment cost of 10 to 40 usd as a onetime purchase without recurring costs even at the lower rates that the unfpa provides these products there are still other nonfiscal considerations the issue with alternative products is that not all women may be comfortable with them or know how to use them cultural context is an important consideration when advocating for certain alternatives such as the menstrual cup lebanons culture is intertwined with religious values and the concept of virginity is highly regarded in many communities a device such as the menstrual cup may be seen as taboo due to its application inside the vagina thereby compromising the currently held beliefs about virginity therefore it may not be the right choice to offer religious unmarried women or girls in certain communities moreover a pilot study in uganda supporting the use of menstrual cups showed that uptake was 87 among participants women reported satisfactory experiences while using the cup and that they needed 26 months to get accustomed to it another population that requires special consideration is refugees in lebanon access to clean water is shamefully limited in refugee campsif these women were given washable pads the water they use to wash them would not clean them more information about the water quality and quantity requirements of different menstrual hygiene products is necessary to tailor recommendations for resourcepoor populations nonetheless a unep report identified menstrual cups as the most ecofriendly menstrual product however this report did not outline the associated water need for the cups therefore a onefitsall solution regarding disposable pad substitutes is not pragmatic and context should be heavily considered for many subpopulations of women in lebanon solutions should include giving women the tools to make informed decisions through education and empowering them by giving them options instead of enforcing a solution that they may not understand or be comfortable with in this way their rights can be protected limitations our stakeholders were limited in number we managed to interview nine individuals whose roles included ngo representatives and obgyn doctors with only two representing governmental authoritiesone parliament member and one moph representative however no representatives from relevant manufacturing industries were interviewed which would have offered valuable insight also all interviews except one were done via webexzoom online meetings which might have limited some interviewees ability to express themselves another limitation of this study is that it explored the views of a few policy stakeholders without including firsthand insight from women in lebanon who are experiencing period poverty more studies are needed to explore the impact of the unmet menstrual needs of women and girls in lebanon these studies should also include a molecular investigation to quantify the medical risks to support the observations of the interviewers in this study additionally more studies are needed to test the stakeholders insight about the effectiveness of the proposed interventions and the feasibility of implementing them conclusion in lebanon challenges regarding mh were historically limited to vulnerable populations such as migrant domestic workers and refugees however the devaluation of the lebanese lira the covid19 pandemic and the august 4th beirut explosion have placed lebanon in a seemingly endless state of crisis the crises have decreased the lebanese populations purchasing power leaving women in the country with an unexpected dilemma to spend their money on menstrual hygiene products or other necessities consequently with the new onset of mass financial poverty period poverty has spread throughout lebanon as well women in lebanon are resorting to unsafe practices that compromise their physical and mental health to a larger degree than ever before to rectify this three main challenges must be tackled alleviating financial burden protecting womens health and fighting social stigma it is necessary to take steps to address these issues to protect womens right to safe clean and accessible mh while some measures must be implemented immediately the fruits of many initiatives may not be seen for some time while women in lebanon navigate the turmoil of the ongoing crises seeds can be sown today so that the newer generation is better equipped to handle gaps in womens health in general including but not limited to mh data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

ezzedin o and fouad fm menstrual health and period poverty in lebanon during economic crisis a qualitative analysis of the challenges and recommendations

Introduction In recent years, the visibility of a type of domestic violence known as child-to-parent violence has increased, awakening the interest of researchers and the exponential growth of studies dealing with this problem . The following definition of CPV is frequently used in research and includes the most relevant aspects of its conceptualization: Repeated behaviors of physical, psychological , or economic violence, directed at the parents, or those who take their place. Specific aggressions are excluded, those that occur in a state of decreased consciousness, which disappear when it is recovered , those caused by psychological alterations , and parricide without a history of previous aggressions . As for the prevalence, the data obtained are inconclusive, producing disparate figures. This may be due to the definition of CPV, differences in sample size and nature, or the data collection method employed in the studies . International research conducted in the United States and Canada indicates a prevalence of physical CPV between 11 and 22% and of psychological CPV between 51 and 75% . In Spain, del Hoyo-Bilbao et al. found a prevalence rate of physical CPV between 8.2% and 9% and between 13.1% and 14% of psychological CPV. Likewise, Ruiz-Fernández et al. found, in the sample analyzed, that 26.83% of the minors had committed serious psychological CPV towards the mother and 22.50% towards the father; 1.43% had exerted serious physical CPV towards the mother and 1.60% towards the father. Finally, in relation to economic violence, 3.99% had performed this economic CPV towards the mother and 2.89% towards the father. Most research indicates a higher rate of violence against mothers than fathers . Studies that examine differences according to sex show that both boys and girls commit CPV, although some authors indicate significant differences in the type of violence perpetrated, establishing that boys commit physical violence more frequently, and girls commit more psychological violence . Recent studies have analyzed the risk factors of CPV, finding a relationship between several variables such as parental ineffectiveness and the influence of peer conflicts , peer violence , permissive, authoritarian and negligent educational style or child abuse , emotional security in the family system , impulsivity and substance abuse . Thus, due to the growing interest in CPV and the diversity of variables involved, some studies have tried to provide an explanatory model for this phenomenon. Cottrell and Monk applied the Nested Ecological Theory to explain CPV. These authors establish that CPV is generated due to the interrelation between the variables belonging to the different subsystems in which the aggressor is involved: an ontogenetic system, comprising individual characteristics and experiences in aggressors ; a microsystem, which includes all those patterns of interaction that can produce violence ; an exosystem, encompassing social structures that could increase violence and condition interactions at the individual and family levels ; and a macrosystem, which involves the system of beliefs and cultural values that naturalize and legitimize violence . In alignment with this, several recent reviews have provided theoretical analyses of the risk factors contributing to the development of CPV. These reviews highlight various risk factors associated with CPV, derived from the subsystems within the Ecological Theory. These factors include individual factors , familial factors or social factors . However, none of them specifically focus on the sex differences of victims and aggressors. Previous studies have shown that sex differences exist in terms of the types of violence perpetrated, with boys displaying a higher tendency for physical aggression compared to girls. These differences can be attributed to a combination of biopsychosocial factors . Specifically, studies on CPV indicates that, while both boys and girls engage in CPV, there are variations in the types of violence committed. Boys are more likely to exhibit physical violence, whereas girls tend to engage in psychological violence . In addition, previous research finds differences in risk factors for CPV depending on the sex of aggressor and victim . However, there isn't an explanatory model as to why differences in risk factors for CPV are found respect to sex. --- Objectives This scoping review was proposed to provide a structured analysis of the variables associated with CPV, drawing from the subsystems within the Ecological Theory, and to establish the interrelationships among these variables. Its aim was to provide a clearer understanding of the risk factors associated with CPV by synthesizing finding from both qualitative and quantitative studies. There are different explanatory theories that have been used as a frame of reference in CPV: Stress Theory , General Strain Theory and Coercion Theory ; Social Learning Theory . However, we consider that the Ecological Theory is the one that best fits the objective of our study, since it takes into consideration psychological, sociological and cultural factors to understand CPV. The goals of the study were: 1) to delimit the risk factors for the development of CPV following the conceptual framework of the Ecological Theory; 2) to identify the risk factors for CPV according to the sex differences of victims and aggressors; and 3) to analyze the limitations of current knowledge about the risk factors for CPV and establish future lines of research. --- Method This study is a scoping review, following the PRISMA guidelines for scoping reviews . --- Inclusion and Exclusion Criteria Concerning the inclusion criteria of the articles, all those that met the following aspects were selected: a) analyzed the risk factors associated with CPV; b) the sample was of community, clinical and/or judicial origin and was made up of adolescents or young people and/or parents; c) published during 2012-2022. This eligibility criterion is used because in Europe there was an increase in the figures of CPV around 2012, leading to its consideration as a form of domestic violence in some countries. Consequently, there has been a surge in interest in its studying and intervening. For instance, between 2013 and 2015, the action-research project "Responding to CPV"-was implemented in five European countries with the goal of modifying violent behavior among children towards their parents . Regarding the exclusion criteria, those studies that involved theoretical or systematic reviews, meta-analyses, case studies, expert opinions, or therapeutic experiences were discarded. --- Search Strategy Empirical articles, from 2012 to 2022, were selected from the following databases: Scopus, Web of Science, Dialnet Plus, ERIC, PsycInfo, PsycArticles, Psychology Database and Pubmed. The Boolean operator "OR" was used. The keywords used were: "children violence to parents" OR "parents abused by their children" OR "adolescent violence towards parents" OR "abuse of parents by their teenage" OR "child to parent violence" OR "adolescent to parents abuse" OR "child to parent aggression". --- Study Eligibility The initial screening of the studies was carried out independently by two team researchers, reading the title and abstract of the articles, verifying whether the inclusion and exclusion criteria were met, and eliminating 802 articles. Subsequently, all the team researchers determined the inclusion of the article as definitive by reading the full text, independently recording the data of the articles, discussing the results, and determining which variables to extract. The data extracted from the 52 articles were recorded in a table , which specified the methodological characteristics of the articles, as well as the variables considered as risk factors for CPV. The Mendeley manager was used to enter the articles and remove duplicates. Likewise, the scientific rigor of the selected articles was evaluated, using the following criteria: a) Credibility, that is, veracity and objectivity of the data obtained ; b) Transferability, that is, the results of the study can be applicable and generalizable ; c) Legitimacy, transferring the data without altering the results of the articles. --- Results --- Characteristics of the Methodology of the Studies Most of the studies came from Spain, making up 78.85% of the sample analyzed . The rest of the research was developed in the United Kingdom, the United States, Germany, Asia, South America, and Mexico . Most of the studies analyzed used a correlational design, specifically, 34 had a cross-sectional correlational design, and 8 had a longitudinal correlational design; 8 studies were quasi-experimental cross-sectional, and 2 were qualitative works. Of the studies analyzed, 76.92% were carried out in the community context , 7.69% in the judicial area , 1.92% in the clinical setting and the rest, that is, 13.46%, combined the community, judicial, and/or clinical contexts . Regarding the informants of the studies, 61.54% were adolescents aged between 11-18 years , 7.69% were youths aged between 18 -28 years , 19.23% were adolescents and youths , 3.85% were adolescents and their parents , 1.92% were parents only , 1.85% were parents, extended family, and professionals and 1.92% were children aged between 9-10 years and parents . Regarding the differences according to sex, 45.45% of the articles analyzed the differences according to the aggressor's sex , and 30.30% did so according to the parent's sex . --- Risk Factors for Child-to-Parent Violence The research evaluated in the study shows risk factors at the individual, family, and social levels for the development of CPV. They can be grouped into three blocks of results: individual factors or ontogenic level, family factors or microsystem, and social factors or exosystem . --- Individual Factors The studies analyzed highlight the aggressor's sex as a risk factor for the commission of CPV. Most authors find similarities in CPV in terms of the aggressor's sex. Nonetheless, this varies depending on the samples analyzed. In the case of community samples, the proportion of female and male aggressors is similar, but in forensic samples, the proportion of males is higher . There is also more controversy regarding differences in the aggressor's sex concerning the type of CPV performed. For example, some authors find no differences in the perpetration of psychological and physical abuse towards parents between girls and boys, whereas other studies report girls' higher rates of psychological CPV than boys' . Another individual-level factor is the minor aggressors' personality characteristics. Authors highlight impulsivity, irritability, lack of empathy, and reflective capacity or low frustration tolerance as risk factors for the development of CPV . Likewise, psychopathological symptomatology is another risk variable for the development of CPV. Symptoms such as hostility, paranoid ideation, anxiety, borderline traits, depression, or antisocial behaviors may be related to CPV . Finally, substance consumption has been another variable in this group of risk factors, with studies indicating occasional substance consumption in approximately 60% -70% of the sample of minor aggressors analyzed. Overall, authors note that alcohol and drug use may be predictors of CPV . --- Results --- Articles --- Family Factors At the microsystem level, most of the results of the studies evaluated indicate that mothers are more frequent victims of CPV than fathers . Continuing at this level, the results of research establish exposure to domestic violence and parental abuse in childhood as main predictors of CPV, which would confirm the hypothesis of bidirectionality of violence. According to this hypothesis, being a victim of domestic violence predicts being an aggressor . On the other hand, some studies indicate ineffective educational styles as a variable that precipitates CPV, that is, the use of coercive strategies , permissive styles or overprotection and lack of communication and affection could lead to CPV . Finally, according to the family structure, adoption or reconstituted families could be variables associated with CPV . Other factors related to the family system are bonding, communication and the attachment style developed. Thus, low levels of communication and affection, together with ineffective parental educational styles, could lead to an increase in CPV rates . Another variable considered in the development of CPV is emotional security in the family system, finding a relationship between strategies that imply emotional insecurity in the family and the development of CPV . --- Social Factors At the exosystem level, peer violence is a relevant predictor of CPV. Specifically, studies suggest that being a victim of violence in peer relationships can increase the probability of performing CPV . In addition, other authors highlight that social and school maladjustment , as well as the influence of conflictive classmates or peers could increase CPV . However, recent research indicates dating violence in adolescents is a risk factor for the development of CPV, finding an association between being an aggressor of dating violence and committing CPV . --- Differences Depending on the Sex of the Aggressor and the Victim Next, are included the results of the investigations divided into two blocks, taking into account the differences in individual, family, and social risk factors depending on the sex of the aggressor and the victim . --- Differences Depending on the Aggressor's Sex Individual Factors Regarding individual or ontogenic-level risk factors, a study carried out with a clinical and judicial sample indicates that female aggressors have a lower level of self-esteem, whereas male aggressors have more problems of substance abuse and escalation of violence -a progressive increase in the severity and frequency of violent behavior- . Authors also report differences in the psychopathological symptomatology depending on the aggressor's sex, indicating that female aggressors show higher levels of psychopathological symptomatology and suicidal ideation and lower levels of family self-concept than males who perform CPV . Similarly, other authors report that interpersonal sensitivity, that is a person's ability to perceive, understand and respond appropriately to the emotions and needs of others in social interaction, is related to CPV in the case of male aggressors, and obsessions and paranoid ideation in the case of female aggressors . Regarding cognitive schemas, Calvete et al. point out that the schema of disconnection and rejection, that includes beliefs that others will hurt, abuse or humiliate and the feeling of being emotionally rejected and defective, predicts CPV both in boys and girls, but the narcissism schema only in boys. --- Family Factors In relation to the risk factors of the microsystem, authors point out that the negative effect of punitive discipline during childhood is more significant in the case of male aggressors than in females; that is, the bidirectionality of family violence is greater in boys . Other studies suggest a significant relationship between being a girl and using the strategy of disengagement in the family system and committing more CPV towards the mother. In contrast, there is a relationship between being a boy and more justification of violence and performing CPV towards the mother . --- Social Factors Concerning the exosystem, there are differences in the predictive role of dating violence in adolescents depending on the aggressor's sex. Thus, girls who perform psychological CPV also commit more psychological dating violence, whereas this relationship does not occur in the case of boys. Moreover, boys who commit physical CPV towards the mother also commit more physical dating aggression, whereas girls who commit physical CPV towards the father also perform more physical dating violence . --- Differences Depending on the Victim's Sex Individual Factors Considering individual risk factors or ontogenic level, various investigations establish differences in proactive and reactive aggression, the components of social informationprocessing, cognitive schemas or narcissistic self-perception, interpersonal sensitivity and obsessions, depending on the parent's sex . Proactive and reactive peer aggression are related to CPV towards the mother . Regarding the components of social information-processing, anger and hostile attribution predict CPV towards the mother, whereas access to an aggressive response predicts CPV towards both parents. In relation to cognitive schemas, the grandiosity schema predicts CPV towards the mother, and the schemas of abandonment, defect, and justification of violence are predictors of CPV towards both parents . --- Family Factors Based on the risk factors of the microsystem, Calvete et al. indicate that being a victim or a witness of domestic violence increases the probability of exercising CPV towards both parents. Further, studies of Calvete et al. indicate that exposure to violence in the family predicts CPV towards the father. On the other hand, some research indicates a relationship between psychological childhood abuse and verbal CPV towards the mother, and between physical childhood abuse and physical CPV towards the mother. These relationships do not occur in the case of CPV towards the father . The results of other studies find an association between mother-to-child violence and CPV towards the mother and father-to-child violence and CPV towards the father . --- Table 2 Risk factors for child-to-parent violence depending on the aggressor's sex and victim's sex Sex Authors --- Risk factors --- Ecological level Results Aggressor Calvete et al., 2012;Calvete et al., 2015b;del Hoyo-Bilbao et al., 2021;Rico et al., 2017;Rosado et al., 2017;Loinaz et al., 2020;López-Martínez et al., 2019;Martínez-Ferrer et al., 2018;Martínez-Ferrer et al., 2020;Navas-Martínez & Cano-Lozano, 2022 Psychopathological symptomatology --- Personality traits Substance abuse Ontogenic Girls aggressors show lower levels of self-esteem and selfconcept, higher levels of psychopathological symptoms and greater alexithymia. Boys aggressors has higher levels of substance abuse and escalation of violence Relationship between motor and attentional impulsivity higher in aggressor girls Calvete et al., 2014a;Calvete et al., 2015a;Lyons et al., 2015;Izaguirre & Calvete, 2017;Del Hoyo-Bilbao et al., 2020;Junco-Guerrero et al., 2021;Cano-Lozano et al., 2021a; Exposure to violence --- Child abuse --- Microsystem Relationship between being a victim violence, using the strategy of disengagement in the family system and justifying violence and to exert CPV toward the mother. Relationship between witnessing violence, using the strategy of disengagement and preoccupation, and justifying violence and exercising CPV toward the father. Corporal punishment is directly related to CPV toward the mother. Direct victimization by the mother increases CPV toward the mother and direct victimization by the father increases CPV toward the father Ruiz-Fernández et al., 2021;Kuay et al., 2021 Exposure to violent video games Peer-to-peer aggression --- Exosystem Regarding the video game use, the flow dimension is related to greater CPV toward the mother, while flow and absorption with CPV toward the father. Proactive and reactive peer aggression are related to CPV toward the mother --- Social Factors In relation to the exosystem factors, the results of the study conducted by Ruiz-Fernández et al. indicate a relationship between exposure to video games and lower rates of CPV towards both parents. However, different results are found regarding the effects of the flow and absorption dimensions of video games depending on the parent's sex. The flow dimension during video game exposure was associated with a higher level of CPV toward the mother, whereas the flow and absorption dimensions were associated with higher CPV toward the father. Therefore, in general, the results show that the consumption of violent video games can reduce CPV rates, but the subject's engagement and their dimensions of flow and absorption must also be considered. On the other hand, Kuay et al propose that proactive and reactive peer aggression is significantly related to CPV towards the mother, but not towards the father. --- Discussion The objective of the present study was to identify the available evidence about individual, family, and social risk factors for the development of CPV, as well as the differences found in the investigations according to the sex of the aggressor and the victim. In relation to the characteristics of the 52 studies analyzed, we observe that most of them use a community sample, followed by the judicial and clinical samples. As previous research indicates, CPV prevalence levels vary depending on the type of sample used . The type of CPV varies depending on the source of the sample, with psychological violence rates are higher in community studies and physical and severe violence are higher in the studies based on judicial samples . Similarly, the risk factors for the development of CPV may vary different depending on the type of sample. Studies indicate that underage aggressors who come from judicial samples have higher levels of peer violence, lower emotional intelligence, a more negative family self-concept and more antisocial attitudes than aggressors from the general population . Most of the studies assessing sex differences in risk factors are community-based, finding differences in personality traits, distress, suicidal ideation, or peer victimization . However, there is no research evaluating sex differences in risk factors by sample type. Therefore, it is necessary to conduct clinical, judicial and community studies to compare differences in risk factors according to sex. In addition, the studies identified in this review were mainly Spanish , with less research developed in other countries, especially those that do not belong to Europe. The studies analyzed from Mexico, Germany, Asia, or Canada show relevant aspects for the clarification of risk factors for CPV. The scarcity of studies carried out in some countries leads to a lack of knowledge about the prevalence levels of CPV at the international level, as well as the risk factors that may contribute to it due to cultural influence . CPV is often a hidden problem due to shame, fear of the children's reactions, or the desire to protect the family image. Therefore, different family socialization processes can vary across cultural context, consequently influencing CPV research . For example, while most of the studies analyzed in this review focus on CPV in Western countries, fewer studies have been carried out in Eastern countries. This disparity may be attributed to cultural aspects such as the influence of filial piety in Asian cultures, which emphasizes respect for parents, elders and ancestors. As a result, the prevalence of CPV may be lower or not extensively researched in these countries, leading to a lack of knowledge about this phenomenon. On the other hand, the vast majority of the research included in this review are cross-sectional studies, with longitudinal studies being very scarce. The longitudinal investigations evaluated clarify some of the risk factors for CPV, establishing causal relationships between the variables analyzed. The authors of these studies point to physical or verbal abuse by parents as a predictor of CPV . Likewise, other authors indicate that the components of the social information-processing concerning aggressive responses and anger or the cognitive schemas of abandonment, grandiosity, or justification of violence predict CPV . This type of research has relevant practical implications and is very important for the generation of prevention programs and intervention in CPV. However, the scarcity of longitudinal studies makes it impossible to establish causal relationships between the variables, so it is essential to carry out more extensive longitudinal studies. Regarding the information extracted about the risk factors for CPV, numerous studies were found that analyze variables based on the Ecological Theory . In addition, some authors indicate interrelationships between variables within different subsystem. For example, studies have shown a relationship between peer violence and CPV, as well as an association between committing CPV and dating violence in adolescents and specific cognitive schemas. For instance, the cognitive schema of distrust would predict an increase in dating violence, whereas schemes of grandiosity and insufficient self-control would predict CPV. These results indicate that the processing of social information could mediate the relationship between CPV and other violent behaviors . Moreover, recent studies have found a relationship between exposure to violence and CPV, this relationship being mediated by the justification of violence and emotional insecurity . Additionally, there is a relationship between violence from parents to children, exposure to violence between parents, various psychological stressors and CPV . This evidence suggests that CPV prevention must occur not only at the individual level, but also at the family and societal level. However, despite previous research on risk factors for CPV, there are still gaps in our knowledge, particularly regarding these social variables. In response to the second objective of the present study, we found a scarcity of research evaluating differences in the predictors of CPV according to the sex of the aggressor and the victim. Regarding the individual, familial and social risk factors for CPV depending on the sex of the aggressor, several studies have examined the differences in personality characteristics and psychopathological symptoms between boys and girls who commit CPV . For instance, the relationship between cognitive schemas, childhood abuse, emotional security in the family system or dating violence and CPV varies depending on the aggressor's sex. This implies that further research is needed on the risk factors for CPV, taking into account the differences according to the sex of the aggressor. Additionally, prevention and intervention programs should address these differences. Finally, regarding the risk factors for CPV depending on the victim's sex, previous research indicates relevant aspects for prevention and intervention in CPV, although they are still insufficient. For example, some authors find differences in the processing of social information or cognitive schemas depending on the victim's sex are noteworthy or in the relationship between child abuse and CPV depending on the victim's sex. This implies that the prevention and intervention in CPV must take consider the victim's sex, as the risk factors in the development of CPV may vary. Moreover, advancing our knowledge in this area could expand the resources available for intervention in the risk factors for CPV depending on the victim's sex, given the limited number of studies that have evaluate, for example, the differences in the factors of the exosystem according to the victim's sex. Previous literature has developed different interpretations for these differences found. The neuroendocrine model of aggression posits an association between the aggressive feelings and male gonadal activity, which would explain the higher rates of aggressive behavior. However, several authors argue that, in humans, the effect of testosterone on aggression is less clear . Feminist Theories have found that mothers often experience CPV the most . Along this line, according to the Social Learning Theory, some studies relate marital violence to CPV, and this may be one of the factors explaining why the mother is the most frequent victim . On the other hand, Ecological Theories proposes that one of the systems that include risk factors for CPV is the macrosystem, with gender roles being the main variable. This theory could explain differences in risk factors depending on the sex of the victim and the aggressor, due to the different socialization processes. --- Limitations During the development of the scoping review, we have identified some limitations that should be taken into account, as they can influence the interpretation of the results obtained. First, there is a very limited number of longitudinal studies, with most of the analyzed studies being cross-sectional, limiting the generation of causal relationships between the variables. A greater number of longitudinal studies would be needed to establish causal relationships between individual, family, and social variables and CPV. In addition, most of the studies included in this study were carried out in Spain, which may limit the generalizability of the results due to cultural differences. Hence, it would be advisable to carry out research at an international level, particularly outside Europe and United States. This would enhance our understanding of CPV in other countries, and shed light on the influence of cultural factors that may modify the prevalence in CPV and the risk factors that increase it. Likewise, a large number of the empirical investigations evaluated used a single informant as a participant, which could lead to a bias in the information, as other important perspectives for our knowledge of the phenomenon, such as those provided by the parents, educators, or other professionals are lacking. It would be appropriate to develop studies that have several informants from different fields, as it would provide a complete and comprehensive knowledge of CPV. On the other hand, the studies analyzed usually present a retrospective design, that is, based on the participants' memory, which can lead to a bias in the information obtained and the knowledge extracted from the investigations. --- Conclusions This scoping review has analyzed 52 studies that evaluate individual, family, and social risk factors for the commission of CPV, as well as the analysis of these variables according to the sex of the aggressor and the victim. This study has theoretical and practical implications. On the one hand, this research contributes to a better understanding of the factors that increase CPV, thus allowing the development of interventions and preventive programs. It can also help health, education, and justice professionals to better identify CPV and develop effective strategies. Information about how personality characteristics, psychopathological symptoms, or substance abuse in aggressors can assist professionals in developing techniques aimed at enhancing emotional self-regulation strategies among aggressors. Additionally, the impact of family factors as risk variables for CPV emphasizes the need for practitioners to intervene within the whole family system when this issue arises. Professionals can provide parents with strategies to address their children's violent behavior, as proposed by the Non-Violent Resistance or Break4Change models . For instance, practitioners could increase positive communication in families, involving all members of the system or provide parents with tools which they commit not to respond to their child's violence and increase their positive presence as caregivers. Moreover, the understanding that there exists a connection between peer violence and CPV implies that professionals should not only intervene within the individual or family context, but also within the social and educational domains. This involves developing psychoeducational projects in children and adolescents that focus on preventing violent behavior. On the other hand, this study helps identify the influence of sex on the risk factors associated with CPV, providing insights into the variations in the prevalence of CPV, as well as the specific needs related to sex in the prevention and treatment of CPV. It also facilitates the development of sexspecific programs and services. For instance, understanding that there are differences in personality characteristics and cognitive schemas between boys and girls that influence CPV indicates that professionals need to develop distinct objectives and techniques in interventions based on the sex of the aggressor. Moreover, the variations in risk factors for CPV based on the sex of the victim also suggest the need for tailored intervention strategies. For example, some authors have found a correlation between childhood abuse and CPV towards the mother, or between exposure to violence in home and CPV towards the father. This implies that professionals should equip parents with tools for positive and caregiving to prevent CPV. Taking proactive measures, such as establishing parent training programmes that conduct psychoeducational activities to address violent behavior and promoting the development of secure and non-violent family environments, aligns with this preventive approach. The results in general are not conclusive, so at present, we do not have a consensual and valid theoretical model that specifies which variables belonging to the levels of the ecological model are at the basis of the generation and increase of CPV. The main conclusions we draw from our study are: a) There are individual, family, and social variables that could constitute risk factors for the commission of CPV; b) Some risk variables for CPV could have a different impact depending on the sex of the aggressor and the; c) There are gaps in the knowledge of the specification of the risk factors for CPV, especially those of the exosystem level or social variables; d) There is no agreed theoretical model that presents the factors that explain the phenomenon of CPV. Therefore, we conclude that more research is needed on the risk factors of CPV, developing longitudinal studies that establish causal relationships between the variables and bearing in mind in the investigations that CPV should be considered a multifactorial phenomenon, taking into account the variables of all the systems that surround the young aggressor and their parents. The generation of a theoretical model that establishes the factors by which CPV occurs would not only imply an advance in the knowledge of this continuously increasing violence, but would also lay the foundations for the development of intervention and prevention programs to reduce CPV, and, therefore, the suffering that it generates in the minors, their families, and society in general. Funding Funding for open access charge: Universidad Málaga/CBUA. One of the authors of this scoping review has a predoctoral contract from the I Plan Propio de Investigación, Transferencia & Divulgación Científica of the Universidad de Málaga, which has allowed carrying out the research. --- Data Availability All data used in the research will be available and without access restrictions. ---

Purpose Child-to-parent violence (CPV) is a socially relevant domestic violence due to its exponential prevalence and negative individual, family, and social consequences. This scoping review aimed to analyze the risk variables involved in CPV and establish the relationships between them and the differences in these factors depending on the sex of the victim and the aggressor. Methods Studies from 2012 to 2022 were reviewed through the following databases: Scopus, Web of Science, Dialnet Plus, ERIC, PsycInfo, PsycArticles, Psychology Database and Pubmed. A total of fifty-two studies were included.The risk factors found are individual (e.g., aggressor's personality characteristics), familial (e.g., the parents' educational style), and social (e.g., peer violence). The study indicates differences in risk variables depending on the sex of the aggressor and the victim, such as the aggressor's personality characteristics, the influence of child abuse, or dating violence in adolescents. Conclusion Although the studies identified differences in risk factors for CPV depending on sex, further research is required to clarify the contradictory findings. This review has certain limitations, such as the predominance of cross-sectional studies and the focus on research carried out in Spain. Nonetheless, it carries practical implications as it expands our understanding of the risk factors associated with CPV. This knowledge can be utilized to develop educational and clinical prevention programs that take these factors into consideration.

introduction in recent years the visibility of a type of domestic violence known as childtoparent violence has increased awakening the interest of researchers and the exponential growth of studies dealing with this problem the following definition of cpv is frequently used in research and includes the most relevant aspects of its conceptualization repeated behaviors of physical psychological or economic violence directed at the parents or those who take their place specific aggressions are excluded those that occur in a state of decreased consciousness which disappear when it is recovered those caused by psychological alterations and parricide without a history of previous aggressions as for the prevalence the data obtained are inconclusive producing disparate figures this may be due to the definition of cpv differences in sample size and nature or the data collection method employed in the studies international research conducted in the united states and canada indicates a prevalence of physical cpv between 11 and 22 and of psychological cpv between 51 and 75 in spain del hoyobilbao et al found a prevalence rate of physical cpv between 82 and 9 and between 131 and 14 of psychological cpv likewise ruizfernández et al found in the sample analyzed that 2683 of the minors had committed serious psychological cpv towards the mother and 2250 towards the father 143 had exerted serious physical cpv towards the mother and 160 towards the father finally in relation to economic violence 399 had performed this economic cpv towards the mother and 289 towards the father most research indicates a higher rate of violence against mothers than fathers studies that examine differences according to sex show that both boys and girls commit cpv although some authors indicate significant differences in the type of violence perpetrated establishing that boys commit physical violence more frequently and girls commit more psychological violence recent studies have analyzed the risk factors of cpv finding a relationship between several variables such as parental ineffectiveness and the influence of peer conflicts peer violence permissive authoritarian and negligent educational style or child abuse emotional security in the family system impulsivity and substance abuse thus due to the growing interest in cpv and the diversity of variables involved some studies have tried to provide an explanatory model for this phenomenon cottrell and monk applied the nested ecological theory to explain cpv these authors establish that cpv is generated due to the interrelation between the variables belonging to the different subsystems in which the aggressor is involved an ontogenetic system comprising individual characteristics and experiences in aggressors a microsystem which includes all those patterns of interaction that can produce violence an exosystem encompassing social structures that could increase violence and condition interactions at the individual and family levels and a macrosystem which involves the system of beliefs and cultural values that naturalize and legitimize violence in alignment with this several recent reviews have provided theoretical analyses of the risk factors contributing to the development of cpv these reviews highlight various risk factors associated with cpv derived from the subsystems within the ecological theory these factors include individual factors familial factors or social factors however none of them specifically focus on the sex differences of victims and aggressors previous studies have shown that sex differences exist in terms of the types of violence perpetrated with boys displaying a higher tendency for physical aggression compared to girls these differences can be attributed to a combination of biopsychosocial factors specifically studies on cpv indicates that while both boys and girls engage in cpv there are variations in the types of violence committed boys are more likely to exhibit physical violence whereas girls tend to engage in psychological violence in addition previous research finds differences in risk factors for cpv depending on the sex of aggressor and victim however there isnt an explanatory model as to why differences in risk factors for cpv are found respect to sex objectives this scoping review was proposed to provide a structured analysis of the variables associated with cpv drawing from the subsystems within the ecological theory and to establish the interrelationships among these variables its aim was to provide a clearer understanding of the risk factors associated with cpv by synthesizing finding from both qualitative and quantitative studies there are different explanatory theories that have been used as a frame of reference in cpv stress theory general strain theory and coercion theory social learning theory however we consider that the ecological theory is the one that best fits the objective of our study since it takes into consideration psychological sociological and cultural factors to understand cpv the goals of the study were 1 to delimit the risk factors for the development of cpv following the conceptual framework of the ecological theory 2 to identify the risk factors for cpv according to the sex differences of victims and aggressors and 3 to analyze the limitations of current knowledge about the risk factors for cpv and establish future lines of research method this study is a scoping review following the prisma guidelines for scoping reviews inclusion and exclusion criteria concerning the inclusion criteria of the articles all those that met the following aspects were selected a analyzed the risk factors associated with cpv b the sample was of community clinical andor judicial origin and was made up of adolescents or young people andor parents c published during 20122022 this eligibility criterion is used because in europe there was an increase in the figures of cpv around 2012 leading to its consideration as a form of domestic violence in some countries consequently there has been a surge in interest in its studying and intervening for instance between 2013 and 2015 the actionresearch project responding to cpvwas implemented in five european countries with the goal of modifying violent behavior among children towards their parents regarding the exclusion criteria those studies that involved theoretical or systematic reviews metaanalyses case studies expert opinions or therapeutic experiences were discarded search strategy empirical articles from 2012 to 2022 were selected from the following databases scopus web of science dialnet plus eric psycinfo psycarticles psychology database and pubmed the boolean operator or was used the keywords used were children violence to parents or parents abused by their children or adolescent violence towards parents or abuse of parents by their teenage or child to parent violence or adolescent to parents abuse or child to parent aggression study eligibility the initial screening of the studies was carried out independently by two team researchers reading the title and abstract of the articles verifying whether the inclusion and exclusion criteria were met and eliminating 802 articles subsequently all the team researchers determined the inclusion of the article as definitive by reading the full text independently recording the data of the articles discussing the results and determining which variables to extract the data extracted from the 52 articles were recorded in a table which specified the methodological characteristics of the articles as well as the variables considered as risk factors for cpv the mendeley manager was used to enter the articles and remove duplicates likewise the scientific rigor of the selected articles was evaluated using the following criteria a credibility that is veracity and objectivity of the data obtained b transferability that is the results of the study can be applicable and generalizable c legitimacy transferring the data without altering the results of the articles results characteristics of the methodology of the studies most of the studies came from spain making up 7885 of the sample analyzed the rest of the research was developed in the united kingdom the united states germany asia south america and mexico most of the studies analyzed used a correlational design specifically 34 had a crosssectional correlational design and 8 had a longitudinal correlational design 8 studies were quasiexperimental crosssectional and 2 were qualitative works of the studies analyzed 7692 were carried out in the community context 769 in the judicial area 192 in the clinical setting and the rest that is 1346 combined the community judicial andor clinical contexts regarding the informants of the studies 6154 were adolescents aged between 1118 years 769 were youths aged between 18 28 years 1923 were adolescents and youths 385 were adolescents and their parents 192 were parents only 185 were parents extended family and professionals and 192 were children aged between 910 years and parents regarding the differences according to sex 4545 of the articles analyzed the differences according to the aggressors sex and 3030 did so according to the parents sex risk factors for childtoparent violence the research evaluated in the study shows risk factors at the individual family and social levels for the development of cpv they can be grouped into three blocks of results individual factors or ontogenic level family factors or microsystem and social factors or exosystem individual factors the studies analyzed highlight the aggressors sex as a risk factor for the commission of cpv most authors find similarities in cpv in terms of the aggressors sex nonetheless this varies depending on the samples analyzed in the case of community samples the proportion of female and male aggressors is similar but in forensic samples the proportion of males is higher there is also more controversy regarding differences in the aggressors sex concerning the type of cpv performed for example some authors find no differences in the perpetration of psychological and physical abuse towards parents between girls and boys whereas other studies report girls higher rates of psychological cpv than boys another individuallevel factor is the minor aggressors personality characteristics authors highlight impulsivity irritability lack of empathy and reflective capacity or low frustration tolerance as risk factors for the development of cpv likewise psychopathological symptomatology is another risk variable for the development of cpv symptoms such as hostility paranoid ideation anxiety borderline traits depression or antisocial behaviors may be related to cpv finally substance consumption has been another variable in this group of risk factors with studies indicating occasional substance consumption in approximately 60 70 of the sample of minor aggressors analyzed overall authors note that alcohol and drug use may be predictors of cpv results articles family factors at the microsystem level most of the results of the studies evaluated indicate that mothers are more frequent victims of cpv than fathers continuing at this level the results of research establish exposure to domestic violence and parental abuse in childhood as main predictors of cpv which would confirm the hypothesis of bidirectionality of violence according to this hypothesis being a victim of domestic violence predicts being an aggressor on the other hand some studies indicate ineffective educational styles as a variable that precipitates cpv that is the use of coercive strategies permissive styles or overprotection and lack of communication and affection could lead to cpv finally according to the family structure adoption or reconstituted families could be variables associated with cpv other factors related to the family system are bonding communication and the attachment style developed thus low levels of communication and affection together with ineffective parental educational styles could lead to an increase in cpv rates another variable considered in the development of cpv is emotional security in the family system finding a relationship between strategies that imply emotional insecurity in the family and the development of cpv social factors at the exosystem level peer violence is a relevant predictor of cpv specifically studies suggest that being a victim of violence in peer relationships can increase the probability of performing cpv in addition other authors highlight that social and school maladjustment as well as the influence of conflictive classmates or peers could increase cpv however recent research indicates dating violence in adolescents is a risk factor for the development of cpv finding an association between being an aggressor of dating violence and committing cpv differences depending on the sex of the aggressor and the victim next are included the results of the investigations divided into two blocks taking into account the differences in individual family and social risk factors depending on the sex of the aggressor and the victim differences depending on the aggressors sex individual factors regarding individual or ontogeniclevel risk factors a study carried out with a clinical and judicial sample indicates that female aggressors have a lower level of selfesteem whereas male aggressors have more problems of substance abuse and escalation of violence a progressive increase in the severity and frequency of violent behavior authors also report differences in the psychopathological symptomatology depending on the aggressors sex indicating that female aggressors show higher levels of psychopathological symptomatology and suicidal ideation and lower levels of family selfconcept than males who perform cpv similarly other authors report that interpersonal sensitivity that is a persons ability to perceive understand and respond appropriately to the emotions and needs of others in social interaction is related to cpv in the case of male aggressors and obsessions and paranoid ideation in the case of female aggressors regarding cognitive schemas calvete et al point out that the schema of disconnection and rejection that includes beliefs that others will hurt abuse or humiliate and the feeling of being emotionally rejected and defective predicts cpv both in boys and girls but the narcissism schema only in boys family factors in relation to the risk factors of the microsystem authors point out that the negative effect of punitive discipline during childhood is more significant in the case of male aggressors than in females that is the bidirectionality of family violence is greater in boys other studies suggest a significant relationship between being a girl and using the strategy of disengagement in the family system and committing more cpv towards the mother in contrast there is a relationship between being a boy and more justification of violence and performing cpv towards the mother social factors concerning the exosystem there are differences in the predictive role of dating violence in adolescents depending on the aggressors sex thus girls who perform psychological cpv also commit more psychological dating violence whereas this relationship does not occur in the case of boys moreover boys who commit physical cpv towards the mother also commit more physical dating aggression whereas girls who commit physical cpv towards the father also perform more physical dating violence differences depending on the victims sex individual factors considering individual risk factors or ontogenic level various investigations establish differences in proactive and reactive aggression the components of social informationprocessing cognitive schemas or narcissistic selfperception interpersonal sensitivity and obsessions depending on the parents sex proactive and reactive peer aggression are related to cpv towards the mother regarding the components of social informationprocessing anger and hostile attribution predict cpv towards the mother whereas access to an aggressive response predicts cpv towards both parents in relation to cognitive schemas the grandiosity schema predicts cpv towards the mother and the schemas of abandonment defect and justification of violence are predictors of cpv towards both parents family factors based on the risk factors of the microsystem calvete et al indicate that being a victim or a witness of domestic violence increases the probability of exercising cpv towards both parents further studies of calvete et al indicate that exposure to violence in the family predicts cpv towards the father on the other hand some research indicates a relationship between psychological childhood abuse and verbal cpv towards the mother and between physical childhood abuse and physical cpv towards the mother these relationships do not occur in the case of cpv towards the father the results of other studies find an association between mothertochild violence and cpv towards the mother and fathertochild violence and cpv towards the father table 2 risk factors for childtoparent violence depending on the aggressors sex and victims sex sex authors risk factors ecological level results aggressor calvete et al 2012calvete et al 2015bdel hoyobilbao et al 2021rico et al 2017rosado et al 2017loinaz et al 2020lópezmartínez et al 2019martínezferrer et al 2018martínezferrer et al 2020navasmartínez canolozano 2022 psychopathological symptomatology personality traits substance abuse ontogenic girls aggressors show lower levels of selfesteem and selfconcept higher levels of psychopathological symptoms and greater alexithymia boys aggressors has higher levels of substance abuse and escalation of violence relationship between motor and attentional impulsivity higher in aggressor girls calvete et al 2014acalvete et al 2015alyons et al 2015izaguirre calvete 2017del hoyobilbao et al 2020juncoguerrero et al 2021canolozano et al 2021a exposure to violence child abuse microsystem relationship between being a victim violence using the strategy of disengagement in the family system and justifying violence and to exert cpv toward the mother relationship between witnessing violence using the strategy of disengagement and preoccupation and justifying violence and exercising cpv toward the father corporal punishment is directly related to cpv toward the mother direct victimization by the mother increases cpv toward the mother and direct victimization by the father increases cpv toward the father ruizfernández et al 2021kuay et al 2021 exposure to violent video games peertopeer aggression exosystem regarding the video game use the flow dimension is related to greater cpv toward the mother while flow and absorption with cpv toward the father proactive and reactive peer aggression are related to cpv toward the mother social factors in relation to the exosystem factors the results of the study conducted by ruizfernández et al indicate a relationship between exposure to video games and lower rates of cpv towards both parents however different results are found regarding the effects of the flow and absorption dimensions of video games depending on the parents sex the flow dimension during video game exposure was associated with a higher level of cpv toward the mother whereas the flow and absorption dimensions were associated with higher cpv toward the father therefore in general the results show that the consumption of violent video games can reduce cpv rates but the subjects engagement and their dimensions of flow and absorption must also be considered on the other hand kuay et al propose that proactive and reactive peer aggression is significantly related to cpv towards the mother but not towards the father discussion the objective of the present study was to identify the available evidence about individual family and social risk factors for the development of cpv as well as the differences found in the investigations according to the sex of the aggressor and the victim in relation to the characteristics of the 52 studies analyzed we observe that most of them use a community sample followed by the judicial and clinical samples as previous research indicates cpv prevalence levels vary depending on the type of sample used the type of cpv varies depending on the source of the sample with psychological violence rates are higher in community studies and physical and severe violence are higher in the studies based on judicial samples similarly the risk factors for the development of cpv may vary different depending on the type of sample studies indicate that underage aggressors who come from judicial samples have higher levels of peer violence lower emotional intelligence a more negative family selfconcept and more antisocial attitudes than aggressors from the general population most of the studies assessing sex differences in risk factors are communitybased finding differences in personality traits distress suicidal ideation or peer victimization however there is no research evaluating sex differences in risk factors by sample type therefore it is necessary to conduct clinical judicial and community studies to compare differences in risk factors according to sex in addition the studies identified in this review were mainly spanish with less research developed in other countries especially those that do not belong to europe the studies analyzed from mexico germany asia or canada show relevant aspects for the clarification of risk factors for cpv the scarcity of studies carried out in some countries leads to a lack of knowledge about the prevalence levels of cpv at the international level as well as the risk factors that may contribute to it due to cultural influence cpv is often a hidden problem due to shame fear of the childrens reactions or the desire to protect the family image therefore different family socialization processes can vary across cultural context consequently influencing cpv research for example while most of the studies analyzed in this review focus on cpv in western countries fewer studies have been carried out in eastern countries this disparity may be attributed to cultural aspects such as the influence of filial piety in asian cultures which emphasizes respect for parents elders and ancestors as a result the prevalence of cpv may be lower or not extensively researched in these countries leading to a lack of knowledge about this phenomenon on the other hand the vast majority of the research included in this review are crosssectional studies with longitudinal studies being very scarce the longitudinal investigations evaluated clarify some of the risk factors for cpv establishing causal relationships between the variables analyzed the authors of these studies point to physical or verbal abuse by parents as a predictor of cpv likewise other authors indicate that the components of the social informationprocessing concerning aggressive responses and anger or the cognitive schemas of abandonment grandiosity or justification of violence predict cpv this type of research has relevant practical implications and is very important for the generation of prevention programs and intervention in cpv however the scarcity of longitudinal studies makes it impossible to establish causal relationships between the variables so it is essential to carry out more extensive longitudinal studies regarding the information extracted about the risk factors for cpv numerous studies were found that analyze variables based on the ecological theory in addition some authors indicate interrelationships between variables within different subsystem for example studies have shown a relationship between peer violence and cpv as well as an association between committing cpv and dating violence in adolescents and specific cognitive schemas for instance the cognitive schema of distrust would predict an increase in dating violence whereas schemes of grandiosity and insufficient selfcontrol would predict cpv these results indicate that the processing of social information could mediate the relationship between cpv and other violent behaviors moreover recent studies have found a relationship between exposure to violence and cpv this relationship being mediated by the justification of violence and emotional insecurity additionally there is a relationship between violence from parents to children exposure to violence between parents various psychological stressors and cpv this evidence suggests that cpv prevention must occur not only at the individual level but also at the family and societal level however despite previous research on risk factors for cpv there are still gaps in our knowledge particularly regarding these social variables in response to the second objective of the present study we found a scarcity of research evaluating differences in the predictors of cpv according to the sex of the aggressor and the victim regarding the individual familial and social risk factors for cpv depending on the sex of the aggressor several studies have examined the differences in personality characteristics and psychopathological symptoms between boys and girls who commit cpv for instance the relationship between cognitive schemas childhood abuse emotional security in the family system or dating violence and cpv varies depending on the aggressors sex this implies that further research is needed on the risk factors for cpv taking into account the differences according to the sex of the aggressor additionally prevention and intervention programs should address these differences finally regarding the risk factors for cpv depending on the victims sex previous research indicates relevant aspects for prevention and intervention in cpv although they are still insufficient for example some authors find differences in the processing of social information or cognitive schemas depending on the victims sex are noteworthy or in the relationship between child abuse and cpv depending on the victims sex this implies that the prevention and intervention in cpv must take consider the victims sex as the risk factors in the development of cpv may vary moreover advancing our knowledge in this area could expand the resources available for intervention in the risk factors for cpv depending on the victims sex given the limited number of studies that have evaluate for example the differences in the factors of the exosystem according to the victims sex previous literature has developed different interpretations for these differences found the neuroendocrine model of aggression posits an association between the aggressive feelings and male gonadal activity which would explain the higher rates of aggressive behavior however several authors argue that in humans the effect of testosterone on aggression is less clear feminist theories have found that mothers often experience cpv the most along this line according to the social learning theory some studies relate marital violence to cpv and this may be one of the factors explaining why the mother is the most frequent victim on the other hand ecological theories proposes that one of the systems that include risk factors for cpv is the macrosystem with gender roles being the main variable this theory could explain differences in risk factors depending on the sex of the victim and the aggressor due to the different socialization processes limitations during the development of the scoping review we have identified some limitations that should be taken into account as they can influence the interpretation of the results obtained first there is a very limited number of longitudinal studies with most of the analyzed studies being crosssectional limiting the generation of causal relationships between the variables a greater number of longitudinal studies would be needed to establish causal relationships between individual family and social variables and cpv in addition most of the studies included in this study were carried out in spain which may limit the generalizability of the results due to cultural differences hence it would be advisable to carry out research at an international level particularly outside europe and united states this would enhance our understanding of cpv in other countries and shed light on the influence of cultural factors that may modify the prevalence in cpv and the risk factors that increase it likewise a large number of the empirical investigations evaluated used a single informant as a participant which could lead to a bias in the information as other important perspectives for our knowledge of the phenomenon such as those provided by the parents educators or other professionals are lacking it would be appropriate to develop studies that have several informants from different fields as it would provide a complete and comprehensive knowledge of cpv on the other hand the studies analyzed usually present a retrospective design that is based on the participants memory which can lead to a bias in the information obtained and the knowledge extracted from the investigations conclusions this scoping review has analyzed 52 studies that evaluate individual family and social risk factors for the commission of cpv as well as the analysis of these variables according to the sex of the aggressor and the victim this study has theoretical and practical implications on the one hand this research contributes to a better understanding of the factors that increase cpv thus allowing the development of interventions and preventive programs it can also help health education and justice professionals to better identify cpv and develop effective strategies information about how personality characteristics psychopathological symptoms or substance abuse in aggressors can assist professionals in developing techniques aimed at enhancing emotional selfregulation strategies among aggressors additionally the impact of family factors as risk variables for cpv emphasizes the need for practitioners to intervene within the whole family system when this issue arises professionals can provide parents with strategies to address their childrens violent behavior as proposed by the nonviolent resistance or break4change models for instance practitioners could increase positive communication in families involving all members of the system or provide parents with tools which they commit not to respond to their childs violence and increase their positive presence as caregivers moreover the understanding that there exists a connection between peer violence and cpv implies that professionals should not only intervene within the individual or family context but also within the social and educational domains this involves developing psychoeducational projects in children and adolescents that focus on preventing violent behavior on the other hand this study helps identify the influence of sex on the risk factors associated with cpv providing insights into the variations in the prevalence of cpv as well as the specific needs related to sex in the prevention and treatment of cpv it also facilitates the development of sexspecific programs and services for instance understanding that there are differences in personality characteristics and cognitive schemas between boys and girls that influence cpv indicates that professionals need to develop distinct objectives and techniques in interventions based on the sex of the aggressor moreover the variations in risk factors for cpv based on the sex of the victim also suggest the need for tailored intervention strategies for example some authors have found a correlation between childhood abuse and cpv towards the mother or between exposure to violence in home and cpv towards the father this implies that professionals should equip parents with tools for positive and caregiving to prevent cpv taking proactive measures such as establishing parent training programmes that conduct psychoeducational activities to address violent behavior and promoting the development of secure and nonviolent family environments aligns with this preventive approach the results in general are not conclusive so at present we do not have a consensual and valid theoretical model that specifies which variables belonging to the levels of the ecological model are at the basis of the generation and increase of cpv the main conclusions we draw from our study are a there are individual family and social variables that could constitute risk factors for the commission of cpv b some risk variables for cpv could have a different impact depending on the sex of the aggressor and the c there are gaps in the knowledge of the specification of the risk factors for cpv especially those of the exosystem level or social variables d there is no agreed theoretical model that presents the factors that explain the phenomenon of cpv therefore we conclude that more research is needed on the risk factors of cpv developing longitudinal studies that establish causal relationships between the variables and bearing in mind in the investigations that cpv should be considered a multifactorial phenomenon taking into account the variables of all the systems that surround the young aggressor and their parents the generation of a theoretical model that establishes the factors by which cpv occurs would not only imply an advance in the knowledge of this continuously increasing violence but would also lay the foundations for the development of intervention and prevention programs to reduce cpv and therefore the suffering that it generates in the minors their families and society in general funding funding for open access charge universidad málagacbua one of the authors of this scoping review has a predoctoral contract from the i plan propio de investigación transferencia divulgación científica of the universidad de málaga which has allowed carrying out the research data availability all data used in the research will be available and without access restrictions

purpose childtoparent violence cpv is a socially relevant domestic violence due to its exponential prevalence and negative individual family and social consequences this scoping review aimed to analyze the risk variables involved in cpv and establish the relationships between them and the differences in these factors depending on the sex of the victim and the aggressor methods studies from 2012 to 2022 were reviewed through the following databases scopus web of science dialnet plus eric psycinfo psycarticles psychology database and pubmed a total of fiftytwo studies were includedthe risk factors found are individual eg aggressors personality characteristics familial eg the parents educational style and social eg peer violence the study indicates differences in risk variables depending on the sex of the aggressor and the victim such as the aggressors personality characteristics the influence of child abuse or dating violence in adolescents conclusion although the studies identified differences in risk factors for cpv depending on sex further research is required to clarify the contradictory findings this review has certain limitations such as the predominance of crosssectional studies and the focus on research carried out in spain nonetheless it carries practical implications as it expands our understanding of the risk factors associated with cpv this knowledge can be utilized to develop educational and clinical prevention programs that take these factors into consideration

Evidence-based Practice in Social Work The question of whether social work can be considered a science has led to thoughtprovoking debates among scholars . Brekke suggested that social work is poised to define itself as a science because of its research productivity. His argument focused on social work in the United States. Perron and colleagues provided evidence of the vast growth of social work research worldwide, as indicated by the ongoing founding of new journals in the discipline. The growth of scientifically generated knowledge and the claim that social work is conceived as a profession -although this professional status is unclear or even rejected by some scholars -has led to increasing attention on the intersection of scientific knowledge and practice. According to the analysis of Okpych and Yu , the orientation towards scientifically generated empirical knowledge is a fundamental part of the current paradigm in social work practice. Their analysis identified the empirical clinical practice movement as the starting point of a new paradigm, whereas the model of evidence-based practice has carried the transition forward from an authority-based to an empirically based paradigm. Other scholars have even labeled EBP itself as a paradigm . Initially founded in medicine and transferred to social work , EBP describes a five-step process to address a practical problem: formulating an answerable question relevant to the given problem, identifying information needed to solve the problem, critically appraising this information, applying the results to the situation and triangulating scientific knowledge with the given circumstances including one's own experience and the client's values and preferences, and evaluating the outcome. Although this definition of EBP, often described as a bottom-up approach , has hardly been unchallenged, the individual understanding of EBP varies . This confusion might be at least partly caused by interpreting the term EBP as advocating research-supported interventions , which is often referred to as a top-down approach . EBP has been extensively discussed, especially in the United States, where the Journal of Evidence-Informed Social Work was founded. The historical analysis of social work practice by Okpych and Yu also focused on the developments in the United States. Hence, their analysis did not answer whether the major influence of EBP on social work practice is evident in other geographical contexts as well. EBP has also had a crucial influence on other countries such as Australia , England , and Sweden . For instance, a citation analysis revealed evidence of the influence of EBP beyond the United States . According to that study, the British Journal of Social Work article by British author Stephen Webb , which critically reflected on EBP, has received more attention than any other article published in a journal dedicated to social work . Although EBP has provoked a strong response in social work, geographical differences seem to exist. In Germany, for instance, the influence of EBP does not seem to fit the historical analysis of Okpych and Yu . Students of social work in German universities are rarely taught about EBP, and many of them have never heard anything about it. Although this claim is only based on our own experiential evidence, there seems to be a crucial difference in the extent to which EBP has been adapted in social work between the founding country and Germany. There have been attempts to elaborate on the reasons for the different adaptations of EBP . These outlined differences imply the first hypothesis: H1: The core of the EBP debate is located in the United States. The main goal of this research is to investigate whether differences exist in the intellectual structure of the EBP discourses between two geographical contexts and why the same knowledge corpus seems to be adapted differently. Previous work might provide explanations for different adaptations of EBP in the German and U.S. discourses. For example, a recent study by Kreisberg and Marsh revealed that disciplinary social work in the United States mainly focuses on research, whereas European social work focuses on theory. Since EBP might inherently apply a research focus and neglect theory, even though considering theory is not excluded , it might have provoked a strong response in the United States and not in German-speaking countries. H2: The EBP discourse in the United States differs from the German discourse in terms of the focus of the publications . --- Knowledge diffusion in scientific disciplines This study aims to analyze the knowledge construction processes around EBP and how the underlying knowledge has diffused in the United States and in German-speaking countries. This section introduces our theoretical perspective, as well as the hypotheses derived from it, followed by the methodological approach applied to investigate knowledge diffusion processes within the social work discipline. --- Theoretical background In the last decades, the importance of knowledge, innovations, and research has continuously grown. This development is conceptualized under the term "knowledge society" . There is a strong political movement aiming for more inclusive and accessible knowledge for all citizens . Scientific disciplines are considered central to a transition to a knowledge society and even seen as "the premier knowledge institution[s] throughout the world" . Scientific disciplines ideally generate new knowledge about phenomena based on existing scholarly work. Knowledge accumulation is often proposed as ideal for scientific disciplines . However, accumulation cannot be understood as a linear process of summing up different pieces of knowledge . Although knowledge diffusion can be defined as "the adaptations and applications of knowledge documented in scientific publications and patents" , it is not assumed to be a technical, linear process, as might be implied by this definition. The local standards and conventions influence the way knowledge is adapted , which might lead to specific knowledge constructions and specific local accumulations . This claim is supported by network analysis results showing a certain degree of disunification of social science disciplines hindering the dissemination of knowledge . Accordingly, it would not be surprising if scientific communities of different geographical contexts adapt EBP differently, especially if the underlying knowledge diffuses and circulates differently within certain entities, for instance, scientific communities. Diffusion is a social process and a specific kind of communication . Liu and Rousseau differentiated two ways of knowledge diffusion within scientific disciplines: diffusion by publications and diffusion by citations. Diffusion by publications "originates from an internal mechanism by which the group itself expands its borders" . However, publications alone are not sufficient to spread knowledge. To influence the scientific discourse, they need to be referred to by others; this is indicated by whether and how often the publications receive citations. The ways of diffusion, by publications and by citations, can be seen as complementary. The hypotheses stated earlier, as well as the next hypotheses, focus on diffusion by publications. They are based on the observation that EBP has not been adapted in Germany but has had a huge influence on U.S. social work . H3: EBP has been diffused through publications in the United States. H4: EBP has not been diffused through publications in German-speaking countries. Diffusion by publications is a process in which the knowledge sender publishes scientifically generated knowledge that enables others to adapt the knowledge. The publication itself is a crucial element of diffusion processes which serves as communication channel . The diffusion process is most effective when the publications are freely available online . Although many journal publications are not freely available and many scholars have no access to specific online journals , one can assume that publishing in journals compared with other publication formats, for instance, monographs, comes with a higher chance of others receiving the published knowledge. Furthermore, in most scientific disciplines, the double-blind peer-review process-which is primarily done for journal publications-might also be one reason for the scientific community to acknowledge and adopt journal publications more than other publication formats. An increase of journal publications within a scientific discipline might, therefore, go along with a more homogeneous knowledge base on which knowledge can freely flow and be exchanged. A relatively limited knowledge exchange about EBP might, therefore, be one reason why EBP has rarely been discussed in German-speaking countries. H5: The U.S. EBP discourse differs from the German EBP discourse in terms of the publication format . Besides the mechanism of knowledge diffusion through publishing, a second kind of diffusion is indicated by citations . Citations can be seen as a valid indicator that disciplinary knowledge flows from a sender to a recipient . Citations also indicate a semantic relationship between the citing and the cited publication . Despite some counterevidence to this assumption , it is widely accepted that citation patterns can reveal intellectual commonalities or the intellectual foundation that the field is based on. They also indicate scientific communication or structural ties . Accordingly, citation analyses can identify patterns of social structure, communication, and knowledge flows within scientific communities . Regarding our research focus and the assumption of differences between the EBP discourse in the United States and in Germanspeaking countries, particularly between "epistemic cultures" , this would mean that EBP publications of these two discourses differ in their intellectual structure, as indicated by different citations. H6: The EBP discourses in the United States and in German-speaking countries are influenced by different schools of thought. Knowledge diffusion is determined by specific citation patterns of actors within national contexts . Shaw claimed that this also applies to social work and that scholars apply an "inward gaze," mainly referring to scholarly work from their own countries. Therefore, the next hypotheses are based on the assumption that scientific disciplines as well as discourses within certain disciplines are self-contained . H7: The EBP discourse network is self-contained in the United States. H8: The EBP discourse network is self-contained in German-speaking countries. The consideration of citations as a proxy for knowledge flow allows for the consideration of scientific disciplines as networks. The underlying presumption is that a scientific network consists of different actors or nodes , which are interconnected with other actors or nodes by ties or edges . Various network concepts are applicable to investigating scientific networks . One of the most often applied concepts is centrality, which was introduced by Bavelas . He investigated how structural properties of actors within groups influence the effectiveness of their communication and group performance. In general, centrality can be seen as an indicator of social capital, which provides central actors with opportunities to influence others or receive flows . The more central the position of an actor in a network, the higher its structural importance. Applied to our research focus, a highly central EBP publication can be perceived as a proxy for the opportunity to forward knowledge . Different highly central publications between two networks might therefore lead to different conceptual embeddings of the scientific discourses, which would mean that the initial knowledge about EBP is merged with other knowledge claims embedded in other publications. H9: The EBP discourses in the United States and in German-speaking countries differ in their conceptual embedding. The degree of knowledge flow is determined by the individual and structural properties of a network . For instance, referring to Crane's concept of invisible colleges, Abbott ) claimed that these more or less dense networks tend to share a set of conventional assumptions. If we assume that these assumptions can be embedded in scientific publications, then a network in which a certain piece of knowledge can be diffused has to show a certain degree of homogeneity. Hence, this presumption might serve as an explanation for why EBP seems to be widely adapted in the United States and rarely adapted in German-speaking countries. H10: The EBP discourse in the United States is more homogeneous than the EBP discourse in German-speaking countries. --- Methodological approaches to investigating knowledge diffusion in scientific disciplines To test our hypotheses, we used network and citation analyses, which will be discussed in the following sections. --- Citation analyses The rapid change in information storage and the development of software tools to analyze disciplinary information have led to increasing efforts to systematically investigate scientific communities, including social work . Scientometrics is a discipline dedicated to the "quantitative study of science, communication in science, and science policy" . Largely influenced by the work of Garfield and de Solla Price , scientometrics has a long tradition in the analysis of citation patterns. Citation analysis has become a major method to evaluate scholarly impact in diverse disciplines. The most widespread measurements are the journal impact factor and the newer h-index, which is applicable on an author level . Despite the criticism of citation analysis for evaluating the performance of individual work , it is commonly used as a proxy to evaluate scholarly work. This is also true for social work. In addition to the journal impact factor or related citation indexing methods applied to social work journals, citation analysis has also been used by individual scholars to systematically investigate the discipline of social work . For citation analysis, different units of analysis can be applied. Citation data can be aggregated on the level of journals or faculty . However, the most used units of analysis are authors or documents . In this study, we focus on documents, particularly on scientific publications. Citation data can be investigated through various methods . The simplest form of citation analysis is the use of direct citations, that is, to count the number of citations that a specific publication, author, or journal has received. Citations can also be analyzed by considering the context in which they appear: bibliographic coupling or co-citations . Bibliographic coupling analyzes the occurrence of the same citation in different publications. Two publications are coupled if at least one common reference appears in their reference lists. Through this method, one can investigate similar citation patterns of different authors. While bibliographic coupling searches for associations between citing publications or authors, co-citation analysis investigates associations between cited articles or authors. The number of co-citations of two publications indicates the closeness of the co-cited documents or authors as perceived by the investigated discipline . Co-citations provide promising data to identify various "conversation topic[s] within the discipline" . Hence, co-citation patterns can reveal the conceptual influence on the construction of EBP and related topics. --- Science mapping Citation analysis methods have often been combined with network analysis. This combination can be found among different methodological concepts, such as "science mapping" , "scientography" , "bibliometric mapping" , and "mapping knowledge domains" . Throughout this study, we refer to science mapping when talking about network analysis based on bibliographic data . Science mapping is seen as a useful tool to "describe how specific disciplines, scientific domains, or research fields are conceptually, intellectually, and socially structured" ). The network of co-citation data, for instance, can be visualized by considering each publication as a node and each appearance with another publication within a reference list as an edge. The result would be a weighted network in which each edge has a specific weight according to the frequency a specific pair of publications is cited together within one other publication. Network analysis methods allow to map and analyze the resulting network. The spatial representation of the data can enhance the analysis process by depicting physical proximity and relative locations of individual articles or authors . Science mapping techniques have also been used in social work . A recent study by Martínez and colleagues , for instance, combined the h-index data with a co-word analysis to depict thematic networks about the evolution of the social work discipline. Network analysis includes a large number of different analytical approaches, and their description is far beyond the scope of this article . This article will focus on two basic network concepts: density and network centrality. Density describes "the general level of linkage among the points in a graph" and represents the ratio of actual edges between nodes to the maximum possible number of edges. The more nodes, for instance, scientific publications, are connected to each other, the denser the network will be. Applied to our research interest, a low density within a co-citation network would indicate that many of the citations appear rarely or only once within the reference lists of EBP publications. A high density would be associated with a certain degree of homogeneity of knowledge that is referred to by EBP writings. The second concept we want to introduce is network centrality. When investigating a scientific field, the use of network centrality is complementary to citation analysis methods . There are different ways of conceptualizing and measuring centrality . Perhaps the most widespread centrality measures are closeness centrality, betweenness centrality, and degree centrality . This study is based on degree centrality and a variation of it called eigenvector centrality. These centrality measures are appropriate for investigating knowledge flows . Degree and eigenvector centrality can be subsumed under degree-like measures because they focus on the direct surroundings of a node by analyzing the direct edges with other nodes . Degree centrality is measured by the number of edges a specific node has with other nodes . Hence, it implies how well connected a node is to its surroundings and indicates the likelihood of being able to influence and becoming influenced by other nodes. In a direct network based on citations, in which each node represents either a cited publication or a citing publication , a node has a high degree centrality when it receives relatively many citations. A high degree centrality in a co-citation network means that a publication is often cited together with other specific publications. This connectedness implies that the scientific knowledge of these pairs of publications flows to one another and is merged within another publication. Therefore, a publication with a high degree centrality indicates a high chance of having influence on the scientific discourse. Eigenvector centrality takes into consideration how well connected the node connected to the analyzed node is . It can be seen as a variation of degree centrality in which the adjacent node is weighted by its centrality . In contrast to a simple degree centrality, this can lead to a low centrality of a highly connected node if this node is connected to only low central nodes. Accordingly, a node can have a high eigenvector centrality if it is connected to only a few other nodes and these adjacent nodes have a high centrality. Hence, in a co-citation network, a low-cited publication can also highly influence the scientific discourse if it is often cited together with one central publication. For our analysis of EBP networks, this means that a rarely cited publication has a high "risk" of influencing the discourse if its citations occur together with the first article about EBP in social work by Gambrill , which is assumed to be a central one within the discourse. --- Method --- Literature search and data preparation A comprehensive literature search was conducted to identify publications relevant to the research questions. Since we expected to find most of the publications of German authors in printed books, a search strategy that went beyond the common databases was necessary. Therefore, the search started with the most common generic and specific databases and was stopped to search other databases once no additional publications could be identified . We retrieved records from the following databases: Social Service Abstracts, Social Citation Index, Education Resources Information Center, PsycINFO, SocIndex, Scopus, ProQuest Social Sciences, Sociological Abstracts, Wirtschaft and Soziales, Psyndex, Sozialwissenschaftliches Fachportal, Bielefeld Academic Search Engine, FIS Bildung, Fachportal Pädagogik, PubPsych, and DZI Solit. We also searched the databases of Social Care Institute for Excellence, the Journal of Evidence-Informed Practice, Google Scholar, and Google Books. In all these databases, we searched for publications fulfilling the following inclusion criteria:  Title includes "evidence-based practice" OR "evidence-informed practice" OR "evidence-based social work" OR "evidence-informed social work" AND "social work" included in keywords OR journal title OR subject terms OR title  Published from 1996 to 2015  Language: German OR English This search strategy was complemented by a hand search, which proved to be relevant especially for German publications. A snowball search was applied until we could no longer find new publications. We eventually identified 961 publications. After excluding 211 duplicates, we ended up with 750 publications for further screening . Through this screening, we identified 18 publications that have been published more than once. For instance, sometimes a journal article was also found as a book chapter. We only excluded these double publications if they were 100% identical. Due to this clear operationalization, an interrater reliability check was not necessary. The same is true for the exclusion of book reviews and the exclusion of publications from other disciplines . If the term "social work" was not found within the publication, it was not considered part of the disciplinary social work discourse. One record was excluded because the existence of the publication could not be verified by a hand search. We recognized that many of the remaining publications did not seem to report any relevant information about EBP itself but rather presented research-supported interventions that do not reflect the conceptual background of EBP. Therefore, we decided on two more exclusion criteria: First, we excluded those publications in which the inclusion terms regarding the title did not appear in a row . We inferred this criterion from the finding that many titles had a structure like "Therapy X: An evidence-based approach for social work practice" . Second, we excluded publications using the plural "evidence-based/-informed practices" in the title. Those publications usually focus on research-supported interventions and are, therefore, not relevant to our research questions. After these exclusion processes, the result was 482 publications . --- INSERT FIGURE 1 ABOUT HERE Since many of the stated hypotheses focus on a comparison of the EBP discourses in the United States and in German-speaking countries, we had to identify the corresponding publications from the remaining sample. Therefore, each publication was coded by the affiliation of the first author. For instance, a publication written by a first author from the United States was considered part of the disciplinary discourse in the United States. Germanspeaking countries included Germany, Austria, and Switzerland. One publication from South Tyrol in Italy was also classified as originating from a German-speaking country. From the identified German and U.S. samples, we had to exclude records of edited book authorships, which led to 302 publications written by U.S. authors and 33 written by German-speaking authors. A further screening of the German and U.S. samples still showed that many of the remaining publications did not provide any definition of or reflections on EBP. Hence, another exclusion criterion was applied, namely, the exclusion of non-conceptual contributions, as indicated by publications reporting on research findings or practice reports. Two independent coders coded 50% of the publications based on three categories: mainly empirical , mainly conceptual , and technical . The coding reached an appropriate interrater reliability with a Cohen's kappa value of 0.82. The remaining conceptual EBP publications from the United States and German-speaking countries served as the basis for further analyses. --- Operationalization of variables Table 1 summarizes the operationalization of the other variables under study. The operationalization of the diffusion of EBP is based on Chen and Hick's argument that knowledge diffusion has occurred if the number of publications exponentially increases. For the comparison of the most central publications within both networks , we excluded the founding publications represented by Gambrill's article , which transferred EBP from medicine to social work, aswell as Sackett and colleagues' article, which is often claimed to be the first work about evidence-based medicine . Besides these two publications, we also excluded the first textbook about evidence-based medicine . This book is considered the first publication to systematically summarize the origins and underlying concepts of evidencebased medicine . The rationale behind this exclusion is that most EBP publications refer to these articles and aim to investigate differences regarding the links between the initial EBP idea and other disciplinary knowledge. --- INSERT TABLE 1 ABOUT HERE --- Network construction The present study aims to examine, among other topics, which concrete intellectual ideas have had an influence on the EBP discourses. Therefore, for a small-grained analysis, scientific publications representing concrete ideas were used as the unit of analysis. We retrieved each reference from 26 German publications. To make the German and U.S. citations comparable, we took a random sample of 26 U.S. publications and retrieved the citations from this sample. Since our samples included many monographs and book chapters, it was not possible to process this data retrieval automatically . Hence, we manually transferred the references to Microsoft Excel and prepared a two-mode matrix with two dimensions: the citing documents and the cited documents . On the one hand, this matrix represents a directed network, which means that the knowledge from the cited document flows to the citing document. On the other hand, the resulting network is unvalued, since the matrix includes only ones and zeros . The resulting network was used to test H1-H5. Since we were also interested in the influence of the cited documents, we excluded the dimension of the citing documents and transformed the two-mode network into a one-mode network , which represents an undirected network. This matrix is called co-occurrence matrix because both dimensions are equal and the values in the cells represent how often two documents co-occur within one citing document. Since the values can be greater than one, this kind ofmatrix represents a valued network. For instance, if document A co-occurs with document B four times, the edge between them has a weight of four. Some scholars have suggested normalizing the data for science mapping techniques . However, there are ambiguous standpoints on how to do so and whether co-occurrence matrices should be normalized . To yield a more empirically valid picture, we decided to follow the suggestion by to use raw data. Normalization was not required because we did not apply advanced networking methods. The constructed co-citation networks consisted of 1,389 nodes with 126,092 edges for the U.S. sample and 833 nodes with 33,442 edges for the German sample. In terms of centrality measures, several different methods have been developed for weighted networks . Although different measures often correlate with each other, they can be considered related but still distinct concepts . For instance, in the case of eigenvector centrality, if there are a few high-degree nodes connected to many low-degree ones, which we can expect in our citation data, then the result might differ from the results of other centrality measures . Therefore, different centrality measures are complementary to each other. Due to the underlying concepts introduced above , we used eigenvector centrality and degree centrality. Degree centrality was calculated on weighted degrees, defined as the sum of each co-occurrence of a publication with another publication . These two measures can be applied to weighted networks without any significant modifications. To depict the network and to calculate and represent the centrality outcome, we used Gephi, a network visualization software . The graph drawingwas based on the algorithm of Fruchterman and Reingold . --- Results --- Diffusion of EBP by publications --- EBP publications worldwide Hypothesis 1 states that the core of the EBP discourse is located in the United States. Table 2 shows the distribution of EBP publications by country. Since German and English written publications were included, Germany and Switzerland had a relatively high number of publications. Most of the publications were written by authors from the United States, which verifies our hypothesis. --- INSERT TABLE 2 ABOUT HERE --- Empirical versus theory focus Hypothesis 2 assumes differences between the U.S. discourse and the German-speaking discourse regarding the focus of the publications. It is assumed that the U.S. discourse have a stronger focus on empirical work while the German discourse applies a theory focus. Out of the 302 EBP publications from the United States, 85 were identified as mainly empirical, eight as technical, and 209 as mainly conceptual. The German sample consisted of three empirical and 26 conceptual publications. Although these results show that the U.S. discourse applies a stronger research focus, conceptual publications were the most common in both samples. A statistical comparison of the conceptual and empirical publications from both samples confirmed a significant association between the country and the type of publication, χ2 = 4.59, p < .05. --- Diffusion of EBP through publications Hypotheses 3 and 4 state that a process of EBP diffusion has happened in the United States but has been absent in German-speaking countries. To depict the dynamics of the publication patterns, the years of publication are compared in Figure 2. The figure shows that the discourse about EBP in the United States started to increase immediately after the article by Gambrill was published in 1999. The discourse reached its peak in 2008 with 32 publications and started to diminish afterwards. It should be noted, however, that the number of publications per year has increased since 2013. In the sample of German-speaking countries, the first article was published in 2005. The most publications per year, namely five, appeared in 2012. Overall, there are fewer publications per year from German-speaking countries, and there appears to be a consistent time lag of 1 to 3 years, with increases and decreases showing a similar pattern as the United States. Regarding the hypothesis that a diffusion of EBP has occurred in the United States, the results show that there have been two phases of diffusion, as indicated by the exponential growth of the number of publications between 1999 and 2004, as well as between 2005 and 2008. The absence of this growth in the German sample provides evidential support for H4. --- INSERT FIGURE 2 ABOUT HERE --- Publication formats Table 3 depicts the publication formats of the identified conceptual EBP publications. It supports our hypotheses that conceptual knowledge about EBP is mainly spread through journal publications in the United States and through other publication formats in German-speaking countries . This difference barely missed statistical significance, χ2 = 3.72, p = .054. Nineteen out of the 26 publications in the German sample are written in German. Moreover, the analysis identified two journals that seem to represent the main communication channel for EBP knowledge: Research on Social Work Practice and Journal of Evidence-Informed Social Work. --- INSERT TABLE 3 ABOUT HERE --- Diffusion of EBP by citations --- Influence of different schools of thought The next step in the analysis was to test the assumption that different schools of thought underlie the EBP discourses in the United States and in German-speaking countries. Table 4 provides an overview of publications frequently cited by the EBP publications under study. The 10 most cited EBP publications of U.S. authors include the canonical works about evidence-based medicine by Sackett andhis colleagues , as well as about EBP in social work by Gambrill ) and Gibbs . Publications about practice guidelines have also influenced the U.S. discourse . Among the most cited publications within the German discourse network is one by McNeece and Thyer proposing a hierarchy of evidence. The article by Webb challenging the validity of EBP is also highly cited within the German sample, in addition to Pawson's work, which challenges the consideration of meta-analyses as the gold standard for EBP . Moreover, the works by Hüttemann and Otto and Ziegler are highly cited German publications critically appraising the underlying concepts of EBP, particularly the concrete application of EBP in German-speaking countries. Ideas of reflexive professionalism or, more generally, a hermeneutic-oriented theory of professionalization can also be found in these most cited publications. These findings support the claim that different scientific knowledge has influenced the German and U.S. discourses. --- INSERT TABLE 4 ABOUT HERE --- Self-contained EBP networks Hypothesis 7 states that the majority of the most cited publications within the U.S. discourse network are written by authors from the United States. After excluding the founding papers , the U.S. network includes seven most cited papers by authors from the United States and three by authors from other countries . This indicates a self-contained network. Hence, H7 can be verified. In contrast, H8 is rejected because the most cited publications referred to by German authors were mainly written by authors from other countries . --- Conceptual embedding of the EBP discourses Hypothesis 9 implies different knowledge construction processes by stating that the conceptual embedding of EBP differs between the German and U.S. discourses. Figure 3 and 4 present spatial representations of the co-citation networks of both samples. The black nodes indicate highly central positions based on eigenvector and degree measures. Each cluster depicted within the whole network represents a reference list of a specific publication under study that is more or less connected with the core of the networks. As shown in Figure 3 , some publications are co-cited within one document but rarely connected across different documents. For instance, the distant cluster on the lower left is rarely connected to the main network. The most central nodes seem to be distributed among two different groups. The enlarged network shows the labels of the most central nodes. The nodes at the core of the network appear to be the most central ones; these publications are also among the most cited publications. --- INSERT FIGURE 3 ABOUT HERE INSERT FIGURE 4 ABOUT HERE Besides these most cited publications, other publications seem to influence the EBP discourse in the United States. For instance, the code of ethics by the National Association of Social Workers has the highest eigenvector centrality . The Contributions about critical thinking skills appear to be influential publications as well . Furthermore, the results indicate that the discussion about the role of theory in research and practice has an influence on the EBP discourse in the United States. Although both publications do not appear among the most central ones, they are depicted in Figure 3 --- INSERT TABLE 5 ABOUT HERE Figure 4 represents the co-citation network of the German sample. The whole network shows two independent networks. On the rightmost side, we can see a small network that is unconnected to the main network. This means that the references found in one EBP publication were not found in any other publication. Setting aside this isolated network, the big network indicates an interconnected EBP discourse. In addition, there seems to be a core of publications that highly influence the discourses. These core publications are depicted in the enlarged image on the left side. The image shows that the publication by McNeece and Thyer has the highest degree centrality, which is confirmed by the centrality outcomes in Table 5. The lower part of the network shows relatively dense connections between different central publications. Since direct citations and degree centrality are related to each other, the highly cited publications are found in the core network . For example, Pawson and Tilley's influential publication about "realistic evaluation" often appears in the German EBP discourse. Their theory-driven evaluation approach emphasized the need to consider the context and underlying mechanisms when evaluating practice outcomes. Moreover, several other highly central publications did not appear in the list of highly cited publications. For instance, a high eigenvector centrality and a high degree centrality were found for the conference report by Kindler about evidence-based diagnosis. Schmidt's article, which advocated the advantages of EBP, also has a high degree centrality. A high eigenvector centrality was also found for Grove, Zald, Lebow, Snitz, and Nelson's meta-analysis about the accuracy of clinical judgement versus mechanical prediction, as well as for Ziegler's critical publication in which he associated EBP with managerialism and the risk of losing professionalism. In conclusion, the founding publications of EBP are embedded differently within other scientific knowledge. The U.S. discourse and the German discourse do not share a single publication that appeared as highly central in both networks. --- Homogeneity of EBP discourses The final analysis aimed at testing our assumption that the co-citation network of the EBP discourse in the United States is more homogeneous than that of German-speaking countries. For this analysis, the co-citation network was treated as an unvalued network for two reasons: to avoid the unclear definition of density in weighted networks , and because the result based on an unvalued network is considered sufficient to interpret the overall connectedness of the EBP discourse. Scott emphasized the problems related to the comparison of the density of two differently sized networks. A larger network tends to result in a lower density value. Since the results even show a higher density in the larger U.S. network than in the smaller German network , we can conclude that the U.S. discourse is based on a more homogeneous intellectual ground. --- Discussion In this section, we discuss the findings in relation to the two research questions: how EBP is diffused by publications, and how EBP is diffused by citations. We also relate these findings to our own experiences with EBP discourses in the United States and in Germanspeaking countries. The interpretation of science mapping results requires specific knowledge about the domain, particularly about the discourse under study . In addition, the results were discussed with two domain experts from Switzerland and Germany. Although we are familiar with both EBP discourses, we want to encourage other scholars to complement our interpretations with their disciplinary experiences. --- Diffusion of EBP by publications Our analysis located most of the EBP publications in the United States . Out of 482 publications, 310 were written by first authors affiliated in the United States. The second most productive country is the United Kingdom, with 67 publications. Regarding the publications from German-speaking countries, we included publications in both the German and English language, which means that the numbers cannot be compared with those of other countries whose native language is not German or English. Furthermore, it would be interesting to relate the absolute number of EBP publications to the total number of social work publications of each country. Although we have not done this yet, one might speculate that, for instance, Sweden would have a high percentage compared with other countries, with 22 EBP publications out of all social work publications. The U.S. publications include more empirical work than the German sample . Although the majority of EBP publications from the United States focus on theory as well, research publications were identified three times more often within the U.S. sample than the German sample . This difference was found to be statistically significant which supports previous findings that revealed a stronger research orientation in the United States than in Europe . This research orientation might be one reason why EBP could be diffused in the United States and not in German-speaking countries, since EBP can be considered atheoretical in nature . The comparison of the publication years of conceptual EBP publications in Germanspeaking countries and the United States revealed major differences . A diffusion of EBP has never happened in German-speaking countries . One explanation for this might be the preferred communication channel . The majority of contributions in the German sample were not published in disciplinary journals , whereas most EBP publications in the United States have appeared in journals. It is important to consider that the results were very close to being significant . Even though our hypothesis has to be formally rejected, this finding indicates a very strong tendency toward different publication habits in the United States and in German speaking countries. Since we assume that our sample was comprised of most written EBP publications, the descriptive difference can also be considered as meaningful evidence for future debates and research. The identified tendency of U.S. scholars to use journals as communication media might have supported the diffusion of EBP in the United States . Our analysis revealed two periods of diffusion in theUnited States. The first diffusion process seemed to be triggered by the seminal work of Gambrill . Although the number of publications dropped from 2004 to 2005, a second diffusion process was observed within the following years. Six years after the first EBP publication was published , the first publication appeared in German-speaking countries. An international conference about EBP organized by Otto and colleagues at the Centre of Social Service Studies in 2005 can be seen as an important driver for bringing EBP into the German scholarly discourse. Moreover, the comparison of publication years revealed that the times in which many EBP publications appeared in the United States might have led to a growth of publications in German-speaking countries. However, since the German sample is small, this assumption has to be tested in further research. Regarding the progression of EBP publications, we want to point out what might be interpreted as a revival of EBP. In the United States, we found a peak of publications in 2008 and a decrease afterwards that lasted until 2013. However, in the following two years, the number of publications increased again. In the timeline of publications from the United States and German-speaking countries, there was a period of start-up in the United States that was followed a few years later by German-speaking countries. Furthermore, a similar pattern can be discerned in the number of publications in the U.S. and German groups, but a time lag exists between the pattern in the United States and the pattern in German-speaking countries. Although it is not represented in our data, EBP is currently attracting attention in German-speaking countries. Our review included articles that were published until December 2015. At the time of writing, it was already clear that an edited book would be published in 2016 with at least five chapters fulfilling our inclusion criteria . This edited book is based on contributions from a 2015 conference held by the German Social Work Association dedicated to the topic of EBP. These observations fit our general impression that EBP has recently become more important within the discipline. However, the development has to be further observed to verify our hypothesis of a revival of EBP. --- Diffusion of EBP by citations Network analysis methods were used to answer the question of how knowledge about EBP has been diffused by citation patterns. The analyses identified some key players whose publications are highly influential in both the U.S. and German discourses. Specifically, different publications of Sackett andcolleagues and Gambrill are central contributions. This finding is not surprising since a conceptual work about EBP without making reference to the origin of EBP would be incomplete. Other publications by Gambrill ) are frequently cited in both samples, which might be partly influenced by the "Matthew Effect." According to Merton , "the Matthew effect consists in the accruing of greater increments of recognition for particular scientific contributions to scientists of considerable repute and the withholding of such recognition from scientists who have not yet made their mark." This effect might be evident not only in citations for Gambrill but also in citations for all scholars of considerable reputation in the corresponding communities. Of course, this does not raise any objections to the scientific value of these contributions. Interestingly, the publications by Sackett and Gambrill are the only ones central in both networks. None of the centrality measures identified additional publications central in both discourses. The findings imply crucial differences regarding the conceptual influence in discussing EBP in German-speaking countries and theUnited States .One specific finding among the German sample is the influence of the notion of reflexive professionalism on EBP, as indicated by some of the most cited titles . This might be caused by the specific historical evolution of German social work. The theoretical work in Germany has been strongly influenced by social pedagogy rooted in the humanities, which has led to many popular theories following a hermeneutical and phenomenological tradition . Another influential difference regarding the constitution of social work in both countries is that U.S. social work has a strong focus on clinical contexts, particularly on "psychologically grounded practice" , whereas a systemic/system-theoretical paradigm is claimed to be predominant in Germany . These differences might have hindered the diffusion of EBP in German-speaking countries since both the norms of social systems, as well as the perceived compatibility of an innovation with the own values and past experiences is key for a successful diffusion process . Contrary to our expectations , the present study provided evidence that the German discourse is not self-contained.Most of the analyzed citations refer to work outside of German-speaking countries. However, the U.S. discourse is self-contained, as indicated by the studies mainly citing publications from the United States . This difference might support the findings that local standards predict the way knowledge is adapted . If the knowledge diffused by citations was constructed within the authors' own community, it might have a higher chance of being adapted since it already reflects the local conventions, methodologies, and assumptions. Given the assumption of disunified social science disciplines , knowledge from other geographical contexts might be hindered from flowing into another entity , which might explain why EBP was never diffused in the German discourse. The German EBP discourse also seems less unified than the U.S. discourse, as indicated by its lower density . Concrete scientific claims, represented by our unit of analysis, namely scientific publications, are less connected in German-speaking countries. Since knowledge diffusion requires knowledge flow between a sender and a recipient, this finding can further explain why EBP has been diffused in the United States but not in German-speaking countries. --- Further interpretations Before presenting further interpretations about the findings, it should be emphasized that these interpretations are based on our own educated guesses and not supported by additional research methods. Hence, a more in-depth analysis is needed to support our claims. We have the impression that the German discourse is strongly based on criticism about the underlying concepts of EBP . Of course, there are also central publications tending to advocate EBP . However, compared with the U.S. sample, the increased number of critical publications within the German sample is remarkable. The critique might be based on an assumed hierarchy of evidence inherent in EBP, as indicated by the fact that the article of McNeece and Thyer was the most central publication . In their article, they proposed a hierarchy of evidence and defined metaanalysis as the gold standard, followed by randomized controlled trials . The high citation count of the work by Pawson , which challenged the value of meta-analyses, might be a direct reaction to this hierarchy. The same might be the case for the high centrality of the study by Pawson and Tilley , which proposed a realistic evaluation approach and emphasized the crucial role of context and mechanisms underlying practice outcomes. For instance, Otto, Polutta, and Ziegler used the reference to Pawson and Tilley to point out the weaknesses of RCTs in generating mechanisms of causal effects. Otto underpinned this critique by referencing Shadish, Cook, and Campbell's work about experimental research , in which they described this weakness of experimental studies. In conclusion, the existence of an overarching hierarchy of evidence is largely rejected even though an evidence hierarchy is undoubtedly applicable in relation to specific questions . In this regard, it is interesting that alternative considerations about this topic were not influential in the German network, although the topic seems to be at the core of the discourse . Much effort is put into arguing against the hierarchy, although the question of whether a hierarchy exists has, internationally speaking, tended to become obsolete. As Hüttemann and Gambrill pointed out, the discussion about qualitative versus quantitative research and positivism versus interpretivism might distract our attention from the potential of EBP to further develop the professional ground of social work. Nevertheless, there might be a well-justified critique on the concrete application of EBP, such as how social policy has adapted and then transformed the underlying ideas of EBP . Regardless of the content of these debates, the underlying conflict between measurement and meaning might be inherent in scientific disciplines . In contrast to the German critical perspective, most scholars in the United States seem to agree on the importance of EBP. The underlying rationale might be as follows: First, attempts to foster social workers' application of scientific knowledge have failed. The authors of the publications under study often referred to the highly influential work by Kirk and Reid to support their call to enhance EBP skills. Second, a closer look at the publications citing the most central publication, namely the code of ethics by the , shows that this code of ethics is cited because of the stated requirements for practitioners to apply researchsupported interventions . This is similar to the cited accreditation standards by the CSWE that also require social workers to apply research-supported interventions. This is interesting because Gambrill , in her seminal publication, criticized the frequent use by social work of these kinds of authorities to justify professionalism. We further interpret the findings as an indicator of a conceptual focus in Germanspeaking countries and a pragmatic focus in the United States. This claim is supported by the finding that the majority of the 10 most cited publications are about how to teach or practice EBP , including work about practice guidelines. Moreover, EBP in the United States seems to be influenced by the notion of EBP as a top-down approach, which is shown by the corresponding central publications . Besides the entanglement with management aspects , this might be one reason for the critical perspective in German-speaking countries, since a sole application of scientific knowledge is widely seen as inappropriate from a specific profession-theoretical point of view . The German discourse is highly influenced by profession-theoretical work by Dewe and Otto , Hüttemann , Oevermann , and Otto and Ziegler . On the one hand, there were publications under study directly relating EBP to a reflexive professionalism . On the other hand, the analysis revealed several highly central publications advocating reflexivity as a feature of professional action. For instance, the publication by Dewe and Otto about this topic appeared to be highly central in all three analyses . The same applies to the professionalization theory by Oevermann , which is related to the notion of reflexive professionalism because it requires that social workers have justifications for conducted interventions and for "substitutional problem solving," which goes along with the ability of hermeneutical judgements. The related focus on case-based and reconstructive problem-solving approaches has already been described as a specific difference between the German and U.S. EBP discourses . In conclusion, the results indicate that the U.S. discourse aims to answer the question of how EBP can be implemented, whereas the German discourse aims to answer the question of whether it should be implemented. The U.S. writings seem to focus less on major theoretical work. Although two of the identified central publications emphasize the need to link theory with EBP , we could not identify a clear theoretical position towards which the discourse is oriented. The impression of a lack of theoretical contributions among the most central publications within the U.S. discourse must be seen as relative to the German sample. Of course, there is elaborated theoretical work embedded in several of those publications . However, to infer theory patterns that mainly influence the U.S. discourse, a more in-depth analysis is needed. --- Limitations and conclusions Although the present study is, to our knowledge, the first one to empirically investigate differences between EBP discourses, the results have to be interpreted against the background of several limitations. First, the a priori definition of two clusters can be challenged. One might argue that the German and U.S. discourses should not be assumed as separate, because different discourse boundaries might exist beyond national borders. Hence, the next step should be to run a cluster analysis of the whole citation database . This additional analysis might identify different networks, particularly epistemic cultures , spanning beyond national borders. Second, we are well aware of the existence of more publications conceptually elaborating on EBP. For instance, some publications have titles containing idiomatic expressions that do not allow us to infer the content. For instance, Schrödter entitled his article about evidence-based practice "Will the Dodo Bird Also Be Hunting Social Work?" Those titles are hard to capture through a comprehensive literature search based on bibliometric information. For the sake of scientific rigour and for our literature search to have the appropriate level of specificity and sensitivity, we decided to stick to the inclusion and exclusion criteria described earlier. Third, our decision against normalizing the co-citation data leads to an increased likelihood of a high centrality outcome for citations occurring within a long reference list. This mechanism has to be considered especially for the German sample since it included four monographs with long reference lists . For instance, we can assume that this effect led to the high centrality of Schmidt , which only received three direct citations but was cited within two monographs. The last limitation is the fact that the analysis regarding H7 and H8 was solely based on highly cited publications. To obtain a more valid picture of the networks, a citation analysis of the whole networks is necessary. Despite these limitations, our study provides evidence that is promising in several respects. Our results show significant differences between the German and U.S. discourse networks in terms of knowledge diffusion processes related to EBP. They show that diffusion by publications about EBP has never happened in German-speaking countries, whereas EBP has been strongly diffused in the United States. The analyses further revealed evidence about possible reasons for this difference. For instance, EBP has been related to different knowledge corpora important within the different geographical contexts. Hence, one can assume that the underlying conceptual understanding of EBP differs between the United States and Germanspeaking countries. These content-wise differences, as well as the finding of a more heterogeneous knowledge base in German-speaking countries, provide plausible explanations for the absence of EBP diffusion. Our study also provides some practical implications. The results can be used by social work researchers, lecturers, historians, policy makers, and students who want to become familiar with EBP and to identify the most central EBP literature. There is widespread confusion and misconceptions about EBP . These misconceptions could be avoided by learning about the canonical and most influential publications. Generally speaking, and in accordance with one of the main goals of this research, the results can help clarify the confusion around EBP since knowing about different conceptual influences is key to understanding different standpoints. Therefore, it is important that scholars engaging in EBP discourse disclose their own perspectives on the underlying concepts. This need is also indicated by our literature search results, which support the findings by Shlonsky and Gibbs that the label "evidence-based" is frequently used for any empirical study investigating social work practice regardless of the quality of the evidence. This is an issue not only in social work but also in other fields . Moreover, the results might be used by practitioners actively involved in social work practice research projects. The comprehensive literature review, as well as the corresponding findings, might foster a better understanding of EBP, which is closely related to the concepts underlying social work practice research. The findings indicating the ubiquity of EBP at least in the U.S. social work might also sensitise practitioners for EBP and its relevance for social work. Finally, it is important to point out the advantage of this methodological approach and to give suggestions for future research. The finding that many relevant publications have appeared in non-electronic formats supports the assumption that automatic retrieval of citations might lead to biased results. Manually retrieving citations is time consuming and suitable for a limited sample size. However, it can lead to a more valid picture of a scientific discourse. Although recent attempts have been made to automatically retrieve citations from books , the manual method still remains superior for specific research questions. In general, science mapping techniques can be usefully applied to study the discipline of social work. Even though scientometric methods have rarely been used in social work research, they have become increasingly important due to the development of advanced indexing methods. For instance, Perron and colleagues' work provides a promising step towards making scientometric data applicable to social work scientists without a background in computer sciences. Regarding the investigation of EBP discourse, we suggest the following two approaches for future research. First, network analysis methods might cluster specific discourse networks to identify "invisible colleges" within the discipline. In terms of the comparison of the German and U.S. samples, it seems promising to look for authors who connect the dialogue and serve as transnational bridges between them . Although we plan further analyses, we are open to sending our data to interested researchers who want to investigate this issue in more detail. Second, the interpretation of science mapping results requires informed judgement by domain experts. The meaning of citation data is ambiguous, and the conclusions beyond the descriptive results can only serve as hypotheses. Hence, to acquire a more detailed picture of the concrete disciplinary argument, a discourse analysis, for instance, one oriented towards the sociologyof-knowledge approach to discourse , might complement our results and lead to a deeper understanding of EBP discourses. We want to thank Daniel Gredig for his thought-provoking feedback on this work as well as Benedikt Lerner for his engagement in reliability testing. We want to express our gratitude to Eileen Gambrill for discussing this work and for providing her view on some issues related to EBP. We also want to thank Manuela Morsch for her hard work on data preparation, as well as two anonymous reviewers for their helpful feedback on this manuscript. Last, we want to thank Markus Eckl for his useful feedback on an earlier draft of this manuscript. Webb, 2001 .81 Gambrill, 1999379 Ziegler, 2003.81 Kindler, 2005334 McNeece & Thyer, 2004.80 Oevermann, 1996309 Oevermann, 1996.79 Schmidt, 2006306 Grove et al., 2000 .78 --- Acknowledgments

Evidence-based practice (EBP) has had a major influence on U.S. social work while it has rarely been adapted in German-speaking countries. This study investigates how knowledge about EBP is diffused within and across geographical contexts. Network analysis methods reveals different diffusion patterns and provide reasons for these differences. For example, the U.S. discourse is self-contained and based on a more homogeneous knowledge base, while the German discourse is more heterogeneous and focuses on a notion of reflexive professionalism. The different conceptual influences within the U.S. and German discourses are discussed in light of future directions of disciplinary social work.

evidencebased practice in social work the question of whether social work can be considered a science has led to thoughtprovoking debates among scholars brekke suggested that social work is poised to define itself as a science because of its research productivity his argument focused on social work in the united states perron and colleagues provided evidence of the vast growth of social work research worldwide as indicated by the ongoing founding of new journals in the discipline the growth of scientifically generated knowledge and the claim that social work is conceived as a profession although this professional status is unclear or even rejected by some scholars has led to increasing attention on the intersection of scientific knowledge and practice according to the analysis of okpych and yu the orientation towards scientifically generated empirical knowledge is a fundamental part of the current paradigm in social work practice their analysis identified the empirical clinical practice movement as the starting point of a new paradigm whereas the model of evidencebased practice has carried the transition forward from an authoritybased to an empirically based paradigm other scholars have even labeled ebp itself as a paradigm initially founded in medicine and transferred to social work ebp describes a fivestep process to address a practical problem formulating an answerable question relevant to the given problem identifying information needed to solve the problem critically appraising this information applying the results to the situation and triangulating scientific knowledge with the given circumstances including ones own experience and the clients values and preferences and evaluating the outcome although this definition of ebp often described as a bottomup approach has hardly been unchallenged the individual understanding of ebp varies this confusion might be at least partly caused by interpreting the term ebp as advocating researchsupported interventions which is often referred to as a topdown approach ebp has been extensively discussed especially in the united states where the journal of evidenceinformed social work was founded the historical analysis of social work practice by okpych and yu also focused on the developments in the united states hence their analysis did not answer whether the major influence of ebp on social work practice is evident in other geographical contexts as well ebp has also had a crucial influence on other countries such as australia england and sweden for instance a citation analysis revealed evidence of the influence of ebp beyond the united states according to that study the british journal of social work article by british author stephen webb which critically reflected on ebp has received more attention than any other article published in a journal dedicated to social work although ebp has provoked a strong response in social work geographical differences seem to exist in germany for instance the influence of ebp does not seem to fit the historical analysis of okpych and yu students of social work in german universities are rarely taught about ebp and many of them have never heard anything about it although this claim is only based on our own experiential evidence there seems to be a crucial difference in the extent to which ebp has been adapted in social work between the founding country and germany there have been attempts to elaborate on the reasons for the different adaptations of ebp these outlined differences imply the first hypothesis h1 the core of the ebp debate is located in the united states the main goal of this research is to investigate whether differences exist in the intellectual structure of the ebp discourses between two geographical contexts and why the same knowledge corpus seems to be adapted differently previous work might provide explanations for different adaptations of ebp in the german and us discourses for example a recent study by kreisberg and marsh revealed that disciplinary social work in the united states mainly focuses on research whereas european social work focuses on theory since ebp might inherently apply a research focus and neglect theory even though considering theory is not excluded it might have provoked a strong response in the united states and not in germanspeaking countries h2 the ebp discourse in the united states differs from the german discourse in terms of the focus of the publications knowledge diffusion in scientific disciplines this study aims to analyze the knowledge construction processes around ebp and how the underlying knowledge has diffused in the united states and in germanspeaking countries this section introduces our theoretical perspective as well as the hypotheses derived from it followed by the methodological approach applied to investigate knowledge diffusion processes within the social work discipline theoretical background in the last decades the importance of knowledge innovations and research has continuously grown this development is conceptualized under the term knowledge society there is a strong political movement aiming for more inclusive and accessible knowledge for all citizens scientific disciplines are considered central to a transition to a knowledge society and even seen as the premier knowledge institution s throughout the world scientific disciplines ideally generate new knowledge about phenomena based on existing scholarly work knowledge accumulation is often proposed as ideal for scientific disciplines however accumulation cannot be understood as a linear process of summing up different pieces of knowledge although knowledge diffusion can be defined as the adaptations and applications of knowledge documented in scientific publications and patents it is not assumed to be a technical linear process as might be implied by this definition the local standards and conventions influence the way knowledge is adapted which might lead to specific knowledge constructions and specific local accumulations this claim is supported by network analysis results showing a certain degree of disunification of social science disciplines hindering the dissemination of knowledge accordingly it would not be surprising if scientific communities of different geographical contexts adapt ebp differently especially if the underlying knowledge diffuses and circulates differently within certain entities for instance scientific communities diffusion is a social process and a specific kind of communication liu and rousseau differentiated two ways of knowledge diffusion within scientific disciplines diffusion by publications and diffusion by citations diffusion by publications originates from an internal mechanism by which the group itself expands its borders however publications alone are not sufficient to spread knowledge to influence the scientific discourse they need to be referred to by others this is indicated by whether and how often the publications receive citations the ways of diffusion by publications and by citations can be seen as complementary the hypotheses stated earlier as well as the next hypotheses focus on diffusion by publications they are based on the observation that ebp has not been adapted in germany but has had a huge influence on us social work h3 ebp has been diffused through publications in the united states h4 ebp has not been diffused through publications in germanspeaking countries diffusion by publications is a process in which the knowledge sender publishes scientifically generated knowledge that enables others to adapt the knowledge the publication itself is a crucial element of diffusion processes which serves as communication channel the diffusion process is most effective when the publications are freely available online although many journal publications are not freely available and many scholars have no access to specific online journals one can assume that publishing in journals compared with other publication formats for instance monographs comes with a higher chance of others receiving the published knowledge furthermore in most scientific disciplines the doubleblind peerreview processwhich is primarily done for journal publicationsmight also be one reason for the scientific community to acknowledge and adopt journal publications more than other publication formats an increase of journal publications within a scientific discipline might therefore go along with a more homogeneous knowledge base on which knowledge can freely flow and be exchanged a relatively limited knowledge exchange about ebp might therefore be one reason why ebp has rarely been discussed in germanspeaking countries h5 the us ebp discourse differs from the german ebp discourse in terms of the publication format besides the mechanism of knowledge diffusion through publishing a second kind of diffusion is indicated by citations citations can be seen as a valid indicator that disciplinary knowledge flows from a sender to a recipient citations also indicate a semantic relationship between the citing and the cited publication despite some counterevidence to this assumption it is widely accepted that citation patterns can reveal intellectual commonalities or the intellectual foundation that the field is based on they also indicate scientific communication or structural ties accordingly citation analyses can identify patterns of social structure communication and knowledge flows within scientific communities regarding our research focus and the assumption of differences between the ebp discourse in the united states and in germanspeaking countries particularly between epistemic cultures this would mean that ebp publications of these two discourses differ in their intellectual structure as indicated by different citations h6 the ebp discourses in the united states and in germanspeaking countries are influenced by different schools of thought knowledge diffusion is determined by specific citation patterns of actors within national contexts shaw claimed that this also applies to social work and that scholars apply an inward gaze mainly referring to scholarly work from their own countries therefore the next hypotheses are based on the assumption that scientific disciplines as well as discourses within certain disciplines are selfcontained h7 the ebp discourse network is selfcontained in the united states h8 the ebp discourse network is selfcontained in germanspeaking countries the consideration of citations as a proxy for knowledge flow allows for the consideration of scientific disciplines as networks the underlying presumption is that a scientific network consists of different actors or nodes which are interconnected with other actors or nodes by ties or edges various network concepts are applicable to investigating scientific networks one of the most often applied concepts is centrality which was introduced by bavelas he investigated how structural properties of actors within groups influence the effectiveness of their communication and group performance in general centrality can be seen as an indicator of social capital which provides central actors with opportunities to influence others or receive flows the more central the position of an actor in a network the higher its structural importance applied to our research focus a highly central ebp publication can be perceived as a proxy for the opportunity to forward knowledge different highly central publications between two networks might therefore lead to different conceptual embeddings of the scientific discourses which would mean that the initial knowledge about ebp is merged with other knowledge claims embedded in other publications h9 the ebp discourses in the united states and in germanspeaking countries differ in their conceptual embedding the degree of knowledge flow is determined by the individual and structural properties of a network for instance referring to cranes concept of invisible colleges abbott claimed that these more or less dense networks tend to share a set of conventional assumptions if we assume that these assumptions can be embedded in scientific publications then a network in which a certain piece of knowledge can be diffused has to show a certain degree of homogeneity hence this presumption might serve as an explanation for why ebp seems to be widely adapted in the united states and rarely adapted in germanspeaking countries h10 the ebp discourse in the united states is more homogeneous than the ebp discourse in germanspeaking countries methodological approaches to investigating knowledge diffusion in scientific disciplines to test our hypotheses we used network and citation analyses which will be discussed in the following sections citation analyses the rapid change in information storage and the development of software tools to analyze disciplinary information have led to increasing efforts to systematically investigate scientific communities including social work scientometrics is a discipline dedicated to the quantitative study of science communication in science and science policy largely influenced by the work of garfield and de solla price scientometrics has a long tradition in the analysis of citation patterns citation analysis has become a major method to evaluate scholarly impact in diverse disciplines the most widespread measurements are the journal impact factor and the newer hindex which is applicable on an author level despite the criticism of citation analysis for evaluating the performance of individual work it is commonly used as a proxy to evaluate scholarly work this is also true for social work in addition to the journal impact factor or related citation indexing methods applied to social work journals citation analysis has also been used by individual scholars to systematically investigate the discipline of social work for citation analysis different units of analysis can be applied citation data can be aggregated on the level of journals or faculty however the most used units of analysis are authors or documents in this study we focus on documents particularly on scientific publications citation data can be investigated through various methods the simplest form of citation analysis is the use of direct citations that is to count the number of citations that a specific publication author or journal has received citations can also be analyzed by considering the context in which they appear bibliographic coupling or cocitations bibliographic coupling analyzes the occurrence of the same citation in different publications two publications are coupled if at least one common reference appears in their reference lists through this method one can investigate similar citation patterns of different authors while bibliographic coupling searches for associations between citing publications or authors cocitation analysis investigates associations between cited articles or authors the number of cocitations of two publications indicates the closeness of the cocited documents or authors as perceived by the investigated discipline cocitations provide promising data to identify various conversation topic s within the discipline hence cocitation patterns can reveal the conceptual influence on the construction of ebp and related topics science mapping citation analysis methods have often been combined with network analysis this combination can be found among different methodological concepts such as science mapping scientography bibliometric mapping and mapping knowledge domains throughout this study we refer to science mapping when talking about network analysis based on bibliographic data science mapping is seen as a useful tool to describe how specific disciplines scientific domains or research fields are conceptually intellectually and socially structured the network of cocitation data for instance can be visualized by considering each publication as a node and each appearance with another publication within a reference list as an edge the result would be a weighted network in which each edge has a specific weight according to the frequency a specific pair of publications is cited together within one other publication network analysis methods allow to map and analyze the resulting network the spatial representation of the data can enhance the analysis process by depicting physical proximity and relative locations of individual articles or authors science mapping techniques have also been used in social work a recent study by martínez and colleagues for instance combined the hindex data with a coword analysis to depict thematic networks about the evolution of the social work discipline network analysis includes a large number of different analytical approaches and their description is far beyond the scope of this article this article will focus on two basic network concepts density and network centrality density describes the general level of linkage among the points in a graph and represents the ratio of actual edges between nodes to the maximum possible number of edges the more nodes for instance scientific publications are connected to each other the denser the network will be applied to our research interest a low density within a cocitation network would indicate that many of the citations appear rarely or only once within the reference lists of ebp publications a high density would be associated with a certain degree of homogeneity of knowledge that is referred to by ebp writings the second concept we want to introduce is network centrality when investigating a scientific field the use of network centrality is complementary to citation analysis methods there are different ways of conceptualizing and measuring centrality perhaps the most widespread centrality measures are closeness centrality betweenness centrality and degree centrality this study is based on degree centrality and a variation of it called eigenvector centrality these centrality measures are appropriate for investigating knowledge flows degree and eigenvector centrality can be subsumed under degreelike measures because they focus on the direct surroundings of a node by analyzing the direct edges with other nodes degree centrality is measured by the number of edges a specific node has with other nodes hence it implies how well connected a node is to its surroundings and indicates the likelihood of being able to influence and becoming influenced by other nodes in a direct network based on citations in which each node represents either a cited publication or a citing publication a node has a high degree centrality when it receives relatively many citations a high degree centrality in a cocitation network means that a publication is often cited together with other specific publications this connectedness implies that the scientific knowledge of these pairs of publications flows to one another and is merged within another publication therefore a publication with a high degree centrality indicates a high chance of having influence on the scientific discourse eigenvector centrality takes into consideration how well connected the node connected to the analyzed node is it can be seen as a variation of degree centrality in which the adjacent node is weighted by its centrality in contrast to a simple degree centrality this can lead to a low centrality of a highly connected node if this node is connected to only low central nodes accordingly a node can have a high eigenvector centrality if it is connected to only a few other nodes and these adjacent nodes have a high centrality hence in a cocitation network a lowcited publication can also highly influence the scientific discourse if it is often cited together with one central publication for our analysis of ebp networks this means that a rarely cited publication has a high risk of influencing the discourse if its citations occur together with the first article about ebp in social work by gambrill which is assumed to be a central one within the discourse method literature search and data preparation a comprehensive literature search was conducted to identify publications relevant to the research questions since we expected to find most of the publications of german authors in printed books a search strategy that went beyond the common databases was necessary therefore the search started with the most common generic and specific databases and was stopped to search other databases once no additional publications could be identified we retrieved records from the following databases social service abstracts social citation index education resources information center psycinfo socindex scopus proquest social sciences sociological abstracts wirtschaft and soziales psyndex sozialwissenschaftliches fachportal bielefeld academic search engine fis bildung fachportal pädagogik pubpsych and dzi solit we also searched the databases of social care institute for excellence the journal of evidenceinformed practice google scholar and google books in all these databases we searched for publications fulfilling the following inclusion criteria  title includes evidencebased practice or evidenceinformed practice or evidencebased social work or evidenceinformed social work and social work included in keywords or journal title or subject terms or title  published from 1996 to 2015  language german or english this search strategy was complemented by a hand search which proved to be relevant especially for german publications a snowball search was applied until we could no longer find new publications we eventually identified 961 publications after excluding 211 duplicates we ended up with 750 publications for further screening through this screening we identified 18 publications that have been published more than once for instance sometimes a journal article was also found as a book chapter we only excluded these double publications if they were 100 identical due to this clear operationalization an interrater reliability check was not necessary the same is true for the exclusion of book reviews and the exclusion of publications from other disciplines if the term social work was not found within the publication it was not considered part of the disciplinary social work discourse one record was excluded because the existence of the publication could not be verified by a hand search we recognized that many of the remaining publications did not seem to report any relevant information about ebp itself but rather presented researchsupported interventions that do not reflect the conceptual background of ebp therefore we decided on two more exclusion criteria first we excluded those publications in which the inclusion terms regarding the title did not appear in a row we inferred this criterion from the finding that many titles had a structure like therapy x an evidencebased approach for social work practice second we excluded publications using the plural evidencebasedinformed practices in the title those publications usually focus on researchsupported interventions and are therefore not relevant to our research questions after these exclusion processes the result was 482 publications insert figure 1 about here since many of the stated hypotheses focus on a comparison of the ebp discourses in the united states and in germanspeaking countries we had to identify the corresponding publications from the remaining sample therefore each publication was coded by the affiliation of the first author for instance a publication written by a first author from the united states was considered part of the disciplinary discourse in the united states germanspeaking countries included germany austria and switzerland one publication from south tyrol in italy was also classified as originating from a germanspeaking country from the identified german and us samples we had to exclude records of edited book authorships which led to 302 publications written by us authors and 33 written by germanspeaking authors a further screening of the german and us samples still showed that many of the remaining publications did not provide any definition of or reflections on ebp hence another exclusion criterion was applied namely the exclusion of nonconceptual contributions as indicated by publications reporting on research findings or practice reports two independent coders coded 50 of the publications based on three categories mainly empirical mainly conceptual and technical the coding reached an appropriate interrater reliability with a cohens kappa value of 082 the remaining conceptual ebp publications from the united states and germanspeaking countries served as the basis for further analyses operationalization of variables table 1 summarizes the operationalization of the other variables under study the operationalization of the diffusion of ebp is based on chen and hicks argument that knowledge diffusion has occurred if the number of publications exponentially increases for the comparison of the most central publications within both networks we excluded the founding publications represented by gambrills article which transferred ebp from medicine to social work aswell as sackett and colleagues article which is often claimed to be the first work about evidencebased medicine besides these two publications we also excluded the first textbook about evidencebased medicine this book is considered the first publication to systematically summarize the origins and underlying concepts of evidencebased medicine the rationale behind this exclusion is that most ebp publications refer to these articles and aim to investigate differences regarding the links between the initial ebp idea and other disciplinary knowledge insert table 1 about here network construction the present study aims to examine among other topics which concrete intellectual ideas have had an influence on the ebp discourses therefore for a smallgrained analysis scientific publications representing concrete ideas were used as the unit of analysis we retrieved each reference from 26 german publications to make the german and us citations comparable we took a random sample of 26 us publications and retrieved the citations from this sample since our samples included many monographs and book chapters it was not possible to process this data retrieval automatically hence we manually transferred the references to microsoft excel and prepared a twomode matrix with two dimensions the citing documents and the cited documents on the one hand this matrix represents a directed network which means that the knowledge from the cited document flows to the citing document on the other hand the resulting network is unvalued since the matrix includes only ones and zeros the resulting network was used to test h1h5 since we were also interested in the influence of the cited documents we excluded the dimension of the citing documents and transformed the twomode network into a onemode network which represents an undirected network this matrix is called cooccurrence matrix because both dimensions are equal and the values in the cells represent how often two documents cooccur within one citing document since the values can be greater than one this kind ofmatrix represents a valued network for instance if document a cooccurs with document b four times the edge between them has a weight of four some scholars have suggested normalizing the data for science mapping techniques however there are ambiguous standpoints on how to do so and whether cooccurrence matrices should be normalized to yield a more empirically valid picture we decided to follow the suggestion by to use raw data normalization was not required because we did not apply advanced networking methods the constructed cocitation networks consisted of 1389 nodes with 126092 edges for the us sample and 833 nodes with 33442 edges for the german sample in terms of centrality measures several different methods have been developed for weighted networks although different measures often correlate with each other they can be considered related but still distinct concepts for instance in the case of eigenvector centrality if there are a few highdegree nodes connected to many lowdegree ones which we can expect in our citation data then the result might differ from the results of other centrality measures therefore different centrality measures are complementary to each other due to the underlying concepts introduced above we used eigenvector centrality and degree centrality degree centrality was calculated on weighted degrees defined as the sum of each cooccurrence of a publication with another publication these two measures can be applied to weighted networks without any significant modifications to depict the network and to calculate and represent the centrality outcome we used gephi a network visualization software the graph drawingwas based on the algorithm of fruchterman and reingold results diffusion of ebp by publications ebp publications worldwide hypothesis 1 states that the core of the ebp discourse is located in the united states table 2 shows the distribution of ebp publications by country since german and english written publications were included germany and switzerland had a relatively high number of publications most of the publications were written by authors from the united states which verifies our hypothesis insert table 2 about here empirical versus theory focus hypothesis 2 assumes differences between the us discourse and the germanspeaking discourse regarding the focus of the publications it is assumed that the us discourse have a stronger focus on empirical work while the german discourse applies a theory focus out of the 302 ebp publications from the united states 85 were identified as mainly empirical eight as technical and 209 as mainly conceptual the german sample consisted of three empirical and 26 conceptual publications although these results show that the us discourse applies a stronger research focus conceptual publications were the most common in both samples a statistical comparison of the conceptual and empirical publications from both samples confirmed a significant association between the country and the type of publication χ2 459 p 05 diffusion of ebp through publications hypotheses 3 and 4 state that a process of ebp diffusion has happened in the united states but has been absent in germanspeaking countries to depict the dynamics of the publication patterns the years of publication are compared in figure 2 the figure shows that the discourse about ebp in the united states started to increase immediately after the article by gambrill was published in 1999 the discourse reached its peak in 2008 with 32 publications and started to diminish afterwards it should be noted however that the number of publications per year has increased since 2013 in the sample of germanspeaking countries the first article was published in 2005 the most publications per year namely five appeared in 2012 overall there are fewer publications per year from germanspeaking countries and there appears to be a consistent time lag of 1 to 3 years with increases and decreases showing a similar pattern as the united states regarding the hypothesis that a diffusion of ebp has occurred in the united states the results show that there have been two phases of diffusion as indicated by the exponential growth of the number of publications between 1999 and 2004 as well as between 2005 and 2008 the absence of this growth in the german sample provides evidential support for h4 insert figure 2 about here publication formats table 3 depicts the publication formats of the identified conceptual ebp publications it supports our hypotheses that conceptual knowledge about ebp is mainly spread through journal publications in the united states and through other publication formats in germanspeaking countries this difference barely missed statistical significance χ2 372 p 054 nineteen out of the 26 publications in the german sample are written in german moreover the analysis identified two journals that seem to represent the main communication channel for ebp knowledge research on social work practice and journal of evidenceinformed social work insert table 3 about here diffusion of ebp by citations influence of different schools of thought the next step in the analysis was to test the assumption that different schools of thought underlie the ebp discourses in the united states and in germanspeaking countries table 4 provides an overview of publications frequently cited by the ebp publications under study the 10 most cited ebp publications of us authors include the canonical works about evidencebased medicine by sackett andhis colleagues as well as about ebp in social work by gambrill and gibbs publications about practice guidelines have also influenced the us discourse among the most cited publications within the german discourse network is one by mcneece and thyer proposing a hierarchy of evidence the article by webb challenging the validity of ebp is also highly cited within the german sample in addition to pawsons work which challenges the consideration of metaanalyses as the gold standard for ebp moreover the works by hüttemann and otto and ziegler are highly cited german publications critically appraising the underlying concepts of ebp particularly the concrete application of ebp in germanspeaking countries ideas of reflexive professionalism or more generally a hermeneuticoriented theory of professionalization can also be found in these most cited publications these findings support the claim that different scientific knowledge has influenced the german and us discourses insert table 4 about here selfcontained ebp networks hypothesis 7 states that the majority of the most cited publications within the us discourse network are written by authors from the united states after excluding the founding papers the us network includes seven most cited papers by authors from the united states and three by authors from other countries this indicates a selfcontained network hence h7 can be verified in contrast h8 is rejected because the most cited publications referred to by german authors were mainly written by authors from other countries conceptual embedding of the ebp discourses hypothesis 9 implies different knowledge construction processes by stating that the conceptual embedding of ebp differs between the german and us discourses figure 3 and 4 present spatial representations of the cocitation networks of both samples the black nodes indicate highly central positions based on eigenvector and degree measures each cluster depicted within the whole network represents a reference list of a specific publication under study that is more or less connected with the core of the networks as shown in figure 3 some publications are cocited within one document but rarely connected across different documents for instance the distant cluster on the lower left is rarely connected to the main network the most central nodes seem to be distributed among two different groups the enlarged network shows the labels of the most central nodes the nodes at the core of the network appear to be the most central ones these publications are also among the most cited publications insert figure 3 about here insert figure 4 about here besides these most cited publications other publications seem to influence the ebp discourse in the united states for instance the code of ethics by the national association of social workers has the highest eigenvector centrality the contributions about critical thinking skills appear to be influential publications as well furthermore the results indicate that the discussion about the role of theory in research and practice has an influence on the ebp discourse in the united states although both publications do not appear among the most central ones they are depicted in figure 3 insert table 5 about here figure 4 represents the cocitation network of the german sample the whole network shows two independent networks on the rightmost side we can see a small network that is unconnected to the main network this means that the references found in one ebp publication were not found in any other publication setting aside this isolated network the big network indicates an interconnected ebp discourse in addition there seems to be a core of publications that highly influence the discourses these core publications are depicted in the enlarged image on the left side the image shows that the publication by mcneece and thyer has the highest degree centrality which is confirmed by the centrality outcomes in table 5 the lower part of the network shows relatively dense connections between different central publications since direct citations and degree centrality are related to each other the highly cited publications are found in the core network for example pawson and tilleys influential publication about realistic evaluation often appears in the german ebp discourse their theorydriven evaluation approach emphasized the need to consider the context and underlying mechanisms when evaluating practice outcomes moreover several other highly central publications did not appear in the list of highly cited publications for instance a high eigenvector centrality and a high degree centrality were found for the conference report by kindler about evidencebased diagnosis schmidts article which advocated the advantages of ebp also has a high degree centrality a high eigenvector centrality was also found for grove zald lebow snitz and nelsons metaanalysis about the accuracy of clinical judgement versus mechanical prediction as well as for zieglers critical publication in which he associated ebp with managerialism and the risk of losing professionalism in conclusion the founding publications of ebp are embedded differently within other scientific knowledge the us discourse and the german discourse do not share a single publication that appeared as highly central in both networks homogeneity of ebp discourses the final analysis aimed at testing our assumption that the cocitation network of the ebp discourse in the united states is more homogeneous than that of germanspeaking countries for this analysis the cocitation network was treated as an unvalued network for two reasons to avoid the unclear definition of density in weighted networks and because the result based on an unvalued network is considered sufficient to interpret the overall connectedness of the ebp discourse scott emphasized the problems related to the comparison of the density of two differently sized networks a larger network tends to result in a lower density value since the results even show a higher density in the larger us network than in the smaller german network we can conclude that the us discourse is based on a more homogeneous intellectual ground discussion in this section we discuss the findings in relation to the two research questions how ebp is diffused by publications and how ebp is diffused by citations we also relate these findings to our own experiences with ebp discourses in the united states and in germanspeaking countries the interpretation of science mapping results requires specific knowledge about the domain particularly about the discourse under study in addition the results were discussed with two domain experts from switzerland and germany although we are familiar with both ebp discourses we want to encourage other scholars to complement our interpretations with their disciplinary experiences diffusion of ebp by publications our analysis located most of the ebp publications in the united states out of 482 publications 310 were written by first authors affiliated in the united states the second most productive country is the united kingdom with 67 publications regarding the publications from germanspeaking countries we included publications in both the german and english language which means that the numbers cannot be compared with those of other countries whose native language is not german or english furthermore it would be interesting to relate the absolute number of ebp publications to the total number of social work publications of each country although we have not done this yet one might speculate that for instance sweden would have a high percentage compared with other countries with 22 ebp publications out of all social work publications the us publications include more empirical work than the german sample although the majority of ebp publications from the united states focus on theory as well research publications were identified three times more often within the us sample than the german sample this difference was found to be statistically significant which supports previous findings that revealed a stronger research orientation in the united states than in europe this research orientation might be one reason why ebp could be diffused in the united states and not in germanspeaking countries since ebp can be considered atheoretical in nature the comparison of the publication years of conceptual ebp publications in germanspeaking countries and the united states revealed major differences a diffusion of ebp has never happened in germanspeaking countries one explanation for this might be the preferred communication channel the majority of contributions in the german sample were not published in disciplinary journals whereas most ebp publications in the united states have appeared in journals it is important to consider that the results were very close to being significant even though our hypothesis has to be formally rejected this finding indicates a very strong tendency toward different publication habits in the united states and in german speaking countries since we assume that our sample was comprised of most written ebp publications the descriptive difference can also be considered as meaningful evidence for future debates and research the identified tendency of us scholars to use journals as communication media might have supported the diffusion of ebp in the united states our analysis revealed two periods of diffusion in theunited states the first diffusion process seemed to be triggered by the seminal work of gambrill although the number of publications dropped from 2004 to 2005 a second diffusion process was observed within the following years six years after the first ebp publication was published the first publication appeared in germanspeaking countries an international conference about ebp organized by otto and colleagues at the centre of social service studies in 2005 can be seen as an important driver for bringing ebp into the german scholarly discourse moreover the comparison of publication years revealed that the times in which many ebp publications appeared in the united states might have led to a growth of publications in germanspeaking countries however since the german sample is small this assumption has to be tested in further research regarding the progression of ebp publications we want to point out what might be interpreted as a revival of ebp in the united states we found a peak of publications in 2008 and a decrease afterwards that lasted until 2013 however in the following two years the number of publications increased again in the timeline of publications from the united states and germanspeaking countries there was a period of startup in the united states that was followed a few years later by germanspeaking countries furthermore a similar pattern can be discerned in the number of publications in the us and german groups but a time lag exists between the pattern in the united states and the pattern in germanspeaking countries although it is not represented in our data ebp is currently attracting attention in germanspeaking countries our review included articles that were published until december 2015 at the time of writing it was already clear that an edited book would be published in 2016 with at least five chapters fulfilling our inclusion criteria this edited book is based on contributions from a 2015 conference held by the german social work association dedicated to the topic of ebp these observations fit our general impression that ebp has recently become more important within the discipline however the development has to be further observed to verify our hypothesis of a revival of ebp diffusion of ebp by citations network analysis methods were used to answer the question of how knowledge about ebp has been diffused by citation patterns the analyses identified some key players whose publications are highly influential in both the us and german discourses specifically different publications of sackett andcolleagues and gambrill are central contributions this finding is not surprising since a conceptual work about ebp without making reference to the origin of ebp would be incomplete other publications by gambrill are frequently cited in both samples which might be partly influenced by the matthew effect according to merton the matthew effect consists in the accruing of greater increments of recognition for particular scientific contributions to scientists of considerable repute and the withholding of such recognition from scientists who have not yet made their mark this effect might be evident not only in citations for gambrill but also in citations for all scholars of considerable reputation in the corresponding communities of course this does not raise any objections to the scientific value of these contributions interestingly the publications by sackett and gambrill are the only ones central in both networks none of the centrality measures identified additional publications central in both discourses the findings imply crucial differences regarding the conceptual influence in discussing ebp in germanspeaking countries and theunited states one specific finding among the german sample is the influence of the notion of reflexive professionalism on ebp as indicated by some of the most cited titles this might be caused by the specific historical evolution of german social work the theoretical work in germany has been strongly influenced by social pedagogy rooted in the humanities which has led to many popular theories following a hermeneutical and phenomenological tradition another influential difference regarding the constitution of social work in both countries is that us social work has a strong focus on clinical contexts particularly on psychologically grounded practice whereas a systemicsystemtheoretical paradigm is claimed to be predominant in germany these differences might have hindered the diffusion of ebp in germanspeaking countries since both the norms of social systems as well as the perceived compatibility of an innovation with the own values and past experiences is key for a successful diffusion process contrary to our expectations the present study provided evidence that the german discourse is not selfcontainedmost of the analyzed citations refer to work outside of germanspeaking countries however the us discourse is selfcontained as indicated by the studies mainly citing publications from the united states this difference might support the findings that local standards predict the way knowledge is adapted if the knowledge diffused by citations was constructed within the authors own community it might have a higher chance of being adapted since it already reflects the local conventions methodologies and assumptions given the assumption of disunified social science disciplines knowledge from other geographical contexts might be hindered from flowing into another entity which might explain why ebp was never diffused in the german discourse the german ebp discourse also seems less unified than the us discourse as indicated by its lower density concrete scientific claims represented by our unit of analysis namely scientific publications are less connected in germanspeaking countries since knowledge diffusion requires knowledge flow between a sender and a recipient this finding can further explain why ebp has been diffused in the united states but not in germanspeaking countries further interpretations before presenting further interpretations about the findings it should be emphasized that these interpretations are based on our own educated guesses and not supported by additional research methods hence a more indepth analysis is needed to support our claims we have the impression that the german discourse is strongly based on criticism about the underlying concepts of ebp of course there are also central publications tending to advocate ebp however compared with the us sample the increased number of critical publications within the german sample is remarkable the critique might be based on an assumed hierarchy of evidence inherent in ebp as indicated by the fact that the article of mcneece and thyer was the most central publication in their article they proposed a hierarchy of evidence and defined metaanalysis as the gold standard followed by randomized controlled trials the high citation count of the work by pawson which challenged the value of metaanalyses might be a direct reaction to this hierarchy the same might be the case for the high centrality of the study by pawson and tilley which proposed a realistic evaluation approach and emphasized the crucial role of context and mechanisms underlying practice outcomes for instance otto polutta and ziegler used the reference to pawson and tilley to point out the weaknesses of rcts in generating mechanisms of causal effects otto underpinned this critique by referencing shadish cook and campbells work about experimental research in which they described this weakness of experimental studies in conclusion the existence of an overarching hierarchy of evidence is largely rejected even though an evidence hierarchy is undoubtedly applicable in relation to specific questions in this regard it is interesting that alternative considerations about this topic were not influential in the german network although the topic seems to be at the core of the discourse much effort is put into arguing against the hierarchy although the question of whether a hierarchy exists has internationally speaking tended to become obsolete as hüttemann and gambrill pointed out the discussion about qualitative versus quantitative research and positivism versus interpretivism might distract our attention from the potential of ebp to further develop the professional ground of social work nevertheless there might be a welljustified critique on the concrete application of ebp such as how social policy has adapted and then transformed the underlying ideas of ebp regardless of the content of these debates the underlying conflict between measurement and meaning might be inherent in scientific disciplines in contrast to the german critical perspective most scholars in the united states seem to agree on the importance of ebp the underlying rationale might be as follows first attempts to foster social workers application of scientific knowledge have failed the authors of the publications under study often referred to the highly influential work by kirk and reid to support their call to enhance ebp skills second a closer look at the publications citing the most central publication namely the code of ethics by the shows that this code of ethics is cited because of the stated requirements for practitioners to apply researchsupported interventions this is similar to the cited accreditation standards by the cswe that also require social workers to apply researchsupported interventions this is interesting because gambrill in her seminal publication criticized the frequent use by social work of these kinds of authorities to justify professionalism we further interpret the findings as an indicator of a conceptual focus in germanspeaking countries and a pragmatic focus in the united states this claim is supported by the finding that the majority of the 10 most cited publications are about how to teach or practice ebp including work about practice guidelines moreover ebp in the united states seems to be influenced by the notion of ebp as a topdown approach which is shown by the corresponding central publications besides the entanglement with management aspects this might be one reason for the critical perspective in germanspeaking countries since a sole application of scientific knowledge is widely seen as inappropriate from a specific professiontheoretical point of view the german discourse is highly influenced by professiontheoretical work by dewe and otto hüttemann oevermann and otto and ziegler on the one hand there were publications under study directly relating ebp to a reflexive professionalism on the other hand the analysis revealed several highly central publications advocating reflexivity as a feature of professional action for instance the publication by dewe and otto about this topic appeared to be highly central in all three analyses the same applies to the professionalization theory by oevermann which is related to the notion of reflexive professionalism because it requires that social workers have justifications for conducted interventions and for substitutional problem solving which goes along with the ability of hermeneutical judgements the related focus on casebased and reconstructive problemsolving approaches has already been described as a specific difference between the german and us ebp discourses in conclusion the results indicate that the us discourse aims to answer the question of how ebp can be implemented whereas the german discourse aims to answer the question of whether it should be implemented the us writings seem to focus less on major theoretical work although two of the identified central publications emphasize the need to link theory with ebp we could not identify a clear theoretical position towards which the discourse is oriented the impression of a lack of theoretical contributions among the most central publications within the us discourse must be seen as relative to the german sample of course there is elaborated theoretical work embedded in several of those publications however to infer theory patterns that mainly influence the us discourse a more indepth analysis is needed limitations and conclusions although the present study is to our knowledge the first one to empirically investigate differences between ebp discourses the results have to be interpreted against the background of several limitations first the a priori definition of two clusters can be challenged one might argue that the german and us discourses should not be assumed as separate because different discourse boundaries might exist beyond national borders hence the next step should be to run a cluster analysis of the whole citation database this additional analysis might identify different networks particularly epistemic cultures spanning beyond national borders second we are well aware of the existence of more publications conceptually elaborating on ebp for instance some publications have titles containing idiomatic expressions that do not allow us to infer the content for instance schrödter entitled his article about evidencebased practice will the dodo bird also be hunting social work those titles are hard to capture through a comprehensive literature search based on bibliometric information for the sake of scientific rigour and for our literature search to have the appropriate level of specificity and sensitivity we decided to stick to the inclusion and exclusion criteria described earlier third our decision against normalizing the cocitation data leads to an increased likelihood of a high centrality outcome for citations occurring within a long reference list this mechanism has to be considered especially for the german sample since it included four monographs with long reference lists for instance we can assume that this effect led to the high centrality of schmidt which only received three direct citations but was cited within two monographs the last limitation is the fact that the analysis regarding h7 and h8 was solely based on highly cited publications to obtain a more valid picture of the networks a citation analysis of the whole networks is necessary despite these limitations our study provides evidence that is promising in several respects our results show significant differences between the german and us discourse networks in terms of knowledge diffusion processes related to ebp they show that diffusion by publications about ebp has never happened in germanspeaking countries whereas ebp has been strongly diffused in the united states the analyses further revealed evidence about possible reasons for this difference for instance ebp has been related to different knowledge corpora important within the different geographical contexts hence one can assume that the underlying conceptual understanding of ebp differs between the united states and germanspeaking countries these contentwise differences as well as the finding of a more heterogeneous knowledge base in germanspeaking countries provide plausible explanations for the absence of ebp diffusion our study also provides some practical implications the results can be used by social work researchers lecturers historians policy makers and students who want to become familiar with ebp and to identify the most central ebp literature there is widespread confusion and misconceptions about ebp these misconceptions could be avoided by learning about the canonical and most influential publications generally speaking and in accordance with one of the main goals of this research the results can help clarify the confusion around ebp since knowing about different conceptual influences is key to understanding different standpoints therefore it is important that scholars engaging in ebp discourse disclose their own perspectives on the underlying concepts this need is also indicated by our literature search results which support the findings by shlonsky and gibbs that the label evidencebased is frequently used for any empirical study investigating social work practice regardless of the quality of the evidence this is an issue not only in social work but also in other fields moreover the results might be used by practitioners actively involved in social work practice research projects the comprehensive literature review as well as the corresponding findings might foster a better understanding of ebp which is closely related to the concepts underlying social work practice research the findings indicating the ubiquity of ebp at least in the us social work might also sensitise practitioners for ebp and its relevance for social work finally it is important to point out the advantage of this methodological approach and to give suggestions for future research the finding that many relevant publications have appeared in nonelectronic formats supports the assumption that automatic retrieval of citations might lead to biased results manually retrieving citations is time consuming and suitable for a limited sample size however it can lead to a more valid picture of a scientific discourse although recent attempts have been made to automatically retrieve citations from books the manual method still remains superior for specific research questions in general science mapping techniques can be usefully applied to study the discipline of social work even though scientometric methods have rarely been used in social work research they have become increasingly important due to the development of advanced indexing methods for instance perron and colleagues work provides a promising step towards making scientometric data applicable to social work scientists without a background in computer sciences regarding the investigation of ebp discourse we suggest the following two approaches for future research first network analysis methods might cluster specific discourse networks to identify invisible colleges within the discipline in terms of the comparison of the german and us samples it seems promising to look for authors who connect the dialogue and serve as transnational bridges between them although we plan further analyses we are open to sending our data to interested researchers who want to investigate this issue in more detail second the interpretation of science mapping results requires informed judgement by domain experts the meaning of citation data is ambiguous and the conclusions beyond the descriptive results can only serve as hypotheses hence to acquire a more detailed picture of the concrete disciplinary argument a discourse analysis for instance one oriented towards the sociologyofknowledge approach to discourse might complement our results and lead to a deeper understanding of ebp discourses we want to thank daniel gredig for his thoughtprovoking feedback on this work as well as benedikt lerner for his engagement in reliability testing we want to express our gratitude to eileen gambrill for discussing this work and for providing her view on some issues related to ebp we also want to thank manuela morsch for her hard work on data preparation as well as two anonymous reviewers for their helpful feedback on this manuscript last we want to thank markus eckl for his useful feedback on an earlier draft of this manuscript webb 2001 81 gambrill 1999379 ziegler 200381 kindler 2005334 mcneece thyer 200480 oevermann 1996309 oevermann 199679 schmidt 2006306 grove et al 2000 78 acknowledgments

evidencebased practice ebp has had a major influence on us social work while it has rarely been adapted in germanspeaking countries this study investigates how knowledge about ebp is diffused within and across geographical contexts network analysis methods reveals different diffusion patterns and provide reasons for these differences for example the us discourse is selfcontained and based on a more homogeneous knowledge base while the german discourse is more heterogeneous and focuses on a notion of reflexive professionalism the different conceptual influences within the us and german discourses are discussed in light of future directions of disciplinary social work

INTRODUCTION Ageing-in-place is a well-known concept and policy driver in urban planning and environmental gerontology, understood as the "ability to live in one's own home and community safely, independently, and comfortably regardless of age, income, or ability level" . Notions surrounding ageing-in-place posit that because older people have reported a preference to remain living in their homes for as long as possible, following ageing-in-place policies will inevitably create optimal social and health outcomes for older individuals. Often, ageing-in-place is assumed to be a positive experience, however this is not always the case for all older individuals . For example, older people who have limited income, are living alone and living with multiple co-morbidities may find it extremely difficult to maintain their homes and the lifestyles that they have grown accustomed to. Thus, for some people, the 'home' can have distinct negative connotations associated with feelings of imprisonment, unnecessary obligations, loneliness and distress, fear and resentment . As such, place transitions can be a common occurrence in later life. According to Schlossberg , adults continuously undergo transitions. A transition can be viewed as an event followed by a process occurring over an undetermined period of time that includes phases of assimilation and continuous assessment and reassessment as people move in, through and out of the transition event . Yet, how one responds to the transition depends on the type of transition event, one's perception of it and the context in which it impacts an individual's everyday reality . In terms of life transitions, 'moving home' is deemed to be one of the most stressful events that can occur in a person's life . Many people would prefer to not move and continue to live in their homes, even if circumstances are not ideal. Though, for many older people, the decision to remain living at home may not be one that is in their control, and as such, they are forced to relocate. Research indicates that a significant proportion of older individuals have experienced forced relocation at some point in their life . Perceived as hostile environmental transitions that contribute to vulnerability in old age, commonly reported forced relocation events in later-life include: natural disasters ; transitions to or between institutions; and across different levels of care . Typically requiring substantial uprooting, a forced relocation event can lead to the loss of social networks and supports and significant challenges during the readjustment period, resulting in overwhelming impacts on one's physical and mental health . However, it is important to note that the notion of 'forced relocation' is not always best described as a singular occurrence or event in time; and can encompass several experiences of many types of involuntary place transitions at different time points throughout a person's life . For instance, experiences of forced migratory relocations can include movement across countries, provinces and cities, and displacement of homes throughout the life-course . Such events can acutely impact the health and wellbeing of older people who can be more dependent on the immediate environment and sensitive to rapid urban change . Frequently, experiences of forced movement and migration become common episodic transitions for more vulnerable older adults. This can result in disruptions to their existing social relationships impacting personal place connectedness to future homes . As described by Oswald and Rowles , "From a long-term temporal perspective, relocation can be understood as a dynamic ecological transition, a developmental process in which each change of residence is experientially linked to the move that preceded it and to future moves that are anticipated to follow as a normative component of the individual's life course" . To better understand older peoples' experiences of forced relocation and the impact on their present living circumstances, this study explores forced movement and migration occurrences of older Western Canadian migrants through inquiries into their place histories. It examines Fang et al. International Journal of Educational and Life Transitions DOI: 10.5334/ijelt.49 how these histories have shaped opportunities and oppression leading up to a forced transition from precarious into affordable housing. This study is timely and important because, at present, many older adults in Metro Vancouver are experiencing forced relocation from their homes, an event propelled by the decrepitude of older buildings when they become worn down and the drive towards high density modern apartment living . The current research offers important insights into a crucial problem area; involving the increasingly limited adequate housing in Metro Vancouver for the diversity of growing older populations from across the world, particularly considering migrants from East Asia and their socio-cultural contexts. To do this, we provide a unique, intersectional place analysis of past and present experiences of place in a group of predominantly ethnically-diverse, low income, older people living in the City of Richmond -a municipality within Metro Vancouver. To effectively capture the socio-cultural, and historical nuances of forced migratory and relocation transitions, a new theoretical model informed by Collins's , the Intersectional Place Perspective was developed for this research. Grounded in concepts underpinning the notions of place and intersectionality , the goal of IPP is to bring together diverse experiences of place and devise an analytical perspective that recognises the importance of psycho-social and physical places and how they shape and centre marginalisation processes across the life-course. Thus, the originality of this study arises, in part, from the design and development of a theoretical model that bridges existing theoretical ideas in intersectional and gerontological scholarship. As well, existing planning methods appear to lack consideration for the combined effect of social factors and transition events and processes that ultimately shape experiences of health and wellbeing across different time points in a person's life . To address these conceptual, methodological, and theoretical challenges, IPP was designed to enhance explorations into how combined effects of unique socio-cultural, environmental, and physical factors and transition events can influence experiences of opportunity and oppression. Foundational features of this model are grounded in central tenets of intersectionality which Hankivsky and colleagues suggest are that: individual lives cannot be reduced to single traits, nor can single traits accurately depict understandings of individual experiences; person categories or locations are socially constructed, fluid, flexible, and inseparable, shaped by social processes, structures, power relations, and influenced by time and place; and prioritization of social justice and equity are of utmost importance. IPP contends that various types of oppression are located in place, are often interlaced with 'constrained' opportunities, and are not only interrelated, but present interlocking dimensions of differentiation used to dominate and exclude those that diverge from normativity . At present, there are no analytical models that effectively conjoin these elements for an in-depth exploration of 'marginality in place' across time -the notion that certain transition events can leave people feeling marginal, disconnected and that they do not matter in time and place . Informed by IPP for this research, we address the following research questions: 1. How can we help older people who have transitioned through experiences of forced relocation to age well in place? 2. How can we enhance our theoretical understandings of and capture socio-cultural nuances of forced migratory experiences? 3. How are older persons' experiences of forced relocation shaped by their combined multiple identit, positionalit, oppression and opportunit across time and place? --- METHODS --- STUDY CONTEXT This research stems from an affordable housing redevelopment project that was designed and developed to house low-income older adults who lived in the City of Richmond, in Metro Vancouver, Canada. To provide relevant historical context, it is important to note that the original building was built in the 1960s -at a time where the population consisted of mainly of White European migrants. The housing block consisted of 122 units . These bungalow, styled apartments were rented to low-income older people for independent living at a reduced cost of approximately one fourth of the average rent in Metro Vancouver. In 2005, members of the housing society, whose primary mandate is the provision of low-cost senior housing, raised concerns regarding the age and quality of this building. Subsequently, an affordable housing redevelopment project for older adults emerged followed by an extensive relocation process that spanned three years -an event which forced tenants to transition from bungalow style apartments into two 16-storey purpose-built highrise condominiums at higher rental costs to tenants. Importantly, over the years, with increased migration from East and South Asian countries into Metro Vancouver, the population mix of the redevelopment site had changed. The residents in the new build constituted a unique blend of older people , 70% from Southeast Asia and 30% of White European decent, recognised in recent decades as the Southeast Asian region of Metro Vancouver. This presented a complex situation consisting of distinct Canadian migration experiences of recent migrants, shaped by post-colonial nuances of Canadian history alongside the difficulties associated with resettlement; and conversely, feelings of forced displacement by previous White European settlers. However, the social mix of different cultural groups was only one of many social issues which challenged the notion that the health and social wellbeing of older tenants could be optimised through environmental design alone. To provide adequate housing for marginalised persons with unique backgrounds and diverse place experiences, necessitated a complex study design that allowed for multiple forms of inquiry, together with a deeper intersectional place analysis, to understand wholly how present housing circumstances are shaped by multiple social factors and place experiences across time. We subsequently acquired funding from the Vancouver Foundation and the Social Sciences and Humanities Research Council of Canada to document and analyse tenants' transitional experiences of forced relocation. --- STUDY DESIGN To meaningfully capture a complex trajectory of forced relocation events and processes, a rigorous multi-method, community-based participatory research approach was undertaken. CBPR is a collaborative research approach that promotes the reciprocal transfer of knowledge and expertise; inclusive participation; power sharing and equity; and co-creation and co-ownership of data across all partners . Guided by a CBPR approach, specific methods: in-depth interviews , storytelling sessions , and photo-tours were selected. Each of the methods served a specific purpose, prioritised the social and relational aspects of the research process, and enabled the emergence of different viewpoints of the problem area . Figure 1 presents a flow diagram that explains the method selection strategy. The richness of the data was enhanced by the level of methodological rigour that constituted the application of the three qualitative methods. In combination, the methods worked as a creative, collaborative system to engage and empower a diversity of older people to share their important and unique stories. The first method employed was the in-depth interview, which consisted of 45-minute one-on-one audio-recorded interviews with the participants. These were conducted in the participant's first language and at their convenience, any time during the day or in the evening, either in person or by telephone. The flexible, open-ended interview process helped establish rapport between researcher and participant and allowed for building trust through mutual sharing of lived experiences, as well as the development of important relationships necessary for the research. In-depth interviews identified important background context including participants' past housing and relocation experiences in Metro Vancouver and their desires and expectations for their new homes, post-move. Subsequent to in-depth interviews, the interview participants were given the opportunity to take part in participant-led photo-tours and/or storytelling sessions . Photo-tours are a way of generating data through a group tour of the participant's immediate living environment where they take photographs of the aspects of home and the community that they find meaningful . The 8 photo-tours in the current study consisted of 2-hour sessions that were led by the participants and conducted in the participant's first language, starting at the participant's place of residence and proceeding in and around their neighbourhoods. For each tour, participants were provided with an iPad and asked to guide the researcher on a tour of their home and neighbourhood whilst capturing photographs of meaningful places, objects, landmarks and aspects of their everyday life that were of importance to them in relation to their relocation. Although place histories were not the main topic of focus during the tour, past experiences of place, especially as it pertained to how the area had evolved or compared to past living environments, were a popular topic for many participants. Finally, 2-hour audio-recorded storytelling sessions conducted in the participant's first language were held at the participant's preferred location , at an agreed upon time, between the participant and the researcher. Storytelling is a method whereby participants share personal stories about a topic or phenomenon. According to Keats , the storytelling method is unstructured and often led by the participant . The key characteristics of storytelling include that they are: un-structured; led by the participant to reveal or inspire understandings about a particular topic or phenomenon in relation to self, whilst simultaneously providing important, in-depth information to the researcher; and often audio-recorded or video-recorded . It is a method that uses a reflexive approach, facilitates inquiry into a person's life story without having to use language that is difficult for a participant to comprehend. Guided by Keats , the storytelling sessions revolved around sharing stories of relocation from place to place and homeland to new country. Several participants requested an informal gathering over food as they engaged in rich storytelling dialogue with the researcher. Storytelling was the final method employed because this process required deep sharing and reflection of personal and often difficult past experiences of forced relocation. This intimate form of knowledge exchange and co-creation of meanings would not have been possible without, first, an establishment of trust, and second, the forming of a bond between the researcher and the participant via the first two methods. In terms of the study instruments, these were informed by IPP. Ensuring that the data generation tools would capture complex intersectional place experiences was crucial for the data analysis and necessary for addressing the research questions. Hence, both the interview guide and especially the storytelling guide were created under the principal assumptions of intersectionality, emphasising the importance of treating one's social identities and the positions that they hold in society as conjoined influencers of oppression and opportunity . Table 1 provides examples of the various formulations. Specifically, all participants were asked to describe how they perceived themselves during three temporal locations . As such, any jargon and inaccessible terminology as well as structured questions were avoided. Last, it is important to note that the narratives are further illuminated by the digital photographs taken by participants during photo-tours of their homes and neighbourhoods. --- STUDY RECRUITMENT AND PARTICIPANT DETAILS To ensure the voices of tenants in the design and planning of the redevelopment, we formed a partnership with the City of Richmond, the older adults' housing society, the developer, local Where did you grow up in China? Who was in political power at the time and how did that impact your family life? What did your parents do for a living? What would you class yourself/your family as growing up? Would you say you were poor, middle-class, wealthy? • How did this impact your life growing up? • How would it be different if you were a boy/girl? • What types of things do you think contributed to these challenges? Whether it is things about yourself or were they things that were out of your hands? Things that you could not control? How would you describe Canada in relation to the idea of 'home'? Tell me about your family circumstances when you first arrived in Canada compared to now? Now try and imagine all the events that have brought you to where you are living right now, what are some thoughts that come to mind? Tell me about your current home situation . What is about your current housing situation that promotes a strong sense of feeling you're at home or that this is your home? Tell me what a typical day looks like for you -routines, activities, community engagement, and interaction with neighbours? Tell me what is it about living here that you like the most ? Tell me what it is about living here that you dislike the most ? Table 1 Provides examples of questions used to guide the interviews and storytelling sessions. *Note: References to 'China' were amended when interviewing participants from different places and were described more broadly. municipal government, several local service organizations, and older people. Relationships with local older adults' service providers, the property manager, municipal government workers and senior members of the older adults' housing society that emerged at the initial proposal development phase, and were thus maintained throughout the project, enabled us to reach a group of predominantly older Chinese migrants specific to the housing relocation project. In total, 28 older adults over 60 years of age were recruited: • Gender: N = 11 Men; N = 17 Women. • Ethnicity: N = 1 East African; N = 19 Chinese; N = 8 European Canadian. • Tenancy Status: N = 23 Grandfathered Tenants ; N = 5 New Tenants. Approximately two thirds of the participants identified as being Chinese and reported having arrived from various cities , provinces , and autonomous provincial regions or territories across the People's Republic of China. The remainder identified as European Canadian from two provinces , and one participant identified as East African having been born and raised in Tanzania. The sample reflects both new tenants and existing tenants . Because this is an independent living residence rather than a nursing or care home, one of the key stipulations for tenancy is that the older person must be ambulatory. Thus, all participants were able-bodied and cognitively sound older people. Tenants were identified through community stakeholders and organisational leaders and invited to participate in the research. To ensure that Chinese participants whose first language was not English fully understood the research process and their involvement, the interviews were conducted in the participant's first language and the study information sheet and consent forms were translated into simplified Chinese and explained in Mandarin or Cantonese. Finally, to capture the full essence of the data provided in Mandarin or Cantonese, all storytelling and interview data were digitally recorded, translated and back-translated as necessary by a researcher that was fluent in both Chinese dialects and in English. --- DATA ANALYSIS Using the IPP model, an intersectional place analysis was conducted to help reveal tenants' self-reported identities and positionalities, and intersectional place experiences of oppression and opportunity. IPP is predicated on the notion that people construct meanings of place through the multiple identities that they hold, the social positionalities which they occupy, the multifarious oppressions they face, as well as the opportunities that are presented as they negotiate their everyday lives-all of which coalesce to create a system that drives various configurations of discrimination and privilege . IPP, a new theoretical model, developed specifically for this study, emerged from the multidimensional intersectionality framework developed by Sixsmith and Fang to challenge extant over-positivised notions of ageing-in-place, and to explore how agency is manifested by older adults in vulnerable social positions when negotiating for permanent housing solutions . The MIF was derived based on Collins's notion of intersectionality as an interweaving of multiple systems of oppression. Specifically, it was based on how such systems are organised through interrelated domains of power. This framework enabled the identification of older adults' positions in society, the identities they assumed or that were imposed upon them, and the oppressions they experienced within the dominant social, structural systems as well as organisational and policy contexts. However, the MIF lacked the necessary analytical features, such as temporality and place, to sufficiently capture experiences of opportunities and oppression across different socio-societal and sociocultural environments, structures, and time. more resilient as they learn, with varying degrees of success, to manage, align, or fit their changing physical and cognitive abilities within the confines of the physical, social, cultural, and structural dimensions of their new home . Subsequently, the MIF was reshaped to the IPP, which enabled a deeper analytical process that allowed for temporality when examining intersectional experiences of oppression and opportunity across different places. IPP encompassed analytical features that were well-suited for responding to the shortcomings of ageing-in-place, through an analysis of the interlocking social and cultural drivers of inequity such as age, gender, ethnicity, socioeconomic status, immigration status, partner status and generation status across place and time. Described in Figure 2, IPP can be understood using a mathematical formulation to better frame the analysis. To conceptualise and facilitate the analysis, each participant or case is denoted as 'k' with the number/type of places described with subscript of 'n' -under the assumption that people reside in several places across the life-course. Specific to each place, each individual can have claimed several identities and held multiple social positions that shape experiences of oppression and opportunity. Identity, positionality, and oppression and opportunity are denoted as accumulation of meaning derived from experiences captured at the different axes of place, respectively identity , positionality , and oppression . This formulation is based on the Multidimensional Intersectionality Framework developed by Sixsmith and Fang and can be found in Sixsmith and colleagues . Storytelling and interview data were analysed in HyperResearch 3.7.3 via a structured Framework Method , where a coding framework was developed systematically by three researchers through initial coding of three transcripts. Subsequent transcripts were analysed using the framework by case and by code . An initial coding structure was developed using low-level, descriptive coding. Coding units of text were labelled with words or phrases that closely corresponded to participants' accounts. To refine the coding structure, an iterative process of reading and re-reading the text was conducted. During this process, codes were subject to interpretation and notes were made to establish the relationships between codes based on their similar meanings. Codes with similar meanings were combined to form larger patterns and structured as initial themes. To ensure the validity and reliability of the coding structure, the initial themes were further interpreted and defined through team discussions. Any disagreements or conflicts in the interpretation of codes were resolved through discussion. As a result, a comprehensive coding structure and framework were developed and agreed upon by the three researchers involved in the study. Informed by IPP and a reading of all transcripts to establish familiarity, a code tree was used to organise participants' identities, positionalities, and experiences of oppression and opportunity according to the three temporal locations and place. Temporal locations indicate a specific time-point where participants had encountered a significant place transition. In the current project, the temporal locations reflect pre-migration , post-migration and post-relocation experiences. Within each temporal location, a range of self-reported identities, positions held in society, and experiences of oppression and opportunity, were identified and reported within sub-categories. For data that fell outside of the initial coding structure, new codes were created and integrated into the framework. An example of a coding framework can be found in another recent publication . Each transcript was imported into the software as an individual case and distinguished by a unique identifier . After the initial coding, cases were cross analysed via constant comparison enabling the generation of themes. Last, informed by Pink's visual data analysis, photo-tour visual data were analysed: using older people's dialogue exchange during participant led tours of their pre-move homes and surrounding neighbourhoods, digitally recorded discussions with the older people were conducted after the tour to interpret the photos they had taken, and the subsequent transcriptions were thematically analysed alongside interview transcripts where quotes of interest were matched with corresponding visual depictions. Relationships between the visual imagery, and storytelling and interview data, enabled data and interpretational triangulation to occur by illuminating different facets of the everyday socio-cultural experiences of older people by viewing the information in different data mediums. --- ETHICS Ethical clearance for this study was obtained through two institutions: Office of Research Ethics at Simon Fraser University, Vancouver, Canada and Heriot-Watt University Ethics Committee, Edinburgh, Scotland. The current study was conducted in accordance with the British Psychological Society's ethical guidelines. Informed consent was obtained from all participants; and participants were asked to only share information they were comfortable with. Because this study focused on older people, extra care was taken to ensure that specific issues in relation to: safety, mobility and cognition were addressed. For instance, it was made clear if at any point the participant felt uncomfortable or unsafe, there was the option to withdraw from the study and this decision would not impact their access to housing supports or services. To ameliorate any mobility issues, participants selected the time and where data generation procedures would take place. --- FINDINGS Findings are reported in the form of migration stories illustrating how older Canadian migrants modify their place of residence because of a series of constraints or decisions, which carry distinct meaning and significance, and stories of forced relocation. Themes and visual imagery are presented according to each participant's self-reported identities, positionalities and experiences of oppression and opportunity within three temporal locations: pre-migration experiences to Metro Vancouver, Canada post-migration experiences to Metro Vancouver, Canada and forced transitions between affordable housing. --- PRE-MIGRATION EXPERIENCES Findings in this section were situated within pre-migration contexts before arriving in Metro Vancouver, Canada. Migration for the purposes of this study is defined broadly as a process where individuals born outside of Metro Vancouver have travelled to the city to settle and start new lives. Because most participants reported having migrated from different countries, their stories largely depicted processes that highlight relocation complexities involving adjustments across cultures and nationalities. The reported social identities appeared strongly tied to the positions participants held in society. For example, age identifiers were coupled with professional social markers and/or family roles or partner status. Situated within the temporal context of pre-migration, most participants self-identified as being young, working professionals or students, highlighting their professional identities , partner identities or family identities . All participants from China identified themselves explicitly as Chinese. Cultural norms, beliefs and practices were reported by participants as being directly linked to China, as their place and their motherland. Yet, the majority reported Canada as being their home, although, no participants who were born outside of Canada identified themselves as Canadian despite having lived in Canada for, at minimum, 5 years. Pre-migration social positions varied across a continuum of being poor, working class to middle-income or middle class and wealthy, upper-class; with a similar number of individuals reported as having come from a wealthy family to those of middle-class or middle-income backgrounds. Family status did not appear to impact whether individuals from China received an education. All participants from China identified themselves as educated or having received education whether they had reported as having grown up in poor working class families or not. Conversely, all participants identifying as European Canadian reported to only have received primary or middle school education, having left home at a young age and either went straight into the workforce or were married. All participants identified as 'employed' or 'having employment' once they had left school or home as young people. Participants from outside of Canada had all held professional positions, often viewed as middle class occupations, either in managerial positions, higher positions within academia or self-employed business owners; whereas European Canadian participants revealed having held manual labour employment positions. Experiences of oppression, although shaped in part by the positions held in society, were more heavily influenced by macro socio-political and cultural contexts of place. For most European Canadian participants, who were mostly women, they had expressed experiencing gender oppression as single, young, women with "nomadic" lifestyles . The women reported struggling with gendered roles, norms and expectation such as pressures to marry at a young age and adopting the housewife role as well as dissuasion away from taking the career path; particularly work roles that were deemed only suitable for men. One participant described a "time when women weren't allowed on the racetracks until 10am…" so she would "dress up like a man and put on a hat and pretend as a regular guy" . Another, spoke of fears of sexual assault as it was uncommon for young women at the time to live on their own. She detailed one experience of a man who watched her through her bedroom window and propositioned her: "when you're alone, let me know. Pull the blind down and I'll come up to your room" . For older Chinese participants, regardless of social position, pre-migration experiences of oppression were significantly shaped by the Cultural Revolution. These include experiences of dangerous work cultures and environments, poor, overcrowded living conditions, forced relocations from urban to rural parts of China, severe income inequities, and limited choice and freedom that often impinged on individual human rights. As illustrated by older Chinese participants, persecutory policies and practices instilled during the Cultural Revolution created an atmosphere of fear and helplessness, often imposed through threats of family separation: "During the cultural revolution, I was assigned to work in rural China. If I accepted, I would have had to migrate my older parents and three children there. I couldn't let my children live in the countryside. If I refused, I would have been charged with going against the Cultural Revolution. I chose the latter option, even if it meant that I had to go to prison, but luckily, I was fine." Other stories of oppression were similarly linked to political subjugation yet were unique and within different contexts since these stemmed from the effects of European imperialism. Experiences of turmoil and loss of cultural and /or sovereign identity were consistently reported by individuals who originated from countries once ruled by Portugal such as Macao, or the United Kingdom such as Hong Kong, and Tanganyika . For years, such countries struggled with attempts to regain independence or resist returning to oppressive regimes linked to communism. Hardships were experienced most severely as countries transitioned into independence or toward reunification. Participants described periods of intense political unrest that often resulted in forced displacement as demonstrated by one example here: "The political situation wasn't good, so we were afraid. We saw, as many places acquired their independence, people getting hurt. With the riots and fighting and, you know, the power struggle. So, we were just afraid, and as the rules and regulations changed, it worked against us, in a sense…the way we were living could not stay the same way as before." In a struggle to regain normalcy and stability after forced relocations, the consensus was that individuals subsequently lived under impoverished conditions and worked tirelessly, making sacrifices for the greater good of the family. Nevertheless, several participants seized opportunities by overcoming their challenged circumstances, which were impacted by their positionalities and identities , as well as the place contexts at significant historical moments. As described in the next passage, despite reports of the Cultural Revolution being a tumultuous period with much human suffering and poverty, living through such an event instilled a sense of resilience in some participants: "I came from a poor family, which has helped me a lot. I understood the harshness of life and how hard life can become even when I was a child. Experiencing poverty can help a person be stronger." European Canadian participants also reported similar stories of resilience through the seizure of opportunistic moments during periods of oppression, as described by two European Canadian women who escaped a life of patriarchal suppression by undertaking risky, nomadic lifestyles. The key message here is that despite being challenged by uncertainty and instability, participants often utilised such difficulties as motivation to express their agency as they transitioned through challenging life experiences. --- POST-MIGRATION EXPERIENCES Identities and positionalities evolve across time and place. Pre-migration identities emphasised childhood and youth conjoined with national and professional identities, as well as partner status. Whereas post-migration identities emphasised immigration and citizenship, as well as personal attributes, roles and responsibilities that exemplified transitions into maturity as one progresses through the life-course. The majority participants at this temporal location identified themselves as older people, highlighting character traits such as 'hospitable,' 'resourceful,' 'humble,' 'quiet,' 'open-minded,' 'assertive,' alongside their roles and responsibilities associated with being an older person such as 'grandparent,' 'carer,' and 'survivor.' Identities that were reported in association with immigration and citizenship were expressed only by ethnic minority participants. Immigrant status was described in reference to a legal category that was assumed, rather than an embodied trait or a self-selected identifier of personal expression. Citizenship was implied as a form of prestige that was earned through the ability to acculturate and become more Western. This was emphasised by one older Chinese woman as an unattainable status for Chinese migrants because, "we cannot become Canadian because we are not white" . Shifts in social positions were revealed by participants as it pertained to the processes that surrounded ageing and changes in family structure, both of which can determine one's ability to maintain employment and an adequate household income. In general, most participants lived alone as their partners have passed on and because their children now resided with their own families. Older women who still had their partners with them, had assumed the role of caregiver. All older men who lived alone were divorced except for one older African man who revealed that his wife had passed away years ago from terminal illness. With the exception of one older Chinese man who worked part time bagging groceries at a Chinese market, none of the participants held paid employment positions, although many were engaged in voluntary work. Several older women participants had reported either living with a long-term health condition or were survivors of a terminal illness. Meanwhile, all participants both men and women had a social network of friends, although, a few older women indicated that they did not enjoy socializing with others and preferred their own company because developing new relationships was too physically and mentally overwhelming in old age. All participants also referred to themselves as low-income or poor older adults; although, existentially, some indicated they were 'wealthy' either through spiritual fulfilment or having overcome past challenges. One unique distinction between persons born in Canada and those that were from outside of Canada, were experiences of transitioning downward down the social status scale as expressed here: "The living environment here is not as good as when we lived in China. Our home in China had four rooms, a living room and a dining room. We had everything including a study room and a piano. Here, we rent a small one-bedroom suite. We are unable to afford a house here. With our combined work income, we had nothing after paying post-secondary education for our two kids." Post-migration experiences of oppression were consistent with reports of having acquired lowered social positioning; a frequently reported occurrence which many argued as stemming from the socio-cultural changes associated with Canada as a post-colonial nation. Within the Canadian context, post-colonialism describes the remnant effects of the colonization of aboriginal land. Primarily through British imperialism, this event has over time, drastically influenced legal, cultural, and political practices and beliefs, creating social and health inequities for both Aboriginal peoples and non-white settlers . Within the current context, older adults of ethnic and cultural sub-groups reported experiencing complex migration challenges that were often discriminatory in nature. For example, some participants felt saddled with disadvantages through experiences of 'otherness' living in Canada, despite a sense of legitimacy through societal contributions: "Even though they were polite to us, we knew that they didn't like us. For changes of my social position, I am fine with it because this was the fact of reality. However, we educated our children here. Our daughter works here and pays tax to the government and thus we are eligible for public services and subsidies. We are not refugees. We have contributed to this country." Meanwhile, rapid changes in the Canadian urban and cultural landscape, as a result of modifications to immigration policies to entice foreign investors, were reported as contributing to feelings of oppression by some participants. Many felt that Chinese immigrants were perceived as invaders of 'our space' -people that occupy without having contributed and/or assimilated socially, politically, and economically. For example, Richmond, Canada before the late 1970s, early 80s, was predominantly farmland and inhabited by mostly European migrants. More recently, with an influx of foreign Chinese investors, Richmond is infamously known as the Chinese region of Metro Vancouver, with unique culturally influenced building designs and Chinese signage. Several European Canadian participants expressed feeling forcefully displaced from a place where they once felt a sense of pride, ownership, and familiarity, to a place that now feels foreign: "That's why I loved it here in Richmond because, at the beginning, I loved this country. When we first came here, it was farmland all around and I loved it. And then they started building on it. I remember telling my friend, "Oh they're ruining my place. I liked it here…they're putting all the buildings on this beautiful land."' Despite reports of historically-influenced, complex challenges, all participants described the opportunities they have gained, and the benefits they have received, simply as a result of living in Canada. A sense of empowerment emerged as participants expressed their achievements. The majority of Chinese participants proclaimed that "Canada is my second motherland" , emphasising the substantial improvement in their overall health and wellbeing since moving to Canada as described here: "My biggest success is my healthy body. Canada has given me health. The medical situation here is really good. Medication for older adults is mostly free. Canada has good medical system and a good natural environment. Clean cities have less disease. So, I seldom become ill. Because of this, even though I am over seventy years old, I look like I'm in my 60s." It was strongly believed that the opportunities afforded to older Chinese migrants were depicted as the result of Canada's deeply embedded altruistic values, beliefs, and practices. One man described the country as, "a truly humanistic society" . Despite having experienced social and structural challenges living in Canada, according to several participants, Canada's redeeming qualities are its establishment of egalitarian principles, alongside preservation of its natural resources. In essence, the opportunities participants acquired through their transitional relocation to Canada were described as having outweighed their struggles and difficulties. --- FORCED TRANSITIONS BETWEEN AFFORDABLE HOUSING Previous sections illustrate place history accounts focused on oppressions and opportunities of forced location as it pertained to movement across Canada and across nations. The following narrative, shaped by prior place migration experiences , demonstrates a microcosm of the broader relocations, and reveals forced transitions between affordable housing contexts. The next sections are depicted according to two transitional and temporal sub-locations: pre-move adversities and post-move prospects. Despite unique social differences between participants, all older people in this study had one commonality that concerned their shared experience of forced relocation into older adults' affordable housing. Accordingly, identities and social positions in the current temporal location had not changed considerably. However, participants discussed their experiences of oppression and opportunity more openly as "older adults with limited income". In particular, place identity was articulated in relation to meanings of home and how such understandings were shaped by migration processes in conjunction with becoming even older. By and large, pre-move experiences depicted the difficulties of moving homes as a much older person with limited resources, whereas post-move experiences tended to highlight the positive aspects of their new home. Pre-move adversities. A key challenge revealed by participants was finding a temporary home. Finding a home and the subsequent tasks associated with the move itself was challenging for most people, yet what was notable in this particular case was that the bodies responsible for the move , had exhibited an overall lack of compassion with limited notice and support, as revealed here: "I was angry with the moving process from the previous housing. They [building management and developer] informed us that we needed to move as soon as possible, but they didn't help us to look for a new place to live." For older adults with limited financial resources, being forced from their homes created heightened stress and anxiety, especially for those with pre-existing conditions. One older Chinese woman had requested us to take a photo of her knees as she explained her transitional health struggles with rheumatoid arthritis, and the impact of the move on this health condition. This story was one that was shared by several participants who revealed how forced relocation as a transitional process, had resulted in mental and physical distress and even death. Participants highlighted how numerous older adults "became sick and ill…because of the stress of having to move", and further emphasised that, "there was a lot of people who died through this transaction that they [building management] put forward" . Meanwhile, the 'worries' linked to forced relocation extended past securing a home for the duration between moves. As a result of the nature of the redevelopment process, previous grandfathered tenants were required to find 'temporary homes' for 3 years while the new building was being developed. Image 2, taken by an older East African man, was used to express the transient nature of his living situation, portrayed by a partially made bed with old sheets that could be discarded once he moved back into the redeveloped building. Most participants were very reluctant to move from the previous residence, primarily because of the affordability of the rent, and the convenient location situated within an age-friendly community. However, due to the initial temporary nature of the forced relocation process, many disclosed how they found themselves being "shuffled around, here, there and everywhere" in addition to "having to sell everything" and moving back to "live with our children" . As the transition period progressed, often a sense of home and community became lost or difficult to establish, as revealed here: "It still takes quite a while to settle down…to get used to things. It takes, oh, gosh, months and it never used to. I mean, the more I moved, the longer it takes me to settle down. To get to call it home again." This particularly related to transient dwellings which impinged on older peoples' ability to adjust and re-establish themselves in a new place and new community. Accordingly, forced relocation had a significant impact on tenants' ability to establish new social networks and relationships. However, the inability to do this effectively resulted in transitional experiences of loneliness and social isolation. One individual felt it was often challenging to "get out into the community" and "that it takes a lot of work to make friends" so they preferred not "to have to do it twice" . For individuals who were unable to secure temporary accommodation with friends or family, many had to move in extremely poor housing conditions. One type of temporary dwelling unknown to the researchers or to housing professionals prior to this study, was the notion of 'family hotels'. Family hotels were described as a popular (temporary or permanent However, when asked whether this individual was looking forward to moving back into a newly built apartment suite, his response identifies home as much more than just a physical space and shelter: "We come from various parts of China and share and prepare cuisines from the different areas. We really enjoy getting together. This is one of my concerns about moving back. Our relationships here are so good. The new building might be better, but the social relationships will not be as good. If anyone here gets sick here, at least one of others will offer medicine immediately." It was clearly voiced by many older people that home is as much about building a community and a social support network, as it is about the physical fabric of place. Establishing new relationships and finding familiarity in the surrounding neighbourhood requires motivation, time, and effort throughout the transition, which can be a rewarding yet simultaneously stressful process. Living spaces without relationality were considered to be transient dwellings rather than homes. Post-move prospects. At the outset, there were concerns regarding the 'social mix' of tenants in the new building that relate to 'culture clash'. Besides language barriers, there was also general concern over differences between cultural norms, behaviours and expectations; nevertheless, several older adults of Chinese descent stressed that they preferred, "not to isolate myself from the English speaking or European people" . Similarly, many English-speaking participants expressed the desire to actively engage with and/or befriend non-English speaking persons because they wanted to socially connect. To support integration across individuals, social, and cultural differences, the new build held several cultural events and celebrations in the multi-purpose room. This was one of the shared amenity spaces used primarily to promote different cultural mixing and shared cuisines . Moving into a brand-new apartment, as many emphasised was 'a privilege' as the high cost of apartment living in Many also expressed how the perception of living in a brand-new place allowed low-income older people to visualise themselves as different people; particularly in respect to elevating their social status in Metro Vancouver. Several individuals reminisced about their previous living arrangements where they experienced "rodent infestations, bedbugs and bad neighbours" . It was clear that having limited financial means prevented them from living in a comfortable and safe environment. The new living opportunity had enabled many participants to feel for the first time in a long while that they "weren't poor"; 'recreating home' and 'recreating self' were an important part of the transition process as highlighted in Image 6 by a proud participant of her new home. Restricted financial freedoms often meant that for older people with minimum income, their personal place preferences were limited or non-existent. Conversely, in this instance, the realization of choice was not bound by their ability to purchase or pay, because potential tenants were able to choose their own suite. Thus, it was less about what they could afford but more about what was available at the time. One individual expressed, quite jovially, how she "liked it [her new apartment] because it's bigger…and it's very nice" and that "there's nothing wrong with it" , because often, persons in her circumstance were required to compromise and accept the defects that came along with the place. --- DISCUSSION As the number of older adult populations is projected to increase worldwide over the next decades, global leaders have appealed for much needed discussions on how to effectively house and care for older people . Other key considerations for ageing populations have emphasised the development of age-friendly cities and communities . and helping older people to remain in their homes for as long as possible . However, creating optimal housing solutions for diverse older populations is difficult when individual's social circumstances can change across time, and investors prefer high end, for-profit housing . Given individual and group diversity, and organisational as well as socio-structural constraints, ageing-in-place is not possible for all older people. Hence, it is crucial to work towards creating more appropriate homes , that will ultimately enable older people to 'age in the right place' or more appropriately, 'age well in the right place' . According to Carroll and colleagues , creating appropriate living spaces for older adults from diverse backgrounds can be a complex process that requires a comprehensive understanding of their social and cultural experiences, as well as their social positions within societal structures. A deeper understanding of these factors is therefore crucial to ensure that living spaces meet the diverse needs of older adults, and reflect the multifaceted aspects of their lives. As such, past place scholars have emphasized the importance of exploring one's own interpretation of their social and cultural world in order to create suitable homes for older adults . In the current study, accounts of place transitions across the life-course were explored in a group of older, low-income adults, and migrants of diverse cultural backgrounds. We aimed to broaden and enhance current understandings of ageing-in-place and inform future urban development initiatives to consider how past encounters of place can shape health and wellbeing experiences in the present. According to Hareven , a fuller understanding of life transitions requires delving into past events in order to gain context for looking to the future. Hareven argues that "chronological age is a less significant variable than the status within which individuals or groups find themselves at a particular point in time" . Aligned with this notion, our findings confirm that positive ageing-in-place events were experienced inconsistently, often shaped by various socio-cultural factors , which ultimately impacted quality-of-life as people transitioned from place to place across the life-course. The intersectional place analysis revealed that ageing in place cannot be considered as a one-dimensional encounter and extends past the physical aspects of moving place to recreating self, and social and cultural meaning in everyday life. As such, experiences of ageing in place were complex, unique to each person and often shaped by evolving social, cultural, economic, and political contexts. These contexts include norms, values, and expectations of the different local, regional, and national places individuals have resided throughout their lives . Over a life span, people can encounter several inter-connected, migratory events in different places -but not all will carry the same meaning and significance. For example, events linked to specific places that created deeper emotional ties than others, as exemplified in the resulting trauma from the Cultural Revolution reported by several participants, which has significant implications in relation to how key societal changes shape individual transitions. Thus, illuminating place intricacies and the impact of such experiences on wellbeing as people establish permanence and settlement in new places, requires considerations for multiple social, environmental and temporal transitions. In addition to the built features of place, were nuances associated with notions of social and emotional bonding, or rootedness , and factors associated with pre-arrival histories that influenced post-arrival successes and challenges that shaped marginality in place . For instance, migration is commonly perceived as a process by which individuals are relocating to a place with better prospects, yet this is not always the case, as revealed in the intersectional place analysis. Often, individuals experience many difficulties when migrating to and on arriving in a new place, which can have both short and long-term impacts on health and well-being, particularly in later life . Highlighted in our analysis are distinct challenges confronting older migrants, such as social isolation, caregiver exploitation, mobility issues coupled with language difficulties, and cross-cultural adjustments . Therefore, it is important to consider the interrelated complexities of one's identities , positionalities , and the oppressions and opportunities encountered across time and place, when exploring factors that shape marginality in place. The implication here is that environments that support ageing should provide opportunities to enable people to connect and be actively involved in the community in order to feel central to the place, rather than feeling like they are living on the outskirts of society . Our analysis revealed that in order to feel involved in and central to a new environment, there are many factors to consider. However, to date, there are limited theoretical perspectives available that can comprehensively capture the complex ways in which our social world shapes our ability to feel connected and involved in new environments. IPP, an intersectional place perspective which interweaves important features of intersectionality, place and ecological theories, was developed purposefully to address this problem and was thus used to frame the study design and subsequent analysis. The IPP helped to uncover, on a case by case basis, shifts in social identities and positionalities across time and environments, and how these conjoined to shape opportune and oppressive experiences of wellbeing and place. For example, while pre-move interviews were conducted with emphasis on age, income and ethnicity, pre-and post-migration events and place experiences highlighted the need for consideration of temporal locations, which was not possible without further theoretical development. IPP enabled the contextualisation of forced relocation events as it related to both experiences of oppression and opportunity for wellbeing . Through an in-depth, intersectional place analysis of the temporal shifts in one's identities and positionalities across time-points, the IPP highlighted temporal, place-based, and sociopsychological transitions. --- STUDY LIMITATIONS While this study has notable strengths in theoretical development, implications for housing and place design, and understanding the life experiences of highly marginalised people, it also has limitations. For the analysis, we only examined three temporal locations, limiting the explanatory power to elucidate the continuum of social influences of earlier life experiences that impact later experiences of forced relocations. Additionally, due to the diversity of participants, it was not possible to accurately identify the continuities and discontinuities of participants' ages. The final limitation of the study relates to the challenges associated with the use of an IPP. A key tenet of intersectionality posits that social categories or locations that shape individual experiences of oppression and opportunity is interlocking and inseparable. However, despite attempts to cross-analyse coded categories during data analysis, the very act of analytical coding, in itself, influenced the separation and creation of new social categories. To address these limitations, we recommend, first, further research to examine across life stages i.e. early life, mid-life and late-life as opposed to specific temporal locations. Second, we encourage social scientists and place scholars to consider investigating more broadly how upstream structural factors impact the health and wellbeing of individuals that hold specific or multiple social categories. For example, instead of pin-pointing these across different individuals, examining how people who hold different social traits manage and operate within structural constraints. --- CONCLUDING REMARKS In an effort to inform future ageing in place initiatives, it is important to acknowledge that diverse historical contexts and life encounters experienced between the different groups of older people, required reconciliation of the differences in interests and concerns. This is exemplified by feelings of discrimination experienced by Chinese migrants, which had emanated from nativeborn groups' feelings of being social and culturally displaced from their familiar environmental surroundings. To address such challenges, we suggest, at the start of public health and urban planning projects, an exploration of the historical, transitional and contextual experiences that capture important social facets. These facets include identity, positionality, oppression, and opportunities across time and place of urban ageing populations to better understand how past place experiences have shaped not only their perceptions of home and place but also their wellbeing. Crucial factors for consideration highlight transitional place elements that challenge relocation , as well as those that can help ease the process . Responding to these through design can enable older people to not only age well in place but age 'well' in the right place. Finally, as knowledge translation is important for research dissemination and shared learning, we would like to conclude by sharing a video developed for the project showcasing one of the forced relocation stories: https://youtu.be/apkPMvZNaxg. --- DATA ACCESSIBILITY STATEMENT Data associated with this research is available upon request from the authors. Our goal is to promote the openness and accessibility of scientific research while also respecting the privacy and confidentiality of the individuals and organizations involved in our study. To request access to the data, please contact the corresponding author via email. --- FUNDING INFORMATION This project is funded by the Vancouver Foundation [UNR13-0506] and the Social Sciences and Humanities Research Council of Canada [752-2016-0059]. Our funders did not have any role in the study design, collection, analysis, interpretation of the data, or writing of the manuscript. --- COMPETING INTERESTS Judith Sixsmith is a member of the Ageing Through a Transitions Lens special issue editorial team. She was removed from any decision making related to the abstract submission and acceptance as well as the review process to ensure independent review and editing. ---

Background: Forced relocation is not always experienced as a single occurrence or event in time. Currently, there is a limited knowledge on how several substantial relocations across a lifetime impacts the health and wellbeing of older people. Aim: This study explores forced relocation experiences of older, low-income migrant Canadians through inquiries into their past place histories and examines how these have shaped opportunities and oppressions leading up to transitions into affordable housing in Richmond, BC, Canada.Informed by an intersectional place perspective model developed specifically for this research, a multi-method, qualitative community-based approach was undertaken involving in-depth interviews (N = 15), storytelling sessions (N = 10), and photo-tours (N = 8), with 28 participants. Narrative and visual data were co-analysed with participants, using a framework thematic analysis approach. Results: The analysis revealed oppressive structures that influenced the everyday lives of older people, which generated feelings of distress, fear, exclusion, feeling unsettled, and being 'othered'. However, within oppressive structures of enforcement emerged experiences of empowerment engendered through gaining a sense of community, realising social belonging and family, maintaining pride and personal integrity as well as capturing community, social, psychological, physical and health transitions. Discussion: Unique insights acquired from an intersectional place analysis highlight how past experiences of place shape current perceptions of home and provide important implications for supporting and maintaining the health and wellbeing of older people during this type of relocation. The theoretical resource developed for this study, offers researchers, planners and developers an important tool for procuring a more critical perspective when creating homes for marginalised persons.

introduction ageinginplace is a wellknown concept and policy driver in urban planning and environmental gerontology understood as the ability to live in ones own home and community safely independently and comfortably regardless of age income or ability level notions surrounding ageinginplace posit that because older people have reported a preference to remain living in their homes for as long as possible following ageinginplace policies will inevitably create optimal social and health outcomes for older individuals often ageinginplace is assumed to be a positive experience however this is not always the case for all older individuals for example older people who have limited income are living alone and living with multiple comorbidities may find it extremely difficult to maintain their homes and the lifestyles that they have grown accustomed to thus for some people the home can have distinct negative connotations associated with feelings of imprisonment unnecessary obligations loneliness and distress fear and resentment as such place transitions can be a common occurrence in later life according to schlossberg adults continuously undergo transitions a transition can be viewed as an event followed by a process occurring over an undetermined period of time that includes phases of assimilation and continuous assessment and reassessment as people move in through and out of the transition event yet how one responds to the transition depends on the type of transition event ones perception of it and the context in which it impacts an individuals everyday reality in terms of life transitions moving home is deemed to be one of the most stressful events that can occur in a persons life many people would prefer to not move and continue to live in their homes even if circumstances are not ideal though for many older people the decision to remain living at home may not be one that is in their control and as such they are forced to relocate research indicates that a significant proportion of older individuals have experienced forced relocation at some point in their life perceived as hostile environmental transitions that contribute to vulnerability in old age commonly reported forced relocation events in laterlife include natural disasters transitions to or between institutions and across different levels of care typically requiring substantial uprooting a forced relocation event can lead to the loss of social networks and supports and significant challenges during the readjustment period resulting in overwhelming impacts on ones physical and mental health however it is important to note that the notion of forced relocation is not always best described as a singular occurrence or event in time and can encompass several experiences of many types of involuntary place transitions at different time points throughout a persons life for instance experiences of forced migratory relocations can include movement across countries provinces and cities and displacement of homes throughout the lifecourse such events can acutely impact the health and wellbeing of older people who can be more dependent on the immediate environment and sensitive to rapid urban change frequently experiences of forced movement and migration become common episodic transitions for more vulnerable older adults this can result in disruptions to their existing social relationships impacting personal place connectedness to future homes as described by oswald and rowles from a longterm temporal perspective relocation can be understood as a dynamic ecological transition a developmental process in which each change of residence is experientially linked to the move that preceded it and to future moves that are anticipated to follow as a normative component of the individuals life course to better understand older peoples experiences of forced relocation and the impact on their present living circumstances this study explores forced movement and migration occurrences of older western canadian migrants through inquiries into their place histories it examines fang et al international journal of educational and life transitions doi 105334ijelt49 how these histories have shaped opportunities and oppression leading up to a forced transition from precarious into affordable housing this study is timely and important because at present many older adults in metro vancouver are experiencing forced relocation from their homes an event propelled by the decrepitude of older buildings when they become worn down and the drive towards high density modern apartment living the current research offers important insights into a crucial problem area involving the increasingly limited adequate housing in metro vancouver for the diversity of growing older populations from across the world particularly considering migrants from east asia and their sociocultural contexts to do this we provide a unique intersectional place analysis of past and present experiences of place in a group of predominantly ethnicallydiverse low income older people living in the city of richmond a municipality within metro vancouver to effectively capture the sociocultural and historical nuances of forced migratory and relocation transitions a new theoretical model informed by collinss the intersectional place perspective was developed for this research grounded in concepts underpinning the notions of place and intersectionality the goal of ipp is to bring together diverse experiences of place and devise an analytical perspective that recognises the importance of psychosocial and physical places and how they shape and centre marginalisation processes across the lifecourse thus the originality of this study arises in part from the design and development of a theoretical model that bridges existing theoretical ideas in intersectional and gerontological scholarship as well existing planning methods appear to lack consideration for the combined effect of social factors and transition events and processes that ultimately shape experiences of health and wellbeing across different time points in a persons life to address these conceptual methodological and theoretical challenges ipp was designed to enhance explorations into how combined effects of unique sociocultural environmental and physical factors and transition events can influence experiences of opportunity and oppression foundational features of this model are grounded in central tenets of intersectionality which hankivsky and colleagues suggest are that individual lives cannot be reduced to single traits nor can single traits accurately depict understandings of individual experiences person categories or locations are socially constructed fluid flexible and inseparable shaped by social processes structures power relations and influenced by time and place and prioritization of social justice and equity are of utmost importance ipp contends that various types of oppression are located in place are often interlaced with constrained opportunities and are not only interrelated but present interlocking dimensions of differentiation used to dominate and exclude those that diverge from normativity at present there are no analytical models that effectively conjoin these elements for an indepth exploration of marginality in place across time the notion that certain transition events can leave people feeling marginal disconnected and that they do not matter in time and place informed by ipp for this research we address the following research questions 1 how can we help older people who have transitioned through experiences of forced relocation to age well in place 2 how can we enhance our theoretical understandings of and capture sociocultural nuances of forced migratory experiences 3 how are older persons experiences of forced relocation shaped by their combined multiple identit positionalit oppression and opportunit across time and place methods study context this research stems from an affordable housing redevelopment project that was designed and developed to house lowincome older adults who lived in the city of richmond in metro vancouver canada to provide relevant historical context it is important to note that the original building was built in the 1960s at a time where the population consisted of mainly of white european migrants the housing block consisted of 122 units these bungalow styled apartments were rented to lowincome older people for independent living at a reduced cost of approximately one fourth of the average rent in metro vancouver in 2005 members of the housing society whose primary mandate is the provision of lowcost senior housing raised concerns regarding the age and quality of this building subsequently an affordable housing redevelopment project for older adults emerged followed by an extensive relocation process that spanned three years an event which forced tenants to transition from bungalow style apartments into two 16storey purposebuilt highrise condominiums at higher rental costs to tenants importantly over the years with increased migration from east and south asian countries into metro vancouver the population mix of the redevelopment site had changed the residents in the new build constituted a unique blend of older people 70 from southeast asia and 30 of white european decent recognised in recent decades as the southeast asian region of metro vancouver this presented a complex situation consisting of distinct canadian migration experiences of recent migrants shaped by postcolonial nuances of canadian history alongside the difficulties associated with resettlement and conversely feelings of forced displacement by previous white european settlers however the social mix of different cultural groups was only one of many social issues which challenged the notion that the health and social wellbeing of older tenants could be optimised through environmental design alone to provide adequate housing for marginalised persons with unique backgrounds and diverse place experiences necessitated a complex study design that allowed for multiple forms of inquiry together with a deeper intersectional place analysis to understand wholly how present housing circumstances are shaped by multiple social factors and place experiences across time we subsequently acquired funding from the vancouver foundation and the social sciences and humanities research council of canada to document and analyse tenants transitional experiences of forced relocation study design to meaningfully capture a complex trajectory of forced relocation events and processes a rigorous multimethod communitybased participatory research approach was undertaken cbpr is a collaborative research approach that promotes the reciprocal transfer of knowledge and expertise inclusive participation power sharing and equity and cocreation and coownership of data across all partners guided by a cbpr approach specific methods indepth interviews storytelling sessions and phototours were selected each of the methods served a specific purpose prioritised the social and relational aspects of the research process and enabled the emergence of different viewpoints of the problem area figure 1 presents a flow diagram that explains the method selection strategy the richness of the data was enhanced by the level of methodological rigour that constituted the application of the three qualitative methods in combination the methods worked as a creative collaborative system to engage and empower a diversity of older people to share their important and unique stories the first method employed was the indepth interview which consisted of 45minute oneonone audiorecorded interviews with the participants these were conducted in the participants first language and at their convenience any time during the day or in the evening either in person or by telephone the flexible openended interview process helped establish rapport between researcher and participant and allowed for building trust through mutual sharing of lived experiences as well as the development of important relationships necessary for the research indepth interviews identified important background context including participants past housing and relocation experiences in metro vancouver and their desires and expectations for their new homes postmove subsequent to indepth interviews the interview participants were given the opportunity to take part in participantled phototours andor storytelling sessions phototours are a way of generating data through a group tour of the participants immediate living environment where they take photographs of the aspects of home and the community that they find meaningful the 8 phototours in the current study consisted of 2hour sessions that were led by the participants and conducted in the participants first language starting at the participants place of residence and proceeding in and around their neighbourhoods for each tour participants were provided with an ipad and asked to guide the researcher on a tour of their home and neighbourhood whilst capturing photographs of meaningful places objects landmarks and aspects of their everyday life that were of importance to them in relation to their relocation although place histories were not the main topic of focus during the tour past experiences of place especially as it pertained to how the area had evolved or compared to past living environments were a popular topic for many participants finally 2hour audiorecorded storytelling sessions conducted in the participants first language were held at the participants preferred location at an agreed upon time between the participant and the researcher storytelling is a method whereby participants share personal stories about a topic or phenomenon according to keats the storytelling method is unstructured and often led by the participant the key characteristics of storytelling include that they are unstructured led by the participant to reveal or inspire understandings about a particular topic or phenomenon in relation to self whilst simultaneously providing important indepth information to the researcher and often audiorecorded or videorecorded it is a method that uses a reflexive approach facilitates inquiry into a persons life story without having to use language that is difficult for a participant to comprehend guided by keats the storytelling sessions revolved around sharing stories of relocation from place to place and homeland to new country several participants requested an informal gathering over food as they engaged in rich storytelling dialogue with the researcher storytelling was the final method employed because this process required deep sharing and reflection of personal and often difficult past experiences of forced relocation this intimate form of knowledge exchange and cocreation of meanings would not have been possible without first an establishment of trust and second the forming of a bond between the researcher and the participant via the first two methods in terms of the study instruments these were informed by ipp ensuring that the data generation tools would capture complex intersectional place experiences was crucial for the data analysis and necessary for addressing the research questions hence both the interview guide and especially the storytelling guide were created under the principal assumptions of intersectionality emphasising the importance of treating ones social identities and the positions that they hold in society as conjoined influencers of oppression and opportunity table 1 provides examples of the various formulations specifically all participants were asked to describe how they perceived themselves during three temporal locations as such any jargon and inaccessible terminology as well as structured questions were avoided last it is important to note that the narratives are further illuminated by the digital photographs taken by participants during phototours of their homes and neighbourhoods study recruitment and participant details to ensure the voices of tenants in the design and planning of the redevelopment we formed a partnership with the city of richmond the older adults housing society the developer local where did you grow up in china who was in political power at the time and how did that impact your family life what did your parents do for a living what would you class yourselfyour family as growing up would you say you were poor middleclass wealthy • how did this impact your life growing up • how would it be different if you were a boygirl • what types of things do you think contributed to these challenges whether it is things about yourself or were they things that were out of your hands things that you could not control how would you describe canada in relation to the idea of home tell me about your family circumstances when you first arrived in canada compared to now now try and imagine all the events that have brought you to where you are living right now what are some thoughts that come to mind tell me about your current home situation what is about your current housing situation that promotes a strong sense of feeling youre at home or that this is your home tell me what a typical day looks like for you routines activities community engagement and interaction with neighbours tell me what is it about living here that you like the most tell me what it is about living here that you dislike the most table 1 provides examples of questions used to guide the interviews and storytelling sessions note references to china were amended when interviewing participants from different places and were described more broadly municipal government several local service organizations and older people relationships with local older adults service providers the property manager municipal government workers and senior members of the older adults housing society that emerged at the initial proposal development phase and were thus maintained throughout the project enabled us to reach a group of predominantly older chinese migrants specific to the housing relocation project in total 28 older adults over 60 years of age were recruited • gender n 11 men n 17 women • ethnicity n 1 east african n 19 chinese n 8 european canadian • tenancy status n 23 grandfathered tenants n 5 new tenants approximately two thirds of the participants identified as being chinese and reported having arrived from various cities provinces and autonomous provincial regions or territories across the peoples republic of china the remainder identified as european canadian from two provinces and one participant identified as east african having been born and raised in tanzania the sample reflects both new tenants and existing tenants because this is an independent living residence rather than a nursing or care home one of the key stipulations for tenancy is that the older person must be ambulatory thus all participants were ablebodied and cognitively sound older people tenants were identified through community stakeholders and organisational leaders and invited to participate in the research to ensure that chinese participants whose first language was not english fully understood the research process and their involvement the interviews were conducted in the participants first language and the study information sheet and consent forms were translated into simplified chinese and explained in mandarin or cantonese finally to capture the full essence of the data provided in mandarin or cantonese all storytelling and interview data were digitally recorded translated and backtranslated as necessary by a researcher that was fluent in both chinese dialects and in english data analysis using the ipp model an intersectional place analysis was conducted to help reveal tenants selfreported identities and positionalities and intersectional place experiences of oppression and opportunity ipp is predicated on the notion that people construct meanings of place through the multiple identities that they hold the social positionalities which they occupy the multifarious oppressions they face as well as the opportunities that are presented as they negotiate their everyday livesall of which coalesce to create a system that drives various configurations of discrimination and privilege ipp a new theoretical model developed specifically for this study emerged from the multidimensional intersectionality framework developed by sixsmith and fang to challenge extant overpositivised notions of ageinginplace and to explore how agency is manifested by older adults in vulnerable social positions when negotiating for permanent housing solutions the mif was derived based on collinss notion of intersectionality as an interweaving of multiple systems of oppression specifically it was based on how such systems are organised through interrelated domains of power this framework enabled the identification of older adults positions in society the identities they assumed or that were imposed upon them and the oppressions they experienced within the dominant social structural systems as well as organisational and policy contexts however the mif lacked the necessary analytical features such as temporality and place to sufficiently capture experiences of opportunities and oppression across different sociosocietal and sociocultural environments structures and time more resilient as they learn with varying degrees of success to manage align or fit their changing physical and cognitive abilities within the confines of the physical social cultural and structural dimensions of their new home subsequently the mif was reshaped to the ipp which enabled a deeper analytical process that allowed for temporality when examining intersectional experiences of oppression and opportunity across different places ipp encompassed analytical features that were wellsuited for responding to the shortcomings of ageinginplace through an analysis of the interlocking social and cultural drivers of inequity such as age gender ethnicity socioeconomic status immigration status partner status and generation status across place and time described in figure 2 ipp can be understood using a mathematical formulation to better frame the analysis to conceptualise and facilitate the analysis each participant or case is denoted as k with the numbertype of places described with subscript of n under the assumption that people reside in several places across the lifecourse specific to each place each individual can have claimed several identities and held multiple social positions that shape experiences of oppression and opportunity identity positionality and oppression and opportunity are denoted as accumulation of meaning derived from experiences captured at the different axes of place respectively identity positionality and oppression this formulation is based on the multidimensional intersectionality framework developed by sixsmith and fang and can be found in sixsmith and colleagues storytelling and interview data were analysed in hyperresearch 373 via a structured framework method where a coding framework was developed systematically by three researchers through initial coding of three transcripts subsequent transcripts were analysed using the framework by case and by code an initial coding structure was developed using lowlevel descriptive coding coding units of text were labelled with words or phrases that closely corresponded to participants accounts to refine the coding structure an iterative process of reading and rereading the text was conducted during this process codes were subject to interpretation and notes were made to establish the relationships between codes based on their similar meanings codes with similar meanings were combined to form larger patterns and structured as initial themes to ensure the validity and reliability of the coding structure the initial themes were further interpreted and defined through team discussions any disagreements or conflicts in the interpretation of codes were resolved through discussion as a result a comprehensive coding structure and framework were developed and agreed upon by the three researchers involved in the study informed by ipp and a reading of all transcripts to establish familiarity a code tree was used to organise participants identities positionalities and experiences of oppression and opportunity according to the three temporal locations and place temporal locations indicate a specific timepoint where participants had encountered a significant place transition in the current project the temporal locations reflect premigration postmigration and postrelocation experiences within each temporal location a range of selfreported identities positions held in society and experiences of oppression and opportunity were identified and reported within subcategories for data that fell outside of the initial coding structure new codes were created and integrated into the framework an example of a coding framework can be found in another recent publication each transcript was imported into the software as an individual case and distinguished by a unique identifier after the initial coding cases were cross analysed via constant comparison enabling the generation of themes last informed by pinks visual data analysis phototour visual data were analysed using older peoples dialogue exchange during participant led tours of their premove homes and surrounding neighbourhoods digitally recorded discussions with the older people were conducted after the tour to interpret the photos they had taken and the subsequent transcriptions were thematically analysed alongside interview transcripts where quotes of interest were matched with corresponding visual depictions relationships between the visual imagery and storytelling and interview data enabled data and interpretational triangulation to occur by illuminating different facets of the everyday sociocultural experiences of older people by viewing the information in different data mediums ethics ethical clearance for this study was obtained through two institutions office of research ethics at simon fraser university vancouver canada and heriotwatt university ethics committee edinburgh scotland the current study was conducted in accordance with the british psychological societys ethical guidelines informed consent was obtained from all participants and participants were asked to only share information they were comfortable with because this study focused on older people extra care was taken to ensure that specific issues in relation to safety mobility and cognition were addressed for instance it was made clear if at any point the participant felt uncomfortable or unsafe there was the option to withdraw from the study and this decision would not impact their access to housing supports or services to ameliorate any mobility issues participants selected the time and where data generation procedures would take place findings findings are reported in the form of migration stories illustrating how older canadian migrants modify their place of residence because of a series of constraints or decisions which carry distinct meaning and significance and stories of forced relocation themes and visual imagery are presented according to each participants selfreported identities positionalities and experiences of oppression and opportunity within three temporal locations premigration experiences to metro vancouver canada postmigration experiences to metro vancouver canada and forced transitions between affordable housing premigration experiences findings in this section were situated within premigration contexts before arriving in metro vancouver canada migration for the purposes of this study is defined broadly as a process where individuals born outside of metro vancouver have travelled to the city to settle and start new lives because most participants reported having migrated from different countries their stories largely depicted processes that highlight relocation complexities involving adjustments across cultures and nationalities the reported social identities appeared strongly tied to the positions participants held in society for example age identifiers were coupled with professional social markers andor family roles or partner status situated within the temporal context of premigration most participants selfidentified as being young working professionals or students highlighting their professional identities partner identities or family identities all participants from china identified themselves explicitly as chinese cultural norms beliefs and practices were reported by participants as being directly linked to china as their place and their motherland yet the majority reported canada as being their home although no participants who were born outside of canada identified themselves as canadian despite having lived in canada for at minimum 5 years premigration social positions varied across a continuum of being poor working class to middleincome or middle class and wealthy upperclass with a similar number of individuals reported as having come from a wealthy family to those of middleclass or middleincome backgrounds family status did not appear to impact whether individuals from china received an education all participants from china identified themselves as educated or having received education whether they had reported as having grown up in poor working class families or not conversely all participants identifying as european canadian reported to only have received primary or middle school education having left home at a young age and either went straight into the workforce or were married all participants identified as employed or having employment once they had left school or home as young people participants from outside of canada had all held professional positions often viewed as middle class occupations either in managerial positions higher positions within academia or selfemployed business owners whereas european canadian participants revealed having held manual labour employment positions experiences of oppression although shaped in part by the positions held in society were more heavily influenced by macro sociopolitical and cultural contexts of place for most european canadian participants who were mostly women they had expressed experiencing gender oppression as single young women with nomadic lifestyles the women reported struggling with gendered roles norms and expectation such as pressures to marry at a young age and adopting the housewife role as well as dissuasion away from taking the career path particularly work roles that were deemed only suitable for men one participant described a time when women werent allowed on the racetracks until 10am… so she would dress up like a man and put on a hat and pretend as a regular guy another spoke of fears of sexual assault as it was uncommon for young women at the time to live on their own she detailed one experience of a man who watched her through her bedroom window and propositioned her when youre alone let me know pull the blind down and ill come up to your room for older chinese participants regardless of social position premigration experiences of oppression were significantly shaped by the cultural revolution these include experiences of dangerous work cultures and environments poor overcrowded living conditions forced relocations from urban to rural parts of china severe income inequities and limited choice and freedom that often impinged on individual human rights as illustrated by older chinese participants persecutory policies and practices instilled during the cultural revolution created an atmosphere of fear and helplessness often imposed through threats of family separation during the cultural revolution i was assigned to work in rural china if i accepted i would have had to migrate my older parents and three children there i couldnt let my children live in the countryside if i refused i would have been charged with going against the cultural revolution i chose the latter option even if it meant that i had to go to prison but luckily i was fine other stories of oppression were similarly linked to political subjugation yet were unique and within different contexts since these stemmed from the effects of european imperialism experiences of turmoil and loss of cultural and or sovereign identity were consistently reported by individuals who originated from countries once ruled by portugal such as macao or the united kingdom such as hong kong and tanganyika for years such countries struggled with attempts to regain independence or resist returning to oppressive regimes linked to communism hardships were experienced most severely as countries transitioned into independence or toward reunification participants described periods of intense political unrest that often resulted in forced displacement as demonstrated by one example here the political situation wasnt good so we were afraid we saw as many places acquired their independence people getting hurt with the riots and fighting and you know the power struggle so we were just afraid and as the rules and regulations changed it worked against us in a sense…the way we were living could not stay the same way as before in a struggle to regain normalcy and stability after forced relocations the consensus was that individuals subsequently lived under impoverished conditions and worked tirelessly making sacrifices for the greater good of the family nevertheless several participants seized opportunities by overcoming their challenged circumstances which were impacted by their positionalities and identities as well as the place contexts at significant historical moments as described in the next passage despite reports of the cultural revolution being a tumultuous period with much human suffering and poverty living through such an event instilled a sense of resilience in some participants i came from a poor family which has helped me a lot i understood the harshness of life and how hard life can become even when i was a child experiencing poverty can help a person be stronger european canadian participants also reported similar stories of resilience through the seizure of opportunistic moments during periods of oppression as described by two european canadian women who escaped a life of patriarchal suppression by undertaking risky nomadic lifestyles the key message here is that despite being challenged by uncertainty and instability participants often utilised such difficulties as motivation to express their agency as they transitioned through challenging life experiences postmigration experiences identities and positionalities evolve across time and place premigration identities emphasised childhood and youth conjoined with national and professional identities as well as partner status whereas postmigration identities emphasised immigration and citizenship as well as personal attributes roles and responsibilities that exemplified transitions into maturity as one progresses through the lifecourse the majority participants at this temporal location identified themselves as older people highlighting character traits such as hospitable resourceful humble quiet openminded assertive alongside their roles and responsibilities associated with being an older person such as grandparent carer and survivor identities that were reported in association with immigration and citizenship were expressed only by ethnic minority participants immigrant status was described in reference to a legal category that was assumed rather than an embodied trait or a selfselected identifier of personal expression citizenship was implied as a form of prestige that was earned through the ability to acculturate and become more western this was emphasised by one older chinese woman as an unattainable status for chinese migrants because we cannot become canadian because we are not white shifts in social positions were revealed by participants as it pertained to the processes that surrounded ageing and changes in family structure both of which can determine ones ability to maintain employment and an adequate household income in general most participants lived alone as their partners have passed on and because their children now resided with their own families older women who still had their partners with them had assumed the role of caregiver all older men who lived alone were divorced except for one older african man who revealed that his wife had passed away years ago from terminal illness with the exception of one older chinese man who worked part time bagging groceries at a chinese market none of the participants held paid employment positions although many were engaged in voluntary work several older women participants had reported either living with a longterm health condition or were survivors of a terminal illness meanwhile all participants both men and women had a social network of friends although a few older women indicated that they did not enjoy socializing with others and preferred their own company because developing new relationships was too physically and mentally overwhelming in old age all participants also referred to themselves as lowincome or poor older adults although existentially some indicated they were wealthy either through spiritual fulfilment or having overcome past challenges one unique distinction between persons born in canada and those that were from outside of canada were experiences of transitioning downward down the social status scale as expressed here the living environment here is not as good as when we lived in china our home in china had four rooms a living room and a dining room we had everything including a study room and a piano here we rent a small onebedroom suite we are unable to afford a house here with our combined work income we had nothing after paying postsecondary education for our two kids postmigration experiences of oppression were consistent with reports of having acquired lowered social positioning a frequently reported occurrence which many argued as stemming from the sociocultural changes associated with canada as a postcolonial nation within the canadian context postcolonialism describes the remnant effects of the colonization of aboriginal land primarily through british imperialism this event has over time drastically influenced legal cultural and political practices and beliefs creating social and health inequities for both aboriginal peoples and nonwhite settlers within the current context older adults of ethnic and cultural subgroups reported experiencing complex migration challenges that were often discriminatory in nature for example some participants felt saddled with disadvantages through experiences of otherness living in canada despite a sense of legitimacy through societal contributions even though they were polite to us we knew that they didnt like us for changes of my social position i am fine with it because this was the fact of reality however we educated our children here our daughter works here and pays tax to the government and thus we are eligible for public services and subsidies we are not refugees we have contributed to this country meanwhile rapid changes in the canadian urban and cultural landscape as a result of modifications to immigration policies to entice foreign investors were reported as contributing to feelings of oppression by some participants many felt that chinese immigrants were perceived as invaders of our space people that occupy without having contributed andor assimilated socially politically and economically for example richmond canada before the late 1970s early 80s was predominantly farmland and inhabited by mostly european migrants more recently with an influx of foreign chinese investors richmond is infamously known as the chinese region of metro vancouver with unique culturally influenced building designs and chinese signage several european canadian participants expressed feeling forcefully displaced from a place where they once felt a sense of pride ownership and familiarity to a place that now feels foreign thats why i loved it here in richmond because at the beginning i loved this country when we first came here it was farmland all around and i loved it and then they started building on it i remember telling my friend oh theyre ruining my place i liked it here…theyre putting all the buildings on this beautiful land despite reports of historicallyinfluenced complex challenges all participants described the opportunities they have gained and the benefits they have received simply as a result of living in canada a sense of empowerment emerged as participants expressed their achievements the majority of chinese participants proclaimed that canada is my second motherland emphasising the substantial improvement in their overall health and wellbeing since moving to canada as described here my biggest success is my healthy body canada has given me health the medical situation here is really good medication for older adults is mostly free canada has good medical system and a good natural environment clean cities have less disease so i seldom become ill because of this even though i am over seventy years old i look like im in my 60s it was strongly believed that the opportunities afforded to older chinese migrants were depicted as the result of canadas deeply embedded altruistic values beliefs and practices one man described the country as a truly humanistic society despite having experienced social and structural challenges living in canada according to several participants canadas redeeming qualities are its establishment of egalitarian principles alongside preservation of its natural resources in essence the opportunities participants acquired through their transitional relocation to canada were described as having outweighed their struggles and difficulties forced transitions between affordable housing previous sections illustrate place history accounts focused on oppressions and opportunities of forced location as it pertained to movement across canada and across nations the following narrative shaped by prior place migration experiences demonstrates a microcosm of the broader relocations and reveals forced transitions between affordable housing contexts the next sections are depicted according to two transitional and temporal sublocations premove adversities and postmove prospects despite unique social differences between participants all older people in this study had one commonality that concerned their shared experience of forced relocation into older adults affordable housing accordingly identities and social positions in the current temporal location had not changed considerably however participants discussed their experiences of oppression and opportunity more openly as older adults with limited income in particular place identity was articulated in relation to meanings of home and how such understandings were shaped by migration processes in conjunction with becoming even older by and large premove experiences depicted the difficulties of moving homes as a much older person with limited resources whereas postmove experiences tended to highlight the positive aspects of their new home premove adversities a key challenge revealed by participants was finding a temporary home finding a home and the subsequent tasks associated with the move itself was challenging for most people yet what was notable in this particular case was that the bodies responsible for the move had exhibited an overall lack of compassion with limited notice and support as revealed here i was angry with the moving process from the previous housing they building management and developer informed us that we needed to move as soon as possible but they didnt help us to look for a new place to live for older adults with limited financial resources being forced from their homes created heightened stress and anxiety especially for those with preexisting conditions one older chinese woman had requested us to take a photo of her knees as she explained her transitional health struggles with rheumatoid arthritis and the impact of the move on this health condition this story was one that was shared by several participants who revealed how forced relocation as a transitional process had resulted in mental and physical distress and even death participants highlighted how numerous older adults became sick and ill…because of the stress of having to move and further emphasised that there was a lot of people who died through this transaction that they building management put forward meanwhile the worries linked to forced relocation extended past securing a home for the duration between moves as a result of the nature of the redevelopment process previous grandfathered tenants were required to find temporary homes for 3 years while the new building was being developed image 2 taken by an older east african man was used to express the transient nature of his living situation portrayed by a partially made bed with old sheets that could be discarded once he moved back into the redeveloped building most participants were very reluctant to move from the previous residence primarily because of the affordability of the rent and the convenient location situated within an agefriendly community however due to the initial temporary nature of the forced relocation process many disclosed how they found themselves being shuffled around here there and everywhere in addition to having to sell everything and moving back to live with our children as the transition period progressed often a sense of home and community became lost or difficult to establish as revealed here it still takes quite a while to settle down…to get used to things it takes oh gosh months and it never used to i mean the more i moved the longer it takes me to settle down to get to call it home again this particularly related to transient dwellings which impinged on older peoples ability to adjust and reestablish themselves in a new place and new community accordingly forced relocation had a significant impact on tenants ability to establish new social networks and relationships however the inability to do this effectively resulted in transitional experiences of loneliness and social isolation one individual felt it was often challenging to get out into the community and that it takes a lot of work to make friends so they preferred not to have to do it twice for individuals who were unable to secure temporary accommodation with friends or family many had to move in extremely poor housing conditions one type of temporary dwelling unknown to the researchers or to housing professionals prior to this study was the notion of family hotels family hotels were described as a popular temporary or permanent however when asked whether this individual was looking forward to moving back into a newly built apartment suite his response identifies home as much more than just a physical space and shelter we come from various parts of china and share and prepare cuisines from the different areas we really enjoy getting together this is one of my concerns about moving back our relationships here are so good the new building might be better but the social relationships will not be as good if anyone here gets sick here at least one of others will offer medicine immediately it was clearly voiced by many older people that home is as much about building a community and a social support network as it is about the physical fabric of place establishing new relationships and finding familiarity in the surrounding neighbourhood requires motivation time and effort throughout the transition which can be a rewarding yet simultaneously stressful process living spaces without relationality were considered to be transient dwellings rather than homes postmove prospects at the outset there were concerns regarding the social mix of tenants in the new building that relate to culture clash besides language barriers there was also general concern over differences between cultural norms behaviours and expectations nevertheless several older adults of chinese descent stressed that they preferred not to isolate myself from the english speaking or european people similarly many englishspeaking participants expressed the desire to actively engage with andor befriend nonenglish speaking persons because they wanted to socially connect to support integration across individuals social and cultural differences the new build held several cultural events and celebrations in the multipurpose room this was one of the shared amenity spaces used primarily to promote different cultural mixing and shared cuisines moving into a brandnew apartment as many emphasised was a privilege as the high cost of apartment living in many also expressed how the perception of living in a brandnew place allowed lowincome older people to visualise themselves as different people particularly in respect to elevating their social status in metro vancouver several individuals reminisced about their previous living arrangements where they experienced rodent infestations bedbugs and bad neighbours it was clear that having limited financial means prevented them from living in a comfortable and safe environment the new living opportunity had enabled many participants to feel for the first time in a long while that they werent poor recreating home and recreating self were an important part of the transition process as highlighted in image 6 by a proud participant of her new home restricted financial freedoms often meant that for older people with minimum income their personal place preferences were limited or nonexistent conversely in this instance the realization of choice was not bound by their ability to purchase or pay because potential tenants were able to choose their own suite thus it was less about what they could afford but more about what was available at the time one individual expressed quite jovially how she liked it her new apartment because its bigger…and its very nice and that theres nothing wrong with it because often persons in her circumstance were required to compromise and accept the defects that came along with the place discussion as the number of older adult populations is projected to increase worldwide over the next decades global leaders have appealed for much needed discussions on how to effectively house and care for older people other key considerations for ageing populations have emphasised the development of agefriendly cities and communities and helping older people to remain in their homes for as long as possible however creating optimal housing solutions for diverse older populations is difficult when individuals social circumstances can change across time and investors prefer high end forprofit housing given individual and group diversity and organisational as well as sociostructural constraints ageinginplace is not possible for all older people hence it is crucial to work towards creating more appropriate homes that will ultimately enable older people to age in the right place or more appropriately age well in the right place according to carroll and colleagues creating appropriate living spaces for older adults from diverse backgrounds can be a complex process that requires a comprehensive understanding of their social and cultural experiences as well as their social positions within societal structures a deeper understanding of these factors is therefore crucial to ensure that living spaces meet the diverse needs of older adults and reflect the multifaceted aspects of their lives as such past place scholars have emphasized the importance of exploring ones own interpretation of their social and cultural world in order to create suitable homes for older adults in the current study accounts of place transitions across the lifecourse were explored in a group of older lowincome adults and migrants of diverse cultural backgrounds we aimed to broaden and enhance current understandings of ageinginplace and inform future urban development initiatives to consider how past encounters of place can shape health and wellbeing experiences in the present according to hareven a fuller understanding of life transitions requires delving into past events in order to gain context for looking to the future hareven argues that chronological age is a less significant variable than the status within which individuals or groups find themselves at a particular point in time aligned with this notion our findings confirm that positive ageinginplace events were experienced inconsistently often shaped by various sociocultural factors which ultimately impacted qualityoflife as people transitioned from place to place across the lifecourse the intersectional place analysis revealed that ageing in place cannot be considered as a onedimensional encounter and extends past the physical aspects of moving place to recreating self and social and cultural meaning in everyday life as such experiences of ageing in place were complex unique to each person and often shaped by evolving social cultural economic and political contexts these contexts include norms values and expectations of the different local regional and national places individuals have resided throughout their lives over a life span people can encounter several interconnected migratory events in different places but not all will carry the same meaning and significance for example events linked to specific places that created deeper emotional ties than others as exemplified in the resulting trauma from the cultural revolution reported by several participants which has significant implications in relation to how key societal changes shape individual transitions thus illuminating place intricacies and the impact of such experiences on wellbeing as people establish permanence and settlement in new places requires considerations for multiple social environmental and temporal transitions in addition to the built features of place were nuances associated with notions of social and emotional bonding or rootedness and factors associated with prearrival histories that influenced postarrival successes and challenges that shaped marginality in place for instance migration is commonly perceived as a process by which individuals are relocating to a place with better prospects yet this is not always the case as revealed in the intersectional place analysis often individuals experience many difficulties when migrating to and on arriving in a new place which can have both short and longterm impacts on health and wellbeing particularly in later life highlighted in our analysis are distinct challenges confronting older migrants such as social isolation caregiver exploitation mobility issues coupled with language difficulties and crosscultural adjustments therefore it is important to consider the interrelated complexities of ones identities positionalities and the oppressions and opportunities encountered across time and place when exploring factors that shape marginality in place the implication here is that environments that support ageing should provide opportunities to enable people to connect and be actively involved in the community in order to feel central to the place rather than feeling like they are living on the outskirts of society our analysis revealed that in order to feel involved in and central to a new environment there are many factors to consider however to date there are limited theoretical perspectives available that can comprehensively capture the complex ways in which our social world shapes our ability to feel connected and involved in new environments ipp an intersectional place perspective which interweaves important features of intersectionality place and ecological theories was developed purposefully to address this problem and was thus used to frame the study design and subsequent analysis the ipp helped to uncover on a case by case basis shifts in social identities and positionalities across time and environments and how these conjoined to shape opportune and oppressive experiences of wellbeing and place for example while premove interviews were conducted with emphasis on age income and ethnicity preand postmigration events and place experiences highlighted the need for consideration of temporal locations which was not possible without further theoretical development ipp enabled the contextualisation of forced relocation events as it related to both experiences of oppression and opportunity for wellbeing through an indepth intersectional place analysis of the temporal shifts in ones identities and positionalities across timepoints the ipp highlighted temporal placebased and sociopsychological transitions study limitations while this study has notable strengths in theoretical development implications for housing and place design and understanding the life experiences of highly marginalised people it also has limitations for the analysis we only examined three temporal locations limiting the explanatory power to elucidate the continuum of social influences of earlier life experiences that impact later experiences of forced relocations additionally due to the diversity of participants it was not possible to accurately identify the continuities and discontinuities of participants ages the final limitation of the study relates to the challenges associated with the use of an ipp a key tenet of intersectionality posits that social categories or locations that shape individual experiences of oppression and opportunity is interlocking and inseparable however despite attempts to crossanalyse coded categories during data analysis the very act of analytical coding in itself influenced the separation and creation of new social categories to address these limitations we recommend first further research to examine across life stages ie early life midlife and latelife as opposed to specific temporal locations second we encourage social scientists and place scholars to consider investigating more broadly how upstream structural factors impact the health and wellbeing of individuals that hold specific or multiple social categories for example instead of pinpointing these across different individuals examining how people who hold different social traits manage and operate within structural constraints concluding remarks in an effort to inform future ageing in place initiatives it is important to acknowledge that diverse historical contexts and life encounters experienced between the different groups of older people required reconciliation of the differences in interests and concerns this is exemplified by feelings of discrimination experienced by chinese migrants which had emanated from nativeborn groups feelings of being social and culturally displaced from their familiar environmental surroundings to address such challenges we suggest at the start of public health and urban planning projects an exploration of the historical transitional and contextual experiences that capture important social facets these facets include identity positionality oppression and opportunities across time and place of urban ageing populations to better understand how past place experiences have shaped not only their perceptions of home and place but also their wellbeing crucial factors for consideration highlight transitional place elements that challenge relocation as well as those that can help ease the process responding to these through design can enable older people to not only age well in place but age well in the right place finally as knowledge translation is important for research dissemination and shared learning we would like to conclude by sharing a video developed for the project showcasing one of the forced relocation stories data accessibility statement data associated with this research is available upon request from the authors our goal is to promote the openness and accessibility of scientific research while also respecting the privacy and confidentiality of the individuals and organizations involved in our study to request access to the data please contact the corresponding author via email funding information this project is funded by the vancouver foundation unr130506 and the social sciences and humanities research council of canada 75220160059 our funders did not have any role in the study design collection analysis interpretation of the data or writing of the manuscript competing interests judith sixsmith is a member of the ageing through a transitions lens special issue editorial team she was removed from any decision making related to the abstract submission and acceptance as well as the review process to ensure independent review and editing

background forced relocation is not always experienced as a single occurrence or event in time currently there is a limited knowledge on how several substantial relocations across a lifetime impacts the health and wellbeing of older people aim this study explores forced relocation experiences of older lowincome migrant canadians through inquiries into their past place histories and examines how these have shaped opportunities and oppressions leading up to transitions into affordable housing in richmond bc canadainformed by an intersectional place perspective model developed specifically for this research a multimethod qualitative communitybased approach was undertaken involving indepth interviews n 15 storytelling sessions n 10 and phototours n 8 with 28 participants narrative and visual data were coanalysed with participants using a framework thematic analysis approach results the analysis revealed oppressive structures that influenced the everyday lives of older people which generated feelings of distress fear exclusion feeling unsettled and being othered however within oppressive structures of enforcement emerged experiences of empowerment engendered through gaining a sense of community realising social belonging and family maintaining pride and personal integrity as well as capturing community social psychological physical and health transitions discussion unique insights acquired from an intersectional place analysis highlight how past experiences of place shape current perceptions of home and provide important implications for supporting and maintaining the health and wellbeing of older people during this type of relocation the theoretical resource developed for this study offers researchers planners and developers an important tool for procuring a more critical perspective when creating homes for marginalised persons

Introduction The engagement of individuals in institutional entrepreneurship has become a central concern in institutional research . Research in this area has yielded a substantial body of knowledge , but we still know little about why individuals get involved in these efforts. This question is central. Engaging in institutional entrepreneurship is a decision individuals are unlikely to take lightly, considering that, because of the difficulties involved, these efforts are expected to be both resource-intensive and risky . Most research exploring institutional entrepreneurship has adopted a macro perspective and focused on the institutional conditions that frame engagement . This research has shown that individuals are more likely to get involved in institutional entrepreneurship when facing events with hard-to-disregard game-changing outcomes, such as technological disruptions , regulatory and policy changes , or a health crisis . This research has also suggested that the likelihood of individual engagement is framed by the institutional logics that define the boundaries of fields . Institutional logics are broader cultural beliefs and rules that structure the cognition of individuals and guide their decision-making in a field . Field boundaries are defined not by a single logic but a plurality of logics, and tensions and conflicts among them -variously precipitated by cracks, overlaps, and contradictions among logics -can trigger individual engagement in institutional entrepreneurship . A focus on macro-conditions advances our understanding of institutional entrepreneurship by explaining why individuals can become institutional entrepreneurs, not why they will. But without exploring why individuals will to get involved, it is difficult to understand why among individuals exposed to the same game-changing events, some work to preserve field logics while others engage in changing them . Neither can we explain why tensions among logics do not always fuel engagement and instead can be overlooked by the individuals experiencing them and/or result in conflicts among individuals heralding different logics . Recently researchers have suggested the value of a micro-institutional perspective to explore differences in behavior among individuals exposed to similar macroinstitutional conditions . This paper departs from this micro stand to explore the question of why individuals are willing to engage in institutional entrepreneurship in the context of the emergence of commercial microfinance in Bolivia. The origin of microfinance is traced back to the founding of Grameen Bank, in the mid-1970s, which demonstrated that organizations lending to the poor could finance their social mission with the proceeds of their market-priced lending operations. The 1992 launch of Banco Solidario in Bolivia marked the beginning of commercial microfinance. It differed from the model pioneered by Grameen in a revolutionary new way: BancoSol was a commercial and regulated financial institution and, as such, had a fiduciary responsibility toward depositors and investors. Since the founding of BancoSol, commercial microfinance has spread throughout the world . The grounded theory exploration conducted in this context showed that engagement in institutional entrepreneurship, as most social action, does not occur in a social vacuum . Institutions are inhabited by social individuals. Institutional entrepreneurship is then not a lone endeavor but a social one. This means that institutional entrepreneurs do not act in isolation but in the context of social groups. All social groups are, of course, institutionally embedded but they are also unique contexts, with references tinted by their shared history of routine and serendipitous interactions and the social dynamics which link and distance their members . Groups can be of any size -a dyad qualifies and so does a baseball team but they are small enough so that the individuals involved know each other as distinct individuals . Their boundaries and membership are fuzzy, but they have enough permanency so that, much like a "stage" , groups provide a context which motivates, inspires, and enables engagement in institutional entrepreneurship. This finding is consistent with research which has shown groups to be crucial both as "vehicles of socialization and social control" as well as "mechanisms of contestation and change" and "incubators of social change" . Building on this coincidence, the paper argues both for an inhabited conceptualization of institutional entrepreneurship as a group-instead of individual-bounded process and for the adoption of the small group , the prototype meso-level unit of analysis , when exploring individual engagement in institutional entrepreneurship. The adoption of an inhabited group-bounded conceptualization advances research in institutional entrepreneurship in at least two relevant ways. First, it helps to overcome what Willmott has described as the voluntaristic bias of most micro-based research on institutional entrepreneurship. Adopting an inhabited understanding of institutional entrepreneurship suggests that social dynamics, such as interpersonal bonds and social-status competition , influence people's will to get involved in institutional entrepreneurship. Second, adopting the group as the unit of analysis of reference helps to overcome the lack of historicity of much research on institutional entrepreneurship , which produces a view of engagement as the product of punctual misalignments between individual interests and dominant logics. Specifically, it helps us see decisions to engage in institutional entrepreneurship as part of a path-dependent history of interactions, so engagements that outside of this path appear to be unwarranted and foolish emerge within it as judicious next steps in a stream of decision-making. --- What the Literature Says About Individual Engagement in Institutional Entrepreneurship Most of what we know about institutional entrepreneurship discusses conditions that explain why individuals can become institutional entrepreneurs. On the one hand, researchers adopting a macrolens have argued that it is individuals' field positioning that allows and motivates engagement by framing their appreciation of how their interests are or are not aligned with field logics . Generally stated, these scholars have suggested that the interests of individuals centrally positioned in a field are likely to be aligned with institutional logics, and therefore these individuals will be motivated to engage in defending the status quo . Similarly, they have argued that the interests of individuals located at the fringe of a field are likely to be misaligned with field logics, and therefore individuals in these field positions have an incentive to get involved in efforts that run against the grain of field logics. On the other hand, researchers adopting a micro-lens on institutional entrepreneurship have, by and large, addressed the question of individual engagement considering the extraordinary skills and access to resources required to advance these efforts . An emerging body of work embracing situated perspectives has begun to consider conditions that can explain differences in involvement among individuals facing similar circumstances . Rooted in the pragmatist and symbolic interactionist traditions, in this research, the status of individuals shifts from a role as "accomplice to social processes of institutionalization and structuration" to a role as "agent whose motivations, behaviors, and relationships" are central to their involvement . Individuals inhabit local contexts , and their behavior varies depending on the peculiarities of these locals . This research has yet to explore empirically the question asked in this paper: Why are individuals willing to engage in institutional entrepreneurship? Theoretically, this research points to dissonance as the answer . Dissonance describes a cognitive state that people experience when their appreciation of situated circumstances violates their expectations of how things ought to be. This cognitive state is unpleasant and can under unusual circumstances generate surprise, puzzlement and thereby motivate individuals to engage in institutional thinking, that is, the type of reflective thinking that allows individuals to question their institutionally-defined expectations . Nevertheless, a consideration of dissonance as the trigger for institutional thinking is at odds with a large body of both sociological and social psychological research . This research has convincingly argued that, when operating under conditions of dissonance, individuals are more likely to engage in selective interpretation so that the situation is emptied of its problematic content than they are to experience puzzlement and engage in institutional thinking. There is a need, then, for empirical research to further our understanding of the conditions influencing individuals' will to engage in institutional entrepreneurship. This paper addresses this need and explores this question using a framework which suggests that individuals' will to engage depends on the co-presence of three conditions: their identifying an opportunity for involvement, their perceiving the risks and costs involved as worthy, and their accessing the resources/support required. This three-pronged framework is well accepted in the institutional entrepreneurship literature and facilitates a parsimonious analysis of the research question. Next, the paper introduces the research methods followed in exploring why individuals are willing to engage in institutional entrepreneurship, conducted in the context of the emergence of commercial microfinance in Bolivia. --- Research Methods --- Data collected The author conducted more than 70 interviews, including interviews with all central firsthand participants, during several visits to Bolivia between 1997 and 1999 . Following grounded theory , interviewees included not only individuals who championed the new commercial microfinance archetype , but also those who supported and resisted it, and even individuals who remained on the sidelines. All the critical participants were interviewed. The open-ended interviews averaged one-and-one-half hours and followed a protocol of questions that evolved with the research project . Questions that persisted throughout the interview process included the following: Where did the original idea originate? How and when did you become personally involved in the project or initiative? How, when, and why did other people become involved? All but a handful of interviews conducted in public spaces where sound quality was too poor were tape-recorded and transcribed. In addition, because the emergence of commercial microfinance in Bolivia had attracted the attention of development scholars, the research also benefited from rich archival material that facilitated triangulation and enabled the author to complement field data with case studies written before, during, and following the fieldwork. The study thus benefited from a historically informed understanding of the individuals and organizations that launched the first commercial microfinance organizations. Among the documents collected were case studies about microfinance in Bolivia , reports generated and statistical information collected by banking regulatory agencies and associations of organizations that lend to the poor , technical reports published by donor organizations , and other professional reports. --- Analysis Analysis began with a simple narrative summarizing the individual efforts that paved the way for the emergence of commercial microfinance. This was followed with a more in-depth exploration of individuals who founded and led organizations with features that went against the grain of the logics of the organizational archetypes dominant in the field of provision of services to support the economic activities of the poor. These engagements were identified as instances of institutional entrepreneurship when they met three conditions: These individuals were involved in efforts that went against the grain of the logics governing the dominant archetypes. With their involvement, they assumed risks and costs beyond those regularly connected with their organizational position. They actively leveraged support and resources to advance these against-the-grain efforts. The value of applying these three criteria became clear in an iterative process of dialogue theory and data . This process showed that adopting these criteria helped to identify multiple instances of institutional entrepreneurship and to match the empirical evidence of these instances with three factors which, while enmeshed in the practice , have been identified in the literature as influencing individual engagement in analytically distinct and relevant ways, i.e. motivation to engage, opportunity for engagement, and resources to advance engagement . The next two steps of the analysis involved an exploration of these three factors to identify patterns in the seven instances of institutional entrepreneurship identified using the above criteria. The exploration revealed the influence on individual engagement of factors identified in the literature, namely, macro-conditions such as events with hard-to-disregard outcomes, logic tensions, and field positioning, and micro-conditions such as access to skills and resources. It also identified the influence of meso-level conditions that had been previously considered subsidiary in our explorations of institutional entrepreneurship, namely, social dynamics, including interpersonal bonds and status competition, and a history of social interactions. These conditions are introduced next to facilitate reading of the empirical evidence and findings. In institutional literature, interpersonal bonds have been equated with social capital and identified as relevant for individual involvement in institutional entrepreneurship considering their role in facilitating access to resources and support to advance these engagements . The evidence suggested, however, that interpersonal bonds also can play a role in engagement by influencing people's motivations to get involved. It showed that, as suggested in other bodies of research in organization theory , individuals' motivations to act are framed not only by their own interests but by those of others with whom the individuals have strong interpersonal bonds . Status competition describes decision-making following individuals' expectations on how their decisions will influence their social status . People derive status from material and cultural or symbolic assets and are said to win or lose status depending on their relative access to these assets. The influence of status competition on individual involvement in institutional entrepreneurship has seldom been acknowledged in the institutional literature . Its influence, however, is well established in organization studies . Finally, research on institutional entrepreneurship has discussed the influence of interactions on individual engagement . Fundamentally, it has suggested that interactions can encourage engagement when they generate dissonance, thereby creating an opportunity for individual engagement in institutional thinking . But as discussed earlier, this research still requires development to explain under what circumstances dissonance is likely to generate puzzlement and thereby engagement in institutional entrepreneurship, since individuals have a tendency to discard dissonance-generating events and information . The next two sections introduce the case and present the exploration conducted. --- The Emergence of Commercial Microfinance in Bolivia The emergence of commercial microfinance is considered an instance of institutional entrepreneurship because the features of this novel archetype run counter to those defining the other organizational archetypes dominant in the provision of financial services to the poor in the late 1980s: state banks, credit cooperatives, and NGOs. Central among these features were the following: • A focus on providing services to the urban poor and particularly street vendors and the like; the urban poor had never been the focus of state banks, credit cooperatives, or NGOs engaged in lending. • Exclusive focus on providing financial services at the expense of other types of services, such as training and technical assistance . • Lending practices defined by a manpower-intensive lending process and insistence on loan repayment . • Presence of an independent board of directors to oversee managers . • Financing of the lending portfolio with earned revenue, savings from the public, and commercial sources. . • The inclusion of private investors as shareholders in organizations providing services to the poor . Figure 1 provides a graphic description of the emergence and evolution of the largest NGOs providing loans to the poor in Bolivia. Table 1 provides a brief but comprehensive chronology of this evolution. As shown in both, two NGOs, namely PRODEM and ProCredito , pioneered commercial microfinance with the founding of BancoSol and Los Andes. They were followed by FIE-NGO which founded FIE and a group of NGOs which jointly founded Ecofuturo. Other NGOs, among them ProMujer and Crecer, continued to operate as NGOs and had never transitioned into commercial microfinance organizations. The next sections discuss in detail the efforts that drove this evolution with a focus on what motivated individuals to engage, how they identified the opportunity that inspired them, and how they accessed the resources that enabled them to realize their efforts. --- Launching of BancoSol-NGO and subsequent launching of BancoSol Bolivia's urban poor had traditionally relied on loan sharks, pawnshops, and pasanaku 1 brokers for their working-capital needs. This reliance began to diminish when Fernando Romero launched BancoSol-NGO in 1987. Considering the hard-to-disregard game-changing conditions that Bolivia was undergoing at this time, the fact that NGOs began to provide loans to the poor at this time appears unsurprising. Between 1980 and 1985, Bolivia's GNP fell by nearly 10%, and inflation reached a historical high of 24,000% . At the time, Paz Estenssoro was leading the country, and, under the advisement of the International Monetary Fund and the World Bank, his administration adopted drastic measures to deal with this unprecedented crisis. One measure was the closing or restructuring of state-owned companies, which was expected to result in sharp increases in unemployment. In this context, there was an urgent need for programs to support the economic activities of the poor, including facilitating their access to loans. But whereas the launching of NGOs to provide loans to the poor was not surprising, it was surprising for any NGO to have someone with the profile of Fernando Romero as founder and for it to have most of the features which we now associate with microfinance -those listed earlier except the two last ones . Fernando Romero possessed the ideal profile of an institutional entrepreneur . "An eclectic and vigorous entrepreneur with an intellectual bent" , he had the requisite social assets and political skills to champion this pioneering NGO. But, in the context of Bolivia, the involvement of any businessman in the NGO field, including Romero, was, to say the least, unusual. As Sanchéz de Lozada, former president of Bolivia, observed, "Bolivia has no Anglo-Saxon tradition of philanthropy. We've got confession to get us to heaven" . Moreover, Romero had, at this time, little understanding of what microfinance was. He had no problem with the idea of BancoSol-NGO serving the urban street vendors, unaware of how this ran against the grain of the practices dominant in the field. But the motivation for his involvement was philanthropic and he was shocked when he realized that BancoSol-NGO was charging interest rates that were about three times those charged by regular financial institutions in Bolivia . So why did he lead the founding of BancoSol-NGO? All interviewees, including Romero himself, answered this question by pointing out how he was convened to do so by Jack Duncan, the chairman of Acción International's board, with whom he shared both a long history of interactions and a personal friendship. Recalled Romero: I met with Duncan, who was the first person I worked for when I graduated from MIT, in WR Grace & Co., and Jack told me: "We are developing a small institution in Boston that is called Acción where we are putting together some money to give credit …" And I said, "Okay, send me one of your guys." Romero would participate as chairman of the board and help the organization leverage local resources, Acción International's staff would provide the operational know-how, and a carefully selected NGO professional would run the organization. Fatefully, the professional hired for the job was Francisco Otero. In the next quote, Otero explains how he was hired for the job. This period [the period he spent working with lending organizations in rural areas] lasted about 10 years, and it is when I learned a lot of things about providing loans to "excluded" people [those not being served by the local institutions]. Then, in the year '86, is when Acción International approaches me to run […] at the same time my sister Maria joined the organization in Honduras […] she had gained their trust, and they said, "Your brother, what do you think?" and she said yes. Under Otero's leadership, BancoSol-NGO succeeded beyond anyone's expectations. Regardless of the high interest rates it charged, "people would wait for hours, around the block, to get a loan" . By 1991, BancoSol-NGO had 22,700 loans outstanding, a portfolio of $4.6 million, and an absurdly low loan-repayment default rate of 0.0002% . Moreover, its client base was growing at a surprising 50% per year . BancoSol-NGO's uncanny success came as a surprise to all involved. Nobody had realized the pent-up demand for loans among Bolivia's poor. The loans BancoSol-NGO was offering were indeed expensive, but poor borrowers had no access to regular bank loans. BancoSol-NGO's loans, when compared with the informal sources accessible to poor borrowers , appeared reliable and even affordable. Romero, who owned a commercial bank, regarded BancoSol-NGO's success with disbelief. He asked Otero to take him on a field visit to learn firsthand who these people were that were borrowing and repaying their loans; BancoSol-NGO's repayment rates were close to 100%, a figure unheard of in the country, even among its most reputable financial institutions. Interestingly, BancoSol-NGO's uncanny success generated an unexpected problem: Donor funds, the conventional source of financing for NGOs, were woefully inadequate to fuel the organization's fantastic rate of growth. BancoSol-NGO's leadership had to revert to its members' personal wealth just to keep up. Recalled one member of BancoSol-NGO's management team: I remember going personally to the banks I knew and asking them for loans. First I would ask them to use [BancoSol-NGO's] loan portfolio as guarantee. But they would say no and ask for other assets, and I would propose someone's jewelry, my father's house. Pancho mortgaged his house; we all mortgaged things to get money […] what the donors were giving was just not enough. BancoSol-NGO's operational success, then, can be fairly described as a moment of dissonance . Its success and the financing difficulties it generated created an opportunity for institutional thinking . Interestingly, consistent with institutional theory insights , the group of individuals involved, namely Acción's staff, Otero, and Romero, discussed and generated ideas which, while testing their boundaries, followed by and large the dominant financing logics. Acción's staff, within their role as NGO experts, suggested a system of loan guarantee letters that BancoSol-NGO could use to get loans from local banks. The source of the guarantee funds was the same -donations -and thus this solution did not break with the dominant donations-based model. Otero, the local NGO professional managing the organization, did not offer any specific solution. He did suggest, however, that it was "a big mistake" to try to alleviate BancoSol-NGO's financing problems with guarantee letters or any other instrument dependent on donors: "Every year we have to go out with the hat to get money to finance [our] growth" . He talked "to anyone willing to listen" about the need to grow BancoSol-NGO so that it could "masificar" microfinance, i.e. extend access to all. Romero shared Otero's dislike for the need to "pass the hat" to get donor financing, a painful reminder of Bolivia's dependency on the whim of donors. But at this point in time he was rather disengaged from the organization. Disengagement was, in fact, the norm for all the businessmen who sat on BancoSol-NGO's board, as a manager from BancoSol-NGO commented: "Board meetings happened over lunch, and dessert would arrive before discussing BancoSol-NGO" . An unexpected and fateful interaction with Martin Connell, a member of Acción's board, redefined the group's thinking. As leaders of BancoSol-NGO, Otero and Romero were part of Acción's network and had traveled together to New York to attend Acción's 1989 board meeting. Connell invited them to join him for dinner. During the meal Connell said: […] we need to create a bank. The interesting example […] was done at the end of the 19th century by Crédit Agricole. […] They used the bakers and gave them a little box. [… T]his will be difficult in Latin America […] We have to imitate McDonald's. Much like the generative metaphor described by Mary Douglas and Donald Schön , this piece of institutional debris put BancoSol-NGO's uncanny success and its financing difficulties in perspective for Romero and Otero. Crédit Agricole had extended access to loans by working with local bakers; Connell thought BancoSol-NGO could accomplish this by franchising like McDonald's. Back in Bolivia, an energized Romero and Otero engaged in institutional thinking , discussing their options. They settled on a plan to launch a commercial microfinance bank. They reasoned that with the creation of a commercial bank, BancoSol-NGO would, like Crédit Agricole, be able to access commercial funds, including deposits, and in this way it would be able to solve, once and for all, its fund-raising difficulties. But they had to convince Acción's staff to support their actions. Acción's staff -all NGO professionalswere reticent. They worried that the commercial transition could, in time, push BancoSol to abandon its social mission. They were also concerned about the impact on Acción itself. Restrictions on the ability of US-based not-for-profit organizations to invest in for-profit endeavors constrained Acción's ability to invest in the future bank: "[They said,] 'Look, we can get you a donation of $5 million, but do not ask us to invest $100,000 because it means accountability, and it is for-profit, and we do not have the situation'" . Romero's point of view prevailed, but only when he turned his request into a personal appeal building on his long-standing bond with Acción's chairman and the newly formed one with Acción's general manager . As Romero commented: "This exception, they took it, because I insisted personally with Jack Duncan and also with Bill Burrows" . With the counsel of legal experts, Acción defined a solution that allowed it to invest in BancoSol. With this agreement, Romero, Otero, Connell, and Acción's leadership began the arduous negotiations necessary to leverage the financial support and regulatory changes required to launch a commercial bank devoted to providing microfinance services. They succeeded, and the commercial microfinance bank Banco Solidario commenced operations in February 1992. --- Plans to launch a development microfinance organization The professionals leading the other Bolivian NGOs also witnessed BancoSol-NGO's success in disbelief. Like Romero, they wondered why people were queuing for hours to get a 45% interestrate loan. But these professionals did not use this moment of dissonance as an occasion to launch a commercial microfinance organization. Even though the NGOs they headed were involved in providing loans, they did not identify themselves as lenders but as development professionals. From this perspective, BancoSol-NGO's unique features, such as targeting street vendors, charging high interest rates and insisting on repayment, were inappropriate, and its plan to form a commercial bank with owners who could privately benefit from its operations was unwarranted and illegitimate. A group of them -namely, the leaders of ANED, CIDRE, FADES, FIE, and Sartawi -began discussing an alternative institutional entrepreneurship opportunity: the launching of a development microfinance organization. All local NGO professionals saw BancoSol-NGO's formation of BancoSol as inappropriate, to say the least, and most remained disengaged. But this group had emerged when these individuals worked together in the launching of FADES, an NGO devoted to providing loans to farmers. From this social platform the launching of a development microfinance organization appeared as a reasonable response. The organization they envisioned would follow up on their design for FADES. Like FADES, it would have an independent board of directors, populated not by businessmen and/or private investors but by themselves, and it would finance its portfolio with donor funds. It would adopt those microfinance innovations that did not conflict with NGO logics, such as microfinance's manpower-intensive approach to loan evaluation. But it would have a large portfolio of loans in manufacturing and agriculture and would not charge the high interest rates of BancoSol, have private investors, or provide services other than credit. This group's plan to launch a development microfinance organization did not progress. In a fateful moment, later referred to by interviewees as the "Los Andes fiasco", their conversations were unexpectedly sidetracked when C.-P. Zeitinger, founder of Internationale Project Consulting gmbf , approached them with the proposal to work with IPC to launch an NGO-founded commercial microfinance organization. Initially Zeitinger's invitation was welcomed. As one participant observed, it was perceived as "an opportunity not to have to do this alone [by themselves]" ; after all, he had already secured funds from the GTZ to finance the project. But this enthusiasm was short-lived. Central to Zeitinger's project was the idea of self-sufficiency, which he thought would be possible only if the organization provided only credit and focused initially on serving urban areas . The group disagreed with his assessment, which they perceived as overly intrusive: "He would get involved in areas of decision-making that are out of the scope of a consultant" . They wanted his know-how and the funds from the GTZ, but they did not want him to change their plan. He insisted, and as a result his proposal was rejected by all except Pilar Velasco, at the time the acting general manager of FIE-NGO. Not surprisingly, her decision cast her, and by extension FIE-NGO, as social deviants . The decision, however, allowed Zeitinger's initiative to continue. --- Plan to launch a commercial microfinance organization with FIE-NGO, which led eventually to the launching of Los Andes Zeitinger began his consulting engagement with FIE-NGO immediately, but it was short-lived. FIE-NGO's leaders were four women who had begun to provide loans the same year BancoSol-NGO was founded, and with financing from the InterAmerican Development Bank they had built a rather healthy loan portfolio. Pilar Velasco had led the idea of engaging Zeitinger and the other women had gone along, but they soon began to have second thoughts. Zeitinger adamantly insisted that FIE-NGO should change its board of directors to include individuals with a high social profile in the country. Recalled one member: "He would say, 'You are a group of mere housewives, and no one is going to want to hear what you have to say. You need an umbrella of important people [on the board]'" . FIE-NGO's founders worried about its implications for their own ability to control the future of FIE-NGO. Since most had no background in finance , it was possible for the new board to consider them unqualified and ask them to leave, with little regard for their role in and contribution to the building of FIE-NGO. Following their disagreement and distrust, the group decided that FIE-NGO should stop working with Zeitinger. They wanted to keep the funds that the GTZ had earmarked for the project but they would ask the GTZ to engage a different consultant to work with them. As one member recalled, "[W]e began questioning why this man [Zeitinger] wants to do this to us. … [T]hen, on a Sunday, we said, 'Leave us; we are going to keep going alone without you'" . Pilar Velasco disagreed, but when she failed to convince the other group members she decided that the only logical thing to do was for her to resign from FIE-NGO. This was a difficult decision. Already written off as an outcast by the local NGO leaders with whom she had worked, she was also now self-excluding herself from FIE-NGO, her home institution which she had helped to found and which was her main source of income. Impressed by Velasco's bold decision, Zeitinger invited her to present with him a reformulated version of the project to the GTZ. In this new version the GTZ funds would be used to launch a brand-new NGO earmarked to transition into a commercial microfinance organization . Together they rushed to the offices of the GTZ in La Paz. Rather dramatically, they arrived a few hours before FIE-NGO's leaders could present their own request for a new consultant. They were granted permission to use the funds earmarked for the project to launch the new NGO. In 1992, working now with Zeitinger and his consultants from IPC, Velasco assumed leadership of this new effort. She leveraged the support and participation of friends and relatives who could act as an "umbrella of important people" and launched Los Andes-NGO. In 1995, after arduous work and negotiations with the regulatory authorities, Los Andes-NGO spun off from Los Andes. The interpersonal bonds of the umbrella of important individuals that Velasco had attracted played an important role in their successful lobbying for the new legislation needed to launch Los Andes as a commercial microfinance organization, as shown in the following comment: Mr. X [a member of the Los Andes-NGO board] has an important level of social standing. He is in the Chamber of Commerce and has access to the leadership of the SBFI [banking regulatory agency] without having to go through secretaries or setting up audiences. --- FIE-NGO's members decide to launch a commercial microfinance organization While Velasco worked to build Los Andes, her ex-peers at FIE-NGO decided to launch their own commercial microfinance organization. The group was fueled by their sense that, without access to the commercial funds available to commercial organizations , FIE would not be able to grow its portfolio as rapidly and would unwarrantedly lose its status vis-à-vis Los Andes . Consider the following comment by the leader of one of these NGOs: "Los Andes was growing […] and then we said, 'If we do not risk it and continue, we are going to remain a very small thing that at some point was a good idea and stay there'" . In their founding of a commercial microfinance organization, FIE-NGO's leaders had hoped to avoid having businesspeople on their board of directors -the suggestion that sparked their disagreements with Zeitinger -but the regulatory agency insisted. As the group grew convinced that they could not continue without assenting to this request, they agreed to assume the risks associated and identified a private investor in Mr Johnson, a local industrialist, and invited him to join them. FIE-NGO launched its own commercial microfinance organization in 1998. Interestingly, the Private Financial Fund legislation that the Los Andes-NGO founding group had lobbied into existence allowed FIE-NGO's founding group to gain the financial support and regulatory approval required to launch their own commercial microfinance organization in 1998. --- Local NGO professionals re-ignite efforts to launch a development microfinance organization and decide to form a commercial microfinance organization The group of leaders of the other NGOs involved in the Los Andes fiasco followed their own path and continued to be involved in two institutional entrepreneurship efforts, namely a new plan to create a development microfinance organization and a plan to launch their own commercial microfinance organization. In 1993, taking advantage of the Bolivian Congress's work on drafting new banking legislation, the group spearheaded lobbying efforts for regulatory changes tailored to their vision for a development microfinance organization. These changes would allow organizations engaged in lending to the poor to capture savings and deposits without requiring them to become for-profit or have private investors, although they could have municipality governments as investors. Their idea was that with access to deposits and, if needed, public investment, they would be able to access sufficient funds and keep up with the growth of BancoSol and Los Andes but without undermining what they called "the human side of microfinance" -their freedom to decide who and how to serve, prioritizing clients' human needs over financial concerns. Interestingly, in parallel with these lobbying efforts, three of them formed another group joining forces with the leaders of two other local NGOs , to launch together a commercial microfinance organization. When asked about their participation in groups with parallel and apparently contradictory initiatives, these individuals argued that it was the only way they could retain their competitive position. In the words of one of them: [Commercial microfinance] is the future, but we are resisting it so it would have a human face and not a monetary face. […] Maybe tomorrow, the group in power will decide that the NGOs are not going to do microfinance anymore. […] In that case, we are out of the battle. It is for that reason that we are in Ecofuturo: to fight also from the side of PFFs [Private Financial Funds]. Source: Boletín Financiero and annual reports . *Year in which the organization transitioned into a commercial financial organization. The efforts of the group working in the development microfinance organization related plan were only partially successful. The Bolivian Congress included the desired language in the new law, but the banking regulatory agency stalled on developing this language into specific legislation. But the efforts of the group to launch a commercial microfinance organization prospered, and this group launched Ecofuturo in 1999. In ending this brief narrative, it is interesting to note that there were several local NGO professionals who, while affected by the emergence of commercial microfinance, did not get involved in institutional entrepreneurship. Among them were the leaders of ProMujer and Crecer, two of the most successful local NGOs providing microfinance. ProMujer's leaders were a local Bolivian and an American living in the United States. Crecer was a foreign implant that belonged to an international network of organizations that provided services to the rural poor around the world. It was led by a foreigner with no ties to the leaders of local NGOs. In contrast with the group of NGO leaders who got involved, these individuals were engaged in alternative groups with pasts which did not include the founding of FADES or discussions to create a development microfinance bank. Their lack of involvement in FADES explains their disengagement from the local NGOs' discussions to launch a development microfinance bank. Their lack of involvement in these discussions, in turn, explains why they never perceived Los Andes as a suitable referent for their status calculations. The leaders of ProMujer and Crecer continued to successfully grow their organizations. They adopted microfinance practices selectively, consistent with their own organizational identity, but they did not assume risks or costs beyond those necessary to advance their mission or leverage resources and support for projects that ran against the grain of the logics of the dominant organizational archetypes . In short, they were successful, entrepreneurial individuals, but they did not become invested in the advancement of any one organizational archetype. By 1997, a street vendor in La Ceja, one of the busiest street markets in Bolivia, was receiving up to three visits a day from loan officers offering credit. Of note, the Private Financial Fund legislation lobbied for by Los Andes was not only used by NGOs to launch commercial microfinance organizations but also co-opted by private investors to launch for-profit consumer lending ones. By 1999 the growth of these consumer lenders, with their disregard for the risks of overindebting clients, created a repayment crisis that threatened the survival of most organizations lending to the poor in Bolivia. Following this crisis, these consumer lenders closed their doors, but, at the time of writing this paper, all the organizations covered in this study had survived the crisis and were still thriving. Poverty continues to be a significant problem, yet Bolivia's poor, both in urban and in rural areas, have unprecedented access to financial services, and the interest rates they pay for loans, while still quite high, have fallen substantially. In 2012, they averaged around 18% -about one-fifth of what they had to pay to loan sharks and pawnshops, their only sources of financing prior to 1987. --- Findings: Groups as the Stage for Institutional Entrepreneurship Commercial microfinance emerged and developed in Bolivia at the hands of groups of individuals who, with their successful and failed institutional entrepreneurial efforts, introduced and mainstreamed this novel organizational archetype . Two groups launched commercial microfinance organizations , and their actions paved the way for others to launch new commercial microfinance organizations . Two others tried but failed to launch an alternative archetype , and their failure further solidified the position of commercial microfinance as a legitimate organizational archetype for providing financial services to the poor. A parsimonious look at these efforts suggests that the interactions and social dynamics that made up these fuzzilybounded groups acted much like a "stage" which motivated, inspired, and enabled the engagement in institutional entrepreneurship of these groups and/or their members. --- Motivating engagement The institutional literature has explained individual motivation to engage in institutional entrepreneurship considering how field positioning defines the alignment or lack thereof between an individual's interests and field logics . The evidence supports the influence of field positioning but also suggests that the social dynamics framing individual relations within their group stage crucially influence their perceptions of alignment beyond field positioning. The groups involved in launching commercial microfinance organizations were positioned at the fringe of the field. The creation of BancoSol-NGO was led by a group that included the chairman of a US-based international NGO and a member of Bolivia's business elite . Duncan was acting on behalf of Acción International, advancing this organization's agenda of expansion. Without the benefit of additional evidence, it is difficult to explain his engagement beyond his organizational role and field positioning. But he was not leading the effort; that person was Romero, his protégé, who, with little understanding of microfinance, agreed to lead the launching of BancoSol-NGO. Romero's acceptance was framed by his concern for the need to alleviate the impact of structural adjustment on the poor. In Bolivia, however, the likelihood of a member of the economic elite forming an NGO was small. They got involved in social issues by assuming positions in government or financing church-based charities, not by launching NGOs. Accordingly, it is unlikely that Romero's general concern for the poor would have materialized in his assuming the risks and cost of launching an NGO outside the group stage created by his interactions and interpersonal bonds with, first, Duncan and subsequently the individuals who worked with him in BancoSol-NGO, i.e. Bill Burrows and Pancho Otero. In the case of Los Andes, the so-called Los Andes fiasco had positioned C.P. Zeitinger and Pilar Velasco at the fringe of the NGO field. But their field positioning only partially explains the motivation of this tight small group. Instead, it is more easily explained by the interactions accompanying the fiasco. Zeitinger's motivations can be easily understood by focusing on his organizational role, but not Ms Velasco's -the eventual leader of the initiative. Her willingness to assume the risks and costs involved emerged from the interactions and decisions that created and followed the fiasco and particularly her decision to quit FIE. Only by considering these interactions can we explain her accepting Zeitinger's invitation to request and use funds already earmarked for FIE to launch Los Andes and her calling on her friends and family to support her in this endeavor. The other initiatives were carried out by two overlapping groups of field insiders. As in the case of field outsiders, field positioning emerges only as a partial explanation for their engagement. Instead, the two overlapping group stages housing these individuals explain why these NGO professionals and not others engaged. The groups had emerged from past interactions which led to the launching of FADES and were buttressed when their efforts to launch a development microfinance organization derailed. From this stage BancoSol and particularly Los Andes stood as relevant status referents and their fantastic operational success as a source of status loss. The wish to regain status vis-à-vis BancoSol and Los Andes fueled the groups' will to assume the risks and costs involved in advancing plans that would allow them to regain the lost status, i.e. lobbying for regulations that would support the launching of development microfinance organizations and launching of a commercial microfinance organization. Absent from these overlapping groups NGO leaders did not consider BancoSol and Los Andes as relevant status referents and therefore lacked the motivation to engage in institutional entrepreneurial efforts. This insight, which suggests that individuals' past interactions influence who are perceived as relevant status referents, and thereby individuals' motivations for action, is consistent with social psychological research exploring the influence of identity and status competition on decision-making within organizations . --- Inspiring opportunity identification As suggested in the institutional literature, individual appreciation of opportunities to engage in institutional entrepreneurial efforts was facilitated by macro-conditions with hard-to-disregard outcomes , such as Bolivia's hyperinflationary crisis, and tensions in field logics , such as those generated by the financial constraints experienced by BancoSol-NGO. Engagement was also facilitated by a micro-factor, namely, the dissonance generated by the unexpected and uncanny operational success of BancoSol-NGO. These macro-and micro-conditions provided ground for opportunity identification, but who perceived in these conditions an alignment with their individual interests so as to justify their engagement in institutional entrepreneurship is better explained by looking at how these macro-and micro-conditions interplayed in the meso-group stage. First, Romero's initial involvement in the launching of an NGO with unusual attributes did not follow from the identification of an opportunity but by his being convened to engage by Jack Duncan, with whom he shared a lengthy history of interactions and a personal friendship. But Romero's later engagement in launching the commercial bank BancoSol emerged within a group stage which now included not only Mr Duncan but also the other members of Acción's staff and Pancho Otero. It occurred in the milieu of the financing difficulties created by the unexpected and uncanny operational success of BancoSol-NGO, but it was fueled by Otero's interpretation of BancoSol-NGO's success as an opportunity to democratize access to loans in Bolivia, and it was irremediably kindled by the interaction with Connell, who unveiled the surprising parallels between BancoSol-NGO and Crédit Agricole. Second, the initiative to develop Los Andes can be traced back to plans that Zeitinger and his staff at IPC had defined prior to their involvement and, therefore, can also be explained without reference to the meso-group stage. However, it required the involvement of Pilar Velasco in order to progress. Only with her engagement as leader of the initiative could it advance. But the engagement of someone with Ms Velasco's profile can only be explained considering the group stage in which she was operating. The launching of a brand new NGO from scratch ran against the grain of dominant practices -something that both Zeitinger and Velasco, aware of its illegitimacy, dismissively described as an exercise in "artificial insemination". The engagement of both Zeitinger and particularly Velasco in such a deviant initiative is hard to imagine outside the tight grouping of Zeitinger and Velasco after her decision to abandon FIE-NGO. Third and finally, as mentioned earlier, the other initiatives were led by groups of field insiders. The literature on the influence of field positioning suggests that these individuals were likely to get involved but only in defense of the dominant archetype that housed them . The evidence, however, shows that they did not work to protect the established archetype and instead engaged in advancing an alternative although related archetype, namely a development microfinance organization. The features of the development microfinance organization were close to that of the dominant archetype, but they still differed from it in relevant ways. The group stages created by these professionals' history of interactions crucially explains their inspiration to engage first in launching a development microfinance bank as well as their later engagement in the launching of a commercial microfinance plan. The development bank plan can be explained considering the history of interaction of the group, which placed FADES, and not Crédit Agricole, as the relevant historical referent. The commercial microfinance plan can be explained considering changes in members' shared understandings sparked by the Los Andes fiasco, which placed two commercial financial institutions as relevant operational referents for the provision of financial services to the poor. --- Enabling access to resources and support Finally, as has been previously argued in the literature , the evidence does suggest that the interpersonal bonds facilitated access to resources and support and thereby enabled institutional entrepreneurship. The launching of BancoSol-NGO and BancoSol was enabled by the wealth of international know-how and access to international donors brought by Duncan and his staff from Acción. They were also enabled by Romero's access to local sources of financing as well as his reputation as a successful businessman. In turn, the launching of Los Andes was enabled by the know-how and access to financing brought by Zeitinger and his staff as well as the network of family and friends brought by Velasco, crucial in negotiations for regulatory approval. Interestingly, the evidence suggests that individuals may engage in institutional entrepreneurship even in the absence of an enabling group stage. But it also suggests that without this stage efforts are likely to fail. Efforts to advance the development microfinance archetype failed largely because individuals could not mobilize funds or regulatory support. Moreover, the later efforts of these individuals to early-adopt the commercial microfinance model with the launching of FIE-PFF and Ecofuturo were possible not because the group stage of its founders enabled their accessing the required resources and regulatory support but because supporting these endeavors had become institutionally acceptable following the launching and operational success of BancoSol and Los Andes. In summary, the evidence does not disconfirm that macro-and micro-conditions allowed individuals to become institutional entrepreneurs. But it suggests that we can explain why individuals facing similar macro-conditions and with similar micro-profiles have a different likelihood of engaging in institutional entrepreneurship considering the interplay of macro-and micro-conditions in the meso-group stage. Engagement in institutional entrepreneurship requires motivation, opportunity, and resources, and these three elements can be present at the group level even when they are not at the level of its individual members . The social dynamics linking individuals can motivate engagement and the shared references tied to the group can inspire opportunity identification. In addition, the evidence shows the relevance of looking at the group as enabling institutional entrepreneurship by facilitating or not facilitating access to the support and resources required to advance institutional efforts. Table 3 provides a summary of the findings. --- Discussion of Findings, Implications, and Future Research This paper asks why individuals are willing to engage in institutional entrepreneurship. The exploration of this question conducted in the context of the emergence of commercial microfinance in Bolivia suggests that it is crucial to consider this question at the meso-group level of analysis. Prior research has acknowledged the role of one meso-level factor, namely linkages among individuals, but only considering their influence as a source of resources and support to advance institutional efforts . But in the institutional entrepreneurship efforts studied, the group stage emerged as central both to motivation and opportunity identification. It also played a role in enabling access to resources and support, but this role was subsidiary; it explained only which institutional entrepreneurship initiatives advanced , while others fail to do so. The paper then advances an inhabited institutions understanding of institutional entrepreneurship and argues for the adoption of the small group , the prototype meso-level unit of analysis, to explore why individuals will engage in institutional entrepreneurship. This reorientation from the micro-to the meso-level of analysis alleviates the need for the heroic conceptualizations that populate most research on institutional entrepreneurship. Institutional entrepreneurs do not need to be heroes, with superhuman foresight and enough resources to spark processes of institutional change. They need only to inhabit a group stage that simultaneously motivates, inspires and enables engagement in institutional entrepreneurship. Such group stages may be rare, the product of unexpected, momentous, and/or serendipitous circumstances, but their inhabitants do not need to possess the kind of superhuman qualities currently associated with institutional entrepreneurs . The proposal to adopt the small group as the unit of analysis of reference implies a rethinking of the methodological individualism defining institutional entrepreneurship scholarship on the linking of micro-actions and macro-outcomes. The value of methodological individualism is that it assures that individuals regain their centrality after they have all but disappeared from organizational institutionalism . The problem of methodological individualism is what Willmott has described as its voluntaristic bias, that is, that even though our understanding of institutions builds on the insight that individuals cannot escape the institutions framing their behavior, we explain individuals' engagement in institutional entrepreneurship suggesting that it is possible only when individuals do escape the cognitive influence of institutions. By adopting the small group as the unit of analysis, we can overcome this bias as it explains engagement, without escaping the institutions framing their cognition, by pointing to the historicity and sociality of individuals' decisions to engage in institutional entrepreneurship. Lack of historicity plagues most research linking individual efforts and macro-outcomes . In the institutional entrepreneurship literature, this problem has been acknowledged ). Still, by and large, our current conceptualizations suggest that individuals identify opportunities for engagement as if in a temporal vacuum. The process hinges only on the alignment, or lack thereof, between individuals' interests and field logics. From this perspective, people are expected to --- Motivating engagement The group stage fuels individuals' will to assume the risks and costs involved. --- Inspiring opportunity identification The group stage allows individuals to appreciate alignments between their interests and field conditions invisible to non-members. Enabling access to support and resources The group stage defines access to resources and support to advance institutional initiatives. identify opportunities for engagement only when there is misalignment or when the existing alignment is under threat . Adopting the small group, in contrast, highlights that the inspiration for opportunity identification is path dependent. Current decisions depend both on past interactions as well as individuals' expectations of future ones. Within a pathdependent history of interactions, decisions that, without it, may appear to be unusual , unwarranted , and even deviant emerge as a judicious next step in a stream of decision-making. Researchers have suggested that, without abandoning the individual as the unit of analysis, we can gain historicity when we conceptualize individuals considering not only their skills and interests but also their personal biography . But adopting the small group has the additional advantage of facilitating observation of the influence of social dynamics which otherwise frame individual decision-making processes. First, up until now, institutional entrepreneurship research has acknowledged the value of people's interpersonal connections as relevant to leverage resources and support. In contrast, this paper suggests that the group is irremediably enmeshed with individuals' will to engage and that its influence in mobilizing support and resources explains not the likelihood of their engagement but whether that engagement translates into field change. This insight needs to be further explored and confirmed with research projects that, like this one, consider not only institutional entrepreneurial initiatives that do generate the field change desired by their promoters but also those that fail to generate it. Second, adopting the small group allows us to expand our understanding of the conditions that motivate individuals to assume the costs and risks of engaging in institutional entrepreneurship. People may be motivated to pursue an individual interest , but they may also be motivated to engage at the service of other individuals with whom they are tightly connected. Incorporating interpersonal bonds as a source of motivation is relevant because it helps explain the engagement in institutional entrepreneurship of individuals who, like Romero, may have the profile and resources to do it but lack the a priori motivation to get involved and may do so only when convened by others. This insight calls for research which problematizes who is the institutional entrepreneur. It may be that the institutional entrepreneur is not a solo individual with the foresight, skill and resources to advance a highly valued interest but participants in a small group which motivates, inspires, and enables engagement. Third and finally, adopting the small group pushes researchers to consider social dynamics other than interpersonal bonds -for example, status competition -as relevant motivation for individuals to engage in institutional entrepreneurship. The institutional literature has acknowledged the influence of status calculations in individuals' decisions to engage . But by disregarding the influence of the group stage on how individuals identify their status competitors, this research cannot explain differences in motivation among individuals with similar field positioning . In contrast, by adopting the small group we can explore differences in engagement considering differences in the stage framing their decision-making. The identification of competition for social status as a relevant dynamic emerged from the evidence, but there may be other social dynamics that are relevant in other settings. The sources can be varied and include social dynamics explored in the social psychology literature, for example, gossip or envy . The relevance of the small group to advance our understanding of institutional entrepreneurship emerged inductively from the study. The empirical setting, however, was rather specific in ways that may be hard to replicate in other studies. La Paz, Bolivia's capital city and the stage where commercial microfinance emerged, is a rather small social space. At the time data was being collected for this study, it was common for the promoters and managers of microfinance organizations to meet, casually at a restaurant or club in La Paz or, per the invitation of a donor organization, at a microfinance forum in Washington, DC, or in Frankfurt, Germany. The tightness of this social space facilitated, in the manner of a "Petri dish", to observe and understand the clustering of individuals along boundaries of small groups that did not respect organizational or socio-demographic boundaries -something difficult to appreciate in most field contexts owing to the considerable number and geographic dispersion of sites . Nonetheless, considering the ubiquity of small groups, the research proposals advanced in this paper might be useful to explore institutional entrepreneurship within more restricted collectives, such as organizations. Current research on inhabited institutions provides a good starting point for this research program. In finishing, it is important to mention that the idea of using the small group as the preferred unit of analysis to explore the interplay of micro-actions and macro-outcomes has been proposed in the context of research on civic engagement . The findings of this paper regarding its centrality to understand individual engagement in institutional entrepreneurship call attention to the need to explore the potential overlap between these two concepts. An action is considered civic engagement when it concerns advancing a collective instead of a private interest; collective interests involve hard-to-privatize desired outcomes. This condition is not required for institutional entrepreneurial actions. Instead, an action is considered institutional entrepreneurship when it advances, changes, or undermines institutional practices, logics, and structures. Nevertheless, the actions identified in this paper and others identified both in the literature on civic engagement study of 19th-century French working-class protests, or Opp and Gern's research on the tearing down of the Berlin Wall) and the literature on institutional entrepreneurship work on consumerwatchdog organizations or Maguire and colleagues' research, on HIV/AIDS treatment advocacy) do both; they advance collective interests and have institutional impact. This recognition points to the need for research exploring whether all or only some institutional entrepreneurial actions can be fairly described as forms of civic engagement. The potential theoretical benefits of such research are substantial, including a clarification of the current rather blurred distinction between entrepreneurial and institutional entrepreneurial actions. A large overlap would imply that we could define institutional entrepreneurial actions as those entrepreneurial actions with hard-to-privatize outcomes. --- Author biography Silvia Dorado is associate professor of management at the University of Rhode Island. Her research explores processes of entrepreneurship in the context of social change including the emergence and survival of socioeconomic hybrid organizations. Silvia received her BA degree from Universidad Autónoma de Madrid , her MA from the Massachusetts Institute of Technology , and her PhD from McGill University .

This paper contributes to the emerging literature on inhabited institutions. It argues that institutional entrepreneurship, as most social action, is not an individual-bounded endeavor, at the hands of isolated individuals, but a group-bounded one, at the hands of social individuals inhabiting groups which motivate, inspire, and enable their engagement. The inhabited group-bounded conceptualization offered helps to overcome voluntaristic biases and atemporalism plaguing much micro research on institutional entrepreneurship. The paper builds on a qualitative case study of the emergence of commercial microfinance in Bolivia.

introduction the engagement of individuals in institutional entrepreneurship has become a central concern in institutional research research in this area has yielded a substantial body of knowledge but we still know little about why individuals get involved in these efforts this question is central engaging in institutional entrepreneurship is a decision individuals are unlikely to take lightly considering that because of the difficulties involved these efforts are expected to be both resourceintensive and risky most research exploring institutional entrepreneurship has adopted a macro perspective and focused on the institutional conditions that frame engagement this research has shown that individuals are more likely to get involved in institutional entrepreneurship when facing events with hardtodisregard gamechanging outcomes such as technological disruptions regulatory and policy changes or a health crisis this research has also suggested that the likelihood of individual engagement is framed by the institutional logics that define the boundaries of fields institutional logics are broader cultural beliefs and rules that structure the cognition of individuals and guide their decisionmaking in a field field boundaries are defined not by a single logic but a plurality of logics and tensions and conflicts among them variously precipitated by cracks overlaps and contradictions among logics can trigger individual engagement in institutional entrepreneurship a focus on macroconditions advances our understanding of institutional entrepreneurship by explaining why individuals can become institutional entrepreneurs not why they will but without exploring why individuals will to get involved it is difficult to understand why among individuals exposed to the same gamechanging events some work to preserve field logics while others engage in changing them neither can we explain why tensions among logics do not always fuel engagement and instead can be overlooked by the individuals experiencing them andor result in conflicts among individuals heralding different logics recently researchers have suggested the value of a microinstitutional perspective to explore differences in behavior among individuals exposed to similar macroinstitutional conditions this paper departs from this micro stand to explore the question of why individuals are willing to engage in institutional entrepreneurship in the context of the emergence of commercial microfinance in bolivia the origin of microfinance is traced back to the founding of grameen bank in the mid1970s which demonstrated that organizations lending to the poor could finance their social mission with the proceeds of their marketpriced lending operations the 1992 launch of banco solidario in bolivia marked the beginning of commercial microfinance it differed from the model pioneered by grameen in a revolutionary new way bancosol was a commercial and regulated financial institution and as such had a fiduciary responsibility toward depositors and investors since the founding of bancosol commercial microfinance has spread throughout the world the grounded theory exploration conducted in this context showed that engagement in institutional entrepreneurship as most social action does not occur in a social vacuum institutions are inhabited by social individuals institutional entrepreneurship is then not a lone endeavor but a social one this means that institutional entrepreneurs do not act in isolation but in the context of social groups all social groups are of course institutionally embedded but they are also unique contexts with references tinted by their shared history of routine and serendipitous interactions and the social dynamics which link and distance their members groups can be of any size a dyad qualifies and so does a baseball team but they are small enough so that the individuals involved know each other as distinct individuals their boundaries and membership are fuzzy but they have enough permanency so that much like a stage groups provide a context which motivates inspires and enables engagement in institutional entrepreneurship this finding is consistent with research which has shown groups to be crucial both as vehicles of socialization and social control as well as mechanisms of contestation and change and incubators of social change building on this coincidence the paper argues both for an inhabited conceptualization of institutional entrepreneurship as a groupinstead of individualbounded process and for the adoption of the small group the prototype mesolevel unit of analysis when exploring individual engagement in institutional entrepreneurship the adoption of an inhabited groupbounded conceptualization advances research in institutional entrepreneurship in at least two relevant ways first it helps to overcome what willmott has described as the voluntaristic bias of most microbased research on institutional entrepreneurship adopting an inhabited understanding of institutional entrepreneurship suggests that social dynamics such as interpersonal bonds and socialstatus competition influence peoples will to get involved in institutional entrepreneurship second adopting the group as the unit of analysis of reference helps to overcome the lack of historicity of much research on institutional entrepreneurship which produces a view of engagement as the product of punctual misalignments between individual interests and dominant logics specifically it helps us see decisions to engage in institutional entrepreneurship as part of a pathdependent history of interactions so engagements that outside of this path appear to be unwarranted and foolish emerge within it as judicious next steps in a stream of decisionmaking what the literature says about individual engagement in institutional entrepreneurship most of what we know about institutional entrepreneurship discusses conditions that explain why individuals can become institutional entrepreneurs on the one hand researchers adopting a macrolens have argued that it is individuals field positioning that allows and motivates engagement by framing their appreciation of how their interests are or are not aligned with field logics generally stated these scholars have suggested that the interests of individuals centrally positioned in a field are likely to be aligned with institutional logics and therefore these individuals will be motivated to engage in defending the status quo similarly they have argued that the interests of individuals located at the fringe of a field are likely to be misaligned with field logics and therefore individuals in these field positions have an incentive to get involved in efforts that run against the grain of field logics on the other hand researchers adopting a microlens on institutional entrepreneurship have by and large addressed the question of individual engagement considering the extraordinary skills and access to resources required to advance these efforts an emerging body of work embracing situated perspectives has begun to consider conditions that can explain differences in involvement among individuals facing similar circumstances rooted in the pragmatist and symbolic interactionist traditions in this research the status of individuals shifts from a role as accomplice to social processes of institutionalization and structuration to a role as agent whose motivations behaviors and relationships are central to their involvement individuals inhabit local contexts and their behavior varies depending on the peculiarities of these locals this research has yet to explore empirically the question asked in this paper why are individuals willing to engage in institutional entrepreneurship theoretically this research points to dissonance as the answer dissonance describes a cognitive state that people experience when their appreciation of situated circumstances violates their expectations of how things ought to be this cognitive state is unpleasant and can under unusual circumstances generate surprise puzzlement and thereby motivate individuals to engage in institutional thinking that is the type of reflective thinking that allows individuals to question their institutionallydefined expectations nevertheless a consideration of dissonance as the trigger for institutional thinking is at odds with a large body of both sociological and social psychological research this research has convincingly argued that when operating under conditions of dissonance individuals are more likely to engage in selective interpretation so that the situation is emptied of its problematic content than they are to experience puzzlement and engage in institutional thinking there is a need then for empirical research to further our understanding of the conditions influencing individuals will to engage in institutional entrepreneurship this paper addresses this need and explores this question using a framework which suggests that individuals will to engage depends on the copresence of three conditions their identifying an opportunity for involvement their perceiving the risks and costs involved as worthy and their accessing the resourcessupport required this threepronged framework is well accepted in the institutional entrepreneurship literature and facilitates a parsimonious analysis of the research question next the paper introduces the research methods followed in exploring why individuals are willing to engage in institutional entrepreneurship conducted in the context of the emergence of commercial microfinance in bolivia research methods data collected the author conducted more than 70 interviews including interviews with all central firsthand participants during several visits to bolivia between 1997 and 1999 following grounded theory interviewees included not only individuals who championed the new commercial microfinance archetype but also those who supported and resisted it and even individuals who remained on the sidelines all the critical participants were interviewed the openended interviews averaged oneandonehalf hours and followed a protocol of questions that evolved with the research project questions that persisted throughout the interview process included the following where did the original idea originate how and when did you become personally involved in the project or initiative how when and why did other people become involved all but a handful of interviews conducted in public spaces where sound quality was too poor were taperecorded and transcribed in addition because the emergence of commercial microfinance in bolivia had attracted the attention of development scholars the research also benefited from rich archival material that facilitated triangulation and enabled the author to complement field data with case studies written before during and following the fieldwork the study thus benefited from a historically informed understanding of the individuals and organizations that launched the first commercial microfinance organizations among the documents collected were case studies about microfinance in bolivia reports generated and statistical information collected by banking regulatory agencies and associations of organizations that lend to the poor technical reports published by donor organizations and other professional reports analysis analysis began with a simple narrative summarizing the individual efforts that paved the way for the emergence of commercial microfinance this was followed with a more indepth exploration of individuals who founded and led organizations with features that went against the grain of the logics of the organizational archetypes dominant in the field of provision of services to support the economic activities of the poor these engagements were identified as instances of institutional entrepreneurship when they met three conditions these individuals were involved in efforts that went against the grain of the logics governing the dominant archetypes with their involvement they assumed risks and costs beyond those regularly connected with their organizational position they actively leveraged support and resources to advance these againstthegrain efforts the value of applying these three criteria became clear in an iterative process of dialogue theory and data this process showed that adopting these criteria helped to identify multiple instances of institutional entrepreneurship and to match the empirical evidence of these instances with three factors which while enmeshed in the practice have been identified in the literature as influencing individual engagement in analytically distinct and relevant ways ie motivation to engage opportunity for engagement and resources to advance engagement the next two steps of the analysis involved an exploration of these three factors to identify patterns in the seven instances of institutional entrepreneurship identified using the above criteria the exploration revealed the influence on individual engagement of factors identified in the literature namely macroconditions such as events with hardtodisregard outcomes logic tensions and field positioning and microconditions such as access to skills and resources it also identified the influence of mesolevel conditions that had been previously considered subsidiary in our explorations of institutional entrepreneurship namely social dynamics including interpersonal bonds and status competition and a history of social interactions these conditions are introduced next to facilitate reading of the empirical evidence and findings in institutional literature interpersonal bonds have been equated with social capital and identified as relevant for individual involvement in institutional entrepreneurship considering their role in facilitating access to resources and support to advance these engagements the evidence suggested however that interpersonal bonds also can play a role in engagement by influencing peoples motivations to get involved it showed that as suggested in other bodies of research in organization theory individuals motivations to act are framed not only by their own interests but by those of others with whom the individuals have strong interpersonal bonds status competition describes decisionmaking following individuals expectations on how their decisions will influence their social status people derive status from material and cultural or symbolic assets and are said to win or lose status depending on their relative access to these assets the influence of status competition on individual involvement in institutional entrepreneurship has seldom been acknowledged in the institutional literature its influence however is well established in organization studies finally research on institutional entrepreneurship has discussed the influence of interactions on individual engagement fundamentally it has suggested that interactions can encourage engagement when they generate dissonance thereby creating an opportunity for individual engagement in institutional thinking but as discussed earlier this research still requires development to explain under what circumstances dissonance is likely to generate puzzlement and thereby engagement in institutional entrepreneurship since individuals have a tendency to discard dissonancegenerating events and information the next two sections introduce the case and present the exploration conducted the emergence of commercial microfinance in bolivia the emergence of commercial microfinance is considered an instance of institutional entrepreneurship because the features of this novel archetype run counter to those defining the other organizational archetypes dominant in the provision of financial services to the poor in the late 1980s state banks credit cooperatives and ngos central among these features were the following • a focus on providing services to the urban poor and particularly street vendors and the like the urban poor had never been the focus of state banks credit cooperatives or ngos engaged in lending • exclusive focus on providing financial services at the expense of other types of services such as training and technical assistance • lending practices defined by a manpowerintensive lending process and insistence on loan repayment • presence of an independent board of directors to oversee managers • financing of the lending portfolio with earned revenue savings from the public and commercial sources • the inclusion of private investors as shareholders in organizations providing services to the poor figure 1 provides a graphic description of the emergence and evolution of the largest ngos providing loans to the poor in bolivia table 1 provides a brief but comprehensive chronology of this evolution as shown in both two ngos namely prodem and procredito pioneered commercial microfinance with the founding of bancosol and los andes they were followed by fiengo which founded fie and a group of ngos which jointly founded ecofuturo other ngos among them promujer and crecer continued to operate as ngos and had never transitioned into commercial microfinance organizations the next sections discuss in detail the efforts that drove this evolution with a focus on what motivated individuals to engage how they identified the opportunity that inspired them and how they accessed the resources that enabled them to realize their efforts launching of bancosolngo and subsequent launching of bancosol bolivias urban poor had traditionally relied on loan sharks pawnshops and pasanaku 1 brokers for their workingcapital needs this reliance began to diminish when fernando romero launched bancosolngo in 1987 considering the hardtodisregard gamechanging conditions that bolivia was undergoing at this time the fact that ngos began to provide loans to the poor at this time appears unsurprising between 1980 and 1985 bolivias gnp fell by nearly 10 and inflation reached a historical high of 24000 at the time paz estenssoro was leading the country and under the advisement of the international monetary fund and the world bank his administration adopted drastic measures to deal with this unprecedented crisis one measure was the closing or restructuring of stateowned companies which was expected to result in sharp increases in unemployment in this context there was an urgent need for programs to support the economic activities of the poor including facilitating their access to loans but whereas the launching of ngos to provide loans to the poor was not surprising it was surprising for any ngo to have someone with the profile of fernando romero as founder and for it to have most of the features which we now associate with microfinance those listed earlier except the two last ones fernando romero possessed the ideal profile of an institutional entrepreneur an eclectic and vigorous entrepreneur with an intellectual bent he had the requisite social assets and political skills to champion this pioneering ngo but in the context of bolivia the involvement of any businessman in the ngo field including romero was to say the least unusual as sanchéz de lozada former president of bolivia observed bolivia has no anglosaxon tradition of philanthropy weve got confession to get us to heaven moreover romero had at this time little understanding of what microfinance was he had no problem with the idea of bancosolngo serving the urban street vendors unaware of how this ran against the grain of the practices dominant in the field but the motivation for his involvement was philanthropic and he was shocked when he realized that bancosolngo was charging interest rates that were about three times those charged by regular financial institutions in bolivia so why did he lead the founding of bancosolngo all interviewees including romero himself answered this question by pointing out how he was convened to do so by jack duncan the chairman of acción internationals board with whom he shared both a long history of interactions and a personal friendship recalled romero i met with duncan who was the first person i worked for when i graduated from mit in wr grace co and jack told me we are developing a small institution in boston that is called acción where we are putting together some money to give credit … and i said okay send me one of your guys romero would participate as chairman of the board and help the organization leverage local resources acción internationals staff would provide the operational knowhow and a carefully selected ngo professional would run the organization fatefully the professional hired for the job was francisco otero in the next quote otero explains how he was hired for the job this period the period he spent working with lending organizations in rural areas lasted about 10 years and it is when i learned a lot of things about providing loans to excluded people those not being served by the local institutions then in the year 86 is when acción international approaches me to run … at the same time my sister maria joined the organization in honduras … she had gained their trust and they said your brother what do you think and she said yes under oteros leadership bancosolngo succeeded beyond anyones expectations regardless of the high interest rates it charged people would wait for hours around the block to get a loan by 1991 bancosolngo had 22700 loans outstanding a portfolio of 46 million and an absurdly low loanrepayment default rate of 00002 moreover its client base was growing at a surprising 50 per year bancosolngos uncanny success came as a surprise to all involved nobody had realized the pentup demand for loans among bolivias poor the loans bancosolngo was offering were indeed expensive but poor borrowers had no access to regular bank loans bancosolngos loans when compared with the informal sources accessible to poor borrowers appeared reliable and even affordable romero who owned a commercial bank regarded bancosolngos success with disbelief he asked otero to take him on a field visit to learn firsthand who these people were that were borrowing and repaying their loans bancosolngos repayment rates were close to 100 a figure unheard of in the country even among its most reputable financial institutions interestingly bancosolngos uncanny success generated an unexpected problem donor funds the conventional source of financing for ngos were woefully inadequate to fuel the organizations fantastic rate of growth bancosolngos leadership had to revert to its members personal wealth just to keep up recalled one member of bancosolngos management team i remember going personally to the banks i knew and asking them for loans first i would ask them to use bancosolngos loan portfolio as guarantee but they would say no and ask for other assets and i would propose someones jewelry my fathers house pancho mortgaged his house we all mortgaged things to get money … what the donors were giving was just not enough bancosolngos operational success then can be fairly described as a moment of dissonance its success and the financing difficulties it generated created an opportunity for institutional thinking interestingly consistent with institutional theory insights the group of individuals involved namely accións staff otero and romero discussed and generated ideas which while testing their boundaries followed by and large the dominant financing logics accións staff within their role as ngo experts suggested a system of loan guarantee letters that bancosolngo could use to get loans from local banks the source of the guarantee funds was the same donations and thus this solution did not break with the dominant donationsbased model otero the local ngo professional managing the organization did not offer any specific solution he did suggest however that it was a big mistake to try to alleviate bancosolngos financing problems with guarantee letters or any other instrument dependent on donors every year we have to go out with the hat to get money to finance our growth he talked to anyone willing to listen about the need to grow bancosolngo so that it could masificar microfinance ie extend access to all romero shared oteros dislike for the need to pass the hat to get donor financing a painful reminder of bolivias dependency on the whim of donors but at this point in time he was rather disengaged from the organization disengagement was in fact the norm for all the businessmen who sat on bancosolngos board as a manager from bancosolngo commented board meetings happened over lunch and dessert would arrive before discussing bancosolngo an unexpected and fateful interaction with martin connell a member of accións board redefined the groups thinking as leaders of bancosolngo otero and romero were part of accións network and had traveled together to new york to attend accións 1989 board meeting connell invited them to join him for dinner during the meal connell said … we need to create a bank the interesting example … was done at the end of the 19th century by crédit agricole … they used the bakers and gave them a little box … t his will be difficult in latin america … we have to imitate mcdonalds much like the generative metaphor described by mary douglas and donald schön this piece of institutional debris put bancosolngos uncanny success and its financing difficulties in perspective for romero and otero crédit agricole had extended access to loans by working with local bakers connell thought bancosolngo could accomplish this by franchising like mcdonalds back in bolivia an energized romero and otero engaged in institutional thinking discussing their options they settled on a plan to launch a commercial microfinance bank they reasoned that with the creation of a commercial bank bancosolngo would like crédit agricole be able to access commercial funds including deposits and in this way it would be able to solve once and for all its fundraising difficulties but they had to convince accións staff to support their actions accións staff all ngo professionalswere reticent they worried that the commercial transition could in time push bancosol to abandon its social mission they were also concerned about the impact on acción itself restrictions on the ability of usbased notforprofit organizations to invest in forprofit endeavors constrained accións ability to invest in the future bank they said look we can get you a donation of 5 million but do not ask us to invest 100000 because it means accountability and it is forprofit and we do not have the situation romeros point of view prevailed but only when he turned his request into a personal appeal building on his longstanding bond with accións chairman and the newly formed one with accións general manager as romero commented this exception they took it because i insisted personally with jack duncan and also with bill burrows with the counsel of legal experts acción defined a solution that allowed it to invest in bancosol with this agreement romero otero connell and accións leadership began the arduous negotiations necessary to leverage the financial support and regulatory changes required to launch a commercial bank devoted to providing microfinance services they succeeded and the commercial microfinance bank banco solidario commenced operations in february 1992 plans to launch a development microfinance organization the professionals leading the other bolivian ngos also witnessed bancosolngos success in disbelief like romero they wondered why people were queuing for hours to get a 45 interestrate loan but these professionals did not use this moment of dissonance as an occasion to launch a commercial microfinance organization even though the ngos they headed were involved in providing loans they did not identify themselves as lenders but as development professionals from this perspective bancosolngos unique features such as targeting street vendors charging high interest rates and insisting on repayment were inappropriate and its plan to form a commercial bank with owners who could privately benefit from its operations was unwarranted and illegitimate a group of them namely the leaders of aned cidre fades fie and sartawi began discussing an alternative institutional entrepreneurship opportunity the launching of a development microfinance organization all local ngo professionals saw bancosolngos formation of bancosol as inappropriate to say the least and most remained disengaged but this group had emerged when these individuals worked together in the launching of fades an ngo devoted to providing loans to farmers from this social platform the launching of a development microfinance organization appeared as a reasonable response the organization they envisioned would follow up on their design for fades like fades it would have an independent board of directors populated not by businessmen andor private investors but by themselves and it would finance its portfolio with donor funds it would adopt those microfinance innovations that did not conflict with ngo logics such as microfinances manpowerintensive approach to loan evaluation but it would have a large portfolio of loans in manufacturing and agriculture and would not charge the high interest rates of bancosol have private investors or provide services other than credit this groups plan to launch a development microfinance organization did not progress in a fateful moment later referred to by interviewees as the los andes fiasco their conversations were unexpectedly sidetracked when cp zeitinger founder of internationale project consulting gmbf approached them with the proposal to work with ipc to launch an ngofounded commercial microfinance organization initially zeitingers invitation was welcomed as one participant observed it was perceived as an opportunity not to have to do this alone by themselves after all he had already secured funds from the gtz to finance the project but this enthusiasm was shortlived central to zeitingers project was the idea of selfsufficiency which he thought would be possible only if the organization provided only credit and focused initially on serving urban areas the group disagreed with his assessment which they perceived as overly intrusive he would get involved in areas of decisionmaking that are out of the scope of a consultant they wanted his knowhow and the funds from the gtz but they did not want him to change their plan he insisted and as a result his proposal was rejected by all except pilar velasco at the time the acting general manager of fiengo not surprisingly her decision cast her and by extension fiengo as social deviants the decision however allowed zeitingers initiative to continue plan to launch a commercial microfinance organization with fiengo which led eventually to the launching of los andes zeitinger began his consulting engagement with fiengo immediately but it was shortlived fiengos leaders were four women who had begun to provide loans the same year bancosolngo was founded and with financing from the interamerican development bank they had built a rather healthy loan portfolio pilar velasco had led the idea of engaging zeitinger and the other women had gone along but they soon began to have second thoughts zeitinger adamantly insisted that fiengo should change its board of directors to include individuals with a high social profile in the country recalled one member he would say you are a group of mere housewives and no one is going to want to hear what you have to say you need an umbrella of important people on the board fiengos founders worried about its implications for their own ability to control the future of fiengo since most had no background in finance it was possible for the new board to consider them unqualified and ask them to leave with little regard for their role in and contribution to the building of fiengo following their disagreement and distrust the group decided that fiengo should stop working with zeitinger they wanted to keep the funds that the gtz had earmarked for the project but they would ask the gtz to engage a different consultant to work with them as one member recalled w e began questioning why this man zeitinger wants to do this to us … t hen on a sunday we said leave us we are going to keep going alone without you pilar velasco disagreed but when she failed to convince the other group members she decided that the only logical thing to do was for her to resign from fiengo this was a difficult decision already written off as an outcast by the local ngo leaders with whom she had worked she was also now selfexcluding herself from fiengo her home institution which she had helped to found and which was her main source of income impressed by velascos bold decision zeitinger invited her to present with him a reformulated version of the project to the gtz in this new version the gtz funds would be used to launch a brandnew ngo earmarked to transition into a commercial microfinance organization together they rushed to the offices of the gtz in la paz rather dramatically they arrived a few hours before fiengos leaders could present their own request for a new consultant they were granted permission to use the funds earmarked for the project to launch the new ngo in 1992 working now with zeitinger and his consultants from ipc velasco assumed leadership of this new effort she leveraged the support and participation of friends and relatives who could act as an umbrella of important people and launched los andesngo in 1995 after arduous work and negotiations with the regulatory authorities los andesngo spun off from los andes the interpersonal bonds of the umbrella of important individuals that velasco had attracted played an important role in their successful lobbying for the new legislation needed to launch los andes as a commercial microfinance organization as shown in the following comment mr x a member of the los andesngo board has an important level of social standing he is in the chamber of commerce and has access to the leadership of the sbfi banking regulatory agency without having to go through secretaries or setting up audiences fiengos members decide to launch a commercial microfinance organization while velasco worked to build los andes her expeers at fiengo decided to launch their own commercial microfinance organization the group was fueled by their sense that without access to the commercial funds available to commercial organizations fie would not be able to grow its portfolio as rapidly and would unwarrantedly lose its status visàvis los andes consider the following comment by the leader of one of these ngos los andes was growing … and then we said if we do not risk it and continue we are going to remain a very small thing that at some point was a good idea and stay there in their founding of a commercial microfinance organization fiengos leaders had hoped to avoid having businesspeople on their board of directors the suggestion that sparked their disagreements with zeitinger but the regulatory agency insisted as the group grew convinced that they could not continue without assenting to this request they agreed to assume the risks associated and identified a private investor in mr johnson a local industrialist and invited him to join them fiengo launched its own commercial microfinance organization in 1998 interestingly the private financial fund legislation that the los andesngo founding group had lobbied into existence allowed fiengos founding group to gain the financial support and regulatory approval required to launch their own commercial microfinance organization in 1998 local ngo professionals reignite efforts to launch a development microfinance organization and decide to form a commercial microfinance organization the group of leaders of the other ngos involved in the los andes fiasco followed their own path and continued to be involved in two institutional entrepreneurship efforts namely a new plan to create a development microfinance organization and a plan to launch their own commercial microfinance organization in 1993 taking advantage of the bolivian congresss work on drafting new banking legislation the group spearheaded lobbying efforts for regulatory changes tailored to their vision for a development microfinance organization these changes would allow organizations engaged in lending to the poor to capture savings and deposits without requiring them to become forprofit or have private investors although they could have municipality governments as investors their idea was that with access to deposits and if needed public investment they would be able to access sufficient funds and keep up with the growth of bancosol and los andes but without undermining what they called the human side of microfinance their freedom to decide who and how to serve prioritizing clients human needs over financial concerns interestingly in parallel with these lobbying efforts three of them formed another group joining forces with the leaders of two other local ngos to launch together a commercial microfinance organization when asked about their participation in groups with parallel and apparently contradictory initiatives these individuals argued that it was the only way they could retain their competitive position in the words of one of them commercial microfinance is the future but we are resisting it so it would have a human face and not a monetary face … maybe tomorrow the group in power will decide that the ngos are not going to do microfinance anymore … in that case we are out of the battle it is for that reason that we are in ecofuturo to fight also from the side of pffs private financial funds source boletín financiero and annual reports year in which the organization transitioned into a commercial financial organization the efforts of the group working in the development microfinance organization related plan were only partially successful the bolivian congress included the desired language in the new law but the banking regulatory agency stalled on developing this language into specific legislation but the efforts of the group to launch a commercial microfinance organization prospered and this group launched ecofuturo in 1999 in ending this brief narrative it is interesting to note that there were several local ngo professionals who while affected by the emergence of commercial microfinance did not get involved in institutional entrepreneurship among them were the leaders of promujer and crecer two of the most successful local ngos providing microfinance promujers leaders were a local bolivian and an american living in the united states crecer was a foreign implant that belonged to an international network of organizations that provided services to the rural poor around the world it was led by a foreigner with no ties to the leaders of local ngos in contrast with the group of ngo leaders who got involved these individuals were engaged in alternative groups with pasts which did not include the founding of fades or discussions to create a development microfinance bank their lack of involvement in fades explains their disengagement from the local ngos discussions to launch a development microfinance bank their lack of involvement in these discussions in turn explains why they never perceived los andes as a suitable referent for their status calculations the leaders of promujer and crecer continued to successfully grow their organizations they adopted microfinance practices selectively consistent with their own organizational identity but they did not assume risks or costs beyond those necessary to advance their mission or leverage resources and support for projects that ran against the grain of the logics of the dominant organizational archetypes in short they were successful entrepreneurial individuals but they did not become invested in the advancement of any one organizational archetype by 1997 a street vendor in la ceja one of the busiest street markets in bolivia was receiving up to three visits a day from loan officers offering credit of note the private financial fund legislation lobbied for by los andes was not only used by ngos to launch commercial microfinance organizations but also coopted by private investors to launch forprofit consumer lending ones by 1999 the growth of these consumer lenders with their disregard for the risks of overindebting clients created a repayment crisis that threatened the survival of most organizations lending to the poor in bolivia following this crisis these consumer lenders closed their doors but at the time of writing this paper all the organizations covered in this study had survived the crisis and were still thriving poverty continues to be a significant problem yet bolivias poor both in urban and in rural areas have unprecedented access to financial services and the interest rates they pay for loans while still quite high have fallen substantially in 2012 they averaged around 18 about onefifth of what they had to pay to loan sharks and pawnshops their only sources of financing prior to 1987 findings groups as the stage for institutional entrepreneurship commercial microfinance emerged and developed in bolivia at the hands of groups of individuals who with their successful and failed institutional entrepreneurial efforts introduced and mainstreamed this novel organizational archetype two groups launched commercial microfinance organizations and their actions paved the way for others to launch new commercial microfinance organizations two others tried but failed to launch an alternative archetype and their failure further solidified the position of commercial microfinance as a legitimate organizational archetype for providing financial services to the poor a parsimonious look at these efforts suggests that the interactions and social dynamics that made up these fuzzilybounded groups acted much like a stage which motivated inspired and enabled the engagement in institutional entrepreneurship of these groups andor their members motivating engagement the institutional literature has explained individual motivation to engage in institutional entrepreneurship considering how field positioning defines the alignment or lack thereof between an individuals interests and field logics the evidence supports the influence of field positioning but also suggests that the social dynamics framing individual relations within their group stage crucially influence their perceptions of alignment beyond field positioning the groups involved in launching commercial microfinance organizations were positioned at the fringe of the field the creation of bancosolngo was led by a group that included the chairman of a usbased international ngo and a member of bolivias business elite duncan was acting on behalf of acción international advancing this organizations agenda of expansion without the benefit of additional evidence it is difficult to explain his engagement beyond his organizational role and field positioning but he was not leading the effort that person was romero his protégé who with little understanding of microfinance agreed to lead the launching of bancosolngo romeros acceptance was framed by his concern for the need to alleviate the impact of structural adjustment on the poor in bolivia however the likelihood of a member of the economic elite forming an ngo was small they got involved in social issues by assuming positions in government or financing churchbased charities not by launching ngos accordingly it is unlikely that romeros general concern for the poor would have materialized in his assuming the risks and cost of launching an ngo outside the group stage created by his interactions and interpersonal bonds with first duncan and subsequently the individuals who worked with him in bancosolngo ie bill burrows and pancho otero in the case of los andes the socalled los andes fiasco had positioned cp zeitinger and pilar velasco at the fringe of the ngo field but their field positioning only partially explains the motivation of this tight small group instead it is more easily explained by the interactions accompanying the fiasco zeitingers motivations can be easily understood by focusing on his organizational role but not ms velascos the eventual leader of the initiative her willingness to assume the risks and costs involved emerged from the interactions and decisions that created and followed the fiasco and particularly her decision to quit fie only by considering these interactions can we explain her accepting zeitingers invitation to request and use funds already earmarked for fie to launch los andes and her calling on her friends and family to support her in this endeavor the other initiatives were carried out by two overlapping groups of field insiders as in the case of field outsiders field positioning emerges only as a partial explanation for their engagement instead the two overlapping group stages housing these individuals explain why these ngo professionals and not others engaged the groups had emerged from past interactions which led to the launching of fades and were buttressed when their efforts to launch a development microfinance organization derailed from this stage bancosol and particularly los andes stood as relevant status referents and their fantastic operational success as a source of status loss the wish to regain status visàvis bancosol and los andes fueled the groups will to assume the risks and costs involved in advancing plans that would allow them to regain the lost status ie lobbying for regulations that would support the launching of development microfinance organizations and launching of a commercial microfinance organization absent from these overlapping groups ngo leaders did not consider bancosol and los andes as relevant status referents and therefore lacked the motivation to engage in institutional entrepreneurial efforts this insight which suggests that individuals past interactions influence who are perceived as relevant status referents and thereby individuals motivations for action is consistent with social psychological research exploring the influence of identity and status competition on decisionmaking within organizations inspiring opportunity identification as suggested in the institutional literature individual appreciation of opportunities to engage in institutional entrepreneurial efforts was facilitated by macroconditions with hardtodisregard outcomes such as bolivias hyperinflationary crisis and tensions in field logics such as those generated by the financial constraints experienced by bancosolngo engagement was also facilitated by a microfactor namely the dissonance generated by the unexpected and uncanny operational success of bancosolngo these macroand microconditions provided ground for opportunity identification but who perceived in these conditions an alignment with their individual interests so as to justify their engagement in institutional entrepreneurship is better explained by looking at how these macroand microconditions interplayed in the mesogroup stage first romeros initial involvement in the launching of an ngo with unusual attributes did not follow from the identification of an opportunity but by his being convened to engage by jack duncan with whom he shared a lengthy history of interactions and a personal friendship but romeros later engagement in launching the commercial bank bancosol emerged within a group stage which now included not only mr duncan but also the other members of accións staff and pancho otero it occurred in the milieu of the financing difficulties created by the unexpected and uncanny operational success of bancosolngo but it was fueled by oteros interpretation of bancosolngos success as an opportunity to democratize access to loans in bolivia and it was irremediably kindled by the interaction with connell who unveiled the surprising parallels between bancosolngo and crédit agricole second the initiative to develop los andes can be traced back to plans that zeitinger and his staff at ipc had defined prior to their involvement and therefore can also be explained without reference to the mesogroup stage however it required the involvement of pilar velasco in order to progress only with her engagement as leader of the initiative could it advance but the engagement of someone with ms velascos profile can only be explained considering the group stage in which she was operating the launching of a brand new ngo from scratch ran against the grain of dominant practices something that both zeitinger and velasco aware of its illegitimacy dismissively described as an exercise in artificial insemination the engagement of both zeitinger and particularly velasco in such a deviant initiative is hard to imagine outside the tight grouping of zeitinger and velasco after her decision to abandon fiengo third and finally as mentioned earlier the other initiatives were led by groups of field insiders the literature on the influence of field positioning suggests that these individuals were likely to get involved but only in defense of the dominant archetype that housed them the evidence however shows that they did not work to protect the established archetype and instead engaged in advancing an alternative although related archetype namely a development microfinance organization the features of the development microfinance organization were close to that of the dominant archetype but they still differed from it in relevant ways the group stages created by these professionals history of interactions crucially explains their inspiration to engage first in launching a development microfinance bank as well as their later engagement in the launching of a commercial microfinance plan the development bank plan can be explained considering the history of interaction of the group which placed fades and not crédit agricole as the relevant historical referent the commercial microfinance plan can be explained considering changes in members shared understandings sparked by the los andes fiasco which placed two commercial financial institutions as relevant operational referents for the provision of financial services to the poor enabling access to resources and support finally as has been previously argued in the literature the evidence does suggest that the interpersonal bonds facilitated access to resources and support and thereby enabled institutional entrepreneurship the launching of bancosolngo and bancosol was enabled by the wealth of international knowhow and access to international donors brought by duncan and his staff from acción they were also enabled by romeros access to local sources of financing as well as his reputation as a successful businessman in turn the launching of los andes was enabled by the knowhow and access to financing brought by zeitinger and his staff as well as the network of family and friends brought by velasco crucial in negotiations for regulatory approval interestingly the evidence suggests that individuals may engage in institutional entrepreneurship even in the absence of an enabling group stage but it also suggests that without this stage efforts are likely to fail efforts to advance the development microfinance archetype failed largely because individuals could not mobilize funds or regulatory support moreover the later efforts of these individuals to earlyadopt the commercial microfinance model with the launching of fiepff and ecofuturo were possible not because the group stage of its founders enabled their accessing the required resources and regulatory support but because supporting these endeavors had become institutionally acceptable following the launching and operational success of bancosol and los andes in summary the evidence does not disconfirm that macroand microconditions allowed individuals to become institutional entrepreneurs but it suggests that we can explain why individuals facing similar macroconditions and with similar microprofiles have a different likelihood of engaging in institutional entrepreneurship considering the interplay of macroand microconditions in the mesogroup stage engagement in institutional entrepreneurship requires motivation opportunity and resources and these three elements can be present at the group level even when they are not at the level of its individual members the social dynamics linking individuals can motivate engagement and the shared references tied to the group can inspire opportunity identification in addition the evidence shows the relevance of looking at the group as enabling institutional entrepreneurship by facilitating or not facilitating access to the support and resources required to advance institutional efforts table 3 provides a summary of the findings discussion of findings implications and future research this paper asks why individuals are willing to engage in institutional entrepreneurship the exploration of this question conducted in the context of the emergence of commercial microfinance in bolivia suggests that it is crucial to consider this question at the mesogroup level of analysis prior research has acknowledged the role of one mesolevel factor namely linkages among individuals but only considering their influence as a source of resources and support to advance institutional efforts but in the institutional entrepreneurship efforts studied the group stage emerged as central both to motivation and opportunity identification it also played a role in enabling access to resources and support but this role was subsidiary it explained only which institutional entrepreneurship initiatives advanced while others fail to do so the paper then advances an inhabited institutions understanding of institutional entrepreneurship and argues for the adoption of the small group the prototype mesolevel unit of analysis to explore why individuals will engage in institutional entrepreneurship this reorientation from the microto the mesolevel of analysis alleviates the need for the heroic conceptualizations that populate most research on institutional entrepreneurship institutional entrepreneurs do not need to be heroes with superhuman foresight and enough resources to spark processes of institutional change they need only to inhabit a group stage that simultaneously motivates inspires and enables engagement in institutional entrepreneurship such group stages may be rare the product of unexpected momentous andor serendipitous circumstances but their inhabitants do not need to possess the kind of superhuman qualities currently associated with institutional entrepreneurs the proposal to adopt the small group as the unit of analysis of reference implies a rethinking of the methodological individualism defining institutional entrepreneurship scholarship on the linking of microactions and macrooutcomes the value of methodological individualism is that it assures that individuals regain their centrality after they have all but disappeared from organizational institutionalism the problem of methodological individualism is what willmott has described as its voluntaristic bias that is that even though our understanding of institutions builds on the insight that individuals cannot escape the institutions framing their behavior we explain individuals engagement in institutional entrepreneurship suggesting that it is possible only when individuals do escape the cognitive influence of institutions by adopting the small group as the unit of analysis we can overcome this bias as it explains engagement without escaping the institutions framing their cognition by pointing to the historicity and sociality of individuals decisions to engage in institutional entrepreneurship lack of historicity plagues most research linking individual efforts and macrooutcomes in the institutional entrepreneurship literature this problem has been acknowledged still by and large our current conceptualizations suggest that individuals identify opportunities for engagement as if in a temporal vacuum the process hinges only on the alignment or lack thereof between individuals interests and field logics from this perspective people are expected to motivating engagement the group stage fuels individuals will to assume the risks and costs involved inspiring opportunity identification the group stage allows individuals to appreciate alignments between their interests and field conditions invisible to nonmembers enabling access to support and resources the group stage defines access to resources and support to advance institutional initiatives identify opportunities for engagement only when there is misalignment or when the existing alignment is under threat adopting the small group in contrast highlights that the inspiration for opportunity identification is path dependent current decisions depend both on past interactions as well as individuals expectations of future ones within a pathdependent history of interactions decisions that without it may appear to be unusual unwarranted and even deviant emerge as a judicious next step in a stream of decisionmaking researchers have suggested that without abandoning the individual as the unit of analysis we can gain historicity when we conceptualize individuals considering not only their skills and interests but also their personal biography but adopting the small group has the additional advantage of facilitating observation of the influence of social dynamics which otherwise frame individual decisionmaking processes first up until now institutional entrepreneurship research has acknowledged the value of peoples interpersonal connections as relevant to leverage resources and support in contrast this paper suggests that the group is irremediably enmeshed with individuals will to engage and that its influence in mobilizing support and resources explains not the likelihood of their engagement but whether that engagement translates into field change this insight needs to be further explored and confirmed with research projects that like this one consider not only institutional entrepreneurial initiatives that do generate the field change desired by their promoters but also those that fail to generate it second adopting the small group allows us to expand our understanding of the conditions that motivate individuals to assume the costs and risks of engaging in institutional entrepreneurship people may be motivated to pursue an individual interest but they may also be motivated to engage at the service of other individuals with whom they are tightly connected incorporating interpersonal bonds as a source of motivation is relevant because it helps explain the engagement in institutional entrepreneurship of individuals who like romero may have the profile and resources to do it but lack the a priori motivation to get involved and may do so only when convened by others this insight calls for research which problematizes who is the institutional entrepreneur it may be that the institutional entrepreneur is not a solo individual with the foresight skill and resources to advance a highly valued interest but participants in a small group which motivates inspires and enables engagement third and finally adopting the small group pushes researchers to consider social dynamics other than interpersonal bonds for example status competition as relevant motivation for individuals to engage in institutional entrepreneurship the institutional literature has acknowledged the influence of status calculations in individuals decisions to engage but by disregarding the influence of the group stage on how individuals identify their status competitors this research cannot explain differences in motivation among individuals with similar field positioning in contrast by adopting the small group we can explore differences in engagement considering differences in the stage framing their decisionmaking the identification of competition for social status as a relevant dynamic emerged from the evidence but there may be other social dynamics that are relevant in other settings the sources can be varied and include social dynamics explored in the social psychology literature for example gossip or envy the relevance of the small group to advance our understanding of institutional entrepreneurship emerged inductively from the study the empirical setting however was rather specific in ways that may be hard to replicate in other studies la paz bolivias capital city and the stage where commercial microfinance emerged is a rather small social space at the time data was being collected for this study it was common for the promoters and managers of microfinance organizations to meet casually at a restaurant or club in la paz or per the invitation of a donor organization at a microfinance forum in washington dc or in frankfurt germany the tightness of this social space facilitated in the manner of a petri dish to observe and understand the clustering of individuals along boundaries of small groups that did not respect organizational or sociodemographic boundaries something difficult to appreciate in most field contexts owing to the considerable number and geographic dispersion of sites nonetheless considering the ubiquity of small groups the research proposals advanced in this paper might be useful to explore institutional entrepreneurship within more restricted collectives such as organizations current research on inhabited institutions provides a good starting point for this research program in finishing it is important to mention that the idea of using the small group as the preferred unit of analysis to explore the interplay of microactions and macrooutcomes has been proposed in the context of research on civic engagement the findings of this paper regarding its centrality to understand individual engagement in institutional entrepreneurship call attention to the need to explore the potential overlap between these two concepts an action is considered civic engagement when it concerns advancing a collective instead of a private interest collective interests involve hardtoprivatize desired outcomes this condition is not required for institutional entrepreneurial actions instead an action is considered institutional entrepreneurship when it advances changes or undermines institutional practices logics and structures nevertheless the actions identified in this paper and others identified both in the literature on civic engagement study of 19thcentury french workingclass protests or opp and gerns research on the tearing down of the berlin wall and the literature on institutional entrepreneurship work on consumerwatchdog organizations or maguire and colleagues research on hivaids treatment advocacy do both they advance collective interests and have institutional impact this recognition points to the need for research exploring whether all or only some institutional entrepreneurial actions can be fairly described as forms of civic engagement the potential theoretical benefits of such research are substantial including a clarification of the current rather blurred distinction between entrepreneurial and institutional entrepreneurial actions a large overlap would imply that we could define institutional entrepreneurial actions as those entrepreneurial actions with hardtoprivatize outcomes author biography silvia dorado is associate professor of management at the university of rhode island her research explores processes of entrepreneurship in the context of social change including the emergence and survival of socioeconomic hybrid organizations silvia received her ba degree from universidad autónoma de madrid her ma from the massachusetts institute of technology and her phd from mcgill university

this paper contributes to the emerging literature on inhabited institutions it argues that institutional entrepreneurship as most social action is not an individualbounded endeavor at the hands of isolated individuals but a groupbounded one at the hands of social individuals inhabiting groups which motivate inspire and enable their engagement the inhabited groupbounded conceptualization offered helps to overcome voluntaristic biases and atemporalism plaguing much micro research on institutional entrepreneurship the paper builds on a qualitative case study of the emergence of commercial microfinance in bolivia

Background The spread of human immunodeficiency virus remains a critical global public health problem. According to statistics from the Joint United Nations Program on HIV/AIDS , 36.9 million people worldwide were living with HIV in 2017 [1]. Sexual transmission is the most common mode of HIV transmission. Young adults, as a sexually active group, are especially susceptible to HIV infection. The estimated number of young adults newly infected with HIV in 2017 was 0.53 million, accounting for 29% of new HIV infections [1]. China had more than 0.79 million HIV-infected people as of April, 2018 [2]. Moreover, a striking increase in HIV prevalence among university students in China has been noted. Statistics from the Chinese Centre for Disease Control and Prevention revealed that from 2011 to 2015, the number of new HIV infections among university students increased by 35% annually and that male students accounted for 80% of the infections [3]. The epidemic could be attributed to several causes. Compared with older generations, contemporary Chinese university students are more open to premarital sex and more likely to begin sexual exploration in college [4]. Male university students possess more permissive attitude towards casual and premarital sexual activities than their female counterparts [5]. However, due to the lack of sexual health education, university students may have a higher likelihood of engaging in risky sexual behaviours, including having sex with commercial sex workers and/or multiple sex partners, and inconsistent use of condoms with casual sex partners [6,7]. The rapid increase in HIV prevalence among university students has gained the attention of the Chinese government. The Ministry of Education and the Ministry of Health jointly issued a document on HIV prevention and among undergraduate students and required schools to provide mandatory education programs on HIV prevention starting in 2015 [8]. HIV prevention services for students are also widely promoted on campuses [9,10]. Various activities organized by the colleges/universities have helped students improve their knowledge of HIV, sexual health, and HIV testing [11]. Despite better access to information on HIV prevention, university students failed to take full advantage of HIV prevention services and demonstrated inadequate knowledge of and improper behaviours in HIV prevention. According to previous studies, only 56.3% of students mastered the basic knowledge of HIV in Wuhan [12]. About 70% of the students still ignored consistent condom use, though they clearly knew that condom use could greatly reduce HIV risks [13]. The lack of translation from knowledge to prevention action was particularly severe among male university students [14,15]. Although university students could access HIV testing through the Red Ribbon Association and blood donation vehicles as well as through self-testing kits available for purchase, only 4.5% of male university students had HIV testing in Guangzhou [16]. This number is even more sobering when compared with corresponding data from the United States, where 37.4% male university students received HIV testing [17]. Factors including low awareness and accessibility to testing services might impede the use of HIV-testing services among Chinese university students [18]. Many studies have described HIV-related knowledge, attitudes, and behaviours and HIV testing among college students [12][13][14][15][16], while information on the use of HIV prevention services, including HIV prevention education and HIV counselling and testing services is very limited but extremely important. It is urgent to conduct studies targeting male students, since HIV prevalence among undergraduate students has been growing at an alarming rate in the past five years, especially among male undergraduate students in China. The present study aims to describe the use of HIV prevention services, HIV-related knowledge, sexual attitudes and behaviours among male undergraduate students in Hunan, China, and to determine factors associated with the use of HIV prevention services. This study may collect information and provide evidence for the design of HIV prevention programs tailored to the preferences and characteristics of male undergraduate Chinese students. --- Methods --- Settings and participants This cross-sectional study was conducted in Hunan, a Central China province. Home to 70 million people, Hunan has approximately 20,000 HIV-infected patients [19]. The 109 universities and colleges in Hunan provide higher education with a variety of disciplines. According to the document on HIV prevention jointly issued by the Ministry of Education and Ministry of Health, all colleges and universities are required to provide HIV/ AIDS prevention education at the very beginning of university life [8]. To fully mobilise students' enthusiasm in participating in AIDS prevention, various youth-friendly services such as lectures, billboards, videos, and school media publicity are encouraged in the universities. All universities/colleges in Hunan offer health education on AIDS prevention, but HIV testing is not available on university campus. Students can access HIV testing at local CDCs, nearby health facilities, or community-based organisations for HIV counselling and testing. The target population of this study was male undergraduate students. Approximately 60,000 male undergraduate students from three comprehensive universities in Hunan were purposefully sampled to ensure an adequate representation of students from various majors and different grades. With the permission of the Student Union of the three universities and departments, we asked for recruitment assistance from each grade. The participants were recruited via peer referral in the selected cohorts. Via WeChat , we successfully sent a unique two-dimensional code linking the electronic questionnaire to potential participants who worked for the student unions of various grades in the universities. In all three universities, these participants then disseminated the two-dimensional code via WeChat group to undergraduates of different grades and various majors. Male undergraduate students who were 18 years and above and used WeChat were eligible for this study. The sample size was calculated based on the proportion of HIV testing. The rate of HIV testing reported in previous studies in Chinese undergraduate students varied from 2.8-47.1% [20,21]. Based on the detection table of the sample size for proportions in Hulley et al. [22], assuming the prevalence of HIV testing was 25%, and for a confidence level of 95% with the width of confidence interval of 0.10, the optimum estimate of 288 students was required. As sexual experience is a precondition of HIV testing, the total sample size based on the proportion of sexual behavior occurrence among Chinese male undergraduate students [23] was 1365 by assumption in this study. --- Study variables and measurements Demographic data regarding the students' age, grade, ethnicity, area of residence, with or without a sexual partner, etc. were collected. Behaviours such as smoking, alcohol drinking, and sexual orientation were also assessed. HIV-related knowledge was assessed with a 13-item questionnaire. The questionnaire was developed on the basis of the unified National AIDS Sentinel Surveillance Questionnaire designed specifically for university students [24] and the existing literatures [25]. Each item was measured via a yes/no/uncertain format, and only the correct response scored 1 point. Mastering 85% or more of the knowledge in the questionnaire was considered as having sufficient knowledge, and a total score of 11 or higher was required to demonstrate 'sufficient knowledge'; otherwise, respondents were regarded as having 'insufficient knowledge'. The internal reliability for this questionnaire was 0.64. In this study, the Sexual Attitude Scale was used to measure the undergraduates' sexual attitudes [26]. The 7-item scale assessed the attitudes towards premarital sex, extramarital sex, commercial sex, homosexual behaviours, one-night stand, and multiple sex partners. Participants rated items on a Likert scale ranging from 1 to 5 . For each item, scores lower than 3 were recoded as 'unacceptable' , and scores of 3 and higher were recoded as 'acceptable'. A composite score was obtained by summing up the scores of each item, with higher scores indicating more conservative sexual attitudes. The original 6-item scale assessed commercial sex behavious without distinguishing between 'paying for sex' and 'selling sex'. In the current study, participants were asked to respond to both situations. The Cronbach's alpha for this scale was 0.84. Sexual behaviours were assessed by asking students about their sexual experiences, heterosexual/ homosexual behaviours, commercial sexual behaviours, and condom use in the past year [24]. Participants who had sexual intercourse in the last year were asked to rate the frequency of condom use on the basis of four response options . HIV prevention services were operationally defined in this study as HIV educational programs, counselling services, and testing services. Considering the differences between the HIV prevention services provided by colleges and universities, public health sectors, and communitybased organisations, the following five questions were asked: Did you receive any HIV prevention education organised by the university in the last year? What types of educational activities did you participate in at the university? Did you take an HIV test in the last year? Are you willing to take an HIV test? and If you are not willing to take an HIV test, what are your reasons for refusing to do so? These questions were designed by the investigators after collecting information from people who organized campus HIV prevention programs and after conducting literature reviews [27,28]. --- Data collection Data were collected online via the Chinese professional survey website Wenjuanxing from November 2017 to January 2018. All potential participants accessed the questionnaires by scanning the two-dimensional code with WeChat, and they were able to submit the questionnaires only when all items were finished. Students were allowed to complete the self-administered questionnaire, which took approximately 20-30 min, in their spare time. Each participant received a bonus of 5 RMB online upon the completion of the survey. To avoid repetition, questionnaires bearing the same IP address as previously submitted questionnaires were not accepted. --- Statistical analysis The data were analysed with SPSS version 20.0. Frequencies, percentages, means, and standard deviations were used to describe the demographic variables, HIV-related knowledge, sexual attitudes and behaviours, and use of HIV prevention services. A chi-square test was used to assess the association between sexual behaviours and the frequency of condom use. Additionally, univariate and multivariate logistic regression analyses were conducted to examine factors associated with the use of HIV prevention education services in colleges and universities. Variables identified as statistically significant at a level of p < 0.1 in the univariate logistic regression analysis were entered into the multivariate logistic regression model with a stepwise forward approach. All statistical analyses were two-tailed, and α level of 0.05 denoted statistical significance. --- Results --- Demographic characteristics Of the 2432 invited male undergraduate students, 254 were excluded by the inclusion criteria . Of the remaining 2178 students, 747 declined to complete the questionnaire, resulting in a final sample of 1431 completed and valid questionnaires. The participants were 18 to 25 years . Most were of Han nationality from urban districts , majoring in nonmedical fields , not living with sexual partners , and from lower grades . Roughly one-fifth of the participants self-reported cigarette smoking, and more than half self-reported alcohol drinking. The majority of the students regarded themselves as heterosexual , and the remaining students considered themselves as either homosexual, bisexual, or unclear . --- HIV knowledge Overall, 1099 students scored 11 or above in HIV-related knowledge, and were considered as having sufficient knowledge. Among the 13 HIV knowledge questions, the two items on safe sex were answered correctly mostly: 97.7% of the students believed unprotected sex would increase the probability of HIV infection, and 95.7% thought using condoms during sex would decrease HIV transmission. Four items had a correct response rate below 80%: two items on HIV transmission routes, namely whether one could be infected through mosquito bites and whether one could be infected by kissing HIV-positive people, showing a correct response rate of 75.3 and 69.7% respectively. The other two items related to the situation after HIV infection had the lowest correct response rate of 69.0 and 62.9%, namely whether AIDS was equal to death and whether HIV antibody could be detected within one week after the infection. These answers indicated that students with sufficient HIV knowledge still had misconceptions that needed further clarification. --- Sexual attitudes and behaviours Our sample demonstrated a highly acceptable attitude towards premarital sex and a neutral attitude towards homosexual sex. For premarital sex, 77.1% of the participants reported acceptable , and 41.8% reported homosexuality acceptable . As to other types of sexual behaviours, 27.9% believed one-night stand acceptable , 22.8% expressed paying for sex acceptable , 17.3% considered selling sex acceptable , 15.2% thought having multiple sexual partners acceptable , and 13.2% stated extramarital sex acceptable . Totally 299 out of the 1431 male undergraduate students reported active sex partners, and 49 out of the 299 engaged in sexual behaviours with males. Regarding sexual partners in the last year among the 299 sexually actively students, 250 reported having sex with fixed female partners, 81 had casual female partners , and 15 had commercial female partners; whereas 33 had fixed male partners, 22 had casual male partners , and 11 had commercial male partners. Those students who had sex with females or male casual partners scored higher in sexual attitudes with more open sexual attitudes. Frequencies of condom use were significantly different among the groups with different partners . The post hoc analysis showed that the variance was mostly attributable to the larger proportion of students who never used condoms when they had sex with casual or fixed male partners and a smaller percentage to those with fixed female partners . --- Use of HIV prevention services Of all the male undergraduate students in the sample, 1068 used HIV prevention education services provided by colleges universities in the last year. More than half of the students had used two forms of the university education services, including publicity materials / billboards and lectures. Other educational services included HIV testing services. Only 105 male students had HIV testing in the last year, but the majority reported willingness to take the tests, and the reasons of 321 students' unwillingness to take HIV testing were given . --- Factors related to the use of HIV prevention education services in colleges and universities Variables significant at p < 0.1 level were included in the multivariate logistic regression. Students who were older , from higher grade , and those who drank alcohol , and had more open attitudes towards paying for sex were less likely to use HIV prevention education services in colleges and universities . --- Discussion Due to the deep influence of Confucianism for thousands of years, Chinese people are believed to be relatively more conservative to sex topics and activities than people in western countries. Chinese greatly emphasize fidelity in marriage relations. However, the moderately open sexual attitudes to premarital and homosexual behaviours uncovered in this study showed the great change in sexual attitudes nowadays among male undergraduate students as compared with those of a decade ago [29,30]. Risky sexual behaviours, especially among homosexual males, were common in this study. The use of HIV prevention services was not satisfactory in this sample. Male undergraduate students in Hunan exhibited open attitudes to premarital sex and homosexuality, which has also been shown in previous studies [31,32], indicating that premarital sex has became frequent. Male students' acceptance of homosexuality was also shown by Kar and colleagues [33]. Although open sexual attitudes help decrease the level of concealment and stigma associated with homosexuality [33], such attitudes may result in an increase in high-risk sex. Sex education, especially education on safe sex, should be urgently incorporated into current HIV prevention programs on campuses. Regarding sexual behaviours, about 21% of the male undergraduate students were sexually active with inconsistent use of condoms, and having sex with casual partners was also common. This finding echoes a previous study conducted in Hefei, China [34], but is much lower than that in Ethiopia reporting more than 70% of university students were sexually active [35]. Alarmingly, though unprotected sex was reported disproportionately by male students with different sexual orientations, it was more frequent during homosexual behaviours, in line with Rong's study [36], which found that risky sexual behaviours were significantly more prevalent among homosexual and bisexual males than heterosexual males. Given the situation that pre-exposure prophylaxis is not widely accessible in China [37], HIV prevention programs specifically designed to reduce high-risk sexual behaviours among men having sex with men are quite necessary on campuses. Nearly four-fifths of this population demonstrated sufficient knowledge by the National AIDS Sentinel Surveillance Questionnaire to assess HIV knowledge. However, high level of HIV knowledge did not show significant associations with safe sex behaviours and use of HIV prevention services. The inconsistency between sufficient HIV knowledge and engaging in risky sex may be caused by the limited HIV knowledge acquired in China, which includes only basic HIV knowledge tailored to the general population. No knowledge about the details of sexual behaviours and unprotected sex was available in the curriculum for most Chinese college and university students. More comprehensive, specific, and detailed information on HIV, especially knowledge of safe sex, should be included in specific HIV knowledge questionnaires and school-based HIV education services. According to this study, the use of the HIV education services in colleges and universities was only slightly higher than 70%, much lower than the expectation that all undergraduate students should receive As suggested in Chi's study [38], HIV prevention education should be more specific to the targeted population, and diverse teaching techniques should be adopted and more comprehensive information included. Considering contemporary education services and the national regulation that HIV education in colleges and universities should clearly focus on students [39], it is essential that university HIV education services for male students include useful and practicable knowledge and details which should be distinguished from general HIV education services. Our findings indicated that male students who were older or in higher grades, and who drank alcohol and had more open attitudes towards paying for sex were less likely to utilise the HIV prevention services organised by universities, suggesting more integrated HIV prevention services are needed for these subgroups. Further qualitative studies are encouraged to help determine the specific needs of male undergraduates and better evaluate HIV education services in colleges and universities. The extremely low use of HIV testing services was also worrisome. We found that the rate of accepting HIV testing was far lower than that of the willingness to be tested due to concerns about privacy exposure and the lack of routine HIV testing in the health service facilities on campuses [40], and also rapid HIV testing has not been widely adopted by colleges and universities in China. Two of the three universities included in this study did not offer rapid HIV testing among students during our survey. This sharply decreased the accessibility of HIV testing, partially contributing to the low rate of testing among this sample. Most of the concern focused on male students who are sexually active , who engage in risky sexual behaviours, and who have inadequate access to individualised HIV prevention counselling and HIV testing on campus. They also have concerns about the potential burden of HIV-positive results which in turn contributes to the low use of HIV testing service [41]. Integrating HIV counselling and testing services into university health care services will help improve the accessibility of HIV services among students and meet the needs of those who are at high risk of HIV infection. Wu and colleagues' [42] suggested that sharing and integrating resources are important strategies for AIDS prevention in colleges and universities. We also suggest that routines for providing HIV services should be developed. Moreover, students should be widely informed of the availability of these services and provided with sufficient contact resources. Several limitations may influence the generalisability of the findings. Firstly our participants were recruited from only three universities in Hunan, and caution should be aroused as to the application of these findings to other university students. Secondly all the data were selfreported and might be subject to selection bias, measurement error, or desirability bias, especially the data on risky sex. Furthermore, the questionnaires for measuring sexual behaviours and use of HIV prevention services were devised by the researchers and thus validation should be taken into consideration. Future studies with more representative samples and more standardised and valid measurements are expected to provide important evidence for developing effective HIV services in Chinese colleges and universities for male undergraduate students. --- Conclusions Although male undergraduate students demonstrate an open attitude to premarital sex and engage in high-risk sexual behaviours, their use of HIV prevention education services is unsatisfactory. HIV education services in Chinese colleges and universities should be designed and provided comprehensively taking into consideration the needs of male undergraduates, including open sexual attitudes, risky sex, imbalance between HIV knowledge and high-risk behaviours, and willingness to take HIV testing. Programs aiming to change the risky sexual behaviours and develop accessible HIV counselling and testing services on campuses are urgent and critical for HIV prevention in Chinese colleges and universities. --- --- Abbreviations China CDC: the Chinese Centre for Disease Control and Prevention; HIV: Human immunodeficiency virus; MSM: Men having sex with men; UNAIDS: the Joint United Nations Program on HIV/AIDS Authors' contributions XHH, XJY, and WHH conceived, designed the study, and obtained grants. XHH, XJY, and XZZ collected the data. XHH, XJY, and XH analysed the data. XHH, XJY, XZZ, and WHH wrote the paper. WAB, XH, LXH, and GL reviewed and edited the manuscript. All authors read and approved the manuscript. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: The dramatic increase in human immunodeficiency virus (HIV) infection among undergraduate students in China, especially among the male students, is alarming. This study aimed to describe sexual attitudes and behaviours and to examine the use of HIV prevention services and related factors among male undergraduate students in Hunan, China. Methods: A cross-sectional survey was conducted from November 2017 to January 2018 among male students from three universities in Hunan, China. Self-administered questionnaires were uploaded online to collect data anonymously. HIV-related knowledge and sexual attitudes were assessed with the unified National AIDS Sentinel Surveillance Questionnaire and Sexual Attitude Scale, whereas sexual behaviours and use of HIV prevention services were examined with researcher-created questionnaires. HIV-related knowledge, sexual attitudes and behaviours, and use of HIV prevention services were described. Chi-square test and logistic regression were used to analyse the factors associated with the use of HIV prevention education services. P values ≤0.05 were considered significant. Results: Of the 1431 respondents, 1068 (74.6%; 95% CI: 72.4-76.0%) used HIV prevention education services and 105 (7.3%) took HIV testing. The openness of sexual attitudes was moderate overall. About 299 (20.9%) of this sample had active sex partners, and 49 (16.4%) of them had sex with males. The consistent use of condoms was unsatisfactory among the sexually active students, especially among those with homosexual behaviours. Participants who were older in age (OR: 0.77, 95% CI: 0.70-0.86), who were university seniors (OR: 0.80, 95% CI: 0.70-0.91), who drank alcohol (OR: 0.71, 95% CI: 0.55-0.93), and who had open attitude towards paid sex (OR: 0.72, 95% CI: 0.54-0.95), were less likely to use HIV prevention education services. Conclusions: Although male undergraduate students show open attitude to premarital sex and engage in risky sexual behaviours, their use of HIV prevention education services is unsatisfactory, particularly in terms of HIV testing. More comprehensive and specific education on HIV prevention and testing services should be designed and offered on campus.

background the spread of human immunodeficiency virus remains a critical global public health problem according to statistics from the joint united nations program on hivaids 369 million people worldwide were living with hiv in 2017 1 sexual transmission is the most common mode of hiv transmission young adults as a sexually active group are especially susceptible to hiv infection the estimated number of young adults newly infected with hiv in 2017 was 053 million accounting for 29 of new hiv infections 1 china had more than 079 million hivinfected people as of april 2018 2 moreover a striking increase in hiv prevalence among university students in china has been noted statistics from the chinese centre for disease control and prevention revealed that from 2011 to 2015 the number of new hiv infections among university students increased by 35 annually and that male students accounted for 80 of the infections 3 the epidemic could be attributed to several causes compared with older generations contemporary chinese university students are more open to premarital sex and more likely to begin sexual exploration in college 4 male university students possess more permissive attitude towards casual and premarital sexual activities than their female counterparts 5 however due to the lack of sexual health education university students may have a higher likelihood of engaging in risky sexual behaviours including having sex with commercial sex workers andor multiple sex partners and inconsistent use of condoms with casual sex partners 67 the rapid increase in hiv prevalence among university students has gained the attention of the chinese government the ministry of education and the ministry of health jointly issued a document on hiv prevention and among undergraduate students and required schools to provide mandatory education programs on hiv prevention starting in 2015 8 hiv prevention services for students are also widely promoted on campuses 910 various activities organized by the collegesuniversities have helped students improve their knowledge of hiv sexual health and hiv testing 11 despite better access to information on hiv prevention university students failed to take full advantage of hiv prevention services and demonstrated inadequate knowledge of and improper behaviours in hiv prevention according to previous studies only 563 of students mastered the basic knowledge of hiv in wuhan 12 about 70 of the students still ignored consistent condom use though they clearly knew that condom use could greatly reduce hiv risks 13 the lack of translation from knowledge to prevention action was particularly severe among male university students 1415 although university students could access hiv testing through the red ribbon association and blood donation vehicles as well as through selftesting kits available for purchase only 45 of male university students had hiv testing in guangzhou 16 this number is even more sobering when compared with corresponding data from the united states where 374 male university students received hiv testing 17 factors including low awareness and accessibility to testing services might impede the use of hivtesting services among chinese university students 18 many studies have described hivrelated knowledge attitudes and behaviours and hiv testing among college students 12 13 14 15 16 while information on the use of hiv prevention services including hiv prevention education and hiv counselling and testing services is very limited but extremely important it is urgent to conduct studies targeting male students since hiv prevalence among undergraduate students has been growing at an alarming rate in the past five years especially among male undergraduate students in china the present study aims to describe the use of hiv prevention services hivrelated knowledge sexual attitudes and behaviours among male undergraduate students in hunan china and to determine factors associated with the use of hiv prevention services this study may collect information and provide evidence for the design of hiv prevention programs tailored to the preferences and characteristics of male undergraduate chinese students methods settings and participants this crosssectional study was conducted in hunan a central china province home to 70 million people hunan has approximately 20000 hivinfected patients 19 the 109 universities and colleges in hunan provide higher education with a variety of disciplines according to the document on hiv prevention jointly issued by the ministry of education and ministry of health all colleges and universities are required to provide hiv aids prevention education at the very beginning of university life 8 to fully mobilise students enthusiasm in participating in aids prevention various youthfriendly services such as lectures billboards videos and school media publicity are encouraged in the universities all universitiescolleges in hunan offer health education on aids prevention but hiv testing is not available on university campus students can access hiv testing at local cdcs nearby health facilities or communitybased organisations for hiv counselling and testing the target population of this study was male undergraduate students approximately 60000 male undergraduate students from three comprehensive universities in hunan were purposefully sampled to ensure an adequate representation of students from various majors and different grades with the permission of the student union of the three universities and departments we asked for recruitment assistance from each grade the participants were recruited via peer referral in the selected cohorts via wechat we successfully sent a unique twodimensional code linking the electronic questionnaire to potential participants who worked for the student unions of various grades in the universities in all three universities these participants then disseminated the twodimensional code via wechat group to undergraduates of different grades and various majors male undergraduate students who were 18 years and above and used wechat were eligible for this study the sample size was calculated based on the proportion of hiv testing the rate of hiv testing reported in previous studies in chinese undergraduate students varied from 28471 2021 based on the detection table of the sample size for proportions in hulley et al 22 assuming the prevalence of hiv testing was 25 and for a confidence level of 95 with the width of confidence interval of 010 the optimum estimate of 288 students was required as sexual experience is a precondition of hiv testing the total sample size based on the proportion of sexual behavior occurrence among chinese male undergraduate students 23 was 1365 by assumption in this study study variables and measurements demographic data regarding the students age grade ethnicity area of residence with or without a sexual partner etc were collected behaviours such as smoking alcohol drinking and sexual orientation were also assessed hivrelated knowledge was assessed with a 13item questionnaire the questionnaire was developed on the basis of the unified national aids sentinel surveillance questionnaire designed specifically for university students 24 and the existing literatures 25 each item was measured via a yesnouncertain format and only the correct response scored 1 point mastering 85 or more of the knowledge in the questionnaire was considered as having sufficient knowledge and a total score of 11 or higher was required to demonstrate sufficient knowledge otherwise respondents were regarded as having insufficient knowledge the internal reliability for this questionnaire was 064 in this study the sexual attitude scale was used to measure the undergraduates sexual attitudes 26 the 7item scale assessed the attitudes towards premarital sex extramarital sex commercial sex homosexual behaviours onenight stand and multiple sex partners participants rated items on a likert scale ranging from 1 to 5 for each item scores lower than 3 were recoded as unacceptable and scores of 3 and higher were recoded as acceptable a composite score was obtained by summing up the scores of each item with higher scores indicating more conservative sexual attitudes the original 6item scale assessed commercial sex behavious without distinguishing between paying for sex and selling sex in the current study participants were asked to respond to both situations the cronbachs alpha for this scale was 084 sexual behaviours were assessed by asking students about their sexual experiences heterosexual homosexual behaviours commercial sexual behaviours and condom use in the past year 24 participants who had sexual intercourse in the last year were asked to rate the frequency of condom use on the basis of four response options hiv prevention services were operationally defined in this study as hiv educational programs counselling services and testing services considering the differences between the hiv prevention services provided by colleges and universities public health sectors and communitybased organisations the following five questions were asked did you receive any hiv prevention education organised by the university in the last year what types of educational activities did you participate in at the university did you take an hiv test in the last year are you willing to take an hiv test and if you are not willing to take an hiv test what are your reasons for refusing to do so these questions were designed by the investigators after collecting information from people who organized campus hiv prevention programs and after conducting literature reviews 2728 data collection data were collected online via the chinese professional survey website wenjuanxing from november 2017 to january 2018 all potential participants accessed the questionnaires by scanning the twodimensional code with wechat and they were able to submit the questionnaires only when all items were finished students were allowed to complete the selfadministered questionnaire which took approximately 2030 min in their spare time each participant received a bonus of 5 rmb online upon the completion of the survey to avoid repetition questionnaires bearing the same ip address as previously submitted questionnaires were not accepted statistical analysis the data were analysed with spss version 200 frequencies percentages means and standard deviations were used to describe the demographic variables hivrelated knowledge sexual attitudes and behaviours and use of hiv prevention services a chisquare test was used to assess the association between sexual behaviours and the frequency of condom use additionally univariate and multivariate logistic regression analyses were conducted to examine factors associated with the use of hiv prevention education services in colleges and universities variables identified as statistically significant at a level of p 01 in the univariate logistic regression analysis were entered into the multivariate logistic regression model with a stepwise forward approach all statistical analyses were twotailed and α level of 005 denoted statistical significance results demographic characteristics of the 2432 invited male undergraduate students 254 were excluded by the inclusion criteria of the remaining 2178 students 747 declined to complete the questionnaire resulting in a final sample of 1431 completed and valid questionnaires the participants were 18 to 25 years most were of han nationality from urban districts majoring in nonmedical fields not living with sexual partners and from lower grades roughly onefifth of the participants selfreported cigarette smoking and more than half selfreported alcohol drinking the majority of the students regarded themselves as heterosexual and the remaining students considered themselves as either homosexual bisexual or unclear hiv knowledge overall 1099 students scored 11 or above in hivrelated knowledge and were considered as having sufficient knowledge among the 13 hiv knowledge questions the two items on safe sex were answered correctly mostly 977 of the students believed unprotected sex would increase the probability of hiv infection and 957 thought using condoms during sex would decrease hiv transmission four items had a correct response rate below 80 two items on hiv transmission routes namely whether one could be infected through mosquito bites and whether one could be infected by kissing hivpositive people showing a correct response rate of 753 and 697 respectively the other two items related to the situation after hiv infection had the lowest correct response rate of 690 and 629 namely whether aids was equal to death and whether hiv antibody could be detected within one week after the infection these answers indicated that students with sufficient hiv knowledge still had misconceptions that needed further clarification sexual attitudes and behaviours our sample demonstrated a highly acceptable attitude towards premarital sex and a neutral attitude towards homosexual sex for premarital sex 771 of the participants reported acceptable and 418 reported homosexuality acceptable as to other types of sexual behaviours 279 believed onenight stand acceptable 228 expressed paying for sex acceptable 173 considered selling sex acceptable 152 thought having multiple sexual partners acceptable and 132 stated extramarital sex acceptable totally 299 out of the 1431 male undergraduate students reported active sex partners and 49 out of the 299 engaged in sexual behaviours with males regarding sexual partners in the last year among the 299 sexually actively students 250 reported having sex with fixed female partners 81 had casual female partners and 15 had commercial female partners whereas 33 had fixed male partners 22 had casual male partners and 11 had commercial male partners those students who had sex with females or male casual partners scored higher in sexual attitudes with more open sexual attitudes frequencies of condom use were significantly different among the groups with different partners the post hoc analysis showed that the variance was mostly attributable to the larger proportion of students who never used condoms when they had sex with casual or fixed male partners and a smaller percentage to those with fixed female partners use of hiv prevention services of all the male undergraduate students in the sample 1068 used hiv prevention education services provided by colleges universities in the last year more than half of the students had used two forms of the university education services including publicity materials billboards and lectures other educational services included hiv testing services only 105 male students had hiv testing in the last year but the majority reported willingness to take the tests and the reasons of 321 students unwillingness to take hiv testing were given factors related to the use of hiv prevention education services in colleges and universities variables significant at p 01 level were included in the multivariate logistic regression students who were older from higher grade and those who drank alcohol and had more open attitudes towards paying for sex were less likely to use hiv prevention education services in colleges and universities discussion due to the deep influence of confucianism for thousands of years chinese people are believed to be relatively more conservative to sex topics and activities than people in western countries chinese greatly emphasize fidelity in marriage relations however the moderately open sexual attitudes to premarital and homosexual behaviours uncovered in this study showed the great change in sexual attitudes nowadays among male undergraduate students as compared with those of a decade ago 2930 risky sexual behaviours especially among homosexual males were common in this study the use of hiv prevention services was not satisfactory in this sample male undergraduate students in hunan exhibited open attitudes to premarital sex and homosexuality which has also been shown in previous studies 3132 indicating that premarital sex has became frequent male students acceptance of homosexuality was also shown by kar and colleagues 33 although open sexual attitudes help decrease the level of concealment and stigma associated with homosexuality 33 such attitudes may result in an increase in highrisk sex sex education especially education on safe sex should be urgently incorporated into current hiv prevention programs on campuses regarding sexual behaviours about 21 of the male undergraduate students were sexually active with inconsistent use of condoms and having sex with casual partners was also common this finding echoes a previous study conducted in hefei china 34 but is much lower than that in ethiopia reporting more than 70 of university students were sexually active 35 alarmingly though unprotected sex was reported disproportionately by male students with different sexual orientations it was more frequent during homosexual behaviours in line with rongs study 36 which found that risky sexual behaviours were significantly more prevalent among homosexual and bisexual males than heterosexual males given the situation that preexposure prophylaxis is not widely accessible in china 37 hiv prevention programs specifically designed to reduce highrisk sexual behaviours among men having sex with men are quite necessary on campuses nearly fourfifths of this population demonstrated sufficient knowledge by the national aids sentinel surveillance questionnaire to assess hiv knowledge however high level of hiv knowledge did not show significant associations with safe sex behaviours and use of hiv prevention services the inconsistency between sufficient hiv knowledge and engaging in risky sex may be caused by the limited hiv knowledge acquired in china which includes only basic hiv knowledge tailored to the general population no knowledge about the details of sexual behaviours and unprotected sex was available in the curriculum for most chinese college and university students more comprehensive specific and detailed information on hiv especially knowledge of safe sex should be included in specific hiv knowledge questionnaires and schoolbased hiv education services according to this study the use of the hiv education services in colleges and universities was only slightly higher than 70 much lower than the expectation that all undergraduate students should receive as suggested in chis study 38 hiv prevention education should be more specific to the targeted population and diverse teaching techniques should be adopted and more comprehensive information included considering contemporary education services and the national regulation that hiv education in colleges and universities should clearly focus on students 39 it is essential that university hiv education services for male students include useful and practicable knowledge and details which should be distinguished from general hiv education services our findings indicated that male students who were older or in higher grades and who drank alcohol and had more open attitudes towards paying for sex were less likely to utilise the hiv prevention services organised by universities suggesting more integrated hiv prevention services are needed for these subgroups further qualitative studies are encouraged to help determine the specific needs of male undergraduates and better evaluate hiv education services in colleges and universities the extremely low use of hiv testing services was also worrisome we found that the rate of accepting hiv testing was far lower than that of the willingness to be tested due to concerns about privacy exposure and the lack of routine hiv testing in the health service facilities on campuses 40 and also rapid hiv testing has not been widely adopted by colleges and universities in china two of the three universities included in this study did not offer rapid hiv testing among students during our survey this sharply decreased the accessibility of hiv testing partially contributing to the low rate of testing among this sample most of the concern focused on male students who are sexually active who engage in risky sexual behaviours and who have inadequate access to individualised hiv prevention counselling and hiv testing on campus they also have concerns about the potential burden of hivpositive results which in turn contributes to the low use of hiv testing service 41 integrating hiv counselling and testing services into university health care services will help improve the accessibility of hiv services among students and meet the needs of those who are at high risk of hiv infection wu and colleagues 42 suggested that sharing and integrating resources are important strategies for aids prevention in colleges and universities we also suggest that routines for providing hiv services should be developed moreover students should be widely informed of the availability of these services and provided with sufficient contact resources several limitations may influence the generalisability of the findings firstly our participants were recruited from only three universities in hunan and caution should be aroused as to the application of these findings to other university students secondly all the data were selfreported and might be subject to selection bias measurement error or desirability bias especially the data on risky sex furthermore the questionnaires for measuring sexual behaviours and use of hiv prevention services were devised by the researchers and thus validation should be taken into consideration future studies with more representative samples and more standardised and valid measurements are expected to provide important evidence for developing effective hiv services in chinese colleges and universities for male undergraduate students conclusions although male undergraduate students demonstrate an open attitude to premarital sex and engage in highrisk sexual behaviours their use of hiv prevention education services is unsatisfactory hiv education services in chinese colleges and universities should be designed and provided comprehensively taking into consideration the needs of male undergraduates including open sexual attitudes risky sex imbalance between hiv knowledge and highrisk behaviours and willingness to take hiv testing programs aiming to change the risky sexual behaviours and develop accessible hiv counselling and testing services on campuses are urgent and critical for hiv prevention in chinese colleges and universities abbreviations china cdc the chinese centre for disease control and prevention hiv human immunodeficiency virus msm men having sex with men unaids the joint united nations program on hivaids authors contributions xhh xjy and whh conceived designed the study and obtained grants xhh xjy and xzz collected the data xhh xjy and xh analysed the data xhh xjy xzz and whh wrote the paper wab xh lxh and gl reviewed and edited the manuscript all authors read and approved the manuscript competing interests the authors declare that they have no competing interests

background the dramatic increase in human immunodeficiency virus hiv infection among undergraduate students in china especially among the male students is alarming this study aimed to describe sexual attitudes and behaviours and to examine the use of hiv prevention services and related factors among male undergraduate students in hunan china methods a crosssectional survey was conducted from november 2017 to january 2018 among male students from three universities in hunan china selfadministered questionnaires were uploaded online to collect data anonymously hivrelated knowledge and sexual attitudes were assessed with the unified national aids sentinel surveillance questionnaire and sexual attitude scale whereas sexual behaviours and use of hiv prevention services were examined with researchercreated questionnaires hivrelated knowledge sexual attitudes and behaviours and use of hiv prevention services were described chisquare test and logistic regression were used to analyse the factors associated with the use of hiv prevention education services p values ≤005 were considered significant results of the 1431 respondents 1068 746 95 ci 724760 used hiv prevention education services and 105 73 took hiv testing the openness of sexual attitudes was moderate overall about 299 209 of this sample had active sex partners and 49 164 of them had sex with males the consistent use of condoms was unsatisfactory among the sexually active students especially among those with homosexual behaviours participants who were older in age or 077 95 ci 070086 who were university seniors or 080 95 ci 070091 who drank alcohol or 071 95 ci 055093 and who had open attitude towards paid sex or 072 95 ci 054095 were less likely to use hiv prevention education services conclusions although male undergraduate students show open attitude to premarital sex and engage in risky sexual behaviours their use of hiv prevention education services is unsatisfactory particularly in terms of hiv testing more comprehensive and specific education on hiv prevention and testing services should be designed and offered on campus

Introduction Transitional age youth and substance use disorders Transitional age youth use higher levels of alcohol and other substances than any other age group in the United States . Specifically, the 2020 National Survey on Drug Use and Health found that among young adults ages 18-25, 5.2 million had an alcohol use disorder, and 4.9 million had an illicit drug use disorder, including 4.5 million with cannabis use disorder. Critically, substance use among TAY leads to significant adverse outcomes, including increased morbidity and mortality, as well as a wide array of cognitive, social, emotional, and behavioral outcomes . Thus, improved understanding of what factors increase substance use risk during this uniquely vulnerable transitional period could suggest novel targets for prevention and intervention. The TAY developmental stage is distinguished from adolescence and adulthood by a variety of factors that likely contribute to increased risk for substance use disorders . For example, TAY assume progressively more independence as they shift from adolescence to adulthood. This increased freedom is related to important developmental tasks such as identity formation in several areas, which may include confirming or departing from their family's identification with specific religious groups. Young adulthood also means increasing exposure to situations that involve substance use . For these reasons, identification of protective factors for SUDs is paramount for the TAY developmental period. --- Religious a liation and substance use disorders One potential protective factor is affiliation with a religious tradition , with some religious traditions being more protective than others. Indeed, multiple studies have shown SUD outcomes relate to affiliation with particular Christian denominations , including in adolescents . For example, in a Swiss sample of young men, Roman Catholic individuals were less likely to display at-risk cannabis use than Protestants and other Christians, and less likely to use mushrooms than other Christians . A study of adults in the US found that affiliation with specific religious traditions was associated with multiple drinking-related outcomes, including abstinence vs. drinking and moderate vs. heavy use. As an example, in the 2000 National Alcohol Survey of adults residing in the US, identification as Mormon, Muslim, Church of God, Pentecostal, Protestant/miscellaneous denominations, or Baptist, was associated with abstinence, while being Jehovah's Witness, Lutheran, or Catholic was associated with drinking alcohol . Furthermore, among adolescents in the U.S., affiliation with a fundamentalist Protestant tradition was inversely associated with alcohol use disorder , cannabis use disorder, cocaine use disorder, and any illicit SUD . The reasons for each of the above findings likely varies by substance, context, and religious tradition. One might argue that these associations could stem from prescriptive rules about the use of certain substances in some traditions , and/or the sense of belonging and community that can be part of one identifying with specific religious traditions. Risk and protective factors for substance use disorders among transitional age youth TAY who are marginalized and excluded from access to resources may face additional challenges. For example, TAY who are marginalized may also experience poverty may rely on underresourced programs like public assistance, which may not be able to meet their needs. Indeed, our work over the past 20 years with the Boricua Youth Study -a longitudinal study of two subsamples of Puerto Rican youth from the South Bronx, NY, US and San Juan, Puerto Rico -has described and characterized the adverse mental and physical health outcomes that can result from the complex and combinatory effects of such forces as marginalization and poverty on youth of Puerto Rican descent . Further, as Puerto Rican individuals are at particularly high risk for SUDs relative to the general US Latine population , identification of protective factors might be especially critical for this population. Religious affiliation may be uniquely protective among TAY in communities that strongly emphasize communal and religious norms, such as Puerto Rican TAY. However, it is also possible that identification with a specific group may generate conflict and distress and, in this case, pave the way to substance misuse . In any case, the relationship between a certain religious affiliation on SUDs has yet to be tested in Puerto Rican TAY. Complicating matters, additional factors have been shown to impact the association between religious affiliation and SUDs among TAY . For example, social context may play a role. A recent study of Indonesian Muslim adolescents found that the religiosity of the social context-including peers, family, community, culturepredicted lower substance use outcomes more than an individual's religious practice or belief . The authors argue that the "deterrent effect of religiosity requires external support from the social environment and community to become significant", underscoring the notion that social context is a critical factor in the association between religiosity and SUDs . Because the religiosity of the Puerto Rican social context can differ between the island of PR and the SBx in NYC , one might argue that the protective effect of religiosity on SUDs would be stronger in the social context where religiosity is a more integral part of the social environment in which one's religious affiliation is embedded. Religious affiliation likely also intersects with gender identity. Indeed, evidence suggests that gender interacts with indices of religiosity/spirituality to affect the development of SUDs . Specifically, Debnam et al. found that spirituality may help male adolescents in reacting to stress, and therefore buffer against substance use . In a study of adolescents from Nova Scotia, Canada, religious service attendance and religious importance were differentially protective based on gender . In this case, religious importance was found to be protective against cannabis use in males but not females; and religious attendance was found to be protective against only binge drinking in males, but all substances in females. Thus, one might argue that a similar interaction between gender and religious identification could be present among TAY of Puerto Rican ethnicity, with implications for SUDs. --- Objectives To that end, we sought to study the association of religious affiliation and SUDs, including the interaction of social context and gender, among TAYs in the BYS-a sample that is balanced by site , and gender . Indeed, our previous work with the BYS as well as several prior studies has demonstrated that rates of SUDs vary by site and gender, with TAYs in PR displaying lower rates of most SUDs compared to those in the SBx, and, congruent with prior studies, women displaying lower rates of SUDs than men . Additionally, we have found that rates of SUDs in the BYS vary based on empirically defined religiosity/spirituality profile , with highly religious participants displaying the lowest rates of SUDs, and those who were spiritual but not religious displaying the highest. We aim to characterize the religious identities of Puerto Rican TAY across two contexts; test the association between religious affiliation and SUDs; and test interactive effects of either social context or gender in the association between religious affiliation and SUDS. Regarding our second aim, we hypothesize Catholics will display the lowest rates of SUDs, and that individuals who identify with any specific religion will have lower rates of SUDs compared to those who do not endorse any religious affiliation or identity . Regarding our third aim, we hypothesize the religious affiliation of the majority of the population in the island of PR will have a stronger protective effect for SUDs among island than US continental Puerto Rican TAY youth. Given the diverse set of findings in the literature, we do not have a specific hypothesis about how gender will interact with religious affiliation in relation to risk of SUDs. --- Methods We utilized data from the aforementioned Boricua Youth Study. All procedures have been reviewed and approved by the New York State Psychiatric Institute and University of Puerto Rico Medical School Institutional Review Boards. The most recent wave of data collection included 2,004 participants ages 15-29 [mean 22.6 ; 95.6% ages 18 or over] from the SBx and the island of PR. TAY self-reported gender as a binary independent variable . Religious affiliation, also self-reported by TAY, was determined based on response to the question "With what religion, doctrine or beliefs do you identify?", which had thirteen possible answer choices. Responses were then collapsed into four religious identities: "Catholic" ; "Non-Catholic Christian" ; and "Other/Mixed" ; "None" . A dichotomous variable contrasted the first three groups with Nones . Four DSM-IV substance use outcomes served as dependent binary variables , as assessed by the World Mental Health Organization Composite International Diagnostic Interview : Past Year Tobacco Dependence ; Past Year Alcohol Abuse/Dependence ; Lifetime Illicit Substance Abuse/Dependence ; and endorsement of TUD, AUD, or illicit SUD . Descriptive demographic information [religious affiliation, gender, age group and receipt of public assistance status ] were summarized for the entire sample and by study site at enrollment. Chi square tests were used to assess differences between each study variable by site, as well as differences in religious affiliation by gender, public assistance, and age group. Using logistic regression models, we tested separate models examining the association of religious affiliation with the four SUDs, adjusting for recruitment context , gender, age group, and public assistance status. These steps were then repeated, substituting a dichotomous religious affiliation variable for the four-category religious affiliation variable. Finally, we tested interaction terms in separate models for site and religious affiliation, as well as gender identity and religious affiliation, to determine whether associations between religious affiliation and SUDs were different between site and/or gender or categories. --- Results Descriptive statistics by site for religious affiliation, gender, age, and public assistance are reported in Table 1. Site differences were observed for religious affiliation ; a higher proportion of participants from the SBx reported no religious affiliation than in PR , while the number of participants identifying as Non-Catholic Christian was higher in PR . Sites did not differ by gender or by age . However, public assistance varied by site such that more participants reported public assistance in the SBx than in PR . TAY gender, age and public assistance were used as covariates in these analyses, while results were stratified by site. In additional chi-square tests, religious affiliation also differed by gender , with 33.3% of males reporting None as their religious affiliation compared to only 24.0% of females. Religious affiliation also differed by public assistance use , such that more participants who identified as Non-Catholic Christian used public assistance than other reported identities. Religious affiliation did not significantly differ by age . After adjusting for covariates, statistically significant associations between religious affiliation and substance use disorders were found . Consistent with our hypothesis regarding our second aim, that Catholics will display the lowest rates of SUDs, compared to no religious affiliation , identifying as Catholic was associated with reduced odds of illicit SUD . Confirming our hypothesis that individuals who identify with a specific religion will have lower rates of SUDs compared to those who do not identify with any, we found that identifying as Non-Catholic Christian was associated with reduced risk for any SUD compared to None , while identifying as Other/Mixed was associated with increased risk for any SUD . There were no statistically significant associations between religious affiliation and past year TUD or past year AUD . In adjusted analyses testing for relationships between religious affiliation vs. no religious affiliation with SUDs and gender, no statistically significant associations were identified . Consistent with our hypothesis regarding our third aim, that religious affiliation of the majority of the population in the island of PR will have a stronger protective effect for SUDs among island than US continental Puerto Rican TAY youth, we found an interaction between site and religious affiliation for illicit SUDs . In PR, being Catholic or Non-Catholic Christian was protective for illicit SUD when compared to None . The same, however, was not true in the SBx . We found no evidence of an interaction between site and religious affiliation for the other three SUDs. We found no evidence of an interaction between religious affiliation and gender for any of the SUDs . --- Discussion --- Religious a liation and substance use disorders in Puerto Rican transitional age youth In the first population-based study investigating religious affiliation and SUDs among Puerto Rican TAY, several notable findings emerged. Consistent with our hypothesis that Catholic affiliation would be associated with the lowest rates of SUDs due to being the religion of the majority of the population, we found that identifying as Catholic was associated with reduced odds of illicit SUD, compared to other groups. Consistent with our prediction that individuals with a specific religion affiliation compared to those who are unaffiliated will have lower rates of SUDs, identifying as Non-Catholic Christian was associated with reduced risk for any past year SUD compared to participants with no affiliation, while identifying as Other/Mixed was associated with increased risk for any SUD. Furthermore, we found evidence supporting our hypothesis that the religious affiliation of the majority of the population in the island of Puerto Rico will have a greater protective effect for SUDs among island when compared to US continental Puerto Rican TAY youth. More specifically, we found an interaction between site and religious affiliation for illicit SUDs, such that in PR, but not in the SBx, being Catholic or Non-Catholic Christian was protective for illicit SUD when compared to None. We did not find evidence supporting an interaction between site and religious affiliation for the other three SUDs, nor evidence of an interaction between religious affiliation and gender for any of the SUDs. --- Demographic findings The percentage of TAY who endorse no religious affiliation in both sites of the BYS sample differs significantly from the general Puerto Rican population . Specifically, based on a 2014 Pew Report, 20 and 8% of Puerto Rican adults living in the US and PR, respectively, do not identify with a religious tradition. In our sample of TAY, the same values are 38 and 21% of TAY in the mainland US and PR, respectively. Interestingly, the majority of the participants in the present sample are Millennials , in whom similar increases in religious non-affiliation have been observed within other social and cultural settings, including the US . The increase in religious non-affiliation is noteworthy from a demographic perspective because it suggests that not identifying with religion may be a generation-wide phenomenon, and not specific to particular ethnic or cultural communities, including Puerto Rican communities in the mainland and on the island of PR. This finding can be explained in multiple ways. One might hypothesize that the increase in TAY who do not endorse a religious affiliation is unique to Millennials; or alternatively, that it reflects spiritual seeking and religious identity development that is characteristic of the TAY from a developmental perspective. Our data and results do not allow us to conclude one way or another, indicating that more research on religious affiliation among TAY is needed-including how Millennials compare to past and future generations, such as Generations Z and Alpha . The demographic findings are also important because they suggest that religious affiliation has an evolving nature-namely, that it is a fluid and dynamic phenomenon responsive to and reflective of multiple variables, including age, generation, and social and geographic context. In this way, the data underscore that religious identity may not be static, but rather subject to such forces as time and place. --- Implications for clinicians and researchers Given the association between religious affiliation and SUDs, this point is not merely an academic one. Indeed, the shifts in religious affiliation could have significant clinical ramifications, as our results suggest here. Specifically, TAY of PR descent who do not endorse a religious affiliation are almost twice as likely as those who identify as Catholic to have illicit SUDs and 1.5 times as likely as Non-Catholic Christian to have any SUD. From the perspective of screening, prevention, and treatment of SUDs, these findings suggest that it would behoove pediatricians, internists, family doctors, and mental health professionals, as well as researchers, to take into consideration their patients' religious identities. In addition, it would be helpful for clinicians and researchers to learn more about the role of religious community for support. Interestingly, the results indicate that the type of religious affiliation-Catholic, Non-Catholic Christian, Other/Mixedmatters when it comes to assessing SUD risk. This is supported by the fact that specific religious affiliations were inversely associated with SUDs, whereas when we tested any religious affiliation vs. no religious affiliation , the protective effect of religious affiliation became non-significant. While this finding may surprise some-given that multiple studies have suggested that various measures of religious/spiritual identity, practice, and belief-independent of religious tradition-are associated with lower rates of SUDs , other studies have suggested that religiosity/spirituality is a risk factor for SUDs. We found that the specific religious affiliation that one's identity, practices, and beliefs is embedded in determines whether religious affiliation is protective or not, which may explain the above inconsistency in the literature. The finding is novel and interesting from a clinical perspective because it suggests that merely assessing for religious affiliation may be less helpful for stratifying risk as inquiring about a specific religious affiliation. In other words, to truly understand a patient's risk, a clinician might need to inquire further, and ask about one's particular religious affiliation. Finally, while the findings related to the Other/Mixed category were non-significant, they nevertheless suggest that this group merits further study. This is because the Other/Mixed category was at an elevated risk for all SUDs in comparison to all other affiliations. Indeed, the finding was non-significant, so we cannot draw any firm conclusions about the association between Other/Mixed and SUDs, but we would argue that these findings indicate that further study in a bigger sample is indicated. If our findings are replicated in a sample with adequate power, one might conclude that the benefits of belonging to a religious tradition may not apply when one does not identify with one of the major religious traditions. However, to say one way or another, further research is necessary. --- E ects of site and gender With respect to the interactive effects of site, our study provides evidence to suggest that the impact of endorsing no religious affiliation is greater in PR than in the SBx when it comes to risk for illicit SUDs. Further, the demographic data also show that having no religious affiliation is less common in PR than in the SBx. Together, these two findings may explain why no religious affiliation is a risk factor in PR but not the SBx: having no religious affiliation, or belonging to a religious group out of the mainstream might be more related to reduced availability of social support in PR but not the SBx. In this way, the risk for illicit SUDs that might result from not having a religious affiliation might be relative to social context, leading to greater risk in communities in which no religious affiliation is less common. This finding emphasizes the critical point that religious affiliation does not occur in a vacuum-it is a culturally-bound phenomenon that is embedded in and inseparable from community and context. In terms of the role of gender in the association between religious affiliation and SUDs, we found no evidence of an interaction. Such a finding might lead one to conclude that gender roles and identities in Puerto Rican religious communities do not intersect to impact the use of substances among TAY. However, it is also possible that Puerto Rican gender identities can and do interact with religious affiliation to impact risk for SUDs, but they do so in complex and sometimes contradictory ways. For example, traditional Puerto Rican notions of masculinity , which are embedded in and stem from a Christian religio-cultural context, may contribute to increased odds of SUDs . On the other hand, recent ethnographic work on male Puerto Rican evangelist street ministries suggests that Pentecostal communities promote an alternative vision of maleness-termed, "new masculinity"-that is linked to abstinence and thus lower odds of SUDs . Likewise among women of Puerto Rican descent, dueling notions of femininity-marianismo and hembrismo-might intersect with religious communities to impact SUD risk, as suggested by Comas-Diaz . In any case, research that incorporates qualitative and ethnographic methods to appreciate the complexity and nuance of these relationships is needed to clarify the complex association between gender and religion. Thus, we view this "non-finding" as a call for further investigation. --- Limitations This research is novel and provides results that contribute to our understanding of cultural and contextual factors relevant to SUDs in Puerto Rican TAY. However, there are several limitations that are worth noting. First, while the grouping of religious identities into Catholic, Non-Catholic Christian, Other/Mixed, and None was based on the expertise of Saunders, who holds a PhD in religious studies, one might argue that the collapsing of diverse religious denominations into just four categories elides significant differences in beliefs and practices that could impact SUD risk. However, the sample size was not large enough to test for differences among all individual denominations, and the religious affiliation groups were categorized based on similarities in belief and practice among intra-group denominations. Second, as noted above, the Other/Mixed category was small in comparison to the other three groups, and heterogeneous. Specifically, it contained persons who identified as Jewish, Muslim, and Mita Congregation, among others, as well as people who identified themselves as belonging to more than one group. These factors prohibit firm conclusions about the impact of belonging to this category. Third, given that multiple hypotheses were tested, these findings could be the result of Type I error and thus warrant replication. Fourth, because the associations studied were cross-sectional, reverse causation is possible, and our results may reflect the effects of low use of substances in one's choice of a religious affiliation. Fifth, the data were collected across four years , and the age range of participants during data collection was 15-29. As such, it is possible that older participants whose data were collected in 2013 may experience and understand religious affiliation/nonaffiliation differently than, say, younger participants whose data were collected in 2017. While we adjusted for age in our analysis, we did not adjust for year of data collection which introduces heterogeneity that we did not address. Therefore, results presented here do not account for potentially shifting attitudes toward religious affiliation in 15-29-year-olds during the period between 2013 and 2017, and instead provide a courser-grain representation of the relationship between religious affiliation and substance use-risk compared to earlier generations. Finally, other kinds of intersecting identities, such as gender identity and sexual orientation may also influence the relationship between religious affiliation and substance use risk, particularly for individuals who feel discriminated against due to their identity by others in their religious group. However, the results presented here do not take this into account. Thus, examining interactions between gender identity, sexual orientation and religious affiliation, in their association with substance use risk is an important topic for future studies. --- Conclusion In this paper we report on the reverse correlation between religious affiliation and substance use disorders among TAY of Puerto Rican descent raised in two social contexts, describing several notable demographic and clinical findings with implications for prevention and treatment efforts. Demographically, the number of Puerto Rican TAY who do not identify with a religious tradition is growing in comparison to prior generations. This is a clinically relevant finding because those who do not identify with a religious tradition are twice as likely as Catholics to have an illicit SUD, and 1.5 times as likely as Non-Catholic Christians to have any SUD. Interestingly, not having a religious affiliation is particularly impactful in PR, but not the SBx, in relation to risk for illicit SUD, highlighting the importance of social context in understanding the relationship between religious affiliation and SUDS. Altogether, these findings underscore the evolving and culturally embedded nature of religious affiliation , including its association with SUDs among TAY of Puerto Rican descent, and should implore clinicians working with such populations to seek to better understand their patient's religious affiliation when it comes to assessing for risk of SUDs. --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- Ethics statement The studies involving human participants were reviewed and approved by New York State Psychiatric Institute; University of Puerto Rico Medical School. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Introduction: Transitional age youth (i. e., ages -; TAY) use higher levels of substances than any age group in the United States. Understanding what factors increase substance use during TAY could suggest novel targets for prevention/intervention. Studies suggest that religious a liation is inversely associated with substance use disorders (SUDs). However, the association of religious a liation and SUD, including the role of gender and social context, has not been studied in TAY of Puerto Rican ethnicity. Methods: Using data from N = , TAY of Puerto Rican ethnicity across two social contexts-Puerto Rico (PR) and the South Bronx, NY (SBx)-we tested the association of religious identity (Catholic, Non-Catholic Christian, Other/Mixed, and no religious a liation, or "None"), and four SUD outcomes (alcohol use disorder, tobacco use disorder, illicit SUD, and any SUD). Logistic regression models were used to examine the association between religious identity and SUDs, then we tested for interaction by social context and gender. Result: Half the sample identified as female; , , and % were -, -, and -years of age, respectively; % of the sample received public assistance. There was a statistically significant di erence between sites for public assistance ( and % in SBx/PR, respectively; p < . ); % of the sample endorsed None ( and % in SBx/PR, respectively.) Compared to None, identifying as Catholic was associated with reduced risk of illicit SUD (OR = . , p = . ), and identifying as Non-Catholic Christian with reduced risk for any SUD (OR = . , p = . ). Additionally, in PR but not SBx, being Catholic or Non-Catholic Christian was protective for illicit SUD when compared to None (OR = . and . , respectively). We found no evidence of an interaction between religious a liation and gender. Discussion: The percentage of PR TAY who endorse no a liation is higher than the general PR population, reflective of increasing religious non-a liation among TAY across cultures. Critically, TAY with no religious a liation are twice as likely as Catholics to have illicit SUD, and . times as likely as Non-Catholic Christians to have any SUD. Endorsing no a liation is more adverse for illicit SUD in PR than the SBx, underscoring the importance of social context.

introduction transitional age youth and substance use disorders transitional age youth use higher levels of alcohol and other substances than any other age group in the united states specifically the 2020 national survey on drug use and health found that among young adults ages 1825 52 million had an alcohol use disorder and 49 million had an illicit drug use disorder including 45 million with cannabis use disorder critically substance use among tay leads to significant adverse outcomes including increased morbidity and mortality as well as a wide array of cognitive social emotional and behavioral outcomes thus improved understanding of what factors increase substance use risk during this uniquely vulnerable transitional period could suggest novel targets for prevention and intervention the tay developmental stage is distinguished from adolescence and adulthood by a variety of factors that likely contribute to increased risk for substance use disorders for example tay assume progressively more independence as they shift from adolescence to adulthood this increased freedom is related to important developmental tasks such as identity formation in several areas which may include confirming or departing from their familys identification with specific religious groups young adulthood also means increasing exposure to situations that involve substance use for these reasons identification of protective factors for suds is paramount for the tay developmental period religious a liation and substance use disorders one potential protective factor is affiliation with a religious tradition with some religious traditions being more protective than others indeed multiple studies have shown sud outcomes relate to affiliation with particular christian denominations including in adolescents for example in a swiss sample of young men roman catholic individuals were less likely to display atrisk cannabis use than protestants and other christians and less likely to use mushrooms than other christians a study of adults in the us found that affiliation with specific religious traditions was associated with multiple drinkingrelated outcomes including abstinence vs drinking and moderate vs heavy use as an example in the 2000 national alcohol survey of adults residing in the us identification as mormon muslim church of god pentecostal protestantmiscellaneous denominations or baptist was associated with abstinence while being jehovahs witness lutheran or catholic was associated with drinking alcohol furthermore among adolescents in the us affiliation with a fundamentalist protestant tradition was inversely associated with alcohol use disorder cannabis use disorder cocaine use disorder and any illicit sud the reasons for each of the above findings likely varies by substance context and religious tradition one might argue that these associations could stem from prescriptive rules about the use of certain substances in some traditions andor the sense of belonging and community that can be part of one identifying with specific religious traditions risk and protective factors for substance use disorders among transitional age youth tay who are marginalized and excluded from access to resources may face additional challenges for example tay who are marginalized may also experience poverty may rely on underresourced programs like public assistance which may not be able to meet their needs indeed our work over the past 20 years with the boricua youth study a longitudinal study of two subsamples of puerto rican youth from the south bronx ny us and san juan puerto rico has described and characterized the adverse mental and physical health outcomes that can result from the complex and combinatory effects of such forces as marginalization and poverty on youth of puerto rican descent further as puerto rican individuals are at particularly high risk for suds relative to the general us latine population identification of protective factors might be especially critical for this population religious affiliation may be uniquely protective among tay in communities that strongly emphasize communal and religious norms such as puerto rican tay however it is also possible that identification with a specific group may generate conflict and distress and in this case pave the way to substance misuse in any case the relationship between a certain religious affiliation on suds has yet to be tested in puerto rican tay complicating matters additional factors have been shown to impact the association between religious affiliation and suds among tay for example social context may play a role a recent study of indonesian muslim adolescents found that the religiosity of the social contextincluding peers family community culturepredicted lower substance use outcomes more than an individuals religious practice or belief the authors argue that the deterrent effect of religiosity requires external support from the social environment and community to become significant underscoring the notion that social context is a critical factor in the association between religiosity and suds because the religiosity of the puerto rican social context can differ between the island of pr and the sbx in nyc one might argue that the protective effect of religiosity on suds would be stronger in the social context where religiosity is a more integral part of the social environment in which ones religious affiliation is embedded religious affiliation likely also intersects with gender identity indeed evidence suggests that gender interacts with indices of religiosityspirituality to affect the development of suds specifically debnam et al found that spirituality may help male adolescents in reacting to stress and therefore buffer against substance use in a study of adolescents from nova scotia canada religious service attendance and religious importance were differentially protective based on gender in this case religious importance was found to be protective against cannabis use in males but not females and religious attendance was found to be protective against only binge drinking in males but all substances in females thus one might argue that a similar interaction between gender and religious identification could be present among tay of puerto rican ethnicity with implications for suds objectives to that end we sought to study the association of religious affiliation and suds including the interaction of social context and gender among tays in the bysa sample that is balanced by site and gender indeed our previous work with the bys as well as several prior studies has demonstrated that rates of suds vary by site and gender with tays in pr displaying lower rates of most suds compared to those in the sbx and congruent with prior studies women displaying lower rates of suds than men additionally we have found that rates of suds in the bys vary based on empirically defined religiosityspirituality profile with highly religious participants displaying the lowest rates of suds and those who were spiritual but not religious displaying the highest we aim to characterize the religious identities of puerto rican tay across two contexts test the association between religious affiliation and suds and test interactive effects of either social context or gender in the association between religious affiliation and suds regarding our second aim we hypothesize catholics will display the lowest rates of suds and that individuals who identify with any specific religion will have lower rates of suds compared to those who do not endorse any religious affiliation or identity regarding our third aim we hypothesize the religious affiliation of the majority of the population in the island of pr will have a stronger protective effect for suds among island than us continental puerto rican tay youth given the diverse set of findings in the literature we do not have a specific hypothesis about how gender will interact with religious affiliation in relation to risk of suds methods we utilized data from the aforementioned boricua youth study all procedures have been reviewed and approved by the new york state psychiatric institute and university of puerto rico medical school institutional review boards the most recent wave of data collection included 2004 participants ages 1529 mean 226 956 ages 18 or over from the sbx and the island of pr tay selfreported gender as a binary independent variable religious affiliation also selfreported by tay was determined based on response to the question with what religion doctrine or beliefs do you identify which had thirteen possible answer choices responses were then collapsed into four religious identities catholic noncatholic christian and othermixed none a dichotomous variable contrasted the first three groups with nones four dsmiv substance use outcomes served as dependent binary variables as assessed by the world mental health organization composite international diagnostic interview past year tobacco dependence past year alcohol abusedependence lifetime illicit substance abusedependence and endorsement of tud aud or illicit sud descriptive demographic information religious affiliation gender age group and receipt of public assistance status were summarized for the entire sample and by study site at enrollment chi square tests were used to assess differences between each study variable by site as well as differences in religious affiliation by gender public assistance and age group using logistic regression models we tested separate models examining the association of religious affiliation with the four suds adjusting for recruitment context gender age group and public assistance status these steps were then repeated substituting a dichotomous religious affiliation variable for the fourcategory religious affiliation variable finally we tested interaction terms in separate models for site and religious affiliation as well as gender identity and religious affiliation to determine whether associations between religious affiliation and suds were different between site andor gender or categories results descriptive statistics by site for religious affiliation gender age and public assistance are reported in table 1 site differences were observed for religious affiliation a higher proportion of participants from the sbx reported no religious affiliation than in pr while the number of participants identifying as noncatholic christian was higher in pr sites did not differ by gender or by age however public assistance varied by site such that more participants reported public assistance in the sbx than in pr tay gender age and public assistance were used as covariates in these analyses while results were stratified by site in additional chisquare tests religious affiliation also differed by gender with 333 of males reporting none as their religious affiliation compared to only 240 of females religious affiliation also differed by public assistance use such that more participants who identified as noncatholic christian used public assistance than other reported identities religious affiliation did not significantly differ by age after adjusting for covariates statistically significant associations between religious affiliation and substance use disorders were found consistent with our hypothesis regarding our second aim that catholics will display the lowest rates of suds compared to no religious affiliation identifying as catholic was associated with reduced odds of illicit sud confirming our hypothesis that individuals who identify with a specific religion will have lower rates of suds compared to those who do not identify with any we found that identifying as noncatholic christian was associated with reduced risk for any sud compared to none while identifying as othermixed was associated with increased risk for any sud there were no statistically significant associations between religious affiliation and past year tud or past year aud in adjusted analyses testing for relationships between religious affiliation vs no religious affiliation with suds and gender no statistically significant associations were identified consistent with our hypothesis regarding our third aim that religious affiliation of the majority of the population in the island of pr will have a stronger protective effect for suds among island than us continental puerto rican tay youth we found an interaction between site and religious affiliation for illicit suds in pr being catholic or noncatholic christian was protective for illicit sud when compared to none the same however was not true in the sbx we found no evidence of an interaction between site and religious affiliation for the other three suds we found no evidence of an interaction between religious affiliation and gender for any of the suds discussion religious a liation and substance use disorders in puerto rican transitional age youth in the first populationbased study investigating religious affiliation and suds among puerto rican tay several notable findings emerged consistent with our hypothesis that catholic affiliation would be associated with the lowest rates of suds due to being the religion of the majority of the population we found that identifying as catholic was associated with reduced odds of illicit sud compared to other groups consistent with our prediction that individuals with a specific religion affiliation compared to those who are unaffiliated will have lower rates of suds identifying as noncatholic christian was associated with reduced risk for any past year sud compared to participants with no affiliation while identifying as othermixed was associated with increased risk for any sud furthermore we found evidence supporting our hypothesis that the religious affiliation of the majority of the population in the island of puerto rico will have a greater protective effect for suds among island when compared to us continental puerto rican tay youth more specifically we found an interaction between site and religious affiliation for illicit suds such that in pr but not in the sbx being catholic or noncatholic christian was protective for illicit sud when compared to none we did not find evidence supporting an interaction between site and religious affiliation for the other three suds nor evidence of an interaction between religious affiliation and gender for any of the suds demographic findings the percentage of tay who endorse no religious affiliation in both sites of the bys sample differs significantly from the general puerto rican population specifically based on a 2014 pew report 20 and 8 of puerto rican adults living in the us and pr respectively do not identify with a religious tradition in our sample of tay the same values are 38 and 21 of tay in the mainland us and pr respectively interestingly the majority of the participants in the present sample are millennials in whom similar increases in religious nonaffiliation have been observed within other social and cultural settings including the us the increase in religious nonaffiliation is noteworthy from a demographic perspective because it suggests that not identifying with religion may be a generationwide phenomenon and not specific to particular ethnic or cultural communities including puerto rican communities in the mainland and on the island of pr this finding can be explained in multiple ways one might hypothesize that the increase in tay who do not endorse a religious affiliation is unique to millennials or alternatively that it reflects spiritual seeking and religious identity development that is characteristic of the tay from a developmental perspective our data and results do not allow us to conclude one way or another indicating that more research on religious affiliation among tay is neededincluding how millennials compare to past and future generations such as generations z and alpha the demographic findings are also important because they suggest that religious affiliation has an evolving naturenamely that it is a fluid and dynamic phenomenon responsive to and reflective of multiple variables including age generation and social and geographic context in this way the data underscore that religious identity may not be static but rather subject to such forces as time and place implications for clinicians and researchers given the association between religious affiliation and suds this point is not merely an academic one indeed the shifts in religious affiliation could have significant clinical ramifications as our results suggest here specifically tay of pr descent who do not endorse a religious affiliation are almost twice as likely as those who identify as catholic to have illicit suds and 15 times as likely as noncatholic christian to have any sud from the perspective of screening prevention and treatment of suds these findings suggest that it would behoove pediatricians internists family doctors and mental health professionals as well as researchers to take into consideration their patients religious identities in addition it would be helpful for clinicians and researchers to learn more about the role of religious community for support interestingly the results indicate that the type of religious affiliationcatholic noncatholic christian othermixedmatters when it comes to assessing sud risk this is supported by the fact that specific religious affiliations were inversely associated with suds whereas when we tested any religious affiliation vs no religious affiliation the protective effect of religious affiliation became nonsignificant while this finding may surprise somegiven that multiple studies have suggested that various measures of religiousspiritual identity practice and beliefindependent of religious traditionare associated with lower rates of suds other studies have suggested that religiosityspirituality is a risk factor for suds we found that the specific religious affiliation that ones identity practices and beliefs is embedded in determines whether religious affiliation is protective or not which may explain the above inconsistency in the literature the finding is novel and interesting from a clinical perspective because it suggests that merely assessing for religious affiliation may be less helpful for stratifying risk as inquiring about a specific religious affiliation in other words to truly understand a patients risk a clinician might need to inquire further and ask about ones particular religious affiliation finally while the findings related to the othermixed category were nonsignificant they nevertheless suggest that this group merits further study this is because the othermixed category was at an elevated risk for all suds in comparison to all other affiliations indeed the finding was nonsignificant so we cannot draw any firm conclusions about the association between othermixed and suds but we would argue that these findings indicate that further study in a bigger sample is indicated if our findings are replicated in a sample with adequate power one might conclude that the benefits of belonging to a religious tradition may not apply when one does not identify with one of the major religious traditions however to say one way or another further research is necessary e ects of site and gender with respect to the interactive effects of site our study provides evidence to suggest that the impact of endorsing no religious affiliation is greater in pr than in the sbx when it comes to risk for illicit suds further the demographic data also show that having no religious affiliation is less common in pr than in the sbx together these two findings may explain why no religious affiliation is a risk factor in pr but not the sbx having no religious affiliation or belonging to a religious group out of the mainstream might be more related to reduced availability of social support in pr but not the sbx in this way the risk for illicit suds that might result from not having a religious affiliation might be relative to social context leading to greater risk in communities in which no religious affiliation is less common this finding emphasizes the critical point that religious affiliation does not occur in a vacuumit is a culturallybound phenomenon that is embedded in and inseparable from community and context in terms of the role of gender in the association between religious affiliation and suds we found no evidence of an interaction such a finding might lead one to conclude that gender roles and identities in puerto rican religious communities do not intersect to impact the use of substances among tay however it is also possible that puerto rican gender identities can and do interact with religious affiliation to impact risk for suds but they do so in complex and sometimes contradictory ways for example traditional puerto rican notions of masculinity which are embedded in and stem from a christian religiocultural context may contribute to increased odds of suds on the other hand recent ethnographic work on male puerto rican evangelist street ministries suggests that pentecostal communities promote an alternative vision of malenesstermed new masculinitythat is linked to abstinence and thus lower odds of suds likewise among women of puerto rican descent dueling notions of femininitymarianismo and hembrismomight intersect with religious communities to impact sud risk as suggested by comasdiaz in any case research that incorporates qualitative and ethnographic methods to appreciate the complexity and nuance of these relationships is needed to clarify the complex association between gender and religion thus we view this nonfinding as a call for further investigation limitations this research is novel and provides results that contribute to our understanding of cultural and contextual factors relevant to suds in puerto rican tay however there are several limitations that are worth noting first while the grouping of religious identities into catholic noncatholic christian othermixed and none was based on the expertise of saunders who holds a phd in religious studies one might argue that the collapsing of diverse religious denominations into just four categories elides significant differences in beliefs and practices that could impact sud risk however the sample size was not large enough to test for differences among all individual denominations and the religious affiliation groups were categorized based on similarities in belief and practice among intragroup denominations second as noted above the othermixed category was small in comparison to the other three groups and heterogeneous specifically it contained persons who identified as jewish muslim and mita congregation among others as well as people who identified themselves as belonging to more than one group these factors prohibit firm conclusions about the impact of belonging to this category third given that multiple hypotheses were tested these findings could be the result of type i error and thus warrant replication fourth because the associations studied were crosssectional reverse causation is possible and our results may reflect the effects of low use of substances in ones choice of a religious affiliation fifth the data were collected across four years and the age range of participants during data collection was 1529 as such it is possible that older participants whose data were collected in 2013 may experience and understand religious affiliationnonaffiliation differently than say younger participants whose data were collected in 2017 while we adjusted for age in our analysis we did not adjust for year of data collection which introduces heterogeneity that we did not address therefore results presented here do not account for potentially shifting attitudes toward religious affiliation in 1529yearolds during the period between 2013 and 2017 and instead provide a coursergrain representation of the relationship between religious affiliation and substance userisk compared to earlier generations finally other kinds of intersecting identities such as gender identity and sexual orientation may also influence the relationship between religious affiliation and substance use risk particularly for individuals who feel discriminated against due to their identity by others in their religious group however the results presented here do not take this into account thus examining interactions between gender identity sexual orientation and religious affiliation in their association with substance use risk is an important topic for future studies conclusion in this paper we report on the reverse correlation between religious affiliation and substance use disorders among tay of puerto rican descent raised in two social contexts describing several notable demographic and clinical findings with implications for prevention and treatment efforts demographically the number of puerto rican tay who do not identify with a religious tradition is growing in comparison to prior generations this is a clinically relevant finding because those who do not identify with a religious tradition are twice as likely as catholics to have an illicit sud and 15 times as likely as noncatholic christians to have any sud interestingly not having a religious affiliation is particularly impactful in pr but not the sbx in relation to risk for illicit sud highlighting the importance of social context in understanding the relationship between religious affiliation and suds altogether these findings underscore the evolving and culturally embedded nature of religious affiliation including its association with suds among tay of puerto rican descent and should implore clinicians working with such populations to seek to better understand their patients religious affiliation when it comes to assessing for risk of suds data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by new york state psychiatric institute university of puerto rico medical school written informed consent to participate in this study was provided by the participants legal guardiannext of kin publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction transitional age youth i e ages tay use higher levels of substances than any age group in the united states understanding what factors increase substance use during tay could suggest novel targets for preventionintervention studies suggest that religious a liation is inversely associated with substance use disorders suds however the association of religious a liation and sud including the role of gender and social context has not been studied in tay of puerto rican ethnicity methods using data from n tay of puerto rican ethnicity across two social contextspuerto rico pr and the south bronx ny sbx we tested the association of religious identity catholic noncatholic christian othermixed and no religious a liation or none and four sud outcomes alcohol use disorder tobacco use disorder illicit sud and any sud logistic regression models were used to examine the association between religious identity and suds then we tested for interaction by social context and gender result half the sample identified as female and were and years of age respectively of the sample received public assistance there was a statistically significant di erence between sites for public assistance and in sbxpr respectively p of the sample endorsed none and in sbxpr respectively compared to none identifying as catholic was associated with reduced risk of illicit sud or p and identifying as noncatholic christian with reduced risk for any sud or p additionally in pr but not sbx being catholic or noncatholic christian was protective for illicit sud when compared to none or and respectively we found no evidence of an interaction between religious a liation and gender discussion the percentage of pr tay who endorse no a liation is higher than the general pr population reflective of increasing religious nona liation among tay across cultures critically tay with no religious a liation are twice as likely as catholics to have illicit sud and times as likely as noncatholic christians to have any sud endorsing no a liation is more adverse for illicit sud in pr than the sbx underscoring the importance of social context

social theory . Given the significance of anthropogenic climate change it is difficult to disagree with the general orientation of such arguments. Indeed, we also think that the current situation holds the potential to institute a genuine 'event' -in the sense that it may come to mark a decisive difference between a 'before' and an 'after'-for both the socio-cultural and the natural sciences. To characterize this event, we offer a detailed examination of new materialist and eco-Marxist approaches to the Anthropocene. We do so because both use the Anthropocene as a platform for developing arguments about novel obligations placed upon contemporary social theory, which are at once far-reaching and far from innocent. Here we identify some unresolved issues. In the name of appreciating material agency, new materialist approaches struggle with legacies of scientism. Meanwhile, new eco-Marxist formulations have difficulties letting go of an impulse towards economic totalization characteristic of many strands of Marxism. Probably due to our position as Science and Technology Studies scholars working with actor-network theory and related ideas, we are particularly attentive to such kinds of problems. On the one hand, ANT's decade-long attempt to specify the conceptual and empirical possibilities of engaging nonhuman agency beyond scientism ) troubles the new materialist ambition to engage inhuman things in themselves. On the other hand, ANT-informed work on the material and pragmatic variability of markets challenges the eco-Marxist rendition of capitalism as the one overarching framework for making sense of ecological disruption . Rather than sweeping these conceptual and methodological issues under the Anthropocene carpet and offering another eclectic combination of more or less incongruent ideassomething that happens with some frequency these days2 -we examine the different ways in which these approaches 'dramatize' the problem of nonhuman materiality. The aim is to get a better handle on how social theorists might inhabit the Anthropocene event, including the question of whether the term itself is adequate for what it names. In brief, and with a deliberate degree of provocation, we argue that an understanding of nonhuman agency informed by ANT entails something like a reversal of the interpretation of the relation between the Anthropocene and social theory put forth by new materialists and eco-Marxists. The present situation is not one in which socio-cultural studies need to 'catch up' with the natural sciences by learning to take nonhumans and materialities seriously. On the contrary, it is the natural sciences that are finally beginning to catch up with the insight that societies and economies are fundamentally shaped by nonhuman agency. 3 But our aim is not the petty one of vindicating ANT against new competitors. Instead, we use new materialist calls for an intensified interest in material agency and eco-Marxist endeavors to rethink the relation between economies and ecologies as an entry-point for our own 'non-innocent' attempt to problematize the Anthropocene event differently. With this in mind, we turn to the figure of Gaia, which, due to the work of Isabelle Stengers and Bruno Latour, has recently re-emerged as an 'intellectually serious' figure for thinking through the implications of anthropogenic climate change . In contrast with the Anthropocene and its inversion, the Capitalocene, Isabelle Stengers' ) version of Gaia simultaneously highlights that humanity is in no position to either control or manage the earth; acknowledges that certain people and corporations are the main causes of Gaia's intrusion; and insists that the needed responses must be at once pragmatic and experimental. The implication is that, rather than placing the problem of response in the hands of scientists, politicians, businesses, or cutting-edge social theorists, it must be distributed across a heterogeneous ecology of practices. We begin by tracing the trajectories that led new materialists towards the Anthropocene, and eco-Marxists towards the Capitalocene. Subsequently, we explore the alternative problematization of the eco-political situation made available by Stengers' Gaia. As indicated, we believe that Gaia opens up a more capacious 'cosmopolitical' scenography; one that entails an experimental search for situated pathways towards the reinvention of numerous practices, including social theory. --- Pathways to matter: The new materialisms In the following sections, we examine two influential new materialist and eco-Marxist responses to the Anthropocene outlined, respectively, by the geographer Nigel Clark ) and the environmental historian Jason Moore . We engage these two particular thinkers, since their ways of dramatizing the issues are interesting in their own right while also holding exemplary value, and because it is important to be specific rather than offering abstract diagnoses. However, we begin with some more general observations about new materialism, because its ideas and premises have significantly influenced current discussions about the Anthropocene in social and cultural theory. In their introduction to the edited volume New Materialisms, Diana Coole and Samantha Frost argued that an adequately updated social theory entails a "reprisal of materialism" that must be "truly radical" . The "contemporary context", including the fact of climate change, they asserted, "demands a theoretical rapprochement with material realism" on the basis of new developments in the natural sciences. In social and cultural theory, this would mean revisiting "the most fundamental questions about the nature of matter and the place of embodied humans within a natural world" . The authors observed that previous materialist philosophers, including Marx, Nietzsche and Freud, had also been influenced by natural science . In the 21 st Century, however, the classical Newtonian paradigm that had inspired these thinkers has been obviated by newer developments and problems. Thus, a new materialism was needed, which would be: "resonant with, and to some extent informed by, developments in natural science" . For Coole and Frost, post-classical physics held special promise, since it had shown matter to be "more elusive" than previously expected, and to contain "an excess, force, vitality, relationality, or difference, that renders matter active, self-creative, productive, unpredictable" . Coole and Frost were explicit that the new materialism would not entail an uncritical acceptance of scientific facts or theories, since "scientific theories cannot simply be imported into philosophy" . At the same time, they were equally emphatic that: "the tropes and rhythms they [scientific theories] suggest can transform theoretical discourses" . However, as their discussion turned towards the realm of sub-atomic particles and dark matter, the distinction between improper theoretical importation and inventive tropic-rhythmic transformation itself began to blur and darken. As they draw the conclusion that Marx and Nietzsche must be questioned, revamped or bypassed since they got their physics wrong, it certainly appears as if new materialism judges the quality of social science on the basis of theories directly imported from natural science. An obvious question pertains to what exactly is gained by drawing on new scientific insights. Coole and Frost indicate that one crucial benefit is an improved understanding of matter, which they describe in terms of excess, relationality and difference, and with recognition of its activity, self-regeneration and unpredictability. In many ways this list of qualities looks appealing, even if it is rather abstract and vague. Upon closer inspection, however, it quickly becomes evident that each of these terms is closely related to concepts that already have extensive histories in sociocultural theory. Thus, excess has long been affiliated with George Bataille, difference with Jacques Derrida and Gilles Deleuze, creativity with Henri Bergson, and relationality and unpredictability with nearly all social thought over the last half century. In other words, it is not altogether clear what it is the new materialism intends to 'radically change.' Coole and Frost also made a number of methodological suggestions. Thus, they argued that to address climate change and global environmental devastation in sociocultural analysis requires sensitivity to the "resilience of matter," to the "importance of bodily experience" as well as to the "myriad interrelated material systems needed to sustain citizens" . Accordingly, they advocated a "multimodal methodology… congruent with multi-tiered ontologies" that "run between different levels of the social system and especially between the micro-level or everyday, and the macrolevel or structural" . At this point, however, another objection to the claim to novelty suggests itself. After all, methodologies that move between scales of 'micro' and 'macro' is by no means a new idea. More importantly, actor-network theory , feminist science studies , and anthropological approaches have long challenged the assumption that scales are given. They have replaced this classic idea with an analytics that sees scales as emergent effects of heterogeneous interactions between humans and nonhumans . Instead of slotting reality into fixed micro-, meso-and macro-scales, each dealing with appropriately delineated topics and operating according to their own principles, these are studies of how scales are constructed through socio-technical ordering processes. As this discussion suggests, despite its welcome insistence on material agency, new materialism contains various ambiguities and unresolved tensions, which makes it difficult to appraise its capacities for dealing with the kinds of ecological transformations indexed by the Anthropocene. The following discussion of the geographer Nigel Clark's Inhuman Nature allows us to examine this question more carefully. --- An inhuman nature for Anthropocene social theory? Given the focus of the discipline, it is probably not very surprising that the most sustained application of new materialist ideas to the Anthropocene has occurred in geography. Along with Kathryn Yusoff and others, Nigel Clark has shown particular commitment to demonstrate not only that humans now shape geology but also that social life is underwritten by geologic agency ). Here, we focus specifically on his Inhuman Nature, which presents a detailed argument for a broad expansion, both speculative and empirical, of the role of the nonhuman in social theory. To develop this argument, Clark combines elements from new materialism and the philosophical approach known as object-oriented ontology. As regards the former, Clark refers to a series of thinkers, including Elizabeth Grosz, Vicki Kirby and Myra Hird, all of whom insist that the biological and "inorganic systems that sustain life" also enable and 'provoke' human culture. Thus, Grosz refers to nature as 'the ground' out of which life emerges and Kirby wants to reclaim nature from those who "would reduce nature or the ground to some kind of culturallinguistic effect" . Clark complements these ideas with the speculative philosopher Quentin Meilassoux's Also similar to Coole and Frost, he is explicit that his own argument depends utterly on the 'substantive' findings of the earth sciences and on the recent philosophical re-activation of the question of 'things-inthemselves' The re-occurrence of this double gesture, which simultaneously acknowledges and side-steps the problem of scientism can be seen as testimony to the real difficulties social scientists face as they try to activate material agency. And in Clark's case, too, it is quite hard to see how 'utter dependence' on the substantive findings of the earth sciences squares with a sustained and critical interrogation of the "premises, practices and products of the physical sciences." Clark cites with approval the philosopher Ray Brassier's claim that "fully mind-independent realities"-of plate tectonics, undiscovered oil reserves, the accretion of the earth-"are found across multitudes of times, spaces, scales or fields of existence" . Yet, if we pause to ask from whence comes the certainty of these 'fully mind-independent' facts about "autonomous, human-independent realities" , the answer is clearly that they come with the unquestioned authority of scientists. It is because the genesis of scientific facts is not subject to scrutiny that it becomes possible to conceive of them as fully mind-independent. 4One finds in the work of Deleuze and Guattari-a source of inspiration for actor-network theory as well as strands of new materialism and Clark's recent work on the Anthropocene-quite a different approach to scientific concepts. Felix Guattari wrote that "there is an urgent need for us to free ourselves of scientistic references and metaphors: to forge new paradigms which are instead ethicoaesthetic in inspiration." Guattari's point was obviously not that either science or matter does not matter. Instead, he highlighted that the creative evolution of different fields and disciplines has to be open to divergence. Thus, each practice will have to invent its own situated modes of attention and response to ecological transformations. As we highlight later, this is also the case for the socio-cultural sciences. --- From inhuman nature and to entangled worlds Nigel Clark is sympathetic to Bruno Latour's long-standing effort to grant nonhumans a role in socio-cultural analysis. At the same time, in line with Coole and Frost's demand for a 'truly radical' reappraisal of materialism, he is critical of what he perceives as ANT's insufficient radicalness. Constitutively hybrid, Latourian actor-networks are composed of a mixture of human and nonhuman entities. If one searches for an ultimately inhuman nature this becomes a problem, since-as Clark notes with reference to Graham Harman-one can find in Latour only "the most flickering hints of networks devoid of human involvement." Moreover, since ANT insists that to speak of or for others implies mediation and translation, "it is hard to imagine how a domain fully independent of the human can legitimately receive attention as anything more than an abstract possibility" . Because actor-networks fail to follow through on the "beautiful and profound idea of nonhumans composing fully autonomous worlds of their own", Clark finds them prosaic and "strangely conventional" . --- On this point he distinguishes sharply between Bruno Latour and Isabelle Stengers whose work on Gaia is crucial for us in what follows. While Latour is described as unable to "concede" the potency of things, and thus ends up a closet correlationist, Clark sees Stengers as keenly attentive to the inhuman. Contrary to "many of her fellow science studies scholars,"5 he writes , "who emphasize the human-nonhuman co-construction of climate", Stengers: drives home the point that issues of global ecological transformation… encourages us to conceive of the planet not just in terms of our own interchanges with it, but in and for itself: "Of the Earth, the present subject of our scenarios, we can presuppose a single thing: it doesn't care about the questions we ask about it" . In fact, it is unlikely that most STS scholars-certainly those working in the tradition of ANT-would disagree. This includes Latour, who began his Irreductions with the following comments: Things-in-themselves? But they are fine, thank you very much. And how are you?… The tree shows what it can do, and as it does so, it discovers what all the other forces it welcomed can do. You laugh because I attribute too much cunning to it? Because you can fell it in five minutes with a chain saw? But don't laugh too soon… Soon you may have no more fuel for your saw. Then the tree with its carboniferous allies may be able to sap your strength. So far it has neither lost nor won, for each defines the game and time span in which its gain or loss is to be measured. As this quote suggests, the difference between ANT and Clark's new materialism is hardly found in the latter's more profound appreciation of nonhuman existence. It pertains, rather, to the possibility of gaining a hold on such existence without mediation, for example by scientists, their instruments and laboratories. On this point, however, there are important differences. They can be brought out by tracing Clark's interpretation of Stengers' observation that "[e]verything changes when one leaves the laboratory" as support for his notion of an inhuman nature. On the one hand, Stengers is indicating that outside the circumscribed space of the laboratory, nonhuman forces cannot easily be controlled. On the outside, she writes, "one finds friction, wind, the irregularity of soil, and the density of milieus" . Yet, on the other hand, this has little to do with a commitment to 'fully mind-independent' things. What Stengers is addressing is rather the impossibility of maintaining a strict separation between scientific facts and cultural fictions outside the space of the laboratory. As vividly exemplified by ecological controversies, on the outside it does indeed become very difficult for scientists to control the situation by referring to objective facts. But this means that it becomes correspondingly harder to identify any pure and untainted testimony to an inhuman nature. Significantly, Clark neglects to follow Stengers' paragraph to the end. After invoking the wind, friction, and the irregularity of soil, she continues: And one also finds a world acted on by other actors, pursuing other projects […]. With regard to these actors, the scientist conscious of changing milieus could ask himself: "Why am I so interesting to them? Where are all the others, who are capable of taking into account everything that my laboratory must eliminate in order to authorize me to speak?" In the end, then, Stengers' concern has nothing to do with trying to access a world indifferent to the plight of humans. Instead, her problem, similar to Latour's , is how to extend the scientific event without obliterating all the 'correlations' that make others-whether humans or nonhumans-act. It follows that the problem is not really one of correlation at all. Instead, the extension of an event is defined by the capacity of new elements-here scientific facts, objects or concerns-to insert themselves in other practices in ways that, by modifying existing relations, generates consequential new kinds of interest. Equidistant from vindicating the idea of a totally external nature and from submitting to human correlations, scientific objects are thus exhibited as gaining or losing existence through processes of mediation and transformation that stretch into varied ecologies of practice . Rather than complying with the dictates of science, these practices further add to and complicate the question of consequences. In turn, this is why the unfolding planetary event, which Stengers calls the intrusion of Gaia, is indeterminate-like all events-except by its effects and "the problem posed in the future it creates" . Gaia can be identified neither with the Anthropocene nor with the Capitalocene , because both, in their different ways, over-determine the situation and foreclose the possibility of staging the problem differently. What is at issue is elucidation of the varied entanglements of people and diverse earthly powers. In appreciation of the event's indeterminacy, Gaia is measured by the multiplicity of its interpretations and effects. Once one leaves the scientific laboratory, Stengers thus urges us to ask: where are all the others, capable of taking into account what the laboratory itself could not? Today, climate and earth scientists are themselves posing such questions-both to socio-cultural scholars and to wider publics . Indeed, Nigel Clark has also recently begun to ask such questions with reference to earth systems governance . Considering the rhetorical energy spent on differentiating his inhuman approach from Latour's 'strangely conventional' analyses, we might expect Clark's own analyses to look altogether different. Like in the case of Coole and Frost, however, it turns out to be difficult to show just how, why, and to whom the attention to radically inhuman matters should matter. The problem is that, as a social scientist, Clark is still obliged to deal with people and their situations. After spending many pages demolishing Latour's residual anthropocentrism-"hunting down shades of anthropocentrism," as Stengers wrote in our introductory quote-he eventually turns to Emmanuel Levinas to develop an analysis of sociality and hospitality in the wake of environmental catastrophe . Rather than entering the 'beautiful and profound' realm of fully autonomous non-human worlds, we find ourselves amidst many socio-cultural relations, organizations, politicians, scientists and other people who make sense of disaster and respond to it. In the end, the notion of inhuman nature functions mainly as a persistent reminder that floods, fires, and storms do indeed occur and that they do affect people in multiple ways. The insight is important and very difficult to disagree with. It is difficult, however, to see this way of problematizing nonhumans in the Anthropocene as adding something particularly radical or new to social theory. --- Updating Marx for the Capitalocene If the central preoccupation of Clark, the geographer, was to activate the earth's geological powers against anthropocentric views that ascribe all agency to people, a core interest of resurgent eco-Marxism is to locate ecological transformations in the context of capitalist history. Marx himself grew increasingly interested in natural science as he developed a theory of the 'metabolism' of Man and Nature and the labor-induced 'metabolic rift' of capitalist exploitation of natural resources . Moreover, like much of the Western Marxist canon, eco-Marxism is typically committed to the possibility of characterizing the 'true', 'underlying', 'systemic' or 'total' view of Socio-Natural Reality. In this sense, much eco-Marxism assumes what the philosopher Graham Harman dubs a 'truth politics' that, to varying degrees, extends scientism from the natural and into the socio-cultural sciences. One case in point is the way the Anthropocene has transformed into the "Capitalocene." The Capitalocene has been given a range of interpretations by quite a heterogeneous group of scholars. The political ecologists Andreas Malm and Alf Hornborg deploy the term as part of a frontal critique of the 'species concept' of the Anthropocene. By locating agency at the level of the human species, they charge, Anthropocene scholarship fails to analyze the 'vested interests' of capitalism as the historical agent of inequality and exploitation all over the planet. Meanwhile, the feminist science studies scholar Donna Haraway uses the Capitalocene as a stepping-stone towards a de-centered call for attending to 'kinships' across human and non-human worlds. 6 Mediating between these positions is the environmental historian Jason W. Moore's highly regarded Capitalism in the Web of Life . In a way, Capitalism in the Web of Life occupies a position resembling that of Nigel Clark's Inhuman Nature, except that its starting point is eco-Marxist rather than new materialist. In lieu of Clark's mixture of new materialism and object-oriented ontology, Moore seeks a radical undoing of any nostalgic vestiges of Society-Nature dualism, which is depicted as preventing earlier forms of Marxism from fully critiquing present-day environmental crises. In a nutshell, Moore develops an analysis of capitalism as working in and through nature, rather than being located on its 'outside.' Conceived as a form of power-laden 'environment-making' , this world-ecological perspective thinks capital and capitalism beyond Society-Nature dualism through the notion of the oikeios, "the creative, historical, and dialectical relation between, and also always within, human and extra-human natures" . As a 'multilayered dialectic,' the oikeios comprises flora and fauna, but also the planet's manifold geological and biospheric processes, as these gets 'bundled' up with forms of 'social' organization. Moore thus sees historical agency as an emergent property of "configurations of human activity with the rest of life." --- The question of alterity; or, how to undo economic totalization? Reading Capitalism in the Web of Life, it is striking to observe how close Moore's project might have been to what he dismissively characterizes as 'cultural studies' that "highlight hybrids, assemblages, and networks" . Yet, even as Moore rhetorically asks whether "anyone today seriously doubt that diseases, or climates, or plants make history as much as any empire?", and although his answer in some ways resembles those given by Latour, Haraway, Stengers or Anna Tsing , his own examination of these more-than-human connections proceeds via the Marxist canon. 7Moore wants to rethink capital as a form of human-and-natural accumulation, which has achieved global hegemony since the 16 th century due to the accessibility of 'cheap nature'-of food, labor-power, energy, and raw materials-for which capital always pays too little . Latter-day ecological crises, however, signal that capital is running out of cheap nature to extract. In the end, therefore, much hinges on the conceptual boundary between capital and its 'outside', or alterity. But this is where things get tricky. As noted, Moore rejects the idea of a pre-capitalist, pristine, or unspoiled Nature, emphasizing instead historically and geographically specific projects of capitalization, wrought within shifting relations of power. In this analysis, cheap nature emerges as a dialectics of contingent-but-powerful capitalist strategies that run up against their own unforeseen consequences. This conceptual maneuver, however, raises the question of whether it is actually possible to conceive of any outside to capitalism, or whether it fully encompasses the whole 'web of life'. The question is important because, as Dipesh Chakrabarty has written in response to his eco-Marxist critics , the existence of unequal global capitalism in general offers no specific conceptual handle on humanity's long-term ecological overshoot. However, even if Capitalism cannot operate as a master concept in the Anthropocene, Chakrabarty insists, this does not mean that it must be replaced with the human species as a successor concept. Instead, it is the very idea of master concepts that needs to go. Analogously, we suggest that the Anthropocene requires the development of concepts and forms of analysis that make it possible to keep very heterogeneous empirical settings and forms of conceptualization in simultaneous view . The problem with Capitalism as an encompassing analytical category is well exemplified in Moore's analysis of the spread of and resistance to the 'cheap nature' of genetically modified crops . In Moore's reading , GMO crops, attendant "super-weeds," and their intensified agro-chemical "taming cycle" primarily demonstrates the speed-up, "time-space compressed" dynamics through which increasingly globalized environments, stretching from the United States to the global South, become part of "the system." Moore, however, has little to say about the importance of nation-state projects and the varied interests and ideologies of the US and Europe . Indeed, he dismisses the environmental movement in general, indicating that it has basically achieved nothing but a shift of production costs from the global North to the global South . With this gesture, the fierce contestations over capitalist projects across the global South, from justice-oriented social reformers, environmental activists, indigenous groups and others are discarded as ephemeral and more or less irrelevant. At the same time, Moore assigns to nonhumans the severely circumscribed role as 'reserve energy' for capital, thus disregarding their agency and unruliness, not to mention their unpredictable political effects . While Moore's analyses of agro-industrial projects appear resonant with Anna Tsing's morethan-human ethnography of capitalist frontiers and ruined landscapes, for example, he bestows no recognition on the unruliness of non-humans, like bacteria and fungi, which Tsing shows to have constantly troubled the strategies of plantation capitalism . In short, if the problem with Clark's new materialism was that no matter how hard he tried to evacuate people from inhuman nature they kept slipping in, the reverse trouble with Moore's eco-Marxism is that even as he tries to find ways of letting non-human, non-capitalist otherness into his analysis, his analytics continuously squeezes it out. Even so, Moore's depiction of capital as a patterned set of historical and power-inflected projects that simultaneously de-valorizes nature and exceeds capitalist aims is interesting. Among other things, it shares critical intent if not conceptual orientation with Stengers' cosmo-political attempt to resist capitalism's eco-political irresponsibility in the face of Gaia's intrusion . The import and stakes of these analyses are captured by Haraway who writes that to think the Anthropocene well: one must surely tell of the networks of sugar, precious metals, plantations, indigenous genocides, and slavery, with their labor innovations and relocations and recompositions of critters and things sweeping up both human and nonhuman workers of all kinds. The question, therefore, is how to recognize the brutal efficacy of capital while also noticing its many gaps and interstices, and while also paying attention to the fragile articulation of global capital with all sorts of other political matters, including unruly nonhumans. How, we might ask with Philippe Pignarre and Isabelle Stengers , is it possible to inherit Marx's pragmatic impulse of anti-capitalist struggle while eschewing theoretical tendencies towards economic totalization? Taken as a general program for rethinking social theory after the Anthropocene event, Moore's world-ecological Marxism seems to us less than fully convincing. Among other things, the failure to accord much conceptual and practical significance to science, culture, or even politics is troublesome, not least in light of the important observation that 'cheap nature' may be coming to an end. If anything, discourses of the Anthropocene have served to stake out limits for and resistances to the spread of capital's projects, through socio-cultural thinking, activist mobilizations, and localized struggles that deserve more attention . Despite its undeniable innovativeness, Moore's eco-Marxist approach is thus ultimately unable to carry through the important task of thinking the limits and vulnerabilities of capital. The very notion of Capitalocene, we sense, signals the difficulty of detecting what may be truly novel and radical about our current eco-political predicament . Accordingly, we feel encouraged to search for supplementary or alternative ways of problematizing the Anthropocene event. We initiate this by tracing the trajectory of STS and ANT, currently prolonged and recast by Isabelle Stengers , who insists that we "accept the reality of Gaia." --- The Intrusion of Gaia: an alternative scenography In our view, the "intellectually serious extra-scientific figures of Gaia" forged in these years in part by Bruno Latour -and intensified and redirected, in important ways, by Isabelle Stengers ) and by Deborah Danowski and Eduardo Viveiros de Castro -offer particularly promising ways of coming to terms with current eco-political events. 8 Among these, Stengers' work stands out for the radical challenge it poses to a social theory bent on fully addressing these realities; challenges which, we affirm, also push back both at established ANT conventions and at Latour's kindred take on the geo-politics of Gaia. 9 The crux of Stengers' cosmo-political proposition for the present times is that, in the face of multiple environmental crises, we must come to 'accept' the reality of Gaia both intellectually and politically. What meaning does this proposition hold? A term of multiple origins, Gaia was a primordial deity in Greek mythology long before it was adopted in the 1960s by the chemist James Lovelock 8 One important manifestation of this wider set of dialogues was the September 2014 Rio de Janeiro colloquium on The Thousand Names of Gaia. Bruno Latour and Donna Haraway presented, and Stengers' contribution was central to the discussions. See Danowski and Viveiros de Castro . 9 Space prevents us from exploring these overlaps and differences. See Clarke for a useful first step. Suffice to say that, in our reading, Stengers' attention to tropes of intrusion and resistance gives to her Gaia a poignant 'cosmo-political' urgency not as readily detectable in Latour. and the microbiologist Lynn Margulis to name the hypothesis of Earth as a complex, self-regulating system . As Stengers notes , however, the term has since been re-incarnated in many guises, including in New Age Gaia is rather the name for a new, ominous being with its own regime of activity and sensitivity. At once hyper-responsive to human actions, and unpredictable in response, she refers to Gaia as 'ticklish ' . Unfortunately, even as these 'ticklish' reactions may well prove deadly to humankind, Gaia is also 'indifferent' to our concerns. Contrary to theaters of political adjudication, where people have a chance to justify their actions, accepting the reality of Gaia means accepting that we are now living in a realm of non-negotiable yet largely indeterminate demands, and that if we fail to respond adequately, our cries will not be heard. This is why Stengers defines Gaia as an 'intrusion' into collective historicity, to which everyone, social theorists included, will have to learn to respond. Stengers figures the response in terms of a cosmo-political 'slowing down' of reasoning, which has multiple implications for how socio-cultural analysis might seek to inherit and transform the Anthropocene event. Given Gaia's indifference to human pleas, it is indeed possible to speak of an asymmetric relation to a new 'ground', of the kind that held Clark's ) attention. For Stengers, however, Gaia does not designate a set of inhuman materials forming autonomous worlds. Quite differently, it operates as a speculative concept constructed to induce new appetites for thinking and acting among entangled practices. Noticeably, therefore, Stengers' key questions concern what accepting the reality of Gaia would mean for and demand from us . At the same time, however, she insists that Gaia's demands must now be assumed to be a permanent feature of the world. Humans, therefore, will be answerable to Gaia for good. Accordingly, Gaia names an unprecedented form of 'mundane' transcendence , deprived of any guarantees. In this precise sense, Gaia's intrusion into historicity marks an irreversible event. According to Stengers , Gaia's hybrid genealogy is particularly useful because it obliges social theorists to scrutinize shifts inside and outside the natural sciences with equal care. What this underscores is the importance of simultaneously analyzing the transformations Gaia undergoes in the hands of different scientific disciplines and in the broader ecology of economic, political and cultural practices, across widely divergent settings. Making clear that there is no given hierarchy between scientific and other forms of knowledge, Stengers argues that Gaia offers a way of resisting "the temptation of brutally opposing the sciences against the reputedly 'nonscientific' knowledges." At issue, instead, is the "necessity of inventing" new ways of 'coupling' divergent forms of knowledge and practice. Accordingly, Gaia's intrusion signifies a situation of radically indeterminate socio-natural practice, inquiry and politics. Importantly, this is not the uncertainty beloved by climate skeptics, since Gaia in its present state was produced by anthropogenic climate change. Instead, it is an indeterminacy that infiltrates science, culture, politics, economics and civic action at the level of practice, as no one can legitimately claim to know beyond any doubt how to adequately respond. Since sociocultural scholars are in no better position than their natural science colleagues to claim an extant position from which to capture the total implications of Gaia, a social theory troubled by its intrusion requires a far-reaching reconsideration of inherited concepts and modes of research. In this novel situation, Stengers thus insists on the importance of social-theoretical experimentation, understood as an ongoing effort to learn from other interested and inventive actors how to collectively resist the probability of a "coming barbarism." She calls for a situated and non-foundational practice of sociocultural inquiry that would take into consideration, and be responsive to, a range of divergent but allied knowledges and practices: natural-scientific, activist-public and otherwise. Since the 1960s, environmental history, activism, and politics across all continents have generated a wealth of novel practices, the conceptual importance and pragmatic efficacy of which is partly exhibited, yet far from exhausted, in social theory . Should trees have legal standing? . Might Earth-beings be ascribed constitutional rights? . Can Japanese Shinto practices re-enchant the capacities of nonhumans? . How to care for and live respectfully in a more-than-human world of charismatic animals and travelling, sprawling fungi ? Can Gaia help break the long legacy of Euro-centrism in social theory, making it sensitive to other histories? . Obviously, the questions raised are legion and no ready-made answers are lying around. Precisely: they are waiting to be invented and given conceptual shape by creative scholars in the socio-cultural sciences in conjunction with heterogeneous practitioners everywhere. Addressing such questions therefore depends on a genuine willingness to put inherited socio-theoretical certainties at risk. This entails a reconfiguration of social theory in the image of what Deleuze and Guattari called the 'following sciences', defined by a focus on empirical and conceptual variations and singularities and by locating natural and socio-cultural research in the world, and operating alongside a multiplicity of other co-inquirers . Were such a reconfiguration to succeed-unlikely as it seems-the Anthropocene might indeed become a re-generative event for social theory. --- Conclusion: Experimenting with matters in social theory After the Anthropocene event, it seems clearer than ever that "theory is always a detour on the way to something more important" . Yet determining which kind of detour Anthropocene theory is going to be and where it is going to lead, depends on what one makes of theory and of its many entanglements. Hall's statement must then be complemented with Donna Haraway's insistence that " [i]t matters what matters we use to think other matters with." As we have seen, the Anthropocene has given rise to calls for new approaches to social theory, and also to some claims to have already delivered them, not least by way of refiguring nonhuman agency and lively matter. It is probably not coincidental that the rush to create new theory for the Anthropocene, and the "agreeable position" in which, according to Isabelle Stengers, this demand places the theorists, has led to the elision of already existing ones. This is not to say that ANT, or STS in general, provides any off-the-shelf solution either. Nevertheless, the sensitivity of STS to the problems of scientism and economic totalization is helpful in opening up the sociocultural sciences to alternative ways of engaging the Anthropocene event. We have suggested that Stengers' dramatization of the problem in terms of accepting the reality of Gaia's intrusion offers a particularly fruitful extension of this legacy-one that entails a serious rethinking not only of the notion of the Anthropocene but also of its mirror image, the Capitalocene. Taking this intrusion seriously, we suggest, requires the development of an art of immanent attention to the politics of varied matters as they unfold across the whole ecology of practices. Well beyond the present preoccupations of Euro-American social theory, environmental history, activism and politics are all full of sites of resistance and experimentation, the political potentials and conceptual capacities of which are far from exhausted. Slowing down theory sufficiently to learn from these multiple sites is the starting point for an approach adequate to the problems posed by the Anthropocene event, and an irritable, ticklish Gaia. Inasmuch as it matters for social theory to continue to learn to expand its modes of attentiveness to nonhuman materialities, one can certainly do worse than detour through the new materialists and eco-Marxists. However, any adequate responses to Gaia's intrusion must be based on an equally firm commitment to following, learning to be affected by, and experimenting with the many divergent knowledges and practices of natural science, environmental activism, and concerned publics currently emerging around the planet.

Signaling that 'humanity' has radically changed the Earth's environmental parameters, the Anthropocene currently generates debate across the socio-cultural sciences. In this context, neo-Marxist and new materialist approaches stand out for the way they oblige social theory to catch up with new material realities. We share the conviction that the Anthropocene might constitute a genuine event for social theory and practice. However, we argue that the search for alternative ways of problematizing and 'dramatizing' our eco-political predicament confronts these approaches with unresolved issues of scientism and economic totalization. Looking for another path, we turn to science and technology studies (STS), and especially actor-network theory (ANT). We relay the long-standing focus on nonhuman agency characteristic of this field via Isabelle Stengers' argument that we must "accept" the reality of Gaia's intrusion into collective historicity. The challenge posed by Stengers, we suggest, requires the development of an art of immanent attention to the politics of varied matters as they unfold across diverse ecologies of practice. Extending further than the present preoccupations of Euro-American social theory, other areas within and across environmental history, activism, and politics offer sites of resistance as well as experimentation whose conceptual possibilities and practical This paper (post-print) has been accepted for publication in The Sociological Review. Edited, revised and typeset version of this paper will be published in The Sociological Review, vol. 67(6) by Sage, All rights reserved. © Sage, 2019 2 efficacies have yet to be explored. Slowing down theory sufficiently to learn from these multiple sites, we argue, is the starting point for an approach more adequate to the problems posed by the Anthropocene event.

social theory given the significance of anthropogenic climate change it is difficult to disagree with the general orientation of such arguments indeed we also think that the current situation holds the potential to institute a genuine event in the sense that it may come to mark a decisive difference between a before and an afterfor both the sociocultural and the natural sciences to characterize this event we offer a detailed examination of new materialist and ecomarxist approaches to the anthropocene we do so because both use the anthropocene as a platform for developing arguments about novel obligations placed upon contemporary social theory which are at once farreaching and far from innocent here we identify some unresolved issues in the name of appreciating material agency new materialist approaches struggle with legacies of scientism meanwhile new ecomarxist formulations have difficulties letting go of an impulse towards economic totalization characteristic of many strands of marxism probably due to our position as science and technology studies scholars working with actornetwork theory and related ideas we are particularly attentive to such kinds of problems on the one hand ants decadelong attempt to specify the conceptual and empirical possibilities of engaging nonhuman agency beyond scientism troubles the new materialist ambition to engage inhuman things in themselves on the other hand antinformed work on the material and pragmatic variability of markets challenges the ecomarxist rendition of capitalism as the one overarching framework for making sense of ecological disruption rather than sweeping these conceptual and methodological issues under the anthropocene carpet and offering another eclectic combination of more or less incongruent ideassomething that happens with some frequency these days2 we examine the different ways in which these approaches dramatize the problem of nonhuman materiality the aim is to get a better handle on how social theorists might inhabit the anthropocene event including the question of whether the term itself is adequate for what it names in brief and with a deliberate degree of provocation we argue that an understanding of nonhuman agency informed by ant entails something like a reversal of the interpretation of the relation between the anthropocene and social theory put forth by new materialists and ecomarxists the present situation is not one in which sociocultural studies need to catch up with the natural sciences by learning to take nonhumans and materialities seriously on the contrary it is the natural sciences that are finally beginning to catch up with the insight that societies and economies are fundamentally shaped by nonhuman agency 3 but our aim is not the petty one of vindicating ant against new competitors instead we use new materialist calls for an intensified interest in material agency and ecomarxist endeavors to rethink the relation between economies and ecologies as an entrypoint for our own noninnocent attempt to problematize the anthropocene event differently with this in mind we turn to the figure of gaia which due to the work of isabelle stengers and bruno latour has recently reemerged as an intellectually serious figure for thinking through the implications of anthropogenic climate change in contrast with the anthropocene and its inversion the capitalocene isabelle stengers version of gaia simultaneously highlights that humanity is in no position to either control or manage the earth acknowledges that certain people and corporations are the main causes of gaias intrusion and insists that the needed responses must be at once pragmatic and experimental the implication is that rather than placing the problem of response in the hands of scientists politicians businesses or cuttingedge social theorists it must be distributed across a heterogeneous ecology of practices we begin by tracing the trajectories that led new materialists towards the anthropocene and ecomarxists towards the capitalocene subsequently we explore the alternative problematization of the ecopolitical situation made available by stengers gaia as indicated we believe that gaia opens up a more capacious cosmopolitical scenography one that entails an experimental search for situated pathways towards the reinvention of numerous practices including social theory pathways to matter the new materialisms in the following sections we examine two influential new materialist and ecomarxist responses to the anthropocene outlined respectively by the geographer nigel clark and the environmental historian jason moore we engage these two particular thinkers since their ways of dramatizing the issues are interesting in their own right while also holding exemplary value and because it is important to be specific rather than offering abstract diagnoses however we begin with some more general observations about new materialism because its ideas and premises have significantly influenced current discussions about the anthropocene in social and cultural theory in their introduction to the edited volume new materialisms diana coole and samantha frost argued that an adequately updated social theory entails a reprisal of materialism that must be truly radical the contemporary context including the fact of climate change they asserted demands a theoretical rapprochement with material realism on the basis of new developments in the natural sciences in social and cultural theory this would mean revisiting the most fundamental questions about the nature of matter and the place of embodied humans within a natural world the authors observed that previous materialist philosophers including marx nietzsche and freud had also been influenced by natural science in the 21 st century however the classical newtonian paradigm that had inspired these thinkers has been obviated by newer developments and problems thus a new materialism was needed which would be resonant with and to some extent informed by developments in natural science for coole and frost postclassical physics held special promise since it had shown matter to be more elusive than previously expected and to contain an excess force vitality relationality or difference that renders matter active selfcreative productive unpredictable coole and frost were explicit that the new materialism would not entail an uncritical acceptance of scientific facts or theories since scientific theories cannot simply be imported into philosophy at the same time they were equally emphatic that the tropes and rhythms they scientific theories suggest can transform theoretical discourses however as their discussion turned towards the realm of subatomic particles and dark matter the distinction between improper theoretical importation and inventive tropicrhythmic transformation itself began to blur and darken as they draw the conclusion that marx and nietzsche must be questioned revamped or bypassed since they got their physics wrong it certainly appears as if new materialism judges the quality of social science on the basis of theories directly imported from natural science an obvious question pertains to what exactly is gained by drawing on new scientific insights coole and frost indicate that one crucial benefit is an improved understanding of matter which they describe in terms of excess relationality and difference and with recognition of its activity selfregeneration and unpredictability in many ways this list of qualities looks appealing even if it is rather abstract and vague upon closer inspection however it quickly becomes evident that each of these terms is closely related to concepts that already have extensive histories in sociocultural theory thus excess has long been affiliated with george bataille difference with jacques derrida and gilles deleuze creativity with henri bergson and relationality and unpredictability with nearly all social thought over the last half century in other words it is not altogether clear what it is the new materialism intends to radically change coole and frost also made a number of methodological suggestions thus they argued that to address climate change and global environmental devastation in sociocultural analysis requires sensitivity to the resilience of matter to the importance of bodily experience as well as to the myriad interrelated material systems needed to sustain citizens accordingly they advocated a multimodal methodology… congruent with multitiered ontologies that run between different levels of the social system and especially between the microlevel or everyday and the macrolevel or structural at this point however another objection to the claim to novelty suggests itself after all methodologies that move between scales of micro and macro is by no means a new idea more importantly actornetwork theory feminist science studies and anthropological approaches have long challenged the assumption that scales are given they have replaced this classic idea with an analytics that sees scales as emergent effects of heterogeneous interactions between humans and nonhumans instead of slotting reality into fixed micro mesoand macroscales each dealing with appropriately delineated topics and operating according to their own principles these are studies of how scales are constructed through sociotechnical ordering processes as this discussion suggests despite its welcome insistence on material agency new materialism contains various ambiguities and unresolved tensions which makes it difficult to appraise its capacities for dealing with the kinds of ecological transformations indexed by the anthropocene the following discussion of the geographer nigel clarks inhuman nature allows us to examine this question more carefully an inhuman nature for anthropocene social theory given the focus of the discipline it is probably not very surprising that the most sustained application of new materialist ideas to the anthropocene has occurred in geography along with kathryn yusoff and others nigel clark has shown particular commitment to demonstrate not only that humans now shape geology but also that social life is underwritten by geologic agency here we focus specifically on his inhuman nature which presents a detailed argument for a broad expansion both speculative and empirical of the role of the nonhuman in social theory to develop this argument clark combines elements from new materialism and the philosophical approach known as objectoriented ontology as regards the former clark refers to a series of thinkers including elizabeth grosz vicki kirby and myra hird all of whom insist that the biological and inorganic systems that sustain life also enable and provoke human culture thus grosz refers to nature as the ground out of which life emerges and kirby wants to reclaim nature from those who would reduce nature or the ground to some kind of culturallinguistic effect clark complements these ideas with the speculative philosopher quentin meilassouxs also similar to coole and frost he is explicit that his own argument depends utterly on the substantive findings of the earth sciences and on the recent philosophical reactivation of the question of thingsinthemselves the reoccurrence of this double gesture which simultaneously acknowledges and sidesteps the problem of scientism can be seen as testimony to the real difficulties social scientists face as they try to activate material agency and in clarks case too it is quite hard to see how utter dependence on the substantive findings of the earth sciences squares with a sustained and critical interrogation of the premises practices and products of the physical sciences clark cites with approval the philosopher ray brassiers claim that fully mindindependent realitiesof plate tectonics undiscovered oil reserves the accretion of the earthare found across multitudes of times spaces scales or fields of existence yet if we pause to ask from whence comes the certainty of these fully mindindependent facts about autonomous humanindependent realities the answer is clearly that they come with the unquestioned authority of scientists it is because the genesis of scientific facts is not subject to scrutiny that it becomes possible to conceive of them as fully mindindependent 4one finds in the work of deleuze and guattaria source of inspiration for actornetwork theory as well as strands of new materialism and clarks recent work on the anthropocenequite a different approach to scientific concepts felix guattari wrote that there is an urgent need for us to free ourselves of scientistic references and metaphors to forge new paradigms which are instead ethicoaesthetic in inspiration guattaris point was obviously not that either science or matter does not matter instead he highlighted that the creative evolution of different fields and disciplines has to be open to divergence thus each practice will have to invent its own situated modes of attention and response to ecological transformations as we highlight later this is also the case for the sociocultural sciences from inhuman nature and to entangled worlds nigel clark is sympathetic to bruno latours longstanding effort to grant nonhumans a role in sociocultural analysis at the same time in line with coole and frosts demand for a truly radical reappraisal of materialism he is critical of what he perceives as ants insufficient radicalness constitutively hybrid latourian actornetworks are composed of a mixture of human and nonhuman entities if one searches for an ultimately inhuman nature this becomes a problem sinceas clark notes with reference to graham harmanone can find in latour only the most flickering hints of networks devoid of human involvement moreover since ant insists that to speak of or for others implies mediation and translation it is hard to imagine how a domain fully independent of the human can legitimately receive attention as anything more than an abstract possibility because actornetworks fail to follow through on the beautiful and profound idea of nonhumans composing fully autonomous worlds of their own clark finds them prosaic and strangely conventional on this point he distinguishes sharply between bruno latour and isabelle stengers whose work on gaia is crucial for us in what follows while latour is described as unable to concede the potency of things and thus ends up a closet correlationist clark sees stengers as keenly attentive to the inhuman contrary to many of her fellow science studies scholars5 he writes who emphasize the humannonhuman coconstruction of climate stengers drives home the point that issues of global ecological transformation… encourages us to conceive of the planet not just in terms of our own interchanges with it but in and for itself of the earth the present subject of our scenarios we can presuppose a single thing it doesnt care about the questions we ask about it in fact it is unlikely that most sts scholarscertainly those working in the tradition of antwould disagree this includes latour who began his irreductions with the following comments thingsinthemselves but they are fine thank you very much and how are you… the tree shows what it can do and as it does so it discovers what all the other forces it welcomed can do you laugh because i attribute too much cunning to it because you can fell it in five minutes with a chain saw but dont laugh too soon… soon you may have no more fuel for your saw then the tree with its carboniferous allies may be able to sap your strength so far it has neither lost nor won for each defines the game and time span in which its gain or loss is to be measured as this quote suggests the difference between ant and clarks new materialism is hardly found in the latters more profound appreciation of nonhuman existence it pertains rather to the possibility of gaining a hold on such existence without mediation for example by scientists their instruments and laboratories on this point however there are important differences they can be brought out by tracing clarks interpretation of stengers observation that e verything changes when one leaves the laboratory as support for his notion of an inhuman nature on the one hand stengers is indicating that outside the circumscribed space of the laboratory nonhuman forces cannot easily be controlled on the outside she writes one finds friction wind the irregularity of soil and the density of milieus yet on the other hand this has little to do with a commitment to fully mindindependent things what stengers is addressing is rather the impossibility of maintaining a strict separation between scientific facts and cultural fictions outside the space of the laboratory as vividly exemplified by ecological controversies on the outside it does indeed become very difficult for scientists to control the situation by referring to objective facts but this means that it becomes correspondingly harder to identify any pure and untainted testimony to an inhuman nature significantly clark neglects to follow stengers paragraph to the end after invoking the wind friction and the irregularity of soil she continues and one also finds a world acted on by other actors pursuing other projects … with regard to these actors the scientist conscious of changing milieus could ask himself why am i so interesting to them where are all the others who are capable of taking into account everything that my laboratory must eliminate in order to authorize me to speak in the end then stengers concern has nothing to do with trying to access a world indifferent to the plight of humans instead her problem similar to latours is how to extend the scientific event without obliterating all the correlations that make otherswhether humans or nonhumansact it follows that the problem is not really one of correlation at all instead the extension of an event is defined by the capacity of new elementshere scientific facts objects or concernsto insert themselves in other practices in ways that by modifying existing relations generates consequential new kinds of interest equidistant from vindicating the idea of a totally external nature and from submitting to human correlations scientific objects are thus exhibited as gaining or losing existence through processes of mediation and transformation that stretch into varied ecologies of practice rather than complying with the dictates of science these practices further add to and complicate the question of consequences in turn this is why the unfolding planetary event which stengers calls the intrusion of gaia is indeterminatelike all eventsexcept by its effects and the problem posed in the future it creates gaia can be identified neither with the anthropocene nor with the capitalocene because both in their different ways overdetermine the situation and foreclose the possibility of staging the problem differently what is at issue is elucidation of the varied entanglements of people and diverse earthly powers in appreciation of the events indeterminacy gaia is measured by the multiplicity of its interpretations and effects once one leaves the scientific laboratory stengers thus urges us to ask where are all the others capable of taking into account what the laboratory itself could not today climate and earth scientists are themselves posing such questionsboth to sociocultural scholars and to wider publics indeed nigel clark has also recently begun to ask such questions with reference to earth systems governance considering the rhetorical energy spent on differentiating his inhuman approach from latours strangely conventional analyses we might expect clarks own analyses to look altogether different like in the case of coole and frost however it turns out to be difficult to show just how why and to whom the attention to radically inhuman matters should matter the problem is that as a social scientist clark is still obliged to deal with people and their situations after spending many pages demolishing latours residual anthropocentrismhunting down shades of anthropocentrism as stengers wrote in our introductory quotehe eventually turns to emmanuel levinas to develop an analysis of sociality and hospitality in the wake of environmental catastrophe rather than entering the beautiful and profound realm of fully autonomous nonhuman worlds we find ourselves amidst many sociocultural relations organizations politicians scientists and other people who make sense of disaster and respond to it in the end the notion of inhuman nature functions mainly as a persistent reminder that floods fires and storms do indeed occur and that they do affect people in multiple ways the insight is important and very difficult to disagree with it is difficult however to see this way of problematizing nonhumans in the anthropocene as adding something particularly radical or new to social theory updating marx for the capitalocene if the central preoccupation of clark the geographer was to activate the earths geological powers against anthropocentric views that ascribe all agency to people a core interest of resurgent ecomarxism is to locate ecological transformations in the context of capitalist history marx himself grew increasingly interested in natural science as he developed a theory of the metabolism of man and nature and the laborinduced metabolic rift of capitalist exploitation of natural resources moreover like much of the western marxist canon ecomarxism is typically committed to the possibility of characterizing the true underlying systemic or total view of socionatural reality in this sense much ecomarxism assumes what the philosopher graham harman dubs a truth politics that to varying degrees extends scientism from the natural and into the sociocultural sciences one case in point is the way the anthropocene has transformed into the capitalocene the capitalocene has been given a range of interpretations by quite a heterogeneous group of scholars the political ecologists andreas malm and alf hornborg deploy the term as part of a frontal critique of the species concept of the anthropocene by locating agency at the level of the human species they charge anthropocene scholarship fails to analyze the vested interests of capitalism as the historical agent of inequality and exploitation all over the planet meanwhile the feminist science studies scholar donna haraway uses the capitalocene as a steppingstone towards a decentered call for attending to kinships across human and nonhuman worlds 6 mediating between these positions is the environmental historian jason w moores highly regarded capitalism in the web of life in a way capitalism in the web of life occupies a position resembling that of nigel clarks inhuman nature except that its starting point is ecomarxist rather than new materialist in lieu of clarks mixture of new materialism and objectoriented ontology moore seeks a radical undoing of any nostalgic vestiges of societynature dualism which is depicted as preventing earlier forms of marxism from fully critiquing presentday environmental crises in a nutshell moore develops an analysis of capitalism as working in and through nature rather than being located on its outside conceived as a form of powerladen environmentmaking this worldecological perspective thinks capital and capitalism beyond societynature dualism through the notion of the oikeios the creative historical and dialectical relation between and also always within human and extrahuman natures as a multilayered dialectic the oikeios comprises flora and fauna but also the planets manifold geological and biospheric processes as these gets bundled up with forms of social organization moore thus sees historical agency as an emergent property of configurations of human activity with the rest of life the question of alterity or how to undo economic totalization reading capitalism in the web of life it is striking to observe how close moores project might have been to what he dismissively characterizes as cultural studies that highlight hybrids assemblages and networks yet even as moore rhetorically asks whether anyone today seriously doubt that diseases or climates or plants make history as much as any empire and although his answer in some ways resembles those given by latour haraway stengers or anna tsing his own examination of these morethanhuman connections proceeds via the marxist canon 7moore wants to rethink capital as a form of humanandnatural accumulation which has achieved global hegemony since the 16 th century due to the accessibility of cheap natureof food laborpower energy and raw materialsfor which capital always pays too little latterday ecological crises however signal that capital is running out of cheap nature to extract in the end therefore much hinges on the conceptual boundary between capital and its outside or alterity but this is where things get tricky as noted moore rejects the idea of a precapitalist pristine or unspoiled nature emphasizing instead historically and geographically specific projects of capitalization wrought within shifting relations of power in this analysis cheap nature emerges as a dialectics of contingentbutpowerful capitalist strategies that run up against their own unforeseen consequences this conceptual maneuver however raises the question of whether it is actually possible to conceive of any outside to capitalism or whether it fully encompasses the whole web of life the question is important because as dipesh chakrabarty has written in response to his ecomarxist critics the existence of unequal global capitalism in general offers no specific conceptual handle on humanitys longterm ecological overshoot however even if capitalism cannot operate as a master concept in the anthropocene chakrabarty insists this does not mean that it must be replaced with the human species as a successor concept instead it is the very idea of master concepts that needs to go analogously we suggest that the anthropocene requires the development of concepts and forms of analysis that make it possible to keep very heterogeneous empirical settings and forms of conceptualization in simultaneous view the problem with capitalism as an encompassing analytical category is well exemplified in moores analysis of the spread of and resistance to the cheap nature of genetically modified crops in moores reading gmo crops attendant superweeds and their intensified agrochemical taming cycle primarily demonstrates the speedup timespace compressed dynamics through which increasingly globalized environments stretching from the united states to the global south become part of the system moore however has little to say about the importance of nationstate projects and the varied interests and ideologies of the us and europe indeed he dismisses the environmental movement in general indicating that it has basically achieved nothing but a shift of production costs from the global north to the global south with this gesture the fierce contestations over capitalist projects across the global south from justiceoriented social reformers environmental activists indigenous groups and others are discarded as ephemeral and more or less irrelevant at the same time moore assigns to nonhumans the severely circumscribed role as reserve energy for capital thus disregarding their agency and unruliness not to mention their unpredictable political effects while moores analyses of agroindustrial projects appear resonant with anna tsings morethanhuman ethnography of capitalist frontiers and ruined landscapes for example he bestows no recognition on the unruliness of nonhumans like bacteria and fungi which tsing shows to have constantly troubled the strategies of plantation capitalism in short if the problem with clarks new materialism was that no matter how hard he tried to evacuate people from inhuman nature they kept slipping in the reverse trouble with moores ecomarxism is that even as he tries to find ways of letting nonhuman noncapitalist otherness into his analysis his analytics continuously squeezes it out even so moores depiction of capital as a patterned set of historical and powerinflected projects that simultaneously devalorizes nature and exceeds capitalist aims is interesting among other things it shares critical intent if not conceptual orientation with stengers cosmopolitical attempt to resist capitalisms ecopolitical irresponsibility in the face of gaias intrusion the import and stakes of these analyses are captured by haraway who writes that to think the anthropocene well one must surely tell of the networks of sugar precious metals plantations indigenous genocides and slavery with their labor innovations and relocations and recompositions of critters and things sweeping up both human and nonhuman workers of all kinds the question therefore is how to recognize the brutal efficacy of capital while also noticing its many gaps and interstices and while also paying attention to the fragile articulation of global capital with all sorts of other political matters including unruly nonhumans how we might ask with philippe pignarre and isabelle stengers is it possible to inherit marxs pragmatic impulse of anticapitalist struggle while eschewing theoretical tendencies towards economic totalization taken as a general program for rethinking social theory after the anthropocene event moores worldecological marxism seems to us less than fully convincing among other things the failure to accord much conceptual and practical significance to science culture or even politics is troublesome not least in light of the important observation that cheap nature may be coming to an end if anything discourses of the anthropocene have served to stake out limits for and resistances to the spread of capitals projects through sociocultural thinking activist mobilizations and localized struggles that deserve more attention despite its undeniable innovativeness moores ecomarxist approach is thus ultimately unable to carry through the important task of thinking the limits and vulnerabilities of capital the very notion of capitalocene we sense signals the difficulty of detecting what may be truly novel and radical about our current ecopolitical predicament accordingly we feel encouraged to search for supplementary or alternative ways of problematizing the anthropocene event we initiate this by tracing the trajectory of sts and ant currently prolonged and recast by isabelle stengers who insists that we accept the reality of gaia the intrusion of gaia an alternative scenography in our view the intellectually serious extrascientific figures of gaia forged in these years in part by bruno latour and intensified and redirected in important ways by isabelle stengers and by deborah danowski and eduardo viveiros de castro offer particularly promising ways of coming to terms with current ecopolitical events 8 among these stengers work stands out for the radical challenge it poses to a social theory bent on fully addressing these realities challenges which we affirm also push back both at established ant conventions and at latours kindred take on the geopolitics of gaia 9 the crux of stengers cosmopolitical proposition for the present times is that in the face of multiple environmental crises we must come to accept the reality of gaia both intellectually and politically what meaning does this proposition hold a term of multiple origins gaia was a primordial deity in greek mythology long before it was adopted in the 1960s by the chemist james lovelock 8 one important manifestation of this wider set of dialogues was the september 2014 rio de janeiro colloquium on the thousand names of gaia bruno latour and donna haraway presented and stengers contribution was central to the discussions see danowski and viveiros de castro 9 space prevents us from exploring these overlaps and differences see clarke for a useful first step suffice to say that in our reading stengers attention to tropes of intrusion and resistance gives to her gaia a poignant cosmopolitical urgency not as readily detectable in latour and the microbiologist lynn margulis to name the hypothesis of earth as a complex selfregulating system as stengers notes however the term has since been reincarnated in many guises including in new age gaia is rather the name for a new ominous being with its own regime of activity and sensitivity at once hyperresponsive to human actions and unpredictable in response she refers to gaia as ticklish unfortunately even as these ticklish reactions may well prove deadly to humankind gaia is also indifferent to our concerns contrary to theaters of political adjudication where people have a chance to justify their actions accepting the reality of gaia means accepting that we are now living in a realm of nonnegotiable yet largely indeterminate demands and that if we fail to respond adequately our cries will not be heard this is why stengers defines gaia as an intrusion into collective historicity to which everyone social theorists included will have to learn to respond stengers figures the response in terms of a cosmopolitical slowing down of reasoning which has multiple implications for how sociocultural analysis might seek to inherit and transform the anthropocene event given gaias indifference to human pleas it is indeed possible to speak of an asymmetric relation to a new ground of the kind that held clarks attention for stengers however gaia does not designate a set of inhuman materials forming autonomous worlds quite differently it operates as a speculative concept constructed to induce new appetites for thinking and acting among entangled practices noticeably therefore stengers key questions concern what accepting the reality of gaia would mean for and demand from us at the same time however she insists that gaias demands must now be assumed to be a permanent feature of the world humans therefore will be answerable to gaia for good accordingly gaia names an unprecedented form of mundane transcendence deprived of any guarantees in this precise sense gaias intrusion into historicity marks an irreversible event according to stengers gaias hybrid genealogy is particularly useful because it obliges social theorists to scrutinize shifts inside and outside the natural sciences with equal care what this underscores is the importance of simultaneously analyzing the transformations gaia undergoes in the hands of different scientific disciplines and in the broader ecology of economic political and cultural practices across widely divergent settings making clear that there is no given hierarchy between scientific and other forms of knowledge stengers argues that gaia offers a way of resisting the temptation of brutally opposing the sciences against the reputedly nonscientific knowledges at issue instead is the necessity of inventing new ways of coupling divergent forms of knowledge and practice accordingly gaias intrusion signifies a situation of radically indeterminate socionatural practice inquiry and politics importantly this is not the uncertainty beloved by climate skeptics since gaia in its present state was produced by anthropogenic climate change instead it is an indeterminacy that infiltrates science culture politics economics and civic action at the level of practice as no one can legitimately claim to know beyond any doubt how to adequately respond since sociocultural scholars are in no better position than their natural science colleagues to claim an extant position from which to capture the total implications of gaia a social theory troubled by its intrusion requires a farreaching reconsideration of inherited concepts and modes of research in this novel situation stengers thus insists on the importance of socialtheoretical experimentation understood as an ongoing effort to learn from other interested and inventive actors how to collectively resist the probability of a coming barbarism she calls for a situated and nonfoundational practice of sociocultural inquiry that would take into consideration and be responsive to a range of divergent but allied knowledges and practices naturalscientific activistpublic and otherwise since the 1960s environmental history activism and politics across all continents have generated a wealth of novel practices the conceptual importance and pragmatic efficacy of which is partly exhibited yet far from exhausted in social theory should trees have legal standing might earthbeings be ascribed constitutional rights can japanese shinto practices reenchant the capacities of nonhumans how to care for and live respectfully in a morethanhuman world of charismatic animals and travelling sprawling fungi can gaia help break the long legacy of eurocentrism in social theory making it sensitive to other histories obviously the questions raised are legion and no readymade answers are lying around precisely they are waiting to be invented and given conceptual shape by creative scholars in the sociocultural sciences in conjunction with heterogeneous practitioners everywhere addressing such questions therefore depends on a genuine willingness to put inherited sociotheoretical certainties at risk this entails a reconfiguration of social theory in the image of what deleuze and guattari called the following sciences defined by a focus on empirical and conceptual variations and singularities and by locating natural and sociocultural research in the world and operating alongside a multiplicity of other coinquirers were such a reconfiguration to succeedunlikely as it seemsthe anthropocene might indeed become a regenerative event for social theory conclusion experimenting with matters in social theory after the anthropocene event it seems clearer than ever that theory is always a detour on the way to something more important yet determining which kind of detour anthropocene theory is going to be and where it is going to lead depends on what one makes of theory and of its many entanglements halls statement must then be complemented with donna haraways insistence that i t matters what matters we use to think other matters with as we have seen the anthropocene has given rise to calls for new approaches to social theory and also to some claims to have already delivered them not least by way of refiguring nonhuman agency and lively matter it is probably not coincidental that the rush to create new theory for the anthropocene and the agreeable position in which according to isabelle stengers this demand places the theorists has led to the elision of already existing ones this is not to say that ant or sts in general provides any offtheshelf solution either nevertheless the sensitivity of sts to the problems of scientism and economic totalization is helpful in opening up the sociocultural sciences to alternative ways of engaging the anthropocene event we have suggested that stengers dramatization of the problem in terms of accepting the reality of gaias intrusion offers a particularly fruitful extension of this legacyone that entails a serious rethinking not only of the notion of the anthropocene but also of its mirror image the capitalocene taking this intrusion seriously we suggest requires the development of an art of immanent attention to the politics of varied matters as they unfold across the whole ecology of practices well beyond the present preoccupations of euroamerican social theory environmental history activism and politics are all full of sites of resistance and experimentation the political potentials and conceptual capacities of which are far from exhausted slowing down theory sufficiently to learn from these multiple sites is the starting point for an approach adequate to the problems posed by the anthropocene event and an irritable ticklish gaia inasmuch as it matters for social theory to continue to learn to expand its modes of attentiveness to nonhuman materialities one can certainly do worse than detour through the new materialists and ecomarxists however any adequate responses to gaias intrusion must be based on an equally firm commitment to following learning to be affected by and experimenting with the many divergent knowledges and practices of natural science environmental activism and concerned publics currently emerging around the planet

signaling that humanity has radically changed the earths environmental parameters the anthropocene currently generates debate across the sociocultural sciences in this context neomarxist and new materialist approaches stand out for the way they oblige social theory to catch up with new material realities we share the conviction that the anthropocene might constitute a genuine event for social theory and practice however we argue that the search for alternative ways of problematizing and dramatizing our ecopolitical predicament confronts these approaches with unresolved issues of scientism and economic totalization looking for another path we turn to science and technology studies sts and especially actornetwork theory ant we relay the longstanding focus on nonhuman agency characteristic of this field via isabelle stengers argument that we must accept the reality of gaias intrusion into collective historicity the challenge posed by stengers we suggest requires the development of an art of immanent attention to the politics of varied matters as they unfold across diverse ecologies of practice extending further than the present preoccupations of euroamerican social theory other areas within and across environmental history activism and politics offer sites of resistance as well as experimentation whose conceptual possibilities and practical this paper postprint has been accepted for publication in the sociological review edited revised and typeset version of this paper will be published in the sociological review vol 67 6 by sage all rights reserved © sage 2019 2 efficacies have yet to be explored slowing down theory sufficiently to learn from these multiple sites we argue is the starting point for an approach more adequate to the problems posed by the anthropocene event

Introduction --- Consumer Food Choice: An Important Role in Achieving Healthy and Sustainable Food System Global food systems possess a complex and multi-faceted set of challenges, regarding both human and environmental health, from farm to fork. From a human society point of view, there are still 690 million people who suffer from hunger while food insecurity is predicted to increase due to the present Coronavirus disease 2019 pandemic and the consequent economic shock [1]. Meanwhile, 677.6 million adults, equal to 13.1% of the population worldwide, are obese [2], resulting in a double burden of malnutrition. The high prevalence of overweight and obesity, especially in urban areas, can be related to a change in lifestyle, low levels of physical activity [3], and unhealthy diets [4] based on the interaction between individual characteristics on food choices and obesogenic environments. Especially, obesogenic environments are recognized as crucial drivers of the increasing prevalence of obesity epidemic [5,6], including microenvironments at individual level and macroenvironments at societal level [7]. The outcome of food choice is based on interactions between environmental and individual factors [8]. Individual food choices, embedded in the pattern of food consumptions, evolved according to the changes of natural environment, biological basis, physical need, lifestyle, and development of technology [9]. In the modern society, owing to increasing national wealth and urbanized living, people consume more animal proteins as well as processed food. At the same time, consumptions of whole food or minimally-processed foods such as whole grains, legumes, and other sources of fiber decreased [10]. Some studies have highlighted that eating patterns and food choice have changed with the change of global food systems and food supply, resulting in a shift toward increased intake of unhealthy food [11]. The change of global food supply chains influences the food environments, [12]. Particularly, food choice with ultra-processed food significantly increased, owing to the easy access, cheap price and marketing strategies [13][14][15]. The vicious cycle has been created between food choice and the consequence of food choice as it is confirmed that consumption of heavily-processed foods is significantly associated with higher BMI and increased likelihood of being obese [13,14,16]. On the other hand, overweight and obese individuals tend to show more liking and to select more energy-dense foods [17][18][19]. Given that negative impacts on human beings as well as on the planet have considerably grown, promoting healthier and more sustainable food choices and better diets have been a new multidisciplinary research impulse [21][22][23][24][25]. According to Food and Agriculture Organization [26], sustainable healthy diets are dietary patterns that promote all dimensions of individuals' health and wellbeing; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable. Grunert [22] has pointed out that consumers have great potential in making food chains more sustainable by choosing more sustainable food production and rejecting less sustainable alternatives through their food choices. For example, choosing low-impact foods and increasing use efficiency of agricultural input offer larger environmental benefits [27]. While food choices with heavily-processed food have negative impacts on the environment [28], lowering consumption of more discretionary products can reduce land use, emission, and freshwater withdrawals [29]. Thus, promoting healthier and more sustainable dietary patterns, rooted in food choices at individual level, has been recognized as a potential and crucial solution [30]. A number of multidisciplinary studies have shed light on the importance of addressing the role of individual food choice in tackling the current nutrition and also environmental crisis [31][32][33]. --- Exploring Factors Influencing Consumer Food Choice and Constructing the Conceptual Models 1.2.1. Three Main Categories of Factors Influencing Food Choices: Food-Related Features, Individual Differences, and Society-Related Features A rich body of literature has focused on exploring factors influencing individual food choice. Due to the complex nature of food choice, proposed factors as well as the categorization of factors differed from one study to another. However, although works from different research fields provided evidence with different perspectives, the factors affecting food choices can be leveled into three main categories: Food-related features: intrinsic features such as color and aroma, and extrinsic features such as information and packaging [34,35]); individual difference: biological , physical , psychological , cognitive , and social factors ; society-related features: culture, economic variables such as price and income, and policy, e.g., [39]. --- The Role of Food Environments as Factors Influencing Food Choices In addition to the three main categories, in recent years, 'food environments' have been defined and recognized as important factors influencing people's food choice. According to Swinburn, et al. [40], food environment equals to the collective physical, economic, policy, and sociocultural surroundings, opportunities, and conditions that influence people's food choices and nutritional status. In fact, 'food environments' include different factors from the aforementioned three main categories, such as physical and social environments as well as economic, policy, and sociocultural environments. Some studies attempted to provide a more holistic point of view by integrating the role of food environments. For example, an early paper [41] proposed that food consumption is based on food preference, under the influence of food characteristics , individual characteristics , and environment characteristics . Rozin [42] specified the influence of biological , psychological , social , and cultural factors on food choice. It has been concluded that there are social and environmental influences on food choice as well as psychological influences on eating behavior [43]. Leng, et al. [44] pointed out the determinant of food choice, including dietary components , physiological mechanisms , cognitive-affective factors , familial, genetic, and epigenetic influences on personality characteristics, and diverse cultural and social pressures. Castro, et al. [45] focused on factors influencing choice in food retail environments such as shelf display and product factors , pricing and price promotion factors, in-store and customer decision-making factors , and store environment factors . Bauer and Reisch [46] summarized that food decisions are affected by individual , social, and environmental factors. --- Development of Early Conceptual Models of Food Choice as the Prototypes It is recognized that food choices are multifaceted, situational, dynamic, and complex [47]. Thus, a multidisciplinary approach and a holistic picture are needed to understand not only how different factors are involved but also how the factors are structured and interact with each other in the decision-making process. To this aim, comprehensive conceptual models of food choice behavior have been developed for understanding the process of making food choices. Furst, et al. [48] proposed the model with factors involved in food choice being categorized into three components: life course, influences, and personal system. According to the authors, the life course includes the personal roles and the social, cultural and physical environments to which a person has been and is exposed. A person's life course generates a set of influences: ideals, personal factors, resources, social framework and food context. These influences inform and shape people's personal systems, including conscious values, negotiations and unconsciously operationalized strategies that may occur in a food-related choice situation. In another model [49], features of food, personal state, and socio-economic factors were included. The features of food can trigger physiological effects that directly influence food choice. Moreover, food features can influence a person's perception which contribute to the formation of attitudes under the influence of socio-economic context . The attitudes then influence the output of food choice. Finally, personal psychological factors such as personality, mood, and beliefs can influence final food choice directly or by affecting the attitudes. Similarly, the model proposed by Steenkamp [50] demonstrated that properties of food personal-related factors , and environmental factors all contribute to the food decision process which involves need recognition, search for information, evaluation, and the final food choice. In addition, Grunert, et al. [51]'s total food quality model distinguishes "before" from "after" purchase evaluations. Cost cues, extrinsic quality cues, intrinsic quality cues, and the perception of these cues all contribute to expected quality , which influence purchase motive fulfillment and intention to buy. Moreover, this model includes the time domain, showing the important influence of experienced quality after purchase on future choices. So far, all these models focus on individual and social determinants of food choice. Sobal, et al. [52] proposed that factors in the bio-physical environment as well as in the social environment affect the consumer behavior. These conceptual models of food choice can be seen as the prototype. They introduced not only factors involved in the food decision-making process but also constructed the model emphasizing the relationship among the factors and indicating the process or pathway contributing to the final food choice. --- Aim of This Review and the Proposed Framework Individual food choice is crucial as it largely affects our health and our planet, with multifactorial determinants rooted in food-related features, individual differences, and society-related features. Moreover, interactions between factors also contribute to the final food choices via direct and/or indirect mechanisms. It is important to understand factors influencing our food choice and thus possible interventions and policy recommendations can be applied for improving food choice to successfully transform the food systems. In addition to early conceptual models of food choice, in recent years, there is abundant literature focusing on expanding and enriching the conceptual models of food choice. However, no single perspective, theory, framework, or model can provide an entire picture of food choice mechanism and properly explain it as influential factors have been categorized in different ways. For example, even though most of the models considered physiological factor as individual difference, some models referred it as a factor of properties of food e.g., [50]. Factors influencing food choice are not clearly leveled across domains of food itself, individuals, and society. Thus, the present paper aims to systematically review existing conceptual models of food choice; summarize and re-categorize factors affecting food choices following the three main categories: food-related features, individual differences, and society-related features; analyze the direction of influences among factors in the conceptual models; and develop and provide a conceptual framework which disentangles the complex and multifactorial nature of individual food choice. Our framework is developed from Eertmans, Baeyens and Van Den Bergh [34]'s model with the categorization of factors influencing food choices as follows: food-internal factors, food-external factors, personal-state factors, cognitive factors, and sociocultural factors. --- Materials and Methods The present review aims at introducing factors influencing individual food choice with a proposed conceptual model by including academic publications as well as gray literature. The inclusion of publications is based on the following criteria: studies had to be published in English; studies which were based on healthy adult population; studies focused on general food choice instead of specific food choice ; studies which were conducted not within specific social cultural context ; studies which proposed at least a conceptual model of food choice. The following databases were used for our search: PubMed, Science Direct, and Google Scholar with keywords as follows: 'Consumer food choice factor' and 'Food choice conceptual model'. The selection process followed the PRISMA guideline . In total, 280 records were screened, and 61 records were excluded . For full-text articles assessed for eligibility, first, 32 publications discussing factors affecting food choice without proposed conceptual models were excluded. A total of 18 publications reported non-conceptual models were not included. A total of 21 publication focusing on factors affecting other food-choice-related dependent variables were rejected. Second, 11 publications targeting non-healthy-adult population and 31 publications addressing food choice within specific sociocultural context were excluded. We excluded also 16 publications addressing food choice of specific food . Finally, 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included. A final set of 59 publications has been analyzed. The analysis focuses on two outcomes. First, we summarized the factors influencing food choice including intrinsic and extrinsic features related to food, individual differences in personal state and in cognitive functions, and factors at societal level such as culture, economy, and policy. Second, we introduced the structures of conceptual models of food choice and indicated the direction and interaction of aforementioned factors in the decision-making process. Details on papers included in the review are reported in Supplementary Materials Table S1. Foods 2020, 9, 1898 5 of 21 of 21 publication focusing on factors affecting other food-choice-related dependent variables were rejected. Second, 11 publications targeting non-healthy-adult population and 31 publications addressing food choice within specific sociocultural context were excluded. We excluded also 16 publications addressing food choice of specific food . Finally, 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included. A final set of 59 publications has been analyzed. The analysis focuses on two outcomes. First, we summarized the factors influencing food choice including intrinsic and extrinsic features related to food, individual differences in personal state and in cognitive functions, and factors at societal level such as culture, economy, and policy. Second, we introduced the structures of conceptual models of food choice and indicated the direction and interaction of aforementioned factors in the decision-making process. Details on papers included in the review are reported in Supplementary Materials Table S1. unrelated to the topic of factors influencing consumer food choice); 2 32 publications discussing factors affecting food choice without proposed conceptual models were excluded; 18 publications reported non-conceptual models were not included; 21 publications focusing on factors affecting other food-choice-related dependent variables were rejected; 11 publications targeting non-healthy-adult population and 31 publications addressing food choice within specific sociocultural context were excluded. We excluded also 16 publications addressing food choice of specific food and 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included. A final set of 59 publications has been analyzed. --- Figure 1. PRISMA flow diagram indicates the selection process of publications related to conceptual models of food choice: 1 61 records were excluded ; 2 32 publications discussing factors affecting food choice without proposed conceptual models were excluded; 18 publications reported non-conceptual models were not included; 21 publications focusing on factors affecting other food-choice-related dependent variables were rejected; 11 publications targeting non-healthy-adult population and 31 publications addressing food choice within specific sociocultural context were excluded. We excluded also 16 publications addressing food choice of specific food and 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included. A final set of 59 publications has been analyzed. --- Results Each conceptual model of food choice was analyzed with factors included in the models being categorized into the following main factors affecting food choice according to our proposed framework developed from Eertmans, Baeyens and Van Den Bergh [34]'s model : food-internal factors, food-external factors, personal-state factors, cognitive factors, and sociocultural factors. Table 1 lists in detail all the factors included in these main factors. We also summarized the directions of influence among the factors from available models. Foods 2020, 9, 1898 6 of 21 --- Results Each conceptual model of food choice was analyzed with factors included in the models being categorized into the following main factors affecting food choice according to our proposed framework developed from Eertmans, Baeyens and Van Den Bergh [34]'s model : food-internal factors, food-external factors, personal-state factors, cognitive factors, and sociocultural factors. Table 1 lists in detail all the factors included in these main factors. We also summarized the directions of influence among the factors from available models. --- Factors Influencing Food Choice in Conceptual Models In this section, we summarize the basic factors included in the conceptual models of general food choices. --- Food-Internal Factor: Sensory and Perceptual Features Food-internal factor is defined as features possessed by the food itself such as sensory and perceptual properties. Twenty-six models have proposed that the sensory and perceptual features influence the food choice [21,32,34,41,[49][50][51][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71]. A review paper summarized that visual and odor cues contribute to identifying food in the near environment, guiding food choice and memory for eating, while tastes and textures influence meal size and the development of satiety after consumption [72]. Another literature review concluded that odor exposure induces appetite while taste and texture contribute to satiation based on eating rate and oral exposure duration of food in the mouth, playing an important role in a nutrient sensing system [73]. In our definition, information about the food item is defined as one of the food-external factors. Twenty-eight models have included food-related information as factors influencing the food choice [21,22,24,32,34,[49][50][51]53,[55][56][57][58]61,62,64,65,70,[74][75][76][77][78][79][80][81][82][83]. In addition to these models, there is a rich body of literature focusing on the effects of food label and food label use on food choice. Food labeling provides information on essential characteristics of food items and food label use has been recognized as an important component of strategies tackling unhealthy diets and obesity. For example, Cowburn and Stockley [84] reviewed papers reporting consumer understanding or use of nutrition labels and concluded that improvements in presenting and designing nutrition labeling could make a contribution towards making the existing point-of-purchase environment more conducive to the selection of healthy choices. Interpretational aid such as verbal descriptors and recommended reference values is needed to help consumers assess the nutrient information in order to improve overall diet. Cecchini and Warin [85] did a meta-analysis and confirmed that nutrition labeling, especially interpretive labels , may be an effective approach to empowering consumers in choosing healthier products and in reducing calorie intake. More recently, a review explored how consumers value and response to nutrition information on food labels against information on environmental and/or social responsibility [86]. Consumers generally have a positive view of environmental and social responsibility food labeling schemes while the most preferred attribute was organic labeling, inferring to information related to health. In brief, interpretive nutrition labels with the combination labeling containing healthy and sustainable attributes can be propriate and effective in promoting healthy and sustainable food choice. Oostenbach, Slits, Robinson and Sacks [57] examined the effect of nutrition claims on food choice. The influences of nutrition claims depend on the type of claim and food with the claim. For example, nutrition claims can influence consumers' perception that the product is healthier and less tasty. However, nutrition claims can make the appropriate portion size appear larger, resulting in the underestimation of the energy content of food products. Nutrition claims also influence food purchase intentions, moderated by the perceived healthfulness of the relevant food products and the health consciousness of individuals. In addition to food-related information, the food environments are considered as food-external factors which also largely affect the food choice. We further divided food environments into two factors, namely social environment and physical environment . Thirty-four models indicated that social environment contributes to the food choice decision [21,23,34,41,47,48,52,53,55,56,59,60,62,70,71,[75][76][77][78]82,83,[87][88][89][90][91][92][93][94][95][96][97][98][99]. In the social environment, family and the home food environment are important influences on dietary intake but this influence is more profound for children and adolescents, not adults [100]. Instead, for adults, individual food choices are influenced by interactions with others beyond the family unit . It is suggested that not only the context of shared meals but also social norms and attitudes among members of a group have impacts on types or amounts of foods that individuals consume no matter whether people eat together or not [100]. Indeed, social modeling determines what and how much people choose to eat, using others' eating behavior as a guide. The effect increases when individuals desire to affiliate with the model or perceive themselves to be similar to the model. The effect reduces for choosing specific food as well as meals [101]. Twenty-eight models pointed out that physical environment contributes to the food choice decision [23,32,34,41,48,49,[51][52][53]55,58,59,61,62,66,70,71,75,76,80,82,[87][88][89][90]92,94,102]. For the physical environment, studies have indicated that food choices and eating behaviors, as well as risk for obesity, are influenced by the physical availability and accessibility of food products in the workplace, surrounding neighborhood, retail food stores, as well as restaurants [100]. A review done by Castro, Majmundar, Williams and Baquero [45] confirmed that food retail environments do shape customer food choices of healthy or unhealthy items and energy intake, including product location on the shelf, the appearance of the products on the shelf, the brands available , as well as product attributes. For example, feeling confined by smaller aisles may encourage consumers to make more varied choices [45]. Finally, some models also included 'time' as an influential factor, mainly referring to time availability for food preparation and home cooking [48,59,70,75,92]. According to a review, lack of time can result in changes in food consumption patterns such as a decrease in food preparation at home, and an increase in the consumption of convenience or ready-prepared foods [103]. --- Personal-State Factors: Biological Features and Physiological Needs, Psychological Components, Habits, and Experiences In our definition, personal states which affect food choice include biological features and physiological needs , psychological components , and personal habits and experiences. Sixteen models have included biological features and physiological needs as factors affecting food choice [21,[48][49][50]53,55,57,61,66,71,77,83,[88][89][90]95]. Except for biological features which are difficult to change, dietary decisions can be regulated by physiological functions such as circulating metabolic hormones and neural mechanism involved in food intake and appetitive behaviors [44]. Vice versa, extreme and narrow food choices could result in fluctuation and unbalanced weight and health status [44]. Psychological components appeared in twenty-nine models [21,23,25,34,[47][48][49][50][51][52][55][56][57]59,60,62,66,71,74,79,80,83,88,89,91,93,95,98,102]. According to these models, the majority of studies focused on how emotion is involved in food decision-making. For instances, the model proposed by Gutjar, de Graaf, Kooijman, de Wijk, Nys, Ter Horst and Jager [74] was dedicated to exploring the role of food-evoked emotion in food choice. Food-evoked emotions, which can be sorted into two dimensions , add predictive value to solely liking ratings, and may guide consumers' choice behavior. For taste-based choice, the combination of liking and emotional valence had stronger prediction. For package-based choice liking, emotional valence and emotional arousal together have a stronger predictive value [74]. In addition to emotion, motivation is also frequently involved in the models. However, the motivation to choose one food over another is driven by the emotional, hedonic and metabolic properties of the foods [44]. In other words, the motivation is actually driven by other factors. Thus, we did not include "motivation" as a factor in our categories. Comparably fewer models mentioned about previous experiences and/or habits [21,47,49,61,71,75,83,89,90]. In these models, experiences were categorized as a psychological factor related to the function of memory while habits were categorized as a situational factor. However, experiences and habits are composed by multi-factors such as emotion, memory, and learning [55]. Moreover, the process of consciousness needs to be considered [104,105]. Thus, in our opinion, when we include experiences and habits under the frame of food choice, it is better to categorize them into personal-state factor, stressing the contribution of experiences and habits to the person at the moment of making food choice. Before reaching the final output of food choice behavior, cognitive factors have their impacts on food decision-making. Possessing knowledge [24,34,48,52,[56][57][58]64,70,78,79,82,88,93,94,97,106,107] as well as food management skills [41,48,52,75,83,90,92,97] can have great influence on food choice. For example, nutrition knowledge has been shown to be a partial mediator of the socio-demographic variation in food intake, especially for fruit and vegetables, implying that knowledge is an important factor in explaining variations in food choice [108]. The second factor is evaluation-based [50], including attitude [21,24,25,41,48,49,56,59-61,68-70, 79,82,90-92,95-97,102,107,109-111], liking [34,63,74,88], and preference [58,69,87,94]. The potential differences among these three components towards food choice can be as follows: attitude represents the implicit evaluation towards food items. Usually, the attitude is based on valence but it can be also based on other concepts [112]. Liking, instead, focus on the sensory evaluation of food [113]. Finally, preference is based on comparison . For example, the preference of obese people for foods was affected more by fat content than by carbohydrate or sucrose content [114]. The third cognitive factor includes expected consequences [34,48,51,54,63,64,66,68,[76][77][78]88,92,95,109,110] regarding the concern for health consequences of food consumption [34]. For example, consumers are prone to choose foods which give desirable consequences such as expected longer life [115]. Last but not least, personal identity, including demographic features such as age, gender, ethnic identity, and education [23,24,41,47,50,59,61,63,64,82,[87][88][89][90][91][93][94][95] can also affect food choices. For instance, food choices represent personal identity as well as the story of families, migrations, assimilation, resistance, and changes over times [116]. Possessing a healthy eating identity was significantly associated with greater fruit and vegetable intakes [117]. Moreover, personal belief and value, shaped by culture and society, also contribute to the decision of food choice [21,23,25,48,49,52,[59][60][61]64,70,75,77,78,82,83,90,95,96,107,111]. Indeed, two early studies have pointed out the potential role of personal belief and value in maintaining goal-directed behavior, especially for health-related food choice [118,119]. --- Sociocultural Factors: Culture, Economic Variables, and Political Elements For previous factors, the influences are mainly at individual level. The final category, sociocultural factors, focuses on societal level. According to Larson and Story [100], the influence of macroenvironment on individual food choice includes income, socioeconomic status, and price of food, reported by twenty-nine models [32,41,[47][48][49][50][51][52][53][54][55][56]58,59,62,65,66,69,70,75,76,79,82,87,88,90,[92][93][94]; cultural norms and values are reported by seventeen models [41,[48][49][50][51]53,55,56,58,70,71,76,88,89,94,97,98]; agricultural and food policy and regulations, reported by nine models [52,55,58,59,76,88,89,94,98]. About income and cost of food, Larson and Story [100] specified that the monetary and time costs of buying and preparing foods , especially ones with health values, are additional barriers to good nutrition for low-income groups. Indeed, higher cost of healthy choices or diets can strengthen socioeconomic disparities in diet quality [120]. Nevertheless, price elasticities for foods can be also a strategy in changing consumer demand, shifting the purchase of unhealthy food to healthier food. The example [121] showed that a 10% increase in soft drink prices should reduce consumption by 8% to 10%. Price and promotion in the food retail environment do affect consumers' purchase intentions and choice [45]. The quantity and quality of food along the supply chain can be affected by agriculture and food polices, resulting in altered food price, directly or indirectly influencing the choice, affordability, as well as the right to nutritious food of the consumer [100]. Finally, we could not ignore the fact that food choice and eating behaviors are influenced by cultural factors, especially shared values and beliefs, which shape perceptions of food and the concept of healthiness [100]. --- Influences among Factors in Conceptual Models of Food Choice Thirty-two conceptual models of food choice indicated possible directions of influence among the factors towards final food choice [41,[47][48][49][50][51][52]54,56,57,[60][61][62][63][64][65][66]74,[76][77][78]87,[90][91][92][93][95][96][97]102,109,110]. --- Possible Influences among Factors in Conceptual Models of Food Choice For most of the conceptual models, the directions of influence among factors affecting food choice are demonstrated with theoretical basis or literature review e.g., [57,61,66,76,77,90,97]. The early-established models can be seen as the porotypes [48][49][50][51][52], allowing consecutive research to expand or enrich the models with new data or evidence. About integrating and expanding existing models, as an example, Rose, Bodor, Hutchinson and Swalm [87] integrated the factor of accessibility around the neighborhood based on an economic model of food consumption. Food cost, taste, preference, and income influenced the food choice for purchasing. The food cost can be directly influenced by in-store price or indirectly affected by the placement of food store via travel cost. In-store characteristics such as product varieties as well as shelf space and placement had impacts on promotional effect and social acceptability, which then further influenced tastes and preferences. Tastes and preferences also can be directly influence by demographic variables such as age, race-ethnicity, and education. The framework proposed by Marreiros and Ness [56] combined main features of the Engel-Blackwell-Miniard model [122] regarding consumers decision-making, and the main constructs of the total food quality model [51] developed for food products concerning mainly consumers quality evaluation. The author bridged these two models with the emphasis on the relationships between them [56]. About adopting and enriching existing models, for instance, the models shown in Connors et al. [54] and in Sobal and Bisogni [47] were both adopted from Furst et al. [48] with modifications or elaborations. The life course and experience created influences including ideals, personal factors, resources, social factors, and context. In the model of Sobal and Bisogni [47], these influences then had an impact on personal food system built upon values, situation, and strategy. The personal food system affected food behavior, which then had a feedback loop in shaping the aforementioned factors . In the model, the personal food system was composite of value, managing relationships, health, taste, cost, convenience, and strategies. However, there was no feedback loop [54]. To briefly conclude, few models have clearly indicated the direction of influence among the factors with experimental data or with mathematical modeling. There is a need of empirical data to support and to disentangle the interactions between the factors. --- Direction of Influence among Factors in Conceptual Models of Food Choice In general, the more specific factors the model addressed, the clearer indications of directions of influence could be made, supported by experimental data. For example, in the model of Gutjar et al. , both sensory and packaging information trigger emotional responses but liking was based on sensory information [74]. Both emotional responses and liking then contribute to the prediction of food choice. Structural equation modeling is frequently used to investigate the directions of influence among factors towards certain food choice. For healthy food choice including fruit and vegetables, factors such as intention, action planning, and self-efficacy, with a person's understanding of nutrition information, can better explain healthy food choice behavior [64]. The mediating roles of food mavenism, food knowledge, food involvement, and equality-universalist values were reported in increasing vegetable intakes [93]. Moreover, market availability, interest in healthy eating, and time pressure significantly influence choice of plant-based convenience foods [92]. Intention, self-identity and past behavior were proved as direct predictors of fruit and vegetable intake [91]. For food with environmentally-sustainable attributes, personal norms regarding the use of organic food affect attitudes toward the use of organic produce in institutional settings, which is partly mediated by own purchase of organic products [96]. Choice of convenience food with environmentally-sustainable attributes is positively related to consumer food shopping habits, food-related environmental behavior, gender, income, and knowledge [102]. Another study also pointed out that likelihood of buying healthy convenience food is affected by overall liking of the meal, which is affected by liking of sensory specific product attributes like appearance, flavor, and odor [63]. For newly emerged food such as genetically modified food, perceived benefits and risks play a significant role in shaping behavioral intentions towards GM food [110], the attitude to GM technology being the main driver of consumers' beliefs about risks and benefits. Public attitudes toward GM food are being formed from trust in science and in public authorities under different cultural contexts, which determines consumer's final purchasing decisions [109]. Finally, some studies examined factors affecting ethical food choice, suggesting that ethical consumption and purchase intention have a direct influence on choice behavior with significant association between social, emotional, and epistemic values with ethical consumption intentions [62]. In addition, universalism was shown having impact on food choices with less meat or free-range meat. This impact was mediated by prevention-oriented food choice motives and motive-congruent animal friendly attitudes [60] Supplementary MaterialsTable S2 summarizes the directions of influence of factors affecting food choices based on publications with empirical data we included. --- Discussion --- Main Findings: The Multifactorial Nature of Individual Food Choice In recent years, research as well as large scale initiatives have been launched, substantiating the imperative for individuals and governments to improve population health by taking substantial actions in the domain of individual food choice and eating behavior [11]. Since consumers' daily food choices have great potential in transforming towards healthier and more sustainable food systems [11,22], the first and essential step before considering interventions is understanding factors influencing individual food choice in a structural and systematic way. The present paper provides an insight into the complex and multifactorial nature of individual food choice by analyzing factors included in conceptual models. The early development of conceptual models of food choice can be dated back to the 1990s. There were three main types of models. The first one, which can be seen as the prototype of the models, already demonstrated three levels of factors influencing the final choice, namely food features, personal system, and environment [41,48,49]. The second type focuses on the effect of price, quality, and value [51,65]. While the third one, the model proposed by Sobal, Khan and Bisogni [52] took into consideration a broader view including relationships of the food and nutrition system to other systems such as environmental system, governmental system, health care system, cultural system, economic system, and even transportation system. The conceptual models we include in the analysis mainly follow the three-level framework of food features, personal system, and environment. However, different models might include different numbers of factors with different ways of categorization within and across these three levels. Thus, the present review analyzed existing conceptual models of food choice, summarized influential factors affecting food choice, then re-categorized and integrated the results from the literature into a proposed three-level framework of factors influencing food choice, namely food-related features, individual differences, and society-related features. The ultimate goal is to provide a clear and simple roadmap for facilitating future development of research in the field of consumer food choice and maximize the contribution from individual studies. Being on the same page, the framework may help researchers communicate the idea, compare research data, and replicate existing results with ease. In our framework, influential factors determining food choice are categorized into food-internal factor , food-external factors , personal-state factors , cognitive factors , and sociocultural factors . In our samples, five most frequently addressed factors in the models are as follows: social environment which belongs to food-external factors [21,23,34,41,47,48,52,53,[55][56][57][58][59][60]62,70,71,[74][75][76][77][78]82,83,[87][88][89][90][91][92][93][94][95][96][97][98][99]; personal-state focusing on psychological component [21,23,25,34,[47][48][49][50][51][52][55][56][57]59,60,62,66,71,74,79,80,83,88,89,91,93,95,98,102]; economic variables such as income, socioeconomic status, and price [21,32,41,[47][48][49][50][51][52][53][54][55][56]58,59,62,65,66,69,70,75,76,79,82,87,88,90,[92][93][94]; food-related information which also belongs to food-external factors [21,22,24,32,34,[49][50][51]53,[55][56][57][58]61,62,64,65,70,[74][75][76][77][78][79][80][81][82][83]; and physical environment which also belongs to food-external factors [23,32,34,41,48,49,[51][52][53]55,58,59,61,62,66,70,71,75,76,80,82,[87][88][89][90]92,94,102]. The results reflect the facts that social environment is the most addressed factor influencing food choice; due to the availability of research evidence, factors such as food information, food environment, and economic variables are easier to be manipulated and measured in the experimental settings. Thus, the role of these factors in influencing food choice is more carefully and clearly examined and concluded; compared to studies from other field, the complex mechanisms and interactions between food perception and bio-physiological still need more investigation and the results should be integrated into the conceptual models of food choice; while some factors affecting food choice could be universal , large-scale and cross-cultural studies are needed to address factors influencing cultural-specific choices . In addition, considering the obesogenic environment nowadays, despite the growing body of literature focusing on the role of cognitive function and food environment in food choice e.g., [124][125][126], we would like to emphasize the importance of understanding the complicated cognitive decision-making process and disentangling the interaction between cognitive functions and food environments, especially food-related information and physical environment in order to develop effective intervention for helping individuals make better choice that is good for human health and the planet [127][128][129]. About the direction of influence among the factors in the conceptual models, fewer conceptual models are supported with empirical data [57,60,[62][63][64]74,78,[91][92][93]96,102,106,109]. Table S2 in the Supplementary Materials summarizes the directions of influence of factors affecting food choices based on publications with empirical data we included. We observed that factors proposed in theory of planned behavior and their effects are frequently examined with experimental settings and thus empirical data was obtained. Some other factors and the effects are also frequently investigated such as liking, food or nutritional knowledge, personal values, emotion, income, and sensory properties of food. Future studies should explore other factors and their effects on food choices. In conclusion, the more specific factors the model addressed, the clearer indications of direction of influence could be made, supported by experimental data. We appreciate the multifactorial nature of individual food choice and the effort of including as many factors as possible in the models in providing a more intact and holistic view. However, the trade-off of expanding the models should be recognized too. In this case, interdisciplinary research is expected for constructing a holistic conceptual model of food choice supported by empirical data from studies in different fields . --- Implication of Factors Influencing Healthy and/or Sustainable Food Choice In recent years, research has shed light on the factors affecting food choice towards healthier and more sustainable products. New conceptual models of food choice have been proposed to further depict how different factors essentially affect healthier and sustainable food choices. Through the literature review, the models were framed according to four types of choices: healthier food choice [24,68,79,80]; sustainable food choice [22,24,81,107,111]; organic food [21,24,25]; and fruit and/or vegetable [69,70]. For food-internal factors, the nutritional properties and the health value of the food items are especially important for the choice [68,69]. Health value [130] is an important index, including absence of contaminants [131]. For food-external factors, information based on nutrition facts, sustainability labels, and organic identity were included in the models as important drives [21][22][23][24][79][80][81]. Moreover, some studies pointed out that certification of origin and food miles, recycling packaging, as well as indications of local, traditional, ethic, and environmentally friendly products, can affect the food choice [130][131][132]. Social interaction and engagement in social institutions in social environment are important for making food decision, especially for fruits, vegetables, and organic food [21,23,70]. For physical environment, the availability of healthy or sustainable food products and the accessibility to nutrition environment, supermarket, or local stores are critical [23,80,130,133]. As personal-state factors, psychological components such as personality [23] as well as emotion [25,133] have impacts on healthier and organic food choice. Some other studies also mentioned motivation and intention as important factors contributing to the final food choice [23,[134][135][136][137]. Cognitive factors such as belief, attitude, awareness, self-concept, and positive outcome expectation were addressed in determining food choice [21][22][23][24][25][68][69][70][79][80][81]107]. Finally, sociocultural context and familiarity based on cultural habits could affect food choices [69,70]. Income and economic situation are still a crucial determinant [69,79]. Food price heavily affects whether consumer will choose healthier and more sustainable food or not [69,70,[130][131][132]137]. For making healthier and more sustainable food choice available, policy plays an essential role not only with healthy food eating policy but also with policies related to food supply chain, especially how food is produced, and environmental sustainability [35,88]. --- Future Research Directions The present review provides an analytic framework of disentangling the complex and multifactorial nature of individual food choice with the aim of shifting towards healthier and more sustainable food systems. Recently, the European Commission has placed consumer food choice as one of the important targets for achieving a more healthy and sustainable EU food system. In 2017, over 950,000 deaths in EU were related to unhealthy diets. Thus, the "Farm to Fork" strategy [138], at the core of the European Green Deal, was launched in May 2020 which emphasized the importance of shifting towards healthier and sustainable diets in the EU by empowering citizens as consumers, to reverse the overweight and obesity trends, as well as to lower the environmental footprints. In addition, Outcome Report FOOD 2030 Pathways Workshop [139] indicated a pathway of research and innovation to develop innovative, healthy, sustainable and personalized nutrition solutions to reduce risk factors for Noncommunicable diseases, malnutrition, and micronutrient deficiencies. More importantly, consumers will be empowered to have a long-lasting, healthy, pleasurable, nutritional and sustainable diet tailored to individual parameters. It has been pointed out that there is a need for research to better understand the factors influencing consumer choice such as food environment, policies, gender, information, education, marketing, incentives, and lifestyles. In line with the goal set by the European Commission in the transformation of food systems, we confirmed that citizens as consumers-and their choices-should be placed at the very center of the problem of both human and planetary health, which calls for urgent investigation and solutions from academic field in providing opportunities and possibilities. Thus, it is crucial to understand individual food choice, factors affecting the choice, and possible interventions. Haddad, et al. [140] have proposed a new global research agenda for food with ten research priorities suggested. Among them, identify entry points for change, agree on what constitutes a healthy diet, make more data on diets widely available, tackle different forms of malnutrition simultaneously, study supply and demand, and identify the economic levers for change are closely related to addressing the important role of consumers' choices in realizing healthier and more sustainable food systems. Lusk and McCluskey [141] further identified priority areas for future research, including dietary-related diseases and efficacy of policies designed to improve dietary choice, trust in the food system and acceptance of new food and farm technologies, environmental impacts of food consumption, changing consumer preferences, and food safety. Regarding data quality and availability, uncertainty in underlying biological and physical sciences, as well as applications of behavioral economic remain as challenges. In our opinion, future research examining factors influencing individual' food choice should also take into account: the need of multidisciplinary impulses and collaboration across research field such as sensory science, cognitive science, social science, as well as business studies; the structural and systematic way of investigating the effect of food-choice related factors as well as the interactions among the factors; the trade-off between the number of factors included in the framework and the capability to investigate and clearly explain the effect of s single factor and the effect of combining different factors; and enriching and improving the framework with empirical observation or data based on a feedback mechanism. --- Limitations The present review has three main limitations. First, we focus on the three-level categorization of factors influencing food choice, namely food-related features, individual differences, and society-related features. However, recent research also pointed out the important roles in determining food choice, played by natural environment such as climate change [142][143][144][145], natural resources [146][147][148], as well as food production and supply chain [149]. Ideally, these factors should be also included into the conceptual framework. Second, the present study summarizes factors affecting food choice proposed in the conceptual models. The keywords we used for literature search may limit the inclusion of publications investigating a single or fewer factor with experimental settings and empirical data. Thus, more meta-analyses are needed for understanding how different but specific factors contribute to food choice. Finally, this review does not include publications focusing on methodology used for understanding factors affecting food choices such as the development and validation of questionnaires , which contain valuable information about the constructs of factors that are crucial for food choice decision. Thus, further examination with the inclusion of the results of factor analyses from food-choice-related questionnaires is recommended. --- Supplementary Materials: The following are available online at http://www.mdpi.com/2304-8158/9/12/1898/s1, Table S1: Factors included in the conceptual models of food choice. Table S2. Direction of influence of factors affecting food choices based on publications with empirical data. Funding: This research received no external funding. ---

Understanding individual food choices is critical for transforming the current food system to ensure healthiness of people and sustainability of the planet. Throughout the years, researchers from different fields have proposed conceptual models addressing factors influencing the food choice, recognized as a key leverage to improve planetary and human health. However, a multidisciplinary approach is needed to better understand how different factors are involved and interact with each other in the decision-making process. The present paper reviews and analyzes existing models, providing an intact point-of-view by integrating key elements into a bigger framework. Key determinants of general food choice are identified and categorized, including food-internal factor (sensory and perceptual features), food-external factors (information, social environment, physical environment), personal-state factors (biological features and physiological needs, psychological components, habits and experiences), cognitive factors (knowledge and skills, attitude, liking and preference, anticipated consequences, and personal identity), as well as sociocultural factors (culture, economic variables, political elements). Moreover, possible directions of influence among the factors towards final food choice were discussed. The need of multidisciplinary impulses across research field with the support of empirical data are crucial for understanding factors influencing food choice as well as for enriching existing conceptual models. The framework proposed here would serve as a roadmap for facilitating communications and collaborations between research fields in a structural and systematic way.

introduction consumer food choice an important role in achieving healthy and sustainable food system global food systems possess a complex and multifaceted set of challenges regarding both human and environmental health from farm to fork from a human society point of view there are still 690 million people who suffer from hunger while food insecurity is predicted to increase due to the present coronavirus disease 2019 pandemic and the consequent economic shock 1 meanwhile 6776 million adults equal to 131 of the population worldwide are obese 2 resulting in a double burden of malnutrition the high prevalence of overweight and obesity especially in urban areas can be related to a change in lifestyle low levels of physical activity 3 and unhealthy diets 4 based on the interaction between individual characteristics on food choices and obesogenic environments especially obesogenic environments are recognized as crucial drivers of the increasing prevalence of obesity epidemic 56 including microenvironments at individual level and macroenvironments at societal level 7 the outcome of food choice is based on interactions between environmental and individual factors 8 individual food choices embedded in the pattern of food consumptions evolved according to the changes of natural environment biological basis physical need lifestyle and development of technology 9 in the modern society owing to increasing national wealth and urbanized living people consume more animal proteins as well as processed food at the same time consumptions of whole food or minimallyprocessed foods such as whole grains legumes and other sources of fiber decreased 10 some studies have highlighted that eating patterns and food choice have changed with the change of global food systems and food supply resulting in a shift toward increased intake of unhealthy food 11 the change of global food supply chains influences the food environments 12 particularly food choice with ultraprocessed food significantly increased owing to the easy access cheap price and marketing strategies 13 14 15 the vicious cycle has been created between food choice and the consequence of food choice as it is confirmed that consumption of heavilyprocessed foods is significantly associated with higher bmi and increased likelihood of being obese 131416 on the other hand overweight and obese individuals tend to show more liking and to select more energydense foods 17 18 19 given that negative impacts on human beings as well as on the planet have considerably grown promoting healthier and more sustainable food choices and better diets have been a new multidisciplinary research impulse 21 22 23 24 25 according to food and agriculture organization 26 sustainable healthy diets are dietary patterns that promote all dimensions of individuals health and wellbeing have low environmental pressure and impact are accessible affordable safe and equitable and are culturally acceptable grunert 22 has pointed out that consumers have great potential in making food chains more sustainable by choosing more sustainable food production and rejecting less sustainable alternatives through their food choices for example choosing lowimpact foods and increasing use efficiency of agricultural input offer larger environmental benefits 27 while food choices with heavilyprocessed food have negative impacts on the environment 28 lowering consumption of more discretionary products can reduce land use emission and freshwater withdrawals 29 thus promoting healthier and more sustainable dietary patterns rooted in food choices at individual level has been recognized as a potential and crucial solution 30 a number of multidisciplinary studies have shed light on the importance of addressing the role of individual food choice in tackling the current nutrition and also environmental crisis 31 32 33 exploring factors influencing consumer food choice and constructing the conceptual models 121 three main categories of factors influencing food choices foodrelated features individual differences and societyrelated features a rich body of literature has focused on exploring factors influencing individual food choice due to the complex nature of food choice proposed factors as well as the categorization of factors differed from one study to another however although works from different research fields provided evidence with different perspectives the factors affecting food choices can be leveled into three main categories foodrelated features intrinsic features such as color and aroma and extrinsic features such as information and packaging 3435 individual difference biological physical psychological cognitive and social factors societyrelated features culture economic variables such as price and income and policy eg 39 the role of food environments as factors influencing food choices in addition to the three main categories in recent years food environments have been defined and recognized as important factors influencing peoples food choice according to swinburn et al 40 food environment equals to the collective physical economic policy and sociocultural surroundings opportunities and conditions that influence peoples food choices and nutritional status in fact food environments include different factors from the aforementioned three main categories such as physical and social environments as well as economic policy and sociocultural environments some studies attempted to provide a more holistic point of view by integrating the role of food environments for example an early paper 41 proposed that food consumption is based on food preference under the influence of food characteristics individual characteristics and environment characteristics rozin 42 specified the influence of biological psychological social and cultural factors on food choice it has been concluded that there are social and environmental influences on food choice as well as psychological influences on eating behavior 43 leng et al 44 pointed out the determinant of food choice including dietary components physiological mechanisms cognitiveaffective factors familial genetic and epigenetic influences on personality characteristics and diverse cultural and social pressures castro et al 45 focused on factors influencing choice in food retail environments such as shelf display and product factors pricing and price promotion factors instore and customer decisionmaking factors and store environment factors bauer and reisch 46 summarized that food decisions are affected by individual social and environmental factors development of early conceptual models of food choice as the prototypes it is recognized that food choices are multifaceted situational dynamic and complex 47 thus a multidisciplinary approach and a holistic picture are needed to understand not only how different factors are involved but also how the factors are structured and interact with each other in the decisionmaking process to this aim comprehensive conceptual models of food choice behavior have been developed for understanding the process of making food choices furst et al 48 proposed the model with factors involved in food choice being categorized into three components life course influences and personal system according to the authors the life course includes the personal roles and the social cultural and physical environments to which a person has been and is exposed a persons life course generates a set of influences ideals personal factors resources social framework and food context these influences inform and shape peoples personal systems including conscious values negotiations and unconsciously operationalized strategies that may occur in a foodrelated choice situation in another model 49 features of food personal state and socioeconomic factors were included the features of food can trigger physiological effects that directly influence food choice moreover food features can influence a persons perception which contribute to the formation of attitudes under the influence of socioeconomic context the attitudes then influence the output of food choice finally personal psychological factors such as personality mood and beliefs can influence final food choice directly or by affecting the attitudes similarly the model proposed by steenkamp 50 demonstrated that properties of food personalrelated factors and environmental factors all contribute to the food decision process which involves need recognition search for information evaluation and the final food choice in addition grunert et al 51 s total food quality model distinguishes before from after purchase evaluations cost cues extrinsic quality cues intrinsic quality cues and the perception of these cues all contribute to expected quality which influence purchase motive fulfillment and intention to buy moreover this model includes the time domain showing the important influence of experienced quality after purchase on future choices so far all these models focus on individual and social determinants of food choice sobal et al 52 proposed that factors in the biophysical environment as well as in the social environment affect the consumer behavior these conceptual models of food choice can be seen as the prototype they introduced not only factors involved in the food decisionmaking process but also constructed the model emphasizing the relationship among the factors and indicating the process or pathway contributing to the final food choice aim of this review and the proposed framework individual food choice is crucial as it largely affects our health and our planet with multifactorial determinants rooted in foodrelated features individual differences and societyrelated features moreover interactions between factors also contribute to the final food choices via direct andor indirect mechanisms it is important to understand factors influencing our food choice and thus possible interventions and policy recommendations can be applied for improving food choice to successfully transform the food systems in addition to early conceptual models of food choice in recent years there is abundant literature focusing on expanding and enriching the conceptual models of food choice however no single perspective theory framework or model can provide an entire picture of food choice mechanism and properly explain it as influential factors have been categorized in different ways for example even though most of the models considered physiological factor as individual difference some models referred it as a factor of properties of food eg 50 factors influencing food choice are not clearly leveled across domains of food itself individuals and society thus the present paper aims to systematically review existing conceptual models of food choice summarize and recategorize factors affecting food choices following the three main categories foodrelated features individual differences and societyrelated features analyze the direction of influences among factors in the conceptual models and develop and provide a conceptual framework which disentangles the complex and multifactorial nature of individual food choice our framework is developed from eertmans baeyens and van den bergh 34 s model with the categorization of factors influencing food choices as follows foodinternal factors foodexternal factors personalstate factors cognitive factors and sociocultural factors materials and methods the present review aims at introducing factors influencing individual food choice with a proposed conceptual model by including academic publications as well as gray literature the inclusion of publications is based on the following criteria studies had to be published in english studies which were based on healthy adult population studies focused on general food choice instead of specific food choice studies which were conducted not within specific social cultural context studies which proposed at least a conceptual model of food choice the following databases were used for our search pubmed science direct and google scholar with keywords as follows consumer food choice factor and food choice conceptual model the selection process followed the prisma guideline in total 280 records were screened and 61 records were excluded for fulltext articles assessed for eligibility first 32 publications discussing factors affecting food choice without proposed conceptual models were excluded a total of 18 publications reported nonconceptual models were not included a total of 21 publication focusing on factors affecting other foodchoicerelated dependent variables were rejected second 11 publications targeting nonhealthyadult population and 31 publications addressing food choice within specific sociocultural context were excluded we excluded also 16 publications addressing food choice of specific food finally 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included a final set of 59 publications has been analyzed the analysis focuses on two outcomes first we summarized the factors influencing food choice including intrinsic and extrinsic features related to food individual differences in personal state and in cognitive functions and factors at societal level such as culture economy and policy second we introduced the structures of conceptual models of food choice and indicated the direction and interaction of aforementioned factors in the decisionmaking process details on papers included in the review are reported in supplementary materials table s1 foods 2020 9 1898 5 of 21 of 21 publication focusing on factors affecting other foodchoicerelated dependent variables were rejected second 11 publications targeting nonhealthyadult population and 31 publications addressing food choice within specific sociocultural context were excluded we excluded also 16 publications addressing food choice of specific food finally 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included a final set of 59 publications has been analyzed the analysis focuses on two outcomes first we summarized the factors influencing food choice including intrinsic and extrinsic features related to food individual differences in personal state and in cognitive functions and factors at societal level such as culture economy and policy second we introduced the structures of conceptual models of food choice and indicated the direction and interaction of aforementioned factors in the decisionmaking process details on papers included in the review are reported in supplementary materials table s1 unrelated to the topic of factors influencing consumer food choice 2 32 publications discussing factors affecting food choice without proposed conceptual models were excluded 18 publications reported nonconceptual models were not included 21 publications focusing on factors affecting other foodchoicerelated dependent variables were rejected 11 publications targeting nonhealthyadult population and 31 publications addressing food choice within specific sociocultural context were excluded we excluded also 16 publications addressing food choice of specific food and 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included a final set of 59 publications has been analyzed figure 1 prisma flow diagram indicates the selection process of publications related to conceptual models of food choice 1 61 records were excluded 2 32 publications discussing factors affecting food choice without proposed conceptual models were excluded 18 publications reported nonconceptual models were not included 21 publications focusing on factors affecting other foodchoicerelated dependent variables were rejected 11 publications targeting nonhealthyadult population and 31 publications addressing food choice within specific sociocultural context were excluded we excluded also 16 publications addressing food choice of specific food and 22 publications emphasizing the intervention for improving food choice and 10 publications examined the methodology or tools for measuring food choice were not included a final set of 59 publications has been analyzed results each conceptual model of food choice was analyzed with factors included in the models being categorized into the following main factors affecting food choice according to our proposed framework developed from eertmans baeyens and van den bergh 34 s model foodinternal factors foodexternal factors personalstate factors cognitive factors and sociocultural factors table 1 lists in detail all the factors included in these main factors we also summarized the directions of influence among the factors from available models foods 2020 9 1898 6 of 21 results each conceptual model of food choice was analyzed with factors included in the models being categorized into the following main factors affecting food choice according to our proposed framework developed from eertmans baeyens and van den bergh 34 s model foodinternal factors foodexternal factors personalstate factors cognitive factors and sociocultural factors table 1 lists in detail all the factors included in these main factors we also summarized the directions of influence among the factors from available models factors influencing food choice in conceptual models in this section we summarize the basic factors included in the conceptual models of general food choices foodinternal factor sensory and perceptual features foodinternal factor is defined as features possessed by the food itself such as sensory and perceptual properties twentysix models have proposed that the sensory and perceptual features influence the food choice 21323441 49 50 51 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 a review paper summarized that visual and odor cues contribute to identifying food in the near environment guiding food choice and memory for eating while tastes and textures influence meal size and the development of satiety after consumption 72 another literature review concluded that odor exposure induces appetite while taste and texture contribute to satiation based on eating rate and oral exposure duration of food in the mouth playing an important role in a nutrient sensing system 73 in our definition information about the food item is defined as one of the foodexternal factors twentyeight models have included foodrelated information as factors influencing the food choice 2122243234 49 50 51 53 55 56 57 58 6162646570 74 75 76 77 78 79 80 81 82 83 in addition to these models there is a rich body of literature focusing on the effects of food label and food label use on food choice food labeling provides information on essential characteristics of food items and food label use has been recognized as an important component of strategies tackling unhealthy diets and obesity for example cowburn and stockley 84 reviewed papers reporting consumer understanding or use of nutrition labels and concluded that improvements in presenting and designing nutrition labeling could make a contribution towards making the existing pointofpurchase environment more conducive to the selection of healthy choices interpretational aid such as verbal descriptors and recommended reference values is needed to help consumers assess the nutrient information in order to improve overall diet cecchini and warin 85 did a metaanalysis and confirmed that nutrition labeling especially interpretive labels may be an effective approach to empowering consumers in choosing healthier products and in reducing calorie intake more recently a review explored how consumers value and response to nutrition information on food labels against information on environmental andor social responsibility 86 consumers generally have a positive view of environmental and social responsibility food labeling schemes while the most preferred attribute was organic labeling inferring to information related to health in brief interpretive nutrition labels with the combination labeling containing healthy and sustainable attributes can be propriate and effective in promoting healthy and sustainable food choice oostenbach slits robinson and sacks 57 examined the effect of nutrition claims on food choice the influences of nutrition claims depend on the type of claim and food with the claim for example nutrition claims can influence consumers perception that the product is healthier and less tasty however nutrition claims can make the appropriate portion size appear larger resulting in the underestimation of the energy content of food products nutrition claims also influence food purchase intentions moderated by the perceived healthfulness of the relevant food products and the health consciousness of individuals in addition to foodrelated information the food environments are considered as foodexternal factors which also largely affect the food choice we further divided food environments into two factors namely social environment and physical environment thirtyfour models indicated that social environment contributes to the food choice decision 212334414748525355565960627071 75 76 77 78 8283 87 88 89 90 91 92 93 94 95 96 97 98 99 in the social environment family and the home food environment are important influences on dietary intake but this influence is more profound for children and adolescents not adults 100 instead for adults individual food choices are influenced by interactions with others beyond the family unit it is suggested that not only the context of shared meals but also social norms and attitudes among members of a group have impacts on types or amounts of foods that individuals consume no matter whether people eat together or not 100 indeed social modeling determines what and how much people choose to eat using others eating behavior as a guide the effect increases when individuals desire to affiliate with the model or perceive themselves to be similar to the model the effect reduces for choosing specific food as well as meals 101 twentyeight models pointed out that physical environment contributes to the food choice decision 233234414849 51 52 53 555859616266707175768082 87 88 89 90 9294102 for the physical environment studies have indicated that food choices and eating behaviors as well as risk for obesity are influenced by the physical availability and accessibility of food products in the workplace surrounding neighborhood retail food stores as well as restaurants 100 a review done by castro majmundar williams and baquero 45 confirmed that food retail environments do shape customer food choices of healthy or unhealthy items and energy intake including product location on the shelf the appearance of the products on the shelf the brands available as well as product attributes for example feeling confined by smaller aisles may encourage consumers to make more varied choices 45 finally some models also included time as an influential factor mainly referring to time availability for food preparation and home cooking 4859707592 according to a review lack of time can result in changes in food consumption patterns such as a decrease in food preparation at home and an increase in the consumption of convenience or readyprepared foods 103 personalstate factors biological features and physiological needs psychological components habits and experiences in our definition personal states which affect food choice include biological features and physiological needs psychological components and personal habits and experiences sixteen models have included biological features and physiological needs as factors affecting food choice 21 48 49 50 5355576166717783 88 89 90 95 except for biological features which are difficult to change dietary decisions can be regulated by physiological functions such as circulating metabolic hormones and neural mechanism involved in food intake and appetitive behaviors 44 vice versa extreme and narrow food choices could result in fluctuation and unbalanced weight and health status 44 psychological components appeared in twentynine models 21232534 47 48 49 50 51 52 55 56 57 596062667174798083888991939598102 according to these models the majority of studies focused on how emotion is involved in food decisionmaking for instances the model proposed by gutjar de graaf kooijman de wijk nys ter horst and jager 74 was dedicated to exploring the role of foodevoked emotion in food choice foodevoked emotions which can be sorted into two dimensions add predictive value to solely liking ratings and may guide consumers choice behavior for tastebased choice the combination of liking and emotional valence had stronger prediction for packagebased choice liking emotional valence and emotional arousal together have a stronger predictive value 74 in addition to emotion motivation is also frequently involved in the models however the motivation to choose one food over another is driven by the emotional hedonic and metabolic properties of the foods 44 in other words the motivation is actually driven by other factors thus we did not include motivation as a factor in our categories comparably fewer models mentioned about previous experiences andor habits 214749617175838990 in these models experiences were categorized as a psychological factor related to the function of memory while habits were categorized as a situational factor however experiences and habits are composed by multifactors such as emotion memory and learning 55 moreover the process of consciousness needs to be considered 104105 thus in our opinion when we include experiences and habits under the frame of food choice it is better to categorize them into personalstate factor stressing the contribution of experiences and habits to the person at the moment of making food choice before reaching the final output of food choice behavior cognitive factors have their impacts on food decisionmaking possessing knowledge 24344852 56 57 58 647078798288939497106107 as well as food management skills 4148527583909297 can have great influence on food choice for example nutrition knowledge has been shown to be a partial mediator of the sociodemographic variation in food intake especially for fruit and vegetables implying that knowledge is an important factor in explaining variations in food choice 108 the second factor is evaluationbased 50 including attitude 2124254148495659616870 798290929597102107109111 liking 34637488 and preference 58698794 the potential differences among these three components towards food choice can be as follows attitude represents the implicit evaluation towards food items usually the attitude is based on valence but it can be also based on other concepts 112 liking instead focus on the sensory evaluation of food 113 finally preference is based on comparison for example the preference of obese people for foods was affected more by fat content than by carbohydrate or sucrose content 114 the third cognitive factor includes expected consequences 3448515463646668 76 77 78 889295109110 regarding the concern for health consequences of food consumption 34 for example consumers are prone to choose foods which give desirable consequences such as expected longer life 115 last but not least personal identity including demographic features such as age gender ethnic identity and education 23244147505961636482 87 88 89 90 91 93 94 95 can also affect food choices for instance food choices represent personal identity as well as the story of families migrations assimilation resistance and changes over times 116 possessing a healthy eating identity was significantly associated with greater fruit and vegetable intakes 117 moreover personal belief and value shaped by culture and society also contribute to the decision of food choice 212325484952 59 60 61 64707577788283909596107111 indeed two early studies have pointed out the potential role of personal belief and value in maintaining goaldirected behavior especially for healthrelated food choice 118119 sociocultural factors culture economic variables and political elements for previous factors the influences are mainly at individual level the final category sociocultural factors focuses on societal level according to larson and story 100 the influence of macroenvironment on individual food choice includes income socioeconomic status and price of food reported by twentynine models 3241 47 48 49 50 51 52 53 54 55 56 5859626566697075767982878890 92 93 94 cultural norms and values are reported by seventeen models 41 48 49 50 51 535556587071768889949798 agricultural and food policy and regulations reported by nine models 525558597688899498 about income and cost of food larson and story 100 specified that the monetary and time costs of buying and preparing foods especially ones with health values are additional barriers to good nutrition for lowincome groups indeed higher cost of healthy choices or diets can strengthen socioeconomic disparities in diet quality 120 nevertheless price elasticities for foods can be also a strategy in changing consumer demand shifting the purchase of unhealthy food to healthier food the example 121 showed that a 10 increase in soft drink prices should reduce consumption by 8 to 10 price and promotion in the food retail environment do affect consumers purchase intentions and choice 45 the quantity and quality of food along the supply chain can be affected by agriculture and food polices resulting in altered food price directly or indirectly influencing the choice affordability as well as the right to nutritious food of the consumer 100 finally we could not ignore the fact that food choice and eating behaviors are influenced by cultural factors especially shared values and beliefs which shape perceptions of food and the concept of healthiness 100 influences among factors in conceptual models of food choice thirtytwo conceptual models of food choice indicated possible directions of influence among the factors towards final food choice 41 47 48 49 50 51 52 545657 60 61 62 63 64 65 66 74 76 77 78 87 90 91 92 93 95 96 97 102109110 possible influences among factors in conceptual models of food choice for most of the conceptual models the directions of influence among factors affecting food choice are demonstrated with theoretical basis or literature review eg 57616676779097 the earlyestablished models can be seen as the porotypes 48 49 50 51 52 allowing consecutive research to expand or enrich the models with new data or evidence about integrating and expanding existing models as an example rose bodor hutchinson and swalm 87 integrated the factor of accessibility around the neighborhood based on an economic model of food consumption food cost taste preference and income influenced the food choice for purchasing the food cost can be directly influenced by instore price or indirectly affected by the placement of food store via travel cost instore characteristics such as product varieties as well as shelf space and placement had impacts on promotional effect and social acceptability which then further influenced tastes and preferences tastes and preferences also can be directly influence by demographic variables such as age raceethnicity and education the framework proposed by marreiros and ness 56 combined main features of the engelblackwellminiard model 122 regarding consumers decisionmaking and the main constructs of the total food quality model 51 developed for food products concerning mainly consumers quality evaluation the author bridged these two models with the emphasis on the relationships between them 56 about adopting and enriching existing models for instance the models shown in connors et al 54 and in sobal and bisogni 47 were both adopted from furst et al 48 with modifications or elaborations the life course and experience created influences including ideals personal factors resources social factors and context in the model of sobal and bisogni 47 these influences then had an impact on personal food system built upon values situation and strategy the personal food system affected food behavior which then had a feedback loop in shaping the aforementioned factors in the model the personal food system was composite of value managing relationships health taste cost convenience and strategies however there was no feedback loop 54 to briefly conclude few models have clearly indicated the direction of influence among the factors with experimental data or with mathematical modeling there is a need of empirical data to support and to disentangle the interactions between the factors direction of influence among factors in conceptual models of food choice in general the more specific factors the model addressed the clearer indications of directions of influence could be made supported by experimental data for example in the model of gutjar et al both sensory and packaging information trigger emotional responses but liking was based on sensory information 74 both emotional responses and liking then contribute to the prediction of food choice structural equation modeling is frequently used to investigate the directions of influence among factors towards certain food choice for healthy food choice including fruit and vegetables factors such as intention action planning and selfefficacy with a persons understanding of nutrition information can better explain healthy food choice behavior 64 the mediating roles of food mavenism food knowledge food involvement and equalityuniversalist values were reported in increasing vegetable intakes 93 moreover market availability interest in healthy eating and time pressure significantly influence choice of plantbased convenience foods 92 intention selfidentity and past behavior were proved as direct predictors of fruit and vegetable intake 91 for food with environmentallysustainable attributes personal norms regarding the use of organic food affect attitudes toward the use of organic produce in institutional settings which is partly mediated by own purchase of organic products 96 choice of convenience food with environmentallysustainable attributes is positively related to consumer food shopping habits foodrelated environmental behavior gender income and knowledge 102 another study also pointed out that likelihood of buying healthy convenience food is affected by overall liking of the meal which is affected by liking of sensory specific product attributes like appearance flavor and odor 63 for newly emerged food such as genetically modified food perceived benefits and risks play a significant role in shaping behavioral intentions towards gm food 110 the attitude to gm technology being the main driver of consumers beliefs about risks and benefits public attitudes toward gm food are being formed from trust in science and in public authorities under different cultural contexts which determines consumers final purchasing decisions 109 finally some studies examined factors affecting ethical food choice suggesting that ethical consumption and purchase intention have a direct influence on choice behavior with significant association between social emotional and epistemic values with ethical consumption intentions 62 in addition universalism was shown having impact on food choices with less meat or freerange meat this impact was mediated by preventionoriented food choice motives and motivecongruent animal friendly attitudes 60 supplementary materialstable s2 summarizes the directions of influence of factors affecting food choices based on publications with empirical data we included discussion main findings the multifactorial nature of individual food choice in recent years research as well as large scale initiatives have been launched substantiating the imperative for individuals and governments to improve population health by taking substantial actions in the domain of individual food choice and eating behavior 11 since consumers daily food choices have great potential in transforming towards healthier and more sustainable food systems 1122 the first and essential step before considering interventions is understanding factors influencing individual food choice in a structural and systematic way the present paper provides an insight into the complex and multifactorial nature of individual food choice by analyzing factors included in conceptual models the early development of conceptual models of food choice can be dated back to the 1990s there were three main types of models the first one which can be seen as the prototype of the models already demonstrated three levels of factors influencing the final choice namely food features personal system and environment 414849 the second type focuses on the effect of price quality and value 5165 while the third one the model proposed by sobal khan and bisogni 52 took into consideration a broader view including relationships of the food and nutrition system to other systems such as environmental system governmental system health care system cultural system economic system and even transportation system the conceptual models we include in the analysis mainly follow the threelevel framework of food features personal system and environment however different models might include different numbers of factors with different ways of categorization within and across these three levels thus the present review analyzed existing conceptual models of food choice summarized influential factors affecting food choice then recategorized and integrated the results from the literature into a proposed threelevel framework of factors influencing food choice namely foodrelated features individual differences and societyrelated features the ultimate goal is to provide a clear and simple roadmap for facilitating future development of research in the field of consumer food choice and maximize the contribution from individual studies being on the same page the framework may help researchers communicate the idea compare research data and replicate existing results with ease in our framework influential factors determining food choice are categorized into foodinternal factor foodexternal factors personalstate factors cognitive factors and sociocultural factors in our samples five most frequently addressed factors in the models are as follows social environment which belongs to foodexternal factors 2123344147485253 55 56 57 58 59 60 627071 74 75 76 77 78 8283 87 88 89 90 91 92 93 94 95 96 97 98 99 personalstate focusing on psychological component 21232534 47 48 49 50 51 52 55 56 57 596062667174798083888991939598102 economic variables such as income socioeconomic status and price 213241 47 48 49 50 51 52 53 54 55 56 5859626566697075767982878890 92 93 94 foodrelated information which also belongs to foodexternal factors 2122243234 49 50 51 53 55 56 57 58 6162646570 74 75 76 77 78 79 80 81 82 83 and physical environment which also belongs to foodexternal factors 233234414849 51 52 53 555859616266707175768082 87 88 89 90 9294102 the results reflect the facts that social environment is the most addressed factor influencing food choice due to the availability of research evidence factors such as food information food environment and economic variables are easier to be manipulated and measured in the experimental settings thus the role of these factors in influencing food choice is more carefully and clearly examined and concluded compared to studies from other field the complex mechanisms and interactions between food perception and biophysiological still need more investigation and the results should be integrated into the conceptual models of food choice while some factors affecting food choice could be universal largescale and crosscultural studies are needed to address factors influencing culturalspecific choices in addition considering the obesogenic environment nowadays despite the growing body of literature focusing on the role of cognitive function and food environment in food choice eg 124 125 126 we would like to emphasize the importance of understanding the complicated cognitive decisionmaking process and disentangling the interaction between cognitive functions and food environments especially foodrelated information and physical environment in order to develop effective intervention for helping individuals make better choice that is good for human health and the planet 127 128 129 about the direction of influence among the factors in the conceptual models fewer conceptual models are supported with empirical data 5760 62 63 64 7478 91 92 93 96102106109 table s2 in the supplementary materials summarizes the directions of influence of factors affecting food choices based on publications with empirical data we included we observed that factors proposed in theory of planned behavior and their effects are frequently examined with experimental settings and thus empirical data was obtained some other factors and the effects are also frequently investigated such as liking food or nutritional knowledge personal values emotion income and sensory properties of food future studies should explore other factors and their effects on food choices in conclusion the more specific factors the model addressed the clearer indications of direction of influence could be made supported by experimental data we appreciate the multifactorial nature of individual food choice and the effort of including as many factors as possible in the models in providing a more intact and holistic view however the tradeoff of expanding the models should be recognized too in this case interdisciplinary research is expected for constructing a holistic conceptual model of food choice supported by empirical data from studies in different fields implication of factors influencing healthy andor sustainable food choice in recent years research has shed light on the factors affecting food choice towards healthier and more sustainable products new conceptual models of food choice have been proposed to further depict how different factors essentially affect healthier and sustainable food choices through the literature review the models were framed according to four types of choices healthier food choice 24687980 sustainable food choice 222481107111 organic food 212425 and fruit andor vegetable 6970 for foodinternal factors the nutritional properties and the health value of the food items are especially important for the choice 6869 health value 130 is an important index including absence of contaminants 131 for foodexternal factors information based on nutrition facts sustainability labels and organic identity were included in the models as important drives 21 22 23 24 79 80 81 moreover some studies pointed out that certification of origin and food miles recycling packaging as well as indications of local traditional ethic and environmentally friendly products can affect the food choice 130 131 132 social interaction and engagement in social institutions in social environment are important for making food decision especially for fruits vegetables and organic food 212370 for physical environment the availability of healthy or sustainable food products and the accessibility to nutrition environment supermarket or local stores are critical 2380130133 as personalstate factors psychological components such as personality 23 as well as emotion 25133 have impacts on healthier and organic food choice some other studies also mentioned motivation and intention as important factors contributing to the final food choice 23 134 135 136 137 cognitive factors such as belief attitude awareness selfconcept and positive outcome expectation were addressed in determining food choice 21 22 23 24 25 68 69 70 79 80 81 107 finally sociocultural context and familiarity based on cultural habits could affect food choices 6970 income and economic situation are still a crucial determinant 6979 food price heavily affects whether consumer will choose healthier and more sustainable food or not 6970 130 131 132 137 for making healthier and more sustainable food choice available policy plays an essential role not only with healthy food eating policy but also with policies related to food supply chain especially how food is produced and environmental sustainability 3588 future research directions the present review provides an analytic framework of disentangling the complex and multifactorial nature of individual food choice with the aim of shifting towards healthier and more sustainable food systems recently the european commission has placed consumer food choice as one of the important targets for achieving a more healthy and sustainable eu food system in 2017 over 950000 deaths in eu were related to unhealthy diets thus the farm to fork strategy 138 at the core of the european green deal was launched in may 2020 which emphasized the importance of shifting towards healthier and sustainable diets in the eu by empowering citizens as consumers to reverse the overweight and obesity trends as well as to lower the environmental footprints in addition outcome report food 2030 pathways workshop 139 indicated a pathway of research and innovation to develop innovative healthy sustainable and personalized nutrition solutions to reduce risk factors for noncommunicable diseases malnutrition and micronutrient deficiencies more importantly consumers will be empowered to have a longlasting healthy pleasurable nutritional and sustainable diet tailored to individual parameters it has been pointed out that there is a need for research to better understand the factors influencing consumer choice such as food environment policies gender information education marketing incentives and lifestyles in line with the goal set by the european commission in the transformation of food systems we confirmed that citizens as consumersand their choicesshould be placed at the very center of the problem of both human and planetary health which calls for urgent investigation and solutions from academic field in providing opportunities and possibilities thus it is crucial to understand individual food choice factors affecting the choice and possible interventions haddad et al 140 have proposed a new global research agenda for food with ten research priorities suggested among them identify entry points for change agree on what constitutes a healthy diet make more data on diets widely available tackle different forms of malnutrition simultaneously study supply and demand and identify the economic levers for change are closely related to addressing the important role of consumers choices in realizing healthier and more sustainable food systems lusk and mccluskey 141 further identified priority areas for future research including dietaryrelated diseases and efficacy of policies designed to improve dietary choice trust in the food system and acceptance of new food and farm technologies environmental impacts of food consumption changing consumer preferences and food safety regarding data quality and availability uncertainty in underlying biological and physical sciences as well as applications of behavioral economic remain as challenges in our opinion future research examining factors influencing individual food choice should also take into account the need of multidisciplinary impulses and collaboration across research field such as sensory science cognitive science social science as well as business studies the structural and systematic way of investigating the effect of foodchoice related factors as well as the interactions among the factors the tradeoff between the number of factors included in the framework and the capability to investigate and clearly explain the effect of s single factor and the effect of combining different factors and enriching and improving the framework with empirical observation or data based on a feedback mechanism limitations the present review has three main limitations first we focus on the threelevel categorization of factors influencing food choice namely foodrelated features individual differences and societyrelated features however recent research also pointed out the important roles in determining food choice played by natural environment such as climate change 142 143 144 145 natural resources 146 147 148 as well as food production and supply chain 149 ideally these factors should be also included into the conceptual framework second the present study summarizes factors affecting food choice proposed in the conceptual models the keywords we used for literature search may limit the inclusion of publications investigating a single or fewer factor with experimental settings and empirical data thus more metaanalyses are needed for understanding how different but specific factors contribute to food choice finally this review does not include publications focusing on methodology used for understanding factors affecting food choices such as the development and validation of questionnaires which contain valuable information about the constructs of factors that are crucial for food choice decision thus further examination with the inclusion of the results of factor analyses from foodchoicerelated questionnaires is recommended supplementary materials the following are available online at table s1 factors included in the conceptual models of food choice table s2 direction of influence of factors affecting food choices based on publications with empirical data funding this research received no external funding

understanding individual food choices is critical for transforming the current food system to ensure healthiness of people and sustainability of the planet throughout the years researchers from different fields have proposed conceptual models addressing factors influencing the food choice recognized as a key leverage to improve planetary and human health however a multidisciplinary approach is needed to better understand how different factors are involved and interact with each other in the decisionmaking process the present paper reviews and analyzes existing models providing an intact pointofview by integrating key elements into a bigger framework key determinants of general food choice are identified and categorized including foodinternal factor sensory and perceptual features foodexternal factors information social environment physical environment personalstate factors biological features and physiological needs psychological components habits and experiences cognitive factors knowledge and skills attitude liking and preference anticipated consequences and personal identity as well as sociocultural factors culture economic variables political elements moreover possible directions of influence among the factors towards final food choice were discussed the need of multidisciplinary impulses across research field with the support of empirical data are crucial for understanding factors influencing food choice as well as for enriching existing conceptual models the framework proposed here would serve as a roadmap for facilitating communications and collaborations between research fields in a structural and systematic way

409 Imperial Agendas, GLobaL SoLidarities, and Third World Socio-legal Studies: Methodological Reflections --- RADHA D'SOUZA* This article interrogates the methodological lenses through which law in the Third World is commonly analyzed in socio-legal studies. Third World socio-Legal studies, this article argues, is a field in search of philosophical foundations. It continues to rely on conceptual categories and analytical frameworks developed through the intellectual, cultural, and social histories of Western capitalist societies, which it extends uncriticaly to different intersubjective orders in Third World contexts. The article examines the common grounds shared by two apparently competing discourses about law in the Third World, which I label imperial agendas and global solidarities. It is difficult to speak about the Third World without becoming mired in conceptual contradictions. One reason for the methodological problems in Third World socio-legal studies is that social philosophy, and liberal philosophy in particular, undermines the concept of society. This article begins by examining the meaning of society in social philosophy. It then interrogates three dichotomous sets of analytical frameworks that are often invoked in Third World socio-Legal studies: economic or modern law versus cultural or traditional law; and state centralism versus legal pluralism. The article argues for a differentiated understanding of society at the ontological, structural, and empirical levels, which should help transcend binary approaches and facilitate theoretical reflections about the Third World without subsuming its specificities. The article concludes by arguing for a sustained research program to put Third World Socio-legal Studies on firm methodological foundations. Cet article tente de comprendre [a lorgnette m~thodologique A travers laquelle les 6tudes socio-juridiques analysent habituellement le droit du Tiers-Monde. Selon ['article, les 6tudes socio-juridiques du Tiers-Monde constituent un domaine en qu6te de fondements philosophiques. E~les continuent de s'appuyer sur des cat6gories conceptuelles et des structures analytiques d6coulant du patrimoine intelLectuel, culturel. et social des soci6t~s capitalistes occidentales, qu'elles appliquent sans discernement A divers rapports intersubjectifs dans des contextes tiers-mondistes. Larticle examine les assises partag6es par deux discours apparemment contradictoires traitant du droit tiers-mondiste, que je qualifierais de vis6es imp6rialistes d'une part et de solidarit6 mondiale d'autre part. It est difficile de s'entretenirdu Tiers-Monde sans s'enliser dans une mer de contradictions conceptuelles. Lune des raisons qui sous-tendent les probl6mes m6thodologiques des 6tudes sociojuridiques du Tiers-Monde est le fait que [a philosophie sociale-et plus particuLirement La philosophie lib6rale-6branle le concept-m6me de soci6t6. Larticle commence paranalyser [a signification du concept de soci6t6 en philosophie sociale. II examine ensuite trois ensembles dichotomiques de structures analytiques qu'invoquent souvent les 6tudes socio-juridiques du Tiers-Monde : a) le droit compar6 par rapport aux th6ories tiers-mondistes du droit international le droit moderne fond6 sur ['6conomie par rapport au droit traditionnel fond6 sur [a culture et cJ le centralisme d'6tat par rapport au pluralisme juridique. Larticle milite en faveur d'une interpr6tation diff6renci6e de [a soci6t6 sur les plans ontologique, structurel. et empirique, qui devrait permettre de transcender les approches dichotomiques et faciliter les r6flexion th6oriques sur le Tiers-Monde sans faire abstraction de ses particu-larit6s. It propose pourterminer [a cr6ation d'un programme continu de recherche destin6 6 doter de soLides fondments m6thodologiques les 6tudes socio-juridiques du Tiers-Monde. 1 This is so notwithstanding the large body of scholarship--comprising both dominant and critical pieces-on different aspects of the operation of law in Third World societies. Necessarily generalizing, scholarship on law and colonialism and on law and development in various academic disciplines highlights the temporal and spatial dimensions of law in Third World societies. 2 More recently, the emphasis on governance in international 1. I use the term in the broadest possible sense as a field of study that examines law in Third World societies and includes sociological, historical, and anthropological approaches as well as policy studies and impact analysis. For distinctions between socio-legal studies and sociology of law and the use of these . For an overview of sociological approaches to organizations such as the World Bank has produced a critique of international law and international relations from the perspective of global justice. 3 This impressive body of scholarship has not, however, produced new innovations in conceptual categories in social philosophy. It remains by and large a descriptive and discursive account of law in Third World societies. Analytical frameworks and conceptual categories provide the prisms through which law in societies is understood. Categories that emphasize structuring mechanisms like class, capital, state, and political economy or subject formation like identity, gender, race, and culture remain, by and large, products of Greco-Roman-Christian intellectual traditions that have evolved through the experiences of Euro-American capitalist societies. TWSLS demands much more than sociological attention to contexts. It challenges us to think about the intersubjectivity of the social contexts, i.e., the cognitive mappings embedded in language and culture, that are constitutive of different civilisations or what Jdirgen Habermas refers to as "lifeworlds." 4 To put it differently, the development of theory and philosophy continues to borrow, modify, extend, advance, develop, and adapt various concepts and methods from different philosophical strands in the Greco-Roman-Christian intellectual traditions, and the Third World societies provide the historical facts or the social data that differentiate the context for the operation of law. If, as critical legal scholars rightly argue, 5 the conceptual categories and analytical methods of law And how can we call them into question without, on the one hand, subsuming the differences between First and Third World societies, as meta-theories with their universal categories and methods tend to do, or on the other hand, undermining the possibility of theory, as postmodern postcolonial emphasis of difference and pluralism tends to do? One reason why critical understandings of law in Third World societies have not pushed the boundaries of concept formation and theory development is the opacity of the meaning of "society" in contemporary social philosophy. Consequently, the epistemological premise ofTWSLS rests on a fault line between philosophical understandings of society, on one hand, and the law that has operated in Third World societies since the advent of colonialism, on the other. This rupture is not adequately captured in TWSLS. Nor are the methodological ramifications of the disjuncture between intersubjective orders and geo-historical realities adequately theorized in TWSLS. If concepts are socially produced in response to geo-historical developments, then it must be acknowledged, in principle at least, that transposing conceptual categories developed in one geo-historical context to another-a method entailed in the universal application of theory-poses methodological questions for TWSLS. Conversely, emphasizing the effects of modern law on Third World societies without adequately understanding the intersubjective, geo-historical, and sociological sources of those effects obfuscates the theory and concepts implicit in those accounts. The epistemological gaps in TWSLS that follow from the fault line mirror a wider problem in social theory. Social philosophy since the Enlightenment and Modernity has conflated the ontological, epistemological, sociological, and empirical meanings of society, as elaborated in Part I below.' Equally, the singular influence of Greco-Roman-Christian intellectual traditions has meant that social philosophy is dominated by dualist methods and binary categories that lock theory and practice in adversarial positions. --- I. W H A T IS S O C IE The epistemological gaps have created paradoxes for TWSLS. Ex-facie dominant TWSLS advances imperial agendas and critical TWSLS advances global solidarities. Bernard S Cohn, Colonialism and Its Forms of Knowledge: 7he British in India . --- 6. For an historical understanding of Modernity, see In philosophical terms, dominant TWSLS and critical TWSLS appear as mirror images of each other in that they share common theoretical grounds but proceed from different vantage points. The development of TWSLS remains thwarted by binary concepts and frameworks. Popular binaries in TWSLS include modern versus traditional or customary law, economics versus culture, and legal centralism versus pluralism. The binary lenses through which law in Third World societies is studied are effective insofar as they help to deconstruct the operation of law. Beyond that, TWSLS is trapped in conceptual and political conundrums. The resulting deadlock is particularly problematic for global solidarity movements that are motivated by the desire to overcome the impasse of Eurocentrism in theory and promote law as a transformative tool for global justice in the widest possible sense. In the Parts that follow, these issues are examined at greater length. Part I locates the epistemological gaps in TWSLS in the opacity of the meaning of society in social theory generally. The opacity of the concept of society makes articulation of the differences between First and Third World societies possible only in dualist, often adversarial ways and in binary terms. Using the meaning of society in social philosophy as the point of departure highlights theoretical and methodological problems in TWSLS that follow from that opacity. Parts II, III, and IV unpack three binary sets of analytical frameworks popular in TWSLS, each set made up of a dominant and a critical approach: comparative law versus Third World Approaches to International Law ; economic or modern law versus cultural or traditional law; and legal centralism versus legal pluralism. Part II examines comparative law, which is the dominant framework for TWSLS, by interrogating the idea of Asian law and juxtaposing the comparative law approach with TWAIL a movement committed to promoting Third World perspectives in international law. Part III widens the scope of the comparative law/TWAIL approaches to examine the divide between economics and culture in TWSLS-a dichotomy closely related to the first but with longer and more enduring roots in colonial history. I use the public/private divide in law to interrogate the ways in which the use of legal concepts sustain specific types of relations between economies and cultures that have come to characterise Third World societies. I argue that there are asymmetries in the language of law and its meanings in particular social contexts, in the substance and form of law, in the abstract legal concepts, and in the historical contexts in which they were introduced and evolved in Third World societies. Part IV interrogates the underpinnings of the economic/cultural divide in TWSLS by examining legal centralism and legal pluralism, two popular frameworks of analysis in dominant and critical TWSLS respectively, and by evaluating them against the specific attributes of societies constituted through processes of imperialism or colonialism. In the concluding Part, I return to the importance of problematizing society as a core concept in social theory in order to transcend binary frameworks. The methodological questions discussed in this article are deeply embedded in TWSLS scholarship. The aim of this article is to open up entrenched approaches for wider engagement and to advocate for a research program that will place TWSLS on firmer philosophical and theoretical foundations. --- I. WHAT IS SOCIETY? There is considerable semantic confusion in the social sciences and humanities on the appropriate vocabulary to characterize societies with histories of imperial rule. Binary terms like First World and Third World, North and South, developed and underdeveloped, colonial and neo-colonial , and West and East are often used to describe societies but are widely contested from different theoretical, ideological, and disciplinary perspectives. While most people understand what is being referred to when such terms are used, the conceptual underpinnings of the terms are often imprecise and inaequate to identify appropriate criteria for classifying these types of societies.' Is it possible that the semantic confusion is due to the opaque meaning of society in social theory? --- 7. The continued use of the term 'Third World' has been called into question. See e.g. Arif Dirlik, "Spectres of the Third World: Global Modernity and the End of the Three Worlds" 25 Third World Q 131. The term is also defended, inter alia, on the grounds that it is still a useful term. See e.g. Obiora Chinedu Okafor, "Newness, Imperialism, and International Legal Reform in Our Time: A TWAIL Perspective" 43 Osgoode Hall LJ 171. Mark Berger asserts that there are historical associations with the term that are important. See e.g. Mark T Berger, "After the Third World? History, Destiny and the Fate of Third Worldism" 25 Third World Q 9. In addition to these reasons, I use the term Third World for a third, more important reason. The historical factors that led to the creation of the 'three worlds'-capitalist , socialist , and colonial -and that formed the structural feature of the post-World War II world order continue to inform the historical, structural, political, economic, and cultural realities of those societies. These features remain even after 'Third Worldism' as a solidarity movement of newly independent countries has stalled and the formal architecture of the world order appears to be subsumed by 'globalization.' Throughout this article the term 'First World' is used to denote European societies that were internally reconstituted through the processes of capitalism and informed by corresponding intellectual developments spearheaded by the European Enlightenment. Tom Bottomore's A Dictionary ofJMarxist Though? defines three uses of the word society: as socialized human beings, as typologies of social formations, and as specific societies. What is important is not to reduce the concept of society to one of these three definitions, but rather to treat all three uses as true and ask ourselves, "What must be the nature of society if all three definitions are true?" Methodologically, such an approach borrows from the non-dualist Jaina traditions of Anekantavada or the philosophy of non-one-sidedness." Anekantavada methods urge us not to frame questions in the "either this is true or it is false" format, but rather to ask, "If A believes this to be true, and B believes it to be false, what must be the nature of reality that invites both beliefs?" The methodological approach in Anekantavada presupposes an ontological conception of the nature of Reality that informs epistemological inquiries. In this article, "Reality" denotes the ontological meaning of the term in the philosophical and cosmological sense that there is a Reality beyond individual spatio-temporal lives, while "reality" denotes the ordinary use of the term to refer to objective existence beyond subjective perceptions as when we speak of social, political, or economic realities. In the Jaina conception, Reality is infinite and irreducible. 0 In the Buddhist conceptions, Reality is interdependent, contingent and non-essential. 11 The role of epistemology is to uncover layers of Reality and real relations, metaphorically like peeling an onion. Liberal theory, to the contrary, is based on what Roy Bhaskar calls a "monovalent" 12 ontology, where the world is reducible, unchanging, and undifferentiated. Bottomore's three uses of "society' may be seen as three levels of meaning, each of which is represented in this article by a different typographical convention: at the ontological level, where human beings are socialized beings and human life is contingent on Society; at the structural level, where Society refers to typologies of geo-historical social formations constituted by a variety of mechanisms ; and at the empirical level, where society refers to specific conjunctures of diverse social, economic, historical, political, and cultural factors and the roles of individuals and groups that characterize specific societies at a given point in time. In this article, therefore, Society denotes the ontological level of meaning, Society the structural, and society or societies the third, empirical level. Taking philosophy of science as his point of departure, Roy Bhaskar argues that Nature, Society, and "Human Life" are ontologically distinct in that they possess different ontological attributes and properties, but that they are nevertheless related. 13 Society is unilaterally contingent on Nature but the converse is not true in that Nature can exist without Society . Society, as social structures, Bhaskar argues, is always geo-historically produced and involves language, concepts, laws, institutions, technology, norms, and ideologies. The ontological property of human life is its psychological and aesthetic dimension, a property of being human. It gives human beings agency and the capacity to change societies at the empirical level in the short term. Human Life is contingent on Society in that everyone is born into some type of social structure without which life is not possible; yet human agency can transform Society at the structural level in the long term. Society thus has dual ontological properties: It is the condition of Human Life, in Bhaskar's terms, and at the same time can be transformed by it. Human Life is concept-dependent and impelled by the desire to be free from the constraints imposed by social structures. Human beings must therefore always rethink philosophy and theory for transformative action. Bhaskar's pluralist ontology makes it possible to develop a non-dualist epistemology that can provide a coherent account of natural, social, and aesthetic life. It allows for the possibility of theory without subsuming difference. At the ontological level, it is possible to argue that Society is the structured relationship of Nature and Human Life; it is the ontological median between the two, as it were. The ontological attributes of Society make it possible to postulate different types of societies that are specific geo-historical conjunctures of natures and peoples-in other words, social structures formed through geo-historical processes. The social structures including law, institutions, norms, and cultures, for example, constrain and enable those living within those structures in different ways. At the human level of individuals and groups, transformative action and solidarities become possible if and only if knowledge is driven by empirical realities, takes into account structural causes, and is foregrounded in ontological awareness, i.e., in awareness of one's philosophical world view about the nature of Reality grounded in conceptions of cosmology and ontology. Liberal philosophy, which continues to be the dominant philosophy in law and social theory, is dismissive of the concept of Society. Society, following William Outhwaite, 15 is not an empirical concept; it is a theoretical concept. Without conceptualizing Society theoretically, liberal philosophy leaves us with empirical expositions that make theoretical assumptions about the meaning of Society. Raymond Williams traces the history of the word from meaning "companionship" in the fourteenth century to greater levels of abstractions to mean "associations" and "groups" by the seventeenth century. 16 The conflicts of the seventeenth century introduced a distinction between Society and state, "... the former an association of free men, drawing on all the early active senses; the latter an organization of power, drawing on all the senses of hierarchy and majesty." 17 Thus, there was a divergence between companionship and associations or organizations. By the eighteenth century the transition was decisive. Society was that to which we all belong-a system of social life-and the state was the apparatus of power. By the nineteenth century, Society became an object related to 'man' and the 'individual' but was not the same thing. This paved the way for social systems and the study of 'the social.' The meaning of Society changed with the transformations in capitalism in a European context. The Enlightenment, as a broad intellectual movement, was instrumental in reconceptualizing the meaning of Society in the wake of capitalism and Modernity. 18 The Enlightenment as an intellectual movement grew in response to European feudalism and responded to the problems of European societies by drawing its conceptual and intellectual resources from the Greco-Roman-Christian traditions within which it remains rooted. 9 My point is not to contrast this response with the Enlightenment's response to colonialism; doing so would lead to the familiar West versus Rest dichotomy and to charges of Eurocentrism, with emotive and ethical overtones that lead to an intellectual cul-de-sac. Rather, the purpose of recalling the social and intellectual context for the Enlightenment is to examine the ramifications of projecting assumptions about the meaning of Society that has evolved within one historical context to societies within which the meaning of Society remains to be defined and understood historically. A key proposition advanced here is that First and Third World societies are constituted through related but distinct processes: the first internal to the social context of capitalism's development, the second its external expansionist processes of imperialism and colonialism. These two processes, one centripetal and the other centrifugal, constitute two different types of societies with distinct features and properties that we recognize as First and Third Worlds. The basis for this differentiation remains under-theorized, however. Consequently, the Third World defined in antithetical terms to the First World as its "other" continues to haunt social theory The ramifications of extending legal concepts and analytical categories developed through capitalism's centripetal or internal processes to societies constituted through its external or expansionist processes understood as colonialism and imperialism must inform TWSLS if we wish to address the fault line on which it is founded. --- "Realism and social science" in According to Karl Polanyi, for the first time in human history, capitalism dis-embeds from Society certain aspects of life associated with material provisions that it characterizes as economic aspects. 2 " It is not necessary to explore this argument for the purposes of this article except to reiterate Polanyi's point that the social transformation brought about by trade and commodification of land and labour was made possible by a philosophy that reduced collective social life-or companionship of the fourteenth century-to relations between individuals, on the one hand, and a relationship with nature through property relations on the other. 21 Equally, what is dis-embedded from Society is re-embedded in institutions of states and markets created through the fiat of law. 22 The scope and processes of embedding, dis-embedding, and re-embedding economic aspects of social life in capitalist and colonial societies produced two distinct types of societies with distinct attributes and properties. These processes have dramatically contrasting implications for the functionality or dysfunctionality of law and institutions in the two types of societies. However, the obfuscation of the concept of Society in theory was a necessary condition for social transformations to occur in both types of societies. Methodologically, the obfuscation of Society as a theoretical category was achieved 20. The Great Transformation: The Political and Economic Origins of Our Time . --- For the difference between legal relationships with individuals and with nature under --- D'SOUZA, IMPERIAL AGENDAS 419 in philosophical liberalism through three moves: a privileging of epistemology over ontology; philosophical dualism including the nature versus society and society versus ethics and aesthetics divisions in social theory; and engagement with the problem of 'Universals' as the binary 'Other' of the 'Particular' in philosophy. It is to these moves that we need to turn our attention in social theory if we are to transcend the problem of binary categories and dualist methods entailed in the West versus Rest polarity that confounds TWSLS. 'The institution of the state complicates the concept of Society. As Outhwaite points out, at first Society was seen as the third estate and a threat to the state; later it came to be squeezed within a territorial or institutional state. 23 According to Outhwaite, when we speak of Society, we enter into a language game that licenses certain types of theoretical moves and not others, and that introduces an element of abstraction. 4 Following Outhwaite, we cannot do without a concept of Society because the alternative is to have an ontology of the individual. 25 As human actions presuppose social networks and social preconditions, some conception of the collective life becomes necessary. Liberalism straddles this question by squeezing society into the state, on the one hand, and reducing it to atomized individuals standing in contractual relations with the state on the other hand. This is the "civil society" of classical liberal theory. 26 The concept of civil society is not to be conflated with Society, however. Civil society under capitalism refers to those institutions in the private sphere that underpin the economy. Society is much more. The increase in the number of sociological and historical accounts of law in Third World societies does not do away with the need to answer the question, "What is Society?" Without answering this question, it is impossible to speak of the First and Third World without becoming mired in contradictions. In the absence of a theoretical understanding of Society, social theory is left with descriptions of societies. Descriptions alone do not provide the cues to make the causal connections between diverse events or facts, nor to identify trajectories of change. Sociological accounts describe social structures and the constraints that the structures impose on human life but tend to be deterministic because the descriptions of structural constraints are less able to integrate ethical and aesthetic dimensions of social life. Descriptions of ethics and aesthetics emphasise agency and subjectivity but tend to be voluntaristic as they are less able to integrate structural constraints for social changes. For example, empirical accounts show real differences between the realities in First and Third World societies. These differences are echoed in everyday language. For example, newspapers and Western politicians routinely use expressions like 'Third World conditions' to describe deteriorating public services in the First World. Sociological accounts of First and Third World realities show the geo-historical mechanisms that structure the two worlds in very different ways even when they remain mutually constitutive and interdependent. Discourses in ethics and aesthetics reveal the desire for justice, freedom, and humanity, and emphasize the solidarity and unity of both worlds. When the concept of Society is foregrounded in the understanding that Nature, Society, and Human Life are ontologically distinct but nevertheless related, it becomes possible to produce an epistemology that simultaneously accounts for differences between societies and sustains human impulses for solidarity and freedom. It becomes possible to argue that First and Third Worlds are specific conjunctures of Nature-Society-Human Life constituted through the geo-historical processes of capitalism and imperialism in different ways. Capitalism and imperialism reconstitute First and Third Worlds in definite ways and imbue the two societies with different characteristics and properties that are experienced as difference in everyday life. The freedoms and constraints of the two types of societies are experienced differently by people living in those societies. The source of solidarity therefore, does not flow from eliminating difference discursively in ethics or analytically in social theory. Rather, it flows from the understanding that the desire for freedom is an ontological attribute of being human that must be respected universally. The ways in which human freedoms are curtailed are different for different types of societies. The differences are often cast in adversarial structural relations with other societies. This way of understanding unity and difference distinguishes between the desire for freedom in all people and the different modes of articulation of that desire in politics, which is prompted by the specificities of social formations in a given geo-historical moment. Bringing ontology to the centre stage of theory helps us to anchor the idea of Third World Society in theory, by whatever name it is called, without subsuming the differences between the societies, nor undermining the possibility of theory. It becomes possible to argue for solidarity without fetishizing the adversarial structural relations that the coupling of capitalism and imperialism creates between First and Third World societies or minimizing the imperatives of structural constraints. An understanding of Society at the ontological level invites us to epistemological inquiries that are ontologically aware, structurally astute, and empirically sensitive. Differences at the structural level do not negate human solidarities. Differences, while recognizing antagonistic interests of groups and societies, can take into account the different types of freedoms that each group or society seeks. They open up the possibilities of directionally different but ontologically consistent political programs for action. If A and B are standing in opposition but wish to reach midpoint-or another destination for that matter-they must travel in different, opposed directions to achieve the same objective. This possibility is foreclosed by liberal philosophy where sameness is contrasted with difference. The reduced emphasis on ontology in liberal philosophy precludes unity at the higher ontological level. One category that produces endless conundrums in social theory is the Universals. In the Greco-Roman-Christian intellectual traditions, the Universal as a category in philosophy stands in opposition to the Particular. This way of framing the Universal as the opposite of the Particular in philosophy has produced binary concepts and dualistic methods wherein social theory must either abstract substance from form, as modernist theories do, or privilege the Particular over the abstractions, as postmodernism does." This is not the only way of understanding Universals, however. In other philosophical traditions, Universals do not stand in opposition to Particulars as in the Greco-Roman-Christian traditions. Raja Ram Dravid, for example, argues that in the Indian traditions Universals are seen as distinct types of properties not necessarily opposed to Particulars. 28 A move in social theory to reconceptualize categories like Universals and Particulars, drawing from philosophical traditions different from the Greco-Roman-Judeo-Christian traditions, has the potential to provide a way out of the current impasse in theory produced by methodological dualism and binary concepts. It opens up possibilities of grounding concepts and theories in the materiality of the contemporary world and at the same time opens up pathways to reconceptualize freedom and emancipation for all. Following these observations on the need to problematize Society in TWSLS, the question emerges, "What are the attributes and properties of societies constituted through the processes of colonialism and imperialism, and what is the role of law in the production of those attributes and properties that we recognize as the Third World?" 'The next three Parts follow this thread by examining three sets of binary frameworks used in TWSLS: first, comparative law versus TWAIL; second, economic versus cultural spheres in law; and third, legal centralism versus pluralism. --- II. WHAT IS 'ASIAN' ABOUT LAW IN ASIA? It may be useful to begin the discussion of comparative law versus TWAIL at the empirical level by considering widely accepted, everyday practices in the academic community on legal issues in the Third World context. In 2003, thirteen law schools in Asia formed the Asian Law Institute under the aegis of the National University of Singapore. ASLI held its inaugural conference in May 2004 in Singapore on the theme of "Law in Asia." Of the twenty-two panels on different sub-themes of law in Asia, only one panel, entitled "On Asian-ness: Traditions, Identity and Impact on Asia and Asians," was explicitly about Asian-ness. 29 There are several other Asian law journals." Like the panels at the ASH conferences, a sweeping overview of the subjects addressed in the Asian law journals reflect a similar pattern, where modern law addresses problems in economics and related fields like labour, environment, and human rights; traditional law-often religious law-addresses cultural issues concerning family and inheritance; and land tenure falls somewhere in between. This architecture of law in Asia-where the jurisdiction of modern law prevails over economic spheres and the jurisdiction of traditional law prevails over cultural spheres outside the economy-is common to most Third World countries. It also mirrors the wider society it services where, generally speaking, the cultural sphere is governed by traditional law and the economic sphere is governed by modern law. Comparative law provides the analytical framework for dominant approaches to law in Asia as evidenced at the conference, or for that matter, dominant TWSLS. Comparative law is methodologically weak. As Burkhard Schafer points out, comparative law starts with an assumption of comparability and some form of functionalism, in that it assumes some correlation between legal forms and social functions and draws on legal history to establish the correlation. 31 Comparative law and legal historiography in dominant scholarship, thus, share common presuppositions-both are premised on the rationality of legal responses to societal demands. 32 For legal systems to be compatible, writes Schafer, it is sufficient they have a shared core: "That is, we either have to identify a historical core programme , or extrapolate one logically ." 33 Schafer draws from comparative legal scholarship on common law and continental civil law to explain how the core of Roman law provides the basis for explanations of the divergent "development of legal systems that share historical roots." 34 These attempts to strengthen the epistemological foundations of comparative law work where shared historical, cultural, and philosophical traditions provide a repertoire of conceptual resources for the development and communication of ideas between the societies within which the legal systems operate. This is seen in common law and continental civil law systems underpinned by a core that is derived from Roman law. The absence of an intersubjective order makes a shared core for comparative law for legal systems in Third World and First World societies methodologically problematic. Is comparative law possible where the legal histories do not provide a shared core? 5 More importantly, in the case of Asia and other Third World societies where comparative law dominates the economic sphere, the pressing question is this: "Is it possible at all to cast economic and social spheres into legal systems with radically different normative, ethical, institutional, and conceptual 'grundnorms"'? 36 We shall return to this architecture of law again in the next section. Suffice it to note here that such a problem does not exist in the Euro-American capitalist societies. 7 While Euro-American law in every sphere has transformed and evolved over time, it remains grounded in, and inspired by, various strands of Greco-Roman-Christian intellectual, cultural, and legal traditions. Dissent, change, and evolution all refer back to, and continue to draw on, the conceptual and philosophical resources from those traditions. Indeed, modern law is a product of those traditions. In Third World societies, the gap between culture and economy 33. Ibid manifests in law as two distinct domains of law. This gap in law-between the historical past where the roots of culture lie and the geographical present where global economic relations play out between states, on the one hand, and its manifestation as a rupture in the intellectual moorings of its economy and culture, on the other hand-is under-theorized in TWSLS. What John ComarofP 9 asks about studies on colonialism and law may be asked about TWSLS more generally. Summarizing the trajectory that seems to have brought studies of law and colonialism to a resting point, Comaroff argues that there is a convergence and consensus on colonial law as being both an instrument of domination and a site of resistance. He asks, "Is there anything more to say on the topic, other than to offer further historical and/or ethnographic illustration?" 40 Although Comaroff answers the question in the affirmative, what is proposed by way of a future agenda for law and colonialism studies is to develop a more nuanced understanding of complexities of the role of law in colonization by undertaking empirically grounded and methodologically improved accounts of law in colonialism. Such approaches could certainly produce better socio-legal studies of the Third World. Whether it will shift the grounds of philosophy of law or social theory is a pressing question. In any event, philosophical questions about law in society cannot be deduced from sociological accounts of law. Nor is it possible to arrive at a theory of Society from sociological accounts. Sociological accounts presuppose concepts and analytical frameworks grounded in social philosophy. In contrast to comparative law approaches in dominant Asian and other regional legal studies, TWAIL claims to be a movement within international law that seeks to study international law from Third World perspectives. Although TWAIL scholars defend the use of the term Third World, there is considerable ambiguity in what is meant by the term and the conceptual basis for its use. For Obiora Okafor, Third World is a contingent but useful category that is selfreferential. 41 Third World therefore becomes a question of identity. For Makau Mutua the term Third World is "a stream of similar historical experiences across virtually all non-European societies that has given rise to a particular voice, a form of intellectual and political consciousness [and] The object of knowledge for TWAIL scholars is international law, not the Third World. TWAIL scholars aim to provide a perspective on international law from the vantage point of marginalized nations. TWAIL approaches deconstruct and contextualize the ways in which international law is formed through the encounter of European powers with colonized societies. 4 Reversing the perspective from European to non-European does not, however, change the conceptual frames that inform international law, nor does it reveal what is entailed in projecting those concepts onto Third World realities. TWAIL approaches embed the Other in epistemology, even when challenging it empirically, and remain constrained by the West versus Rest dichotomy. In their normative standards, TWAIL scholars remain modernist inasmuch as they seek ethical interventions to reform international law so that it lives up to its normative claims of equality and non-discrimination. It is beside the point whether such approaches are offshoots of Northern scholarship or not. 45 What is important is whether the scholarship falls back on moral or ethical transformation and voluntarism to ground ideas of freedom and equality between all societies and whether or not it opens pathways for transformation where freedom and equality between societies qua societies are grounded in the materiality of a world based on relations of super-and subordination. Andrew Sunter argues that TWAIL approaches may be described as naturalized epistemological inquiries." As such, they rely on a posterior empirical knowledge to arrive at a priori claims. TWAIL approaches, therefore, fall back on philosophical empiricism in the form of past experiences of the Third World to critique international law. These approaches reify the status quo by grounding the possibility of transcendence in past experiences. While this critique and deconstruction make an important contribution to our understanding of the role of international law in sustaining inequalities between societies in the past and present, deconstruction alone does not suffice for transcendence of the West versus Rest polarity. Nor does it help to redefine the meaning of freedom. We remain in what Teemu Ruskola calls the "hermeneutical loop." 7 We do not have a way of answering the question, What is 'Asian' about Asian law? Fear of essentialism and reductionism, on the one hand, and universalism and meta-theories without social content, on the other hand, prevents escape from hermeneutical loops. Some scholars have argued that there is a spatial tension in the theorypractice dialectic of knowledge production in that theory production remains located in the First World but is based on experiences produced in the Third World. 4 8 While locations and spatial dialectics of knowledge production are important, we must be careful not to over-determine the case for location to the detriment of intellectual creativity and human solidarities. Rather, the problems may lie in philosophical dualism, which dominates Modernist and Enlightenment thinking. Philosophical dualism produces conceptual deadlocks by locking binary categories into oppositional positions and thereby forestalling transcendence and emergence. As Roy Bhaskar shows in his work Dialectics: Pulse of Freedom, thesis and antithesis share common grounds. 49 The hermeneutical cycles create and recreate familiar patterns in the analytical frameworks that inform knowledge of the Third World and continue to reproduce unequal relations even after several centuries of resistances and solidarities to end them. The result is pessimism and obeisance to what is described metaphorically as the "empire of law." 50 In the light of these observations about TWSLS, how may we understand the dichotomy, exemplified by the ASLI conference, between modern or economic domains, on one hand, and traditional or cultural domains, on the other? The next Part explores this question by interrogating the public/ private divide in law. --- III. TRADITIONAL IN CULTURE AND MODERN IN ECONOMY? The opposing directionality of capitalism and imperialism in the constitution of societies in the First and Third Worlds produces asymmetries in the substance and form of concepts used to analyze modern societies. In other words, the geo-historical content of concepts in social theory is not comparable even when comparable vocabulary is used. This is more significant in law because legal concepts define social relations and reify their normativity. Law-in particular the foundations of positive law-rests on definitions. In order to understand the economic-modern versus cultural-traditional architecture of law in the Third World, it becomes necessary to problematize the language of law by interrogating core legal categories in light of insights provided by historical and sociological critique. It is necessary to go beyond comparing and contrasting the observable effects of law in different nation-states, as in sociological and anthropological studies, and to begin building a philosophical foundation for TWSLS. How the asymmetries in the substance and form of legal concepts sustain the divide between modern law in the domain of the economy and traditional law in the domain of culture in the legal architecture of Third World societies may be exemplified by interrogating the use of the legal categories of "public" and "private" in law. The public/private divide is a structural feature of modern law. Legal theory works on the premise that law has two branches that operate in two different social spheres. Jowitt' Dictionary ofEnglish Law defines Public Law it as follows: [L]aw is either public or private. ... Public law is that part of the law which deals with the State, either by itself or in its relations with individuals, and is called constitutional, when it regulates the relations between the various divisions of the sovereign power; and administrative, when it regulates the business which the state has to do.... --- To the contrary: Private or civil law deals with those relations between individuals with which the state is not directly concerned: as in the relations between husband and wife, parent and child, and the various kinds of property, contracts, torts, trusts, legacies, the right recognized by the rules of admiralty etc. --- 52 The two branches of law limit the role of the state and sovereign power in First World societies. The public/private divide is not as neat in reality as it is conceptually, nor is it uncontested. Over time, the boundaries have been contested, altered, and realigned. 53 of private law, were legislated into existence through public law in the colonies. 58 Colonial law introduced a field of law called "personal law" or "tribal law." Matters concerning family, inheritance, succession, marriage, divorce, and adoption were left to be governed by the religious and tribal norms of diverse communities. Personal/tribal law shrunk the private sphere in the colonies and expanded the public sphere by subsuming the economy within the public sphere. 5 9 Although the concepts of public and private law are routinely used as foundational legal categories everywhere, they denote different socio-economic and geo-historical realities and social spheres in the Third World. In the First World, the public/private divide limited the role of the state and defined sovereign powers. In the Third World, it expanded the role of the state and shrank the private sphere. Retaining the legal language of the public/private divide fetishized the assumption of sovereignty over resources and populations that were traditionally in the private sphere in the European legal tradition. More significantly, it enabled the colonial state to incorporate diverse communities into the political economy of colonialism under the umbrella of the modern colonial state. The modern state structure in the Third World has continuities with the colonial state. The economic-modern versus cultural-traditional law divide, in retrospect, was foundational for indirect rule, which subsequently became the dominant mode of imperial governance globally. Arguably, it was that architecture of law that made formal decolonization possible under the United Nations System at the end of World War II. The theoretical assumptions underlying personal and tribal law are important. The assumption is that culture can somehow continue to be practiced without its moorings in the materiality of the economy. Conversely, there is the assumption that somehow the economy will transform and modernize social relations. Both these assumptions are mired in contradictions. Inasmuch as all cultures must be grounded in the materiality of societies, the assumption that cultural practices can be continued even after the political economy has changed is fundamentally flawed. Sir Henry Maine argued that colonial societies would progress from status-based to contract-based relations in the same way as had happened under European capitalism." This social Darwinism in legal theory was at odds with the colonial imperative of imperial governance that necessitated incorporation of local family and tribal structures within the wider colonial state. 61 Consequently, contractual relations in the economy did not evolve into general contract forms of social relations in all spheres of social life. 62 The processes that extended public/private concepts in law to different socio-historical realities of the Third World created a structural schism within Third World societies, where two sets of values, norms, institutions, and laws-one for the economy, another for culture-regulate two aspects of society as if the two were unrelated. The structural schism between economy and culture is a characteristic of Third World societies, an attribute acquired through the socio-economic and geo-historical experiences of colonialism. This attribute assumes diverse manifestations depending on local histories, politics, and other specificities. The schism has a profound influence on institutions in Third World societies. Economic institutions continue to be driven by impulses for harmonization from dominant capitalist economies, and social institutions continue to be driven by the impulses of nationalism and culture. The schism in the legal architecture of the Third World sustains the swings between what Clifford Geertz calls "epochalism" and "essentialism" that is so typical of Third World nationalism. 63 The schism produces traumatic internal upheavals. Can Iran remain a player in the world oil markets, emerge as a nuclear power, and at the same time adhere to pristine Islamic traditions under the same constitution? How does one fulfill the obligation to care for one's unemployed family members in an extended family when the labour market is based on the sale of individual labour power? widows must work because the labour market does not recognize family labour, can the moral authority of Hindu traditions alone stop her from remarrying? And how do tribes maintain tribal authorities and traditional structures of governance when the economy has slipped away from the tribal society? The individual as an atomized, irreducible legal category, standing in contractual relations with the state, created the conditions for citizenship in the First World in the wake of capitalism. In the Third World, by contrast, ethnic, religious, and linguistic communities were co-opted into markets and assigned places within market institutions. Amy Chua shows how, in the Third World, the nationalization and privatization programs prompted by the international economy impact specific communities in definite ways, depending on their positions in the economy."1 In the Third World, the impacts of international economic policies emanating from the centres of capital are experienced as ethnic and racial tensions differently by different communities. 65 For example, in the context of Malaysian colonial history, because of the respective locations of Tamils, Malays, and Chinese in the economy and market institutions as communities, a policy that adversely affects the rubber industry will affect Tamils, agricultural policies will affect Malays, and trade policies will affect the Chinese. Widespread, divisive ethnic conflicts in the Third World may have to do with a legal architecture where cultural aspirations are cut adrift from political economy and where citizenship itself remains collective rather than individual. We are witness to the political economy of globalization, which is followed by cultural conflicts. 66 Contrary to the expectations of global solidarity movements that campaigned for the rights of people in the wake of globalization, in Thailand, people embraced religion and karma in preference to rights against the state; and contrary to expectations, neoliberalism had the effect of expanding the scope of shar'ia in Aceh, a region with long traditions of legal pluralism going back to pre-colonial times. 67 This 'choice,' if it may be called that, ought not to surprise The unproblematic use of the language of rights by protest movements-as if it refers to the same type of citizen-state relationship as in the First World-has the effect of reifying and embedding unequal relations between societies, even when the intention is to the contrary. 9 Using the same vocabulary to analyze different social realities has the effect of reifying unequal relations between First and Third Worlds. The language of public/private in law obscures the social realities in the Third World. The use of a common vocabulary suggests comparable meanings and substance. 0 The field of comparative law helps to point out similarities and dissimilarities at the descriptive and definitional levels, but it does not do the same with respect to the geo-historical causal processes that produce radically different effects of law in different societies. Critical theories reverse the vantage point from similarities to dissimilarities but remain methodologically within dualist frameworks working with binary categories. 1 The structural schism also means that the tensions in Society, because of the structural disjuncture between economy and culture, remain unresolved. This irresolution is another attribute of Third World societies, in which law, imperial agendas and global solidarities, contribute in turn to reproducing the schism in these societies. The co-existence of multiple legal systems in the cultural sphere and in the informal economy is commonly analyzed through the framework of legal pluralism. Legal pluralism, as an analytical framework, draws on law in Third World societies to a large extent because of the apparent co-existence of different normative orders that characterize Third World societies more than others. Given the influence and popularity of legal pluralism as an analytical framework for law in Third World societies, it is this concept that we must turn to next in order to expand upon the economic-modern versus cultural-traditional architecture of law in Third World societies. --- IV. LEGAL PLURALISM, CENTRALISM, AND THIRD WORLD SOCIETIES Beginning with attempts to theorize the meaning of law in the writings of Eugen Ehrlich, Bronislaw Malinowski and others," more recent expositions see legal pluralism variously as co-presence of diverse legal systems in society; 73 as processual; 74 as postmodern, inspired by polycentricity; as autopoiesis;76 as praxiological; 77 and as anti-hegemonic.1 8 This brief snapshot does not attempt to capture the nuances and orientations of the diversity in the approaches to legal pluralism. 79 The purpose of the snapshot is to make the point that the idea of legal pluralism is an enduring one with an extended genealogy in socio-legal studies; that it uses analytical, empirical, and pragmatic methods; that it is popular in anthropological and sociological studies of law; and that the debates on legal pluralism have changed over time. While the analytical and conceptual engagement with legal pluralism do not limit legal pluralism to Third World or colonial societies, the empirical studies on legal pluralism are dominated by examples of multiple legal systems under colonialism and in contemporary Third World societies. The point here is not about legal pluralism as such, but rather about the epistemological implications of the use of legal pluralism for analysis of Third World societies. At the core of legal pluralism is the idea that law cannot be limited to state-centred law and that multiple systems of law operate in society. It is a reaction to the privileging of state law in modern societies. The idea of legal pluralism developed in juxtaposition to state law. Later strands in legal pluralist thought engage the meaning of law and the state-society context within which law, however understood, operates. The idea that state-centred law is the only legitimate law is an idea that emerged with capitalism. John Griffiths refers to this as the ideology of legal centralism. According to Griffiths: An important part of the ideological heritage of the bourgeois revolutions and liberal hegemony of the last few centuries is the complex of ideas concerning the nature of law and its place in social life. According to what I shall call the ideology of legal centralism, law is and should be the law of the state, uniform for all persons, exclusive of all other law, and administered by a single set of state institutions. To the extent that other, lesser normative orderings, such as the church, the family, the voluntary association and the economic organization exist, they ought to be and in fact are hierarchically subordinate to the law and the institution of the state. 80 From this, Griffiths goes on to develop the argument that legal pluralism is concomitant to social pluralism. In other words, as social action always takes place in multiple semi-autonomous fields, there are multiple fields of law reflective of the wider social fields. 81 It is worth dwelling on Griffiths' idea that the primacy given to state law is a heritage of bourgeois revolutions. From the geo-historical experiences of Western societies, is it possible to abstract the proposition that legal centralism is ideology everywhere and legal pluralism the reality, as Griffiths does? In the geo-historical context of capitalism, legal pluralism in the First World refers to those unrecognized, invisible, law-like relations, facilitative of the smooth functioning of society. Legal pluralists in the First World argue that these contributions of non-state law must be valued and recognized. Equally, since the bourgeois revolutions that established capitalism as the social order in the West, 80. Griffiths, "Legal Pluralism," supra note 73 at 2. 81. Ibid. more and more aspects of social life have been commodified. Stated differently, more and more aspects of social life are brought under legal centralism by making them contingent on incorporated entities created by the fiat of law. Even everyday social support activities like caring for the sick and elderly, protection from crime, and caring for children rely on provisioning services through legally sanctioned entities like cancer victims support groups, neighbourhood watch groups, or childcare centres, whether voluntary or paid. In contrast, in the Third World, it is legal pluralism that is ideological. Legal pluralism in the Third World holds out the possibility of the co-existence of imperialism and nationalism, a modern economy driven by the centres of capital like the G8 nations, where nationalism comes to be defined in terms of racial identities and cultural practices. It fetishizes the ways in which institutional developments in the Third World reproduce relations of super-and subordination in the economy on the one hand, and anchors the right to self-determination in essentialized identities on the other. It is important to bear in mind that both markets and states are complexes of laws. As creatures of the law, they provide the institutional infrastructure for capitalism. 82 In the Third World, modern institutions developed largely with regard to those aspects of society that were operationally brought under the capitalist economy through imperialism. 3 Therefore, large swathes of economy and society continue to remain outside modern institutions. For example, the so-called informal sectors of the economy in the Third World that dominate the literature on poverty and development exist outside state centralism. 84 When viewed through an empirical lens, the informal economy appears as diversity and validates legal pluralism. However, as an analytical framework for law in the Third World, legal pluralism sustains the wider political economy of capitalism and imperialism in reproducing two types of labour markets-formal and informalwhere the formal labour market is tied to global political economy and the informal to subsistence and survival. In the wider context of asymmetrical power relationships, legal pluralism plays an ideological role in imperial governance in a number of ways. First, legal pluralism rationalizes the politics of exclusion. The positive connotations and values attributed to legal pluralism means that the exclusion of some segments of society from modern institutions is rationalized. It obscures the reality that co-existence is not a voluntary or desirable state of affairs. For example, workers in the informal sector may improvise law-like norms and codes for survival. These norms and codes exist alongside those in the formal sector, where workers are protected by modern law. The co-existence of the two sectors is rationalized as plural orders. The creativity of the informal sector workers is celebrated. 85 This celebration obscures the ways in which imperialism constitutes two classes of workers-one protected by trade unions and rights of collective bargaining and another who are excluded from legal protection and left to their own creative strategies for survival. 86 The normative idea, however, remains one where trade unions and rights of collective bargaining are recognized by the state and extended to all, even when large sections of the workforce must necessarily be excluded from the normative ideal because of the structure of global labour markets. While legal pluralism invites us to recognize the normative and regulatory aspects of informal sectors of the economy and to celebrate the human spirit that challenges its exclusion, it fetishizes the exclusion of large sections of the workforce from the norms and regulations of the state and conceals the reality that not all workers in the Third World can be protected by law. This example 85. Legal pluralism produces curious outcomes. For example, the well-known Marxist geographer David Harvey analyzes the shift in the international divisions of labour from Fordist to post-Fordist modes of production and concludes that "the turn to more flexible labor processes could be seen as an opening to a new era of democratic and highly decentralized labor relations and co-operative endeavours." See David Harvey, The Condition ofPostmodernity: An Enquiry into the Origins of Cultural Change at 353. Hernando de Soto, a well-known neo-liberal advocate of privatisation and private property rights, also recognises de facto legal pluralism but argues for including such plurality as part of a regime of private property rights. He writes, "Outside the west, extralegal social contracts prevail for a good reason: They have managed much better than formal law to build on the actual consensus between people about how their assets ought to be governed. Any attempt to create a unified property system that does not take into account the collective contracts that underpin existing property arrangements will crash into the very roots of the rights most people rely on for holding onto their assets. may be extended to other aspects of life in the Third World, including shelter, food, education, and other basic necessities of life. 87 The celebration of agency in legal pluralism misjudges the cause of creativity, in this case the resilience of informal sector workers and their capacities to create alternative norms to survive. It is the ontological desire for freedom that drives the creativity of the unorganized sector workers. The inability to conceptualize this ontological drive, which is an essential attribute of being human, leads to epistemological confusion over how to understand their creativity and resilience. Legal pluralism's celebration of agency misdirects us from important political questions about the commodification of labour, the modes of its institutionalization in global labour markets, and the way in which human agency might apply its desire for emancipation towards intentional structural transformations beyond existence and survival in the present. Second, legal pluralism is ideological in that the exclusion of swathes of the economy and society from modern institutions makes state centralization the normative ideal. Third World states must endeavour to bring more and more aspects of the economy and society into their fold, in the same way this happened under Western capitalism. The lending policies of international organizations and Western governments and ideas of good governance promoted by both are premised on the normative ideal of state law and the state's role in introducing regulatory changes compatible with international economy. Third, legal pluralism as an ideology provides the Third World state with devices to govern and manage the social outcomes of appropriation and expropriation by capitalism and imperialism. It does this by switching between economy and culture as rationale for law-that is, by switching, in Geertz's words, from epochalism to essentialism so as to stave off systemic crisis. 88 Lastly, it fetishizes the fact that colonialism structurally transformed the Third World and that it is not possible to have capitalist-style social transformation there without the opportunities for colonialism, expansionism, and militarism. Those opportunities have been foreclosed for Third World societies historically. Legal pluralism was an essential condition for the creation of the colonial state. It was the legal device that brought pre-existing communities tied to land and social groups such as tribes or castes into a relationship with the colonial state and provided them a place within the colonial political economy. 9 These relationships continue to characterize the Third World and inform international relations, whether they are ethnic conflicts or economic relations. The introduction of personal law, for example, must be evaluated by taking into account the introduction of economic laws, the creation of the colonial state, and the discourses that rationalized the courses of action in economy and culture. Legal pluralists, drawing on sociological and anthropological research, have argued that the introduction of personal law in colonial societies was due to uncertainties of colonial rule and have tended to provide explanations based on the enhanced scope for agency of subordinate social groups. 9 However, without some conception of Society within which social relationships exist-for example, between men and women or between upper and lower class-the categories used in sociological and anthropological research remain dehistoricized and despatialized. Accordingly, they can either lead to classical modernist universalism or to critical postmodern particularism. Politically, cultural and empirical explanations for personal law produce vacillating orientations to imperialism and colonialism by seeing them as progressive in some respects and oppressive in others: On the one hand, ethno-centric nationalisms that arose after formal decolonization are fetishized; on the other hand, economic subordination by international organizations is represented as an historical inevitability. Concepts, including sociological and anthropological categories of analysis, are also products of social history and geography. Without a conception of Society in philosophy and social theory, critical scholarship is caught in the hermeneutic loop of either decrying imperialism or qualifying it by alluding to its 'liberating' aspects, and in both cases obfuscating the wider question of the relationship between economy and culture in social theory. The point here is not that legal centralism is superior to legal pluralism or vice versa, or that they can be used in hegemonic ways for imperial agendas and in counter-hegemonic ways by global solidarity movements. Nor is it limited to showing how hegemonic and counter-hegemonic uses share common conceptual grounds that reproduce unequal relations between societies forged under colonialism. Rather, the purpose is to open up pathways for transcending the economy/culture schism internally in Third World societies, on the one hand, and the unequal relations between First and Third World societies externally, on the other. The challenge is to find ways 89. Undoubtedly these changes opened up new possibilities for action for social groups that is captured in the literature on legal pluralism. See e.g. Engle Merry, "Uncertainties," supra note 2. Arguably, it is necessary to evaluate the new possibilities against emerging structural constraints that new forms of imperialism subsequently introduced in those societies. 90. See also ibid; Engle Merry, "Law and Colonialism," supra note 2. of conceptualizing structural autonomy in economic relations between societies and of anchoring politics and culture to the materiality of societies everywhere. In other words, the challenge is to create the conditions in which real diversity can flourish and innovative socio-legal frameworks of analysis can be devised that are capable of sustaining this diversity in everyday life. --- V. CONCLUSION There are two impulses that drive the development of law in the Third World. One consists of the economic interests of capitalism; the other of the institutional and social infrastructures necessary for economic actors to operate. In the First World, both of these impulses are internal to the historically constituted societies within which capitalism arose. The dynamics of the social transformation were analyzed in Karl Marx's writings and later in Marxist literature, and inform a rich and diverse critique of capitalist transformation in the First World. 91 What Jiirgen Habermas refers to as "system" and "lifeworld" both exist in unity as society or, rather, Western societies. 2 The distinction made by Habermas is an analytical one. In the Third World, there is a spatial and historical rupture between the economic impulse generated by the production relations in the centres of capitalism and the alien lifeworld in the Third World where the economy must operate without a shared intersubjective order. In other words, there is a spatio-temporal rupture between system and lifeworlds as a result of imperialism: capitalism's expansionist external dimension. This disjuncture characterizes Society in the Third World. Law reifies the disjuncture. This is not the same thing as centre and periphery in World Systems approaches or what David Harvey analyzes as different logics of capital and territory, 93 but rather it is about differentiating between the internal dimensions of capitalism constituted by subordination of classes within society, and the external dimensions of capitalism constituted by colonialism, expansionism and their subordination of societies qua societies. Class, production, colonial relations, and expansionist governance are organized through directionally opposite processes in capitalist-internal and imperialist-external dimensions of capitalist development. 'The result is two different modes of constitution of societies that produce distinct properties, attributes, features, and internal and external dynamics that we recognize as First and Third Worlds. 94 Legal concepts and categories are integral to this process. They hold out the key to explanations for the continued reproduction of unequal relations between societies qua societies, a problem at the heart of global justice in the contemporary world. The national liberation struggles of the twentieth century overestimated political sovereignty and formal legal statehood. The post-independence experience has brought about a deep awareness that structural autonomy cannot be achieved solely through political sovereignty and formal legal statehood. The post-independence period has highlighted the significance of history and geography, capitalism and imperialism, and nature and culture for the problems of the contemporary world. Legal studies, including critical legal studies, tend to take the conceptual vocabulary of law at face value. The result is a philosophical impasse imposed by the epistemologies of Modernism and Enlightenment. It is to this impasse that TWSLS must pay serious attention if it is to remain critically engaged in a transformative social process for freedom and emancipation. As Zygmunt Bauman argues, postmodernism in philosophy is closely tied to the transformations in the stage of capitalism in the post-World War II era. 95 The emphasis on culture and context in recent theoretical developments provides valuable tools to deconstruct the philosophical resources that provide capitalism and imperialism with the resilience they have shown. Postcolonialism, as Aijaz Ahmad and others argue, takes its philosophical cues from postmodernism.96 TWSLS challenges us to move beyond deconstruction at the empirical and phenomenological levels and to innovate conceptual and philosophical resources that help us transcend the constraints of philosophical liberalism in ways that take freedom and emancipation in philosophy and theory seriously. In legal and social theory, it challenges us to find ways of speaking about global justice and law in the Third World in ways that anchor the Third World to realities at all 94. For the distinctions between colonialism, neo-colonialism, and postcolonialism, see Radha D'Souza, " levels: ontological, structural, and empirical. Philosophical questions cannot be resolved by sociological analysis alone; they must be resolved philosophically. For social theory to attempt to find answers to inequities of colonialism and imperialism within the same level of philosophical consciousness that brought about Modernism, Enlightenment, and capitalism is to abandon the struggle for justice altogether. Equally, if dualism and binary categories dominate Western philosophy, as critical theory is at pains to point out, there is nothing stopping us from looking to other philosophical traditions for answers to the problems of our times. These reflections on methodology in TWSLS raise questions that quickly transcend Third World issues and call into question assumptions in social theory more generally. The questions raised here are big ones by any reckoning, big enough to warrant a research program to put TWSLS on more solid theoretical foundations. This article has hinted at what such a research program might look like. It is not possible within the space of a single article to develop an alternative methodology. To attempt to provide quick-fix solutions would risk reducing embedded questions with deep roots in social theory to banalities. Besides, the nature of the questions posed in this article call for sustained engagement with the wider scholarly community. Nevertheless, it may be possible to identify a set of methodological sensitivities that TWSLS scholars could be aware of when approaching specific themes or issues about law in Third World societies. First, it is important to recognize that there is something called Society. Both law and society need to be problematized in TWSLS. Understandings of society must be differentiated at ontological, structural, and empirical levels and accounted for in analyses of concrete problems. The recognition that at the ontological level human life is contingent on Society calls for interrogation of the assumptions of sociological theories about structures, agents, and social transformations. At the empirical level, it calls for investigation of the specific geo-historical conjunctures of the relations between natures, social structures, and peoples that give to particular societies their specific attributes and properties. The questions for TWSLS must therefore encompass properties and attributes of the societies in question as well as the natural and social relations that give to that society its specific attributes and properties. In attempting to do so, disciplinary boundaries, traditions, and vocabularies present problems or render their existence opaque. Greater reflection is called for on the ways in which disciplinary boundaries present a problem in TWSLS. Second, if concepts develop within and in response to geo-historical processes, how may we recognize this and yet communicate with each other? Had I written this article using the language of Jaina or Buddhist philosophy, for example, I could have made the same arguments, though they would have been comprehensible to very few, even in the Third World. The Orientalist critique in the 19 6 0s and 1970s deconstructed the reasons for and ramifications of Orientalism." It is necessary to move beyond that now. At the empirical level, whatever the historical reasons for it, we have inherited a vocabulary that is in circulation and that is not of our choosing. Nevertheless, the awareness that deconstruction has provided must lead to greater reflection on what is entailed in the use of the vocabulary. Communication is necessarily a social and collective act. Transformations of vocabularies occur only through transformative engagement. In retrospect, did the Enlightenment not change the meanings of society, rights, and so many other terms through sustained engagements with the concepts? If it did, then can a more reflexive TWSLS not transform meanings and vocabulary in more emancipatory ways? For example, in this article I have used terms, phrases, and concepts drawn from Marxist and critical theories to articulate wider concerns about approaches in TWSLS, and in doing I have sought to provide a different inflection on those terms and meanings. Third, what does it mean to be 'non-dualist' when the world is full of diversity? The challenge here is not to stop at description or indeed presentation of the thesis and the antithesis in any problem, but also, simultaneously, to interrogate the common grounds they share. Such an approach calls for reframing the questions in ways that allow the interrogation of a problem to go beyond dualist framings. The types of answers we get depend, often, on how we frame the question. In the Jaina tradition, for example, a problem is first presented from a range of perceptions that exist about it in the empirical world. The inquiry does not ask which of these is true or false, or which one is better , but rather it moves on to the next level of reality by asking the non-dualist question, "What must be the nature of reality in this instance if there are all these different perceptions, all of which are true and co-exist?" What is human freedom in the contemporary world, for example, where global solidarity movements critique the use of human rights for imperialist agendas , imperialist institutions use human rights for domination , and where both are real and co-exist? Fourth, postmodern deconstruction has generated recognition of diverse philosophical traditions. For example, it is difficult to envisage any serious scholarly argument today that claims that the Greco-Roman-Christian intellectual tradition 97. Edward Said's works were perhaps the most influential in deconstructing Orientaism. See Edward Said, Orientalism ; Also see Edward Said, Culture and Imperialism . is intrinsically superior to all others. This recognition has opened up a rich and varied conceptual repertoire that is widely available to scholars. The challenge is to actually dip into it so as to develop conceptual resources needed for social transformations. It is possible, for example, to argue that while Marxism provides valuable tools for a critique of capitalism, something more is needed to realize the aspirations of a just and egalitarian world-socialism, if that is what we want to call such a world-and further, that we may need to look elsewhere, outside the Western tradition, for conceptual resources to build such a society. Here, Marxism and indigenous traditions both have their value and contributions to make. The purpose of this article has been a limited one: to open up a sub-field in socio-legal studies by identifying methodological problems in the approaches to TWSLS. The reflections are informed by my practical experiences as an activist lawyer in a Third World context and a legal academic in a First World context. 98 Whether this call for a new research agenda for TWSLS will be another call in the wilderness or whether it will generate responses from critical scholars, time alone can tell. --- divide just as the debate revived after the end of World War II in the context of rebuilding economies and society and the "welfare states" in capitalist societies. 54 Nevertheless, the two spheres of law continue to define the role of the state in society and to provide a point of reference for the architecture of law. What is important for our purposes is that in the history of the First World, normatively and conceptually, economy and culture simultaneously formed part of the private spheres of law and defined the boundaries of the state. Land, trade, and property rights-alongside marriage, inheritance, adoption, and such-were part of the private spheres where the state's role needed to be policed against incursions. When statutes trespassed into the private spheres, they required special justifications. Classical liberal theory devoted considerable energy to keeping the state at arm's length from the economy and from culture. Equally important is that in policing the boundaries, the public/private divide continued to rely on the extended history of the concept in Roman law.s 5 Indeed the public/private concepts and divisions developed through contested histories in Europe and contributed to the development of capitalism and imperialism during all its phases. 56 It is not surprising that the public/private divide became the focus of debate in the globalization phase of capitalism and imperialism." In contrast, colonial law extended the conceptual categories of public/private spheres to colonial societies, but infused them with different socio-economic content. Colonial rule gathered a diverse range of castes, communities, tribes, and nationalities under the umbrella of the colonial state. Economic matters such as contracts, easements, trade, forests, fisheries, minerals, and land-traditionally within the private sphere in Europe under Roman law traditions-were brought under state regulation through public law statutes. Even contracts, the sacred cow

This article interrogates the methodological lenses through which law in the Third World is commonly analyzed in socio-legal studies. Third World socio-legal studies, this article argues, is a field in search of philosophical foundations. It continues to rely on conceptual categories and analytical frameworks developed through the intellectual, cultural, and social histories of Western capitalist societies, which it extends uncritically to different intersubjective orders in Third World contexts. The article examines the common grounds shared by two apparently competing discourses about law in the Third World, which I label imperial agendas and global solidarities. It is difficult to speak about the Third World without becoming mired in conceptual contradictions. One reason for the methodological problems in Third World socio-legal studies is that social philosophy, and liberal philosophy in particular, undermines the concept of society. This article begins by examining the meaning of society in social philosophy. It then interrogates three dichotomous sets of analytical frameworks that are often invoked in Third World sociolegal studies: (a] comparative law versus Third World Approaches to International Law (TWAILI; (b) economic or modern law versus cultural or traditional law; and (c) state centralism versus legal pluralism. The article argues for a differentiated understanding of society at the ontological, structural, and empirical levels, which should help transcend binary approaches and facilitate theoretical reflections about the Third World without subsuming its specificities. The article concludes by arguing for a sustained research program to put Third World Socio-legal Studies on firm methodological foundations.

409 imperial agendas global solidarities and third world sociolegal studies methodological reflections radha dsouza this article interrogates the methodological lenses through which law in the third world is commonly analyzed in sociolegal studies third world sociolegal studies this article argues is a field in search of philosophical foundations it continues to rely on conceptual categories and analytical frameworks developed through the intellectual cultural and social histories of western capitalist societies which it extends uncriticaly to different intersubjective orders in third world contexts the article examines the common grounds shared by two apparently competing discourses about law in the third world which i label imperial agendas and global solidarities it is difficult to speak about the third world without becoming mired in conceptual contradictions one reason for the methodological problems in third world sociolegal studies is that social philosophy and liberal philosophy in particular undermines the concept of society this article begins by examining the meaning of society in social philosophy it then interrogates three dichotomous sets of analytical frameworks that are often invoked in third world sociolegal studies economic or modern law versus cultural or traditional law and state centralism versus legal pluralism the article argues for a differentiated understanding of society at the ontological structural and empirical levels which should help transcend binary approaches and facilitate theoretical reflections about the third world without subsuming its specificities the article concludes by arguing for a sustained research program to put third world sociolegal studies on firm methodological foundations cet article tente de comprendre a lorgnette m thodologique a travers laquelle les 6tudes sociojuridiques analysent habituellement le droit du tiersmonde selon article les 6tudes sociojuridiques du tiersmonde constituent un domaine en qu6te de fondements philosophiques e les continuent de sappuyer sur des cat6gories conceptuelles et des structures analytiques d6coulant du patrimoine intellectuel culturel et social des soci6t s capitalistes occidentales quelles appliquent sans discernement a divers rapports intersubjectifs dans des contextes tiersmondistes larticle examine les assises partag6es par deux discours apparemment contradictoires traitant du droit tiersmondiste que je qualifierais de vis6es imp6rialistes dune part et de solidarit6 mondiale dautre part it est difficile de sentretenirdu tiersmonde sans senliser dans une mer de contradictions conceptuelles lune des raisons qui soustendent les probl6mes m6thodologiques des 6tudes sociojuridiques du tiersmonde est le fait que a philosophie socialeet plus particulirement la philosophie lib6rale6branle le conceptm6me de soci6t6 larticle commence paranalyser a signification du concept de soci6t6 en philosophie sociale ii examine ensuite trois ensembles dichotomiques de structures analytiques quinvoquent souvent les 6tudes sociojuridiques du tiersmonde a le droit compar6 par rapport aux th6ories tiersmondistes du droit international le droit moderne fond6 sur 6conomie par rapport au droit traditionnel fond6 sur a culture et cj le centralisme d6tat par rapport au pluralisme juridique larticle milite en faveur dune interpr6tation diff6renci6e de a soci6t6 sur les plans ontologique structurel et empirique qui devrait permettre de transcender les approches dichotomiques et faciliter les r6flexion th6oriques sur le tiersmonde sans faire abstraction de ses particularit6s it propose pourterminer a cr6ation dun programme continu de recherche destin6 6 doter de solides fondments m6thodologiques les 6tudes sociojuridiques du tiersmonde 1 this is so notwithstanding the large body of scholarshipcomprising both dominant and critical pieceson different aspects of the operation of law in third world societies necessarily generalizing scholarship on law and colonialism and on law and development in various academic disciplines highlights the temporal and spatial dimensions of law in third world societies 2 more recently the emphasis on governance in international 1 i use the term in the broadest possible sense as a field of study that examines law in third world societies and includes sociological historical and anthropological approaches as well as policy studies and impact analysis for distinctions between sociolegal studies and sociology of law and the use of these for an overview of sociological approaches to organizations such as the world bank has produced a critique of international law and international relations from the perspective of global justice 3 this impressive body of scholarship has not however produced new innovations in conceptual categories in social philosophy it remains by and large a descriptive and discursive account of law in third world societies analytical frameworks and conceptual categories provide the prisms through which law in societies is understood categories that emphasize structuring mechanisms like class capital state and political economy or subject formation like identity gender race and culture remain by and large products of grecoromanchristian intellectual traditions that have evolved through the experiences of euroamerican capitalist societies twsls demands much more than sociological attention to contexts it challenges us to think about the intersubjectivity of the social contexts ie the cognitive mappings embedded in language and culture that are constitutive of different civilisations or what jdirgen habermas refers to as lifeworlds 4 to put it differently the development of theory and philosophy continues to borrow modify extend advance develop and adapt various concepts and methods from different philosophical strands in the grecoromanchristian intellectual traditions and the third world societies provide the historical facts or the social data that differentiate the context for the operation of law if as critical legal scholars rightly argue 5 the conceptual categories and analytical methods of law and how can we call them into question without on the one hand subsuming the differences between first and third world societies as metatheories with their universal categories and methods tend to do or on the other hand undermining the possibility of theory as postmodern postcolonial emphasis of difference and pluralism tends to do one reason why critical understandings of law in third world societies have not pushed the boundaries of concept formation and theory development is the opacity of the meaning of society in contemporary social philosophy consequently the epistemological premise oftwsls rests on a fault line between philosophical understandings of society on one hand and the law that has operated in third world societies since the advent of colonialism on the other this rupture is not adequately captured in twsls nor are the methodological ramifications of the disjuncture between intersubjective orders and geohistorical realities adequately theorized in twsls if concepts are socially produced in response to geohistorical developments then it must be acknowledged in principle at least that transposing conceptual categories developed in one geohistorical context to anothera method entailed in the universal application of theoryposes methodological questions for twsls conversely emphasizing the effects of modern law on third world societies without adequately understanding the intersubjective geohistorical and sociological sources of those effects obfuscates the theory and concepts implicit in those accounts the epistemological gaps in twsls that follow from the fault line mirror a wider problem in social theory social philosophy since the enlightenment and modernity has conflated the ontological epistemological sociological and empirical meanings of society as elaborated in part i below equally the singular influence of grecoromanchristian intellectual traditions has meant that social philosophy is dominated by dualist methods and binary categories that lock theory and practice in adversarial positions i w h a t is s o c ie the epistemological gaps have created paradoxes for twsls exfacie dominant twsls advances imperial agendas and critical twsls advances global solidarities bernard s cohn colonialism and its forms of knowledge 7he british in india 6 for an historical understanding of modernity see in philosophical terms dominant twsls and critical twsls appear as mirror images of each other in that they share common theoretical grounds but proceed from different vantage points the development of twsls remains thwarted by binary concepts and frameworks popular binaries in twsls include modern versus traditional or customary law economics versus culture and legal centralism versus pluralism the binary lenses through which law in third world societies is studied are effective insofar as they help to deconstruct the operation of law beyond that twsls is trapped in conceptual and political conundrums the resulting deadlock is particularly problematic for global solidarity movements that are motivated by the desire to overcome the impasse of eurocentrism in theory and promote law as a transformative tool for global justice in the widest possible sense in the parts that follow these issues are examined at greater length part i locates the epistemological gaps in twsls in the opacity of the meaning of society in social theory generally the opacity of the concept of society makes articulation of the differences between first and third world societies possible only in dualist often adversarial ways and in binary terms using the meaning of society in social philosophy as the point of departure highlights theoretical and methodological problems in twsls that follow from that opacity parts ii iii and iv unpack three binary sets of analytical frameworks popular in twsls each set made up of a dominant and a critical approach comparative law versus third world approaches to international law economic or modern law versus cultural or traditional law and legal centralism versus legal pluralism part ii examines comparative law which is the dominant framework for twsls by interrogating the idea of asian law and juxtaposing the comparative law approach with twail a movement committed to promoting third world perspectives in international law part iii widens the scope of the comparative lawtwail approaches to examine the divide between economics and culture in twslsa dichotomy closely related to the first but with longer and more enduring roots in colonial history i use the publicprivate divide in law to interrogate the ways in which the use of legal concepts sustain specific types of relations between economies and cultures that have come to characterise third world societies i argue that there are asymmetries in the language of law and its meanings in particular social contexts in the substance and form of law in the abstract legal concepts and in the historical contexts in which they were introduced and evolved in third world societies part iv interrogates the underpinnings of the economiccultural divide in twsls by examining legal centralism and legal pluralism two popular frameworks of analysis in dominant and critical twsls respectively and by evaluating them against the specific attributes of societies constituted through processes of imperialism or colonialism in the concluding part i return to the importance of problematizing society as a core concept in social theory in order to transcend binary frameworks the methodological questions discussed in this article are deeply embedded in twsls scholarship the aim of this article is to open up entrenched approaches for wider engagement and to advocate for a research program that will place twsls on firmer philosophical and theoretical foundations i what is society there is considerable semantic confusion in the social sciences and humanities on the appropriate vocabulary to characterize societies with histories of imperial rule binary terms like first world and third world north and south developed and underdeveloped colonial and neocolonial and west and east are often used to describe societies but are widely contested from different theoretical ideological and disciplinary perspectives while most people understand what is being referred to when such terms are used the conceptual underpinnings of the terms are often imprecise and inaequate to identify appropriate criteria for classifying these types of societies is it possible that the semantic confusion is due to the opaque meaning of society in social theory 7 the continued use of the term third world has been called into question see eg arif dirlik spectres of the third world global modernity and the end of the three worlds 25 third world q 131 the term is also defended inter alia on the grounds that it is still a useful term see eg obiora chinedu okafor newness imperialism and international legal reform in our time a twail perspective 43 osgoode hall lj 171 mark berger asserts that there are historical associations with the term that are important see eg mark t berger after the third world history destiny and the fate of third worldism 25 third world q 9 in addition to these reasons i use the term third world for a third more important reason the historical factors that led to the creation of the three worldscapitalist socialist and colonial and that formed the structural feature of the postworld war ii world order continue to inform the historical structural political economic and cultural realities of those societies these features remain even after third worldism as a solidarity movement of newly independent countries has stalled and the formal architecture of the world order appears to be subsumed by globalization throughout this article the term first world is used to denote european societies that were internally reconstituted through the processes of capitalism and informed by corresponding intellectual developments spearheaded by the european enlightenment tom bottomores a dictionary ofjmarxist though defines three uses of the word society as socialized human beings as typologies of social formations and as specific societies what is important is not to reduce the concept of society to one of these three definitions but rather to treat all three uses as true and ask ourselves what must be the nature of society if all three definitions are true methodologically such an approach borrows from the nondualist jaina traditions of anekantavada or the philosophy of nononesidedness anekantavada methods urge us not to frame questions in the either this is true or it is false format but rather to ask if a believes this to be true and b believes it to be false what must be the nature of reality that invites both beliefs the methodological approach in anekantavada presupposes an ontological conception of the nature of reality that informs epistemological inquiries in this article reality denotes the ontological meaning of the term in the philosophical and cosmological sense that there is a reality beyond individual spatiotemporal lives while reality denotes the ordinary use of the term to refer to objective existence beyond subjective perceptions as when we speak of social political or economic realities in the jaina conception reality is infinite and irreducible 0 in the buddhist conceptions reality is interdependent contingent and nonessential 11 the role of epistemology is to uncover layers of reality and real relations metaphorically like peeling an onion liberal theory to the contrary is based on what roy bhaskar calls a monovalent 12 ontology where the world is reducible unchanging and undifferentiated bottomores three uses of society may be seen as three levels of meaning each of which is represented in this article by a different typographical convention at the ontological level where human beings are socialized beings and human life is contingent on society at the structural level where society refers to typologies of geohistorical social formations constituted by a variety of mechanisms and at the empirical level where society refers to specific conjunctures of diverse social economic historical political and cultural factors and the roles of individuals and groups that characterize specific societies at a given point in time in this article therefore society denotes the ontological level of meaning society the structural and society or societies the third empirical level taking philosophy of science as his point of departure roy bhaskar argues that nature society and human life are ontologically distinct in that they possess different ontological attributes and properties but that they are nevertheless related 13 society is unilaterally contingent on nature but the converse is not true in that nature can exist without society society as social structures bhaskar argues is always geohistorically produced and involves language concepts laws institutions technology norms and ideologies the ontological property of human life is its psychological and aesthetic dimension a property of being human it gives human beings agency and the capacity to change societies at the empirical level in the short term human life is contingent on society in that everyone is born into some type of social structure without which life is not possible yet human agency can transform society at the structural level in the long term society thus has dual ontological properties it is the condition of human life in bhaskars terms and at the same time can be transformed by it human life is conceptdependent and impelled by the desire to be free from the constraints imposed by social structures human beings must therefore always rethink philosophy and theory for transformative action bhaskars pluralist ontology makes it possible to develop a nondualist epistemology that can provide a coherent account of natural social and aesthetic life it allows for the possibility of theory without subsuming difference at the ontological level it is possible to argue that society is the structured relationship of nature and human life it is the ontological median between the two as it were the ontological attributes of society make it possible to postulate different types of societies that are specific geohistorical conjunctures of natures and peoplesin other words social structures formed through geohistorical processes the social structures including law institutions norms and cultures for example constrain and enable those living within those structures in different ways at the human level of individuals and groups transformative action and solidarities become possible if and only if knowledge is driven by empirical realities takes into account structural causes and is foregrounded in ontological awareness ie in awareness of ones philosophical world view about the nature of reality grounded in conceptions of cosmology and ontology liberal philosophy which continues to be the dominant philosophy in law and social theory is dismissive of the concept of society society following william outhwaite 15 is not an empirical concept it is a theoretical concept without conceptualizing society theoretically liberal philosophy leaves us with empirical expositions that make theoretical assumptions about the meaning of society raymond williams traces the history of the word from meaning companionship in the fourteenth century to greater levels of abstractions to mean associations and groups by the seventeenth century 16 the conflicts of the seventeenth century introduced a distinction between society and state the former an association of free men drawing on all the early active senses the latter an organization of power drawing on all the senses of hierarchy and majesty 17 thus there was a divergence between companionship and associations or organizations by the eighteenth century the transition was decisive society was that to which we all belonga system of social lifeand the state was the apparatus of power by the nineteenth century society became an object related to man and the individual but was not the same thing this paved the way for social systems and the study of the social the meaning of society changed with the transformations in capitalism in a european context the enlightenment as a broad intellectual movement was instrumental in reconceptualizing the meaning of society in the wake of capitalism and modernity 18 the enlightenment as an intellectual movement grew in response to european feudalism and responded to the problems of european societies by drawing its conceptual and intellectual resources from the grecoromanchristian traditions within which it remains rooted 9 my point is not to contrast this response with the enlightenments response to colonialism doing so would lead to the familiar west versus rest dichotomy and to charges of eurocentrism with emotive and ethical overtones that lead to an intellectual culdesac rather the purpose of recalling the social and intellectual context for the enlightenment is to examine the ramifications of projecting assumptions about the meaning of society that has evolved within one historical context to societies within which the meaning of society remains to be defined and understood historically a key proposition advanced here is that first and third world societies are constituted through related but distinct processes the first internal to the social context of capitalisms development the second its external expansionist processes of imperialism and colonialism these two processes one centripetal and the other centrifugal constitute two different types of societies with distinct features and properties that we recognize as first and third worlds the basis for this differentiation remains undertheorized however consequently the third world defined in antithetical terms to the first world as its other continues to haunt social theory the ramifications of extending legal concepts and analytical categories developed through capitalisms centripetal or internal processes to societies constituted through its external or expansionist processes understood as colonialism and imperialism must inform twsls if we wish to address the fault line on which it is founded realism and social science in according to karl polanyi for the first time in human history capitalism disembeds from society certain aspects of life associated with material provisions that it characterizes as economic aspects 2 it is not necessary to explore this argument for the purposes of this article except to reiterate polanyis point that the social transformation brought about by trade and commodification of land and labour was made possible by a philosophy that reduced collective social lifeor companionship of the fourteenth centuryto relations between individuals on the one hand and a relationship with nature through property relations on the other 21 equally what is disembedded from society is reembedded in institutions of states and markets created through the fiat of law 22 the scope and processes of embedding disembedding and reembedding economic aspects of social life in capitalist and colonial societies produced two distinct types of societies with distinct attributes and properties these processes have dramatically contrasting implications for the functionality or dysfunctionality of law and institutions in the two types of societies however the obfuscation of the concept of society in theory was a necessary condition for social transformations to occur in both types of societies methodologically the obfuscation of society as a theoretical category was achieved 20 the great transformation the political and economic origins of our time for the difference between legal relationships with individuals and with nature under dsouza imperial agendas 419 in philosophical liberalism through three moves a privileging of epistemology over ontology philosophical dualism including the nature versus society and society versus ethics and aesthetics divisions in social theory and engagement with the problem of universals as the binary other of the particular in philosophy it is to these moves that we need to turn our attention in social theory if we are to transcend the problem of binary categories and dualist methods entailed in the west versus rest polarity that confounds twsls the institution of the state complicates the concept of society as outhwaite points out at first society was seen as the third estate and a threat to the state later it came to be squeezed within a territorial or institutional state 23 according to outhwaite when we speak of society we enter into a language game that licenses certain types of theoretical moves and not others and that introduces an element of abstraction 4 following outhwaite we cannot do without a concept of society because the alternative is to have an ontology of the individual 25 as human actions presuppose social networks and social preconditions some conception of the collective life becomes necessary liberalism straddles this question by squeezing society into the state on the one hand and reducing it to atomized individuals standing in contractual relations with the state on the other hand this is the civil society of classical liberal theory 26 the concept of civil society is not to be conflated with society however civil society under capitalism refers to those institutions in the private sphere that underpin the economy society is much more the increase in the number of sociological and historical accounts of law in third world societies does not do away with the need to answer the question what is society without answering this question it is impossible to speak of the first and third world without becoming mired in contradictions in the absence of a theoretical understanding of society social theory is left with descriptions of societies descriptions alone do not provide the cues to make the causal connections between diverse events or facts nor to identify trajectories of change sociological accounts describe social structures and the constraints that the structures impose on human life but tend to be deterministic because the descriptions of structural constraints are less able to integrate ethical and aesthetic dimensions of social life descriptions of ethics and aesthetics emphasise agency and subjectivity but tend to be voluntaristic as they are less able to integrate structural constraints for social changes for example empirical accounts show real differences between the realities in first and third world societies these differences are echoed in everyday language for example newspapers and western politicians routinely use expressions like third world conditions to describe deteriorating public services in the first world sociological accounts of first and third world realities show the geohistorical mechanisms that structure the two worlds in very different ways even when they remain mutually constitutive and interdependent discourses in ethics and aesthetics reveal the desire for justice freedom and humanity and emphasize the solidarity and unity of both worlds when the concept of society is foregrounded in the understanding that nature society and human life are ontologically distinct but nevertheless related it becomes possible to produce an epistemology that simultaneously accounts for differences between societies and sustains human impulses for solidarity and freedom it becomes possible to argue that first and third worlds are specific conjunctures of naturesocietyhuman life constituted through the geohistorical processes of capitalism and imperialism in different ways capitalism and imperialism reconstitute first and third worlds in definite ways and imbue the two societies with different characteristics and properties that are experienced as difference in everyday life the freedoms and constraints of the two types of societies are experienced differently by people living in those societies the source of solidarity therefore does not flow from eliminating difference discursively in ethics or analytically in social theory rather it flows from the understanding that the desire for freedom is an ontological attribute of being human that must be respected universally the ways in which human freedoms are curtailed are different for different types of societies the differences are often cast in adversarial structural relations with other societies this way of understanding unity and difference distinguishes between the desire for freedom in all people and the different modes of articulation of that desire in politics which is prompted by the specificities of social formations in a given geohistorical moment bringing ontology to the centre stage of theory helps us to anchor the idea of third world society in theory by whatever name it is called without subsuming the differences between the societies nor undermining the possibility of theory it becomes possible to argue for solidarity without fetishizing the adversarial structural relations that the coupling of capitalism and imperialism creates between first and third world societies or minimizing the imperatives of structural constraints an understanding of society at the ontological level invites us to epistemological inquiries that are ontologically aware structurally astute and empirically sensitive differences at the structural level do not negate human solidarities differences while recognizing antagonistic interests of groups and societies can take into account the different types of freedoms that each group or society seeks they open up the possibilities of directionally different but ontologically consistent political programs for action if a and b are standing in opposition but wish to reach midpointor another destination for that matterthey must travel in different opposed directions to achieve the same objective this possibility is foreclosed by liberal philosophy where sameness is contrasted with difference the reduced emphasis on ontology in liberal philosophy precludes unity at the higher ontological level one category that produces endless conundrums in social theory is the universals in the grecoromanchristian intellectual traditions the universal as a category in philosophy stands in opposition to the particular this way of framing the universal as the opposite of the particular in philosophy has produced binary concepts and dualistic methods wherein social theory must either abstract substance from form as modernist theories do or privilege the particular over the abstractions as postmodernism does this is not the only way of understanding universals however in other philosophical traditions universals do not stand in opposition to particulars as in the grecoromanchristian traditions raja ram dravid for example argues that in the indian traditions universals are seen as distinct types of properties not necessarily opposed to particulars 28 a move in social theory to reconceptualize categories like universals and particulars drawing from philosophical traditions different from the grecoromanjudeochristian traditions has the potential to provide a way out of the current impasse in theory produced by methodological dualism and binary concepts it opens up possibilities of grounding concepts and theories in the materiality of the contemporary world and at the same time opens up pathways to reconceptualize freedom and emancipation for all following these observations on the need to problematize society in twsls the question emerges what are the attributes and properties of societies constituted through the processes of colonialism and imperialism and what is the role of law in the production of those attributes and properties that we recognize as the third world the next three parts follow this thread by examining three sets of binary frameworks used in twsls first comparative law versus twail second economic versus cultural spheres in law and third legal centralism versus pluralism ii what is asian about law in asia it may be useful to begin the discussion of comparative law versus twail at the empirical level by considering widely accepted everyday practices in the academic community on legal issues in the third world context in 2003 thirteen law schools in asia formed the asian law institute under the aegis of the national university of singapore asli held its inaugural conference in may 2004 in singapore on the theme of law in asia of the twentytwo panels on different subthemes of law in asia only one panel entitled on asianness traditions identity and impact on asia and asians was explicitly about asianness 29 there are several other asian law journals like the panels at the ash conferences a sweeping overview of the subjects addressed in the asian law journals reflect a similar pattern where modern law addresses problems in economics and related fields like labour environment and human rights traditional lawoften religious lawaddresses cultural issues concerning family and inheritance and land tenure falls somewhere in between this architecture of law in asiawhere the jurisdiction of modern law prevails over economic spheres and the jurisdiction of traditional law prevails over cultural spheres outside the economyis common to most third world countries it also mirrors the wider society it services where generally speaking the cultural sphere is governed by traditional law and the economic sphere is governed by modern law comparative law provides the analytical framework for dominant approaches to law in asia as evidenced at the conference or for that matter dominant twsls comparative law is methodologically weak as burkhard schafer points out comparative law starts with an assumption of comparability and some form of functionalism in that it assumes some correlation between legal forms and social functions and draws on legal history to establish the correlation 31 comparative law and legal historiography in dominant scholarship thus share common presuppositionsboth are premised on the rationality of legal responses to societal demands 32 for legal systems to be compatible writes schafer it is sufficient they have a shared core that is we either have to identify a historical core programme or extrapolate one logically 33 schafer draws from comparative legal scholarship on common law and continental civil law to explain how the core of roman law provides the basis for explanations of the divergent development of legal systems that share historical roots 34 these attempts to strengthen the epistemological foundations of comparative law work where shared historical cultural and philosophical traditions provide a repertoire of conceptual resources for the development and communication of ideas between the societies within which the legal systems operate this is seen in common law and continental civil law systems underpinned by a core that is derived from roman law the absence of an intersubjective order makes a shared core for comparative law for legal systems in third world and first world societies methodologically problematic is comparative law possible where the legal histories do not provide a shared core 5 more importantly in the case of asia and other third world societies where comparative law dominates the economic sphere the pressing question is this is it possible at all to cast economic and social spheres into legal systems with radically different normative ethical institutional and conceptual grundnorms 36 we shall return to this architecture of law again in the next section suffice it to note here that such a problem does not exist in the euroamerican capitalist societies 7 while euroamerican law in every sphere has transformed and evolved over time it remains grounded in and inspired by various strands of grecoromanchristian intellectual cultural and legal traditions dissent change and evolution all refer back to and continue to draw on the conceptual and philosophical resources from those traditions indeed modern law is a product of those traditions in third world societies the gap between culture and economy 33 ibid manifests in law as two distinct domains of law this gap in lawbetween the historical past where the roots of culture lie and the geographical present where global economic relations play out between states on the one hand and its manifestation as a rupture in the intellectual moorings of its economy and culture on the other handis undertheorized in twsls what john comarofp 9 asks about studies on colonialism and law may be asked about twsls more generally summarizing the trajectory that seems to have brought studies of law and colonialism to a resting point comaroff argues that there is a convergence and consensus on colonial law as being both an instrument of domination and a site of resistance he asks is there anything more to say on the topic other than to offer further historical andor ethnographic illustration 40 although comaroff answers the question in the affirmative what is proposed by way of a future agenda for law and colonialism studies is to develop a more nuanced understanding of complexities of the role of law in colonization by undertaking empirically grounded and methodologically improved accounts of law in colonialism such approaches could certainly produce better sociolegal studies of the third world whether it will shift the grounds of philosophy of law or social theory is a pressing question in any event philosophical questions about law in society cannot be deduced from sociological accounts of law nor is it possible to arrive at a theory of society from sociological accounts sociological accounts presuppose concepts and analytical frameworks grounded in social philosophy in contrast to comparative law approaches in dominant asian and other regional legal studies twail claims to be a movement within international law that seeks to study international law from third world perspectives although twail scholars defend the use of the term third world there is considerable ambiguity in what is meant by the term and the conceptual basis for its use for obiora okafor third world is a contingent but useful category that is selfreferential 41 third world therefore becomes a question of identity for makau mutua the term third world is a stream of similar historical experiences across virtually all noneuropean societies that has given rise to a particular voice a form of intellectual and political consciousness and the object of knowledge for twail scholars is international law not the third world twail scholars aim to provide a perspective on international law from the vantage point of marginalized nations twail approaches deconstruct and contextualize the ways in which international law is formed through the encounter of european powers with colonized societies 4 reversing the perspective from european to noneuropean does not however change the conceptual frames that inform international law nor does it reveal what is entailed in projecting those concepts onto third world realities twail approaches embed the other in epistemology even when challenging it empirically and remain constrained by the west versus rest dichotomy in their normative standards twail scholars remain modernist inasmuch as they seek ethical interventions to reform international law so that it lives up to its normative claims of equality and nondiscrimination it is beside the point whether such approaches are offshoots of northern scholarship or not 45 what is important is whether the scholarship falls back on moral or ethical transformation and voluntarism to ground ideas of freedom and equality between all societies and whether or not it opens pathways for transformation where freedom and equality between societies qua societies are grounded in the materiality of a world based on relations of superand subordination andrew sunter argues that twail approaches may be described as naturalized epistemological inquiries as such they rely on a posterior empirical knowledge to arrive at a priori claims twail approaches therefore fall back on philosophical empiricism in the form of past experiences of the third world to critique international law these approaches reify the status quo by grounding the possibility of transcendence in past experiences while this critique and deconstruction make an important contribution to our understanding of the role of international law in sustaining inequalities between societies in the past and present deconstruction alone does not suffice for transcendence of the west versus rest polarity nor does it help to redefine the meaning of freedom we remain in what teemu ruskola calls the hermeneutical loop 7 we do not have a way of answering the question what is asian about asian law fear of essentialism and reductionism on the one hand and universalism and metatheories without social content on the other hand prevents escape from hermeneutical loops some scholars have argued that there is a spatial tension in the theorypractice dialectic of knowledge production in that theory production remains located in the first world but is based on experiences produced in the third world 4 8 while locations and spatial dialectics of knowledge production are important we must be careful not to overdetermine the case for location to the detriment of intellectual creativity and human solidarities rather the problems may lie in philosophical dualism which dominates modernist and enlightenment thinking philosophical dualism produces conceptual deadlocks by locking binary categories into oppositional positions and thereby forestalling transcendence and emergence as roy bhaskar shows in his work dialectics pulse of freedom thesis and antithesis share common grounds 49 the hermeneutical cycles create and recreate familiar patterns in the analytical frameworks that inform knowledge of the third world and continue to reproduce unequal relations even after several centuries of resistances and solidarities to end them the result is pessimism and obeisance to what is described metaphorically as the empire of law 50 in the light of these observations about twsls how may we understand the dichotomy exemplified by the asli conference between modern or economic domains on one hand and traditional or cultural domains on the other the next part explores this question by interrogating the public private divide in law iii traditional in culture and modern in economy the opposing directionality of capitalism and imperialism in the constitution of societies in the first and third worlds produces asymmetries in the substance and form of concepts used to analyze modern societies in other words the geohistorical content of concepts in social theory is not comparable even when comparable vocabulary is used this is more significant in law because legal concepts define social relations and reify their normativity lawin particular the foundations of positive lawrests on definitions in order to understand the economicmodern versus culturaltraditional architecture of law in the third world it becomes necessary to problematize the language of law by interrogating core legal categories in light of insights provided by historical and sociological critique it is necessary to go beyond comparing and contrasting the observable effects of law in different nationstates as in sociological and anthropological studies and to begin building a philosophical foundation for twsls how the asymmetries in the substance and form of legal concepts sustain the divide between modern law in the domain of the economy and traditional law in the domain of culture in the legal architecture of third world societies may be exemplified by interrogating the use of the legal categories of public and private in law the publicprivate divide is a structural feature of modern law legal theory works on the premise that law has two branches that operate in two different social spheres jowitt dictionary ofenglish law defines public law it as follows l aw is either public or private public law is that part of the law which deals with the state either by itself or in its relations with individuals and is called constitutional when it regulates the relations between the various divisions of the sovereign power and administrative when it regulates the business which the state has to do to the contrary private or civil law deals with those relations between individuals with which the state is not directly concerned as in the relations between husband and wife parent and child and the various kinds of property contracts torts trusts legacies the right recognized by the rules of admiralty etc 52 the two branches of law limit the role of the state and sovereign power in first world societies the publicprivate divide is not as neat in reality as it is conceptually nor is it uncontested over time the boundaries have been contested altered and realigned 53 of private law were legislated into existence through public law in the colonies 58 colonial law introduced a field of law called personal law or tribal law matters concerning family inheritance succession marriage divorce and adoption were left to be governed by the religious and tribal norms of diverse communities personaltribal law shrunk the private sphere in the colonies and expanded the public sphere by subsuming the economy within the public sphere 5 9 although the concepts of public and private law are routinely used as foundational legal categories everywhere they denote different socioeconomic and geohistorical realities and social spheres in the third world in the first world the publicprivate divide limited the role of the state and defined sovereign powers in the third world it expanded the role of the state and shrank the private sphere retaining the legal language of the publicprivate divide fetishized the assumption of sovereignty over resources and populations that were traditionally in the private sphere in the european legal tradition more significantly it enabled the colonial state to incorporate diverse communities into the political economy of colonialism under the umbrella of the modern colonial state the modern state structure in the third world has continuities with the colonial state the economicmodern versus culturaltraditional law divide in retrospect was foundational for indirect rule which subsequently became the dominant mode of imperial governance globally arguably it was that architecture of law that made formal decolonization possible under the united nations system at the end of world war ii the theoretical assumptions underlying personal and tribal law are important the assumption is that culture can somehow continue to be practiced without its moorings in the materiality of the economy conversely there is the assumption that somehow the economy will transform and modernize social relations both these assumptions are mired in contradictions inasmuch as all cultures must be grounded in the materiality of societies the assumption that cultural practices can be continued even after the political economy has changed is fundamentally flawed sir henry maine argued that colonial societies would progress from statusbased to contractbased relations in the same way as had happened under european capitalism this social darwinism in legal theory was at odds with the colonial imperative of imperial governance that necessitated incorporation of local family and tribal structures within the wider colonial state 61 consequently contractual relations in the economy did not evolve into general contract forms of social relations in all spheres of social life 62 the processes that extended publicprivate concepts in law to different sociohistorical realities of the third world created a structural schism within third world societies where two sets of values norms institutions and lawsone for the economy another for cultureregulate two aspects of society as if the two were unrelated the structural schism between economy and culture is a characteristic of third world societies an attribute acquired through the socioeconomic and geohistorical experiences of colonialism this attribute assumes diverse manifestations depending on local histories politics and other specificities the schism has a profound influence on institutions in third world societies economic institutions continue to be driven by impulses for harmonization from dominant capitalist economies and social institutions continue to be driven by the impulses of nationalism and culture the schism in the legal architecture of the third world sustains the swings between what clifford geertz calls epochalism and essentialism that is so typical of third world nationalism 63 the schism produces traumatic internal upheavals can iran remain a player in the world oil markets emerge as a nuclear power and at the same time adhere to pristine islamic traditions under the same constitution how does one fulfill the obligation to care for ones unemployed family members in an extended family when the labour market is based on the sale of individual labour power widows must work because the labour market does not recognize family labour can the moral authority of hindu traditions alone stop her from remarrying and how do tribes maintain tribal authorities and traditional structures of governance when the economy has slipped away from the tribal society the individual as an atomized irreducible legal category standing in contractual relations with the state created the conditions for citizenship in the first world in the wake of capitalism in the third world by contrast ethnic religious and linguistic communities were coopted into markets and assigned places within market institutions amy chua shows how in the third world the nationalization and privatization programs prompted by the international economy impact specific communities in definite ways depending on their positions in the economy1 in the third world the impacts of international economic policies emanating from the centres of capital are experienced as ethnic and racial tensions differently by different communities 65 for example in the context of malaysian colonial history because of the respective locations of tamils malays and chinese in the economy and market institutions as communities a policy that adversely affects the rubber industry will affect tamils agricultural policies will affect malays and trade policies will affect the chinese widespread divisive ethnic conflicts in the third world may have to do with a legal architecture where cultural aspirations are cut adrift from political economy and where citizenship itself remains collective rather than individual we are witness to the political economy of globalization which is followed by cultural conflicts 66 contrary to the expectations of global solidarity movements that campaigned for the rights of people in the wake of globalization in thailand people embraced religion and karma in preference to rights against the state and contrary to expectations neoliberalism had the effect of expanding the scope of sharia in aceh a region with long traditions of legal pluralism going back to precolonial times 67 this choice if it may be called that ought not to surprise the unproblematic use of the language of rights by protest movementsas if it refers to the same type of citizenstate relationship as in the first worldhas the effect of reifying and embedding unequal relations between societies even when the intention is to the contrary 9 using the same vocabulary to analyze different social realities has the effect of reifying unequal relations between first and third worlds the language of publicprivate in law obscures the social realities in the third world the use of a common vocabulary suggests comparable meanings and substance 0 the field of comparative law helps to point out similarities and dissimilarities at the descriptive and definitional levels but it does not do the same with respect to the geohistorical causal processes that produce radically different effects of law in different societies critical theories reverse the vantage point from similarities to dissimilarities but remain methodologically within dualist frameworks working with binary categories 1 the structural schism also means that the tensions in society because of the structural disjuncture between economy and culture remain unresolved this irresolution is another attribute of third world societies in which law imperial agendas and global solidarities contribute in turn to reproducing the schism in these societies the coexistence of multiple legal systems in the cultural sphere and in the informal economy is commonly analyzed through the framework of legal pluralism legal pluralism as an analytical framework draws on law in third world societies to a large extent because of the apparent coexistence of different normative orders that characterize third world societies more than others given the influence and popularity of legal pluralism as an analytical framework for law in third world societies it is this concept that we must turn to next in order to expand upon the economicmodern versus culturaltraditional architecture of law in third world societies iv legal pluralism centralism and third world societies beginning with attempts to theorize the meaning of law in the writings of eugen ehrlich bronislaw malinowski and others more recent expositions see legal pluralism variously as copresence of diverse legal systems in society 73 as processual 74 as postmodern inspired by polycentricity as autopoiesis76 as praxiological 77 and as antihegemonic1 8 this brief snapshot does not attempt to capture the nuances and orientations of the diversity in the approaches to legal pluralism 79 the purpose of the snapshot is to make the point that the idea of legal pluralism is an enduring one with an extended genealogy in sociolegal studies that it uses analytical empirical and pragmatic methods that it is popular in anthropological and sociological studies of law and that the debates on legal pluralism have changed over time while the analytical and conceptual engagement with legal pluralism do not limit legal pluralism to third world or colonial societies the empirical studies on legal pluralism are dominated by examples of multiple legal systems under colonialism and in contemporary third world societies the point here is not about legal pluralism as such but rather about the epistemological implications of the use of legal pluralism for analysis of third world societies at the core of legal pluralism is the idea that law cannot be limited to statecentred law and that multiple systems of law operate in society it is a reaction to the privileging of state law in modern societies the idea of legal pluralism developed in juxtaposition to state law later strands in legal pluralist thought engage the meaning of law and the statesociety context within which law however understood operates the idea that statecentred law is the only legitimate law is an idea that emerged with capitalism john griffiths refers to this as the ideology of legal centralism according to griffiths an important part of the ideological heritage of the bourgeois revolutions and liberal hegemony of the last few centuries is the complex of ideas concerning the nature of law and its place in social life according to what i shall call the ideology of legal centralism law is and should be the law of the state uniform for all persons exclusive of all other law and administered by a single set of state institutions to the extent that other lesser normative orderings such as the church the family the voluntary association and the economic organization exist they ought to be and in fact are hierarchically subordinate to the law and the institution of the state 80 from this griffiths goes on to develop the argument that legal pluralism is concomitant to social pluralism in other words as social action always takes place in multiple semiautonomous fields there are multiple fields of law reflective of the wider social fields 81 it is worth dwelling on griffiths idea that the primacy given to state law is a heritage of bourgeois revolutions from the geohistorical experiences of western societies is it possible to abstract the proposition that legal centralism is ideology everywhere and legal pluralism the reality as griffiths does in the geohistorical context of capitalism legal pluralism in the first world refers to those unrecognized invisible lawlike relations facilitative of the smooth functioning of society legal pluralists in the first world argue that these contributions of nonstate law must be valued and recognized equally since the bourgeois revolutions that established capitalism as the social order in the west 80 griffiths legal pluralism supra note 73 at 2 81 ibid more and more aspects of social life have been commodified stated differently more and more aspects of social life are brought under legal centralism by making them contingent on incorporated entities created by the fiat of law even everyday social support activities like caring for the sick and elderly protection from crime and caring for children rely on provisioning services through legally sanctioned entities like cancer victims support groups neighbourhood watch groups or childcare centres whether voluntary or paid in contrast in the third world it is legal pluralism that is ideological legal pluralism in the third world holds out the possibility of the coexistence of imperialism and nationalism a modern economy driven by the centres of capital like the g8 nations where nationalism comes to be defined in terms of racial identities and cultural practices it fetishizes the ways in which institutional developments in the third world reproduce relations of superand subordination in the economy on the one hand and anchors the right to selfdetermination in essentialized identities on the other it is important to bear in mind that both markets and states are complexes of laws as creatures of the law they provide the institutional infrastructure for capitalism 82 in the third world modern institutions developed largely with regard to those aspects of society that were operationally brought under the capitalist economy through imperialism 3 therefore large swathes of economy and society continue to remain outside modern institutions for example the socalled informal sectors of the economy in the third world that dominate the literature on poverty and development exist outside state centralism 84 when viewed through an empirical lens the informal economy appears as diversity and validates legal pluralism however as an analytical framework for law in the third world legal pluralism sustains the wider political economy of capitalism and imperialism in reproducing two types of labour marketsformal and informalwhere the formal labour market is tied to global political economy and the informal to subsistence and survival in the wider context of asymmetrical power relationships legal pluralism plays an ideological role in imperial governance in a number of ways first legal pluralism rationalizes the politics of exclusion the positive connotations and values attributed to legal pluralism means that the exclusion of some segments of society from modern institutions is rationalized it obscures the reality that coexistence is not a voluntary or desirable state of affairs for example workers in the informal sector may improvise lawlike norms and codes for survival these norms and codes exist alongside those in the formal sector where workers are protected by modern law the coexistence of the two sectors is rationalized as plural orders the creativity of the informal sector workers is celebrated 85 this celebration obscures the ways in which imperialism constitutes two classes of workersone protected by trade unions and rights of collective bargaining and another who are excluded from legal protection and left to their own creative strategies for survival 86 the normative idea however remains one where trade unions and rights of collective bargaining are recognized by the state and extended to all even when large sections of the workforce must necessarily be excluded from the normative ideal because of the structure of global labour markets while legal pluralism invites us to recognize the normative and regulatory aspects of informal sectors of the economy and to celebrate the human spirit that challenges its exclusion it fetishizes the exclusion of large sections of the workforce from the norms and regulations of the state and conceals the reality that not all workers in the third world can be protected by law this example 85 legal pluralism produces curious outcomes for example the wellknown marxist geographer david harvey analyzes the shift in the international divisions of labour from fordist to postfordist modes of production and concludes that the turn to more flexible labor processes could be seen as an opening to a new era of democratic and highly decentralized labor relations and cooperative endeavours see david harvey the condition ofpostmodernity an enquiry into the origins of cultural change at 353 hernando de soto a wellknown neoliberal advocate of privatisation and private property rights also recognises de facto legal pluralism but argues for including such plurality as part of a regime of private property rights he writes outside the west extralegal social contracts prevail for a good reason they have managed much better than formal law to build on the actual consensus between people about how their assets ought to be governed any attempt to create a unified property system that does not take into account the collective contracts that underpin existing property arrangements will crash into the very roots of the rights most people rely on for holding onto their assets may be extended to other aspects of life in the third world including shelter food education and other basic necessities of life 87 the celebration of agency in legal pluralism misjudges the cause of creativity in this case the resilience of informal sector workers and their capacities to create alternative norms to survive it is the ontological desire for freedom that drives the creativity of the unorganized sector workers the inability to conceptualize this ontological drive which is an essential attribute of being human leads to epistemological confusion over how to understand their creativity and resilience legal pluralisms celebration of agency misdirects us from important political questions about the commodification of labour the modes of its institutionalization in global labour markets and the way in which human agency might apply its desire for emancipation towards intentional structural transformations beyond existence and survival in the present second legal pluralism is ideological in that the exclusion of swathes of the economy and society from modern institutions makes state centralization the normative ideal third world states must endeavour to bring more and more aspects of the economy and society into their fold in the same way this happened under western capitalism the lending policies of international organizations and western governments and ideas of good governance promoted by both are premised on the normative ideal of state law and the states role in introducing regulatory changes compatible with international economy third legal pluralism as an ideology provides the third world state with devices to govern and manage the social outcomes of appropriation and expropriation by capitalism and imperialism it does this by switching between economy and culture as rationale for lawthat is by switching in geertzs words from epochalism to essentialism so as to stave off systemic crisis 88 lastly it fetishizes the fact that colonialism structurally transformed the third world and that it is not possible to have capitaliststyle social transformation there without the opportunities for colonialism expansionism and militarism those opportunities have been foreclosed for third world societies historically legal pluralism was an essential condition for the creation of the colonial state it was the legal device that brought preexisting communities tied to land and social groups such as tribes or castes into a relationship with the colonial state and provided them a place within the colonial political economy 9 these relationships continue to characterize the third world and inform international relations whether they are ethnic conflicts or economic relations the introduction of personal law for example must be evaluated by taking into account the introduction of economic laws the creation of the colonial state and the discourses that rationalized the courses of action in economy and culture legal pluralists drawing on sociological and anthropological research have argued that the introduction of personal law in colonial societies was due to uncertainties of colonial rule and have tended to provide explanations based on the enhanced scope for agency of subordinate social groups 9 however without some conception of society within which social relationships existfor example between men and women or between upper and lower classthe categories used in sociological and anthropological research remain dehistoricized and despatialized accordingly they can either lead to classical modernist universalism or to critical postmodern particularism politically cultural and empirical explanations for personal law produce vacillating orientations to imperialism and colonialism by seeing them as progressive in some respects and oppressive in others on the one hand ethnocentric nationalisms that arose after formal decolonization are fetishized on the other hand economic subordination by international organizations is represented as an historical inevitability concepts including sociological and anthropological categories of analysis are also products of social history and geography without a conception of society in philosophy and social theory critical scholarship is caught in the hermeneutic loop of either decrying imperialism or qualifying it by alluding to its liberating aspects and in both cases obfuscating the wider question of the relationship between economy and culture in social theory the point here is not that legal centralism is superior to legal pluralism or vice versa or that they can be used in hegemonic ways for imperial agendas and in counterhegemonic ways by global solidarity movements nor is it limited to showing how hegemonic and counterhegemonic uses share common conceptual grounds that reproduce unequal relations between societies forged under colonialism rather the purpose is to open up pathways for transcending the economyculture schism internally in third world societies on the one hand and the unequal relations between first and third world societies externally on the other the challenge is to find ways 89 undoubtedly these changes opened up new possibilities for action for social groups that is captured in the literature on legal pluralism see eg engle merry uncertainties supra note 2 arguably it is necessary to evaluate the new possibilities against emerging structural constraints that new forms of imperialism subsequently introduced in those societies 90 see also ibid engle merry law and colonialism supra note 2 of conceptualizing structural autonomy in economic relations between societies and of anchoring politics and culture to the materiality of societies everywhere in other words the challenge is to create the conditions in which real diversity can flourish and innovative sociolegal frameworks of analysis can be devised that are capable of sustaining this diversity in everyday life v conclusion there are two impulses that drive the development of law in the third world one consists of the economic interests of capitalism the other of the institutional and social infrastructures necessary for economic actors to operate in the first world both of these impulses are internal to the historically constituted societies within which capitalism arose the dynamics of the social transformation were analyzed in karl marxs writings and later in marxist literature and inform a rich and diverse critique of capitalist transformation in the first world 91 what jiirgen habermas refers to as system and lifeworld both exist in unity as society or rather western societies 2 the distinction made by habermas is an analytical one in the third world there is a spatial and historical rupture between the economic impulse generated by the production relations in the centres of capitalism and the alien lifeworld in the third world where the economy must operate without a shared intersubjective order in other words there is a spatiotemporal rupture between system and lifeworlds as a result of imperialism capitalisms expansionist external dimension this disjuncture characterizes society in the third world law reifies the disjuncture this is not the same thing as centre and periphery in world systems approaches or what david harvey analyzes as different logics of capital and territory 93 but rather it is about differentiating between the internal dimensions of capitalism constituted by subordination of classes within society and the external dimensions of capitalism constituted by colonialism expansionism and their subordination of societies qua societies class production colonial relations and expansionist governance are organized through directionally opposite processes in capitalistinternal and imperialistexternal dimensions of capitalist development the result is two different modes of constitution of societies that produce distinct properties attributes features and internal and external dynamics that we recognize as first and third worlds 94 legal concepts and categories are integral to this process they hold out the key to explanations for the continued reproduction of unequal relations between societies qua societies a problem at the heart of global justice in the contemporary world the national liberation struggles of the twentieth century overestimated political sovereignty and formal legal statehood the postindependence experience has brought about a deep awareness that structural autonomy cannot be achieved solely through political sovereignty and formal legal statehood the postindependence period has highlighted the significance of history and geography capitalism and imperialism and nature and culture for the problems of the contemporary world legal studies including critical legal studies tend to take the conceptual vocabulary of law at face value the result is a philosophical impasse imposed by the epistemologies of modernism and enlightenment it is to this impasse that twsls must pay serious attention if it is to remain critically engaged in a transformative social process for freedom and emancipation as zygmunt bauman argues postmodernism in philosophy is closely tied to the transformations in the stage of capitalism in the postworld war ii era 95 the emphasis on culture and context in recent theoretical developments provides valuable tools to deconstruct the philosophical resources that provide capitalism and imperialism with the resilience they have shown postcolonialism as aijaz ahmad and others argue takes its philosophical cues from postmodernism96 twsls challenges us to move beyond deconstruction at the empirical and phenomenological levels and to innovate conceptual and philosophical resources that help us transcend the constraints of philosophical liberalism in ways that take freedom and emancipation in philosophy and theory seriously in legal and social theory it challenges us to find ways of speaking about global justice and law in the third world in ways that anchor the third world to realities at all 94 for the distinctions between colonialism neocolonialism and postcolonialism see radha dsouza levels ontological structural and empirical philosophical questions cannot be resolved by sociological analysis alone they must be resolved philosophically for social theory to attempt to find answers to inequities of colonialism and imperialism within the same level of philosophical consciousness that brought about modernism enlightenment and capitalism is to abandon the struggle for justice altogether equally if dualism and binary categories dominate western philosophy as critical theory is at pains to point out there is nothing stopping us from looking to other philosophical traditions for answers to the problems of our times these reflections on methodology in twsls raise questions that quickly transcend third world issues and call into question assumptions in social theory more generally the questions raised here are big ones by any reckoning big enough to warrant a research program to put twsls on more solid theoretical foundations this article has hinted at what such a research program might look like it is not possible within the space of a single article to develop an alternative methodology to attempt to provide quickfix solutions would risk reducing embedded questions with deep roots in social theory to banalities besides the nature of the questions posed in this article call for sustained engagement with the wider scholarly community nevertheless it may be possible to identify a set of methodological sensitivities that twsls scholars could be aware of when approaching specific themes or issues about law in third world societies first it is important to recognize that there is something called society both law and society need to be problematized in twsls understandings of society must be differentiated at ontological structural and empirical levels and accounted for in analyses of concrete problems the recognition that at the ontological level human life is contingent on society calls for interrogation of the assumptions of sociological theories about structures agents and social transformations at the empirical level it calls for investigation of the specific geohistorical conjunctures of the relations between natures social structures and peoples that give to particular societies their specific attributes and properties the questions for twsls must therefore encompass properties and attributes of the societies in question as well as the natural and social relations that give to that society its specific attributes and properties in attempting to do so disciplinary boundaries traditions and vocabularies present problems or render their existence opaque greater reflection is called for on the ways in which disciplinary boundaries present a problem in twsls second if concepts develop within and in response to geohistorical processes how may we recognize this and yet communicate with each other had i written this article using the language of jaina or buddhist philosophy for example i could have made the same arguments though they would have been comprehensible to very few even in the third world the orientalist critique in the 19 6 0s and 1970s deconstructed the reasons for and ramifications of orientalism it is necessary to move beyond that now at the empirical level whatever the historical reasons for it we have inherited a vocabulary that is in circulation and that is not of our choosing nevertheless the awareness that deconstruction has provided must lead to greater reflection on what is entailed in the use of the vocabulary communication is necessarily a social and collective act transformations of vocabularies occur only through transformative engagement in retrospect did the enlightenment not change the meanings of society rights and so many other terms through sustained engagements with the concepts if it did then can a more reflexive twsls not transform meanings and vocabulary in more emancipatory ways for example in this article i have used terms phrases and concepts drawn from marxist and critical theories to articulate wider concerns about approaches in twsls and in doing i have sought to provide a different inflection on those terms and meanings third what does it mean to be nondualist when the world is full of diversity the challenge here is not to stop at description or indeed presentation of the thesis and the antithesis in any problem but also simultaneously to interrogate the common grounds they share such an approach calls for reframing the questions in ways that allow the interrogation of a problem to go beyond dualist framings the types of answers we get depend often on how we frame the question in the jaina tradition for example a problem is first presented from a range of perceptions that exist about it in the empirical world the inquiry does not ask which of these is true or false or which one is better but rather it moves on to the next level of reality by asking the nondualist question what must be the nature of reality in this instance if there are all these different perceptions all of which are true and coexist what is human freedom in the contemporary world for example where global solidarity movements critique the use of human rights for imperialist agendas imperialist institutions use human rights for domination and where both are real and coexist fourth postmodern deconstruction has generated recognition of diverse philosophical traditions for example it is difficult to envisage any serious scholarly argument today that claims that the grecoromanchristian intellectual tradition 97 edward saids works were perhaps the most influential in deconstructing orientaism see edward said orientalism also see edward said culture and imperialism is intrinsically superior to all others this recognition has opened up a rich and varied conceptual repertoire that is widely available to scholars the challenge is to actually dip into it so as to develop conceptual resources needed for social transformations it is possible for example to argue that while marxism provides valuable tools for a critique of capitalism something more is needed to realize the aspirations of a just and egalitarian worldsocialism if that is what we want to call such a worldand further that we may need to look elsewhere outside the western tradition for conceptual resources to build such a society here marxism and indigenous traditions both have their value and contributions to make the purpose of this article has been a limited one to open up a subfield in sociolegal studies by identifying methodological problems in the approaches to twsls the reflections are informed by my practical experiences as an activist lawyer in a third world context and a legal academic in a first world context 98 whether this call for a new research agenda for twsls will be another call in the wilderness or whether it will generate responses from critical scholars time alone can tell divide just as the debate revived after the end of world war ii in the context of rebuilding economies and society and the welfare states in capitalist societies 54 nevertheless the two spheres of law continue to define the role of the state in society and to provide a point of reference for the architecture of law what is important for our purposes is that in the history of the first world normatively and conceptually economy and culture simultaneously formed part of the private spheres of law and defined the boundaries of the state land trade and property rightsalongside marriage inheritance adoption and suchwere part of the private spheres where the states role needed to be policed against incursions when statutes trespassed into the private spheres they required special justifications classical liberal theory devoted considerable energy to keeping the state at arms length from the economy and from culture equally important is that in policing the boundaries the publicprivate divide continued to rely on the extended history of the concept in roman laws 5 indeed the publicprivate concepts and divisions developed through contested histories in europe and contributed to the development of capitalism and imperialism during all its phases 56 it is not surprising that the publicprivate divide became the focus of debate in the globalization phase of capitalism and imperialism in contrast colonial law extended the conceptual categories of publicprivate spheres to colonial societies but infused them with different socioeconomic content colonial rule gathered a diverse range of castes communities tribes and nationalities under the umbrella of the colonial state economic matters such as contracts easements trade forests fisheries minerals and landtraditionally within the private sphere in europe under roman law traditionswere brought under state regulation through public law statutes even contracts the sacred cow

this article interrogates the methodological lenses through which law in the third world is commonly analyzed in sociolegal studies third world sociolegal studies this article argues is a field in search of philosophical foundations it continues to rely on conceptual categories and analytical frameworks developed through the intellectual cultural and social histories of western capitalist societies which it extends uncritically to different intersubjective orders in third world contexts the article examines the common grounds shared by two apparently competing discourses about law in the third world which i label imperial agendas and global solidarities it is difficult to speak about the third world without becoming mired in conceptual contradictions one reason for the methodological problems in third world sociolegal studies is that social philosophy and liberal philosophy in particular undermines the concept of society this article begins by examining the meaning of society in social philosophy it then interrogates three dichotomous sets of analytical frameworks that are often invoked in third world sociolegal studies a comparative law versus third world approaches to international law twaili b economic or modern law versus cultural or traditional law and c state centralism versus legal pluralism the article argues for a differentiated understanding of society at the ontological structural and empirical levels which should help transcend binary approaches and facilitate theoretical reflections about the third world without subsuming its specificities the article concludes by arguing for a sustained research program to put third world sociolegal studies on firm methodological foundations

highlighting the need to characterize role participation as multidimensional. It points to the importance of taking into account the meaning of roles at different ages among those with chronic diseases like OA when developing interventions to help understand the impact of roles on psychological well-being. --- Introduction Living with a chronic disease can pose a significant threat to an individual's participation in social roles such as employment, parenting, intimate relationships, leisure, and community involvement. Conceptual reviews of life course research highlight the importance of roles, events, and transitions over time and emphasize that role activities are influenced by biological forces like disease, as well as by psychological, social, historical and geographical factors . Critical to a life course perspective is that individuals proactively manage and shape their roles . The element of time is also essential. It illuminates age-graded sequences of events and can be used as a social benchmark . That is, individuals of different ages have social timetables related to their roles that shape a role's occupancy and their perceived meaning . For example, when time is perceived as relatively long, many roles can be pursued. When time is perceived as limited, as in older age, roles may be given up or re-prioritized . Moreover, if expected or anticipated roles do not occur or they occur at a time that is not perceived as normative , individuals may report distress or change their behaviour to better manage a role . Research on health and disablement has increasingly focused on role participation and social functioning as a critical, underemphasized domain of study . In general, most of these studies have not applied conceptual perspectives from life course research. That is, although age is often included in research as an important personal factor, it is typically a proxy for the likelihood that health and functioning will decline over time. For example, numerous studies show that older adults are more likely to report ongoing health problems that may result in activity limitations and role participation restrictions than younger adults . Lacking is an examination of perceived role participation at different ages within the context of health and chronic disease. Drawing on research from the health and disability literature, as well as integrating perspectives from life course research, role participation can be conceived of as multi-faceted. It includes not only involvement in a role , but also perceptions of the importance of a role , appraisals of limitations or difficulties with role performance, and satisfaction with the ability to perform a role in the way an individual would prefer. These different perceptions of the meaning of role participation may vary by age and health. Role perceptions also could be important in explaining psychological appraisals of distress and behaviours like health care utilization and coping efforts. To examine this further, we took the example of a highly prevalent chronic illness, osteoarthritis . OA ranks among the top ten causes of disability worldwide , 2009; Murray & Lopez, 1996). It results in pain, fatigue, functional limitations, increased health care utilization and substantial costs to society . Research on specific roles, especially employment, finds that OA is associated with role loss, role conflict , stress and depression . Moreover, OA disease symptoms are often minimized and normalized as part of "growing old" . As a result, OA is useful as a disease within which perceptions of role participation can be examined. More specifically, in this study, we compared the role perceptions of middle- and older-aged adults . Although imperfect, we followed the lead of other researchers and used broad age groups as a proxy to assess potential differences in perceived role participation that may approximate life course changes. We also contrasted individuals who have no chronic disabilities with individuals living with OA. We expected that a higher proportion of middle-aged adults, regardless of OA, would be involved in more roles like employment and caregiving for children than older-aged adults. However, despite age-related differences in role occupation, participation across a wide range of roles would be perceived as important across age groups and regardless of OA. Role limitations might present a different scenario. Middle-and older-aged adults with OA were expected to report greater pain, fatigue, and disability than healthy adults and report more role difficulties or limitations. Limitations in role participation were expected to relate to lower role satisfaction, particularly for those with OA. However, older adults with OA may perceive the onset of the disease as normative, while middle-aged adults may perceive it as premature or "offtime" . If so, both age and OA would be associated with role satisfaction, such that middle-aged adults with OA would report lower role satisfaction than older adults with OA and healthy adults . Previous studies have found that those with OA are more likely to report greater distress and health care utilization than healthy adults . We expected similar findings. However, we also expected an age by OA interaction such that middle-aged adults with OA will report the greatest depression, stress, role conflict, health care utilization and behavioural coping efforts compared to other groups. Moreover, role perceptions are also expected to be important. In particular, greater role limitations and decreased role satisfaction are expected to relate to increased depression, stress, role conflict, health care utilization and self-management behaviours. In sum, we hypothesized that a variety of roles would be salient to individuals regardless of their age or the presence of OA. Role limitations were likely to be shaped by OA and be less influenced by age. However, satisfaction with roles was likely to be shaped both by age and OA. Role limitations and satisfaction were also expected to mediate the relationship between age, OA and psychological well-being like depression, stress, and role conflict, as well as health care utilization and self-management behaviours. --- Methods --- --- Measures Role Participation. Social roles were assessed using the Social Role Participation Questionnaire , which was modified from its original version to include information on role limitations . Three components of roles were measured. The first was role salience, which assessed the extent to which different roles were important to a person, regardless of whether or not an individual was currently engaged in that role . Eleven role domains and one global question were gauged: 1) work; 2) education; 3) intimate relationships; 4) children/stepchildren/grandchildren; 5) other family; 6) community involvement; 7) socializing; 8) casual contact with others; 9) travel; 10) physical activity; and 11) hobbies. Responses were on a 5-point scale from 1 = not at all important to 5 = extremely important. Participants were also asked whether they were currently employed, attending school, involved in an intimate relationship, or had children, step-children, or grandchildren . The second component of the SRPQ, role limitations, asked participants how difficult it was, given their present health status, to participate in each of the role domains. Responses were on a 4-point scale from 0 = no difficulty; 1 = some difficulty; 2 = a lot of difficulty; 3 = not able to do. A not applicable category was provided for respondents not currently engaged in a role. Finally, role satisfaction questions asked participants to consider their health and assess the extent to which they were satisfied with their ability to participate in each of the applicable roles in the ways they would like. Responses ranged from 1 = not at all satisfied to 5 = extremely satisfied. The SRPQ takes 5-10 minutes to complete. Mean scores were calculated for role salience, role limitations and role satisfaction. Those reporting a role was not applicable to them on the role limitation subscale were coded as not being restricted in that role and were given a score of 0 . Because individuals may not engage in all roles, a mean role satisfaction score was calculated if participants responded to at least 9 of 12 domains. Demographics. Data on age, gender, education, marital status, employment status, income and living with children under age 18 were collected. Age was dichotomised into two groups: middle-age and older-age . Health Outcomes. Self-reported Health was measured with a single item, "In general, how would you rate your health" . Pain in the past month was assessed with a 0-10-point visual analogue scale . The Profile of Mood States fatigue subscale asked the extent to which participants felt worn out, fatigued, exhausted, sluggish and weary in the previous month . The Health Assessment Questionnaire II measured limitations with everyday activities . Ten items assessed difficulty with activities like walking, stair climbing, and lifting. Responses were on a 4-point scale where 0 = without any difficulty; 3 = unable to do. A mean score was analysed . Respondents with OA were asked for the duration of their disease symptoms in years. Mental Health. The 20-item Center for Epidemiologic Studies Depression Scale measured depressive symptoms . Respondents reported on the frequency of symptoms experienced in the past week . Summed scores were analysed . Scores of 16 or more are often taken as evidence of depression. The 14-item Perceived Stress Scale measured global stress levels in the previous month . Summed scores were analysed . Role Conflict. Four new items were developed for this study measuring role conflict. Items asked the extent to which individuals had chosen between roles, given up time in important roles, had difficulty balancing roles, and perceived they had too many role responsibilities. Responses were on a 5-point scale . Summed scores were analysed . Health Care Utilization. Respondents reported whether or not they consulted with each of 12 categories of health professionals in the past year . The number of responses was summed as an indication of health care utilization. A 4-item Behavioural Coping scale measured efforts to self-manage one's health and included giving up or limiting time spent in activities; modifying activities; planning, pacing, or anticipating problems before they happened; and receiving help . Responses on a 5-point scale were summed . --- Analyses Frequencies, means, and standard deviations were calculated for all variables. Chi-square and two-way analyses of variance tests compared OA and healthy control participants on sample characteristics. Pearson correlations examined the interrelationships among the role salience, limitations and satisfaction components for those with OA and healthy controls. Linear regression analyses examined age, OA, age by OA interaction effects and role salience, role limitations, and role satisfaction as potential predictors of depression, stress, role conflict, health care utilization, and behavioural coping efforts. Analyses proceeded in steps. Age and OA main effects were entered first followed by age by OA interaction effects. Then role salience, role limitations, and role satisfaction variables were entered in the model. --- Results Table 1 presents characteristics of the sample. In general, healthy control group participants were similar in demographic characteristics to the OA sample. On average, middle-aged participants were 50 years old and older participants were 67 years old. The sample included more women than men. Fewer older-aged OA participants had university educations and middle-aged healthy controls were less likely to be married. In keeping with their disease, respondents with OA reported greater pain and activity limitations than healthy controls . Middle-aged respondents with OA had significantly poorer self-reported health and greater fatigue than all other groups. Older adults with OA reported longer disease durations than middle-aged adults with OA . However, their pain and activity limitations did not significantly differ. Not all respondents were involved in all roles assessed by the SRPQ. Overall,38.5% were not involved in an intimate relationship; 38.5% did not have children, stepchildren, or grandchildren; 45.3% of respondents were not employed; and 84.1% were not enrolled in educational activities. Two-way ANOVA's found no group differences in involvement in an intimate relationship. Middle-aged adults were significantly more likely than older adults to be living with children under age 18 and be employed. Healthy adults also were more likely to be employed and to be involved in continuing education than those with OA. Because educational pursuits were not applicable to most participants, this role was dropped from subsequent analyses. Significant main effects for age and OA were found with middle-aged respondents and those with arthritis reporting greater depression, stress, role conflict and behavioural coping efforts. A significant interaction effect was found for health care utilization with middle-aged respondents with OA reporting the greatest health care utilization of all groups. The findings for the three role participation dimensions show that means were relatively high for role salience indicating that many participants rated a range of roles as important to their lives. Middle-aged respondents, regardless of their health, reported that roles were more important to them than older-aged respondents. Middle-aged respondents were also significantly more likely to report lower role satisfaction than their older counterparts. However, there was also a significant main effect for OA with those having arthritis reporting less role satisfaction than healthy controls. An interaction between age and OA emerged for role limitations with middle-aged participants with OA reporting significantly greater difficulties with their roles than all other groups. We next examined the relationship of age, OA, and role perceptions to depression, stress, role conflict, health care utilization and behavioural coping efforts . Linear regression analyses were performed in steps. Main effects for age and OA were tested first followed by age by OA interaction effects. To simplify presentation of the data, these data are combined and presented in Model 1. Model 2 adds role salience, role limitations, and role satisfaction to the analyses. For Model 1, there were significant age effects with middle-aged respondents reporting greater stress and role conflict, as well as a trend for greater depression, than older adults. Model 1 also reveals that individuals with OA were significantly more likely to report depression, stress, role conflict, health care utilization and behavioural coping efforts than all other groups. There was a significant age by OA interaction for health care utilization indicating that middle-aged adults reported greater health care utilization compared to all other groups. There was also a trend for middle-aged adults with OA to report greater depression than other groups . Model 1 R-squares were relatively low for depression, stress, and role conflict accounting for between 13-19% of the variance. R-squared values for health care utilization and behavioural coping efforts were 22% and 47%, respectively. Model 2 examined the addition of role salience, role limitations, and role satisfaction to the analyses. Age remained significant for stress and role conflict but was not significant for depression. Those with OA continued to report greater health care utilization and behavioural coping efforts. However, OA was no longer significantly related to role conflict and only trends were found in predicting greater depression and stress . Age by OA interaction effects were not found, with the exception of a trend for depression . Instead, those with greater role limitations and lower role satisfaction reported significantly greater depression, stress, role conflict, and behavioural coping efforts. Greater role salience and role limitations were also associated with more health care utilization. Model 2 R-square values increased and accounted for 27% of the variance for role conflict and 39% and 44% of the variance for stress and depression, respectively. Model 2 accounted for 30% of the variance for health care utilization and 59% of the variance for behavioural coping. --- Discussion Findings support hypotheses that both age and OA relate to role participation perceptions and that middle-aged participants with OA may report more difficulties with roles than their older counterparts or healthy individuals. It also found support for assessing the meaning of roles as multidimensional and for examining role salience, role limitations, and role satisfaction. These dimensions, especially role limitations and satisfaction, were related to depression, stress, role conflict, health care utilization and behavioural coping efforts. The findings are important because adults in their middle years typically are expected to take on a large number of diverse roles. If individuals perceive that they are not able to participate fully in valued areas of life because of chronic diseases like OA, it may have personal and societal consequences, including implications for physical and psychological health. Findings from the study revealed that involvement in diverse roles was common among participants and that there were few group differences. Differences that existed generally were associated with age, not OA . Although middle-aged healthy adults reported greater salience or importance of roles in their lives compared to older-aged OA adults, mean scores were relatively high suggesting that older adults may not be withdrawing from or reprioritizing their social roles as hypothesized in some theories of aging . Additional research needs to further examine involvement in roles and role salience, particularly in larger population samples. Although our sample was diverse in terms of gender, education, marital status and income, and participants with OA were comparable to clinical and population health studies in terms of pain, disability, and disease duration, further research would enable a better understanding of whether role differences are largely related to age, health, or other factors. Middle-and older-aged respondents with OA reported similar levels of disease severity . Yet, middle-aged adults with OA reported greater fatigue and role limitations than older adults with OA. It is not immediately clear why this occurred. However, it suggests that variables other than a disease diagnosis are important in understanding people's perceptions of role limitations. Conceptual discussions of the life course would speculate that it may reflect divergent social timetables and perceptions of what is normative at this time of life across middleand older-aged adults with OA . For example, middle-aged adults with OA may have contact with fewer individuals who, like them, are living with OA. As a result, they may compare themselves to healthy peers who are able to do more or whose performance they believe is superior to their own. To date, we lack data on the role expectations of different age groups living with chronic illnesses. If middle-aged adults with OA perceive their condition as occurring prematurely and if their role expectations lead them to believe they are more limited in their role performance, it can also explain why middle-aged adults with OA reported lower role satisfaction than others. Perceptions of role participation, age, and OA were also important in understanding depression, stress, and perceived role conflict. Previous studies have found that individuals with chronic diseases are more likely to report poorer psychological wellbeing than their healthy counterparts. However, little attention has been given to specific sources of distress. This study points to role limitations and role dissatisfaction as potential factors that contribute to poorer psychological well-being. This was particularly true for those with OA. However, middle-aged adults also reported greater stress and role conflict than older adults. As such, perceptions of role participation and age may warrant greater attention in intervention studies for those with chronic disabling diseases. Many self-management programs focus primarily on symptom management and do not explicitly highlight limitations with role participation or perceptions of role dissatisfaction. The findings are also important given that psychological health and physical health are often inter-related. Longitudinal research needs to examine the longterm implications of role limitations and dissatisfaction on changes in health like pain, fatigue, and activity limitations, and whether this is moderated by other role perceptions such as role conflict. Differences in perceived role participation were also related to health care consultations and behavioural coping strategies. Age was unrelated to these variables. Not surprisingly, those with OA reported more health care utilization and behavioural coping. Specifically, greater role salience and role limitations were associated with consulting a greater range of health care professionals. Participants with more role limitations and less role satisfaction reported more behavioural coping efforts. These findings are preliminary and need to be replicated, particularly with longitudinal data. Additional research may point to role perceptions as being important factors in motivating health behaviours. If so, this information is of potential value to clinicians. Currently, clinicians often emphasize the value of treatments in alleviating symptoms and delaying or halting disease progression. However, it may be important to discuss role demands in a patient's life and their salience, as well as the potential for treatment to impact role limitations and satisfaction. As such, the relationship of role participation perceptions to treatment adherence deserves increased attention. Several limitations to this research should be acknowledged. First, as noted in the introduction, age is an imperfect proxy for life course demands. Although the age groups used in this study captured expected differences in role involvement , additional research needs to more fully explore diverse roles in the lives of individuals of different ages. In addition, we created indices reflecting the importance, difficulties, and satisfaction individuals have with their roles. But, additional research needs to be conducted validating the SRPQ and assessing whether there are other dimensions that reflect the meaning, quality, and quantity of role domains. This study drew on a sample of adults with OA and those with no chronic disabling health conditions. Although OA is among the most prevalent chronic diseases causing disability, research is needed to replicate these findings with a greater range of chronic health samples and conditions, including visibly disabling conditions and those that include cognitive impairments. Moreover, including younger adults and adults with different onset ages of chronic disease in studies would increase our understanding of life course issues related to health and disability . Finally, the study was cross-sectional making the direction of effects unclear. Longitudinal studies would help clarify, not only the direction of relationships related to health and role participation, but also the impact of changes in participation on health. Population health studies are also needed to examine the generalizability of the findings. In summary, this study highlights that participation in roles is perceived as important across the life course. However, the occurrence of chronic health problems at different ages has important implications, not only for role limitations and satisfaction, but also for psychological well-being. In particular, middle-aged adults with chronic conditions like OA may report more limitations in role participation and heightened distress than older adults. This suggests potential new directions for interventions that take into account life course factors and that focus on helping individuals maintain involvement in valued roles.

Social role participation and the life course in healthy adults and individuals with osteoarthritis: Are we overlooking the impact on the middle-aged? Soc Sci Med.

highlighting the need to characterize role participation as multidimensional it points to the importance of taking into account the meaning of roles at different ages among those with chronic diseases like oa when developing interventions to help understand the impact of roles on psychological wellbeing introduction living with a chronic disease can pose a significant threat to an individuals participation in social roles such as employment parenting intimate relationships leisure and community involvement conceptual reviews of life course research highlight the importance of roles events and transitions over time and emphasize that role activities are influenced by biological forces like disease as well as by psychological social historical and geographical factors critical to a life course perspective is that individuals proactively manage and shape their roles the element of time is also essential it illuminates agegraded sequences of events and can be used as a social benchmark that is individuals of different ages have social timetables related to their roles that shape a roles occupancy and their perceived meaning for example when time is perceived as relatively long many roles can be pursued when time is perceived as limited as in older age roles may be given up or reprioritized moreover if expected or anticipated roles do not occur or they occur at a time that is not perceived as normative individuals may report distress or change their behaviour to better manage a role research on health and disablement has increasingly focused on role participation and social functioning as a critical underemphasized domain of study in general most of these studies have not applied conceptual perspectives from life course research that is although age is often included in research as an important personal factor it is typically a proxy for the likelihood that health and functioning will decline over time for example numerous studies show that older adults are more likely to report ongoing health problems that may result in activity limitations and role participation restrictions than younger adults lacking is an examination of perceived role participation at different ages within the context of health and chronic disease drawing on research from the health and disability literature as well as integrating perspectives from life course research role participation can be conceived of as multifaceted it includes not only involvement in a role but also perceptions of the importance of a role appraisals of limitations or difficulties with role performance and satisfaction with the ability to perform a role in the way an individual would prefer these different perceptions of the meaning of role participation may vary by age and health role perceptions also could be important in explaining psychological appraisals of distress and behaviours like health care utilization and coping efforts to examine this further we took the example of a highly prevalent chronic illness osteoarthritis oa ranks among the top ten causes of disability worldwide 2009 murray lopez 1996 it results in pain fatigue functional limitations increased health care utilization and substantial costs to society research on specific roles especially employment finds that oa is associated with role loss role conflict stress and depression moreover oa disease symptoms are often minimized and normalized as part of growing old as a result oa is useful as a disease within which perceptions of role participation can be examined more specifically in this study we compared the role perceptions of middle and olderaged adults although imperfect we followed the lead of other researchers and used broad age groups as a proxy to assess potential differences in perceived role participation that may approximate life course changes we also contrasted individuals who have no chronic disabilities with individuals living with oa we expected that a higher proportion of middleaged adults regardless of oa would be involved in more roles like employment and caregiving for children than olderaged adults however despite agerelated differences in role occupation participation across a wide range of roles would be perceived as important across age groups and regardless of oa role limitations might present a different scenario middleand olderaged adults with oa were expected to report greater pain fatigue and disability than healthy adults and report more role difficulties or limitations limitations in role participation were expected to relate to lower role satisfaction particularly for those with oa however older adults with oa may perceive the onset of the disease as normative while middleaged adults may perceive it as premature or offtime if so both age and oa would be associated with role satisfaction such that middleaged adults with oa would report lower role satisfaction than older adults with oa and healthy adults previous studies have found that those with oa are more likely to report greater distress and health care utilization than healthy adults we expected similar findings however we also expected an age by oa interaction such that middleaged adults with oa will report the greatest depression stress role conflict health care utilization and behavioural coping efforts compared to other groups moreover role perceptions are also expected to be important in particular greater role limitations and decreased role satisfaction are expected to relate to increased depression stress role conflict health care utilization and selfmanagement behaviours in sum we hypothesized that a variety of roles would be salient to individuals regardless of their age or the presence of oa role limitations were likely to be shaped by oa and be less influenced by age however satisfaction with roles was likely to be shaped both by age and oa role limitations and satisfaction were also expected to mediate the relationship between age oa and psychological wellbeing like depression stress and role conflict as well as health care utilization and selfmanagement behaviours methods measures role participation social roles were assessed using the social role participation questionnaire which was modified from its original version to include information on role limitations three components of roles were measured the first was role salience which assessed the extent to which different roles were important to a person regardless of whether or not an individual was currently engaged in that role eleven role domains and one global question were gauged 1 work 2 education 3 intimate relationships 4 childrenstepchildrengrandchildren 5 other family 6 community involvement 7 socializing 8 casual contact with others 9 travel 10 physical activity and 11 hobbies responses were on a 5point scale from 1 not at all important to 5 extremely important participants were also asked whether they were currently employed attending school involved in an intimate relationship or had children stepchildren or grandchildren the second component of the srpq role limitations asked participants how difficult it was given their present health status to participate in each of the role domains responses were on a 4point scale from 0 no difficulty 1 some difficulty 2 a lot of difficulty 3 not able to do a not applicable category was provided for respondents not currently engaged in a role finally role satisfaction questions asked participants to consider their health and assess the extent to which they were satisfied with their ability to participate in each of the applicable roles in the ways they would like responses ranged from 1 not at all satisfied to 5 extremely satisfied the srpq takes 510 minutes to complete mean scores were calculated for role salience role limitations and role satisfaction those reporting a role was not applicable to them on the role limitation subscale were coded as not being restricted in that role and were given a score of 0 because individuals may not engage in all roles a mean role satisfaction score was calculated if participants responded to at least 9 of 12 domains demographics data on age gender education marital status employment status income and living with children under age 18 were collected age was dichotomised into two groups middleage and olderage health outcomes selfreported health was measured with a single item in general how would you rate your health pain in the past month was assessed with a 010point visual analogue scale the profile of mood states fatigue subscale asked the extent to which participants felt worn out fatigued exhausted sluggish and weary in the previous month the health assessment questionnaire ii measured limitations with everyday activities ten items assessed difficulty with activities like walking stair climbing and lifting responses were on a 4point scale where 0 without any difficulty 3 unable to do a mean score was analysed respondents with oa were asked for the duration of their disease symptoms in years mental health the 20item center for epidemiologic studies depression scale measured depressive symptoms respondents reported on the frequency of symptoms experienced in the past week summed scores were analysed scores of 16 or more are often taken as evidence of depression the 14item perceived stress scale measured global stress levels in the previous month summed scores were analysed role conflict four new items were developed for this study measuring role conflict items asked the extent to which individuals had chosen between roles given up time in important roles had difficulty balancing roles and perceived they had too many role responsibilities responses were on a 5point scale summed scores were analysed health care utilization respondents reported whether or not they consulted with each of 12 categories of health professionals in the past year the number of responses was summed as an indication of health care utilization a 4item behavioural coping scale measured efforts to selfmanage ones health and included giving up or limiting time spent in activities modifying activities planning pacing or anticipating problems before they happened and receiving help responses on a 5point scale were summed analyses frequencies means and standard deviations were calculated for all variables chisquare and twoway analyses of variance tests compared oa and healthy control participants on sample characteristics pearson correlations examined the interrelationships among the role salience limitations and satisfaction components for those with oa and healthy controls linear regression analyses examined age oa age by oa interaction effects and role salience role limitations and role satisfaction as potential predictors of depression stress role conflict health care utilization and behavioural coping efforts analyses proceeded in steps age and oa main effects were entered first followed by age by oa interaction effects then role salience role limitations and role satisfaction variables were entered in the model results table 1 presents characteristics of the sample in general healthy control group participants were similar in demographic characteristics to the oa sample on average middleaged participants were 50 years old and older participants were 67 years old the sample included more women than men fewer olderaged oa participants had university educations and middleaged healthy controls were less likely to be married in keeping with their disease respondents with oa reported greater pain and activity limitations than healthy controls middleaged respondents with oa had significantly poorer selfreported health and greater fatigue than all other groups older adults with oa reported longer disease durations than middleaged adults with oa however their pain and activity limitations did not significantly differ not all respondents were involved in all roles assessed by the srpq overall385 were not involved in an intimate relationship 385 did not have children stepchildren or grandchildren 453 of respondents were not employed and 841 were not enrolled in educational activities twoway anovas found no group differences in involvement in an intimate relationship middleaged adults were significantly more likely than older adults to be living with children under age 18 and be employed healthy adults also were more likely to be employed and to be involved in continuing education than those with oa because educational pursuits were not applicable to most participants this role was dropped from subsequent analyses significant main effects for age and oa were found with middleaged respondents and those with arthritis reporting greater depression stress role conflict and behavioural coping efforts a significant interaction effect was found for health care utilization with middleaged respondents with oa reporting the greatest health care utilization of all groups the findings for the three role participation dimensions show that means were relatively high for role salience indicating that many participants rated a range of roles as important to their lives middleaged respondents regardless of their health reported that roles were more important to them than olderaged respondents middleaged respondents were also significantly more likely to report lower role satisfaction than their older counterparts however there was also a significant main effect for oa with those having arthritis reporting less role satisfaction than healthy controls an interaction between age and oa emerged for role limitations with middleaged participants with oa reporting significantly greater difficulties with their roles than all other groups we next examined the relationship of age oa and role perceptions to depression stress role conflict health care utilization and behavioural coping efforts linear regression analyses were performed in steps main effects for age and oa were tested first followed by age by oa interaction effects to simplify presentation of the data these data are combined and presented in model 1 model 2 adds role salience role limitations and role satisfaction to the analyses for model 1 there were significant age effects with middleaged respondents reporting greater stress and role conflict as well as a trend for greater depression than older adults model 1 also reveals that individuals with oa were significantly more likely to report depression stress role conflict health care utilization and behavioural coping efforts than all other groups there was a significant age by oa interaction for health care utilization indicating that middleaged adults reported greater health care utilization compared to all other groups there was also a trend for middleaged adults with oa to report greater depression than other groups model 1 rsquares were relatively low for depression stress and role conflict accounting for between 1319 of the variance rsquared values for health care utilization and behavioural coping efforts were 22 and 47 respectively model 2 examined the addition of role salience role limitations and role satisfaction to the analyses age remained significant for stress and role conflict but was not significant for depression those with oa continued to report greater health care utilization and behavioural coping efforts however oa was no longer significantly related to role conflict and only trends were found in predicting greater depression and stress age by oa interaction effects were not found with the exception of a trend for depression instead those with greater role limitations and lower role satisfaction reported significantly greater depression stress role conflict and behavioural coping efforts greater role salience and role limitations were also associated with more health care utilization model 2 rsquare values increased and accounted for 27 of the variance for role conflict and 39 and 44 of the variance for stress and depression respectively model 2 accounted for 30 of the variance for health care utilization and 59 of the variance for behavioural coping discussion findings support hypotheses that both age and oa relate to role participation perceptions and that middleaged participants with oa may report more difficulties with roles than their older counterparts or healthy individuals it also found support for assessing the meaning of roles as multidimensional and for examining role salience role limitations and role satisfaction these dimensions especially role limitations and satisfaction were related to depression stress role conflict health care utilization and behavioural coping efforts the findings are important because adults in their middle years typically are expected to take on a large number of diverse roles if individuals perceive that they are not able to participate fully in valued areas of life because of chronic diseases like oa it may have personal and societal consequences including implications for physical and psychological health findings from the study revealed that involvement in diverse roles was common among participants and that there were few group differences differences that existed generally were associated with age not oa although middleaged healthy adults reported greater salience or importance of roles in their lives compared to olderaged oa adults mean scores were relatively high suggesting that older adults may not be withdrawing from or reprioritizing their social roles as hypothesized in some theories of aging additional research needs to further examine involvement in roles and role salience particularly in larger population samples although our sample was diverse in terms of gender education marital status and income and participants with oa were comparable to clinical and population health studies in terms of pain disability and disease duration further research would enable a better understanding of whether role differences are largely related to age health or other factors middleand olderaged respondents with oa reported similar levels of disease severity yet middleaged adults with oa reported greater fatigue and role limitations than older adults with oa it is not immediately clear why this occurred however it suggests that variables other than a disease diagnosis are important in understanding peoples perceptions of role limitations conceptual discussions of the life course would speculate that it may reflect divergent social timetables and perceptions of what is normative at this time of life across middleand olderaged adults with oa for example middleaged adults with oa may have contact with fewer individuals who like them are living with oa as a result they may compare themselves to healthy peers who are able to do more or whose performance they believe is superior to their own to date we lack data on the role expectations of different age groups living with chronic illnesses if middleaged adults with oa perceive their condition as occurring prematurely and if their role expectations lead them to believe they are more limited in their role performance it can also explain why middleaged adults with oa reported lower role satisfaction than others perceptions of role participation age and oa were also important in understanding depression stress and perceived role conflict previous studies have found that individuals with chronic diseases are more likely to report poorer psychological wellbeing than their healthy counterparts however little attention has been given to specific sources of distress this study points to role limitations and role dissatisfaction as potential factors that contribute to poorer psychological wellbeing this was particularly true for those with oa however middleaged adults also reported greater stress and role conflict than older adults as such perceptions of role participation and age may warrant greater attention in intervention studies for those with chronic disabling diseases many selfmanagement programs focus primarily on symptom management and do not explicitly highlight limitations with role participation or perceptions of role dissatisfaction the findings are also important given that psychological health and physical health are often interrelated longitudinal research needs to examine the longterm implications of role limitations and dissatisfaction on changes in health like pain fatigue and activity limitations and whether this is moderated by other role perceptions such as role conflict differences in perceived role participation were also related to health care consultations and behavioural coping strategies age was unrelated to these variables not surprisingly those with oa reported more health care utilization and behavioural coping specifically greater role salience and role limitations were associated with consulting a greater range of health care professionals participants with more role limitations and less role satisfaction reported more behavioural coping efforts these findings are preliminary and need to be replicated particularly with longitudinal data additional research may point to role perceptions as being important factors in motivating health behaviours if so this information is of potential value to clinicians currently clinicians often emphasize the value of treatments in alleviating symptoms and delaying or halting disease progression however it may be important to discuss role demands in a patients life and their salience as well as the potential for treatment to impact role limitations and satisfaction as such the relationship of role participation perceptions to treatment adherence deserves increased attention several limitations to this research should be acknowledged first as noted in the introduction age is an imperfect proxy for life course demands although the age groups used in this study captured expected differences in role involvement additional research needs to more fully explore diverse roles in the lives of individuals of different ages in addition we created indices reflecting the importance difficulties and satisfaction individuals have with their roles but additional research needs to be conducted validating the srpq and assessing whether there are other dimensions that reflect the meaning quality and quantity of role domains this study drew on a sample of adults with oa and those with no chronic disabling health conditions although oa is among the most prevalent chronic diseases causing disability research is needed to replicate these findings with a greater range of chronic health samples and conditions including visibly disabling conditions and those that include cognitive impairments moreover including younger adults and adults with different onset ages of chronic disease in studies would increase our understanding of life course issues related to health and disability finally the study was crosssectional making the direction of effects unclear longitudinal studies would help clarify not only the direction of relationships related to health and role participation but also the impact of changes in participation on health population health studies are also needed to examine the generalizability of the findings in summary this study highlights that participation in roles is perceived as important across the life course however the occurrence of chronic health problems at different ages has important implications not only for role limitations and satisfaction but also for psychological wellbeing in particular middleaged adults with chronic conditions like oa may report more limitations in role participation and heightened distress than older adults this suggests potential new directions for interventions that take into account life course factors and that focus on helping individuals maintain involvement in valued roles

social role participation and the life course in healthy adults and individuals with osteoarthritis are we overlooking the impact on the middleaged soc sci med

Introduction Mobile social networking has gained the attention from academia, industry and governments during the past decade. Due to the technical advances of the WWW and mobile technologies, researchers in the field have done considerable work in promoting social communication in different ways [3][8]. But to our knowledge, few studies have investigated why and how people do social networking using mobile devices. Mobile devices are becoming a popular interface for accessing social networking services; when coupled with social networking these devices are allowing people to connect with family, friends, strangers and the community throughout the day, regardless of location. Mobile social networks services provide their users with instant and real-time access to their network. Based on a previous pilot study where we interviewed participants from a US university regarding their information needs and search behaviors on mobile devices, we found staying connected to social networks to be one of the emergent trends that motivate users to access the mobile Internet [6]. On an attempt to further understand this new trend, we distributed an online survey to various listservs in the world. This paper reports our results of the survey data and discusses the findings and our future work. --- Literature Review There is a rich set of work towards characterizing user behaviors in online social networks, however less has been done to study user behaviors in the mobile social network space. Mobile social networks could be classified into native mobile social networks and web-based social networks with mobile version. For example, Dodgeball is a mobile social networking service that allows people to broadcast their location via text messages to their networks. Dodgeball is a native mobile social network that does not have an online presence. On the other hand, Facebook, Google+ and Twitter are social networks which started online, and due to the increase in mobile devices use provide mobile access through an application. Some of the studies on mobile social networks have focused on native mobile social networks [4] [7], while others focused on social networks that exist online and provide mobile access through an app such as Facebook, Google+ and Twitter [2] [9] [13]. Research has shown differences between the way native and web-based mobile are used. Native mobile social networks have been used more to facilitate face-to-face interactions [4] [7]. As Köbler et al. pointed out, there has been a shift in the behavioral patterns and intentions of users of various mobile social networks towards a closer association between socializing in real life and the use of Social Network Systems. Hmphreys has focused on Dodgball. His study indicated that mobile social networks are used by people to be part of social molecularization. People use them to discover new places and alert others of the existence of such places, by checking in these places. According to him, by indirectly communicating about a place in real time, people exchange social-location information. This can result in a collective momentum of using the mobile social network system [4]. While the research reviewed above focused on native mobile social network services, this section focuses on web-based social networks. Cui & Wang conducted a diary study with 12 users in South Korea to characterize the experience of accessing social networks through mobile device. They found social connection, awareness, diversions and following notifications to be the main motivations behind this activity. "Awareness" emphasizes effortless access to information that enables people to pick it up with ease, make sense of it, and adjust their behavior accordingly. Their study reveals cross-medium alerts, especially push-messaging alert as a common trigger for mobile social networking sessions [2]. Rotman in their study of students and faculty members social networks use, reported responding to an alert is one of the major motivations to use mobile social networks. Mobile Facebook users observed in the study were continually looking for new updates, usually without a clear goal other than keeping up to date. They also observed Mobile Facebook users to check updates, but to seldom perform any active synchronous interactions with other users [9]. A more recent report by IDC Research supported by Facebook indicates that a "sense of being connected" is the strongest sentiment to use mobile social networks. It spans demographics and brands, services and applications used. In this study IDC conducted an online survey of 7,446 18-44 year old iPhone and Android smartphone owners in the U.S. over the course of one week. The study was an attempt to understand how smartphone owners use their mobile phones, with an emphasis on social media and communication. Participants in this study reports higher use of social applications during events when they are out socially interacting with others. The main reason behind this use is to instantly share experiences. Moreover, the ease of use mobile devices provide encourages sharing even more. The study has also looked at the different popularity of social networks including LinkedIn, Instagram and Twitter. In comparison to other mobile social network sites, the Facebook app dominates regarding the total time spent on social and communications activities on a smartphone [13]. Users have different concerns while using mobile social networks. Privacy is one of the main concerns regarding mobile social networking, especially for applications making use of Bluetooth sensing or applications that track users daily routines and preferences through their location [7]. Explicit, implicit, and automated sharing raise new concerns about privacy. Privacy is one of the main reasons that prevents people from sharing content online. Wiese et al. proposed creating a model of the interpersonal relationships between different people, rather than a social graph where everyone is simply a "friend" as a solution to manage information sharing in a better way. Their proposition is based on their findings that from all data they collected describing 2730 social relationships, self reported closeness was the best indicator of whether or not to share a piece of information, where common information is more likely to be shared [12]. The studies identified in this literature review did not focus on understanding any differences perceived by the users between sharing through a mobile device and a personal computer. These studies did not, as well, investigate the reasons that might discourage social networking users from accessing their networks through a mobile device. Our study is an attempt to explore these areas and to further understand mobile social networking user behaviors. In the following sections we will present our methodology, findings and future work. --- Methodology A survey was developed with different constructs related to social networking behaviors on mobile devices such as, frequency of usage, preferred social networks, topics shared, locations, and differences between behaviors on the mobile device and personal computer. This survey was sent to a variety of listservs including university and professional listservs. Participation on the survey was anonymous and the participants had the option of whether or not to answer specific questions in the survey. The internal validity of the survey was tested using 3 different pilots. --- --- Results The participants in our study expressed their use of a device for social networking. This is actually the case for 68.97% of our poll. The majority of these participants accessed social networks on a daily basis, 12.5% participants accessed them on a weekly basis and 5% rarely accessed them. Facebook was the most visited social network website among participants. The majority of participants said they use Facebook very often, 17.5% use it often and 12.5% use it sometimes and 5% use it rarely . Twitter was the most frequently used social network among participants, where 17.14% of the participants use it very often, 8.57% use it often, 25.71% use it sometimes, 20% use it rarely and 28.57% had never used it. Participants had also used their mobile device to blog, where 5.71% use it very often, 8.57% use it often, 17.14 use it sometime, and 17.14% use it rarely. Participants who access social networks through a mobile device used it mainly to read other people's updates and view photos posted by others . A fewer number of participants used these tools actively to post status updates, post pictures or comments. Only 5% of participants used the device to chat using social networks. Only 5% of participants used it to read articles. The main reasons for participants not to use their mobile devices for social networking are: 1) Device related: "the phone is not for this purpose" or "I do not trust the app"; 2) Network related: the connection is slow or expensive; and 3) Personal preference: I am not a fan of social networks. The majority of participants noticed minor differences between the topics they share using the mobile device and personal computers. According to participants, the topics shared through the mobile devices are more immediate, essential and pertaining to something current. One participant stated, "Topics I share through the phone are immediately pertaining to something instead of waiting to get to a computer to put up the status." These topics will be less descriptive and could be expressed with a shorter text due to the difficulty of typing on the mobile device keyboard, and as a participant pointed out "Less description because I don't like the keyboard on my phone. The phone is for quick, spontaneous thoughts or photo uploads." Topics that include links are more likely to be shared using the personal computer because of the copy-paste functionality. Pictures, on the other hand, are more likely to be shared using the mobile device instantly right after the photo is captured. The main reasons these participants prefer mobile devices to a personal computers are mobility , convenience and ease of use . Participants access social networks through their mobile devices everywhere , when they do not have access to a computer , in bed , on the go , in school and at work . --- Conclusion and Future Work We collected data from an online survey that asked questions regarding people's use of social networking using mobile devices. Our findings are of great interest for our area of research. It seems that Facebook and Twitter are the most popularly used social networking sites. When people do social networking, they read or write posts, and share posts and pictures with each others. They share similar topics using mobile and using personal computers. We also found that mobile devices made social networking more convenient because people can stay connected almost everywhere, whenever they want to. Privacy did not seem to prevent participants from using mobile social network. Participants in our survey did not indicate any concern regarding their privacy. In this study, we made an effort towards a better understanding of mobile users' social networking behavior. We plan to further explore how people collaborate in the social networking environment and how they interact with each other using mobile phones. In the next phase we plan to extend our study by targeting a larger number of participants; and using responses from this survey to create categories for the next survey questions. Other areas discussed in this paper are in need of more research. One of the findings indicates that the majority of activities reported by participants in our survey were more passive than active . A future research could investigate the reasons for which users prefer to be passive rather than active while using mobile social networks. The study also reports perceived differences between the topics shared using a mobile device and a personal computer. As a next step, we will emphasize more the understanding of which topics users share with others and whether or not they have any privacy concerns while sharing these topics. Moreover, the next phase will investigate how mobile social interactions may affect social interactions with others in general. This is of great interest to the authors since it is one of the areas where mobile social networks differ from online social networks.

The burgeoning domain of social media has infiltrated general populations and has achieved broad applicability [10]. This domain has been studied extensively but there is a deficiency of research in the area of social media and mobile access and use [1] [11]. This study examines not only the use of social media on mobile devices but extends the ideas of this area of research to evaluate how social media is being used on mobile devices. It reports the findings of an online survey of 73 participants recruited from different listservs in the world. The study shows that the majority of participants use social networks as consumers (e.g. read other people posts), more than producers (i.e. post status update or a photo). It also reveals some differences between the topics participants share through a mobile device and a personal computer.

introduction mobile social networking has gained the attention from academia industry and governments during the past decade due to the technical advances of the www and mobile technologies researchers in the field have done considerable work in promoting social communication in different ways 3 8 but to our knowledge few studies have investigated why and how people do social networking using mobile devices mobile devices are becoming a popular interface for accessing social networking services when coupled with social networking these devices are allowing people to connect with family friends strangers and the community throughout the day regardless of location mobile social networks services provide their users with instant and realtime access to their network based on a previous pilot study where we interviewed participants from a us university regarding their information needs and search behaviors on mobile devices we found staying connected to social networks to be one of the emergent trends that motivate users to access the mobile internet 6 on an attempt to further understand this new trend we distributed an online survey to various listservs in the world this paper reports our results of the survey data and discusses the findings and our future work literature review there is a rich set of work towards characterizing user behaviors in online social networks however less has been done to study user behaviors in the mobile social network space mobile social networks could be classified into native mobile social networks and webbased social networks with mobile version for example dodgeball is a mobile social networking service that allows people to broadcast their location via text messages to their networks dodgeball is a native mobile social network that does not have an online presence on the other hand facebook google and twitter are social networks which started online and due to the increase in mobile devices use provide mobile access through an application some of the studies on mobile social networks have focused on native mobile social networks 4 7 while others focused on social networks that exist online and provide mobile access through an app such as facebook google and twitter 2 9 13 research has shown differences between the way native and webbased mobile are used native mobile social networks have been used more to facilitate facetoface interactions 4 7 as köbler et al pointed out there has been a shift in the behavioral patterns and intentions of users of various mobile social networks towards a closer association between socializing in real life and the use of social network systems hmphreys has focused on dodgball his study indicated that mobile social networks are used by people to be part of social molecularization people use them to discover new places and alert others of the existence of such places by checking in these places according to him by indirectly communicating about a place in real time people exchange sociallocation information this can result in a collective momentum of using the mobile social network system 4 while the research reviewed above focused on native mobile social network services this section focuses on webbased social networks cui wang conducted a diary study with 12 users in south korea to characterize the experience of accessing social networks through mobile device they found social connection awareness diversions and following notifications to be the main motivations behind this activity awareness emphasizes effortless access to information that enables people to pick it up with ease make sense of it and adjust their behavior accordingly their study reveals crossmedium alerts especially pushmessaging alert as a common trigger for mobile social networking sessions 2 rotman in their study of students and faculty members social networks use reported responding to an alert is one of the major motivations to use mobile social networks mobile facebook users observed in the study were continually looking for new updates usually without a clear goal other than keeping up to date they also observed mobile facebook users to check updates but to seldom perform any active synchronous interactions with other users 9 a more recent report by idc research supported by facebook indicates that a sense of being connected is the strongest sentiment to use mobile social networks it spans demographics and brands services and applications used in this study idc conducted an online survey of 7446 1844 year old iphone and android smartphone owners in the us over the course of one week the study was an attempt to understand how smartphone owners use their mobile phones with an emphasis on social media and communication participants in this study reports higher use of social applications during events when they are out socially interacting with others the main reason behind this use is to instantly share experiences moreover the ease of use mobile devices provide encourages sharing even more the study has also looked at the different popularity of social networks including linkedin instagram and twitter in comparison to other mobile social network sites the facebook app dominates regarding the total time spent on social and communications activities on a smartphone 13 users have different concerns while using mobile social networks privacy is one of the main concerns regarding mobile social networking especially for applications making use of bluetooth sensing or applications that track users daily routines and preferences through their location 7 explicit implicit and automated sharing raise new concerns about privacy privacy is one of the main reasons that prevents people from sharing content online wiese et al proposed creating a model of the interpersonal relationships between different people rather than a social graph where everyone is simply a friend as a solution to manage information sharing in a better way their proposition is based on their findings that from all data they collected describing 2730 social relationships self reported closeness was the best indicator of whether or not to share a piece of information where common information is more likely to be shared 12 the studies identified in this literature review did not focus on understanding any differences perceived by the users between sharing through a mobile device and a personal computer these studies did not as well investigate the reasons that might discourage social networking users from accessing their networks through a mobile device our study is an attempt to explore these areas and to further understand mobile social networking user behaviors in the following sections we will present our methodology findings and future work methodology a survey was developed with different constructs related to social networking behaviors on mobile devices such as frequency of usage preferred social networks topics shared locations and differences between behaviors on the mobile device and personal computer this survey was sent to a variety of listservs including university and professional listservs participation on the survey was anonymous and the participants had the option of whether or not to answer specific questions in the survey the internal validity of the survey was tested using 3 different pilots results the participants in our study expressed their use of a device for social networking this is actually the case for 6897 of our poll the majority of these participants accessed social networks on a daily basis 125 participants accessed them on a weekly basis and 5 rarely accessed them facebook was the most visited social network website among participants the majority of participants said they use facebook very often 175 use it often and 125 use it sometimes and 5 use it rarely twitter was the most frequently used social network among participants where 1714 of the participants use it very often 857 use it often 2571 use it sometimes 20 use it rarely and 2857 had never used it participants had also used their mobile device to blog where 571 use it very often 857 use it often 1714 use it sometime and 1714 use it rarely participants who access social networks through a mobile device used it mainly to read other peoples updates and view photos posted by others a fewer number of participants used these tools actively to post status updates post pictures or comments only 5 of participants used the device to chat using social networks only 5 of participants used it to read articles the main reasons for participants not to use their mobile devices for social networking are 1 device related the phone is not for this purpose or i do not trust the app 2 network related the connection is slow or expensive and 3 personal preference i am not a fan of social networks the majority of participants noticed minor differences between the topics they share using the mobile device and personal computers according to participants the topics shared through the mobile devices are more immediate essential and pertaining to something current one participant stated topics i share through the phone are immediately pertaining to something instead of waiting to get to a computer to put up the status these topics will be less descriptive and could be expressed with a shorter text due to the difficulty of typing on the mobile device keyboard and as a participant pointed out less description because i dont like the keyboard on my phone the phone is for quick spontaneous thoughts or photo uploads topics that include links are more likely to be shared using the personal computer because of the copypaste functionality pictures on the other hand are more likely to be shared using the mobile device instantly right after the photo is captured the main reasons these participants prefer mobile devices to a personal computers are mobility convenience and ease of use participants access social networks through their mobile devices everywhere when they do not have access to a computer in bed on the go in school and at work conclusion and future work we collected data from an online survey that asked questions regarding peoples use of social networking using mobile devices our findings are of great interest for our area of research it seems that facebook and twitter are the most popularly used social networking sites when people do social networking they read or write posts and share posts and pictures with each others they share similar topics using mobile and using personal computers we also found that mobile devices made social networking more convenient because people can stay connected almost everywhere whenever they want to privacy did not seem to prevent participants from using mobile social network participants in our survey did not indicate any concern regarding their privacy in this study we made an effort towards a better understanding of mobile users social networking behavior we plan to further explore how people collaborate in the social networking environment and how they interact with each other using mobile phones in the next phase we plan to extend our study by targeting a larger number of participants and using responses from this survey to create categories for the next survey questions other areas discussed in this paper are in need of more research one of the findings indicates that the majority of activities reported by participants in our survey were more passive than active a future research could investigate the reasons for which users prefer to be passive rather than active while using mobile social networks the study also reports perceived differences between the topics shared using a mobile device and a personal computer as a next step we will emphasize more the understanding of which topics users share with others and whether or not they have any privacy concerns while sharing these topics moreover the next phase will investigate how mobile social interactions may affect social interactions with others in general this is of great interest to the authors since it is one of the areas where mobile social networks differ from online social networks

the burgeoning domain of social media has infiltrated general populations and has achieved broad applicability 10 this domain has been studied extensively but there is a deficiency of research in the area of social media and mobile access and use 1 11 this study examines not only the use of social media on mobile devices but extends the ideas of this area of research to evaluate how social media is being used on mobile devices it reports the findings of an online survey of 73 participants recruited from different listservs in the world the study shows that the majority of participants use social networks as consumers eg read other people posts more than producers ie post status update or a photo it also reveals some differences between the topics participants share through a mobile device and a personal computer

Parent-child relationships are lifelong, generally only "partially voluntary" and "based on interconnected experiences in the past and the expectation of interconnected experiences in the future" . Taking a contextual view on parent-child relationships across the lifespan is critical as changes occur in the larger social and physical environment. A recent contextual change was the emergence of the novel coronavirus , which was declared a national health emergency in the United States on March 13, 2020 . Throughout history, families have experienced expected and unexpected crises, and families have varied in how they have weathered these crises . The current study was designed to explore parents' perceptions of how the early weeks of the COVID-19 pandemic influenced their parent-child relationships. --- Theoretical Framework From an Ecological Systems perspective, humans develop through bidirectional interactions within concentric ecosystems ). These systems include micro-, meso-, exo-, macro-, and chronosystems. The microsystem involves the enduring, day-to-day interactions, which includes the parent-child relationship . The mesosystem includes the interactions between two microsystems , the exosystem represents an environment that influences the developing human, but they are not directly involved , and the macrosystem includes the cultural and societal values in which the developing human is embedded. Finally, the chronosystem accounts for time and the sociohistorical conditions in which development occurs . --- 3 Adults experience typical changes in their ecological system levels across early , middle , and late adulthood . These changes over time influence the role of parents and children within the parent-child microsystem . The chronosystem also accounts for the atypical sociohistorical conditions that affect human development, which would include the declaration of the COVID-19 pandemic in March 2020 . At the beginning of the COVID-19 pandemic, at exoand macrosystem levels, non-pharmaceutical public health interventions were implemented to slow the spread of the virus and there was uncertainty about the virus and potential duration of the pandemic . Menter et al. explained: The COVID-19 pandemic has resulted in widespread impact on the daily lives of children and their parents. Human development occurs within interactive systems, and thus, disruptions such as those attributed to COVID-19 across multiple systems may impact children and families. The current study focused on experiences within the parent-child relationship in the context of the onset of the COVID-19 pandemic . Capturing the experience of parent-child relationships in the early weeks of this pandemic could provide knowledge related to how best to support parents and children in the onset of potential future public health crises. --- Parent-Child Relationships and COVID-19 Pandemic Parents and children have likely experienced a variety of changes as a consequence of the COVID-19 pandemic . To slow the spread of the virus, public health interventions were implemented, and by March 23, 2020, 43 states had state-wide stay-athome orders . This led to changes for parents and children as schools and childcare agencies closed, work expectations shifted, and socializing opportunities became restricted . This resulted in "profound changes to family routines and rituals that are often taken for granted," but there was likely "considerable variability" in the ways families were impacted in the early weeks of the COVID-19 pandemic . Many parents of school age children found themselves balancing working from home while caring for and educating their children . However, this balancing of new roles may be different for father-child and mother-child relationships. Although father engagement in childcare responsibilities and time spent with children has been increasing, mothers continue to spend more time with children and do more of the childcare responsibilities . In general, during the pandemic, parents have had to increase their time spent caring for their children, but mothers have continued to spend more time on childcare responsibilities than fathers and have also experienced a higher likelihood of reducing work hours, transitioning out of the workforce, and experiencing higher psychological distress . It is unclear how these new roles might have influenced parent-child relationships, but it is possible with limited interaction outside the home and parents taking on more roles in their children's lives that there could be increased strain on parent-child relationships. For instance, in qualitative pandemic research, adolescents indicated that they felt isolated and some reported arguing more with their parents . Further, the quality of parent-child interactions with young children could have also potentially declined during the pandemic as mothers of young children have been reported to be at higher risk for parenting-related exhaustion . Although, parent-child relational experiences may have been more typical earlier in the pandemic because there was not a clear perspective on the potential duration of the pandemic. Parents and children of all ages may have experienced increased social isolation, economic challenges, and limited access to supportive resources . Adults over the age of 65 are at higher risk of getting seriously ill or dying from COVID-19 . Parents in late adulthood may have also experienced disrupted family routines in order to stay protected from contracting the virus-especially those grandparents providing care for grandchildren while their adult children work and older adults receiving care from their adult children . Parents in late adulthood may have also experienced more demonstrations of concern from their children during the pandemic as adult children "transition from the one being protected in the relationship to the one who is doing the protecting" . In emerging qualitative research with older adults during the pandemic, participants reported that they were worried about their adult children's health and were missing their families . Although, these same older adults reported that they were still connecting with family and friends via technology during the pandemic. Women in late adulthood reported higher rates than men in viewing digital communication as a source of joy during the pandemic. At present, research with parents during the COVID-19 pandemic has primarily focused on parenting stress and burnout of parents of school age children. Brown and colleagues indicated that parents did experience changes in mood and increased general stress levels during the COVID-19 pandemic, which is problematic because these parents also likely had lower access to support from external sources. Potential risks of increased parental stress have been reported to be child abuse or decreased parent-child relational quality due to "coercive cycles in parent-child interactions" . As research on the COVID-19 pandemic and parent-child relationships continues, there would be value in expanding research beyond parent-child relationships with school-aged children and to begin to understand parent-child relationships across the lifespan. --- Purpose of the Current Study There will be individual and relational differences in how parents are influenced by the COVID-19 pandemic . It is also likely there will be different experiences at the beginning, middle, and end of the pandemic. For instance, the public health measures were stricter in the early weeks/months , and there was unknown information about the virus. The current exploratory study was designed to understand how parents perceived their parent-child relationships were influenced by the early weeks of the COVID-19 pandemic. Consistent with previous conceptualizations of adulthood age groups , experiences of parents were examined by early , middle , and late adulthood. --- Methods --- Sample Participants included 365 adults from 44 states in the United States . Participants reported having between one and eight children . Parents indicated that they had between zero and seven children ages 18 and under currently living with them . See Table 1 for sample characteristics. --- Procedures Study procedures were approved by a university Institutional Review Board. This study is part of a larger study on wellbeing during the COVID-19 pandemic . Data were collected in two ways: snowball sampling through social media with a gift card raffle incentive and through Prime Panels , which is an established way of recruiting diverse community samples . All participants completed an online survey administered through Qualtrics between March 21 and 31, 2020. To check for understanding and refine the survey, the survey was piloted with 20 adults prior to data collection. Various strategies were used with the online survey to ensure data quality . Sample inclusion required the participant to have at least one child. Initially, 663 participants completed the survey, and 221 were excluded because they did not report having children, 14 additional participants did not provide enough information to be included , and 63 of surveys were excluded because they did not meet the established data quality requirements. --- Data Collection and Analysis The survey asked for demographic information and level of social distancing. Additionally, participants reported how many children they had and how many were 18 years or younger and living with them. Participants were asked an open-ended item: How would you say the coronavirus A conventional qualitative content analytic approach was selected for this study . This qualitative analytic approach is used to "describe a phenomenon" through gaining "direct information from study participants without imposing preconceived categories" and is described an inductive method . This was an appropriate approach as the goal was to understand how parents perceived their parent-child relationships were influenced by the early weeks of the COVID-19 pandemic-allowing the codes and themes to "flow from the data" . The two researchers who conducted the qualitative analysis had previous training and experience in qualitative analysis. Consistent with qualitative conventional content analysis , two researchers independently immersed themselves in the data to identify key words and ideas. The two researchers then met together and identified and defined 14 coding categories that represented participant experiences. To evaluate the utility of the coding scheme, the researchers initially coded 20 responses independently, compared coding decisions, and then made necessary refinements to coding rules/definitions. The two researchers then independently coded the full dataset , and coding disagreements were resolved through discussion. In line with qualitative conventional content analysis , the two researchers reviewed the similarities within codes and identified three key categories or themes that represented the participants' experiences. To further enhance the trustworthiness of the results, member checking was used . At the conclusion of the survey, participants who were recruited through snowball sampling were directed to a separate survey where they could document their participation for the incentive. This survey also had an item that explained member checking and invited participants to provide their email address if they were willing to review the completed results and provide feedback via email. Ten of the participants who volunteered were selected at random and emailed the complete results section to consider how the results represented their own experience, their peers' experiences, and to make any recommended changes. Participants indicated that results did represent their own/their peers' experiences. --- Results Participants' experiences in parent-child relationships during the early weeks of the COVID-19 pandemic were represented in three themes (see --- Relational Steadiness Participants reported that their parent-child relationships remained steady during the early weeks of the COVID-19 pandemic. Young and middle-aged adults explained that they were "now spending more time with my children than before due to the coronavirus pandemic" , "but how we behave and interact [in our parent-child relationships] hasn't changed" . Older adults did not report more time with their adult children during the onset of the pandemic but did report that there were "no changes" in their parent-child relationships. --- Young Adults Participants within this age group emphasized that the early weeks of the pandemic had "not influenced my relationship with my children" , "things [in my parent-child relationship] are about the same" , or "it really hasn't taken a toll on my [parent-child relationship]" . Young adults explained that they were spending more parent-child time together, but more women than men reported this. Most participants indicated that this increased time was not affecting their parent-child relationships because their children were young and already required more parental time and attention and were unaware of "what's going on in the world" . More young adult parents who were full-time students or part time employed shared this perspective than those who were homemakers , full time employed , or unemployed . For example, participants shared "My children are very young. COVID-19 hasn't had a direct effect on my relationship with my children, other than me spending more time at home with them" , and "Since my son is not old enough for school yet, things are about the same" . --- Middle-Aged Adults Participants in the middle-aged adult age group explained that the pandemic had "no impact on my relationship with my children" . The participants explained that they had established quality parent-child relationships prior to the pandemic, and this did not change at the onset of the pandemic. Commenting on the parent-child relationships prior to the pandemic, participants shared that, "I feel that we had a good [parent-child] relationship before COVID-19" or "We have a close [parent-child] relationship already" and that the changes related to the pandemic have not influenced their relationships. For example, a mother who was full-time employed explained, "My son is an 18-yearold senior in high school. Prior to the pandemic, we were really close. COVID-19 has not changed this." Some middle-aged adult participants acknowledged that there was a change in the quantity of time they spent with their children during the early weeks of the pandemic-"I have more time to be with [my children]" . This was reported more by participants who were part-time employed or homemakers than those who were unemployed or full time employed . However, participants did not feel that this increased time had influenced their parent-child relationships. For instance, participants explained, "We've had more time to spend together because we are under quarantine, but the nature of our relationship is still the same" , and "It hasn't really affected our relationship. I've gotten more time for them" . --- Older Adults Participants in late adulthood contributing to this theme reported that the early weeks of the pandemic had "no influence," "no effect," or led to "no changes" in their parent-child relationships. These participants further explained that "my children are all adult children" , "my children are grown" , and "none of our children live with us" . Although parent-child relationships were reported as having "always been close" , there was already physical distance in the parent-child relationship prior to the pandemic so "our [parent-child] relationship has really not changed" . Emphasizing this point a participant shared, "[the pandemic] has not affected the [parent-child] relationships. One of our children lives in Spain and the other in Hawaii, while we are in California" . As adult children were not living with their parents and there was physical distance prior to the pandemic, no older adult participants reported spending more time with their children as a result of the early weeks of the pandemic. Participants reported that the COVID-19 pandemic increased fear, anxiety, uncertainty, and stress. Further, the affiliated non-pharmaceutical public health interventions resulted in restricted activities, stay-at-home orders, and new or revised roles. Participants explained that these pandemic generated experiences posed challenges that had to be navigated within parent-child relationships. --- Young Adults Participants indicated that there were a lot of unknowns at the onset of the pandemic, and they were prioritizing keeping their children "safe" and "doing the best I can to protect them" . Young adults explained that time spent in the parent-child relationship involved teaching their children about methods to decrease "spreading germs" and specifically having to navigate social distancing expectations . Participants reported that their children were frustrated with them because they wanted to "go places," were "missing friends," and were "getting bored" and "stir crazy" from having parents as "their only social interaction right now" . A mother shared, "I had to spend a lot of time explaining to my 4-year-old why t-ball, preschool, church, and his birthday party were cancelled." Participants stated that children and parents experienced "anxiety" and "stress" around the virus and public health interventions, and this led to "concern," "less patience," and "tension" in the parent-child relationships. Some older children experienced anxiety about the virus itself and parents were trying to navigate how to address children's fears. A participant explained that she was trying to figure out how best to address her son's fear because, "My oldest is struggling with the 'virus' talk. It is scary to him because he does not understand the entire context, and when he hears taglines like '15 people died today' it is scary." Participants worried about how their own fear and stress were influencing their parent-child relationships. They realized they were using "screen time" to entertain children, taking less time to "play with kids," and using "more emotional responses to children's misbehavior instead of teaching responses" . A participant disclosed : I have become more fearful in general and more irritable. More prone to yelling. I try to apologize and make things right with my kids, but at the very least they see my tension and fear which I pray is not damaging. Adding to the stress and strain on the parent-child relationships, young adults reported having to provide care for their children all day and assist older children with their schooling . This required finding a new balance for many as they were also working or completing schooling from home. More women than men reported having to find balance in these roles. --- Middle-Aged Adults Participants indicated that they were working to navigate COVID-19 concerns and social distancing expectations in their parent-child relationships, which meant they "had to answer some tough questions" from their children as they learned to "take and stick to measures stipulated by the CDC" . Having to enforce adherence to public health guidelines and having a lot of parent-child time reportedly led to more parental and child frustration for middle-aged adults. Participants explained, "It's stressful communicating with my 3 children in their 20's about the importance of social distancing" , and "[My son] believes COVID-19 is a government conspiracy and is frustrated that I don't agree" . Parents had to help children cope with the loss of events, social activities, the consistency of school attendance/moving home to complete college remotely, and adult children losing jobs while both parents and children experienced "fear," "uneasiness," "anxiety," and "concern." A mother of six children elaborated The youngest are not understanding why they can't play at the neighbor's house or why we are staying home day in and day out. Our older 3 are concerned, and helpful. Our 11-year-old had spent the last six months earning money to tour Italy with some other students from his school as well as his dad. That trip was cancelled, and spring break has been spent at home. The rain is needed, but also isolating at this time. We are up and down with our patience and understanding with each other [in the parent-child relationships]. More middle-aged adult women than men reported having to figure out how to balance their different professional, family, and new roles during the early weeks of the pandemic. Participants who were homemakers reported this more than those with other employment statuses . A mother shared Things are strained in our [parent-child] relationships due to working from home in addition to trying to supervise four kids . I think the older kids find us to be irritable at times, but when we're not working, we're making extra effort to focus on them. We're having … more strained and tense moments. A grandmother , who had adult children who had to continue working without the availability of school or childcare, had to take on new roles to support her children because she could work from home. She explained that her grandchildren were brought to her house, and "I am now the childcare provider, homeschool teacher, online teacher [her professional position], chief cook, and bottle washer. This is no exaggeration. I have grandkids that are 12, 4, 2 and 11 months." Further, participants reported more parent-child relationship challenges as they took on ensuring their children completed their schoolwork at home-"teenagers have online courses and are not doing their part to keep up-requiring me to 'hound' them a bit more than I'd like" . --- Older Adults Where young and middle-aged adults reported spending more time or too much time with their children, older adults expressed that social distancing had decreased the time they physically spent with their adult children-"[My adult children] don't visit now" and "We are not able to get together as often as we did [before the pandemic]" . Older adults explained that they and their adult children had concerns about COVID-19 particularly related to older adults being "considered high risk" for serious complications with the virus. Older adults especially reported that they and their adult children were "being more cautious," "cancel[ed] family gatherings, " and "visit[ed] in the yard at a distance" out of concern for each other's health and safety. Some adult children were reported to be insistent about their parents' practice of social distancing. A participant shared, "[My son] won't let me go anywhere because of my age and my health." Another participant explained that she and her husband "usually watch the grandchildren," but because of the pandemic, they had discontinued this as "they [the adult children/grandchildren] are self-quarantining away from us". Apart from health concerns related to COVID-19, an older adult also expressed concerns about employment for one of her adult children. She explained that she had two adult children, "One has lost his job. It is very stressful, and he will need our support. My other son is doing fine as he lives with his partner and both are currently employed." --- Relational Enhancement Some participants shared that they experienced enhancements in their parent-child relationships during the early weeks of the pandemic. There was an opportunity for more quality in-person time in early and middle-aged adult parent-child relationships. Older adults experienced more technology facilitated connection with their children. --- Young Adults Despite the unknowns and stress of the pandemic, some young adults expressed that their parent-child relationships had improved and that they were able to spend more quality parent-child time together . More quality parent-child time during the early weeks of the pandemic was reported by those who were homemakers or full time employed , but some full-time students and parttime employed individuals shared this perspective. One mother reported feeling "more grateful for the little things, like snuggling [my son] before naps or kissing him before bed" and a father simply stated that the increased [parent-child] time together, "[during this pandemic has] helped us draw closer together"] . Young adult women found creative ways to engage their children through increased educational and enrichment activities. A mother stated, "I have become a lot more creative in things [during pandemic restrictions]. I find myself concentrating on teaching [my children] more academic things. ." Other participants reported bonding through more play time. For example, a mother described, "we have a lot more time to cook nice meals and play Legos together" . Participants explained that in addition to more quality time spent together, they had also been more reflective in their parenting role, which led to improvements in their parent-child relationships. A mother shared It has been tricky to know if we need more structure or less structure. … But we're not overwhelmed. I'm taking things easy and slow for them. I feel like this is really giving me time to reflect on their needs, what makes them each a person, and how can I support their development. I find myself thinking more about this on a different and deeper level than I did before. I'm also thinking a lot about what family values and culture I can create during this time. --- Middle-Aged Adults While COVID-19 brought up some challenges in family connections, some middle-aged adults conveyed that the public health restrictions had enhanced their parent-child relationships . Participants remarked on how appreciative they were of the time they were spending together. Participants indicated that the pandemic did not just increase the quantity of time together, but also the quality of time spent in parent-child relationships. More parent-child quality time was reported by middle-aged adults who were homemakers than those who were part time employed , full time employed , unemployed , and disabled . The closures and cancelation of events created more downtime and parents explained, "we've had fun slowing down and spending all our time together" . A father explained that he experienced: much more interaction than when I am at work for most of the day and [my children] are at school . Not only is our interaction more frequent, but it has definitely led me to helping [my children] with … their chores and doing other activities with them. Each day has become a Saturday! Some participants explained that they had become more creative with their parent-child time-"we are reading together, playing games & cooking together" . Quality parent-child interactions also increased with older children who were not living at home via technology. In line with this sentiment, two mothers explained that the pandemic, "has affected my relationship with [my young adult children] for the better because we've had more in-depth conversations about the virus, but also life in general" and "I check up on them more and am very interested in how they are feeling/coping" . --- Older Adults Older adults did not report that they had the opportunity to have more quality in-person time with their children during the early weeks of the pandemic. However, they did report that they had been "check[ing] on each other more frequently" and "keeping in touch more and checking in more frequently" within their parent-child relationships. Older adults explained that various technology-based communication mediums have been used to keep in contact with their adult children "frequently", "daily," and "more often." For instance, "[My adult children and I] keep in contact via Facebook" , and "We have Face Timed so we can 'see' [our adult children] and are checking in with each other more by phone and text and the Group Me App is being used even more" . Older adult parents reported things like, "I feel closer to [my adult children]" and "Calling more often has allowed for sharing more feelings. Although, not directly about the pandemic" as they discussed how the "closer contact" during the initial weeks of the pandemic had enhanced their parent-child relationships. --- Discussion The current study explored parent-child relationships in the context of the early weeks of the COVID-19 pandemic through parent perceptions. Bronfenbrenner indicated that development is influenced at the chronosystem level, which accounts for the sociohistorical conditions. COVID-19 is a unique sociohistorical condition for contemporary parent-child relationships . It is imperative to investigate parent-child relationships during significant, on-going, and dramatic changes at a societal level to understand how these relationships are affected by such changes , and the COVID-19 pandemic significantly influenced day-to-day life across the world . Nearly one third of the parents in this study believed that the early weeks of the COVID-19 pandemic did not lead to significant changes within their parent-child microsystems. Young adults explained that their children were young, did not understand what was happening, and already required more time for parental care. Where middle-aged adults indicated that they had established positive parent-child relationships prior to the pandemic and the pandemic did not change this. Some young and middle-aged adults did acknowledge that because of school closures and movement to remote work that they had more time in the homes together but did not feel this drastically changed anything in their parent-child relationships. Although, consistent with emerging pandemic research, more women reported increasing time spent with their children than men , and considering a mesosystem level, those adults who were students, part time employed, and homemakers also reported more time with children than those who were full time employed. Older adults also stated that their parent-child relationships remained unchanged during the early weeks of the pandemic. In line with typical adult development , their children were adults who lived independently, and many expressed there was already physical distance in their relationships prior to the pandemic. Prime and colleagues postulated that the pandemic increased demands on the parent-child dyad to negotiate topics that, prepandemic, may not have been problematic or that were virtually nonexistent . The effects of extended isolation and home confinement that are inherent to the COVID-19 crisis are causing profound changes to family routines and rituals that are often taken for granted … In line with this postulation, there were some parents in the young and middle-aged adult age groups who expressed difficulties at the parent-child microsystem and mesosystem levels as they discussed having to adapt to taking on new roles, spending too much time together in the house and coping with fluctuations in patience and understanding. Zamarro and Prados concluded that, "women have carried a heavier load than men in the provision of childcare during the COVID-19 crisis, even while still working" . In the current study, more young and middle-aged adult women shared that they had to balance new and existing roles than men. Brown and colleagues stated, "The global COVID-19 pandemic is a stressor that originated outside of the family system but given the novelty and uncertainty concerning this disease, it is likely to be perceived as a significant stressor for many parents and children" . Parents in the sample did perceive that both parents and children experienced some anxiety related to COVID-19 or related uncertainties. Within the adults' responses, there was evidence of awareness and concern with the bidirectional influence within the parent-child microsystems as they described the potential influence of their own stress and anxiety on their children and vice versa. Public health interventions required more adaption-young adults largely focused on teaching children about preventing the spread of germs, where middle-aged adults focused their attention explaining and enforcing social distancing protocols with their children. Parents in early and middle adulthood explained that they had to be considerate about how to talk to their children about the virus, while also helping them understand and grieve/cope with missed events . Older adults reported that their adult children were concerned about their age and the potential health risks of the disease. These older adults indicated larger changes in the parent-child microsystem as they described experiencing a decreased amount of in-person time spent with their adult children during the early weeks of the pandemic and that this was related to the implementations of social distancing. As children age into adulthood, parent-child relationships become more reciprocal . This parent-child reciprocity was evidenced by adult children's concerns for parent health/implementation of public health interventions, the few parents who were concerned about their adult children's financial well-being, and the increased communication from adult children as reported by their parents. Prime and colleagues reasoned that the impact of the COVID-19 pandemic would vary greatly by family. In line with this reasoning, some parents in this study highlighted that the parent-child microsystem experienced relational enhancement during the early weeks of the pandemic. Participants in the early and middle years of adulthood explained that they did not just spend more time with their children but also experienced more quality time with children as busy schedules slowed or stopped. Vaterlaus and colleagues postulated that interactive technology could be an adaptive tool at the microsystem level to facilitate connection in a parent-child relationship when physically apart. Consistent with this postulation, participants with adult children expressed enhanced parent-child relationships as they communicated more through a variety technology platforms and devices. Whitehead and Torossian reported that more older adult women than men viewed digital communication as a source of joy during the pandemic. In the current study, more women than men specifically addressed that they had engaged in more digital communication with their children during the early weeks of the pandemic. --- Limitations This study did have limitations and the results and implications should be considered with these limitations in mind. The study was cross sectional and only represented experiences from the initial weeks of the pandemic. Stressors build in families and parent-child relational experiences could be quite different after one year into the pandemic depending on the resources available within the family. The survey design allowed for data collection from a broad group of adults in a short period of time, but the use of one open-ended question in the survey did not allow for further probing or clarifying questions. In-depth interviews should be considered in follow-up studies. The study also had lower participation of older adults and did not represent the experience of adults living in long-term care or assisted living facilities. The use of online recruitment and online surveys may have not reached older adults who do not use or experience lower comfortability with technology. While the sampling procedure was appropriate for an exploratory study, a non-probability sample can limit the representativeness of the experiences. There was lower participation of people of color, most of the sample was employed and had earned college degrees . The COVID-19 pandemic has had a disproportionate impact on underrepresented racial groups and people with lower economic resources in the United States , which may have a deleterious influence on parent-child relationships with the potential for increased stressors and lack of support from external resources during the pandemic . Further, only parent perceptions on the parent-child relationship were included. Future longitudinal research should aim to replicate this study with parents and children from a variety of racial groups, employment statuses, and educational/ income levels. --- Implications and Future Research Despite the limitations, the present study's approach acknowledged that parent-child relationships change over time and that parent-child relationships should be studied in context when there are significant and on-going changes in society . Prime et al. indicated that the impact of the COVID-19 "pandemic on family well-being is presently unknown" and this study contributes to emerging knowledge. Further, most published studies with parent samples during the pandemic have focused solely on adults with school-aged children and parenting stress or burnout . It is of great importance to continue with these research topics to ensure the safety of parents and children, and it is also important to acknowledge that there is "considerable variability in how families will be impacted by the COVID-19 pandemic" . The current study showed varied perceived impacts of the pandemic on parent-child relationships from the perceptions of young, middle-aged, and older adults during the first weeks of the pandemic. Some perceived no change while others perceived challenges or even relational enhancement. The focus of this study was on parent-child relationships during the early weeks of the pandemic. There is the potential for future large-scale public health crises and results in the current study may provide helpful implications and future research directions that could support parent-child relationships in the initial onset of similar crises. Young and middle-aged adults may benefit from brief, accessible resources regarding how to discuss the health crisis, non-pharmaceutical interventions, uncertainties, and grief in developmentally appropriate ways for children and adolescents. Parents in the current study were also concerned about how their own stress and anxiety around the pandemic were influencing their parent-child relationships. Many factors influence parenting and integrating some information about parenting self-care into these resources for helping children would be important. Further research with children and parents on what they perceived worked well in related parent-child discussions during this pandemic could strengthen and inform these resources. It may be helpful to consider how the parent-child relationships become more reciprocal in late adulthood when determining implications for supporting older adults in a future public health crisis. Older adults in this study appreciated the increased and more frequent connection with their adult children through technology. In terms of prevention, adult children could consider discussing with parents what technology they have and their comfortability using it. Helping parents acquire new technologies if they do not have them and ensuring they know how to use them may promote continued connection within the parent-child relationships in the wake of a large-scale public health crises. Further, future professionals who will provide services that support parent-child relationships continue to be trained during the pandemic. Hughes and colleagues indicated that as instructors in higher education adapt courses for teaching during the pandemic, they should ask themselves, "how could you use the current situation [the COVID-19 pandemic] to make learning more effective" ? Educational standards set by the National Association of State Administrators of Family and Consumer Sciences and National Council on Family Relations highlight the importance of educating students regarding contextual factors influencing individuals, families, and interpersonal relationships. Results from this study could be used in family science and human development courses to introduce concepts such as the influence of context and environment on parent-child relationships. Instructors should be clear that professionals supporting parents and children during public health crises should acknowledge and emphasize the diversity of parent-child experiences in adapting to such crises. For example, some parents expressed how the early weeks of the pandemic required them to balance existing responsibilities with new roles and students could be challenged to consider how future interventions could support these parents while promoting gender equity. Again, this study was conducted during the early weeks of the pandemic in the United States and the pandemic is on-going-COVID-19 cases are rising and families continue to experience changes in routines and traditions with necessary public health precautions . Continued research on parent-child and family relationships is needed. The on-going pandemic may affect parent-child relationships at different stages of the pandemic. Emerging research is indicating that parents are experiencing compounded stressors and limited access to external resources for support . A family's positive adaption to a crisis and compounded stressors is more likely when there are helpful financial, relational, and emotional resources available . Many parents in this study indicated that their parentrelationships were unchanged or improved during the early weeks of the pandemic-indicating some families were doing well or had utilized strengths during the pandemic. One innovative research direction may be to utilize a family strengths approach in future public health crisis research to identify what is working in parent-child relationships versus challenges or problems. The family strengths approach aims to identify what is working or what strengths are in a family and then uses the shared identified strengths to assist families from similar backgrounds. This research would require identifying parents within certain age groups from specific cultural groups who are navigating the current pandemic or future public health crises well. This approach could be a way to meaningfully inform parenting interventions by identifying strengths/factors that could be malleable. Funding There is no funding to report for this project. --- Data Availability The data are not publicly available. --- --- Consent to Participate and Publication Participants all completed an informed consent form where they agreed to participate and acknowledged that the research would be disseminated through publication. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The impact of the COVID-19 pandemic on families is currently unknown. Parents and children have experienced a variety of changes as public health interventions have been implemented to slow the spread of the virus. The current exploratory qualitative study recruited parents (n = 365) in early (ages 20-34), middle (ages 35-64), and late (ages 65 and older) adulthood to understand how the early weeks of the pandemic influenced their parent-child relationships. Participants completed an online survey between March 21 and 31, 2020. Three themes emerged through qualitative content analysis: (1) relational steadiness, (2) navigating COVID-19 challenges in relationships, and (3) relational enhancement.

parentchild relationships are lifelong generally only partially voluntary and based on interconnected experiences in the past and the expectation of interconnected experiences in the future taking a contextual view on parentchild relationships across the lifespan is critical as changes occur in the larger social and physical environment a recent contextual change was the emergence of the novel coronavirus which was declared a national health emergency in the united states on march 13 2020 throughout history families have experienced expected and unexpected crises and families have varied in how they have weathered these crises the current study was designed to explore parents perceptions of how the early weeks of the covid19 pandemic influenced their parentchild relationships theoretical framework from an ecological systems perspective humans develop through bidirectional interactions within concentric ecosystems these systems include micro meso exo macro and chronosystems the microsystem involves the enduring daytoday interactions which includes the parentchild relationship the mesosystem includes the interactions between two microsystems the exosystem represents an environment that influences the developing human but they are not directly involved and the macrosystem includes the cultural and societal values in which the developing human is embedded finally the chronosystem accounts for time and the sociohistorical conditions in which development occurs 3 adults experience typical changes in their ecological system levels across early middle and late adulthood these changes over time influence the role of parents and children within the parentchild microsystem the chronosystem also accounts for the atypical sociohistorical conditions that affect human development which would include the declaration of the covid19 pandemic in march 2020 at the beginning of the covid19 pandemic at exoand macrosystem levels nonpharmaceutical public health interventions were implemented to slow the spread of the virus and there was uncertainty about the virus and potential duration of the pandemic menter et al explained the covid19 pandemic has resulted in widespread impact on the daily lives of children and their parents human development occurs within interactive systems and thus disruptions such as those attributed to covid19 across multiple systems may impact children and families the current study focused on experiences within the parentchild relationship in the context of the onset of the covid19 pandemic capturing the experience of parentchild relationships in the early weeks of this pandemic could provide knowledge related to how best to support parents and children in the onset of potential future public health crises parentchild relationships and covid19 pandemic parents and children have likely experienced a variety of changes as a consequence of the covid19 pandemic to slow the spread of the virus public health interventions were implemented and by march 23 2020 43 states had statewide stayathome orders this led to changes for parents and children as schools and childcare agencies closed work expectations shifted and socializing opportunities became restricted this resulted in profound changes to family routines and rituals that are often taken for granted but there was likely considerable variability in the ways families were impacted in the early weeks of the covid19 pandemic many parents of school age children found themselves balancing working from home while caring for and educating their children however this balancing of new roles may be different for fatherchild and motherchild relationships although father engagement in childcare responsibilities and time spent with children has been increasing mothers continue to spend more time with children and do more of the childcare responsibilities in general during the pandemic parents have had to increase their time spent caring for their children but mothers have continued to spend more time on childcare responsibilities than fathers and have also experienced a higher likelihood of reducing work hours transitioning out of the workforce and experiencing higher psychological distress it is unclear how these new roles might have influenced parentchild relationships but it is possible with limited interaction outside the home and parents taking on more roles in their childrens lives that there could be increased strain on parentchild relationships for instance in qualitative pandemic research adolescents indicated that they felt isolated and some reported arguing more with their parents further the quality of parentchild interactions with young children could have also potentially declined during the pandemic as mothers of young children have been reported to be at higher risk for parentingrelated exhaustion although parentchild relational experiences may have been more typical earlier in the pandemic because there was not a clear perspective on the potential duration of the pandemic parents and children of all ages may have experienced increased social isolation economic challenges and limited access to supportive resources adults over the age of 65 are at higher risk of getting seriously ill or dying from covid19 parents in late adulthood may have also experienced disrupted family routines in order to stay protected from contracting the virusespecially those grandparents providing care for grandchildren while their adult children work and older adults receiving care from their adult children parents in late adulthood may have also experienced more demonstrations of concern from their children during the pandemic as adult children transition from the one being protected in the relationship to the one who is doing the protecting in emerging qualitative research with older adults during the pandemic participants reported that they were worried about their adult childrens health and were missing their families although these same older adults reported that they were still connecting with family and friends via technology during the pandemic women in late adulthood reported higher rates than men in viewing digital communication as a source of joy during the pandemic at present research with parents during the covid19 pandemic has primarily focused on parenting stress and burnout of parents of school age children brown and colleagues indicated that parents did experience changes in mood and increased general stress levels during the covid19 pandemic which is problematic because these parents also likely had lower access to support from external sources potential risks of increased parental stress have been reported to be child abuse or decreased parentchild relational quality due to coercive cycles in parentchild interactions as research on the covid19 pandemic and parentchild relationships continues there would be value in expanding research beyond parentchild relationships with schoolaged children and to begin to understand parentchild relationships across the lifespan purpose of the current study there will be individual and relational differences in how parents are influenced by the covid19 pandemic it is also likely there will be different experiences at the beginning middle and end of the pandemic for instance the public health measures were stricter in the early weeksmonths and there was unknown information about the virus the current exploratory study was designed to understand how parents perceived their parentchild relationships were influenced by the early weeks of the covid19 pandemic consistent with previous conceptualizations of adulthood age groups experiences of parents were examined by early middle and late adulthood methods sample participants included 365 adults from 44 states in the united states participants reported having between one and eight children parents indicated that they had between zero and seven children ages 18 and under currently living with them see table 1 for sample characteristics procedures study procedures were approved by a university institutional review board this study is part of a larger study on wellbeing during the covid19 pandemic data were collected in two ways snowball sampling through social media with a gift card raffle incentive and through prime panels which is an established way of recruiting diverse community samples all participants completed an online survey administered through qualtrics between march 21 and 31 2020 to check for understanding and refine the survey the survey was piloted with 20 adults prior to data collection various strategies were used with the online survey to ensure data quality sample inclusion required the participant to have at least one child initially 663 participants completed the survey and 221 were excluded because they did not report having children 14 additional participants did not provide enough information to be included and 63 of surveys were excluded because they did not meet the established data quality requirements data collection and analysis the survey asked for demographic information and level of social distancing additionally participants reported how many children they had and how many were 18 years or younger and living with them participants were asked an openended item how would you say the coronavirus a conventional qualitative content analytic approach was selected for this study this qualitative analytic approach is used to describe a phenomenon through gaining direct information from study participants without imposing preconceived categories and is described an inductive method this was an appropriate approach as the goal was to understand how parents perceived their parentchild relationships were influenced by the early weeks of the covid19 pandemicallowing the codes and themes to flow from the data the two researchers who conducted the qualitative analysis had previous training and experience in qualitative analysis consistent with qualitative conventional content analysis two researchers independently immersed themselves in the data to identify key words and ideas the two researchers then met together and identified and defined 14 coding categories that represented participant experiences to evaluate the utility of the coding scheme the researchers initially coded 20 responses independently compared coding decisions and then made necessary refinements to coding rulesdefinitions the two researchers then independently coded the full dataset and coding disagreements were resolved through discussion in line with qualitative conventional content analysis the two researchers reviewed the similarities within codes and identified three key categories or themes that represented the participants experiences to further enhance the trustworthiness of the results member checking was used at the conclusion of the survey participants who were recruited through snowball sampling were directed to a separate survey where they could document their participation for the incentive this survey also had an item that explained member checking and invited participants to provide their email address if they were willing to review the completed results and provide feedback via email ten of the participants who volunteered were selected at random and emailed the complete results section to consider how the results represented their own experience their peers experiences and to make any recommended changes participants indicated that results did represent their owntheir peers experiences results participants experiences in parentchild relationships during the early weeks of the covid19 pandemic were represented in three themes see relational steadiness participants reported that their parentchild relationships remained steady during the early weeks of the covid19 pandemic young and middleaged adults explained that they were now spending more time with my children than before due to the coronavirus pandemic but how we behave and interact in our parentchild relationships hasnt changed older adults did not report more time with their adult children during the onset of the pandemic but did report that there were no changes in their parentchild relationships young adults participants within this age group emphasized that the early weeks of the pandemic had not influenced my relationship with my children things in my parentchild relationship are about the same or it really hasnt taken a toll on my parentchild relationship young adults explained that they were spending more parentchild time together but more women than men reported this most participants indicated that this increased time was not affecting their parentchild relationships because their children were young and already required more parental time and attention and were unaware of whats going on in the world more young adult parents who were fulltime students or part time employed shared this perspective than those who were homemakers full time employed or unemployed for example participants shared my children are very young covid19 hasnt had a direct effect on my relationship with my children other than me spending more time at home with them and since my son is not old enough for school yet things are about the same middleaged adults participants in the middleaged adult age group explained that the pandemic had no impact on my relationship with my children the participants explained that they had established quality parentchild relationships prior to the pandemic and this did not change at the onset of the pandemic commenting on the parentchild relationships prior to the pandemic participants shared that i feel that we had a good parentchild relationship before covid19 or we have a close parentchild relationship already and that the changes related to the pandemic have not influenced their relationships for example a mother who was fulltime employed explained my son is an 18yearold senior in high school prior to the pandemic we were really close covid19 has not changed this some middleaged adult participants acknowledged that there was a change in the quantity of time they spent with their children during the early weeks of the pandemici have more time to be with my children this was reported more by participants who were parttime employed or homemakers than those who were unemployed or full time employed however participants did not feel that this increased time had influenced their parentchild relationships for instance participants explained weve had more time to spend together because we are under quarantine but the nature of our relationship is still the same and it hasnt really affected our relationship ive gotten more time for them older adults participants in late adulthood contributing to this theme reported that the early weeks of the pandemic had no influence no effect or led to no changes in their parentchild relationships these participants further explained that my children are all adult children my children are grown and none of our children live with us although parentchild relationships were reported as having always been close there was already physical distance in the parentchild relationship prior to the pandemic so our parentchild relationship has really not changed emphasizing this point a participant shared the pandemic has not affected the parentchild relationships one of our children lives in spain and the other in hawaii while we are in california as adult children were not living with their parents and there was physical distance prior to the pandemic no older adult participants reported spending more time with their children as a result of the early weeks of the pandemic participants reported that the covid19 pandemic increased fear anxiety uncertainty and stress further the affiliated nonpharmaceutical public health interventions resulted in restricted activities stayathome orders and new or revised roles participants explained that these pandemic generated experiences posed challenges that had to be navigated within parentchild relationships young adults participants indicated that there were a lot of unknowns at the onset of the pandemic and they were prioritizing keeping their children safe and doing the best i can to protect them young adults explained that time spent in the parentchild relationship involved teaching their children about methods to decrease spreading germs and specifically having to navigate social distancing expectations participants reported that their children were frustrated with them because they wanted to go places were missing friends and were getting bored and stir crazy from having parents as their only social interaction right now a mother shared i had to spend a lot of time explaining to my 4yearold why tball preschool church and his birthday party were cancelled participants stated that children and parents experienced anxiety and stress around the virus and public health interventions and this led to concern less patience and tension in the parentchild relationships some older children experienced anxiety about the virus itself and parents were trying to navigate how to address childrens fears a participant explained that she was trying to figure out how best to address her sons fear because my oldest is struggling with the virus talk it is scary to him because he does not understand the entire context and when he hears taglines like 15 people died today it is scary participants worried about how their own fear and stress were influencing their parentchild relationships they realized they were using screen time to entertain children taking less time to play with kids and using more emotional responses to childrens misbehavior instead of teaching responses a participant disclosed i have become more fearful in general and more irritable more prone to yelling i try to apologize and make things right with my kids but at the very least they see my tension and fear which i pray is not damaging adding to the stress and strain on the parentchild relationships young adults reported having to provide care for their children all day and assist older children with their schooling this required finding a new balance for many as they were also working or completing schooling from home more women than men reported having to find balance in these roles middleaged adults participants indicated that they were working to navigate covid19 concerns and social distancing expectations in their parentchild relationships which meant they had to answer some tough questions from their children as they learned to take and stick to measures stipulated by the cdc having to enforce adherence to public health guidelines and having a lot of parentchild time reportedly led to more parental and child frustration for middleaged adults participants explained its stressful communicating with my 3 children in their 20s about the importance of social distancing and my son believes covid19 is a government conspiracy and is frustrated that i dont agree parents had to help children cope with the loss of events social activities the consistency of school attendancemoving home to complete college remotely and adult children losing jobs while both parents and children experienced fear uneasiness anxiety and concern a mother of six children elaborated the youngest are not understanding why they cant play at the neighbors house or why we are staying home day in and day out our older 3 are concerned and helpful our 11yearold had spent the last six months earning money to tour italy with some other students from his school as well as his dad that trip was cancelled and spring break has been spent at home the rain is needed but also isolating at this time we are up and down with our patience and understanding with each other in the parentchild relationships more middleaged adult women than men reported having to figure out how to balance their different professional family and new roles during the early weeks of the pandemic participants who were homemakers reported this more than those with other employment statuses a mother shared things are strained in our parentchild relationships due to working from home in addition to trying to supervise four kids i think the older kids find us to be irritable at times but when were not working were making extra effort to focus on them were having … more strained and tense moments a grandmother who had adult children who had to continue working without the availability of school or childcare had to take on new roles to support her children because she could work from home she explained that her grandchildren were brought to her house and i am now the childcare provider homeschool teacher online teacher her professional position chief cook and bottle washer this is no exaggeration i have grandkids that are 12 4 2 and 11 months further participants reported more parentchild relationship challenges as they took on ensuring their children completed their schoolwork at hometeenagers have online courses and are not doing their part to keep uprequiring me to hound them a bit more than id like older adults where young and middleaged adults reported spending more time or too much time with their children older adults expressed that social distancing had decreased the time they physically spent with their adult children my adult children dont visit now and we are not able to get together as often as we did before the pandemic older adults explained that they and their adult children had concerns about covid19 particularly related to older adults being considered high risk for serious complications with the virus older adults especially reported that they and their adult children were being more cautious cancel ed family gatherings and visit ed in the yard at a distance out of concern for each others health and safety some adult children were reported to be insistent about their parents practice of social distancing a participant shared my son wont let me go anywhere because of my age and my health another participant explained that she and her husband usually watch the grandchildren but because of the pandemic they had discontinued this as they the adult childrengrandchildren are selfquarantining away from us apart from health concerns related to covid19 an older adult also expressed concerns about employment for one of her adult children she explained that she had two adult children one has lost his job it is very stressful and he will need our support my other son is doing fine as he lives with his partner and both are currently employed relational enhancement some participants shared that they experienced enhancements in their parentchild relationships during the early weeks of the pandemic there was an opportunity for more quality inperson time in early and middleaged adult parentchild relationships older adults experienced more technology facilitated connection with their children young adults despite the unknowns and stress of the pandemic some young adults expressed that their parentchild relationships had improved and that they were able to spend more quality parentchild time together more quality parentchild time during the early weeks of the pandemic was reported by those who were homemakers or full time employed but some fulltime students and parttime employed individuals shared this perspective one mother reported feeling more grateful for the little things like snuggling my son before naps or kissing him before bed and a father simply stated that the increased parentchild time together during this pandemic has helped us draw closer together young adult women found creative ways to engage their children through increased educational and enrichment activities a mother stated i have become a lot more creative in things during pandemic restrictions i find myself concentrating on teaching my children more academic things other participants reported bonding through more play time for example a mother described we have a lot more time to cook nice meals and play legos together participants explained that in addition to more quality time spent together they had also been more reflective in their parenting role which led to improvements in their parentchild relationships a mother shared it has been tricky to know if we need more structure or less structure … but were not overwhelmed im taking things easy and slow for them i feel like this is really giving me time to reflect on their needs what makes them each a person and how can i support their development i find myself thinking more about this on a different and deeper level than i did before im also thinking a lot about what family values and culture i can create during this time middleaged adults while covid19 brought up some challenges in family connections some middleaged adults conveyed that the public health restrictions had enhanced their parentchild relationships participants remarked on how appreciative they were of the time they were spending together participants indicated that the pandemic did not just increase the quantity of time together but also the quality of time spent in parentchild relationships more parentchild quality time was reported by middleaged adults who were homemakers than those who were part time employed full time employed unemployed and disabled the closures and cancelation of events created more downtime and parents explained weve had fun slowing down and spending all our time together a father explained that he experienced much more interaction than when i am at work for most of the day and my children are at school not only is our interaction more frequent but it has definitely led me to helping my children with … their chores and doing other activities with them each day has become a saturday some participants explained that they had become more creative with their parentchild timewe are reading together playing games cooking together quality parentchild interactions also increased with older children who were not living at home via technology in line with this sentiment two mothers explained that the pandemic has affected my relationship with my young adult children for the better because weve had more indepth conversations about the virus but also life in general and i check up on them more and am very interested in how they are feelingcoping older adults older adults did not report that they had the opportunity to have more quality inperson time with their children during the early weeks of the pandemic however they did report that they had been check ing on each other more frequently and keeping in touch more and checking in more frequently within their parentchild relationships older adults explained that various technologybased communication mediums have been used to keep in contact with their adult children frequently daily and more often for instance my adult children and i keep in contact via facebook and we have face timed so we can see our adult children and are checking in with each other more by phone and text and the group me app is being used even more older adult parents reported things like i feel closer to my adult children and calling more often has allowed for sharing more feelings although not directly about the pandemic as they discussed how the closer contact during the initial weeks of the pandemic had enhanced their parentchild relationships discussion the current study explored parentchild relationships in the context of the early weeks of the covid19 pandemic through parent perceptions bronfenbrenner indicated that development is influenced at the chronosystem level which accounts for the sociohistorical conditions covid19 is a unique sociohistorical condition for contemporary parentchild relationships it is imperative to investigate parentchild relationships during significant ongoing and dramatic changes at a societal level to understand how these relationships are affected by such changes and the covid19 pandemic significantly influenced daytoday life across the world nearly one third of the parents in this study believed that the early weeks of the covid19 pandemic did not lead to significant changes within their parentchild microsystems young adults explained that their children were young did not understand what was happening and already required more time for parental care where middleaged adults indicated that they had established positive parentchild relationships prior to the pandemic and the pandemic did not change this some young and middleaged adults did acknowledge that because of school closures and movement to remote work that they had more time in the homes together but did not feel this drastically changed anything in their parentchild relationships although consistent with emerging pandemic research more women reported increasing time spent with their children than men and considering a mesosystem level those adults who were students part time employed and homemakers also reported more time with children than those who were full time employed older adults also stated that their parentchild relationships remained unchanged during the early weeks of the pandemic in line with typical adult development their children were adults who lived independently and many expressed there was already physical distance in their relationships prior to the pandemic prime and colleagues postulated that the pandemic increased demands on the parentchild dyad to negotiate topics that prepandemic may not have been problematic or that were virtually nonexistent the effects of extended isolation and home confinement that are inherent to the covid19 crisis are causing profound changes to family routines and rituals that are often taken for granted … in line with this postulation there were some parents in the young and middleaged adult age groups who expressed difficulties at the parentchild microsystem and mesosystem levels as they discussed having to adapt to taking on new roles spending too much time together in the house and coping with fluctuations in patience and understanding zamarro and prados concluded that women have carried a heavier load than men in the provision of childcare during the covid19 crisis even while still working in the current study more young and middleaged adult women shared that they had to balance new and existing roles than men brown and colleagues stated the global covid19 pandemic is a stressor that originated outside of the family system but given the novelty and uncertainty concerning this disease it is likely to be perceived as a significant stressor for many parents and children parents in the sample did perceive that both parents and children experienced some anxiety related to covid19 or related uncertainties within the adults responses there was evidence of awareness and concern with the bidirectional influence within the parentchild microsystems as they described the potential influence of their own stress and anxiety on their children and vice versa public health interventions required more adaptionyoung adults largely focused on teaching children about preventing the spread of germs where middleaged adults focused their attention explaining and enforcing social distancing protocols with their children parents in early and middle adulthood explained that they had to be considerate about how to talk to their children about the virus while also helping them understand and grievecope with missed events older adults reported that their adult children were concerned about their age and the potential health risks of the disease these older adults indicated larger changes in the parentchild microsystem as they described experiencing a decreased amount of inperson time spent with their adult children during the early weeks of the pandemic and that this was related to the implementations of social distancing as children age into adulthood parentchild relationships become more reciprocal this parentchild reciprocity was evidenced by adult childrens concerns for parent healthimplementation of public health interventions the few parents who were concerned about their adult childrens financial wellbeing and the increased communication from adult children as reported by their parents prime and colleagues reasoned that the impact of the covid19 pandemic would vary greatly by family in line with this reasoning some parents in this study highlighted that the parentchild microsystem experienced relational enhancement during the early weeks of the pandemic participants in the early and middle years of adulthood explained that they did not just spend more time with their children but also experienced more quality time with children as busy schedules slowed or stopped vaterlaus and colleagues postulated that interactive technology could be an adaptive tool at the microsystem level to facilitate connection in a parentchild relationship when physically apart consistent with this postulation participants with adult children expressed enhanced parentchild relationships as they communicated more through a variety technology platforms and devices whitehead and torossian reported that more older adult women than men viewed digital communication as a source of joy during the pandemic in the current study more women than men specifically addressed that they had engaged in more digital communication with their children during the early weeks of the pandemic limitations this study did have limitations and the results and implications should be considered with these limitations in mind the study was cross sectional and only represented experiences from the initial weeks of the pandemic stressors build in families and parentchild relational experiences could be quite different after one year into the pandemic depending on the resources available within the family the survey design allowed for data collection from a broad group of adults in a short period of time but the use of one openended question in the survey did not allow for further probing or clarifying questions indepth interviews should be considered in followup studies the study also had lower participation of older adults and did not represent the experience of adults living in longterm care or assisted living facilities the use of online recruitment and online surveys may have not reached older adults who do not use or experience lower comfortability with technology while the sampling procedure was appropriate for an exploratory study a nonprobability sample can limit the representativeness of the experiences there was lower participation of people of color most of the sample was employed and had earned college degrees the covid19 pandemic has had a disproportionate impact on underrepresented racial groups and people with lower economic resources in the united states which may have a deleterious influence on parentchild relationships with the potential for increased stressors and lack of support from external resources during the pandemic further only parent perceptions on the parentchild relationship were included future longitudinal research should aim to replicate this study with parents and children from a variety of racial groups employment statuses and educational income levels implications and future research despite the limitations the present studys approach acknowledged that parentchild relationships change over time and that parentchild relationships should be studied in context when there are significant and ongoing changes in society prime et al indicated that the impact of the covid19 pandemic on family wellbeing is presently unknown and this study contributes to emerging knowledge further most published studies with parent samples during the pandemic have focused solely on adults with schoolaged children and parenting stress or burnout it is of great importance to continue with these research topics to ensure the safety of parents and children and it is also important to acknowledge that there is considerable variability in how families will be impacted by the covid19 pandemic the current study showed varied perceived impacts of the pandemic on parentchild relationships from the perceptions of young middleaged and older adults during the first weeks of the pandemic some perceived no change while others perceived challenges or even relational enhancement the focus of this study was on parentchild relationships during the early weeks of the pandemic there is the potential for future largescale public health crises and results in the current study may provide helpful implications and future research directions that could support parentchild relationships in the initial onset of similar crises young and middleaged adults may benefit from brief accessible resources regarding how to discuss the health crisis nonpharmaceutical interventions uncertainties and grief in developmentally appropriate ways for children and adolescents parents in the current study were also concerned about how their own stress and anxiety around the pandemic were influencing their parentchild relationships many factors influence parenting and integrating some information about parenting selfcare into these resources for helping children would be important further research with children and parents on what they perceived worked well in related parentchild discussions during this pandemic could strengthen and inform these resources it may be helpful to consider how the parentchild relationships become more reciprocal in late adulthood when determining implications for supporting older adults in a future public health crisis older adults in this study appreciated the increased and more frequent connection with their adult children through technology in terms of prevention adult children could consider discussing with parents what technology they have and their comfortability using it helping parents acquire new technologies if they do not have them and ensuring they know how to use them may promote continued connection within the parentchild relationships in the wake of a largescale public health crises further future professionals who will provide services that support parentchild relationships continue to be trained during the pandemic hughes and colleagues indicated that as instructors in higher education adapt courses for teaching during the pandemic they should ask themselves how could you use the current situation the covid19 pandemic to make learning more effective educational standards set by the national association of state administrators of family and consumer sciences and national council on family relations highlight the importance of educating students regarding contextual factors influencing individuals families and interpersonal relationships results from this study could be used in family science and human development courses to introduce concepts such as the influence of context and environment on parentchild relationships instructors should be clear that professionals supporting parents and children during public health crises should acknowledge and emphasize the diversity of parentchild experiences in adapting to such crises for example some parents expressed how the early weeks of the pandemic required them to balance existing responsibilities with new roles and students could be challenged to consider how future interventions could support these parents while promoting gender equity again this study was conducted during the early weeks of the pandemic in the united states and the pandemic is ongoingcovid19 cases are rising and families continue to experience changes in routines and traditions with necessary public health precautions continued research on parentchild and family relationships is needed the ongoing pandemic may affect parentchild relationships at different stages of the pandemic emerging research is indicating that parents are experiencing compounded stressors and limited access to external resources for support a familys positive adaption to a crisis and compounded stressors is more likely when there are helpful financial relational and emotional resources available many parents in this study indicated that their parentrelationships were unchanged or improved during the early weeks of the pandemicindicating some families were doing well or had utilized strengths during the pandemic one innovative research direction may be to utilize a family strengths approach in future public health crisis research to identify what is working in parentchild relationships versus challenges or problems the family strengths approach aims to identify what is working or what strengths are in a family and then uses the shared identified strengths to assist families from similar backgrounds this research would require identifying parents within certain age groups from specific cultural groups who are navigating the current pandemic or future public health crises well this approach could be a way to meaningfully inform parenting interventions by identifying strengthsfactors that could be malleable funding there is no funding to report for this project data availability the data are not publicly available consent to participate and publication participants all completed an informed consent form where they agreed to participate and acknowledged that the research would be disseminated through publication publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the impact of the covid19 pandemic on families is currently unknown parents and children have experienced a variety of changes as public health interventions have been implemented to slow the spread of the virus the current exploratory qualitative study recruited parents n 365 in early ages 2034 middle ages 3564 and late ages 65 and older adulthood to understand how the early weeks of the pandemic influenced their parentchild relationships participants completed an online survey between march 21 and 31 2020 three themes emerged through qualitative content analysis 1 relational steadiness 2 navigating covid19 challenges in relationships and 3 relational enhancement

Results: In Study 1, exploratory factor analysis of the OWSQLI obtained robust findings: the total variance explained by one single factor with the final selection of 22 items was over 44%. The OWSQLI demonstrated strong internal consistency , adequate criterion validity with the SIMSS , and moderate concurrent validity with the MOS SF-36 for both physical and mental quality of life. In order to confirm the validity of the 22-item OWSQLI scale that emerged from Study 1 analyses, we replicated those analyses in Study 2, although using confirmatory factor analysis. The total variance accounted for by one factor was about 42%, again quite high and indicative of a strong single-factor solution. Study 2 data analyses yielded the same strong reliability findings . The 22-item OWSQLI was correlated with the SIMSS in the expected direction. Finally, correlations with the MOS SF-36 demonstrated moderate concurrent validity for physical and mental quality of life, as expected. Conclusions: The findings of these two studies highlight the potential for our new tool to provide a valid measure of older women's social quality of life, yet they require duplication in longitudinal research. Interested clinicians should consider using the OWSQLI in their assessment battery to identify older women's areas of lower versus higher social quality of life, and should establish the maximization of patients' social quality of life as an important therapeutic goal, as this variable is significantly related to both physical and mental health. --- Background The growing diversity of aging populations and corresponding expectations of successful aging have motivated multidisciplinary investigations of quality of life . Several researchers have highlighted the need to develop assessment tools to properly quantify psychosocial variance in older age [1][2][3][4]. Research on social facets of QofL in later life may contribute to an increased understanding of protective social resources that could enhance the biopsychosocial health of older adults. In turn, this process could assist in addressing the aging population's health care impact on public resources, leading to a more cost-effective use of the health care system [5][6][7]. The social QofL of older women in particular should be a topic of focused investigation because this population, compared to older men, typically seeks medical help more often, experiences less than adequate assistance with basic life activities, and reports fewer financial resources [8][9][10]. Considering the aforementioned disadvantages, maximizing older women's social QofL is critical. The focus of the present research is the initial validation of a new social QofL tool, which is intended for use with older women from diverse ethnic backgrounds. Ethnic minorities in general are understudied in QofL research for a variety of reasons. Several researchers have identified factors such as low socioeconomic status [11,12] and limited English-language proficiency [13] as barriers to the inclusion of ethnic minority groups in QofL studies. Also, scarcity of culturally-competent researchers is often problematic [14]. In addition, older women's limited financial means can present difficulties regarding transportation to research sites [15]. We have minimized these challenging issues in the current research, as described in the Methods section. There is ample evidence on the contribution of social variables to the well-being of older women . Many such issues hold unique relevance among older individuals from ethnic minority backgrounds due to the emphasis placed upon family, friends, and the community at large, as they typically favor a collectivistic orientation [20]. In research on older women, a satisfying social life has been related to better physical health. For instance, in a study on 471 women over the age of 60 living with cardiac disease, respondents in recovery from cardiac events who had satisfactory social resources displayed fewer depressive symptoms and better coping skills [21]. Moreover, those who reported greater social support exhibited enhanced emotional well-being, lower symptom impact, and greater perceived health. Social networks could produce satisfying and trusting relationships with family and close friends and, importantly, enhance older women's ability to compensate for physical functioning deficits by reducing levels of distress [23]. Indeed, mental health is significantly related to satisfaction with one's social life and resources. Numerous studies have confirmed the positive role of social support, integration, and engagement in providing psychosocial benefits for improved mental well-being and QofL in later life [5,[24][25][26]. Additionally, Jang, Haley, Small, and Mortimer [22], in a study of 406 women diagnosed with cardiac disease, discovered that social resources enhanced psychological resilience. Social integration may also protect older adults from cognitive decline by positively influencing social competence and mood [27]. Furthermore, emotional and social expectations attached to social interactions afford a perception of continued value, meaningful connections to others, and emotional support for reassurance and affection, which contribute to morale and satisfaction in older age [28,29]. In addition, social resources are associated with enhanced feelings of self-esteem, which may strengthen older adults' coping skills and lessen the impact of negative life events, losses, and functional decline [22,30]. The Need for a Measure of Older Women's Social QofL Due to the lack of an appropriate measure to quantify social QofL in older women, to date, researchers interested in assessing psychosocial aspects of well-being in this population have relied mostly on health-related QofL measures that were typically not designed to capture the increasing diversity of older populations. Furthermore, by definition, all health-related QofL instruments confound physical health status with social well-being, if they assess the latter at all. Given the advanced age of our target population and the corresponding high potential for health problems and functional limitations that could extend to all areas of older women's lives, instruments need to be developed for the quantification of social QofL independently from physical/medical symptomatology. This task should be accomplished with a measure that is designed to be sensitive to culturally-relevant social variables, given the ethnic diversity of older women populations. However, few researchers have targeted the above-mentioned QofL issues within non-clinical older populations from diverse ethnic backgrounds [31]. In fact, a web-based search for this kind of tool resulted in few qualified measures. What follows is a brief review of some of the popular QofL scales, organized by their limitations in assessing social QofL in the target population of the present research. --- Researchers Must Be Able to Discriminate Between Physical and Social QofL Most of the commonly used measures confound socioemotional QofL with physical/medical health. For example, the utilization of the Medical Outcome Study 36-Item Short-Form Health Survey [32] allows the quantification of both physical and mental health components of QofL. While researchers who implemented this measure have reported good sensitivity as well as cross-cultural generalizability [33][34][35], the MOS SF-36 was constructed mainly to quantify limitations in social activities caused by health problems, thus confounding general health status and functional loss with QofL. Similarly, the Quality of Life Index -Generic Version [36] and the World Health Organization's QofL assessment [37] confound social aspects of QofL with health status. --- Assessment Tools Must Allow Generalization of Findings to Non-Clinical Populations Measures designed specifically for use with clinical populations may not be sensitive to minor changes in status within non-clinical populations. To offer an example, one of the earliest QofL assessments, the Spitzer QL-Index [38] has been shown to effectively assess general health, social support, and psychological outlook. However, this assessment tool was validated on cancer patients in palliative care. A scale designed to be relevant to individuals with terminal illness may not be sufficiently discriminatory or applicable to healthy-or relatively healthy-populations. Similarly, the 46-item Schedule for the Evaluation of Individual Quality of Life [39] and the SEIQoL-DW15item version [40] were originally created to assess QofL in palliative care settings. Although empirical evidence seems to indicate that both measures are psychometrically sound, the appropriateness of their application for routine use in non-palliative care settings or with individuals without serious illness is dubious [41]. Similar criticism can be applied to the Nottingham Health Profile [42] and the Quality of Well-Being Scale [43,44], which primarily assess the impact of disease and illness, making their applicability to fairly healthy populations questionable. --- Measures Need to Be Validated on Ethnically Diverse Older Adult Populations Few QofL measures have been explicitly normalized or psychometrically validated on ethnically diverse populations, which limits their external validity. Indeed, researchers have challenged assumptions of the universality of health-related assessment tools such as the MOS SF-36 [45]. In particular, Staniszewska, Ahmed, and Jenkinson discovered that cultural influences in White and Indian cardiac patients' descriptions of their physical health were similar, yet greater avoidance of terms such as "mental" and "emotional" surfaced among Indian participants. Additionally, different religious perceptions affected the interpretation of disease by these two groups. Deyo conducted a study [46] comparing the original English language version of the Sickness Impact Profile [47] to a Spanish language version within a sample of non-Hispanic and Mexican-American participants with low back pain. The SIP produced results with English-speaking individuals that seemed highly valid, while findings for Mexican-American participants who used the English language SIP measure were poor. Mexican-American patients using the Spanish version of the SIP obtained the poorest results. This suggests that simply producing an adequate translation of the SIP does not address culturally unique responses to symptoms, such as the reluctance of some cultures to answer personal questions and the general effects that acculturation may produce in the comfort level experienced by individuals responding to scale items [45]. Many popular QofL measures appear to disregard older adults, a segment of the population for whom reliable assessment of the social components of QofL may be especially critical . Unfortunately, current QofL measures are not well-designed to serve this population. For instance, Bowling stated that the MOS SF-36 does not cover sleep, economic welfare, sexual functioning, education, independence, or religion; these are all domains that influence QofL perceptions in later life [2]. Moreover, the QLI referenced earlier [36] is reportedly less sensitive to QofL change in older adults with chronic illness than the MOS SF-36 [34]. We identified a few instruments that cover social QofL issues and were used on older populations. However, a closer examination of such measures revealed many of the same limitations already discussed. For example, the Quality of Life Scale for the Elderly [48], which was ostensibly designed to quantify the social QofL of healthy older adults from non-clinical populations, was presented in a doctoral dissertation, but, to our knowledge, has not been used in peer-reviewed empirical research. More importantly, an examination of the content of the QLSE items reveals that this tool confounds social QofL with physical QofL. Another measure, the Quality of Life Enjoyment and Satisfaction Scale [49], covers social aspects of QofL. However, although it has been administered to older populations, it was not designed for older adults or older women in particular. Furthermore, all of the studies that we were able to identify on this scale covered clinical populations that presented some form of mental illness or disability [50][51][52]. --- The Social QofL Measure Proposed Herein The literature summarized above regarding available tools for the assessment of social QofL demonstrates a gap in the psychometric research on this topic concerning non-clinical populations of older women. An instrument constructed specifically for use with communitydwelling, ethnically diverse older women is critical to capturing the impact of familial and community support systems on these women's QofL, as well as their perception of power, respect, understanding, and honor within their family and community-all of which are concepts that are critical to social well-being in older age, as mentioned earlier. Before describing our two studies on this measure, it is appropriate to briefly illustrate their conceptual foundations. In a classic theorization , Engel [53,54] argued that the boundaries between health and disease are intertwined with social, medical, and psychological factors. Thus, one's perception of social well-being represents an essential component of health and should not be neglected in research; based on this theoretical approach, we compiled original items that could best assess social QofL in older women from diverse ethnic backgrounds. We focused on including in this measure items covering topics that emerged from the review of the existing literature on older women's social resources, particularly aspects of life related to their social ties that have been associated with QofL, yet not assessed via a single measure. It should be noted that the new instrument proposed herein does not assess health-related QofL , unlike most of the aforementioned tools such as the MOS SF-12/36, the QLI, the SIP, and the NHP, among others. Our social QofL measure quantifies instead the perceptions and reactions of older women to several facets of their environment . A similar conceptual framework provided the foundation for the Life Satisfaction in the Elderly Scale [55,56]. However, the latter scale is not gender-specific and confounds health status with QofL. To our knowledge, our new measure is the first tool created specifically to assess community-dwelling older women's social QofL beyond health status. We hypothesized that, in both studies, the new instrument would show strong factor analysis, reliability, and initial validity findings. Concerning the latter, we expected that scores on our measure would be moderately related to the size of respondents' support network. Moreover, we anticipated a significant relationship between social QofL and both kinds of QofL that have been most commonly targeted in prior studies, i.e., physical and mental. However, only a modest association with these two facets of QofL was hypothesized, given the specific social focus of the new tool. --- Methods --- Sample Characteristics The ethnically diverse sample of Study 1 consisted of 220 older women who resided in several urban and suburban communities in Los Angeles County; each respondent selfidentified as a member of one of seven ethnic/pan-ethnic groups. The demographic characteristics of the sample are displayed in Table 1. Participants ranged in age from 60 to 97 years, with a reported median age of 71 and an interquartile range of 66.25 to 78.00 years of age. A little over one-third of the sample was European-American; more than half indicated being born outside of the United States . About 51% of the participants had a high school education or less. Most of the respondents were retired and mainly married or widowed. For Study 2, we recruited 241 older women who resided in the same urban and suburban communities of Los Angeles County as Study 1 participants. These women reported a median age of 68 years, with a total range of 60 to 90 years and an interquartile range of 64.00 to 75.00 years of age. In this second sample, women self-identified as belonging to one of seven ethnic/pan-ethnic groups. Table 2 illustrates the demographic characteristics of this sample. Approximately 40% of the participants identified as European-American and indicated an educational level equal to or lower than high school completion. Nearly half reported being born outside of the U.S. Inclusion criteria for both studies were as follows: 60 years of age or older , English fluency , ability to provide informed consent, and independent living status. Excluding individuals in assisted living facilities decreased the possibility of recruiting participants with significant cognitive impairment . --- Recruitment Strategies We recruited participants for both samples using purposive sampling through RAs' connections within their ethnic communities. Recruitment sites included senior centers, grocery stores, and libraries in Los Angeles County. A significant effort was made to identify and minimize barriers to recruitment, with a focus on relevance of questions posed, respect of cultural perspective, and alignment of research goals with those of ethnic minority populations [57,58]. Additionally, we employed face-to-face recruitment to encourage research participation and refrained from asking participants to travel to a research center. Recruitment was challenging, as we attempted to recruit as many older women as possible from a vast variety of ethnic backgrounds; several of the women originally contacted were wary of research efforts and uninterested in participating in these two investigations. We allowed for flexible interview scheduling and assigned ethnicitymatched interviewers to establish initial contact and conduct interviews. Moreover, we tailored our recruitment strategies for inclusion of women from all income levels, as socio-economic factors often affect willingness of ethnic minority older adults to engage in research [60]. The utilization of this selection of recruitment tactics and sites maximized the number of ethnic minority participants in the two studies. The first part of the assessment procedure involved the solicitation of basic demographic information from each participant and the administration of the brief screener to determine research eligibility. RAs read all items in the test battery aloud and were instructed to complete the assessment in two sessions, with a short break between sessions to minimize fatigue. We also asked them to write all responses to the measures in legible hand-writing in the assessment packets. RAs allowed flexible scheduling of assessment sessions and accommodated location preferences to maximize participants' comfort level. Typically, respondents chose to be assessed in their homes or at community locations including libraries and senior centers. We took great care to exercise patience and preserve the dignity of the older women participating in this research. --- Procedure --- Assessment Tools RAs were instructed to first administer an original Screening tool to verify research eligibility. This short measure employs a combination of items from a standardized tool as well as demographic items required to determine eligibility. Specifically, it contains a brief portion of the Survey Psychiatric Assessment Schedule [61], a 51-item instrument with strong psychometric properties that was used exclusively for screening purposes . Our screener comprised only the first five items of the lengthy SPAS, thus excluding the SPAS section "Other survey questions about general health of subject." This choice allowed for the assessment of factors that are potentially indicative of gross cognitive impairment/ dementia such as participants' ability to: spell their own name, remember their own birthday, and exhibit an awareness of spatial orientation. RAs were instructed to recruit only women with perfect scores in these three areas. We used a brief Demographics list to assess variables such as ethnicity, place of birth, education, and income, as well as marital and employment status. An indicator of social support, i.e., the number of people in one's social network, was quantified via the Single Item Measure of Social Support . Although extremely short, this instrument is a strong predictor of morbidity and has good psychometric properties [62]. This single item is comprised of the question "How many people do you have near you that you can readily count on for help in times of difficulty such as watch over children or pets, give rides to hospital or store, or help when you are sick?" Response options are 0, 1, 2-5, 6-10, or more. Responses of 0 or 1 indicate low tangible assistance; 6-10 or more indicate high tangible assistance. Use of this short measure allowed us to avoid utilizing one of the much longer questionnaires on social support, thus rendering the assessment process less cumbersome for older women. To assess physical and mental QofL, we utilized the Medical Outcome Study 36-item Short Form Health Survey . This tool was developed to assess general health status and functional loss [63] and quantifies eight health constructs, namely: 1) limitations in physical activities due to health problems; 2) limitations in social activities resulting from physical or emotional problems; 3) limitations in usual role activities due to physical health problems; 4) bodily pain; 5) general mental health ; 6) limitations in usual role activities because of emotional problems; 7) vitality ; and 8) general health perceptions. Subtotals for physical and mental health provided a quantification of physical QofL and mental QofL; clinical tests of the validity of this tool have achieved excellent results [64]. We utilized the MOS software to conduct all the analyses relative to physical and mental QofL. The Older Women's Social Quality of Life Inventory was used for the first time in the present research. This original measure was developed by the first author; unlike most of the currently available measures on this topic, it is not confounded with health status. As elaborated in the Results, the OWSQLI was created from an original pool of 50 items following an extensive literature review . This tool was designed to target many culturally-relevant social QofL issues . "Others" include family, friends, and the community at large. Item responses are coded on a 7-point Likert-type scale, ranging from "strongly disagree" to "strongly agree." Two sample items are: "I have the power & respect I deserve in my community as an older person with experience & knowledge" and "My children fully understand my social needs." --- Analytic Strategy We implemented all data analyses through the Statistical Package for the Social Sciences, version 17.0 . For both studies, we first calculated the sample's descriptive statistics. In Study 1, we conducted an exploratory factor analysis of the new tool; moreover, we computed the internal consistency/Cronbach's a value for the OWSQLI through a reliability analysis. Additionally, we validated the OWSQLI by relating its scores to those of instruments that measure social support , as well as physical and mental QofL . In cases in which a question was not applicable to a given respondent , this question was excluded from the analysis and from any scale construction for that given participant. This is preferable to a listwise deletion that would exclude the person in question from all analyses due to non-applicable responses to a few items. Once the results of the EFA in Study 1 were examined, we conducted a confirmatory factor analysis using Study 2 sample. The CFA was implemented specifically to ascertain whether the 22 items that emerged in Study 1 continued to represent a single strong factor from the original 50-item pool in Study 2. Furthermore, we repeated the reliability and validity procedures employed in the previous study and examined potential ethnic group differences in OWSQLI scores. --- Results Concerning the EFA in Study 1, our statistical consultant set the criterion of item retention at a factor loading of .32 or higher, which is generally accepted as the minimum value for an item loading on a given factor [65]. A .32 loading is approximately equal to 10% overlapping variance with the other items on that factor. This provided a means to shorten the measure and, consequently, avoid burdening older women with a lengthy instrument in future research in this area. Based on this criterion, 22 of the original 50 items were retained. With 22 items, the mean of the OWSQLI was 39.13 and the standard deviation 20.78. Scores on one item were reversed, as this item is negatively worded . The factor analysis of the OWSQLI obtained robust findings. Based on the 50 original items, the percentage of total score variance explained by one single factor was 44.04% . Thus, the comparative weight of this factor is strong. Examinations of the Eigen values also pointed to a single-factor solution with a clear drop in size between the first and second factor . Furthermore, the 7.99% total variance gained in moving to a 2-factor solution was not deemed sufficient, in view of the practical disadvantages of a longer scale and the related greater difficulty in interpretability. Table 3 contains the matrix with the factor loading, which illustrates the degree to which each of the 22 items loaded on one factor, with the most highly loaded items displayed first. To further confirm this 22item, single factor solution, we conducted a CFA using Study 2 sample. Given the nature of this analysis, Principal Axis Factoring was chosen as the extraction method. All 22 items met the .32 loading threshold with this second independent sample. The OWSQLI yielded a mean of 40.41 and a standard deviation of 19.15. The single factor of the OWSQLI had a strong comparative weight, as it explained a high percentage of total score variance . The matrix with Study 2 factor loading is displayed in Table 4 with the most highly loaded OWSQLI items appearing first. Tables 5 and6 illustrate the item-total statistics for Study 1 and Study 2; the 22 items correlated very well with each other for both samples, which was to be expected, given that they assess facets of one construct, social QofL. In these two tables, we displayed the content of each item next to its original number . The new measure demonstrated the same high internal consistency in both studies . Moreover, as reported in Table 7 , we conducted a preliminary validity test of the OWSQLI by relating its scores to those on size of social support network, as well as to MOS SF-36 total scores. Good criterion validity was observed when OWSQLI scores were related to scores on the number of people in the respondents' social network for both samples. Concurrent validity of the OWSQLI was assessed by comparing its scores in both Study 1 and 2 to those on physical and mental QofL. As expected, correlations among these scales were significant, although modest. Finally, the samples from Study 1 and Study 2 were combined into one dataset to conduct a preliminary examination of potential ethnic group differences in OWSQLI scores. Combining the datasets was necessary in order to achieve the necessary sample size for mean comparison tests to be meaningful. Even with the significantly larger total sample, it should be noted that only pan-ethnic groupings rather than specific national-ethnic groupings were possible. We conducted a one-way ANOVA, which was followed by Tukey posthoc comparisons. Neither the overall omnibus test, F = 1.53, p = .135, nor any paired comparison between pan-ethnic groups was statistically significant, indicating the general absence of significant pan-ethnic between-group variation in OWSQLI scores. --- Discussion The findings of Study 1 analyses indicate that the new tool presented herein is characterized by a strong single factor and high internal consistency. These findings were confirmed in Study 2 analyses, whose results were nearly identical to those of Study 1. Furthermore, as expected, the OWSQLI demonstrated adequate criterion validity with a social support indicator, as well as moderate concurrent validity with both physical and mental QofL. These validity results are noteworthy, because they confirm that our measure advances beyond assessment of social support as well as physical and mental QofL to quantify social QofL. Upon examining specific items loading on the single factor explaining a large part of the OWSQLI's score variance, we discovered that our samples' social QofL scores were affected primarily by satisfying relations with family members. Friends and the community at large were also valued, but their contribution to personal sense of well-being was less critical than familial relationships. This finding substantiates evidence reported in prior literature that the family network is typically the primary social resource available for emotional and financial support in older age, although support from friends and community can provide similar protective effects [66,67]. It also corroborates the notion, reinforced in a recent literature review [68], that family ties are particularly important for non-European-American older adults . Interestingly, the notion of respect appears in the items that have some of the highest loadings in the scale, which highlights the importance of respect and of one's role in the family in older age, especially considering compelling research relating family role to mortality in older age [69][70][71]. The fact that issues such as being loved and cared for by family and friends were strongly related to total OWSQLI scores suggests that it is imperative for mental health providers to encourage older patients to focus on ties with family and friends in order to strengthen such ties and, in turn, possibly enhance biopsychosocial functioning in later life. In particular, the "friends-related" finding offers supportive empirical evidence for Yeh and Lo's recommendations to provide incentives within communities to engage older adults in social activities and enhance their social contacts and resources [72]. We also discovered that a sense of belonging and maintenance of status as a contributing family member is positively linked to older women's social QofL. These findings complement prior empirical evidence demonstrating that supportive relationships and activities that are perceived as important help maintain older women's self-esteem and reduce stress [73], and that social contact and frequent social interaction produce higher life satisfaction in later life [74]. Another consistent result across both studies was that perceived size of social network was significantly related to OWSQLI scores, again indicating that the amount of available help is an important factor with regard to older women's social QofL. These findings are corroborated by prior literature on this topic [23]. Our results concerning the significant relationship between physical health and social QofL are also consistent with prior empirical evidence on this topic linking social resources to better physical health and a lessened impact of chronic disease [21]. Moreover, the significance of the relationship between mental and social QofL corroborates the findings of other researchers [27,30]. As a whole, the results of our two studies indicate that the new measure of social QofL is a psychometrically sound instrument with desirable properties for utilization with older women from diverse ethnic backgrounds. Moreover, the items comprising the OWSQLI employ rather simple language, which is a strength of the measure, given the modest educational level of both samples. These two investigations have several limitations that could be addressed in future studies. Among them, our findings do not imply causation, because their design was correlational. Longitudinal research is needed to verify the present results. Also, the OWSQLI was not validated against a previously established socially-related QofL instrument. Yet, because, to our knowledge, this is the first tool of its kind, such a limitation was unavoidable. However, it would have been ideal to validate the OWSQLI against a measure of social support that was more lengthy and in-depth than the SIMSS. A focus on keeping the assessment battery short prevented us from using a lengthier social support instrument. In future studies, researchers could compare scores on the OWSQLI to those on other well-established social support measures such as the Q-LES-Q [49]. Another limitation of our research was that we recruited women exclusively; men's social QofL should also be studied using our tool, as the latter could be validated and modified accordingly for use with ethnically diverse older men. Furthermore, a few of the items in the OWSQLI are worded somewhat vaguely, especially given that the scale was administered to women as young as 60 . For instance, the meaning of "... regardless of my age" could be unclear; we meant that, no matter how old the participant was, she felt respected by the people in her community and by her family members. Having a few items with words that could be assigned different meanings is a shortcoming of most of the aforementioned tools. Special attention should be paid to clarifying the meaning of unclear items and encouraging research participants to raise questions if items are not understandable . Moreover, the sample sizes of specific ethnic groups did not allow for the testing of national groupsalthough we did attempt to unveil different social relationship patterns via mean comparisons across pan-ethnic groupings, but found no significant differences in mean OWSQLI scores. Interested researchers could identify how older adults from different ethnic minorities respond to this tool and develop culture-specific norms based on their findings. In this regard, the meaning of words such as "having power in one's family" could vary across ethnic groups. Ideally, these issues should be explored via in-depth qualitative interviews to clarify item comprehension and assignment of meaning to complex concepts like power. Including collection of qualitative data to study social QofL would allow a more in-depth study of this topic via mixed methods procedures. Concerning additional limitations of these two research endeavors, all participants in both studies were fluent in English; interested investigators should consider using and validating this new tool in other languages. Also, our two cohorts were not based on random community sampling, so our findings may not be fully generalizable to our catchment area. However, about half of both our samples reported holding a high school degree at best, similarly to findings on the general Los Angeles County population [75]. Judging from those statistics, the two samples utilized in this research are possibly representative of their catchment area. Nonetheless, our results could be due, at least partially, to variables not assessed herein such as medication use and/or acculturation. Further psychometric evaluation, such as testing for differences on a subset of the items of the OWSQLI across a stratified sample, may be warranted, but was beyond the scope of this preliminary test of our measure. Additionally, the exclusive use of self-rated measures, although implemented in most of the aforementioned investigations, is a limitation. Overall, in spite of multiple limitations, our studies represent a necessary step in the direction of properly quantifying the social QofL of ethnically diverse older women, thus making a needed contribution to the growing area of ethnogeriatric psychometrics. --- Conclusions In our research, we intended to start addressing a gap in the available geriatric literature concerning the need to develop an instrument to assess social QofL in older age independent of physical QofL. Our research findings with two non-clinical samples of community-dwelling older women from diverse ethnic backgrounds reinforce the notion that QofL in older age is truly multi-dimensional and must be carefully quantified through domainspecific tools that are sensitive to older adults' complex needs and resources. The evaluation of physical and mental QofL alone is insufficient for a comprehensive quantification of well-being in later life. As testing of our tool achieved promising results, clinicians who intend to assess social QofL in older women should consider adding this new measure to their assessment battery. This would allow them to gain a deeper understanding of social areas in which their patients are lacking support, as well as social areas of particular strength. Both could be enhanced via interventions such as individual therapy to increase psychosocial resilience, family therapy, and implementation of programs targeting social activities that the older patients in question find personally meaningful. Interested investigators should test the psychometric properties of the OWSQLI further; currently, in our laboratory, we are collecting data utilizing this measure on ethnically diverse older men in order to refine this tool for use with older male populations. As a final consideration, researchers interested in clinical applications of the OWSQLI could relate its scores to those on adjustment to challenges commonly experienced in older age, including chronic impairments such as vision problems. Utilization of the OWSQLI, given its "family and friends" focus, could be ideal with clinical populations similar to the one targeted in a recent study [76] in which family was found to provide social support during the initial adaptation of older individuals to vision impairment, while friends provided support in long-term adaptation. Given the differences between our studies' non-clinical population and the clinical one in question, the factor structure of the OWSQLI for patients with progressive physical impairments could look significantly different than the structure obtained herein. --- Authors' contributions LL, the principal investigator, created the OWSQLI, designed the two studies, conducted Study 1 analyses, and wrote most of the paper. MLB wrote some parts of the literature review and a first draft of a portion of this paper. IB wrote some parts of the literature review, contributed to the writing of all sections, verified the accuracy of the methodological parts of the paper, and conducted Study 2 data analyses. All authors read and approved the final manuscript. --- Competing interests The authors declare that they have no competing interests.

Background: To our knowledge, the available psychometric literature does not include an instrument for the quantification of social quality of life among older women from diverse ethnic backgrounds. To address the need for a tool of this kind, we conducted two studies to assess the initial reliability and validity of a new instrument. The latter was created specifically to quantify the contribution of a) social networks and resources (e.g., family, friends, and community) as well as b) one's perceived power and respect within family and community to subjective well-being in non-clinical, ethnically diverse populations of older women. Methods: In Study 1, we recruited a cross-sectional sample of primarily non-European-American older women (N = 220) at a variety of community locations. Participants were administered the following: a short screener for dementia; a demographic list; an initial pool of 50 items from which the final items of the new Older Women's Social Quality of Life Inventory (OWSQLI) were to be chosen (based on a statistical criterion to apply to the factor analysis findings); the Single Item Measure of Social Support (SIMSS); and the Medical Outcome Study 36-item Short-Form Health Survey (MOS SF-36). Study 2 was conducted on a second independent sample of ethnically diverse older women. The same recruitment strategies, procedures, and instruments as those of Study 1 were utilized in Study 2, whose sample was comprised of 241 older women with mostly non-European-American ethnic status.

results in study 1 exploratory factor analysis of the owsqli obtained robust findings the total variance explained by one single factor with the final selection of 22 items was over 44 the owsqli demonstrated strong internal consistency adequate criterion validity with the simss and moderate concurrent validity with the mos sf36 for both physical and mental quality of life in order to confirm the validity of the 22item owsqli scale that emerged from study 1 analyses we replicated those analyses in study 2 although using confirmatory factor analysis the total variance accounted for by one factor was about 42 again quite high and indicative of a strong singlefactor solution study 2 data analyses yielded the same strong reliability findings the 22item owsqli was correlated with the simss in the expected direction finally correlations with the mos sf36 demonstrated moderate concurrent validity for physical and mental quality of life as expected conclusions the findings of these two studies highlight the potential for our new tool to provide a valid measure of older womens social quality of life yet they require duplication in longitudinal research interested clinicians should consider using the owsqli in their assessment battery to identify older womens areas of lower versus higher social quality of life and should establish the maximization of patients social quality of life as an important therapeutic goal as this variable is significantly related to both physical and mental health background the growing diversity of aging populations and corresponding expectations of successful aging have motivated multidisciplinary investigations of quality of life several researchers have highlighted the need to develop assessment tools to properly quantify psychosocial variance in older age 1 2 3 4 research on social facets of qofl in later life may contribute to an increased understanding of protective social resources that could enhance the biopsychosocial health of older adults in turn this process could assist in addressing the aging populations health care impact on public resources leading to a more costeffective use of the health care system 5 6 7 the social qofl of older women in particular should be a topic of focused investigation because this population compared to older men typically seeks medical help more often experiences less than adequate assistance with basic life activities and reports fewer financial resources 8 9 10 considering the aforementioned disadvantages maximizing older womens social qofl is critical the focus of the present research is the initial validation of a new social qofl tool which is intended for use with older women from diverse ethnic backgrounds ethnic minorities in general are understudied in qofl research for a variety of reasons several researchers have identified factors such as low socioeconomic status 1112 and limited englishlanguage proficiency 13 as barriers to the inclusion of ethnic minority groups in qofl studies also scarcity of culturallycompetent researchers is often problematic 14 in addition older womens limited financial means can present difficulties regarding transportation to research sites 15 we have minimized these challenging issues in the current research as described in the methods section there is ample evidence on the contribution of social variables to the wellbeing of older women many such issues hold unique relevance among older individuals from ethnic minority backgrounds due to the emphasis placed upon family friends and the community at large as they typically favor a collectivistic orientation 20 in research on older women a satisfying social life has been related to better physical health for instance in a study on 471 women over the age of 60 living with cardiac disease respondents in recovery from cardiac events who had satisfactory social resources displayed fewer depressive symptoms and better coping skills 21 moreover those who reported greater social support exhibited enhanced emotional wellbeing lower symptom impact and greater perceived health social networks could produce satisfying and trusting relationships with family and close friends and importantly enhance older womens ability to compensate for physical functioning deficits by reducing levels of distress 23 indeed mental health is significantly related to satisfaction with ones social life and resources numerous studies have confirmed the positive role of social support integration and engagement in providing psychosocial benefits for improved mental wellbeing and qofl in later life 5 24 25 26 additionally jang haley small and mortimer 22 in a study of 406 women diagnosed with cardiac disease discovered that social resources enhanced psychological resilience social integration may also protect older adults from cognitive decline by positively influencing social competence and mood 27 furthermore emotional and social expectations attached to social interactions afford a perception of continued value meaningful connections to others and emotional support for reassurance and affection which contribute to morale and satisfaction in older age 2829 in addition social resources are associated with enhanced feelings of selfesteem which may strengthen older adults coping skills and lessen the impact of negative life events losses and functional decline 2230 the need for a measure of older womens social qofl due to the lack of an appropriate measure to quantify social qofl in older women to date researchers interested in assessing psychosocial aspects of wellbeing in this population have relied mostly on healthrelated qofl measures that were typically not designed to capture the increasing diversity of older populations furthermore by definition all healthrelated qofl instruments confound physical health status with social wellbeing if they assess the latter at all given the advanced age of our target population and the corresponding high potential for health problems and functional limitations that could extend to all areas of older womens lives instruments need to be developed for the quantification of social qofl independently from physicalmedical symptomatology this task should be accomplished with a measure that is designed to be sensitive to culturallyrelevant social variables given the ethnic diversity of older women populations however few researchers have targeted the abovementioned qofl issues within nonclinical older populations from diverse ethnic backgrounds 31 in fact a webbased search for this kind of tool resulted in few qualified measures what follows is a brief review of some of the popular qofl scales organized by their limitations in assessing social qofl in the target population of the present research researchers must be able to discriminate between physical and social qofl most of the commonly used measures confound socioemotional qofl with physicalmedical health for example the utilization of the medical outcome study 36item shortform health survey 32 allows the quantification of both physical and mental health components of qofl while researchers who implemented this measure have reported good sensitivity as well as crosscultural generalizability 33 34 35 the mos sf36 was constructed mainly to quantify limitations in social activities caused by health problems thus confounding general health status and functional loss with qofl similarly the quality of life index generic version 36 and the world health organizations qofl assessment 37 confound social aspects of qofl with health status assessment tools must allow generalization of findings to nonclinical populations measures designed specifically for use with clinical populations may not be sensitive to minor changes in status within nonclinical populations to offer an example one of the earliest qofl assessments the spitzer qlindex 38 has been shown to effectively assess general health social support and psychological outlook however this assessment tool was validated on cancer patients in palliative care a scale designed to be relevant to individuals with terminal illness may not be sufficiently discriminatory or applicable to healthyor relatively healthypopulations similarly the 46item schedule for the evaluation of individual quality of life 39 and the seiqoldw15item version 40 were originally created to assess qofl in palliative care settings although empirical evidence seems to indicate that both measures are psychometrically sound the appropriateness of their application for routine use in nonpalliative care settings or with individuals without serious illness is dubious 41 similar criticism can be applied to the nottingham health profile 42 and the quality of wellbeing scale 4344 which primarily assess the impact of disease and illness making their applicability to fairly healthy populations questionable measures need to be validated on ethnically diverse older adult populations few qofl measures have been explicitly normalized or psychometrically validated on ethnically diverse populations which limits their external validity indeed researchers have challenged assumptions of the universality of healthrelated assessment tools such as the mos sf36 45 in particular staniszewska ahmed and jenkinson discovered that cultural influences in white and indian cardiac patients descriptions of their physical health were similar yet greater avoidance of terms such as mental and emotional surfaced among indian participants additionally different religious perceptions affected the interpretation of disease by these two groups deyo conducted a study 46 comparing the original english language version of the sickness impact profile 47 to a spanish language version within a sample of nonhispanic and mexicanamerican participants with low back pain the sip produced results with englishspeaking individuals that seemed highly valid while findings for mexicanamerican participants who used the english language sip measure were poor mexicanamerican patients using the spanish version of the sip obtained the poorest results this suggests that simply producing an adequate translation of the sip does not address culturally unique responses to symptoms such as the reluctance of some cultures to answer personal questions and the general effects that acculturation may produce in the comfort level experienced by individuals responding to scale items 45 many popular qofl measures appear to disregard older adults a segment of the population for whom reliable assessment of the social components of qofl may be especially critical unfortunately current qofl measures are not welldesigned to serve this population for instance bowling stated that the mos sf36 does not cover sleep economic welfare sexual functioning education independence or religion these are all domains that influence qofl perceptions in later life 2 moreover the qli referenced earlier 36 is reportedly less sensitive to qofl change in older adults with chronic illness than the mos sf36 34 we identified a few instruments that cover social qofl issues and were used on older populations however a closer examination of such measures revealed many of the same limitations already discussed for example the quality of life scale for the elderly 48 which was ostensibly designed to quantify the social qofl of healthy older adults from nonclinical populations was presented in a doctoral dissertation but to our knowledge has not been used in peerreviewed empirical research more importantly an examination of the content of the qlse items reveals that this tool confounds social qofl with physical qofl another measure the quality of life enjoyment and satisfaction scale 49 covers social aspects of qofl however although it has been administered to older populations it was not designed for older adults or older women in particular furthermore all of the studies that we were able to identify on this scale covered clinical populations that presented some form of mental illness or disability 50 51 52 the social qofl measure proposed herein the literature summarized above regarding available tools for the assessment of social qofl demonstrates a gap in the psychometric research on this topic concerning nonclinical populations of older women an instrument constructed specifically for use with communitydwelling ethnically diverse older women is critical to capturing the impact of familial and community support systems on these womens qofl as well as their perception of power respect understanding and honor within their family and communityall of which are concepts that are critical to social wellbeing in older age as mentioned earlier before describing our two studies on this measure it is appropriate to briefly illustrate their conceptual foundations in a classic theorization engel 5354 argued that the boundaries between health and disease are intertwined with social medical and psychological factors thus ones perception of social wellbeing represents an essential component of health and should not be neglected in research based on this theoretical approach we compiled original items that could best assess social qofl in older women from diverse ethnic backgrounds we focused on including in this measure items covering topics that emerged from the review of the existing literature on older womens social resources particularly aspects of life related to their social ties that have been associated with qofl yet not assessed via a single measure it should be noted that the new instrument proposed herein does not assess healthrelated qofl unlike most of the aforementioned tools such as the mos sf1236 the qli the sip and the nhp among others our social qofl measure quantifies instead the perceptions and reactions of older women to several facets of their environment a similar conceptual framework provided the foundation for the life satisfaction in the elderly scale 5556 however the latter scale is not genderspecific and confounds health status with qofl to our knowledge our new measure is the first tool created specifically to assess communitydwelling older womens social qofl beyond health status we hypothesized that in both studies the new instrument would show strong factor analysis reliability and initial validity findings concerning the latter we expected that scores on our measure would be moderately related to the size of respondents support network moreover we anticipated a significant relationship between social qofl and both kinds of qofl that have been most commonly targeted in prior studies ie physical and mental however only a modest association with these two facets of qofl was hypothesized given the specific social focus of the new tool methods sample characteristics the ethnically diverse sample of study 1 consisted of 220 older women who resided in several urban and suburban communities in los angeles county each respondent selfidentified as a member of one of seven ethnicpanethnic groups the demographic characteristics of the sample are displayed in table 1 participants ranged in age from 60 to 97 years with a reported median age of 71 and an interquartile range of 6625 to 7800 years of age a little over onethird of the sample was europeanamerican more than half indicated being born outside of the united states about 51 of the participants had a high school education or less most of the respondents were retired and mainly married or widowed for study 2 we recruited 241 older women who resided in the same urban and suburban communities of los angeles county as study 1 participants these women reported a median age of 68 years with a total range of 60 to 90 years and an interquartile range of 6400 to 7500 years of age in this second sample women selfidentified as belonging to one of seven ethnicpanethnic groups table 2 illustrates the demographic characteristics of this sample approximately 40 of the participants identified as europeanamerican and indicated an educational level equal to or lower than high school completion nearly half reported being born outside of the us inclusion criteria for both studies were as follows 60 years of age or older english fluency ability to provide informed consent and independent living status excluding individuals in assisted living facilities decreased the possibility of recruiting participants with significant cognitive impairment recruitment strategies we recruited participants for both samples using purposive sampling through ras connections within their ethnic communities recruitment sites included senior centers grocery stores and libraries in los angeles county a significant effort was made to identify and minimize barriers to recruitment with a focus on relevance of questions posed respect of cultural perspective and alignment of research goals with those of ethnic minority populations 5758 additionally we employed facetoface recruitment to encourage research participation and refrained from asking participants to travel to a research center recruitment was challenging as we attempted to recruit as many older women as possible from a vast variety of ethnic backgrounds several of the women originally contacted were wary of research efforts and uninterested in participating in these two investigations we allowed for flexible interview scheduling and assigned ethnicitymatched interviewers to establish initial contact and conduct interviews moreover we tailored our recruitment strategies for inclusion of women from all income levels as socioeconomic factors often affect willingness of ethnic minority older adults to engage in research 60 the utilization of this selection of recruitment tactics and sites maximized the number of ethnic minority participants in the two studies the first part of the assessment procedure involved the solicitation of basic demographic information from each participant and the administration of the brief screener to determine research eligibility ras read all items in the test battery aloud and were instructed to complete the assessment in two sessions with a short break between sessions to minimize fatigue we also asked them to write all responses to the measures in legible handwriting in the assessment packets ras allowed flexible scheduling of assessment sessions and accommodated location preferences to maximize participants comfort level typically respondents chose to be assessed in their homes or at community locations including libraries and senior centers we took great care to exercise patience and preserve the dignity of the older women participating in this research procedure assessment tools ras were instructed to first administer an original screening tool to verify research eligibility this short measure employs a combination of items from a standardized tool as well as demographic items required to determine eligibility specifically it contains a brief portion of the survey psychiatric assessment schedule 61 a 51item instrument with strong psychometric properties that was used exclusively for screening purposes our screener comprised only the first five items of the lengthy spas thus excluding the spas section other survey questions about general health of subject this choice allowed for the assessment of factors that are potentially indicative of gross cognitive impairment dementia such as participants ability to spell their own name remember their own birthday and exhibit an awareness of spatial orientation ras were instructed to recruit only women with perfect scores in these three areas we used a brief demographics list to assess variables such as ethnicity place of birth education and income as well as marital and employment status an indicator of social support ie the number of people in ones social network was quantified via the single item measure of social support although extremely short this instrument is a strong predictor of morbidity and has good psychometric properties 62 this single item is comprised of the question how many people do you have near you that you can readily count on for help in times of difficulty such as watch over children or pets give rides to hospital or store or help when you are sick response options are 0 1 25 610 or more responses of 0 or 1 indicate low tangible assistance 610 or more indicate high tangible assistance use of this short measure allowed us to avoid utilizing one of the much longer questionnaires on social support thus rendering the assessment process less cumbersome for older women to assess physical and mental qofl we utilized the medical outcome study 36item short form health survey this tool was developed to assess general health status and functional loss 63 and quantifies eight health constructs namely 1 limitations in physical activities due to health problems 2 limitations in social activities resulting from physical or emotional problems 3 limitations in usual role activities due to physical health problems 4 bodily pain 5 general mental health 6 limitations in usual role activities because of emotional problems 7 vitality and 8 general health perceptions subtotals for physical and mental health provided a quantification of physical qofl and mental qofl clinical tests of the validity of this tool have achieved excellent results 64 we utilized the mos software to conduct all the analyses relative to physical and mental qofl the older womens social quality of life inventory was used for the first time in the present research this original measure was developed by the first author unlike most of the currently available measures on this topic it is not confounded with health status as elaborated in the results the owsqli was created from an original pool of 50 items following an extensive literature review this tool was designed to target many culturallyrelevant social qofl issues others include family friends and the community at large item responses are coded on a 7point likerttype scale ranging from strongly disagree to strongly agree two sample items are i have the power respect i deserve in my community as an older person with experience knowledge and my children fully understand my social needs analytic strategy we implemented all data analyses through the statistical package for the social sciences version 170 for both studies we first calculated the samples descriptive statistics in study 1 we conducted an exploratory factor analysis of the new tool moreover we computed the internal consistencycronbachs a value for the owsqli through a reliability analysis additionally we validated the owsqli by relating its scores to those of instruments that measure social support as well as physical and mental qofl in cases in which a question was not applicable to a given respondent this question was excluded from the analysis and from any scale construction for that given participant this is preferable to a listwise deletion that would exclude the person in question from all analyses due to nonapplicable responses to a few items once the results of the efa in study 1 were examined we conducted a confirmatory factor analysis using study 2 sample the cfa was implemented specifically to ascertain whether the 22 items that emerged in study 1 continued to represent a single strong factor from the original 50item pool in study 2 furthermore we repeated the reliability and validity procedures employed in the previous study and examined potential ethnic group differences in owsqli scores results concerning the efa in study 1 our statistical consultant set the criterion of item retention at a factor loading of 32 or higher which is generally accepted as the minimum value for an item loading on a given factor 65 a 32 loading is approximately equal to 10 overlapping variance with the other items on that factor this provided a means to shorten the measure and consequently avoid burdening older women with a lengthy instrument in future research in this area based on this criterion 22 of the original 50 items were retained with 22 items the mean of the owsqli was 3913 and the standard deviation 2078 scores on one item were reversed as this item is negatively worded the factor analysis of the owsqli obtained robust findings based on the 50 original items the percentage of total score variance explained by one single factor was 4404 thus the comparative weight of this factor is strong examinations of the eigen values also pointed to a singlefactor solution with a clear drop in size between the first and second factor furthermore the 799 total variance gained in moving to a 2factor solution was not deemed sufficient in view of the practical disadvantages of a longer scale and the related greater difficulty in interpretability table 3 contains the matrix with the factor loading which illustrates the degree to which each of the 22 items loaded on one factor with the most highly loaded items displayed first to further confirm this 22item single factor solution we conducted a cfa using study 2 sample given the nature of this analysis principal axis factoring was chosen as the extraction method all 22 items met the 32 loading threshold with this second independent sample the owsqli yielded a mean of 4041 and a standard deviation of 1915 the single factor of the owsqli had a strong comparative weight as it explained a high percentage of total score variance the matrix with study 2 factor loading is displayed in table 4 with the most highly loaded owsqli items appearing first tables 5 and6 illustrate the itemtotal statistics for study 1 and study 2 the 22 items correlated very well with each other for both samples which was to be expected given that they assess facets of one construct social qofl in these two tables we displayed the content of each item next to its original number the new measure demonstrated the same high internal consistency in both studies moreover as reported in table 7 we conducted a preliminary validity test of the owsqli by relating its scores to those on size of social support network as well as to mos sf36 total scores good criterion validity was observed when owsqli scores were related to scores on the number of people in the respondents social network for both samples concurrent validity of the owsqli was assessed by comparing its scores in both study 1 and 2 to those on physical and mental qofl as expected correlations among these scales were significant although modest finally the samples from study 1 and study 2 were combined into one dataset to conduct a preliminary examination of potential ethnic group differences in owsqli scores combining the datasets was necessary in order to achieve the necessary sample size for mean comparison tests to be meaningful even with the significantly larger total sample it should be noted that only panethnic groupings rather than specific nationalethnic groupings were possible we conducted a oneway anova which was followed by tukey posthoc comparisons neither the overall omnibus test f 153 p 135 nor any paired comparison between panethnic groups was statistically significant indicating the general absence of significant panethnic betweengroup variation in owsqli scores discussion the findings of study 1 analyses indicate that the new tool presented herein is characterized by a strong single factor and high internal consistency these findings were confirmed in study 2 analyses whose results were nearly identical to those of study 1 furthermore as expected the owsqli demonstrated adequate criterion validity with a social support indicator as well as moderate concurrent validity with both physical and mental qofl these validity results are noteworthy because they confirm that our measure advances beyond assessment of social support as well as physical and mental qofl to quantify social qofl upon examining specific items loading on the single factor explaining a large part of the owsqlis score variance we discovered that our samples social qofl scores were affected primarily by satisfying relations with family members friends and the community at large were also valued but their contribution to personal sense of wellbeing was less critical than familial relationships this finding substantiates evidence reported in prior literature that the family network is typically the primary social resource available for emotional and financial support in older age although support from friends and community can provide similar protective effects 6667 it also corroborates the notion reinforced in a recent literature review 68 that family ties are particularly important for noneuropeanamerican older adults interestingly the notion of respect appears in the items that have some of the highest loadings in the scale which highlights the importance of respect and of ones role in the family in older age especially considering compelling research relating family role to mortality in older age 69 70 71 the fact that issues such as being loved and cared for by family and friends were strongly related to total owsqli scores suggests that it is imperative for mental health providers to encourage older patients to focus on ties with family and friends in order to strengthen such ties and in turn possibly enhance biopsychosocial functioning in later life in particular the friendsrelated finding offers supportive empirical evidence for yeh and los recommendations to provide incentives within communities to engage older adults in social activities and enhance their social contacts and resources 72 we also discovered that a sense of belonging and maintenance of status as a contributing family member is positively linked to older womens social qofl these findings complement prior empirical evidence demonstrating that supportive relationships and activities that are perceived as important help maintain older womens selfesteem and reduce stress 73 and that social contact and frequent social interaction produce higher life satisfaction in later life 74 another consistent result across both studies was that perceived size of social network was significantly related to owsqli scores again indicating that the amount of available help is an important factor with regard to older womens social qofl these findings are corroborated by prior literature on this topic 23 our results concerning the significant relationship between physical health and social qofl are also consistent with prior empirical evidence on this topic linking social resources to better physical health and a lessened impact of chronic disease 21 moreover the significance of the relationship between mental and social qofl corroborates the findings of other researchers 2730 as a whole the results of our two studies indicate that the new measure of social qofl is a psychometrically sound instrument with desirable properties for utilization with older women from diverse ethnic backgrounds moreover the items comprising the owsqli employ rather simple language which is a strength of the measure given the modest educational level of both samples these two investigations have several limitations that could be addressed in future studies among them our findings do not imply causation because their design was correlational longitudinal research is needed to verify the present results also the owsqli was not validated against a previously established sociallyrelated qofl instrument yet because to our knowledge this is the first tool of its kind such a limitation was unavoidable however it would have been ideal to validate the owsqli against a measure of social support that was more lengthy and indepth than the simss a focus on keeping the assessment battery short prevented us from using a lengthier social support instrument in future studies researchers could compare scores on the owsqli to those on other wellestablished social support measures such as the qlesq 49 another limitation of our research was that we recruited women exclusively mens social qofl should also be studied using our tool as the latter could be validated and modified accordingly for use with ethnically diverse older men furthermore a few of the items in the owsqli are worded somewhat vaguely especially given that the scale was administered to women as young as 60 for instance the meaning of regardless of my age could be unclear we meant that no matter how old the participant was she felt respected by the people in her community and by her family members having a few items with words that could be assigned different meanings is a shortcoming of most of the aforementioned tools special attention should be paid to clarifying the meaning of unclear items and encouraging research participants to raise questions if items are not understandable moreover the sample sizes of specific ethnic groups did not allow for the testing of national groupsalthough we did attempt to unveil different social relationship patterns via mean comparisons across panethnic groupings but found no significant differences in mean owsqli scores interested researchers could identify how older adults from different ethnic minorities respond to this tool and develop culturespecific norms based on their findings in this regard the meaning of words such as having power in ones family could vary across ethnic groups ideally these issues should be explored via indepth qualitative interviews to clarify item comprehension and assignment of meaning to complex concepts like power including collection of qualitative data to study social qofl would allow a more indepth study of this topic via mixed methods procedures concerning additional limitations of these two research endeavors all participants in both studies were fluent in english interested investigators should consider using and validating this new tool in other languages also our two cohorts were not based on random community sampling so our findings may not be fully generalizable to our catchment area however about half of both our samples reported holding a high school degree at best similarly to findings on the general los angeles county population 75 judging from those statistics the two samples utilized in this research are possibly representative of their catchment area nonetheless our results could be due at least partially to variables not assessed herein such as medication use andor acculturation further psychometric evaluation such as testing for differences on a subset of the items of the owsqli across a stratified sample may be warranted but was beyond the scope of this preliminary test of our measure additionally the exclusive use of selfrated measures although implemented in most of the aforementioned investigations is a limitation overall in spite of multiple limitations our studies represent a necessary step in the direction of properly quantifying the social qofl of ethnically diverse older women thus making a needed contribution to the growing area of ethnogeriatric psychometrics conclusions in our research we intended to start addressing a gap in the available geriatric literature concerning the need to develop an instrument to assess social qofl in older age independent of physical qofl our research findings with two nonclinical samples of communitydwelling older women from diverse ethnic backgrounds reinforce the notion that qofl in older age is truly multidimensional and must be carefully quantified through domainspecific tools that are sensitive to older adults complex needs and resources the evaluation of physical and mental qofl alone is insufficient for a comprehensive quantification of wellbeing in later life as testing of our tool achieved promising results clinicians who intend to assess social qofl in older women should consider adding this new measure to their assessment battery this would allow them to gain a deeper understanding of social areas in which their patients are lacking support as well as social areas of particular strength both could be enhanced via interventions such as individual therapy to increase psychosocial resilience family therapy and implementation of programs targeting social activities that the older patients in question find personally meaningful interested investigators should test the psychometric properties of the owsqli further currently in our laboratory we are collecting data utilizing this measure on ethnically diverse older men in order to refine this tool for use with older male populations as a final consideration researchers interested in clinical applications of the owsqli could relate its scores to those on adjustment to challenges commonly experienced in older age including chronic impairments such as vision problems utilization of the owsqli given its family and friends focus could be ideal with clinical populations similar to the one targeted in a recent study 76 in which family was found to provide social support during the initial adaptation of older individuals to vision impairment while friends provided support in longterm adaptation given the differences between our studies nonclinical population and the clinical one in question the factor structure of the owsqli for patients with progressive physical impairments could look significantly different than the structure obtained herein authors contributions ll the principal investigator created the owsqli designed the two studies conducted study 1 analyses and wrote most of the paper mlb wrote some parts of the literature review and a first draft of a portion of this paper ib wrote some parts of the literature review contributed to the writing of all sections verified the accuracy of the methodological parts of the paper and conducted study 2 data analyses all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background to our knowledge the available psychometric literature does not include an instrument for the quantification of social quality of life among older women from diverse ethnic backgrounds to address the need for a tool of this kind we conducted two studies to assess the initial reliability and validity of a new instrument the latter was created specifically to quantify the contribution of a social networks and resources eg family friends and community as well as b ones perceived power and respect within family and community to subjective wellbeing in nonclinical ethnically diverse populations of older women methods in study 1 we recruited a crosssectional sample of primarily noneuropeanamerican older women n 220 at a variety of community locations participants were administered the following a short screener for dementia a demographic list an initial pool of 50 items from which the final items of the new older womens social quality of life inventory owsqli were to be chosen based on a statistical criterion to apply to the factor analysis findings the single item measure of social support simss and the medical outcome study 36item shortform health survey mos sf36 study 2 was conducted on a second independent sample of ethnically diverse older women the same recruitment strategies procedures and instruments as those of study 1 were utilized in study 2 whose sample was comprised of 241 older women with mostly noneuropeanamerican ethnic status

impact on the quality of life of those suffering from them, but they also carry impose a substantial socio-economic burden. It is noteworthy that adolescents with mental disorders are more likely to develop psychological disorders in adulthood, as well as have more difficulty in dealing with financial and social problems, and experiencing greater challenges in managing family relationships and friendships [3]. As a result, researches focusing on adolescent mental disorders have increased in recent decades, and the issue of adolescent mental health has emerged as a global challenge. According to data from 41 studies from 27 countries in 2015, it was determined that at least 11-16% of children and adolescents suffer from one or more mental disorders [2]. However, despite the high prevalence rates, many studies have shown that the number of adolescents currently receiving treatment for mental disorders is much lower than the number of universal screening [4][5][6]. These suggest that a considerable number of adolescents are not receiving adequate professional diagnosis and treatment for their mental health conditions. Hence, it is critical to increase research and awareness of adolescent mental disorders to address the above problems and improve the quality of life for affected individuals. Furthermore, it is essential to provide accessible and effective mental health services and supports to guarantee that adolescents' mental health problems are identified and managed promptly and adequately. In China, mental and psychiatric disorders rank first in the country's total burden of disease, with adolescents accounting for about a quarter of those treated for mental disorders each year [7,8]. The Institute of Psychology of the Chinese Academy of Sciences conducted a survey in 2020 to assess the levels of various dimensions of mental health among China's youth population. The survey results indicate that the attainment rate of mental health literacy among the China's youth is notably low, measuring at 14.24% [7,8]. In addition, the China Youth Development Report, published in December 2019, estimates that a minimum of 30 million children and young people under 17 years of age in China are experiencing diverse emotional and behavioural difficulties [7,8]. What is more, the imbalance between the psychological development and physical development of adolescents makes them more prone to difficulties in psychological integration, leading to negative states of mind, such as worry, anxiety, depression, loneliness and low self-esteem, and thus mental health problems. In recent years, the number of children and adolescents experiencing mental problems worldwide has been on the rise and is of increasing concern to families, schools and society. Although there are more research studies on the mental health status of adolescents, the findings are not consistent across different geographical areas and different levels of economic development [7,8]. The aim of this study was to investigate the prevalence and distribution of common mental disorders in Shaoxing, China. A two-stage epidemiological survey was conducted. The mental health status of a total of 8219 students in eight middle schools was screened using a questionnaire, and then the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria were used to determine the diagnosis to clarify the current status of mental disorders among these students. This study will contribute to the future provision of medical resources, health policies and prevention strategies. --- Methods --- --- The screening tool The Mental Health Screening Checklist completed by the students was used, which consists of five scales: symptom inventory 90 , Self-rating depression scale , Self-rating anxiety scale , Yale-Brown obsessive compulsive scale and Pittsburgh sleep quality index . The SCL-90 is a self-reported mental health instrument proposed by Derogatis and is widely used to detect clinical psychiatric symptoms and mental health conditions [9][10][11]. It can distinguish healthy individuals from those with psychosis and has good reliability and validity for assessing the mental health of individuals as well as the overall assessment of mental health in different groups. Both the SDS and SAS cover 20 items specific to psychological and physical conditions and are used as selfmeasures of depression and anxiety, respectively, rated by the respondent on the basis of the past week, with higher scores indicating poorer psychological conditions [12,13]. The Y-BOCS is considered to be the gold standard for assessing the severity of OCD and consists of a symptom checklist and 10 items [14]. PSQI is one of the most widely used measures of sleep quality, consisting of seven sleep parameters to assess different sleep problems, and is valuable in predicting the risk of depressive symptoms [15]. --- Diagnostic criteria and tools Two types of interviews were conducted sequentially based on the Mini International Neuropsychiatric Interview for Children and Adolescents and DSM-IV criteria [16,17]. The MINI-KID was used for a brief formal psychiatric examination and its scores were provided to the psychiatrist conducting the DSM-IV interview as a reference for the final diagnosis. --- Assessment procedure The project was approved by the Ethics Review Committee of the Zhejiang Rehabilitation Medical Center. This study consisted of two steps, with the first step using MHSC as the investigative tool. The survey was conducted by a team of psychiatrists, qualified doctors and medical students. The survey data were initially processed by a statistician and after excluding items with incomplete or confusing responses, all individuals with complete MHSC records were analyzed. Of the 7723 participants who completed the questionnaire, 7493 were eligible, with 28.6% of the students scoring positive, i.e., scoring positive on at least one of the five scales included in the MHSC. Then, the second step included all participants with MHSC positive, as well as 1000 randomly selected participants with a negative result, who were chosen to assess the false-negative rate of MHSC. The second step consisted of two interviews. The psychiatrist first conducted a semi-structured interview based on the MINI-KID, followed by a DSM-IV interview to confirm the diagnosis, and finally a total of participants were identified as having at least one psychiatric disorder. The procedure is illustrated in Fig. 1. --- Statistical analysis Data analysis was performed using SPSS 25.0 software. Prevalence, frequencies and 95% confidence intervals were estimated for mental disorders and comorbidities. The gender, age and regional distribution of the sample, as well as the prevalence of different mental disorders in different age groups, were assessed and subsamples were compared using T tests and Chi-square tests. All statistical tests were two-tailed with a significance level of 0.05. Logistic regression analysis was used to study the age group, gender, region, prevalence and the interaction among them. --- Results A total of 8,219 students participated in the MHSC questionnaire and 7493 qualified questionnaires eventually returned, with a gender distribution of 3702 males and 3791 females. Among them, 2140 students were found to have psychological problems, with a detection rate of 28.6% . The prevalence rate of girls was significantly higher than that of boys . Furthermore, as shown in Table 1, the prevalence rate was 23.5% for 12-13 years, 29.8% for 14-15 years and 36.9% for 16-18 years, and there was a statistically significant difference in the detection rate of metal disorders by age group . Of the 7493 students, 2140 participants with MHSC positive and 1000 participants with MHSC negative were included in the secondary interview. A total of fourteen types of mental disorder were diagnosed in 930 children through the MINI-KID and DSM-IV interview. Among these mental disorders, obsessive compulsive disorder had the highest prevalence , followed by major depressive disorder , anxiety disorders , attention-deficit hyperactivity disorder , oppositional Fig. 1 Study flow chart defiant disorder and sleep disorder . As shown in Table 3, the overall point prevalence rate for boys was 10.8% lower than the 14.0% for girls. Compare to boys, the prevalence of the MDD, AD, OCD, SD, bulimia nervosa and anorexia nervosa was significantly higher in girls, at 10.0% , 5.5% , 10.0% , 2.3% , 1.4% and 0.3% , respectively. However, prevalence rates for ADHD, tic disorder , substance use disorder and mania or hypomania were higher for boys, at 3.5% , 1.5% , 1.5% and 0.8% , respectively. There was no gender difference in the risk of ODD, social phobia , post-traumatic stress disorder and psychotic disorder . It is noteworthy that the prevalence of overall mental disorders increases with age, as shown in Table 4. The prevalence of mental disorders was upwards of 20% in the 17-18-year-old age group relative to other age groups , while the lowest prevalence in the 12-yearold age group at less than 10% . The prevalence of MDD and anxiety disorders was highest among participants aged 18 years , and the prevalence of OCD, SD and SUD was highest among participants aged 17 years . Inconsistently, the younger the age, the higher the risk of ADHD, ODD and TD, with prevalence rates of 5.2% , 3.5% and 3.3% , respectively, in the 12-year-old group . Comorbidities of the several common mental disorders are shown in Table 5. Individuals diagnosed with MDD, AD, OCD and SD had higher rates of comorbidity. MDD was most frequently comorbid with AD , OCD , and SD in 220, 218, and 134 individuals, respectively. The most common comorbidity of ADHD was AD , ODD was ADHD , TD was MDD and SUD was SD . --- Discussion The mental health of adolescents has become a major public health concern in recent years. Mental disorders are highly prevalent among adolescents and can significantly affect their academic, social, and emotional functioning. Therefore, understanding the prevalence and distribution of mental disorders among them is essential for developing effective prevention and intervention strategies. This study aimed to discuss the findings on the prevalence and distribution of four mental disorders among a large sample of middle school students and examine the gender and age differences in their prevalence rates. In this study, 2,140 students with mental problems were identified from valid data of 7493 middle school students , indicating that more than one in four students were affected by one or more psychiatric disorders. The prevalence rate was generally consistent with data from national and international studies [18,19], but higher than other studies that screened with the Child Behavior Checklist scale. This difference may be due to the fact that the CBCL is completed by caregivers or students, whereas the MHSC is completed by students only. In addition, the prevalence rate of psychiatric disorders also varied by age group. The prevalence rate was lowest among 12-13 years , increased among 14-15 years , and was highest among 16-18 years , implying that the prevalence of mental disorders increases with age. What is more, following the MINI-KID interview and DSM criteria for diagnosis, four types of psychiatric disorders were diagnosed in a total of 930 students out of 7943 participants, for an overall point rate of 12.4%. This result is consistent with those reported in epidemiological studies of mental disorders based on a two-stage approach conducted in other countries [18,20,21]. The point prevalence of mental disorders in this study was lower than the pooled prevalence of 13.4% in a meta-analysis. Of these, the prevalence of MDD was higher than the pooled prevalence , while the prevalence of anxiety was lower . Gender comparisons showed a higher overall prevalence of psychiatric disorders in girls relative to boys , contrary to the results of some studies [18,20,21]. This result might be related to the inconsistency of the age groups we studied. As other studies have shown, the most common mental disorder among girls is anxiety and depression [19], and in our study, adolescent girls had a higher prevalence of these disorders than boys. However, for disorders, such as ADHD, SUD, TD, SUD and MA, the prevalence was significantly higher in boys than in girls, which was consistent with most studies. According to the results of two-stage epidemiological survey, there is a general trend of increasing prevalence among students aged 12-18, which may be attributed to the fact that they are in transition from childhood to adulthood, not only going through physical and psychological changes, but also facing other adverse factors that lead to mental health problems, such as academic pressure and family relationships. The 17-18 age group has the highest prevalence rate , which may be related to the transition to university, as they face more difficult courses, and university entrance exams , with increasing pressure from teachers and parents. On the other hand, we found that the most common comorbidity was MDD rather than ADHD, which is inconsistent with previous findings [22]. This may be due to the fact that our survey respondents were between the ages of 12 and 18 years, while the high prevalence of ADHD is between the ages of 6 and 12 years. Thus, early identification and treatment of psychiatric disorders are essential for preventing negative outcomes, so schools and healthcare providers should screen adolescents for psychiatric disorders and provide appropriate interventions for those who screen positive. Gender and age differences in the prevalence of psychiatric disorders suggest that prevention and intervention strategies should be tailored to specific subgroups of adolescents. For example, targeting girls or older adolescents for prevention and intervention programs may be particularly effective in reducing the prevalence. In addition, the high prevalence of OCD and MDD among adolescents highlights the need for targeted prevention and intervention strategies for these disorders. The findings suggest that prevention and intervention strategies should be tailored to specific subgroups of adolescents and targeted at reducing risk factors and increasing protective factors for specific disorders. --- Conclusion In conclusion, our study showed that nearly one in ten middle school students in Shaoxing suffer from a mental disorder, with OCD and MDD being the most common disorders in the sample, and the prevalence increases almost with age. The study provides valuable insights into the prevalence of psychological disorders among students and the gender and age differences in their prevalence rates. In addition, our findings highlighted the need for early screening of middle school students for mental disorders, which facilitates the allocation of public mental health resources and policy development. Further research is needed to explore the underlying factors contributing to these gender and age differences and develop effective interventions to improve mental health outcomes in students. --- Limitation There are several limitations to this study that should be considered when interpreting the findings. First, academic stress and family relationships may be important factors influencing prevalence, but the lack of relevant data collection prevented a correlation analysis in this study. Second, the study did not assess the duration of these mental disorders, which may be important factors in determining the need for intervention. Finally, the study was conducted in a specific geographic region, which may limit the generalizability of the findings to other populations. --- --- Abbreviations --- --- Funding The Zhejiang Provincial Disabled Persons' Federation supported the design of the study and data collection. --- --- --- Competing interests The authors declare that they have no competing interests. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year ---

Background In China, adolescents account for about a quarter of those treated for mental disorders each year, and adolescent mental health issues have become a social hotspot. Although several epidemiological surveys of mental disorders have been conducted in China, no study has yet focused on the prevalence of mental disorders among adolescents in a certain region of Zhejiang.In the first stage, 8219 middle school students aged 12-18 years in a city of Zhejiang Province (Shaoxing) were screened with the mental health screening checklist. In the second stage, participants who screened positive were tested with the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Then, the prevalence of mental disorders were calculated.The overall prevalence in this population was 12.4%, with prevalence rates exceeding 20% in both the 17and 18-year-old age groups. The most common mental disorders were obsessive-compulsive disorder (OCD) (9.1%) and major depressive disorder (MDD) (8.9%).Mental disorders are common among middle school students, and girls are at higher risk than boys. As the most prevalent mental disorders, OCD and MDD should receive timely attention, especially for upper grade students.

impact on the quality of life of those suffering from them but they also carry impose a substantial socioeconomic burden it is noteworthy that adolescents with mental disorders are more likely to develop psychological disorders in adulthood as well as have more difficulty in dealing with financial and social problems and experiencing greater challenges in managing family relationships and friendships 3 as a result researches focusing on adolescent mental disorders have increased in recent decades and the issue of adolescent mental health has emerged as a global challenge according to data from 41 studies from 27 countries in 2015 it was determined that at least 1116 of children and adolescents suffer from one or more mental disorders 2 however despite the high prevalence rates many studies have shown that the number of adolescents currently receiving treatment for mental disorders is much lower than the number of universal screening 4 5 6 these suggest that a considerable number of adolescents are not receiving adequate professional diagnosis and treatment for their mental health conditions hence it is critical to increase research and awareness of adolescent mental disorders to address the above problems and improve the quality of life for affected individuals furthermore it is essential to provide accessible and effective mental health services and supports to guarantee that adolescents mental health problems are identified and managed promptly and adequately in china mental and psychiatric disorders rank first in the countrys total burden of disease with adolescents accounting for about a quarter of those treated for mental disorders each year 78 the institute of psychology of the chinese academy of sciences conducted a survey in 2020 to assess the levels of various dimensions of mental health among chinas youth population the survey results indicate that the attainment rate of mental health literacy among the chinas youth is notably low measuring at 1424 78 in addition the china youth development report published in december 2019 estimates that a minimum of 30 million children and young people under 17 years of age in china are experiencing diverse emotional and behavioural difficulties 78 what is more the imbalance between the psychological development and physical development of adolescents makes them more prone to difficulties in psychological integration leading to negative states of mind such as worry anxiety depression loneliness and low selfesteem and thus mental health problems in recent years the number of children and adolescents experiencing mental problems worldwide has been on the rise and is of increasing concern to families schools and society although there are more research studies on the mental health status of adolescents the findings are not consistent across different geographical areas and different levels of economic development 78 the aim of this study was to investigate the prevalence and distribution of common mental disorders in shaoxing china a twostage epidemiological survey was conducted the mental health status of a total of 8219 students in eight middle schools was screened using a questionnaire and then the diagnostic and statistical manual of mental disorders fourth edition criteria were used to determine the diagnosis to clarify the current status of mental disorders among these students this study will contribute to the future provision of medical resources health policies and prevention strategies methods the screening tool the mental health screening checklist completed by the students was used which consists of five scales symptom inventory 90 selfrating depression scale selfrating anxiety scale yalebrown obsessive compulsive scale and pittsburgh sleep quality index the scl90 is a selfreported mental health instrument proposed by derogatis and is widely used to detect clinical psychiatric symptoms and mental health conditions 9 10 11 it can distinguish healthy individuals from those with psychosis and has good reliability and validity for assessing the mental health of individuals as well as the overall assessment of mental health in different groups both the sds and sas cover 20 items specific to psychological and physical conditions and are used as selfmeasures of depression and anxiety respectively rated by the respondent on the basis of the past week with higher scores indicating poorer psychological conditions 1213 the ybocs is considered to be the gold standard for assessing the severity of ocd and consists of a symptom checklist and 10 items 14 psqi is one of the most widely used measures of sleep quality consisting of seven sleep parameters to assess different sleep problems and is valuable in predicting the risk of depressive symptoms 15 diagnostic criteria and tools two types of interviews were conducted sequentially based on the mini international neuropsychiatric interview for children and adolescents and dsmiv criteria 1617 the minikid was used for a brief formal psychiatric examination and its scores were provided to the psychiatrist conducting the dsmiv interview as a reference for the final diagnosis assessment procedure the project was approved by the ethics review committee of the zhejiang rehabilitation medical center this study consisted of two steps with the first step using mhsc as the investigative tool the survey was conducted by a team of psychiatrists qualified doctors and medical students the survey data were initially processed by a statistician and after excluding items with incomplete or confusing responses all individuals with complete mhsc records were analyzed of the 7723 participants who completed the questionnaire 7493 were eligible with 286 of the students scoring positive ie scoring positive on at least one of the five scales included in the mhsc then the second step included all participants with mhsc positive as well as 1000 randomly selected participants with a negative result who were chosen to assess the falsenegative rate of mhsc the second step consisted of two interviews the psychiatrist first conducted a semistructured interview based on the minikid followed by a dsmiv interview to confirm the diagnosis and finally a total of participants were identified as having at least one psychiatric disorder the procedure is illustrated in fig 1 statistical analysis data analysis was performed using spss 250 software prevalence frequencies and 95 confidence intervals were estimated for mental disorders and comorbidities the gender age and regional distribution of the sample as well as the prevalence of different mental disorders in different age groups were assessed and subsamples were compared using t tests and chisquare tests all statistical tests were twotailed with a significance level of 005 logistic regression analysis was used to study the age group gender region prevalence and the interaction among them results a total of 8219 students participated in the mhsc questionnaire and 7493 qualified questionnaires eventually returned with a gender distribution of 3702 males and 3791 females among them 2140 students were found to have psychological problems with a detection rate of 286 the prevalence rate of girls was significantly higher than that of boys furthermore as shown in table 1 the prevalence rate was 235 for 1213 years 298 for 1415 years and 369 for 1618 years and there was a statistically significant difference in the detection rate of metal disorders by age group of the 7493 students 2140 participants with mhsc positive and 1000 participants with mhsc negative were included in the secondary interview a total of fourteen types of mental disorder were diagnosed in 930 children through the minikid and dsmiv interview among these mental disorders obsessive compulsive disorder had the highest prevalence followed by major depressive disorder anxiety disorders attentiondeficit hyperactivity disorder oppositional fig 1 study flow chart defiant disorder and sleep disorder as shown in table 3 the overall point prevalence rate for boys was 108 lower than the 140 for girls compare to boys the prevalence of the mdd ad ocd sd bulimia nervosa and anorexia nervosa was significantly higher in girls at 100 55 100 23 14 and 03 respectively however prevalence rates for adhd tic disorder substance use disorder and mania or hypomania were higher for boys at 35 15 15 and 08 respectively there was no gender difference in the risk of odd social phobia posttraumatic stress disorder and psychotic disorder it is noteworthy that the prevalence of overall mental disorders increases with age as shown in table 4 the prevalence of mental disorders was upwards of 20 in the 1718yearold age group relative to other age groups while the lowest prevalence in the 12yearold age group at less than 10 the prevalence of mdd and anxiety disorders was highest among participants aged 18 years and the prevalence of ocd sd and sud was highest among participants aged 17 years inconsistently the younger the age the higher the risk of adhd odd and td with prevalence rates of 52 35 and 33 respectively in the 12yearold group comorbidities of the several common mental disorders are shown in table 5 individuals diagnosed with mdd ad ocd and sd had higher rates of comorbidity mdd was most frequently comorbid with ad ocd and sd in 220 218 and 134 individuals respectively the most common comorbidity of adhd was ad odd was adhd td was mdd and sud was sd discussion the mental health of adolescents has become a major public health concern in recent years mental disorders are highly prevalent among adolescents and can significantly affect their academic social and emotional functioning therefore understanding the prevalence and distribution of mental disorders among them is essential for developing effective prevention and intervention strategies this study aimed to discuss the findings on the prevalence and distribution of four mental disorders among a large sample of middle school students and examine the gender and age differences in their prevalence rates in this study 2140 students with mental problems were identified from valid data of 7493 middle school students indicating that more than one in four students were affected by one or more psychiatric disorders the prevalence rate was generally consistent with data from national and international studies 1819 but higher than other studies that screened with the child behavior checklist scale this difference may be due to the fact that the cbcl is completed by caregivers or students whereas the mhsc is completed by students only in addition the prevalence rate of psychiatric disorders also varied by age group the prevalence rate was lowest among 1213 years increased among 1415 years and was highest among 1618 years implying that the prevalence of mental disorders increases with age what is more following the minikid interview and dsm criteria for diagnosis four types of psychiatric disorders were diagnosed in a total of 930 students out of 7943 participants for an overall point rate of 124 this result is consistent with those reported in epidemiological studies of mental disorders based on a twostage approach conducted in other countries 182021 the point prevalence of mental disorders in this study was lower than the pooled prevalence of 134 in a metaanalysis of these the prevalence of mdd was higher than the pooled prevalence while the prevalence of anxiety was lower gender comparisons showed a higher overall prevalence of psychiatric disorders in girls relative to boys contrary to the results of some studies 182021 this result might be related to the inconsistency of the age groups we studied as other studies have shown the most common mental disorder among girls is anxiety and depression 19 and in our study adolescent girls had a higher prevalence of these disorders than boys however for disorders such as adhd sud td sud and ma the prevalence was significantly higher in boys than in girls which was consistent with most studies according to the results of twostage epidemiological survey there is a general trend of increasing prevalence among students aged 1218 which may be attributed to the fact that they are in transition from childhood to adulthood not only going through physical and psychological changes but also facing other adverse factors that lead to mental health problems such as academic pressure and family relationships the 1718 age group has the highest prevalence rate which may be related to the transition to university as they face more difficult courses and university entrance exams with increasing pressure from teachers and parents on the other hand we found that the most common comorbidity was mdd rather than adhd which is inconsistent with previous findings 22 this may be due to the fact that our survey respondents were between the ages of 12 and 18 years while the high prevalence of adhd is between the ages of 6 and 12 years thus early identification and treatment of psychiatric disorders are essential for preventing negative outcomes so schools and healthcare providers should screen adolescents for psychiatric disorders and provide appropriate interventions for those who screen positive gender and age differences in the prevalence of psychiatric disorders suggest that prevention and intervention strategies should be tailored to specific subgroups of adolescents for example targeting girls or older adolescents for prevention and intervention programs may be particularly effective in reducing the prevalence in addition the high prevalence of ocd and mdd among adolescents highlights the need for targeted prevention and intervention strategies for these disorders the findings suggest that prevention and intervention strategies should be tailored to specific subgroups of adolescents and targeted at reducing risk factors and increasing protective factors for specific disorders conclusion in conclusion our study showed that nearly one in ten middle school students in shaoxing suffer from a mental disorder with ocd and mdd being the most common disorders in the sample and the prevalence increases almost with age the study provides valuable insights into the prevalence of psychological disorders among students and the gender and age differences in their prevalence rates in addition our findings highlighted the need for early screening of middle school students for mental disorders which facilitates the allocation of public mental health resources and policy development further research is needed to explore the underlying factors contributing to these gender and age differences and develop effective interventions to improve mental health outcomes in students limitation there are several limitations to this study that should be considered when interpreting the findings first academic stress and family relationships may be important factors influencing prevalence but the lack of relevant data collection prevented a correlation analysis in this study second the study did not assess the duration of these mental disorders which may be important factors in determining the need for intervention finally the study was conducted in a specific geographic region which may limit the generalizability of the findings to other populations abbreviations funding the zhejiang provincial disabled persons federation supported the design of the study and data collection competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year

background in china adolescents account for about a quarter of those treated for mental disorders each year and adolescent mental health issues have become a social hotspot although several epidemiological surveys of mental disorders have been conducted in china no study has yet focused on the prevalence of mental disorders among adolescents in a certain region of zhejiangin the first stage 8219 middle school students aged 1218 years in a city of zhejiang province shaoxing were screened with the mental health screening checklist in the second stage participants who screened positive were tested with the mini international neuropsychiatric interview for children and adolescents minikid and the diagnostic and statistical manual of mental disorders fourth edition dsmiv then the prevalence of mental disorders were calculatedthe overall prevalence in this population was 124 with prevalence rates exceeding 20 in both the 17and 18yearold age groups the most common mental disorders were obsessivecompulsive disorder ocd 91 and major depressive disorder mdd 89 mental disorders are common among middle school students and girls are at higher risk than boys as the most prevalent mental disorders ocd and mdd should receive timely attention especially for upper grade students

Background The sub-Saharan HIV epidemic presents patterns that challenge conventional understandings of the relationships between socioeconomic status and health. The notion that poverty was the underlying factor increasing susceptibility to HIV infection had become one of the main messages sent out by the global health field [1]. It has often been assumed that Africa's status as the continent with the highest HIV infection rates is linked to its endemic high poverty and a corresponding lack of access to adequate health care resources [2]. Poverty reduction strategies were therefore touted as the most viable long-term option in the fight against the disease [3]. In SSA, high SES individuals have higher levels of formal education, greater exposure to health education messages and mass media, increased access to health care, and better access to condoms, which should all lower their risk for contracting HIV [4]. However, a growing number of studies show that wealthier individuals , wealthier regions , and wealthier countries within SSA often display the highest levels of HIV infection [5][6][7][8][9][10][11][12][13][14][15]. In a study of eight African countries, Mishra and colleagues [12], provide evidence of a positive association between household wealth and HIV prevalence. Similarly, a review of thirty-five studies on SES and HIV status in SSA, found ten cross sectional studies and one cohort study that described a positive association, between high SES and HIV infection [15]. Theories for why SES and HIV are positively related often point to social and cultural mechanisms, especially lifestyles associated with increased income which are associated with increased vulnerability to HIV infection [5]. Of primary interest therefore, are patterns of risky sexual behavior that are positively linked to an individual's wealth, including the number of multiple and non-marital sexual partners, and premarital sexual intercourse. Mumah and Jackson-Smith [16], in a recent study found that the length of premarital sexual activity among high SES women significantly increases their vulnerability to HIV, because high SES women are more likely to delay first marriage, yet be sexually active. For men, level of education and income increases the probability individuals will have non-regular sexual partners, which is known to also increase exposure to STDs including HIV [17][18]. Kongnyuy and colleagues [17], found that wealthy men in Cameroon had higher rates of HIV infection, which in part was explained by their riskier sexual behaviors including earlier sexual debut, multiple concurrent and lifetime partners, and limited use of condoms with partners other than wives or cohabiting partners. Similar patterns are found for high SES women. One recent study argues that it is the 'pursuit of modernity' that explains female risky sexual behaviors in SSA [18]. The authors found evidence from Kenya and South Africa that materialism and pursuit of consumer goods such as cars, cash and cell phones drives transactional sex, rather than absolute poverty [18][19]. Fox [5], argues therefore that for women, having multiple partners can be a mechanism for achieving upward mobility, while for men, multiple partnership is an avenue to validate 'sexual prowess and social status'. Similarly, numerous studies indicate that the direction of transmission of HIV among migrants is not limited to transmission from migrant males to their wives, but also from the non-migrating wives to their spouses, because they had other sexual partners while their spouses were away [20]. As in the case with wealth, higher levels of formal education are often associated with increased risk of HIV, particularly in Eastern and Southern Africa [10,[21][22]. One study found that those with basic primary education had twice the odds of being HIV-positive as those with no education [10]. Studies that find a positive association between wealth and HIV often do not find the same pattern with education, suggesting that SES-HIV linkages are complex [22][23][24][25]. Moreover, controlling for other individual characteristics can reduce or eliminate statistical associations between HIV status and education levels [26]. Despite evidence of a positive SES-HIV gradient, researchers and policy-makers frequently assume that a range of protective interventions -increasing awareness of mechanisms of HIV transmission and techniques for prevention, greater access to health care facilities , and greater availability of condoms -will reduce the likelihood of contracting HIV [27][28], even among higher SES populations [29]. Similarly, researchers have called for empowering women to have more control over sexual decision-making through socioeconomic development [6]. The presumed mechanism for protection is a change in behavior that could place a person at risk for contracting HIV. In this paper, we examine evidence from a nationally representative survey of Cameroonian women and explore how SES is related to HIV status. Previously published research documented that higher SES women are much more likely to contract HIV than their low SES counterparts [22,[24][25][26][30][31]. Our analysis accounts for three core sets of intervening variables , and assesses the key role of risky and protective sexual behaviors in determining HIV status. We also account for the effects of partner SES, depending on the marital status of the woman, and control for several other contextual characteristics. A graphic representation of our theoretical model, with illustrations of the hypothesized direction of relationships can be found in Figure 1. --- Data and Methods --- Data The 2004 Cameroon Demographic and Health Survey , is a nationally representative survey involving residents aged 15-49. The DHS uses a multi-layer protocol review system to obtain ethical review in the United States and host country before data collection begins. The survey and the protocol for blood specimen collection and analysis were approved by the Institutional Review Board for ORC Macro, Calverton, USA. In Cameroon, the National Ethics Committee in the Ministry of Health reviewed the protocol and provided ethical clearance and approval. Written informed consent, which was vetted and approved by the National Ethics Committee in Ministry of Health, was gotten from all survey participants prior to participation and all information was collected confidentially. The informed consent forms were translated to the appropriate local language before being administered to participants. The CDHS uses a multi-stage complex cluster sampling methodology with response rates well in excess of 90 percent [32][33][34]. The CDHS survey provides information on a variety of topics including HIV test results for nearly all respondents, determined via voluntary blood samples. The CDHS included 5, 155 female respondents in the sample, with conclusive test results for all but one case. The ability to link HIV testing with individual characteristics provides a unique opportunity to assess factors associated with HIV infection. Analysis in this study was run using both weighted and unweighted data. The results shown in this paper uses the unweighted sample data because there were no meaningful or substantive differences between results estimated from the weighted and unweighted samples. Measures. Socioeconomic status is captured both at the individual-level and household-level . Female SES has been linked both to the timing and nature of marriage and to the SES of her partner, therefore the impact of partner's SES on a woman's HIV risk is mediated by her marital status/relationship status and history. In the analysis, dummy variables for currently married, never married, cohabiting and early marriage are used. The first two sets of intervening variables reflect better access to health care and knowledge about HIV, which we expect to increase with higher levels of SES [29]. Access to health care is captured by indicators of respondents' awareness and use of Centre de De ´pistage volontaire clinics , whether the respondent visited any health facility in the last 12 months, and self-reports of barriers to accessing local health clinics . Knowledge of HIV infection and prevention mechanisms was measured by constructing an additive scale using 15 knowledge items in the CDHS [35]. The scale met conventional standards for reliability and ranges in value from 0-15. A woman's ability to access health care will influence her knowledge about HIV. In turn, a woman's knowledge of HIV and prevention methods is presumed to influence her behaviors which could be risky or protective, thereby determining her HIV status. The third set of intervening variables reflects a woman's decision-making power in her relationships. Power in relationships is captured in scale constructed from questions about household decision making , attitudes toward wife beating , and perceptions of a woman's power in sexual decision-making . SES is theoretically linked to a woman's power in her sexual relationships, which in turn should influence the behaviors of both women and their partners. We theorize here that the more power a woman commands in her relationship the less risky will be her behaviors . Our theoretical model captures the fact that HIV status is most directly affected by sexual behaviors and the influence of SES, access to health care, HIV knowledge and power should manifest as differences in levels of these behaviors. Female sexual behavior is captured in our analysis via both female protective sexual behaviors , and female risky sexual behaviors . Finally, our analysis controls for other contextual factors including place of residence, region and religion. Dummy variables for rural/urban residence and cultural regions are used because there are large regional and urban/rural differences within the country and a study of SES and risk of HIV needs to take these contextual factors into consideration. Due to large number of ethnic categories with some having very few cases, a collapsed version of region, rather than ethnicity is used in our analyses. Kuate-Defo [36], posits that the more than 200 ethnic groups in Cameroon fall into four major cultural regions of the country: Center, South, and East; Littoral and South West; West and North West; and Nord, Adamaoua and Extreme Nord. This collapsed version of regions is used as a proxy for ethnicity. Because religious affiliations are not perfectly correlated with region, dummy variables for the respondent's personal religious affiliation: Catholic, Protestant, Muslim and Other are included. Analyses. Bivariate analyses are first utilized to illustrate the simple associations among women's SES status, each of the intervening variables, and HIV status. We begin by describing the relationship between HIV and all the other variables to highlight the factors most associated with the prevalence of HIV infection among women in Cameroon. Second, we examine the relationships between SES and the intervening variables to see if SES is associated with the expected intervening variables in ways that are expected to increase or decrease HIV risk. Third, we look at the link between access to health care, HIV knowledge, and indicators of sexual behavior. Three types of bivariate analyses are used: cross tabulations, ANOVA-tests, and t-tests. Chi-square and Fishers' Exact tests are used to determine statistical relationship between the categorical variables analyzed in cross tabulations. Strength of association was assessed using Cramer's V and gamma. We then estimate two multivariate binary logistic regression models to contrast the effects of women's SES status on HIV with and without the presence of intervening variables. The full model also estimates the relative contribution of access, knowledge, and power to explaining the positive bivariate SES-HIV relationship. The multivariate models use 4,916 cases because 239 cases were missing at least one core variable used in the analyses. The overall fit of the model was assessed using the negative log-likelihood and the Homer and Lemeshow statistic , while the explanatory adequacy of the model were assessed using the Cox & Snell and Nagelkerke R-Squares. This study utilized IBM SPSS version 19 to manage and analyse the data. --- Results --- Bivariate analyses Relationship between Core Variables and HIV Status. As noted above, the CDHS provides a rare opportunity to combine information about the characteristics of large representative samples of adults with actual HIV blood test results. Table 1 shows the proportion of women in the CDHS sample and the incidence of HIV by various indicators of SES. The results clearly show that household wealth, educational attainment, and occupational status are significantly and positively related to HIV status among women in Cameroon. A woman's partners' SES is also associated with her HIV status. Among the 23 percent of women with no current partner, HIV rates are relatively low . However, the incidence of HIV among The relationship between access to health care, sexual behaviors, and HIV rates among Cameroonian women is also shown in Table 1. There is a strong pattern where women with greater access to and use of health care facilities have higher rates of HIV. It is unlikely that the use of health care resources causes HIV infection, so this counterintuitive finding may reflect a pattern in which HIV-positive women are more likely to go to health care providers because they suffer from symptoms of the disease. Alternatively, women living in more remote rural areas have less access to health care, but also face a much lower overall background rate of population HIV infection. A similar pattern is also seen in Table 1 where women who have higher rates of condom use are also more likely to test positive for the HIV virus. Again, it is possible that condom use is caused by positive HIV status . Meanwhile, as expected women who report engaging in risky sexual behaviors are more likely to have HIV. Finally, we compared the mean scale scores for HIV positive and negative women on a set of indicators for HIV knowledge, premarital sexual experience, and three indicators of a woman's power in her personal relationships, where higher values reflect higher power . The results suggest that HIV positive women have higher levels of knowledge of HIV transmission and prevention, more years of premarital sexual experience, and higher scores on the power scales reflecting household decisionmaking. Interestingly, at the bivariate level, HIV status was not significantly associated with attitudes towards wife beating or women's control over sexual decisions. Relationship between SES and Access to Health Care, Knowledge, and Sexual Behaviors. Overall, as expected, there was a positive and highly significant association between SES and access to health care . Wealthier and more educated women were more likely to have visited a health facility in the last 12 months , and to have heard of and visited a Voluntary Counseling and Testing Center . Higher SES women were also significantly less likely to report barriers to accessing health care. In fact each increase in a woman's educational attainment was associated with a decrease in the number reporting barriers to health care. Access to health care also varied by the different occupational categories. Women in professional or white collar professions were more likely to report visiting a CPDV , more likely to have accessed a health facility within the last year, and faced the fewest barriers to health care of any occupational group. A woman's SES was also significantly associated with both protective and risky sexual behaviors, though the pattern was not consistent across different measures . Condom use was significantly and positively associated with a woman's SES. Specifically, women in high wealth households, with secondary or post-secondary education, and with professional/white collar jobs report dramatically higher rates of past and present condom use than women in the other SES groups. By contrast, condom use among women with no formal education or living in low wealth households was almost non-existent. The pattern is somewhat different for risky behaviors. Women in higher wealth households and post-secondary education reported less alcohol use at last sexual intercourse and were less likely to initiate sexual activity before the age of 15. However, these high SES women were the most likely to report recent sex with a partner other than their current partner, and to have had more than 1 sexual partner over the previous year. A similarly complex story can be told of the relationship between occupation and the incidence of risky sexual practices. The relationship between drinking alcohol and sex was most prevalent among agricultural workers and professional/white collar occupations, while unemployed women were the least likely to report this behavior. Meanwhile, unemployed women were the most likely to report early sexual activity, and women working in the agricultural sector were least likely to report sex outside of relationships or multiple partners, by contrast, both professional workers and manual/domestic workers had notably higher rates of these practices. Finally, we compared mean scores on the knowledge, premarital sex, and decision-making power scales among women in different SES groups . As expected, higher SES women reported consistently higher levels of knowledge about HIV transmission and prevention methods. Women with secondary and postsecondary education had scores that were almost double that of women with no formal education. A woman's occupation was also significantly associated with knowledge of HIV prevention method, with women in professional/white collar professions commanding the highest mean knowledge score and women in agricultural professions reporting the lowest scores. SES was also significantly and positively associated with the duration of premarital sex. Whether measured by wealth, education, and occupation, high SES women reported consistently greater gaps between their initiation of sexual activity and their first marriage. Higher SES women also report generally higher levels of decision-making power and authority in their relationships . Women in the highest wealth category had the highest score on a domestic decision-making control index and both indicators of attitudes toward women's power in relationships . Educational attainment and decision-making power was somewhat more complicated. As expected, women with post-secondary education had the highest score on all three indicators of power; however, women with secondary education had a slightly lower mean score on domestic decision-making authority compared to women with primary level education. Post-hoc significance tests suggest that the differences between these two intermediate groups were not statistically meaningful. Finally, decision-making power was significantly associated with a respondent's occupation. Women in professional/white collar professions commanded the highest average decision-making authority on all three indicators compared to the other professions. Women in agriculture and manual or domestic occupations generally expressed the weakest attitudes toward a woman's ability to refuse sex or justifications for wife beating. Women who were unemployed had the lowest levels of household decision-making authority, but intermediate attitudes towards control over sexual decisions and wife beating. Relationship between Access to Health Care, HIV Knowledge, and Sexual Behaviors. Because access to health care and HIV knowledge appear to be positively related to HIV status among women in Cameroon, we explored whether or not people who had better access to health care resources and higher knowledge of HIV adopted safer sexual practices . On the one hand, access to health care was associated with increased protective sexual behaviors. Women who have visited CPDV or general health clinics are more likely to report condom use. Similarly, women with higher scores on the HIV knowledge scale reported consistently higher condom use. On the other hand, health care access is not systematically related to levels of risky sexual behaviors . Women who had accessed a health clinic in the last twelve months were more likely to have consumed alcohol at their last sexual intercourse and to be unfaithful to their partners. Meanwhile, visits to CPDV clinics were not related to any of the measures of risky behavior. As expected, the amount of knowledge of HIV prevention methods a woman commanded was significantly and positively associated with protective sexual behaviors. Women who scored less than 5 and below on the knowledge scale had the lowest rates of past and current condom use. On the other hand, women who scored 10 and above on the knowledge scale had higher rates of both current and past condom use. However, women who scored higher on the knowledge scale also had higher rates of risky sexual behavior, with higher rates of sex outside of relationships as well as greater incidence of multiple sexual partners in the last twelve months. --- Multivariate analyses To ascertain how the positive SES-HIV relationship observed at the bivariate level is mediated by key theoretically relevant and/or empirically significant indicators, we ran two multivariate binary logistic regression models to predict the likelihood of a woman testing positive for HIV in Cameroon . The first model illustrates the effect of a woman's SES characteristics on the odds of testing positive for HIV. The second model includes indicators of the various intervening variables illustrated in our theoretical model above. Results of the crude model highlight the positive association between a woman's education and household wealth and the prevalence of HIV in Cameroon. Women with higher levels of formal education and women living in high wealth households were nearly twice as likely to test positive for HIV as women with no formal education or who live in low wealth households. None of the occupational measures were statistically significant predictors of HIV status. Results of the full model indicate that the significant association between a woman's SES and her HIV status is attenuated when we account for other factors. After accounting for partners' characteristics, access to health care, HIV knowledge, and power in relationships, neither education nor wealth are significant predictors of testing positive for HIV. An interesting exception in the full model is the newly significant coefficient for women in with professional/white collar occupations, who have a 53 percent lower chance of testing positive for HIV than women working in agriculture, net the impact of the other variables in the model . In the full model, one coefficient for partner's occupation was significant; women whose partners had professional/white collar or manual/domestic jobs were roughly twice as likely to have tested positive for HIV as women whose partners worked in the agricultural sector. Indicators for access to health care provided inconsistent results in that visits to a CPDV clinic was associated with higher odds of HIV infection, while reported barriers to accessing health care facilities was associated with lower odds of testing positive for HIV. The coefficient measuring visits to any health facility was positively related to HIV status, but fell just below the threshold of statistical significance. Interestingly, in the full model, the indicator of knowledge about HIV prevention methods was not a significant predictor of HIV status. Two measures of women's power were included in the full model and produced contradictory results . Women who had more authority over household domestic decisions had an elevated HIV risk , while those who were less tolerant of wife beating had a lower HIV risk as they were 9 percent less likely to test positive for HIV . The measures of protective and risky behaviors were generally not significant predictors of HIV status . For women in Cameroon, each additional year of premarital sexual exposure increased their odds of testing positive for HIV by 9 percent . Meanwhile, two marital status variables significantly increased the risk of HIV for Cameroonian women: relative to women who were currently married, those who were cohabiting were 2.3 times more likely and those who were widowed, divorced or separated were 3.6 times more likely to test positive for HIV . None of the control variables achieved the criterion for statistical significance. --- Discussion The positive relationship between SES and rates of HIV infection in Cameroon at the bivariate level reflects a situation where increased access to health care, HIV information, and personal power have not yet translated into reductions in risky behaviors that are known to increase transmission of HIV. Higher SES women do have greater access to medical help, command greater knowledge of HIV prevention methods, report more use of condoms , and express greater decision making authority within their relationships, but these fail to protect them from having the highest HIV rates among women in the country. Our multivariate analyses show that inclusion of measures of intervening factors attenuates the positive relationship between SES and HIV among Cameroonian women significantly. The SES-HIV relationship is influenced by partners' occupation, marital status, length of premarital exposure, and power within relationships, and greater access to health care. Given these results, the key question remains: Why are the benefits of increased resources associated with higher SES not protecting women in Cameroon from HIV infection? At least through 2004, any benefit that may have accrued from high SES appears to be offset by a tendency to engage in more risky sexual practices -including longer periods of premarital sexual activity, greater numbers of recent sexual partners, and higher rates of sex outside of relationships. This suggests that economic vulnerability and traditional gender roles may not be the only risk factors that put women in SSA at greater risk of contracting HIV. High SES women, in particular, may also be at increased risk through their relationships with higher SES men . These results support the idea that the pursuit of modern identities can create aspirations and desires for social mobility that can lead to riskier behaviors among high SES women [5,17]. Conversely, high SES women could also be at risk not only from their primary partners but from having concurrent relationships even within the context of marriage. As a recent analysis of DHS suggests, contrary to what was commonly presumed, it is women rather than men that are infecting their partners within relationships [13]. The results fail to support the expectations of traditional gender theory in that greater household and sexual decision-making power have not necessarily translated into lower risks of HIV in Cameroon. The unexpected positive relationship between 'power' and HIV status may reflect the spurious effects of a third common variable associated with socioeconomic status . It is also worth noting that delayed marriage and longer periods of premarital sexual activity significantly increases risk for high SES women [37]. Similarly, Fortson [38], in a multicounty analysis including Cameroon found that women with greater than 6 years of schooling were 16 percent times more likely to have had premarital sex, compare to women with more schooling. With regards to results from our multivariate analysis, the attenuation of the SES-HIV relationship suggests that there may be no direct association between SES and HIV among women in Cameroon. This result mirrors findings from other studies in SSA [19,25,39]. It is possible this result reflects the complex intervening effects of the other variables associated with higher SES status among Cameroonian women, especially sexual behaviors and personal power [40]. As Gillespie et al. [39], note, it is also possible that the preexisting sexual behaviors of the wealthy at this early stage of the epidemic increased their vulnerability to the disease. The recently released 2011 CDHS will provide a great opportunity to assess if the association between SES and HIV changes as the epidemic matures. Our study has several limitations. The cross-sectional nature of the data makes it difficult to determine the causal order of statistically significant relationships . It is likely that women were more inclined to visit a health facility because they are feeling ill, which could reflect the fact that they had already contracted the disease. Similarly, women who already contracted HIV may be more likely to develop better knowledge of the disease , which could explain the positive bivariate relationship between HIV status and HIV knowledge. Other potential limitations include the point that several key variables are self-reported. Many researchers have argued that women in Sub-Saharan Africa usually under report either their premarital or their extramarital sexual activity [41]. Findings using self-reported data may be biased to the extent that sex outside of relationships, total number of partners, and condom use are misreported by women in a pattern that varies across the different SES groups [42]. It is worth noting that the risk associated with sexual relations with a person other than a partner can be moderated by whether a condom was used during sexual intercourse, which was not measured in this study. Similarly, we are unable to determine from the DHS data if the origin of HIV was from a spouse or regular partner , or from another sexual partner . We also have no direct measures of a woman's sexual networks. Finally, future analyses would benefit from including direct measures for partner's sexual behavior, women's sexual networks, and direct exposure to gender violence, which have been critical factors in explaining higher rates of HIV among SSA women in other studies [16,[43][44]. --- Conclusion Taken as a whole, the results suggest that traditional approaches to HIV prevention which rely on poverty reduction, improving access to health care, improving HIV knowledge, and boosting women's social and economic power may be insufficient to address key drivers of HIV infection among women in Cameroon. In particular, the persistence of risky behaviors among higher SES populations suggests that a targeted program to change cultural practices and mores might be required to prevent the continued spread of the disease. This study adds to the growing body of work which notes that in certain areas poverty may not be the main driver of HIV risk, and that pathways between SES and HIV infection can vary by SES group [5,19,39]. Targeted interventions to address the impacts of sex outside of relationships and reducing sexual concurrency among higher SES women would appear to be warranted. ---

Background: Despite evidence of a positive SES-HIV gradient in some SSA countries, researchers and policy-makers frequently assume that a range of protective interventions -increasing awareness of mechanisms of HIV transmission, techniques for prevention, greater access to health care facilities, and greater availability of condoms -will reduce the likelihood of contracting HIV, even among higher SES populations. We therefore explore the relationships between SES and these intervening behaviors to illuminate the complex factors that link SES and HIV among women in Cameroon.We use bivariate and multivariate statistical analysis to examine patterns among the 5, 155 women aged 15-49 who participated in the 2004 CDHS.The results show a strong pattern where higher SES women have greater access to and use of health care facilities, higher levels of condom use, more HIV knowledge, and command higher power within their relationships, yet also have higher rates of HIV. These traditionally protective factors appear to be offset by riskier sexual behaviors on the part of women with increased resources, most notably longer years of premarital sexual experience, multiple partners in last 12 months, and sexual encounters outside of relationship. Multivariate analyses suggests net of the effect of other factors, women who command higher decision-making power, have greater access to health care, more negative attitudes toward wife beating, longer years of premarital sexual exposure, and partners with professional/white collar jobs (characteristics associated with rising SES) had higher odds of testing positive for HIV.Results show that higher riskier sexual practices on part of high SES women offset benefits that may have accrued from their increased access to resources. The results suggest that traditional approaches to HIV prevention which rely on poverty reduction, improving access to health care, improving HIV knowledge, and boosting women's social and economic power may be insufficient to address other drivers of HIV infection among women in SSA.

background the subsaharan hiv epidemic presents patterns that challenge conventional understandings of the relationships between socioeconomic status and health the notion that poverty was the underlying factor increasing susceptibility to hiv infection had become one of the main messages sent out by the global health field 1 it has often been assumed that africas status as the continent with the highest hiv infection rates is linked to its endemic high poverty and a corresponding lack of access to adequate health care resources 2 poverty reduction strategies were therefore touted as the most viable longterm option in the fight against the disease 3 in ssa high ses individuals have higher levels of formal education greater exposure to health education messages and mass media increased access to health care and better access to condoms which should all lower their risk for contracting hiv 4 however a growing number of studies show that wealthier individuals wealthier regions and wealthier countries within ssa often display the highest levels of hiv infection 5 6 7 8 9 10 11 12 13 14 15 in a study of eight african countries mishra and colleagues 12 provide evidence of a positive association between household wealth and hiv prevalence similarly a review of thirtyfive studies on ses and hiv status in ssa found ten cross sectional studies and one cohort study that described a positive association between high ses and hiv infection 15 theories for why ses and hiv are positively related often point to social and cultural mechanisms especially lifestyles associated with increased income which are associated with increased vulnerability to hiv infection 5 of primary interest therefore are patterns of risky sexual behavior that are positively linked to an individuals wealth including the number of multiple and nonmarital sexual partners and premarital sexual intercourse mumah and jacksonsmith 16 in a recent study found that the length of premarital sexual activity among high ses women significantly increases their vulnerability to hiv because high ses women are more likely to delay first marriage yet be sexually active for men level of education and income increases the probability individuals will have nonregular sexual partners which is known to also increase exposure to stds including hiv 17 18 kongnyuy and colleagues 17 found that wealthy men in cameroon had higher rates of hiv infection which in part was explained by their riskier sexual behaviors including earlier sexual debut multiple concurrent and lifetime partners and limited use of condoms with partners other than wives or cohabiting partners similar patterns are found for high ses women one recent study argues that it is the pursuit of modernity that explains female risky sexual behaviors in ssa 18 the authors found evidence from kenya and south africa that materialism and pursuit of consumer goods such as cars cash and cell phones drives transactional sex rather than absolute poverty 18 19 fox 5 argues therefore that for women having multiple partners can be a mechanism for achieving upward mobility while for men multiple partnership is an avenue to validate sexual prowess and social status similarly numerous studies indicate that the direction of transmission of hiv among migrants is not limited to transmission from migrant males to their wives but also from the nonmigrating wives to their spouses because they had other sexual partners while their spouses were away 20 as in the case with wealth higher levels of formal education are often associated with increased risk of hiv particularly in eastern and southern africa 10 21 22 one study found that those with basic primary education had twice the odds of being hivpositive as those with no education 10 studies that find a positive association between wealth and hiv often do not find the same pattern with education suggesting that seshiv linkages are complex 22 23 24 25 moreover controlling for other individual characteristics can reduce or eliminate statistical associations between hiv status and education levels 26 despite evidence of a positive seshiv gradient researchers and policymakers frequently assume that a range of protective interventions increasing awareness of mechanisms of hiv transmission and techniques for prevention greater access to health care facilities and greater availability of condoms will reduce the likelihood of contracting hiv 27 28 even among higher ses populations 29 similarly researchers have called for empowering women to have more control over sexual decisionmaking through socioeconomic development 6 the presumed mechanism for protection is a change in behavior that could place a person at risk for contracting hiv in this paper we examine evidence from a nationally representative survey of cameroonian women and explore how ses is related to hiv status previously published research documented that higher ses women are much more likely to contract hiv than their low ses counterparts 22 24 25 26 30 31 our analysis accounts for three core sets of intervening variables and assesses the key role of risky and protective sexual behaviors in determining hiv status we also account for the effects of partner ses depending on the marital status of the woman and control for several other contextual characteristics a graphic representation of our theoretical model with illustrations of the hypothesized direction of relationships can be found in figure 1 data and methods data the 2004 cameroon demographic and health survey is a nationally representative survey involving residents aged 1549 the dhs uses a multilayer protocol review system to obtain ethical review in the united states and host country before data collection begins the survey and the protocol for blood specimen collection and analysis were approved by the institutional review board for orc macro calverton usa in cameroon the national ethics committee in the ministry of health reviewed the protocol and provided ethical clearance and approval written informed consent which was vetted and approved by the national ethics committee in ministry of health was gotten from all survey participants prior to participation and all information was collected confidentially the informed consent forms were translated to the appropriate local language before being administered to participants the cdhs uses a multistage complex cluster sampling methodology with response rates well in excess of 90 percent 32 33 34 the cdhs survey provides information on a variety of topics including hiv test results for nearly all respondents determined via voluntary blood samples the cdhs included 5 155 female respondents in the sample with conclusive test results for all but one case the ability to link hiv testing with individual characteristics provides a unique opportunity to assess factors associated with hiv infection analysis in this study was run using both weighted and unweighted data the results shown in this paper uses the unweighted sample data because there were no meaningful or substantive differences between results estimated from the weighted and unweighted samples measures socioeconomic status is captured both at the individuallevel and householdlevel female ses has been linked both to the timing and nature of marriage and to the ses of her partner therefore the impact of partners ses on a womans hiv risk is mediated by her marital statusrelationship status and history in the analysis dummy variables for currently married never married cohabiting and early marriage are used the first two sets of intervening variables reflect better access to health care and knowledge about hiv which we expect to increase with higher levels of ses 29 access to health care is captured by indicators of respondents awareness and use of centre de de ´pistage volontaire clinics whether the respondent visited any health facility in the last 12 months and selfreports of barriers to accessing local health clinics knowledge of hiv infection and prevention mechanisms was measured by constructing an additive scale using 15 knowledge items in the cdhs 35 the scale met conventional standards for reliability and ranges in value from 015 a womans ability to access health care will influence her knowledge about hiv in turn a womans knowledge of hiv and prevention methods is presumed to influence her behaviors which could be risky or protective thereby determining her hiv status the third set of intervening variables reflects a womans decisionmaking power in her relationships power in relationships is captured in scale constructed from questions about household decision making attitudes toward wife beating and perceptions of a womans power in sexual decisionmaking ses is theoretically linked to a womans power in her sexual relationships which in turn should influence the behaviors of both women and their partners we theorize here that the more power a woman commands in her relationship the less risky will be her behaviors our theoretical model captures the fact that hiv status is most directly affected by sexual behaviors and the influence of ses access to health care hiv knowledge and power should manifest as differences in levels of these behaviors female sexual behavior is captured in our analysis via both female protective sexual behaviors and female risky sexual behaviors finally our analysis controls for other contextual factors including place of residence region and religion dummy variables for ruralurban residence and cultural regions are used because there are large regional and urbanrural differences within the country and a study of ses and risk of hiv needs to take these contextual factors into consideration due to large number of ethnic categories with some having very few cases a collapsed version of region rather than ethnicity is used in our analyses kuatedefo 36 posits that the more than 200 ethnic groups in cameroon fall into four major cultural regions of the country center south and east littoral and south west west and north west and nord adamaoua and extreme nord this collapsed version of regions is used as a proxy for ethnicity because religious affiliations are not perfectly correlated with region dummy variables for the respondents personal religious affiliation catholic protestant muslim and other are included analyses bivariate analyses are first utilized to illustrate the simple associations among womens ses status each of the intervening variables and hiv status we begin by describing the relationship between hiv and all the other variables to highlight the factors most associated with the prevalence of hiv infection among women in cameroon second we examine the relationships between ses and the intervening variables to see if ses is associated with the expected intervening variables in ways that are expected to increase or decrease hiv risk third we look at the link between access to health care hiv knowledge and indicators of sexual behavior three types of bivariate analyses are used cross tabulations anovatests and ttests chisquare and fishers exact tests are used to determine statistical relationship between the categorical variables analyzed in cross tabulations strength of association was assessed using cramers v and gamma we then estimate two multivariate binary logistic regression models to contrast the effects of womens ses status on hiv with and without the presence of intervening variables the full model also estimates the relative contribution of access knowledge and power to explaining the positive bivariate seshiv relationship the multivariate models use 4916 cases because 239 cases were missing at least one core variable used in the analyses the overall fit of the model was assessed using the negative loglikelihood and the homer and lemeshow statistic while the explanatory adequacy of the model were assessed using the cox snell and nagelkerke rsquares this study utilized ibm spss version 19 to manage and analyse the data results bivariate analyses relationship between core variables and hiv status as noted above the cdhs provides a rare opportunity to combine information about the characteristics of large representative samples of adults with actual hiv blood test results table 1 shows the proportion of women in the cdhs sample and the incidence of hiv by various indicators of ses the results clearly show that household wealth educational attainment and occupational status are significantly and positively related to hiv status among women in cameroon a womans partners ses is also associated with her hiv status among the 23 percent of women with no current partner hiv rates are relatively low however the incidence of hiv among the relationship between access to health care sexual behaviors and hiv rates among cameroonian women is also shown in table 1 there is a strong pattern where women with greater access to and use of health care facilities have higher rates of hiv it is unlikely that the use of health care resources causes hiv infection so this counterintuitive finding may reflect a pattern in which hivpositive women are more likely to go to health care providers because they suffer from symptoms of the disease alternatively women living in more remote rural areas have less access to health care but also face a much lower overall background rate of population hiv infection a similar pattern is also seen in table 1 where women who have higher rates of condom use are also more likely to test positive for the hiv virus again it is possible that condom use is caused by positive hiv status meanwhile as expected women who report engaging in risky sexual behaviors are more likely to have hiv finally we compared the mean scale scores for hiv positive and negative women on a set of indicators for hiv knowledge premarital sexual experience and three indicators of a womans power in her personal relationships where higher values reflect higher power the results suggest that hiv positive women have higher levels of knowledge of hiv transmission and prevention more years of premarital sexual experience and higher scores on the power scales reflecting household decisionmaking interestingly at the bivariate level hiv status was not significantly associated with attitudes towards wife beating or womens control over sexual decisions relationship between ses and access to health care knowledge and sexual behaviors overall as expected there was a positive and highly significant association between ses and access to health care wealthier and more educated women were more likely to have visited a health facility in the last 12 months and to have heard of and visited a voluntary counseling and testing center higher ses women were also significantly less likely to report barriers to accessing health care in fact each increase in a womans educational attainment was associated with a decrease in the number reporting barriers to health care access to health care also varied by the different occupational categories women in professional or white collar professions were more likely to report visiting a cpdv more likely to have accessed a health facility within the last year and faced the fewest barriers to health care of any occupational group a womans ses was also significantly associated with both protective and risky sexual behaviors though the pattern was not consistent across different measures condom use was significantly and positively associated with a womans ses specifically women in high wealth households with secondary or postsecondary education and with professionalwhite collar jobs report dramatically higher rates of past and present condom use than women in the other ses groups by contrast condom use among women with no formal education or living in low wealth households was almost nonexistent the pattern is somewhat different for risky behaviors women in higher wealth households and postsecondary education reported less alcohol use at last sexual intercourse and were less likely to initiate sexual activity before the age of 15 however these high ses women were the most likely to report recent sex with a partner other than their current partner and to have had more than 1 sexual partner over the previous year a similarly complex story can be told of the relationship between occupation and the incidence of risky sexual practices the relationship between drinking alcohol and sex was most prevalent among agricultural workers and professionalwhite collar occupations while unemployed women were the least likely to report this behavior meanwhile unemployed women were the most likely to report early sexual activity and women working in the agricultural sector were least likely to report sex outside of relationships or multiple partners by contrast both professional workers and manualdomestic workers had notably higher rates of these practices finally we compared mean scores on the knowledge premarital sex and decisionmaking power scales among women in different ses groups as expected higher ses women reported consistently higher levels of knowledge about hiv transmission and prevention methods women with secondary and postsecondary education had scores that were almost double that of women with no formal education a womans occupation was also significantly associated with knowledge of hiv prevention method with women in professionalwhite collar professions commanding the highest mean knowledge score and women in agricultural professions reporting the lowest scores ses was also significantly and positively associated with the duration of premarital sex whether measured by wealth education and occupation high ses women reported consistently greater gaps between their initiation of sexual activity and their first marriage higher ses women also report generally higher levels of decisionmaking power and authority in their relationships women in the highest wealth category had the highest score on a domestic decisionmaking control index and both indicators of attitudes toward womens power in relationships educational attainment and decisionmaking power was somewhat more complicated as expected women with postsecondary education had the highest score on all three indicators of power however women with secondary education had a slightly lower mean score on domestic decisionmaking authority compared to women with primary level education posthoc significance tests suggest that the differences between these two intermediate groups were not statistically meaningful finally decisionmaking power was significantly associated with a respondents occupation women in professionalwhite collar professions commanded the highest average decisionmaking authority on all three indicators compared to the other professions women in agriculture and manual or domestic occupations generally expressed the weakest attitudes toward a womans ability to refuse sex or justifications for wife beating women who were unemployed had the lowest levels of household decisionmaking authority but intermediate attitudes towards control over sexual decisions and wife beating relationship between access to health care hiv knowledge and sexual behaviors because access to health care and hiv knowledge appear to be positively related to hiv status among women in cameroon we explored whether or not people who had better access to health care resources and higher knowledge of hiv adopted safer sexual practices on the one hand access to health care was associated with increased protective sexual behaviors women who have visited cpdv or general health clinics are more likely to report condom use similarly women with higher scores on the hiv knowledge scale reported consistently higher condom use on the other hand health care access is not systematically related to levels of risky sexual behaviors women who had accessed a health clinic in the last twelve months were more likely to have consumed alcohol at their last sexual intercourse and to be unfaithful to their partners meanwhile visits to cpdv clinics were not related to any of the measures of risky behavior as expected the amount of knowledge of hiv prevention methods a woman commanded was significantly and positively associated with protective sexual behaviors women who scored less than 5 and below on the knowledge scale had the lowest rates of past and current condom use on the other hand women who scored 10 and above on the knowledge scale had higher rates of both current and past condom use however women who scored higher on the knowledge scale also had higher rates of risky sexual behavior with higher rates of sex outside of relationships as well as greater incidence of multiple sexual partners in the last twelve months multivariate analyses to ascertain how the positive seshiv relationship observed at the bivariate level is mediated by key theoretically relevant andor empirically significant indicators we ran two multivariate binary logistic regression models to predict the likelihood of a woman testing positive for hiv in cameroon the first model illustrates the effect of a womans ses characteristics on the odds of testing positive for hiv the second model includes indicators of the various intervening variables illustrated in our theoretical model above results of the crude model highlight the positive association between a womans education and household wealth and the prevalence of hiv in cameroon women with higher levels of formal education and women living in high wealth households were nearly twice as likely to test positive for hiv as women with no formal education or who live in low wealth households none of the occupational measures were statistically significant predictors of hiv status results of the full model indicate that the significant association between a womans ses and her hiv status is attenuated when we account for other factors after accounting for partners characteristics access to health care hiv knowledge and power in relationships neither education nor wealth are significant predictors of testing positive for hiv an interesting exception in the full model is the newly significant coefficient for women in with professionalwhite collar occupations who have a 53 percent lower chance of testing positive for hiv than women working in agriculture net the impact of the other variables in the model in the full model one coefficient for partners occupation was significant women whose partners had professionalwhite collar or manualdomestic jobs were roughly twice as likely to have tested positive for hiv as women whose partners worked in the agricultural sector indicators for access to health care provided inconsistent results in that visits to a cpdv clinic was associated with higher odds of hiv infection while reported barriers to accessing health care facilities was associated with lower odds of testing positive for hiv the coefficient measuring visits to any health facility was positively related to hiv status but fell just below the threshold of statistical significance interestingly in the full model the indicator of knowledge about hiv prevention methods was not a significant predictor of hiv status two measures of womens power were included in the full model and produced contradictory results women who had more authority over household domestic decisions had an elevated hiv risk while those who were less tolerant of wife beating had a lower hiv risk as they were 9 percent less likely to test positive for hiv the measures of protective and risky behaviors were generally not significant predictors of hiv status for women in cameroon each additional year of premarital sexual exposure increased their odds of testing positive for hiv by 9 percent meanwhile two marital status variables significantly increased the risk of hiv for cameroonian women relative to women who were currently married those who were cohabiting were 23 times more likely and those who were widowed divorced or separated were 36 times more likely to test positive for hiv none of the control variables achieved the criterion for statistical significance discussion the positive relationship between ses and rates of hiv infection in cameroon at the bivariate level reflects a situation where increased access to health care hiv information and personal power have not yet translated into reductions in risky behaviors that are known to increase transmission of hiv higher ses women do have greater access to medical help command greater knowledge of hiv prevention methods report more use of condoms and express greater decision making authority within their relationships but these fail to protect them from having the highest hiv rates among women in the country our multivariate analyses show that inclusion of measures of intervening factors attenuates the positive relationship between ses and hiv among cameroonian women significantly the seshiv relationship is influenced by partners occupation marital status length of premarital exposure and power within relationships and greater access to health care given these results the key question remains why are the benefits of increased resources associated with higher ses not protecting women in cameroon from hiv infection at least through 2004 any benefit that may have accrued from high ses appears to be offset by a tendency to engage in more risky sexual practices including longer periods of premarital sexual activity greater numbers of recent sexual partners and higher rates of sex outside of relationships this suggests that economic vulnerability and traditional gender roles may not be the only risk factors that put women in ssa at greater risk of contracting hiv high ses women in particular may also be at increased risk through their relationships with higher ses men these results support the idea that the pursuit of modern identities can create aspirations and desires for social mobility that can lead to riskier behaviors among high ses women 517 conversely high ses women could also be at risk not only from their primary partners but from having concurrent relationships even within the context of marriage as a recent analysis of dhs suggests contrary to what was commonly presumed it is women rather than men that are infecting their partners within relationships 13 the results fail to support the expectations of traditional gender theory in that greater household and sexual decisionmaking power have not necessarily translated into lower risks of hiv in cameroon the unexpected positive relationship between power and hiv status may reflect the spurious effects of a third common variable associated with socioeconomic status it is also worth noting that delayed marriage and longer periods of premarital sexual activity significantly increases risk for high ses women 37 similarly fortson 38 in a multicounty analysis including cameroon found that women with greater than 6 years of schooling were 16 percent times more likely to have had premarital sex compare to women with more schooling with regards to results from our multivariate analysis the attenuation of the seshiv relationship suggests that there may be no direct association between ses and hiv among women in cameroon this result mirrors findings from other studies in ssa 192539 it is possible this result reflects the complex intervening effects of the other variables associated with higher ses status among cameroonian women especially sexual behaviors and personal power 40 as gillespie et al 39 note it is also possible that the preexisting sexual behaviors of the wealthy at this early stage of the epidemic increased their vulnerability to the disease the recently released 2011 cdhs will provide a great opportunity to assess if the association between ses and hiv changes as the epidemic matures our study has several limitations the crosssectional nature of the data makes it difficult to determine the causal order of statistically significant relationships it is likely that women were more inclined to visit a health facility because they are feeling ill which could reflect the fact that they had already contracted the disease similarly women who already contracted hiv may be more likely to develop better knowledge of the disease which could explain the positive bivariate relationship between hiv status and hiv knowledge other potential limitations include the point that several key variables are selfreported many researchers have argued that women in subsaharan africa usually under report either their premarital or their extramarital sexual activity 41 findings using selfreported data may be biased to the extent that sex outside of relationships total number of partners and condom use are misreported by women in a pattern that varies across the different ses groups 42 it is worth noting that the risk associated with sexual relations with a person other than a partner can be moderated by whether a condom was used during sexual intercourse which was not measured in this study similarly we are unable to determine from the dhs data if the origin of hiv was from a spouse or regular partner or from another sexual partner we also have no direct measures of a womans sexual networks finally future analyses would benefit from including direct measures for partners sexual behavior womens sexual networks and direct exposure to gender violence which have been critical factors in explaining higher rates of hiv among ssa women in other studies 16 43 44 conclusion taken as a whole the results suggest that traditional approaches to hiv prevention which rely on poverty reduction improving access to health care improving hiv knowledge and boosting womens social and economic power may be insufficient to address key drivers of hiv infection among women in cameroon in particular the persistence of risky behaviors among higher ses populations suggests that a targeted program to change cultural practices and mores might be required to prevent the continued spread of the disease this study adds to the growing body of work which notes that in certain areas poverty may not be the main driver of hiv risk and that pathways between ses and hiv infection can vary by ses group 51939 targeted interventions to address the impacts of sex outside of relationships and reducing sexual concurrency among higher ses women would appear to be warranted

background despite evidence of a positive seshiv gradient in some ssa countries researchers and policymakers frequently assume that a range of protective interventions increasing awareness of mechanisms of hiv transmission techniques for prevention greater access to health care facilities and greater availability of condoms will reduce the likelihood of contracting hiv even among higher ses populations we therefore explore the relationships between ses and these intervening behaviors to illuminate the complex factors that link ses and hiv among women in cameroonwe use bivariate and multivariate statistical analysis to examine patterns among the 5 155 women aged 1549 who participated in the 2004 cdhsthe results show a strong pattern where higher ses women have greater access to and use of health care facilities higher levels of condom use more hiv knowledge and command higher power within their relationships yet also have higher rates of hiv these traditionally protective factors appear to be offset by riskier sexual behaviors on the part of women with increased resources most notably longer years of premarital sexual experience multiple partners in last 12 months and sexual encounters outside of relationship multivariate analyses suggests net of the effect of other factors women who command higher decisionmaking power have greater access to health care more negative attitudes toward wife beating longer years of premarital sexual exposure and partners with professionalwhite collar jobs characteristics associated with rising ses had higher odds of testing positive for hivresults show that higher riskier sexual practices on part of high ses women offset benefits that may have accrued from their increased access to resources the results suggest that traditional approaches to hiv prevention which rely on poverty reduction improving access to health care improving hiv knowledge and boosting womens social and economic power may be insufficient to address other drivers of hiv infection among women in ssa

Introduction --- Background Much has been written about the impact of COVID-19 on health care delivery, especially the increased use of telehealth in expanded clinical situations, including primary care, mental health, prenatal care, substance use disorder, orthodontics, urology, inpatient care, emergency triage, and physical therapy [1][2][3][4][5][6][7]. Although various forms of telehealth existed for many years prior to the pandemic, especially in rural contexts, it was relatively underused or restricted to within health care systems [8][9][10][11]. However, within the first 3 months of the COVID-19 pandemic, telehealth policy makers loosened or lifted many legal and practical restrictions, and the use of telehealth increased by 766% while outpatient visits dropped by over 80% in some institutions [12][13][14]. In the early stages of the COVID-19 pandemic, telehealth was primarily adopted to reduce viral transmission. As a mechanism to preserve personal protective equipment, even inpatients who required consultations with subspecialized teams or interactions with multidisciplinary members of the health care team sometimes received their consults via video conference [15,16]. --- Telehealth Versus Telemedicine The Federal Communications Commission defines telemedicine as medical services provided with the support of telecommunications technologies, such as diagnostic testing or monitoring a patient's posttreatment progress. Telehealth includes a broader scope of clinical and nonclinical remote health care services-often provided by nurses-such as patient education, help with medication adherence, and troubleshooting health issues [17]. The World Health Organization has defined telehealth as being health care services provided by any health care professional and telemedicine as being services provided by a physician; however, the two terms are often used interchangeably [18]. Some observers predict that telemedicine and telehealth should be the delivery paradigm of the future because of their potential to equalize access to health care. Others have highlighted the potential of telemedicine and telehealth to exacerbate current inequality and inequity in health and access to health care [19] by raising barriers for those who do not have internet access, are disadvantaged from a socioeconomic perspective, are less digitally literate, or face language barriers [20][21][22][23][24]. Much attention has also been paid to privacy, data security, and connectivity concerns, which can threaten the rollout and sustainability of telehealth [25,26]. Finally, cultural and relational barriers may hamper the effectiveness of telehealth. Some individuals have reported that a remote discussion with a health care provider does not constitute an effective health care interaction [27]. Substantial literature has been published during the pandemic documenting the increased uptake and use of telehealth, but there has been less research focus on garnering the views of telehealth users [28,29]. Although some studies have examined the concerns of health care professionals, few have captured the experiences and perceptions of the public about these adaptations and the use of telehealth, including concerns [30][31][32][33][34][35]. Furthermore, studies capturing the views of diverse and underresourced communities about telehealth have been lacking. This study is part of a larger community-engaged research study conducted over a 9-month period that used mixed methods to assess the impact of COVID-19 on marginalized communities across diverse geographic regions. CEnR has been defined by the Centers for Disease Control and Prevention as "the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the wellbeing of those people" [36,37]. CEnR can support the translation of scientific discovery into a reduction in heath disparities as it seeks to understand stakeholder and community needs. CEnR can foster benefits such as influencing public health initiatives and improved health outcomes [38,39]. This work describes differences in perceptions and experiences of telehealth during COVID-19 across vulnerable and underresourced communities, including apprehensions, perceived quality of care received, and potential advantages. --- Methods --- Study Setting and Design We performed a multisite, multiphase, mixed methods study from January to November 2021 in three geographic regions of the United States: the southwest, southeast, and midwest [40]. We used CEnR methods to explore the needs, assets, and challenges of surrounding communities to understand the impact of COVID-19. Details of the methods are described elsewhere [41] but are briefly outlined below. This project is part of a broader effort toward exploring several issues about the impact of COVID-19 on historically marginalized communities. We here focus on the content that informs considerations around telehealth. The study employed quantitative and qualitative methods in three phases. Phase 1 involved qualitative key informant interviews, phase 2 involved focus groups , and phase 3 employed an anonymous online survey [42]. As stated by Kelle et al [43], mixed methods research can support "mutual validation of data" as well as provide a "more coherent and complete" picture than a single research strategy alone. --- Ethical Considerations The qualitative phases of the study were approved as minimal risk by the Mayo Clinic Institutional Review Board . The quantitative phase was hosted by an external survey research company. As verified by Research Compliance, Mayo Clinic had no participant contact, was therefore not engaged in human subjects' research, and this phase was not eligible for Institutional Review Board review. All data analysis was conducted by our study team. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000. During FGs, the moderator began the activity by outlining the elements of informed consent that had been shared prior to scheduling with participants and they were asked to confirm consent verbally. Participants received a US $50 financial remuneration for their time. As with most surveys, respondents are assumed to have provided consent if they complete the survey. Those who completed the survey received US $10 digital financial remuneration. All data from the survey and FGs were deidentified and stored on password-protected computers or in locked cabinets to which only the study team had access. We here report the phase 2 perspectives of FG participants about their experience with telehealth and the phase 3 survey participant responses about telehealth. --- FGs and Surveys --- FG Recruitment and Data Collection The broader multidisciplinary study team developed the moderator guide, which included questions about the impact of COVID-19 on access and use of health care. The moderator's guide covered the following COVID impact topics: future hopes, personal, medical, worries, vaccines, household, mental health, and community impacts. We disseminated flyers in Spanish and English through social media and community organizations and convened FGs in all three regions. The purpose of the study, risks and benefits, and the option to decline any question and/or withdraw at any time were outlined to participants before scheduling. Participants were placed in FGs with others who represented similar demographic, residential, or social communities. We also collaborated with local Departments of Health who were conducting FGs about the impact of COVID-19 on communities and were able to negotiate data sharing. Most FGs were conducted via online videoconferencing ; some were conducted in person. FGs were scheduled for 1 hour. Two FGs were conducted in Spanish with bilingual moderators. --- Survey Instrument and Sampling We developed an electronic survey with the input of community and scientific leaders as well as other key stakeholders. The survey questions about telehealth were adapted from questions developed to evaluate the attitudes of patients living with HIV about telehealth in lieu of face-to-face visits [44]. They included questions about internet access, use of telehealth since the start of the pandemic, likelihood of using telehealth in the future, as well as perceived benefits of telehealth and concerns with telehealth . The survey was pilot-tested extensively, and we solicited comments and suggestions from Community Advisory Boards, existing panels of health equity, and community engagement researchers across the institution as well as volunteers from the community networks of those researchers [45]. The survey was also translated into Spanish by a licensed medical translator and tested by bilingual English/Spanish speakers. The survey was distributed through existing networks of community partners and organizations using social media and email lists for 8 weeks in the fall of 2021. A professional research firm hosted, accrued, and deidentified the data. --- Analysis --- FG Qualitative Data Analysis We digitally recorded the FGs, and they were transcribed by a Health Insurance Portability and Accountability Act-compliant professional firm and deidentified before analysis. Data from FGs conducted by our team and those conducted by others were stored and analyzed in parallel using identical coding structures, but were not combined into one data set. We used the framework analytic approach to code our data [46] in which the verbatim content of FG transcripts is summarized in a matrix. In this matrix, deductive themes from group moderation guides create the columns and individual FGs create the rows. Inductive-emerging-themes may add additional columns. Transcript page numbers are noted with paraphrased content within the relevant cells. Two trained coders collaborated on all phases of analysis, including initial content paraphrasing, indexing to codebook development, and illustrative quote retrieval. --- Survey Data Analysis Statistical analyses were performed using SAS Software 9.04 . Categorical variables are reported as counts with percentages and were analyzed with the Pearson χ 2 test, Fisher exact test, and general linear models with Tukey options to test simultaneous differences between percentage means where appropriate. Continuous variables are reported as medians with IQR and analyzed with the Wilcoxon rank-sum test. A 2-sided P value of less than .05 was considered statistically significant. When looking at the difference between means with the Tukey honest-significant test, we tested if the difference between means is equal to zero. This may occasionally result in a significant difference between two groups even when the confidence intervals for those two groups overlap. --- Results --- FG Participants' Baseline Characteristics In total, data were analyzed for 47 FGs conducted during 2021 by our team and colleagues at Arizona State University. FGs were demographically and geographically discrete, and included separate groups who were uninsured and underinsured, those experiencing homelessness, LGBTQI, Latinx women and men, parents of young children, cancer survivors, Black men and women, Indigenous Americans, immigrants and Spanish-speaking adults, veterans, and older Asian Americans . --- Survey Respondents' Baseline Characteristics The completed survey data set included 3447 English-language responses and 146 Spanish-language responses. Responses are proportionate to the geographic population of the area surveyed. Due to the mode of dissemination, we cannot calculate a response rate . We conducted site-specific analysis as well as analysis across different demographic groups that included all sites. Of note, the subset identifying their primary identity as Asian was too small to analyze and has been excluded from this paper but included in other work. --- Internet Access Internet access was high across all sites with over 90% of participants reporting access. Access was the highest among southwest participants, with 98% reporting internet access. Black Hispanics, Indigenous, and white non-Hispanics had lower rates of internet access than other racial and ethnic groups such as Black non-Hispanic and white Hispanic. No significant differences were detected across groups defined by age, sex, gender identity, or education . --- Use of Telehealth to Date A total of 3260 participants answered the question about use of telehealth since the start of the pandemic. Across all sites, any use of telehealth during this time was high with 94% overall using telehealth at some stage. The proportions for telehealth use by subgroup are presented in Table 2. All three locations showed statistically significant different usage of telehealth. Florida had the lowest rate, with 88% having used telehealth. In Arizona, 94% and in the midwest 97% had used telehealth since the COVID-19 pandemic started. Black Hispanics had the highest use of telehealth at 97.7% , which was significantly greater than the use of white non-Hispanics at 94.4% . Among those aged 30-39 years, 94.8% used telehealth, similar to the rate of those aged 40-49 years at 94.3% . This was significantly more than that of participants aged 18-29 years but was not significantly higher than the use rate of those aged 50-75 years . There were no significant differences in use of telehealth based on education, sex, or gender identity. --- Perceived Benefits of Telehealth Survey questions about the perceived benefits of telehealth included those related to telehealth fitting into people's schedule better and not needing to travel. The proportions for perceived telehealth benefits by subgroup are presented in Table 3. Over half of all respondents agreed or strongly agreed that telehealth fit their schedule better than in-person visits. Indigenous respondents were significantly more likely to feel this way than any other groups except non-Hispanic white individuals, at 65.8% agreement. Those with moderate levels of education were significantly more likely than those with lower levels to report that telehealth fit their schedule better . Those with moderate levels of education were significantly more likely to agree that telehealth would reduce the need to travel than those with lower levels of education . Additionally, the Indigenous population was significantly more likely to agree that not traveling was a benefit than any other group, at 64.3% . There was a marginal age difference, with those aged 50-75 years being least likely to agree . This was significantly lower than that for participants aged 40-49 years , but not for the other age groups . --- Perceived Concerns With Telehealth Survey questions about the perceived concerns of telehealth included those related to not being examined properly and not being able to express oneself. The proportions for perceived telehealth concerns by subgroup are presented in Table 4. Overall, approximately half of all respondents felt that telehealth would hinder the ability of the provider to examine them well. This pattern was consistent across all demographic groups with some notable differences. Those aged 30-39 years and 40-49 years were the most concerned about this issue at 49.4% and 53.4% , respectively, which was significantly higher than the rate of agreement for those aged 18-29 years at 43.4% . Those with moderate levels of education were significantly more likely to be concerned about this issue than those with lower levels of education . Indigenous respondents were statistically the most concerned about lack of sufficient examination through telehealth, with 63.9% agreeing or strongly agreeing that "the doctor would not be able to examine me well." In all other racial and ethnic groups, only about half of all respondents agreed or strongly agreed with the statement. No significant differences were detected across groups defined by sex or gender identity . Overall, 45.2% of participants agreed or strongly agreed that they "would not be able to express themselves well." The participants in the southeast differed from those of other sites, with only 38.4% concerned about the issue of expressing themselves. Indigenous respondents had more concerns than other demographic groups, with 60.2% agreeing or strongly agreeing that they "would not be able to express themselves well." No statistically significant differences between age groups, sex, gender, or education level were noted . --- FG Data FGs discussed the broad issue of the impact of COVID-19 on medical care. Telehealth was one of several impactful topics within this realm. Some FG participants supported the concept of the convenience of telehealth, reflecting the findings from the survey data. These views were found in different geographic locations in which FGs were conducted. Participants found telehealth easier, convenient, and helpful, as it avoided the need to travel and park at a clinic, facilitated health care discussions, and was less disruptive than going in person. Textbox 1 provides representative quotes from the FG discussions highlighting these benefits. Textbox 1. Representative quotes from focus group discussions on the benefits of telehealth during the COVID-19 pandemic. "Everything I have done is virtual which honestly for my lifestyle is more convenient for me." [Florida, Black millennials/Black women focus group] "Fortunately enough, I've had…help and virtual doctors where I can tell them my symptoms …, and then they'll prescribe me medicine, and I can just pick it up. That's been really helpful." [Arizona, LGBTQ+ focus group] "…we now have access to telehealth. …and I think that, in the end, it's been positive for those people who don't have access to go to a clinic personally." [Florida, Spanish-speaking populations focus group] "We actually prefer virtual, just so then we don't actually have to get over there and drive and pay for parking and go back." [Midwest, pregnancy focus group] "My doctors are in [a different location] and it makes it easier for us to talk to them virtually." [Arizona, Gila Bend, Maricopa County focus group] "There's a discretionary process to see should you even be in-person, or can we do this virtually. I had an ear infection a couple of months ago... 'we'll put you on with a nurse and you can describe all your symptoms. If it's actually an ear infection, we'll put in a prescription for you and we won't make you come in'." [Florida, Black millennials/Black women focus group] However, as in the survey findings, several FG participants had concerns about telehealth. These views included worries about not being assessed adequately, lack of trust in the sufficiency of telehealth, feeling uncomfortable, and sometimes just wanting to see a clinician in person. These views were found across all geographic locations in which FGs were conducted. Textbox 2 provides representative quotes about these concerns. "During COVID, everything was via video call. … I did not feel comfortable about it because I wanted to see …the doctor personally." [Florida, Spanish-speaking populations focus group] "It's awkward. I prefer being touched and having them look at my eyes to see how I am. They can't do that over the internet." [Florida, unhoused people focus group] "Well, it's hard to diagnose anybody or see anybody, how they're really doin' or whatever when you don't see them physically. You don't really see what's goin' on." [Arizona, Guadalupe, Maricopa County focus group] "I feel like remote visits to the doctor are fairly worthless. … You're just telling them your symptoms. They can't look at you and assess you in person. I feel like I just paid $100 for nothing…" [Arizona, parents with young children focus group] "Theoretically, you have everything you need there, but you don't. You're missing a third dimension." [Arizona, veterans focus group] "You just don't feel satisfaction . We had our annual check-up, for the year, 2020, using telehealth. I know my wife didn't feel that a thorough evaluation of her health condition with the general practitioner got done. Obviously, I feel somewhat similar too." [Arizona, Asian American 65+ focus group] Furthermore, some FG participants articulated a concern with not being listened to or understood, including themes of minimization of symptoms, potential for medical errors, and lack of high-quality care. LGBTQ+ FG] Notably, sometimes within the same FG, divergent opinions and perceptions of telehealth were voiced. For example, participants in the LGBTQ+ and the Spanish-speaking FGs expressed both positive and negative perceived views of telehealth. Those who were unhoused articulated negative views about telehealth overall. --- Discussion --- Principal Findings This CEnR, mixed methods study used a community survey and FGs to collect data from diverse and underserved populations across three regions of the United States about the use and perceptions of telehealth from January to November 2021 of the COVID-19 pandemic. Although telehealth was widely used by all demographic groups and in all states, perceived benefits and concerns differed. Despite frequently voiced apprehension in the news media about connectivity and its impact on telehealth, over 90% of our participants had internet access. What was most striking from the survey data findings was the coexisting perceived benefits and concerns among Indigenous respondents. Indigenous respondents, like other ethnic groups, enjoyed the convenience of telehealth as they did not need to travel and it fit in their schedule; however, they also had greater concerns than other groups about telehealth, including the ability of their clinicians to examine them properly and for them to be able to express themselves to their clinicians. Evidence from studies conducted prepandemic suggested that lack of physical examination has been a consistent concern for patients. Guidelines to help determine the appropriateness of a virtual visit as well as guidance for conducting virtual physical examinations have been developed as a result [47,48]. TechQuity is a recently developed term that incorporates an antiracism and proequity ethos to the use of technology in health care. While telehealth is a small part of the increasing use of technology within the health care realm, we should be mindful that telehealth does not exacerbate structural racism and inequities and take note of these findings [49]. Other potential barriers to the use of telehealth not assessed in our study relate to digital literacy and comfort with technology, which may be worse among older adults. This group may benefit substantially from avoiding in-person visits owing to their susceptibility to contagion and mobility challenges [50,51]. However, they faced challenges with online scheduling of vaccination appointments and may require assistance to use telehealth, which may not always be available [52,53]. Language barriers and poor health literacy may also be obstacles to the use of telehealth [54,55]. Just as the above factors substantially impacted vaccine uptake due to difficulties in accessing patient portal messages and online scheduling, it is likely that a telehealth visit without sufficient support from a caregiver or family member would not meet patient needs sufficiently and detract from the patient experience [53,56]. Since the previously ubiquitous reimbursement and licensure hurdles that hampered adoption have been largely overcome during the pandemic, telehealth is appealing to institutions as a mechanism to efficiently deliver some forms of health care [10]. The exponential increase in the use of telehealth during the pandemic has encouraged health care institutions to maintain telehealth as a permanent modality for delivering certain types of care [57][58][59]. While telehealth has some advantages for convenience as highlighted in our findings, concerns remain and warrant further exploration, particularly as they relate to the patient experience. --- Study Strengths We leveraged CEnR methodology as an important tool to understand and address equity issues associated with telehealth in our communities [37,38]. The study utilized a mixed methods approach within a limited time frame across multiple states and sites safely during the pandemic. We disseminated a community-wide electronic survey among diverse and underserved populations using our community networks, partnerships, and organizational connections, utilizing social media to reach those not usually surveyed by academic institutions. We did not use a convenience sample of empaneled patients. The survey was translated into Spanish using a licensed medical translator and it was pilot-tested by bilingual English/Spanish speakers. Participants needed only a mobile phone to participate in both the surveys and FGs. We combined our quantitative survey methods with qualitative research approaches using FGs, providing us with a deeper contextual understanding of the data [40]. We had a multidisciplinary study team who had expertise in survey methods, qualitative methods, and mixed methods, ensuring all phases of the research were conducted in a scientifically robust manner [60]. Another strength of this study is the use of the framework method to analyze the FG data. This approach has several advantages over other qualitative analytic methods. It can be deployed in multidisciplinary research teams where some members have limited qualitative experience but can still engage in sense-making under the guidance of an experienced qualitative researcher. Furthermore, the framework analysis supported a structure for cross-disciplinary analysis of matrices we developed over time as well as a robust audit trail for our study team [46]. --- Study Limitations As with all surveys, response bias is a potential concern. It is possible that those with strong opinions are more likely to respond. We are unable to calculate a response rate for the survey due to the social media mode of dissemination, and while this was assessed to be the most successful mode for capturing diverse and underserved community voices, people who do not use social media may have been less likely to be aware of the study. Nonusers of social media may also be less familiar with digital technology; thus, these findings may underestimate some of the potential concerns. We conducted most FGs through Zoom technology, which likely supported engagement among most participants and was less burdensome than traveling for an in-person FG, but it is possible that this deterred some from participating or fully engaging. Even with broad-reaching recruitment strategies, we received few survey responses from those identifying as Asian. Our findings elucidate important technological considerations about telehealth, including internet access, but also other less explored worries that patients may have about whether telehealth is as effective as in-person clinic visits. It is likely that health care systems will have differing priorities to patients when decisions about telehealth access and utilization are discussed [61][62][63]. Health care systems that invested time, staff, and other resources into supporting telehealth have been able to overcome barriers such as reimbursement and now hope to promote telehealth in many health care settings as a viable return on investment [63]. As health care institutions roll out and sustain telehealth, considerations need to include not only internet access and connectivity but also ease with use of telehealth based on education, language, technology savvy and health literacy, and the patient experience. --- Conclusion This manuscript describes findings from a mixed methods CEnR study about telehealth, including perceived benefits and concerns. As well as being thoughtful about the logistical elements of implementing new health care delivery modalities and processes, our work also highlights the imperative to understand the impact of these novel modalities on the patient experience and actual or perceived quality of care received. Although telehealth is popular among health care systems, overall, patients have concerns that include not being able to express themselves and not having a physical exam. --- Conflicts of Interest None declared. --- Multimedia Appendix 1

Background: Telehealth has been increasingly adopted by health care systems since the start of the COVID-19 pandemic. Although telehealth may provide convenience for patients and clinicians, there are several barriers to accessing it and using it effectively to provide high-quality patient care. Objective: This study was part of a larger multisite community-engaged study conducted to understand the impact of COVID-19 on diverse communities. The work described here explored the perceptions of and experience with telehealth use among diverse and underserved community members during COVID-19.We used mixed methods across three regions in the United States (Midwest, Arizona, and Florida) from January to November 2021. We promoted our study through social media and community partnerships, disseminating flyers in English and Spanish. We developed a moderator guide and conducted focus groups in English and Spanish, mostly using a videoconferencing platform. Participants were placed in focus groups with others who shared similar demographic attributes and geographic location. Focus groups were audio-recorded and transcribed. We analyzed our qualitative data using the framework analytic approach. We developed our broader survey using validated scales and with input from community and scientific leaders, which was then distributed through social media in both English and Spanish. We included a previously published questionnaire that had been used to assess perceptions about telehealth among patients with HIV. We analyzed our quantitative data using SAS software and standard statistical approaches. We examined the effect of region, age, ethnicity/race, and education on the use and perceptions of telehealth.We included data from 47 focus groups. Owing to our mode of dissemination, we were not able to calculate a response rate for the survey. However, we received 3447 English-language and 146 Spanish-language responses. Over 90% of participants had internet access and 94% had used telehealth. Approximately half of all participants agreed or strongly agreed that telehealth

introduction background much has been written about the impact of covid19 on health care delivery especially the increased use of telehealth in expanded clinical situations including primary care mental health prenatal care substance use disorder orthodontics urology inpatient care emergency triage and physical therapy 1 2 3 4 5 6 7 although various forms of telehealth existed for many years prior to the pandemic especially in rural contexts it was relatively underused or restricted to within health care systems 8 9 10 11 however within the first 3 months of the covid19 pandemic telehealth policy makers loosened or lifted many legal and practical restrictions and the use of telehealth increased by 766 while outpatient visits dropped by over 80 in some institutions 12 13 14 in the early stages of the covid19 pandemic telehealth was primarily adopted to reduce viral transmission as a mechanism to preserve personal protective equipment even inpatients who required consultations with subspecialized teams or interactions with multidisciplinary members of the health care team sometimes received their consults via video conference 1516 telehealth versus telemedicine the federal communications commission defines telemedicine as medical services provided with the support of telecommunications technologies such as diagnostic testing or monitoring a patients posttreatment progress telehealth includes a broader scope of clinical and nonclinical remote health care servicesoften provided by nursessuch as patient education help with medication adherence and troubleshooting health issues 17 the world health organization has defined telehealth as being health care services provided by any health care professional and telemedicine as being services provided by a physician however the two terms are often used interchangeably 18 some observers predict that telemedicine and telehealth should be the delivery paradigm of the future because of their potential to equalize access to health care others have highlighted the potential of telemedicine and telehealth to exacerbate current inequality and inequity in health and access to health care 19 by raising barriers for those who do not have internet access are disadvantaged from a socioeconomic perspective are less digitally literate or face language barriers 20 21 22 23 24 much attention has also been paid to privacy data security and connectivity concerns which can threaten the rollout and sustainability of telehealth 2526 finally cultural and relational barriers may hamper the effectiveness of telehealth some individuals have reported that a remote discussion with a health care provider does not constitute an effective health care interaction 27 substantial literature has been published during the pandemic documenting the increased uptake and use of telehealth but there has been less research focus on garnering the views of telehealth users 2829 although some studies have examined the concerns of health care professionals few have captured the experiences and perceptions of the public about these adaptations and the use of telehealth including concerns 30 31 32 33 34 35 furthermore studies capturing the views of diverse and underresourced communities about telehealth have been lacking this study is part of a larger communityengaged research study conducted over a 9month period that used mixed methods to assess the impact of covid19 on marginalized communities across diverse geographic regions cenr has been defined by the centers for disease control and prevention as the process of working collaboratively with and through groups of people affiliated by geographic proximity special interest or similar situations to address issues affecting the wellbeing of those people 3637 cenr can support the translation of scientific discovery into a reduction in heath disparities as it seeks to understand stakeholder and community needs cenr can foster benefits such as influencing public health initiatives and improved health outcomes 3839 this work describes differences in perceptions and experiences of telehealth during covid19 across vulnerable and underresourced communities including apprehensions perceived quality of care received and potential advantages methods study setting and design we performed a multisite multiphase mixed methods study from january to november 2021 in three geographic regions of the united states the southwest southeast and midwest 40 we used cenr methods to explore the needs assets and challenges of surrounding communities to understand the impact of covid19 details of the methods are described elsewhere 41 but are briefly outlined below this project is part of a broader effort toward exploring several issues about the impact of covid19 on historically marginalized communities we here focus on the content that informs considerations around telehealth the study employed quantitative and qualitative methods in three phases phase 1 involved qualitative key informant interviews phase 2 involved focus groups and phase 3 employed an anonymous online survey 42 as stated by kelle et al 43 mixed methods research can support mutual validation of data as well as provide a more coherent and complete picture than a single research strategy alone ethical considerations the qualitative phases of the study were approved as minimal risk by the mayo clinic institutional review board the quantitative phase was hosted by an external survey research company as verified by research compliance mayo clinic had no participant contact was therefore not engaged in human subjects research and this phase was not eligible for institutional review board review all data analysis was conducted by our study team all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the helsinki declaration of 1975 as revised in 2000 during fgs the moderator began the activity by outlining the elements of informed consent that had been shared prior to scheduling with participants and they were asked to confirm consent verbally participants received a us 50 financial remuneration for their time as with most surveys respondents are assumed to have provided consent if they complete the survey those who completed the survey received us 10 digital financial remuneration all data from the survey and fgs were deidentified and stored on passwordprotected computers or in locked cabinets to which only the study team had access we here report the phase 2 perspectives of fg participants about their experience with telehealth and the phase 3 survey participant responses about telehealth fgs and surveys fg recruitment and data collection the broader multidisciplinary study team developed the moderator guide which included questions about the impact of covid19 on access and use of health care the moderators guide covered the following covid impact topics future hopes personal medical worries vaccines household mental health and community impacts we disseminated flyers in spanish and english through social media and community organizations and convened fgs in all three regions the purpose of the study risks and benefits and the option to decline any question andor withdraw at any time were outlined to participants before scheduling participants were placed in fgs with others who represented similar demographic residential or social communities we also collaborated with local departments of health who were conducting fgs about the impact of covid19 on communities and were able to negotiate data sharing most fgs were conducted via online videoconferencing some were conducted in person fgs were scheduled for 1 hour two fgs were conducted in spanish with bilingual moderators survey instrument and sampling we developed an electronic survey with the input of community and scientific leaders as well as other key stakeholders the survey questions about telehealth were adapted from questions developed to evaluate the attitudes of patients living with hiv about telehealth in lieu of facetoface visits 44 they included questions about internet access use of telehealth since the start of the pandemic likelihood of using telehealth in the future as well as perceived benefits of telehealth and concerns with telehealth the survey was pilottested extensively and we solicited comments and suggestions from community advisory boards existing panels of health equity and community engagement researchers across the institution as well as volunteers from the community networks of those researchers 45 the survey was also translated into spanish by a licensed medical translator and tested by bilingual englishspanish speakers the survey was distributed through existing networks of community partners and organizations using social media and email lists for 8 weeks in the fall of 2021 a professional research firm hosted accrued and deidentified the data analysis fg qualitative data analysis we digitally recorded the fgs and they were transcribed by a health insurance portability and accountability actcompliant professional firm and deidentified before analysis data from fgs conducted by our team and those conducted by others were stored and analyzed in parallel using identical coding structures but were not combined into one data set we used the framework analytic approach to code our data 46 in which the verbatim content of fg transcripts is summarized in a matrix in this matrix deductive themes from group moderation guides create the columns and individual fgs create the rows inductiveemergingthemes may add additional columns transcript page numbers are noted with paraphrased content within the relevant cells two trained coders collaborated on all phases of analysis including initial content paraphrasing indexing to codebook development and illustrative quote retrieval survey data analysis statistical analyses were performed using sas software 904 categorical variables are reported as counts with percentages and were analyzed with the pearson χ 2 test fisher exact test and general linear models with tukey options to test simultaneous differences between percentage means where appropriate continuous variables are reported as medians with iqr and analyzed with the wilcoxon ranksum test a 2sided p value of less than 05 was considered statistically significant when looking at the difference between means with the tukey honestsignificant test we tested if the difference between means is equal to zero this may occasionally result in a significant difference between two groups even when the confidence intervals for those two groups overlap results fg participants baseline characteristics in total data were analyzed for 47 fgs conducted during 2021 by our team and colleagues at arizona state university fgs were demographically and geographically discrete and included separate groups who were uninsured and underinsured those experiencing homelessness lgbtqi latinx women and men parents of young children cancer survivors black men and women indigenous americans immigrants and spanishspeaking adults veterans and older asian americans survey respondents baseline characteristics the completed survey data set included 3447 englishlanguage responses and 146 spanishlanguage responses responses are proportionate to the geographic population of the area surveyed due to the mode of dissemination we cannot calculate a response rate we conducted sitespecific analysis as well as analysis across different demographic groups that included all sites of note the subset identifying their primary identity as asian was too small to analyze and has been excluded from this paper but included in other work internet access internet access was high across all sites with over 90 of participants reporting access access was the highest among southwest participants with 98 reporting internet access black hispanics indigenous and white nonhispanics had lower rates of internet access than other racial and ethnic groups such as black nonhispanic and white hispanic no significant differences were detected across groups defined by age sex gender identity or education use of telehealth to date a total of 3260 participants answered the question about use of telehealth since the start of the pandemic across all sites any use of telehealth during this time was high with 94 overall using telehealth at some stage the proportions for telehealth use by subgroup are presented in table 2 all three locations showed statistically significant different usage of telehealth florida had the lowest rate with 88 having used telehealth in arizona 94 and in the midwest 97 had used telehealth since the covid19 pandemic started black hispanics had the highest use of telehealth at 977 which was significantly greater than the use of white nonhispanics at 944 among those aged 3039 years 948 used telehealth similar to the rate of those aged 4049 years at 943 this was significantly more than that of participants aged 1829 years but was not significantly higher than the use rate of those aged 5075 years there were no significant differences in use of telehealth based on education sex or gender identity perceived benefits of telehealth survey questions about the perceived benefits of telehealth included those related to telehealth fitting into peoples schedule better and not needing to travel the proportions for perceived telehealth benefits by subgroup are presented in table 3 over half of all respondents agreed or strongly agreed that telehealth fit their schedule better than inperson visits indigenous respondents were significantly more likely to feel this way than any other groups except nonhispanic white individuals at 658 agreement those with moderate levels of education were significantly more likely than those with lower levels to report that telehealth fit their schedule better those with moderate levels of education were significantly more likely to agree that telehealth would reduce the need to travel than those with lower levels of education additionally the indigenous population was significantly more likely to agree that not traveling was a benefit than any other group at 643 there was a marginal age difference with those aged 5075 years being least likely to agree this was significantly lower than that for participants aged 4049 years but not for the other age groups perceived concerns with telehealth survey questions about the perceived concerns of telehealth included those related to not being examined properly and not being able to express oneself the proportions for perceived telehealth concerns by subgroup are presented in table 4 overall approximately half of all respondents felt that telehealth would hinder the ability of the provider to examine them well this pattern was consistent across all demographic groups with some notable differences those aged 3039 years and 4049 years were the most concerned about this issue at 494 and 534 respectively which was significantly higher than the rate of agreement for those aged 1829 years at 434 those with moderate levels of education were significantly more likely to be concerned about this issue than those with lower levels of education indigenous respondents were statistically the most concerned about lack of sufficient examination through telehealth with 639 agreeing or strongly agreeing that the doctor would not be able to examine me well in all other racial and ethnic groups only about half of all respondents agreed or strongly agreed with the statement no significant differences were detected across groups defined by sex or gender identity overall 452 of participants agreed or strongly agreed that they would not be able to express themselves well the participants in the southeast differed from those of other sites with only 384 concerned about the issue of expressing themselves indigenous respondents had more concerns than other demographic groups with 602 agreeing or strongly agreeing that they would not be able to express themselves well no statistically significant differences between age groups sex gender or education level were noted fg data fgs discussed the broad issue of the impact of covid19 on medical care telehealth was one of several impactful topics within this realm some fg participants supported the concept of the convenience of telehealth reflecting the findings from the survey data these views were found in different geographic locations in which fgs were conducted participants found telehealth easier convenient and helpful as it avoided the need to travel and park at a clinic facilitated health care discussions and was less disruptive than going in person textbox 1 provides representative quotes from the fg discussions highlighting these benefits textbox 1 representative quotes from focus group discussions on the benefits of telehealth during the covid19 pandemic everything i have done is virtual which honestly for my lifestyle is more convenient for me florida black millennialsblack women focus group fortunately enough ive had…help and virtual doctors where i can tell them my symptoms … and then theyll prescribe me medicine and i can just pick it up thats been really helpful arizona lgbtq focus group …we now have access to telehealth …and i think that in the end its been positive for those people who dont have access to go to a clinic personally florida spanishspeaking populations focus group we actually prefer virtual just so then we dont actually have to get over there and drive and pay for parking and go back midwest pregnancy focus group my doctors are in a different location and it makes it easier for us to talk to them virtually arizona gila bend maricopa county focus group theres a discretionary process to see should you even be inperson or can we do this virtually i had an ear infection a couple of months ago well put you on with a nurse and you can describe all your symptoms if its actually an ear infection well put in a prescription for you and we wont make you come in florida black millennialsblack women focus group however as in the survey findings several fg participants had concerns about telehealth these views included worries about not being assessed adequately lack of trust in the sufficiency of telehealth feeling uncomfortable and sometimes just wanting to see a clinician in person these views were found across all geographic locations in which fgs were conducted textbox 2 provides representative quotes about these concerns during covid everything was via video call … i did not feel comfortable about it because i wanted to see …the doctor personally florida spanishspeaking populations focus group its awkward i prefer being touched and having them look at my eyes to see how i am they cant do that over the internet florida unhoused people focus group well its hard to diagnose anybody or see anybody how theyre really doin or whatever when you dont see them physically you dont really see whats goin on arizona guadalupe maricopa county focus group i feel like remote visits to the doctor are fairly worthless … youre just telling them your symptoms they cant look at you and assess you in person i feel like i just paid 100 for nothing… arizona parents with young children focus group theoretically you have everything you need there but you dont youre missing a third dimension arizona veterans focus group you just dont feel satisfaction we had our annual checkup for the year 2020 using telehealth i know my wife didnt feel that a thorough evaluation of her health condition with the general practitioner got done obviously i feel somewhat similar too arizona asian american 65 focus group furthermore some fg participants articulated a concern with not being listened to or understood including themes of minimization of symptoms potential for medical errors and lack of highquality care lgbtq fg notably sometimes within the same fg divergent opinions and perceptions of telehealth were voiced for example participants in the lgbtq and the spanishspeaking fgs expressed both positive and negative perceived views of telehealth those who were unhoused articulated negative views about telehealth overall discussion principal findings this cenr mixed methods study used a community survey and fgs to collect data from diverse and underserved populations across three regions of the united states about the use and perceptions of telehealth from january to november 2021 of the covid19 pandemic although telehealth was widely used by all demographic groups and in all states perceived benefits and concerns differed despite frequently voiced apprehension in the news media about connectivity and its impact on telehealth over 90 of our participants had internet access what was most striking from the survey data findings was the coexisting perceived benefits and concerns among indigenous respondents indigenous respondents like other ethnic groups enjoyed the convenience of telehealth as they did not need to travel and it fit in their schedule however they also had greater concerns than other groups about telehealth including the ability of their clinicians to examine them properly and for them to be able to express themselves to their clinicians evidence from studies conducted prepandemic suggested that lack of physical examination has been a consistent concern for patients guidelines to help determine the appropriateness of a virtual visit as well as guidance for conducting virtual physical examinations have been developed as a result 4748 techquity is a recently developed term that incorporates an antiracism and proequity ethos to the use of technology in health care while telehealth is a small part of the increasing use of technology within the health care realm we should be mindful that telehealth does not exacerbate structural racism and inequities and take note of these findings 49 other potential barriers to the use of telehealth not assessed in our study relate to digital literacy and comfort with technology which may be worse among older adults this group may benefit substantially from avoiding inperson visits owing to their susceptibility to contagion and mobility challenges 5051 however they faced challenges with online scheduling of vaccination appointments and may require assistance to use telehealth which may not always be available 5253 language barriers and poor health literacy may also be obstacles to the use of telehealth 5455 just as the above factors substantially impacted vaccine uptake due to difficulties in accessing patient portal messages and online scheduling it is likely that a telehealth visit without sufficient support from a caregiver or family member would not meet patient needs sufficiently and detract from the patient experience 5356 since the previously ubiquitous reimbursement and licensure hurdles that hampered adoption have been largely overcome during the pandemic telehealth is appealing to institutions as a mechanism to efficiently deliver some forms of health care 10 the exponential increase in the use of telehealth during the pandemic has encouraged health care institutions to maintain telehealth as a permanent modality for delivering certain types of care 57 58 59 while telehealth has some advantages for convenience as highlighted in our findings concerns remain and warrant further exploration particularly as they relate to the patient experience study strengths we leveraged cenr methodology as an important tool to understand and address equity issues associated with telehealth in our communities 3738 the study utilized a mixed methods approach within a limited time frame across multiple states and sites safely during the pandemic we disseminated a communitywide electronic survey among diverse and underserved populations using our community networks partnerships and organizational connections utilizing social media to reach those not usually surveyed by academic institutions we did not use a convenience sample of empaneled patients the survey was translated into spanish using a licensed medical translator and it was pilottested by bilingual englishspanish speakers participants needed only a mobile phone to participate in both the surveys and fgs we combined our quantitative survey methods with qualitative research approaches using fgs providing us with a deeper contextual understanding of the data 40 we had a multidisciplinary study team who had expertise in survey methods qualitative methods and mixed methods ensuring all phases of the research were conducted in a scientifically robust manner 60 another strength of this study is the use of the framework method to analyze the fg data this approach has several advantages over other qualitative analytic methods it can be deployed in multidisciplinary research teams where some members have limited qualitative experience but can still engage in sensemaking under the guidance of an experienced qualitative researcher furthermore the framework analysis supported a structure for crossdisciplinary analysis of matrices we developed over time as well as a robust audit trail for our study team 46 study limitations as with all surveys response bias is a potential concern it is possible that those with strong opinions are more likely to respond we are unable to calculate a response rate for the survey due to the social media mode of dissemination and while this was assessed to be the most successful mode for capturing diverse and underserved community voices people who do not use social media may have been less likely to be aware of the study nonusers of social media may also be less familiar with digital technology thus these findings may underestimate some of the potential concerns we conducted most fgs through zoom technology which likely supported engagement among most participants and was less burdensome than traveling for an inperson fg but it is possible that this deterred some from participating or fully engaging even with broadreaching recruitment strategies we received few survey responses from those identifying as asian our findings elucidate important technological considerations about telehealth including internet access but also other less explored worries that patients may have about whether telehealth is as effective as inperson clinic visits it is likely that health care systems will have differing priorities to patients when decisions about telehealth access and utilization are discussed 61 62 63 health care systems that invested time staff and other resources into supporting telehealth have been able to overcome barriers such as reimbursement and now hope to promote telehealth in many health care settings as a viable return on investment 63 as health care institutions roll out and sustain telehealth considerations need to include not only internet access and connectivity but also ease with use of telehealth based on education language technology savvy and health literacy and the patient experience conclusion this manuscript describes findings from a mixed methods cenr study about telehealth including perceived benefits and concerns as well as being thoughtful about the logistical elements of implementing new health care delivery modalities and processes our work also highlights the imperative to understand the impact of these novel modalities on the patient experience and actual or perceived quality of care received although telehealth is popular among health care systems overall patients have concerns that include not being able to express themselves and not having a physical exam conflicts of interest none declared multimedia appendix 1

background telehealth has been increasingly adopted by health care systems since the start of the covid19 pandemic although telehealth may provide convenience for patients and clinicians there are several barriers to accessing it and using it effectively to provide highquality patient care objective this study was part of a larger multisite communityengaged study conducted to understand the impact of covid19 on diverse communities the work described here explored the perceptions of and experience with telehealth use among diverse and underserved community members during covid19we used mixed methods across three regions in the united states midwest arizona and florida from january to november 2021 we promoted our study through social media and community partnerships disseminating flyers in english and spanish we developed a moderator guide and conducted focus groups in english and spanish mostly using a videoconferencing platform participants were placed in focus groups with others who shared similar demographic attributes and geographic location focus groups were audiorecorded and transcribed we analyzed our qualitative data using the framework analytic approach we developed our broader survey using validated scales and with input from community and scientific leaders which was then distributed through social media in both english and spanish we included a previously published questionnaire that had been used to assess perceptions about telehealth among patients with hiv we analyzed our quantitative data using sas software and standard statistical approaches we examined the effect of region age ethnicityrace and education on the use and perceptions of telehealthwe included data from 47 focus groups owing to our mode of dissemination we were not able to calculate a response rate for the survey however we received 3447 englishlanguage and 146 spanishlanguage responses over 90 of participants had internet access and 94 had used telehealth approximately half of all participants agreed or strongly agreed that telehealth

Participatory research can be used in conjunction with quantitative, other qualitative, and mixed methods research methods to collaboratively address priority global health issues that are greatly influenced by social norms. Social norms have been identified as key components of deeply held beliefs that perpetuate as well as change detrimental health practices. At all levels of global health research, from program development to monitoring and evaluation, participatory tools can be used to honor the ethic of working with the target population, incorporating their needs, and engaging a community to improve health-related behaviors. This paper shows how to use two visually based participatory tools to impact social and behavior change around Female Genital Mutilation and Menstrual Hygiene Management . Both FGM and MHM have been identified as critical to UNICEF's Child Protection and to meeting the United Nations Global Sustainability Goals. We also outline how Social Network Mapping and 2x2 Tables were implemented to address complex social norms around FMG and MHM. The discussion then illustrates how they have been used within research and program development more broadly. These tools are valuable methods to understand and impact social and behavior change in a wide variety of public health issues. Global health research addresses large-scale health issues worldwide, often focusing on marginalized, impoverished, and vulnerable populations. Participatory research in global health provides a practical and ethical approach to working toward positive health change while respecting a community's autonomy, desire for change or intervention, embedded systems of communication, and social norms . Intervening to address social norms around an entrenched health problem has been identified as a primary driver of effective behavior and social change. Conversely, regulatory interventions often have very little impact on changing behaviors as part of persistent cultural norms . Participatory approaches and methodologies serve overarching research values of working with research participants and honoring community knowledge while utilizing specific research tools and methods that both engage the community to discuss difficult and stigmatizing health issues and encourage community-centered behavior and social change. Participatory approaches such as community-based participatory research and participatory action research are increasingly recognized and encouraged in global health work by multinational donors, researchers, and practitioners . However, there is a gap in research-based evidence that evaluates whether participatory interventions using a social norms research approach have the intended impact . This paper explores two visual tools -social network mapping and 2x2 tables -used for participatory data collection in interventions that seek to shift social norms to facilitate change for women's health. We begin with an introduction to social norms as the context in which participatory approaches and tools can be used to effect change. We then outline two examples of research to discuss how social network mapping and 2x2 tables were used as part of participatory methodology in public health interventions that tackle social norms. We conclude by identifying these tools' limitations and challenges as well as their potential for application to other research areas. This paper seeks to answer the following questions: How have the visually informed participatory research tools, social network mapping and 2x2 tables, been used to promote social and behavior change? How can these participatory mixed-method approaches support the development of programs, monitoring and evaluation , and assess social and behavior change for public health issues around the world? --- Social Norm Theorizing Social norms are the unwritten rules that guide human behavior: they are what we do, what we believe others do, and what we believe others think we should do . For their existence, social norms require a reference group, i.e., a network of people to whom we identify and compare ourselves . This reference group determines norms because identifying a behavior with a specific group influences whether that behavior is considered normative within the group and, in turn, may predict whether a new behavior will be adopted . Members of a group expect, are expected to follow, and are motivated to follow norms because of sanctions for non-adherence and rewards for adherence. Finally, collective norms are what people actually do, i.e., the actual prevalence of a behavior. See Table 1 for these distinctions in social norms constructs. Change of social norms requires cognitive shifts in deeply embedded schema and scripts formed within dynamic interpersonal relationships with people who serve as primary reference groups. Social and behavior change communication theory states that social networks are primary mechanisms that may drive behavior change through the action of education and dialogue that counteracts prevailing ideas about a given area of concern. There are many behavior-change theories that operationalize social norms and target types of norms. For purposes of this discussion, social norms are the construct that we mean to change via public health interventions by using participatory methods such as social network maps and 2x2 Tables. The inclusion of audience participation makes these tools effective for applying to social norms change with deeply embedded cultural practices where the potential social consequences for engaging or not engaging in the practice seem dire and structural barriers seem great. with global and local experts, and discussion with program implementers, followed by rigorous pretesting of each of the tools were all used to ensure that these methods were acceptable. --- Research and Programs to Impact Female Genital Mutilation A framework was designed to provide adaptable yet standardized participatory measures of social and behavior change for female genital mutilation in Ethiopia and Guinea . Called ACT, the framework addresses: "A" assessing for affective and normative data about the practice; "C" the context in which these practices occur; and "T", tracking or monitoring of behavior change . FGM is the practice of altering, injuring, or "cutting" female genitalia for non-medical purposes and is an international public health concern affecting millions of girls and women worldwide . Practiced in cultures in more than 30 countries throughout Africa, parts of Asia, and the Middle East FGM now exists in nearly every country due to migration. It is tied to social norms of marriageability, perceived purity, and social acceptability of girls and women across the lifespan. Yet, it results in trauma, chronic pain, severe complications with sex and childbirth, and even death from infections or blood loss. --- Research and Programming to Impact Menstrual Hygiene Management in India The Girls' Adolescent and Reproductive Rights program addressed menstrual health and hygiene management in India . Unsanitary practices of MHM lead to poor hygiene, infection, disease, shame, and social ostracization of menstruating females . Addressing menstrual hygiene management in India is a critical area of women's health spotlighted by UNICEF to address gender equity and economic policy in the Global South . Inadequate MHM leaves girls and women vulnerable to disease and is a primary driver of gender inequality and social exclusion . A culture of silence has been identified as the root of poor MHM, leaving young girls with poor knowledge and myths related to the care of their bodies during menstruation. While infrastructure around adequate facilities for washing and disposing of menstrual products is part of the solution, influencing social networks of the young girls has been found to have a greater impact on behavior change, including addressing larger sexual and reproductive health issues in India . --- Methods Ethics and Positionality Statements This research was approved by Drexel's IRB as well as a local IRB and it further followed UNEG standards and ethical guidelines. Funding and programming for this research were provided by UNICEF. Researchers first gained oral consent from participants. Consent forms were translated into local dialects, though verbal consent was given as customary with populations where literacy may be low and local dialects may not be translated. Postcards were left with participants to provide research information and follow-up contact information. Standard protocols were followed regarding global health research and consent, ethics, and respect for personal autonomy . The research reflected in this paper was designed by Dr. Sood through the Dornsife School of Public Health in partnership with UNICEF. Local researchers and practitioners collected, cleaned, and transcribed the data. J.R. HaileSelasse is a doctoral research fellow working with Dr. Sood at the Dornsife School's Community Health and Prevention while the other two authors are researchers at Drexel University in Creative Arts Therapies, College of Nursing and Health Professions. Both Dr. Sood and Dr. Kaimal are of Indian descent with contemporary ties to that country while HaileSelasse and K. Snyder are white Americans. All four women share a worldview that includes the promotion of women's health and human rights, respect for the agency of participants in research, a pragmatic focus on working toward positive change in people's lives through research, program implementation, evaluation and monitoring, and community-engaged learning whenever possible. Our case study examples are from research conducted by Dr. Sood's team with community teams in the field in each location. It is our hope, as a cross-disciplinary team, to share the value of these participatory visual tools and community-engaged methodology. --- Social Network Mapping Social network mapping is a visual technique that illustrates how community members are connected and how information flows through social networks . Participants draw or fill in graphics or "maps" that show and list who is in their social network in relation to themselves and others. This illustrates where and how information is shared and can even be used to explore types of information . As such, social network mapping is a great way to identify participants' key sources of information as well as barriers to communication. This tool is based on social network theory, which explains decision-making as largely influenced by group relationships, norms, and expectations . When a participant completes a map, not only does it provide data on the nature of their social network but also offers insight into how they see or perceive that network and their role within it. As a transformative activity, SNM can have a therapeutic effect on participants, where they visualize themselves, perhaps for the first time, as part of a social network and within the context of the health issue being discussed. With this information, researchers can assess the influence of structural and relational dynamics on health status . The maps themselves can take many forms . For example, they may show concentric circles with each one representing different layers of society . Participants can also draw maps with themselves in the middle Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... and their contacts connected by lines, like a web. The size of the map components can be used to illustrate the importance of that person within a social network with larger circles, lines, or arrows indicating greater importance. No matter the format, the key is to have maps that illustrate relational ties. Each format may have its own potential benefits for data collection, illustration, and transformation. --- Journal of Participatory Research Methods This preliminary exercise with the participant helps show who within the social network influences their beliefs and behaviors. By identifying such network groups within an ecological model, the participant is primed to consider the way that they have come to view a social norm, practice, or expectation. Participants can then visually map individuals whom they consider as providing accurate information as well as people who need to be included in future programming. Then, the community-based program efforts focus on reaching the individuals identified as important by the participants. Ongoing programs then target such beliefs and support social network changes. For example, primary caregivers may be brought in for dialogue or other activities to engage them in considering alternatives to the detrimental practice. In later research stages, diagrams might be re-examined to monitor the impact of community interventions, including quantification of changes in patterns of interpersonal communication among program participants. This provides programmatic visual proof of any intended expanding networks that have effectively displaced the culture of silence around these issues. When it comes to program evaluations, maps can be specific to show whom participants speak with about the program. By conducting another SNM later in the program, participants may develop personal insight into changing views about Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... --- Journal of Participatory Research Methods the detrimental practices and new health practices as well as continued social norms and networks that either support positive change or inhibit it. This information equips field experts to quickly address the community in new ways to bring about desired change, developing programs that fully support all community members. Beyond research and evaluation, social network maps encourage participant and community dialogue, and, as seen in later case examples, helped the girls who participated in our study to identify whom their community-based programs needed to work with and how. Allies are leveraged for promoting desired behaviors while individuals who create barriers are assessed for additional interventions to promote behavioral change. --- How to Create a Social Network Map The activity of mapping begins with a visual template, as seen in Figure 3, that is either printed and handed to the participant or drawn during the process as participants speak. The mapping process translates well to low-technology environments and could be done on blackboards with photos taken of the process and final product. Face-to-face settings can use paper, flip charts, or other simple means to create maps. Web-based, sharable graphic applications can be used in virtual settings. In any setting and use of material, providing an introductory example to participants is a good means of building participant confidence as well as maintaining the continuity and integrity of the data. Participants are asked to identify the people in their lives and their places within each of the categories of social influence, along with provided examples. As they list individuals within each category, participants are asked to identify what types of support they have received from each person. Researchers/ facilitators should make notes about these relationships, including relevant themes such as allyship, barriers, and any foreseen potential barriers to positive change with the intervention. The participant is then asked to rank the people that they have listed in order of support and influence. Other probes that can be part of the process include asking a participant to consider their level of investment in each relationship in the context of the targeted health issue. Filling in this social network map illustrates social and informational concepts about the health concern and environmental influences. This will be important for data interpretation and analysis to assess the social norms relevant to the health concern. One advantage of social network mapping is that resulting data may be interpreted relatively quickly and in the field. Data are first divided based on participant characteristics such as gender, age, socio-economic status, and either change of time or intervention versus comparison if used at the M&E phase. Frequency counts are tallied across all observations and different social categories, noting the most common level of social influence. This can include counting allies and barriers to behavioral change as relevant to findings. Finally, thematic analysis helps to pull out the most common themes and ideas that explain how individuals in this group perceive their social network influence in relation to the health concern. Reviewing the data and relevant themes provides insight into the importance of engaging different reference groups in the community. Aggregate data reveals the most important community members' influence over a particular health behavior to target programs and interventions. Responses to any probing questions used may also suggest how communication flows with the various reference group members. --- 2x2 Tables The visual participatory 2x2 tables method aids researchers, participants, and communities in assessing the existence, persistence, and change in social norms over time. Though they can be simple visual depictions with limited text and four boxes, conceptually they are complex and require consistent high-quality training for researchers/facilitators. Pretesting is strongly recommended. The facilitator of this activity needs to have a clear understanding of the types of social norms that it measures. The exercise must be understood as designed to measure three types of social norms as discussed in the introduction and summarized here to emphasize the importance of training facilitators. The 2x2 Tables measure an individual's behaviors or what we do, descriptive norms as what we think others do, and injunctive norms as what we think others expect or believe that we should do. This tool provides rich mixed methods data for analysis that can be used to design programs, measure norms and behaviors at baseline and end-line, and measure change as part of monitoring and evaluating a program for efficacy. Resulting data includes frequencies and prevalence of behaviors and norms as well as qualitative data shared in discussions of why participants provide their answers and links to social rewards and punishments that are related to social norms. For these reasons, it is helpful to collect observational data and Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... notes while the activity is underway. Importantly, the data allows programmers to understand if an issue is normative in nature. Generating the data allows participants to visualize differences between their approval, societal approval, social expectations, and behaviors. If facilitated, this leads to dialogue on why and how harmful practices persist due to normative and injunctive expectations. This data can also be used to revise the activity after pre-testing or to identify appropriate outcomes for a program. --- Journal of Participatory Research Methods --- How to Use a 2x2 Table To conduct the exercise, clear definitions and examples of the target behavior should be provided, allowing participants to ask any questions or clarify what they are being asked to consider when filling in a table. Participants are first asked to identify, in their opinion, what proportion of community members engage in this behavior. This helps indicate their perceptions about the prevalence of a given behavior. Then they work through two 2x2 tables concerning a behavior. The first table measures attitudes by asking participants if they approve or disapprove of the behavior , and whether they think others approve or disapprove of the behavior. The second table measures injunctive and descriptive norms by asking whether others in their community practice the behavior and expect them to do so as well. The "others" in this case are members of the participant's social network, comprised of individuals whose opinion matters to the participant as established by creating the socialecological network map. Participants are also asked to provide the associated rewards and punishments , which allows assessment of outcome expectancies. Any behavior can be measured using 2x2 Tables for Social Norms. It may be best to include 2x2 tables for social norms as part of a larger study so Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... To complete the two tables, participants need to respond to two separate questions with yes/no answers. The first questions are whether they approve of a given behavior, and to what extent they think "others" approve of a given behavior. Have them place a mark in one of the four quadrants based on their answers. If they answered yes to both questions, put a mark in the top left quadrant. If they answered yes to the first question and no to the second question, put a mark in the top right quadrant. If they answered no to the first question and yes to the second question, put a mark in the bottom left quadrant. If they answered no to both questions, put a mark in the bottom right quadrant. It's important for the researcher to remind participants to respond only with yes or no answers. Emphasize while you understand that different types of people do and think different things, for this activity you want them to select either "yes" or "no" based on what they think more people do and think. --- Journal of Participatory Research Methods Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... --- Journal of Participatory Research Methods Next, have participants fill out the second 2x2 table for behavior. Use the same instructions as before. However, instead of approval, ask if "others" practice a given behavior and if they expect the participant to practice the behavior. Have them fill out Figure 4 in the same way as they did the previous table. If they answered yes to both questions above, put a mark in the top left quadrant. If they answered yes to the first question and no to the second question, put a mark in the top right quadrant. If they answered no to the first question and yes to the second question, put a mark in the bottom left quadrant. If they answered no to both questions, put a mark in the bottom right quadrant. Then, when helpful to the research and appropriate to the participant, ask them to reflect on the reasons why they are in a given quadrant to elucidate more context. Depending on the behavior in question, the first question on the second table can ask participants about their own behavior and the behavior of others. The table can then be followed by the question "Do others expect you to participate in this behavior?" To ensure participants understand the activity, one can use several different representations. For example, ask each question and have them write the answers on a piece of paper, then read their responses aloud or pass them along to the interviewer . For non-or low-literate populations, one can use different colored stickers or sticky notes to display their answers. Once the responses are recorded, the interviewer asks a variety of probing questions depending on the behavior. For example, why they and/ or others fit into the selected quadrants, discrepancies and/or concurrence between approval and behavior, and how individual-and societal-level change can be achieved to encourage participants to recognize and challenge social norms. To analyze results from the 2x2 tables, data are pulled and divided into groups based on participant characteristics such as age, socio-economic status, etc. Frequency counts are made for each quadrant in each of the two 2x2 tables to look at both perceptions of the behavior and practices of the behavior for self and others. The frequencies for each quadrant help to understand how the participants feel in relation to injunctive and descriptive social norms ; beliefs about the prevalence of behavior practices; beliefs about what others expect us to do; and social rewards or sanctions that maintain the behavior in question. Some quantitative analysis may be conducted to determine any significant differences by quadrant between respondent groups as well as within quadrants on approval/attitude and behavior tables. Thematic analysis helps to find common responses among the participants from the probing questions. Analyses may focus on statements related to rewards and sanctions for the continuation of the behavior, rewards, and sanctions for abandonment of the behavior, and other ways that the participant perceives the social expectations for the behavior. Interpretation of the 2x2 tables consists of mapping frequencies of responses within the quadrants. When responses fall more heavily in the extreme quadrants social norms are indicated as driving the behavior. Whereas when responses fall within the top right or bottom left quadrants, participants are assumed to either be abiding by a normative behavior that they would prefer not to practice or that they are challenging a widely accepted normative practice. When using information gleaned from these tables, it is important to keep the context of the intended behavior change in mind. An intervention might promote the uptake of a new behavior such as using disposable menstrual pads, or it might promote abandoning an existing behavior such as FGM. When the data predominantly fall in the top left quadrant, this suggests that knowledge and awareness strategies are suited for intervention. Similarly, when responses fall predominantly in the bottom right quadrant, programs that ensure the maintenance of positive behaviors and support abandoning negative behaviors are indicated, since the behavior is normative. Additional program models may emerge out of the data looking at personal and environmental reasons, rewards, and punishments behind behaviors that may need increased communication interventions at different levels. Results/Discussion As part of ACT, participatory action tools are utilized to engage the target audiences in communities and to monitor program effectiveness to make changes in real time based on participation . These activities allow participants to reflect and discuss behaviors and norms and explore the reasons why these norms exist, especially when follow-up dialogue is facilitated as part of the activity. Social network maps and 2x2 tables were designed to be used together, with the latter exercise measuring norms by building off the former exercise that visualizes realms of social influence. However, these tools can be used separately or in conjunction with other relevant visual tools, participatory activities, and a range of quantitative and qualitative methods. When used together, it can be helpful to have completed maps visible as visual prompts to Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... participants as they conduct the 2x2 table activity. For a step-by-step training and implementation guide for these visual tools, access the following link: https://www.unicef.org/documents/ act-framework-package-measuringsocial-norms-around-female-genital-mutilation. --- Journal of Participatory Research Methods In Ethiopia, the use of the 2x2 tables helped researchers and frontline community program workers to parse participants' understanding of where their beliefs and practices regarding FGM come from to loosen the grip of such beliefs. Research happened through programs that were created by local community groups to address education and opportunities for community members, specifically girls at risk for FGM. Outcome expectancies play a substantial role in the maintenance of FGM practice and where rewards are seemingly low, sanctions might be perceived as high. This provided the program with crucial information on potential messaging to address sanctions while promoting rewards. Such discrepancies between the approval of a behavior and the practice of that behavior suggest that a norm influences the ongoing behavior. With research on FGM, these two tools provided researchers with data to support the triangulation of all data collected, specifically around indicators of injunctive and descriptive social norms. In India, GARIMA targeted adolescent girls who are most impacted by the oppressive beliefs and practices related to menstruation. Their mothers were included in the primary audience along with their fathers, frontline health workers, and schoolteachers in the second tier. The social network map was used to help young girls express who influences them and their decisionmaking, attitudes, and practices. Development of these network maps aided researchers in defining relevant reference groups across social domains from family to friends and peers and the larger community to create programming that will target all domains in relevant ways and make real-time changes to ongoing programs where new messages and critical dialogue occur. Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... The visual participatory tools highlighted here were used in two ways for this study. First, during the behavior monitoring assessment conducted in the three districts in Uttar Pradesh, the tools highlighted three barriers to effective change around MHM: 1) feelings of "impurity" on behalf of the young girls; 2) absence of functional sanitation facilities or privacy for changing or washing; and 3) inadequate disposal facilities. Identification of these barriers established a relationship between menstruation and school absenteeism for young girls which equates to gender inequities and often leads to girls dropping out of school. --- Journal of Participatory Research Methods Second, an end-line evaluation was conducted to assess the relevance, effectiveness, efficiency, impact, and sustainability of the GARIMA program separate from the initial baseline assessment. Focus groups and interviews with key informants utilized these same participatory tools to reveal beliefs, attitudes, and restrictions coming from social norms perspectives and allow openness of communication across stakeholders, such as mothers, daughters, and peers. In comparison to non-intervention village adolescent girls, girls who have participated in GARIMA programs were better able to discuss a wider variety of aspects of menstruation and hygiene management, had more knowledge about puberty and reproductive body parts, and had more positive attitudes about gender . Using participatory methods, researchers work closely with program partners throughout the program cycle to meet the community in their program settings, reduce disruptions, and improve research compliance . Qualitative and participatory practices complement larger quantitative data gathering while providing the nuance of participant experience, measure impact in ways that may not be clear through quantitative data, and provide a means for evaluating necessary program changes. It is essential to the research design process that the type and level of participation are determined as to the best interests of the community and the research. See Figure 5 for an illustration of how participatory methods can be used during activities throughout each stage of research. Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... --- Journal of Participatory Research Methods Qualitative methods are not inherently participatory and quantitative tools are not always non-participatory . It is imperative that the research team consider how they engage the community as fully as possible when social norms are deeply embedded in a community, such as in the examples that we have provided, and where social change is dependent on shifting such deeply held beliefs. These tools may leverage research and program development to be integrated into larger community change. The activities can also catalyze change as part of participatory programs that can help community members to feel that they are part of the process of change. These visual tools are also a more inclusive means of promoting dialogue and discussion across knowledge and literacy levels, allowing for reciprocal interaction to better design, change, and adapt programs while also allowing room for innovation at the community level. Participatory methods can be used to support equity in research designed to consider the agency and leadership of participant communities, culturecenteredness, de-colonial approaches, and other perspectives relevant to a particular community's needs, concerns, and practices . In the examples we provided, communities are actively part of the research to develop formative program planning and implementation. --- Conclusion This paper set out to answer how visually informed participatory research tools have been used to promote SBC and how these participatory mixed-method approaches can support the development of programs, monitoring and evaluation , and assess social and behavior change for public health issues around the world. These two tools support larger research and program agendas by assessing aspects of a social-ecological network and the influence of key social reference groups and individuals for social and behavioral communication. Social network mapping and 2x2 tables support participants in developing an awareness of their social networks, the influences of key reference groups and individuals on one's own understanding of a particular health issue, as well as larger social norms and communication networks that can perpetuate maladaptive and harmful health practices. Having a visual tool allows participants to manageably envision the complexities of who is in their social network and the importance that they place on their opinions or beliefs. Other standard qualitative and ranking methods, such as a verbal interview, may not have primed the participant to think so deeply and widely about specific individuals in their social networks. Similarly, asking about attitudes and perceptions within a standard focus group or interview may be less effective at parsing out the fullness of attitudes and behavior practices compared to using the 2x2 tables, where time is taken to fully appreciate each concept and the social consequences around breaking the norm. Each tool has been field tested in various global health contexts throughout the world and may be The use of participatory tools engages the intended audience in safely exploring sensitive, embedded notions that raise their awareness and create openings toward social behavior communication change. Community involvement may also serve to increase community accountability and support the tracking of change over time. Limitations to any visual participatory methods such as we have discussed include their application to specific issues that may not be as relevant or engaging with all community members. Social network maps may conceptually differ in how researchers think to display them and how participants may conceptualize themselves within their social network. Designing the maps and pretesting them is essential to overcoming this limitation. 2x2 tables are limited in being a small-scale contingency table that accommodates such yes or no questions but is not flexible if perceptions are rooted in less distinct forms. Finally, participatory methods may be part of larger research endeavors in global public health but they cannot tell the whole story nor illustrate every aspect of such problems and efforts. Though there is data from many specific programs where these tools have been used, published research that shows their efficacy is limited. These tools are also limited to programs focusing on social networks and social behavioral communication around social norms impacting health practices and behavior. Many important health issues are less influenced by entrenched social norms that need to be addressed to see significant behavior change over time. Additionally, research to date has focused on health practices that have been of concern for decades. Not all relevant public health concerns are rooted in social norms, or are entrenched issues, and may not need such participatory interventions to consider how to untangle messages of influence. --- Recommendations Additional global health concerns that may introduce visual participatory research methods might include violence against children; issues around water, sanitation, and hygiene ; positive parenting; gender socialization; or other health and human-rights issues, such as child marriage. General public health issues that may or may not reach a global scale can also benefit from tools that engage the audience as formative research and monitoring and evaluation support social behavior communication change. More localized issues in the United States, such as adolescent substance use , and risky sexual behavior may be influenced by smaller-scale social networks. Community interventions to disrupt such behavior could benefit from a participatory approach to formative research and intervention design. The research values and methods outlined in the paper provide strong encouragement to use visual participatory methods for data collection, analysis, and interpretation. To the latter points, member-checking results with Assessing Social Norms, Health Behavior, and Change Using Visually Informed Participatory Research Tools: Social Network... --- Journal of Participatory Research Methods a community stakeholder who can gauge the accuracy of findings can build trust and support validity. As for data collection, engaging participants in the development or conceptualizations of, and then pre-testing, visual tools will improve the accuracy of the data collection process. Researchers are encouraged to consider how participatory research tools could benefit their larger public health issue and approach. These tools may be an important part of initial program development when factors such as attitudes, health behavior, and social networks are implicated. They are also an accessible and flexible method to support ongoing monitoring and evaluation for adaptive changes during programming. Participant data can be triangulated with other data and add relevance as well as perspective to large-scale public health issues as policy and practice are implemented. --- Journal of Participatory Research Methods

This paper discusses the application of social network mapping and 2x2 tables to social norms around the issues of female genital mutilation (FGM) and menstrual hygiene management (MHM). After briefly introducing the context of these issues and our work, we will introduce each tool, how to use them, and provide examples of how they were used in our work, including their advantages and limitations. Two illustrations of participatory research with young women and relevant community members to address global health concerns will be used to show how these participatory visual tools have addressed health-related social norms in low-income countries. These examples come from our work on significant women's health issues as sponsored by the United Nations under a framework that addresses women's and girls' health as part of the global Sustainable Development Goals (UNFPA/UNICEF, 2020). Small focus group discussions and evaluations were part of the framework for participant involvement in both the FGM and MHM programs. Consultation

participatory research can be used in conjunction with quantitative other qualitative and mixed methods research methods to collaboratively address priority global health issues that are greatly influenced by social norms social norms have been identified as key components of deeply held beliefs that perpetuate as well as change detrimental health practices at all levels of global health research from program development to monitoring and evaluation participatory tools can be used to honor the ethic of working with the target population incorporating their needs and engaging a community to improve healthrelated behaviors this paper shows how to use two visually based participatory tools to impact social and behavior change around female genital mutilation and menstrual hygiene management both fgm and mhm have been identified as critical to unicefs child protection and to meeting the united nations global sustainability goals we also outline how social network mapping and 2x2 tables were implemented to address complex social norms around fmg and mhm the discussion then illustrates how they have been used within research and program development more broadly these tools are valuable methods to understand and impact social and behavior change in a wide variety of public health issues global health research addresses largescale health issues worldwide often focusing on marginalized impoverished and vulnerable populations participatory research in global health provides a practical and ethical approach to working toward positive health change while respecting a communitys autonomy desire for change or intervention embedded systems of communication and social norms intervening to address social norms around an entrenched health problem has been identified as a primary driver of effective behavior and social change conversely regulatory interventions often have very little impact on changing behaviors as part of persistent cultural norms participatory approaches and methodologies serve overarching research values of working with research participants and honoring community knowledge while utilizing specific research tools and methods that both engage the community to discuss difficult and stigmatizing health issues and encourage communitycentered behavior and social change participatory approaches such as communitybased participatory research and participatory action research are increasingly recognized and encouraged in global health work by multinational donors researchers and practitioners however there is a gap in researchbased evidence that evaluates whether participatory interventions using a social norms research approach have the intended impact this paper explores two visual tools social network mapping and 2x2 tables used for participatory data collection in interventions that seek to shift social norms to facilitate change for womens health we begin with an introduction to social norms as the context in which participatory approaches and tools can be used to effect change we then outline two examples of research to discuss how social network mapping and 2x2 tables were used as part of participatory methodology in public health interventions that tackle social norms we conclude by identifying these tools limitations and challenges as well as their potential for application to other research areas this paper seeks to answer the following questions how have the visually informed participatory research tools social network mapping and 2x2 tables been used to promote social and behavior change how can these participatory mixedmethod approaches support the development of programs monitoring and evaluation and assess social and behavior change for public health issues around the world social norm theorizing social norms are the unwritten rules that guide human behavior they are what we do what we believe others do and what we believe others think we should do for their existence social norms require a reference group ie a network of people to whom we identify and compare ourselves this reference group determines norms because identifying a behavior with a specific group influences whether that behavior is considered normative within the group and in turn may predict whether a new behavior will be adopted members of a group expect are expected to follow and are motivated to follow norms because of sanctions for nonadherence and rewards for adherence finally collective norms are what people actually do ie the actual prevalence of a behavior see table 1 for these distinctions in social norms constructs change of social norms requires cognitive shifts in deeply embedded schema and scripts formed within dynamic interpersonal relationships with people who serve as primary reference groups social and behavior change communication theory states that social networks are primary mechanisms that may drive behavior change through the action of education and dialogue that counteracts prevailing ideas about a given area of concern there are many behaviorchange theories that operationalize social norms and target types of norms for purposes of this discussion social norms are the construct that we mean to change via public health interventions by using participatory methods such as social network maps and 2x2 tables the inclusion of audience participation makes these tools effective for applying to social norms change with deeply embedded cultural practices where the potential social consequences for engaging or not engaging in the practice seem dire and structural barriers seem great with global and local experts and discussion with program implementers followed by rigorous pretesting of each of the tools were all used to ensure that these methods were acceptable research and programs to impact female genital mutilation a framework was designed to provide adaptable yet standardized participatory measures of social and behavior change for female genital mutilation in ethiopia and guinea called act the framework addresses a assessing for affective and normative data about the practice c the context in which these practices occur and t tracking or monitoring of behavior change fgm is the practice of altering injuring or cutting female genitalia for nonmedical purposes and is an international public health concern affecting millions of girls and women worldwide practiced in cultures in more than 30 countries throughout africa parts of asia and the middle east fgm now exists in nearly every country due to migration it is tied to social norms of marriageability perceived purity and social acceptability of girls and women across the lifespan yet it results in trauma chronic pain severe complications with sex and childbirth and even death from infections or blood loss research and programming to impact menstrual hygiene management in india the girls adolescent and reproductive rights program addressed menstrual health and hygiene management in india unsanitary practices of mhm lead to poor hygiene infection disease shame and social ostracization of menstruating females addressing menstrual hygiene management in india is a critical area of womens health spotlighted by unicef to address gender equity and economic policy in the global south inadequate mhm leaves girls and women vulnerable to disease and is a primary driver of gender inequality and social exclusion a culture of silence has been identified as the root of poor mhm leaving young girls with poor knowledge and myths related to the care of their bodies during menstruation while infrastructure around adequate facilities for washing and disposing of menstrual products is part of the solution influencing social networks of the young girls has been found to have a greater impact on behavior change including addressing larger sexual and reproductive health issues in india methods ethics and positionality statements this research was approved by drexels irb as well as a local irb and it further followed uneg standards and ethical guidelines funding and programming for this research were provided by unicef researchers first gained oral consent from participants consent forms were translated into local dialects though verbal consent was given as customary with populations where literacy may be low and local dialects may not be translated postcards were left with participants to provide research information and followup contact information standard protocols were followed regarding global health research and consent ethics and respect for personal autonomy the research reflected in this paper was designed by dr sood through the dornsife school of public health in partnership with unicef local researchers and practitioners collected cleaned and transcribed the data jr haileselasse is a doctoral research fellow working with dr sood at the dornsife schools community health and prevention while the other two authors are researchers at drexel university in creative arts therapies college of nursing and health professions both dr sood and dr kaimal are of indian descent with contemporary ties to that country while haileselasse and k snyder are white americans all four women share a worldview that includes the promotion of womens health and human rights respect for the agency of participants in research a pragmatic focus on working toward positive change in peoples lives through research program implementation evaluation and monitoring and communityengaged learning whenever possible our case study examples are from research conducted by dr soods team with community teams in the field in each location it is our hope as a crossdisciplinary team to share the value of these participatory visual tools and communityengaged methodology social network mapping social network mapping is a visual technique that illustrates how community members are connected and how information flows through social networks participants draw or fill in graphics or maps that show and list who is in their social network in relation to themselves and others this illustrates where and how information is shared and can even be used to explore types of information as such social network mapping is a great way to identify participants key sources of information as well as barriers to communication this tool is based on social network theory which explains decisionmaking as largely influenced by group relationships norms and expectations when a participant completes a map not only does it provide data on the nature of their social network but also offers insight into how they see or perceive that network and their role within it as a transformative activity snm can have a therapeutic effect on participants where they visualize themselves perhaps for the first time as part of a social network and within the context of the health issue being discussed with this information researchers can assess the influence of structural and relational dynamics on health status the maps themselves can take many forms for example they may show concentric circles with each one representing different layers of society participants can also draw maps with themselves in the middle assessing social norms health behavior and change using visually informed participatory research tools social network and their contacts connected by lines like a web the size of the map components can be used to illustrate the importance of that person within a social network with larger circles lines or arrows indicating greater importance no matter the format the key is to have maps that illustrate relational ties each format may have its own potential benefits for data collection illustration and transformation journal of participatory research methods this preliminary exercise with the participant helps show who within the social network influences their beliefs and behaviors by identifying such network groups within an ecological model the participant is primed to consider the way that they have come to view a social norm practice or expectation participants can then visually map individuals whom they consider as providing accurate information as well as people who need to be included in future programming then the communitybased program efforts focus on reaching the individuals identified as important by the participants ongoing programs then target such beliefs and support social network changes for example primary caregivers may be brought in for dialogue or other activities to engage them in considering alternatives to the detrimental practice in later research stages diagrams might be reexamined to monitor the impact of community interventions including quantification of changes in patterns of interpersonal communication among program participants this provides programmatic visual proof of any intended expanding networks that have effectively displaced the culture of silence around these issues when it comes to program evaluations maps can be specific to show whom participants speak with about the program by conducting another snm later in the program participants may develop personal insight into changing views about assessing social norms health behavior and change using visually informed participatory research tools social network journal of participatory research methods the detrimental practices and new health practices as well as continued social norms and networks that either support positive change or inhibit it this information equips field experts to quickly address the community in new ways to bring about desired change developing programs that fully support all community members beyond research and evaluation social network maps encourage participant and community dialogue and as seen in later case examples helped the girls who participated in our study to identify whom their communitybased programs needed to work with and how allies are leveraged for promoting desired behaviors while individuals who create barriers are assessed for additional interventions to promote behavioral change how to create a social network map the activity of mapping begins with a visual template as seen in figure 3 that is either printed and handed to the participant or drawn during the process as participants speak the mapping process translates well to lowtechnology environments and could be done on blackboards with photos taken of the process and final product facetoface settings can use paper flip charts or other simple means to create maps webbased sharable graphic applications can be used in virtual settings in any setting and use of material providing an introductory example to participants is a good means of building participant confidence as well as maintaining the continuity and integrity of the data participants are asked to identify the people in their lives and their places within each of the categories of social influence along with provided examples as they list individuals within each category participants are asked to identify what types of support they have received from each person researchers facilitators should make notes about these relationships including relevant themes such as allyship barriers and any foreseen potential barriers to positive change with the intervention the participant is then asked to rank the people that they have listed in order of support and influence other probes that can be part of the process include asking a participant to consider their level of investment in each relationship in the context of the targeted health issue filling in this social network map illustrates social and informational concepts about the health concern and environmental influences this will be important for data interpretation and analysis to assess the social norms relevant to the health concern one advantage of social network mapping is that resulting data may be interpreted relatively quickly and in the field data are first divided based on participant characteristics such as gender age socioeconomic status and either change of time or intervention versus comparison if used at the m e phase frequency counts are tallied across all observations and different social categories noting the most common level of social influence this can include counting allies and barriers to behavioral change as relevant to findings finally thematic analysis helps to pull out the most common themes and ideas that explain how individuals in this group perceive their social network influence in relation to the health concern reviewing the data and relevant themes provides insight into the importance of engaging different reference groups in the community aggregate data reveals the most important community members influence over a particular health behavior to target programs and interventions responses to any probing questions used may also suggest how communication flows with the various reference group members 2x2 tables the visual participatory 2x2 tables method aids researchers participants and communities in assessing the existence persistence and change in social norms over time though they can be simple visual depictions with limited text and four boxes conceptually they are complex and require consistent highquality training for researchersfacilitators pretesting is strongly recommended the facilitator of this activity needs to have a clear understanding of the types of social norms that it measures the exercise must be understood as designed to measure three types of social norms as discussed in the introduction and summarized here to emphasize the importance of training facilitators the 2x2 tables measure an individuals behaviors or what we do descriptive norms as what we think others do and injunctive norms as what we think others expect or believe that we should do this tool provides rich mixed methods data for analysis that can be used to design programs measure norms and behaviors at baseline and endline and measure change as part of monitoring and evaluating a program for efficacy resulting data includes frequencies and prevalence of behaviors and norms as well as qualitative data shared in discussions of why participants provide their answers and links to social rewards and punishments that are related to social norms for these reasons it is helpful to collect observational data and assessing social norms health behavior and change using visually informed participatory research tools social network notes while the activity is underway importantly the data allows programmers to understand if an issue is normative in nature generating the data allows participants to visualize differences between their approval societal approval social expectations and behaviors if facilitated this leads to dialogue on why and how harmful practices persist due to normative and injunctive expectations this data can also be used to revise the activity after pretesting or to identify appropriate outcomes for a program journal of participatory research methods how to use a 2x2 table to conduct the exercise clear definitions and examples of the target behavior should be provided allowing participants to ask any questions or clarify what they are being asked to consider when filling in a table participants are first asked to identify in their opinion what proportion of community members engage in this behavior this helps indicate their perceptions about the prevalence of a given behavior then they work through two 2x2 tables concerning a behavior the first table measures attitudes by asking participants if they approve or disapprove of the behavior and whether they think others approve or disapprove of the behavior the second table measures injunctive and descriptive norms by asking whether others in their community practice the behavior and expect them to do so as well the others in this case are members of the participants social network comprised of individuals whose opinion matters to the participant as established by creating the socialecological network map participants are also asked to provide the associated rewards and punishments which allows assessment of outcome expectancies any behavior can be measured using 2x2 tables for social norms it may be best to include 2x2 tables for social norms as part of a larger study so assessing social norms health behavior and change using visually informed participatory research tools social network to complete the two tables participants need to respond to two separate questions with yesno answers the first questions are whether they approve of a given behavior and to what extent they think others approve of a given behavior have them place a mark in one of the four quadrants based on their answers if they answered yes to both questions put a mark in the top left quadrant if they answered yes to the first question and no to the second question put a mark in the top right quadrant if they answered no to the first question and yes to the second question put a mark in the bottom left quadrant if they answered no to both questions put a mark in the bottom right quadrant its important for the researcher to remind participants to respond only with yes or no answers emphasize while you understand that different types of people do and think different things for this activity you want them to select either yes or no based on what they think more people do and think journal of participatory research methods assessing social norms health behavior and change using visually informed participatory research tools social network journal of participatory research methods next have participants fill out the second 2x2 table for behavior use the same instructions as before however instead of approval ask if others practice a given behavior and if they expect the participant to practice the behavior have them fill out figure 4 in the same way as they did the previous table if they answered yes to both questions above put a mark in the top left quadrant if they answered yes to the first question and no to the second question put a mark in the top right quadrant if they answered no to the first question and yes to the second question put a mark in the bottom left quadrant if they answered no to both questions put a mark in the bottom right quadrant then when helpful to the research and appropriate to the participant ask them to reflect on the reasons why they are in a given quadrant to elucidate more context depending on the behavior in question the first question on the second table can ask participants about their own behavior and the behavior of others the table can then be followed by the question do others expect you to participate in this behavior to ensure participants understand the activity one can use several different representations for example ask each question and have them write the answers on a piece of paper then read their responses aloud or pass them along to the interviewer for nonor lowliterate populations one can use different colored stickers or sticky notes to display their answers once the responses are recorded the interviewer asks a variety of probing questions depending on the behavior for example why they and or others fit into the selected quadrants discrepancies andor concurrence between approval and behavior and how individualand societallevel change can be achieved to encourage participants to recognize and challenge social norms to analyze results from the 2x2 tables data are pulled and divided into groups based on participant characteristics such as age socioeconomic status etc frequency counts are made for each quadrant in each of the two 2x2 tables to look at both perceptions of the behavior and practices of the behavior for self and others the frequencies for each quadrant help to understand how the participants feel in relation to injunctive and descriptive social norms beliefs about the prevalence of behavior practices beliefs about what others expect us to do and social rewards or sanctions that maintain the behavior in question some quantitative analysis may be conducted to determine any significant differences by quadrant between respondent groups as well as within quadrants on approvalattitude and behavior tables thematic analysis helps to find common responses among the participants from the probing questions analyses may focus on statements related to rewards and sanctions for the continuation of the behavior rewards and sanctions for abandonment of the behavior and other ways that the participant perceives the social expectations for the behavior interpretation of the 2x2 tables consists of mapping frequencies of responses within the quadrants when responses fall more heavily in the extreme quadrants social norms are indicated as driving the behavior whereas when responses fall within the top right or bottom left quadrants participants are assumed to either be abiding by a normative behavior that they would prefer not to practice or that they are challenging a widely accepted normative practice when using information gleaned from these tables it is important to keep the context of the intended behavior change in mind an intervention might promote the uptake of a new behavior such as using disposable menstrual pads or it might promote abandoning an existing behavior such as fgm when the data predominantly fall in the top left quadrant this suggests that knowledge and awareness strategies are suited for intervention similarly when responses fall predominantly in the bottom right quadrant programs that ensure the maintenance of positive behaviors and support abandoning negative behaviors are indicated since the behavior is normative additional program models may emerge out of the data looking at personal and environmental reasons rewards and punishments behind behaviors that may need increased communication interventions at different levels resultsdiscussion as part of act participatory action tools are utilized to engage the target audiences in communities and to monitor program effectiveness to make changes in real time based on participation these activities allow participants to reflect and discuss behaviors and norms and explore the reasons why these norms exist especially when followup dialogue is facilitated as part of the activity social network maps and 2x2 tables were designed to be used together with the latter exercise measuring norms by building off the former exercise that visualizes realms of social influence however these tools can be used separately or in conjunction with other relevant visual tools participatory activities and a range of quantitative and qualitative methods when used together it can be helpful to have completed maps visible as visual prompts to assessing social norms health behavior and change using visually informed participatory research tools social network participants as they conduct the 2x2 table activity for a stepbystep training and implementation guide for these visual tools access the following link actframeworkpackagemeasuringsocialnormsaroundfemalegenitalmutilation journal of participatory research methods in ethiopia the use of the 2x2 tables helped researchers and frontline community program workers to parse participants understanding of where their beliefs and practices regarding fgm come from to loosen the grip of such beliefs research happened through programs that were created by local community groups to address education and opportunities for community members specifically girls at risk for fgm outcome expectancies play a substantial role in the maintenance of fgm practice and where rewards are seemingly low sanctions might be perceived as high this provided the program with crucial information on potential messaging to address sanctions while promoting rewards such discrepancies between the approval of a behavior and the practice of that behavior suggest that a norm influences the ongoing behavior with research on fgm these two tools provided researchers with data to support the triangulation of all data collected specifically around indicators of injunctive and descriptive social norms in india garima targeted adolescent girls who are most impacted by the oppressive beliefs and practices related to menstruation their mothers were included in the primary audience along with their fathers frontline health workers and schoolteachers in the second tier the social network map was used to help young girls express who influences them and their decisionmaking attitudes and practices development of these network maps aided researchers in defining relevant reference groups across social domains from family to friends and peers and the larger community to create programming that will target all domains in relevant ways and make realtime changes to ongoing programs where new messages and critical dialogue occur assessing social norms health behavior and change using visually informed participatory research tools social network the visual participatory tools highlighted here were used in two ways for this study first during the behavior monitoring assessment conducted in the three districts in uttar pradesh the tools highlighted three barriers to effective change around mhm 1 feelings of impurity on behalf of the young girls 2 absence of functional sanitation facilities or privacy for changing or washing and 3 inadequate disposal facilities identification of these barriers established a relationship between menstruation and school absenteeism for young girls which equates to gender inequities and often leads to girls dropping out of school journal of participatory research methods second an endline evaluation was conducted to assess the relevance effectiveness efficiency impact and sustainability of the garima program separate from the initial baseline assessment focus groups and interviews with key informants utilized these same participatory tools to reveal beliefs attitudes and restrictions coming from social norms perspectives and allow openness of communication across stakeholders such as mothers daughters and peers in comparison to nonintervention village adolescent girls girls who have participated in garima programs were better able to discuss a wider variety of aspects of menstruation and hygiene management had more knowledge about puberty and reproductive body parts and had more positive attitudes about gender using participatory methods researchers work closely with program partners throughout the program cycle to meet the community in their program settings reduce disruptions and improve research compliance qualitative and participatory practices complement larger quantitative data gathering while providing the nuance of participant experience measure impact in ways that may not be clear through quantitative data and provide a means for evaluating necessary program changes it is essential to the research design process that the type and level of participation are determined as to the best interests of the community and the research see figure 5 for an illustration of how participatory methods can be used during activities throughout each stage of research assessing social norms health behavior and change using visually informed participatory research tools social network journal of participatory research methods qualitative methods are not inherently participatory and quantitative tools are not always nonparticipatory it is imperative that the research team consider how they engage the community as fully as possible when social norms are deeply embedded in a community such as in the examples that we have provided and where social change is dependent on shifting such deeply held beliefs these tools may leverage research and program development to be integrated into larger community change the activities can also catalyze change as part of participatory programs that can help community members to feel that they are part of the process of change these visual tools are also a more inclusive means of promoting dialogue and discussion across knowledge and literacy levels allowing for reciprocal interaction to better design change and adapt programs while also allowing room for innovation at the community level participatory methods can be used to support equity in research designed to consider the agency and leadership of participant communities culturecenteredness decolonial approaches and other perspectives relevant to a particular communitys needs concerns and practices in the examples we provided communities are actively part of the research to develop formative program planning and implementation conclusion this paper set out to answer how visually informed participatory research tools have been used to promote sbc and how these participatory mixedmethod approaches can support the development of programs monitoring and evaluation and assess social and behavior change for public health issues around the world these two tools support larger research and program agendas by assessing aspects of a socialecological network and the influence of key social reference groups and individuals for social and behavioral communication social network mapping and 2x2 tables support participants in developing an awareness of their social networks the influences of key reference groups and individuals on ones own understanding of a particular health issue as well as larger social norms and communication networks that can perpetuate maladaptive and harmful health practices having a visual tool allows participants to manageably envision the complexities of who is in their social network and the importance that they place on their opinions or beliefs other standard qualitative and ranking methods such as a verbal interview may not have primed the participant to think so deeply and widely about specific individuals in their social networks similarly asking about attitudes and perceptions within a standard focus group or interview may be less effective at parsing out the fullness of attitudes and behavior practices compared to using the 2x2 tables where time is taken to fully appreciate each concept and the social consequences around breaking the norm each tool has been field tested in various global health contexts throughout the world and may be the use of participatory tools engages the intended audience in safely exploring sensitive embedded notions that raise their awareness and create openings toward social behavior communication change community involvement may also serve to increase community accountability and support the tracking of change over time limitations to any visual participatory methods such as we have discussed include their application to specific issues that may not be as relevant or engaging with all community members social network maps may conceptually differ in how researchers think to display them and how participants may conceptualize themselves within their social network designing the maps and pretesting them is essential to overcoming this limitation 2x2 tables are limited in being a smallscale contingency table that accommodates such yes or no questions but is not flexible if perceptions are rooted in less distinct forms finally participatory methods may be part of larger research endeavors in global public health but they cannot tell the whole story nor illustrate every aspect of such problems and efforts though there is data from many specific programs where these tools have been used published research that shows their efficacy is limited these tools are also limited to programs focusing on social networks and social behavioral communication around social norms impacting health practices and behavior many important health issues are less influenced by entrenched social norms that need to be addressed to see significant behavior change over time additionally research to date has focused on health practices that have been of concern for decades not all relevant public health concerns are rooted in social norms or are entrenched issues and may not need such participatory interventions to consider how to untangle messages of influence recommendations additional global health concerns that may introduce visual participatory research methods might include violence against children issues around water sanitation and hygiene positive parenting gender socialization or other health and humanrights issues such as child marriage general public health issues that may or may not reach a global scale can also benefit from tools that engage the audience as formative research and monitoring and evaluation support social behavior communication change more localized issues in the united states such as adolescent substance use and risky sexual behavior may be influenced by smallerscale social networks community interventions to disrupt such behavior could benefit from a participatory approach to formative research and intervention design the research values and methods outlined in the paper provide strong encouragement to use visual participatory methods for data collection analysis and interpretation to the latter points memberchecking results with assessing social norms health behavior and change using visually informed participatory research tools social network journal of participatory research methods a community stakeholder who can gauge the accuracy of findings can build trust and support validity as for data collection engaging participants in the development or conceptualizations of and then pretesting visual tools will improve the accuracy of the data collection process researchers are encouraged to consider how participatory research tools could benefit their larger public health issue and approach these tools may be an important part of initial program development when factors such as attitudes health behavior and social networks are implicated they are also an accessible and flexible method to support ongoing monitoring and evaluation for adaptive changes during programming participant data can be triangulated with other data and add relevance as well as perspective to largescale public health issues as policy and practice are implemented journal of participatory research methods

this paper discusses the application of social network mapping and 2x2 tables to social norms around the issues of female genital mutilation fgm and menstrual hygiene management mhm after briefly introducing the context of these issues and our work we will introduce each tool how to use them and provide examples of how they were used in our work including their advantages and limitations two illustrations of participatory research with young women and relevant community members to address global health concerns will be used to show how these participatory visual tools have addressed healthrelated social norms in lowincome countries these examples come from our work on significant womens health issues as sponsored by the united nations under a framework that addresses womens and girls health as part of the global sustainable development goals unfpaunicef 2020 small focus group discussions and evaluations were part of the framework for participant involvement in both the fgm and mhm programs consultation

"Your democratically elected governments continuously perpetrate atrocities against my people all over the world. And your support of them makes you directly responsible, just as I am directly responsible for protecting and avenging my Muslim brothers and sisters." An excerpt from the videotape of Mohammad Sidique Khan following the London bombings in 2005 . Osama bin Laden and Mohammad Sidique Khan, known terrorists responsible for two major terrorist attacks in the West, expressed very similar reasons for carrying out their respective attacks. Despite the fact that they grew up in different cultural contexts, they both mention the atrocities faced by their fellow Muslims elsewhere, and the need to avenge the plight of Muslims who have suffered at the hands of Western interventions. This suggests that, across different cultural contexts, the same underlying social psychological processes might explain why some individuals are compelled to commit violent extremist acts to defend Muslims. Scholars from various disciplines have proposed various causes of Islamist extremism , pointing to Islamic ideology , political strategy , social identification processes , threat perceptions , and mental illness . However, only a fraction of the academic literature on terrorism is based on empirical data . In a nascent line of social psychological research, some have applied a social identity perspective on collective action and group-based emotions to explain Islamist extremism . According to these perspectives, Islamist extremism represents one example of general group identification processes. Even if such general explanations are plausible, there is still a need to examine these processes in different contexts where Islamist extremism is prevalent. One could ask, for instance, whether the same identification processes that explain extremism among Muslim minorities in Western Europe can shed light on extremist violence in the Middle East. Such questions have not been examined in the literature to date. Many scholars have argued that Islamist extremism is the result of Western-led military interventions and foreign policy in Muslimmajority countries . However, even in the absence of direct personal experience of Western-led occupation, perpetrators of Islamist extremist violence often allude to a sense of perceived injustice against Muslims globally . The feeling of injustice becomes particularly strong since many Muslims have come to see themselves as a unified community cutting across national borders, and that what matters is the experience of the group and not the experience of specific individuals . It is therefore apparent that Muslim identity plays a key role in Islamist extremism, uniting Muslims through a perception of shared or collective suffering regardless of geographical location or personal experience. Importantly, this suggests that individual engagement in Islamist extremism might be explained by a similar model in the West and in Muslimmajority countries. The current paper aims to empirically test this notion. Islamist extremism, broadly defined, encompasses behaviours, ideas, intentions, and attitudes that are in opposition to fundamental values and norms of society, including democracy and the rule of law . We define Western military interventions as encompassing Western wars, sanctions, drone attacks, occupations, targeted killing operation campaigns, and crossborder raids. --- Theoretical Background Whilst few scholars have specifically outlined theoretical models that illustrate the social psychological antecedents of Islamist extremism per se, a review of social identity theory and subsequent theorizing and research on collective action and relative deprivation is consistent with the notion that group identification and negative group-based emotions underlie willingness to engage in collective action . According to SIT , people think, feel, and act, in part due to the circumstances of the groups with which they identify. Members of disadvantaged groups who perceive this disadvantage as illegitimate and unjust are more inclined to identify with their group and engage in collective action in an attempt to rectify the perceived inequality . Thus, according to SIT, identification with a disadvantaged group is a predictor of collective action . Van Zomeren et al. have conducted a comprehensive meta-analysis on the effects of identity, perceived injustice, and efficacy on collective action. Of particular relevance to the present study, Van Zomeren et al. found that the association between disadvantaged group identification and intention to engage in collective action is partially mediated by subjectively experienced group-based injustice. Van Zomeren's meta-analysis also laid the foundation for the development of the social identity model of collective action , an integrative theoretical model of collective action which proposes that social identity predicts collective action directly, as well as indirectly via groupbased injustice and group-based efficacy. Moreover, individuals who more strongly identify with their group are more inclined to think, feel, and act for their group when their group is disadvantaged . Group identification predicts collective action directly , but it also predicts other motivations for collective action, such as group-based anger and feelings of injustice . Furthermore, such processes are more likely when differences between groups become increasingly salient . In other words, the more people talk about differences between Muslims and Westerners, and the more these groups appear to behave differently, we would expect stronger cognitive, emotional, and behavioural reactions associated with such group identities. Recently, the Social Identity, Relative Deprivation, collective Efficacy model of social change has combined the social identity, relative deprivation, and collective efficacy perspectives to predict participation in protest action . According to the SIRDE model, strong group identification in combination with feelings of deprivation, anger, and lack of collective efficacy is a stronger predictor of collective protests . In sum, the reviewed models are applicable to any social identity when ingroup identification is seen to be important to people. Nevertheless, this line of research has mostly been studied in the context of Western countries mainly focusing on protest actions . However, recent work has successfully applied insights from research on relative deprivation, social identity, and intergroup emotion to explain normative and nonnormative collective action among Muslim minority groups . In the past two decades, Muslim identity has become increasingly salient, particularly when scholars as well as prominent politicians such as Donald Trump emphasize a "clash of civilizations" between Muslims and non-Muslims . In part due to this "clash of civilizations" rhetoric, Muslims are subject to discrimination globally , with anti-Muslim activities and violence against Muslims intensifying in the last decade , leading to feelings of anger and deprivation. Consequently, in the midst of growing tensions between Muslims and non-Muslims, Muslim identification is central to Muslims' sense of self . In line with this reasoning, Obaidi, Bergh, et al. examined both violent as well as nonviolent intentions among Muslims living in Denmark. Specifically, based on insights from social categorization and intergroup emotions theory as well as collective action literature, Obaidi, Bergh, et al. proposed and tested a model with Muslim identification and perceived injustice of Western foreign policy and interventions as independent variables, violent and nonviolent behavioural intentions as dependent variables, and group-based anger as a mediator. Consistent with this model, Muslim identification, group-based anger, and perceived injustice were all positively associated with violent intentions to defend Islam and other Muslims. However, Obaidi, Bergh, et al. Some research suggests that different exposure to violence affects both prosocial and antisocial behaviours at a local level . In contrast, we examined global effects of experiences and threat of missile strikes, power outages, disrupted transportations, etc., as a result of a foreign power's military actions among Muslims in Afghanistan and Pakistan, compared to not experiencing such conditions . Here, we explored the possibility that individual engagement in Islamist extremism might have a common identity-based explanatory model in the West and in Muslim-majority countries. Muslims may come to identify with a global Muslim community due to perceptions of different threats that target Muslims . Hence, identification with a global Muslim community can be seen as a coping strategy to mitigate the impacts of such experiences. According to SIT, ethnic or racial discrimination may lead individuals to seek a sense of belonging to and acceptance in their in-group communities . Indeed, previous research shows that some people strongly identify with their ingroup in the face of threat and discrimination , and that strong ingroup identification, in turn, mitigates the aversive effect of difficult psychological states . Further, recent studies show that the experience of intergroup conflict and war-related violence fosters more group participation and increases people's engagement with their religious group , which may help people cope with aversive psychological effects . However, when group identification is politicized and coupled with aversive experiences, such as discrimination and injustice, it may lead to collective action on behalf of one's group . In particular, a Muslim identity based on collective suffering could explain why individuals who have committed extremist violence often express anger and feelings of injustice over Western-led military interventions faced by their fellow Muslimsregardless if they live in countries targeted by such interventions or not. Nevertheless, there is still a need to directly examine whether the social psychological underpinnings of political violence are similar among Muslims living in Muslim-majority countries and Muslims living in the West. Similarity across these contexts would imply that group identification processes and the associations between the psychological variables do indeed cut across borders, contexts, and varying degrees of personal experience of war and occupation, hence supporting the underlying role of a Muslim identity in predicting Islamist extremism . --- The Present Research The aim of this paper was to examine if predictors of Islamist extremism in the West reappear and are similarly interrelated in Muslim-majority countries with prolonged and ongoing experience of Western-led military interventions. We hypothesized that the individual difference variables that predict violent behavioural intentions would be the same across countries, regardless if the country was the target of military actions by Western powers or not. To the best of our knowledge, no studies to date have directly assessed the cross-cultural generalizability of a social psychological model of Islamist extremism by directly and empirically comparing models of extremism in Western countries and in Muslim-majority countries that are subject to Western military interventions. Thus, we sampled Muslims from two such Muslim-majority countries-Pakistan and Afghanistan-where extremism is also prevalent . We also collected data from Pakistani Muslims living in 20 different Western countries , for comparison with our participants living in Muslim countries. We tested our hypotheses in a path analytic framework where we compared these four samples. Across all samples, we examined whether Muslim group identification and injustice appraisals of Western foreign policy would predict intentions to commit violence on behalf of Muslims, through group-based anger. --- Rationale for Focusing on Pakistan and Afghanistan In the following, we first describe the reasons why we focus on Pakistan and Afghanistan, and then we describe each sample. In the first three samples, we focused on Muslims of Pakistani origin living in Pakistan , as well as sampling Pakistani Muslims living in 20 different Western countries . Pakistan is currently among the countries with the greatest prevalence of terrorist attacks , which appear to occur in response to Western interventions . Importantly, terrorism in Pakistan has been known to spread not only to neighboring countries, such as India and Afghanistan, but globally as well, with a number of terrorist attacks occurring in the West having ties to extremist groups in Pakistan . Furthermore, in a global armed conflict against Al-Qa'ida, the Pakistani Taliban, and in the context of the post-9/11 war on terror, Pakistan has been increasingly the target of airstrikes, occasional Special Forces attacks, cross-border raids, targeted killings, and drone strikes by the US resulting in numerous civilian casualties . The numerous civilian casualties create anger and anti-Western resentment, providing a breeding ground for terrorist recruitment and incitement of Islamist extremism . Thus, if Islamist extremism results from experiences of living in a country consistently targeted by Western military actions, then Pakistan would be an ideal country to study these effects. For comparison, we explored whether the same model might also apply to Pakistanis who have moved to Western countries . For Study 2, we turned to Afghanistan, a country being targeted by extensive interventions from Western powers. Afghanistan was invaded by the US and their allies following the terrorist attacks of 9/11. As of January 2015, the Watson Institute of Brown University estimated that more than 26,000 civilian Afghans have been killed, and nearly 100,000 people have been injured and maimed since the 2001 occupation of the country. In total, the U.S.-led war has resulted in 92,000 casualties in all categories of direct war violence . Further, the war and occupation has exacerbated the effects of poverty, malnutrition, poor sanitation, and lack of access to health care . Moreover, the country is a major target of U.S. airstrikes, resulting in a large number of civilian casualties. For instance, documents show that during the course of a 5-month targeted killing operation campaign, nearly 9 out of 10 people who died in airstrikes were not the U.S. military's direct targets . Furthermore, in part due to the ongoing U.S. war against terrorism, terrorist attacks are common in Afghanistan, with the country ranking second as the country with the most terrorist attacks in 2017 . --- Study 1 --- Sample 1a Participants and procedure. Study 1a and the subsequent studies were approved by the Institutional Review Board of the primary affiliation of the first and second authors. Participants were asked to take part in a study investigating social and political issues faced by their respective societies. The first page of the survey was an informed consent form; participants needed to give their consent in order to proceed. Although we had planned to exclude any non-Muslim participants, all participants identified as Muslims. Since we had no other exclusion criterion, no participants were excluded from our study. In this sample, a total of 425 Pakistani participants living in Pakistan were recruited from universities in Islamabad. The study was conducted in 2017 and it was a paper-and-pencil study. Data collection took roughly three months to complete. Both private and public sector universities were selected in an effort to obtain a diverse pool of participants, particularly with regard to socioeconomic background. Moreover, students were selected from these universities because they get a fairly equal representation from various socioeconomic and provincial backgrounds. All students volunteered to participate in the study. Of the total sample, 5.4% of participants indicated that they were upper class, 72.2% upper middle class, 18.3% lower middle class, and 4.0% working class. 1 All participants were born in Pakistan. --- Sample 1b Participants and procedure. Study 1a was conducted in 2018 among students from both private and public sector universities. Data collection took roughly three months to complete. The Higher Education Commission of Pakistan have raised concerns about the recent observation that Pakistani students from private universities hold more moderate attitudes toward extremism compared to students from public universities . Therefore, in Study 1b we only targeted students from public universities 2 in Karachi. A total of 402 participants were approached directly by four research assistants in two major public universities. All participants were born in Pakistan and identified as Muslims. A combination of convenience and snowball sampling was used to recruit the participants. Of the total sample, 13.2% of participants indicated that they were upper class, 77.1% upper middle class, 8.2% middle class, and 1.0% lower middle class. 3 --- Sample 1c Participants and procedure. Data for Sample 1c were collected in 2017 among Pakistani Muslims living in 20 different Western countries . Data collection took roughly three months to complete. The sample comprised 366 Muslims living in the United Kingdom , the United States , Canada , Germany , Norway , France , Australia , Sweden , and Switzerland . For more details, see Table S3 in the online supplemental material. A combination of convenience and snowball sampling was used to recruit the participants. Specifically, participants were recruited by four university students and three research assistants both directly and via various Facebook pages and other portals for Pakistani immigrants living abroad. All participants identified as Muslims. Of the total sample, 18% of participants indicated that they were upper middle class, 67.6% middle class, 12.6% lower middle class, and 1.9% working class. 4 --- Study 2 --- Participants and Procedure Study 2 was conducted in 2018 among Afghans in Kabul. It was an online study using a convenience sample from Facebook. We recruited 127 Afghans , and data collection took approximately three months. All of our participants were born in Afghanistan and identified as Muslims. Of the total sample, 15.7% of participants indicated that they were upper class, 25.2% upper middle class, 29.9% middle class, 18.9% lower middle class, and 7.1% working class. 5 --- Method Power rationale. We used a multigroup analysis to examine whether the path model is similar across all samples. A question then was how much the samples might vary before rejecting the notion of a common model. Thus, we estimated the power for detecting overall differences in the model raising the RMSEA to .05, a conventional cut-off for "close fit" . In addition, we ran a simulation to examine the power for detecting sample differences in particular coefficients. Here we used results from Obaidi, Bergh, et al. as population values, except that we set one path to zero in the smallest sample . The power to detect such a difference was .93. Assuming a smaller difference, 0.07 versus 0.22, the power would be .68 . Measures. All items were answered on 7-point Likert scales . In Afghanistan, the survey was administered in Dari. All items were translated into Dari and subsequently back-translated into English. Among Pakistanis living in Pakistan and in the West, the surveys were either conducted in Urdu or English. For the Urdu survey, all items were translated into Urdu and subsequently backtranslated into English. Muslim identification. Four items were used to measure participants' Muslim identification with the exception of Study 2, in which Item 4 was reverse-coded . Perceived injustice. Five items from Obaidi and colleagues were used to measure participants' perceived injustice . Group-based anger. Three items from Obaidi and colleagues were used to measure participants' groupbased anger , with the exception of Study 2, in which Item 3 was reversecoded . --- Violent behavioural intentions. Violent behavioural intentions were assessed using two items . --- Results Variable descriptive statistics and correlations for Samples 1a, 1b, 1c, and Study 2 can be found in Table 1. --- Multigroup Path Analyses To address the objectives of this paper, we conducted a multigroup path analysis, comparing two samples of Muslim Pakistanis living in Pakistan, Muslim Afghans living in Afghanistan, and Muslim Pakistanis living in Western societies. Multigroup structural equation modelling is a standard method to examine if the relation between a set of variables is similar across different samples . Differences across samples were evaluated by constraining parameters as equal across samples, which could be compared to a model without such constraints. In our theoretical model, Muslim identification and perceived injustice were independent variables, violent intentions the dependent variable, and group-based anger was positioned as a mediator. Across all the samples, the models were estimated using robust maximum likelihood in Mplus Version 7 in order to account for skewed variables. Full information maximum likelihood is used by default in Mplus to handle missing data . We first estimated a model where all paths were constrained to equality across the groups . In other words, the model tests the assumption that the relations between the variables are the same in Pakistan, Afghanistan, and Western societies, net of random variability. The constrained model fit the empirical data reasonably well; scaled χ 2 = 47.12, p < .001, CFI = .97, RMSEA = .07, 90% CI [0.05, 0.09], SRMR = .08. We also inspected modification indices for individual paths that might differ across the four samples. The fit improved further when we released the constraint for one path in the first sample from Pakistan -from perceived injustice to violent intentions, χ 2 = 30.76, p = .02, CFI = .99, RMSEA = .05, 90% CI [0.02, 0.08], SRMR = .07. Additional modifications were associated with small changes in model fit , compared to guidelines considering ΔRMSEA > .015 and ΔCFI > .01 substantial enough to disconfirm assumptions of invariance across groups . Overall, this indicates that the relationships between the variables were similar across all four samples, with one exception being the first sample obtained in Pakistan . To illustrate the minor variations in the path coefficients overall, we present standardized coefficients in each sample in Figure 1. We further examined the indirect effects using bootstrapping with 5,000 random resamples in the model with all coefficients being held equal across samples . This analysis was based on regular maximum likelihood estimation. Both Muslim identification and perceived injustice had an indirect positive effect on violent intentions via group-based anger. To test whether these findings were robust to the introduction of demographic variables, we ran the same model controlling for the effects of age, gender, and socioeconomic status. All paths that were significant without these control variables remained as strong in this analysis . Overall, the results of Samples 1a, 1b, and Study 2 among Muslims living in Muslim-majority countries , and Sample 1c among Muslims living in 20 different Western countries indicate that the social psychological predictors of Islamic extremism in the West are similarly interrelated in Muslim-majority countries that have been the direct and prolonged target of Western military interventions. --- General Discussion Across four studies, we assessed the generalizability of a social psychological model of Islamist extremism. We directly and empirically compared the results obtained from Muslim-majority countries with prolonged and ongoing exposure to Western military and foreign policy to results obtained from Muslims in the West . In particular, we examined whether Muslim group identification and injustice appraisals of Western military and foreign interventions would predict intentions to commit violence on behalf of Muslims, through group-based anger. Results of the multigroup path analyses provide evidence that the social psychological predictors of Islamist extremism generalized across the different contexts, with one minor exception for sample 1a. To our knowledge, the present research is among the first to empirically examine social identity predictors of violent intentions among Muslims living in Muslim-majority countries. Importantly, the present research is also among the first to specifically examine the generalizability of a social psychological model of Islamist extremism by directly examining whether the relationships between the variables are consistent across Muslim-majority and Muslim-minority samples with differing exposure to Western-led wars and occupation. Despite the differences in exposure to Western-led foreign policies and military interventions, and different political landscapes and cultural contexts, we obtained similar results across all our studies. Results from both Muslimmajority countries and Western Muslims were consistent with a previous study conducted in the West . This provides further empirical evidence for the role of a Muslim identity as an underlying factor in radicalization, and the converging validity of our results. Identification with a disadvantaged group is a key predictor of collective action . In the context of the present studies, identifying with a disadvantaged group did not directly predict nonnormative collective action across all four studies, but it did so indirectly through injustice appraisal and group-based anger. Importantly, this finding converges with previous findings and theorizing about how social identity relates to collective action more generally . Moreover, our findings suggest that merely identifying with Muslims does not lead directly to violent behaviour, which is consistent with the general observation that a relatively small minority of Muslims engage in violent actions to defend their fellow Muslims . Thus, our findings provide some evidence to refute the popular belief in the West that Islam as a religion is inherently violent and that there is a direct link between being Muslim and extremism . Our findings that group-based anger directly predicted violent intentions across all four studies is worth noting since they provide further evidence for the role of anger in predicting nonnormative collective action despite other recent theorizing and findings that anger does not predict nonnormative collective action . For instance, Tausch et al. found that contempt but not anger predicted nonnormative collective action. Although Tausch et al.'s general findings appear to be inconsistent with our findings, one of the exceptions to their findings was that anger was positively associated with support for violence by Islamist groups against Western military. This latter finding appears to be consistent with our present findings, and the observed inconsistencies between our findings and Tausch et al.'s are likely due to differences in the specific contexts in question. Consider that anger is an approach-related affect, such that it often promotes an effort to eliminate perceived violations of what "ought" to be, and often constitutes an act of rectifying an injustice . With this in mind, anger is likely to be a more appropriate reaction in the context of perceived injustice of Western foreign policy and occupation, because these specific acts are more likely to evoke stronger emotional responses and "move against" tendencies compared to, for example, an increase in student tuition. Further research is required to clarify the role of anger in predicting nonnormative collective action in various contexts. --- Strengths, Limitations, and Future Research The present research provides a new contribution to the growing body of empirical research on Islamist extremism, since we demonstrate empirically that the social psychological underpinnings of Islamist extremism appear to be similar in Muslim-majority countries and the West. Psychological research, and social psychological theory in particular, has been based predominantly on samples from Western, educated, industrialized, rich, and democratic societies , and has therefore neglected to represent diverse human populations . Given that Muslim populations-particularly those living in Muslimmajority countries-represent hard-to-reach, non-WEIRD populations, a key strength of our research is our representation of this otherwise underrepresented population in social psychological research. Naturally, there are also limitations of our research. First, one can argue that our measure of Muslim identification may lead the respondents to think of particular Muslim communities , rather than a global Muslim community. Nevertheless, our logic follows a long line of social psychological research showing that the experience of group threat and discrimination leads to a common identity . In order to unite the Muslim population around the globe into a unified community of ummah, Islamist groups depict Muslims, and Islam in general, to be under constant Western threat . Further, participation in collective action becomes a means to assert one's identity in the face of injustice and leads to protest against those perceived to be responsible . Thus, the connection between Muslim identification, perceptions of injustice, as well as anger and violent intentions directed toward the West are all natural from the perspective that "we" represent Muslims overall and "they" represent non-Muslim Westerners . This reasoning is also consistent with research showing that Muslims in recent years have come to see themselves as a unified community which first identifies with other Muslims than with other categories . Although there are theoretical reasons to believe that a global sense of identity-based on the perception of collective Muslim sufferingmay be an underlying factor in Islamist extremism, we did not actually measure identification with the global ummah. As such, the role of a global Muslim identity is somewhat speculative. Future research should attempt to improve upon our current studies by actually including items that specifically refer to the transnational element of Muslim identity. Furthermore, two limitations of our research are our type of measures and our means of recruiting participants. Specifically, we assessed violent intentions with self-reports. As such, we cannot be certain that our model would also extend to actual extremist behaviour. On the other hand, intentions are generally good predictors of overt behaviour . Moreover, if social desirability influenced the present results, we would have expected to obtain different results in the Western sample. By extension, that would have made it harder to establish a common model across the different study contexts. Our use of snowball sampling and Facebook sampling for Sample 1c and Study 2 are also less than optimal for recruiting participants. However, given that our research topic is a particularly sensitive issue in the contexts in which we sampled from, these sampling methods were the most feasible options. Future research should continue to sample from various hard-to-reach populations in order to assess how culturally diverse or universal the proposed key predictors of extremism are. Finally, to directly compare the predictive utility of key variables across these groups, we refrained from using context-specific measures. Instead, we adopted an etic approach, which assumes that different processes studied in one culture have significance in other cultures . This approach fits with our aim to examine whether the social psychological underpinnings of Islamist extremism in the West are similar to the underpinnings of Islamist extremism in countries with prolonged experience of Western military interventions. Nevertheless, an etic approach may overlook specific cultural perspectives or culturally specific behavioural nuances. Therefore, it would be relevant for future studies examining the social psychological underpinnings of Islamist extremism to adopt context-specific measures. --- Concluding Remarks Muslims around the world have come to see themselves as one unified group, and Western-led military interventions on Muslim-majority countries are likely to be perceived as an attack on the group as a whole. Such perceived attack may trigger feelings of injustice and anger, as well as violent action tendencies even in the absence of prolonged and ongoing experiences of Western military interventions. This research suggests that a combination of Muslim identity, perceived injustice, and group-based anger fuels violent intentions against Western targets. More importantly, this recipe for hostility seems equally applicable to Islamist extremism emerging in the West and in countries where people are living with the experience of Western military interventions. --- Funding The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported by grants from the Sasakawa Young Leader's Fellowship to Milan Obaidi, and from the Marianne and Marcus Wallenberg Foundation to Robin Bergh. The research was also supported by Riksbankens Jubileumsfond . --- ORCID iDs Milan Obaidi https://orcid.org/0000-0001-6416 -1805 Gulnaz Anjum https://orcid.org/0000-0002-2589 -7884 --- Supplemental material Supplemental material for this article is available online. --- Notes 1. In the current sample we also measured perceived group-based relative deprivation to answer a different research question. The data have not been reported before. 2. The data, indeed, confirmed this prediction. The mean of violent intentions for students from public universities was much higher than that for students from private universities. 3. Given the difficulty in reaching our samples, Sample 1b was part of a larger battery of variables collected to answer different research questions within the same surveys. Variables not included here concerned, for example, a priming manipulation , need for cognitive closure, and violent behavioural intentions and Muslim extremism. The variables for the current sample were measured before the experimental manipulation. The data have not been reported before. 4. This data set was previously reported in Obaidi et al. to answer a different research question. 5. Given the difficulty in reaching our samples, Study 2 was part of a larger battery of variables collected to answer different research questions within the same surveys. Variables not included here concerned, for example, the HEXACO Personality Inventory, openness to intellect, altruism, nonviolent behavioural intentions, violent behavioural intentions, support for violence, and group-based relative deprivation. The data have not been reported before. 6. Specifically, we measured violent behavioural intentions with two items, but only one of these referred particularly to violence in defence of Muslims. We acknowledge that the item in question does not identify a clear target. This item was directly translated from Doosje et al. . To facilitate comparisons with other research in this area, we adopted most scales as they have been used in the past rather than introducing many modifications of this kind. However, both items have been validated in Obaidi, Bergh, et al. , predicting violent intentions in defence of Muslims and/or Islam. More importantly, Obaidi et al. examined and addressed this issue in their paper by including two additional items that specifically targeted violent intentions on behalf of one's group , and they compared the results for the additional items with the two items used here. Their analyses showed a strong overlap between their added items and the current ones, and almost identical relations with the other variables we examine here .

A sense of shared Muslim suffering seems to play a key role in uniting Muslims around the world. Therefore, in the current paper we hypothesized that the social psychological underpinnings of Islamist extremism would be similar for Muslims living in the West and Muslims living in countries with prolonged and ongoing exposure to Western-led military interventions. Across 4 studies among Muslims in Pakistan and Afghanistan (Ns = 425, 402, and 127) and Muslims living in 20 Western countries (N = 366), we examined a path model in which group-based anger mediated the link between Muslim identification, perceived injustice of Western military and foreign policy, and violent behaviour intentions. Our results indicate that regardless of whether Muslims live in places with prolonged and ongoing experience of Western military interventions or not, the social psychological factors predicting violent Islamist extremism appear to be similar. We discuss implications for future theory and research.

your democratically elected governments continuously perpetrate atrocities against my people all over the world and your support of them makes you directly responsible just as i am directly responsible for protecting and avenging my muslim brothers and sisters an excerpt from the videotape of mohammad sidique khan following the london bombings in 2005 osama bin laden and mohammad sidique khan known terrorists responsible for two major terrorist attacks in the west expressed very similar reasons for carrying out their respective attacks despite the fact that they grew up in different cultural contexts they both mention the atrocities faced by their fellow muslims elsewhere and the need to avenge the plight of muslims who have suffered at the hands of western interventions this suggests that across different cultural contexts the same underlying social psychological processes might explain why some individuals are compelled to commit violent extremist acts to defend muslims scholars from various disciplines have proposed various causes of islamist extremism pointing to islamic ideology political strategy social identification processes threat perceptions and mental illness however only a fraction of the academic literature on terrorism is based on empirical data in a nascent line of social psychological research some have applied a social identity perspective on collective action and groupbased emotions to explain islamist extremism according to these perspectives islamist extremism represents one example of general group identification processes even if such general explanations are plausible there is still a need to examine these processes in different contexts where islamist extremism is prevalent one could ask for instance whether the same identification processes that explain extremism among muslim minorities in western europe can shed light on extremist violence in the middle east such questions have not been examined in the literature to date many scholars have argued that islamist extremism is the result of westernled military interventions and foreign policy in muslimmajority countries however even in the absence of direct personal experience of westernled occupation perpetrators of islamist extremist violence often allude to a sense of perceived injustice against muslims globally the feeling of injustice becomes particularly strong since many muslims have come to see themselves as a unified community cutting across national borders and that what matters is the experience of the group and not the experience of specific individuals it is therefore apparent that muslim identity plays a key role in islamist extremism uniting muslims through a perception of shared or collective suffering regardless of geographical location or personal experience importantly this suggests that individual engagement in islamist extremism might be explained by a similar model in the west and in muslimmajority countries the current paper aims to empirically test this notion islamist extremism broadly defined encompasses behaviours ideas intentions and attitudes that are in opposition to fundamental values and norms of society including democracy and the rule of law we define western military interventions as encompassing western wars sanctions drone attacks occupations targeted killing operation campaigns and crossborder raids theoretical background whilst few scholars have specifically outlined theoretical models that illustrate the social psychological antecedents of islamist extremism per se a review of social identity theory and subsequent theorizing and research on collective action and relative deprivation is consistent with the notion that group identification and negative groupbased emotions underlie willingness to engage in collective action according to sit people think feel and act in part due to the circumstances of the groups with which they identify members of disadvantaged groups who perceive this disadvantage as illegitimate and unjust are more inclined to identify with their group and engage in collective action in an attempt to rectify the perceived inequality thus according to sit identification with a disadvantaged group is a predictor of collective action van zomeren et al have conducted a comprehensive metaanalysis on the effects of identity perceived injustice and efficacy on collective action of particular relevance to the present study van zomeren et al found that the association between disadvantaged group identification and intention to engage in collective action is partially mediated by subjectively experienced groupbased injustice van zomerens metaanalysis also laid the foundation for the development of the social identity model of collective action an integrative theoretical model of collective action which proposes that social identity predicts collective action directly as well as indirectly via groupbased injustice and groupbased efficacy moreover individuals who more strongly identify with their group are more inclined to think feel and act for their group when their group is disadvantaged group identification predicts collective action directly but it also predicts other motivations for collective action such as groupbased anger and feelings of injustice furthermore such processes are more likely when differences between groups become increasingly salient in other words the more people talk about differences between muslims and westerners and the more these groups appear to behave differently we would expect stronger cognitive emotional and behavioural reactions associated with such group identities recently the social identity relative deprivation collective efficacy model of social change has combined the social identity relative deprivation and collective efficacy perspectives to predict participation in protest action according to the sirde model strong group identification in combination with feelings of deprivation anger and lack of collective efficacy is a stronger predictor of collective protests in sum the reviewed models are applicable to any social identity when ingroup identification is seen to be important to people nevertheless this line of research has mostly been studied in the context of western countries mainly focusing on protest actions however recent work has successfully applied insights from research on relative deprivation social identity and intergroup emotion to explain normative and nonnormative collective action among muslim minority groups in the past two decades muslim identity has become increasingly salient particularly when scholars as well as prominent politicians such as donald trump emphasize a clash of civilizations between muslims and nonmuslims in part due to this clash of civilizations rhetoric muslims are subject to discrimination globally with antimuslim activities and violence against muslims intensifying in the last decade leading to feelings of anger and deprivation consequently in the midst of growing tensions between muslims and nonmuslims muslim identification is central to muslims sense of self in line with this reasoning obaidi bergh et al examined both violent as well as nonviolent intentions among muslims living in denmark specifically based on insights from social categorization and intergroup emotions theory as well as collective action literature obaidi bergh et al proposed and tested a model with muslim identification and perceived injustice of western foreign policy and interventions as independent variables violent and nonviolent behavioural intentions as dependent variables and groupbased anger as a mediator consistent with this model muslim identification groupbased anger and perceived injustice were all positively associated with violent intentions to defend islam and other muslims however obaidi bergh et al some research suggests that different exposure to violence affects both prosocial and antisocial behaviours at a local level in contrast we examined global effects of experiences and threat of missile strikes power outages disrupted transportations etc as a result of a foreign powers military actions among muslims in afghanistan and pakistan compared to not experiencing such conditions here we explored the possibility that individual engagement in islamist extremism might have a common identitybased explanatory model in the west and in muslimmajority countries muslims may come to identify with a global muslim community due to perceptions of different threats that target muslims hence identification with a global muslim community can be seen as a coping strategy to mitigate the impacts of such experiences according to sit ethnic or racial discrimination may lead individuals to seek a sense of belonging to and acceptance in their ingroup communities indeed previous research shows that some people strongly identify with their ingroup in the face of threat and discrimination and that strong ingroup identification in turn mitigates the aversive effect of difficult psychological states further recent studies show that the experience of intergroup conflict and warrelated violence fosters more group participation and increases peoples engagement with their religious group which may help people cope with aversive psychological effects however when group identification is politicized and coupled with aversive experiences such as discrimination and injustice it may lead to collective action on behalf of ones group in particular a muslim identity based on collective suffering could explain why individuals who have committed extremist violence often express anger and feelings of injustice over westernled military interventions faced by their fellow muslimsregardless if they live in countries targeted by such interventions or not nevertheless there is still a need to directly examine whether the social psychological underpinnings of political violence are similar among muslims living in muslimmajority countries and muslims living in the west similarity across these contexts would imply that group identification processes and the associations between the psychological variables do indeed cut across borders contexts and varying degrees of personal experience of war and occupation hence supporting the underlying role of a muslim identity in predicting islamist extremism the present research the aim of this paper was to examine if predictors of islamist extremism in the west reappear and are similarly interrelated in muslimmajority countries with prolonged and ongoing experience of westernled military interventions we hypothesized that the individual difference variables that predict violent behavioural intentions would be the same across countries regardless if the country was the target of military actions by western powers or not to the best of our knowledge no studies to date have directly assessed the crosscultural generalizability of a social psychological model of islamist extremism by directly and empirically comparing models of extremism in western countries and in muslimmajority countries that are subject to western military interventions thus we sampled muslims from two such muslimmajority countriespakistan and afghanistanwhere extremism is also prevalent we also collected data from pakistani muslims living in 20 different western countries for comparison with our participants living in muslim countries we tested our hypotheses in a path analytic framework where we compared these four samples across all samples we examined whether muslim group identification and injustice appraisals of western foreign policy would predict intentions to commit violence on behalf of muslims through groupbased anger rationale for focusing on pakistan and afghanistan in the following we first describe the reasons why we focus on pakistan and afghanistan and then we describe each sample in the first three samples we focused on muslims of pakistani origin living in pakistan as well as sampling pakistani muslims living in 20 different western countries pakistan is currently among the countries with the greatest prevalence of terrorist attacks which appear to occur in response to western interventions importantly terrorism in pakistan has been known to spread not only to neighboring countries such as india and afghanistan but globally as well with a number of terrorist attacks occurring in the west having ties to extremist groups in pakistan furthermore in a global armed conflict against alqaida the pakistani taliban and in the context of the post911 war on terror pakistan has been increasingly the target of airstrikes occasional special forces attacks crossborder raids targeted killings and drone strikes by the us resulting in numerous civilian casualties the numerous civilian casualties create anger and antiwestern resentment providing a breeding ground for terrorist recruitment and incitement of islamist extremism thus if islamist extremism results from experiences of living in a country consistently targeted by western military actions then pakistan would be an ideal country to study these effects for comparison we explored whether the same model might also apply to pakistanis who have moved to western countries for study 2 we turned to afghanistan a country being targeted by extensive interventions from western powers afghanistan was invaded by the us and their allies following the terrorist attacks of 911 as of january 2015 the watson institute of brown university estimated that more than 26000 civilian afghans have been killed and nearly 100000 people have been injured and maimed since the 2001 occupation of the country in total the usled war has resulted in 92000 casualties in all categories of direct war violence further the war and occupation has exacerbated the effects of poverty malnutrition poor sanitation and lack of access to health care moreover the country is a major target of us airstrikes resulting in a large number of civilian casualties for instance documents show that during the course of a 5month targeted killing operation campaign nearly 9 out of 10 people who died in airstrikes were not the us militarys direct targets furthermore in part due to the ongoing us war against terrorism terrorist attacks are common in afghanistan with the country ranking second as the country with the most terrorist attacks in 2017 study 1 sample 1a participants and procedure study 1a and the subsequent studies were approved by the institutional review board of the primary affiliation of the first and second authors participants were asked to take part in a study investigating social and political issues faced by their respective societies the first page of the survey was an informed consent form participants needed to give their consent in order to proceed although we had planned to exclude any nonmuslim participants all participants identified as muslims since we had no other exclusion criterion no participants were excluded from our study in this sample a total of 425 pakistani participants living in pakistan were recruited from universities in islamabad the study was conducted in 2017 and it was a paperandpencil study data collection took roughly three months to complete both private and public sector universities were selected in an effort to obtain a diverse pool of participants particularly with regard to socioeconomic background moreover students were selected from these universities because they get a fairly equal representation from various socioeconomic and provincial backgrounds all students volunteered to participate in the study of the total sample 54 of participants indicated that they were upper class 722 upper middle class 183 lower middle class and 40 working class 1 all participants were born in pakistan sample 1b participants and procedure study 1a was conducted in 2018 among students from both private and public sector universities data collection took roughly three months to complete the higher education commission of pakistan have raised concerns about the recent observation that pakistani students from private universities hold more moderate attitudes toward extremism compared to students from public universities therefore in study 1b we only targeted students from public universities 2 in karachi a total of 402 participants were approached directly by four research assistants in two major public universities all participants were born in pakistan and identified as muslims a combination of convenience and snowball sampling was used to recruit the participants of the total sample 132 of participants indicated that they were upper class 771 upper middle class 82 middle class and 10 lower middle class 3 sample 1c participants and procedure data for sample 1c were collected in 2017 among pakistani muslims living in 20 different western countries data collection took roughly three months to complete the sample comprised 366 muslims living in the united kingdom the united states canada germany norway france australia sweden and switzerland for more details see table s3 in the online supplemental material a combination of convenience and snowball sampling was used to recruit the participants specifically participants were recruited by four university students and three research assistants both directly and via various facebook pages and other portals for pakistani immigrants living abroad all participants identified as muslims of the total sample 18 of participants indicated that they were upper middle class 676 middle class 126 lower middle class and 19 working class 4 study 2 participants and procedure study 2 was conducted in 2018 among afghans in kabul it was an online study using a convenience sample from facebook we recruited 127 afghans and data collection took approximately three months all of our participants were born in afghanistan and identified as muslims of the total sample 157 of participants indicated that they were upper class 252 upper middle class 299 middle class 189 lower middle class and 71 working class 5 method power rationale we used a multigroup analysis to examine whether the path model is similar across all samples a question then was how much the samples might vary before rejecting the notion of a common model thus we estimated the power for detecting overall differences in the model raising the rmsea to 05 a conventional cutoff for close fit in addition we ran a simulation to examine the power for detecting sample differences in particular coefficients here we used results from obaidi bergh et al as population values except that we set one path to zero in the smallest sample the power to detect such a difference was 93 assuming a smaller difference 007 versus 022 the power would be 68 measures all items were answered on 7point likert scales in afghanistan the survey was administered in dari all items were translated into dari and subsequently backtranslated into english among pakistanis living in pakistan and in the west the surveys were either conducted in urdu or english for the urdu survey all items were translated into urdu and subsequently backtranslated into english muslim identification four items were used to measure participants muslim identification with the exception of study 2 in which item 4 was reversecoded perceived injustice five items from obaidi and colleagues were used to measure participants perceived injustice groupbased anger three items from obaidi and colleagues were used to measure participants groupbased anger with the exception of study 2 in which item 3 was reversecoded violent behavioural intentions violent behavioural intentions were assessed using two items results variable descriptive statistics and correlations for samples 1a 1b 1c and study 2 can be found in table 1 multigroup path analyses to address the objectives of this paper we conducted a multigroup path analysis comparing two samples of muslim pakistanis living in pakistan muslim afghans living in afghanistan and muslim pakistanis living in western societies multigroup structural equation modelling is a standard method to examine if the relation between a set of variables is similar across different samples differences across samples were evaluated by constraining parameters as equal across samples which could be compared to a model without such constraints in our theoretical model muslim identification and perceived injustice were independent variables violent intentions the dependent variable and groupbased anger was positioned as a mediator across all the samples the models were estimated using robust maximum likelihood in mplus version 7 in order to account for skewed variables full information maximum likelihood is used by default in mplus to handle missing data we first estimated a model where all paths were constrained to equality across the groups in other words the model tests the assumption that the relations between the variables are the same in pakistan afghanistan and western societies net of random variability the constrained model fit the empirical data reasonably well scaled χ 2 4712 p 001 cfi 97 rmsea 07 90 ci 005 009 srmr 08 we also inspected modification indices for individual paths that might differ across the four samples the fit improved further when we released the constraint for one path in the first sample from pakistan from perceived injustice to violent intentions χ 2 3076 p 02 cfi 99 rmsea 05 90 ci 002 008 srmr 07 additional modifications were associated with small changes in model fit compared to guidelines considering δrmsea 015 and δcfi 01 substantial enough to disconfirm assumptions of invariance across groups overall this indicates that the relationships between the variables were similar across all four samples with one exception being the first sample obtained in pakistan to illustrate the minor variations in the path coefficients overall we present standardized coefficients in each sample in figure 1 we further examined the indirect effects using bootstrapping with 5000 random resamples in the model with all coefficients being held equal across samples this analysis was based on regular maximum likelihood estimation both muslim identification and perceived injustice had an indirect positive effect on violent intentions via groupbased anger to test whether these findings were robust to the introduction of demographic variables we ran the same model controlling for the effects of age gender and socioeconomic status all paths that were significant without these control variables remained as strong in this analysis overall the results of samples 1a 1b and study 2 among muslims living in muslimmajority countries and sample 1c among muslims living in 20 different western countries indicate that the social psychological predictors of islamic extremism in the west are similarly interrelated in muslimmajority countries that have been the direct and prolonged target of western military interventions general discussion across four studies we assessed the generalizability of a social psychological model of islamist extremism we directly and empirically compared the results obtained from muslimmajority countries with prolonged and ongoing exposure to western military and foreign policy to results obtained from muslims in the west in particular we examined whether muslim group identification and injustice appraisals of western military and foreign interventions would predict intentions to commit violence on behalf of muslims through groupbased anger results of the multigroup path analyses provide evidence that the social psychological predictors of islamist extremism generalized across the different contexts with one minor exception for sample 1a to our knowledge the present research is among the first to empirically examine social identity predictors of violent intentions among muslims living in muslimmajority countries importantly the present research is also among the first to specifically examine the generalizability of a social psychological model of islamist extremism by directly examining whether the relationships between the variables are consistent across muslimmajority and muslimminority samples with differing exposure to westernled wars and occupation despite the differences in exposure to westernled foreign policies and military interventions and different political landscapes and cultural contexts we obtained similar results across all our studies results from both muslimmajority countries and western muslims were consistent with a previous study conducted in the west this provides further empirical evidence for the role of a muslim identity as an underlying factor in radicalization and the converging validity of our results identification with a disadvantaged group is a key predictor of collective action in the context of the present studies identifying with a disadvantaged group did not directly predict nonnormative collective action across all four studies but it did so indirectly through injustice appraisal and groupbased anger importantly this finding converges with previous findings and theorizing about how social identity relates to collective action more generally moreover our findings suggest that merely identifying with muslims does not lead directly to violent behaviour which is consistent with the general observation that a relatively small minority of muslims engage in violent actions to defend their fellow muslims thus our findings provide some evidence to refute the popular belief in the west that islam as a religion is inherently violent and that there is a direct link between being muslim and extremism our findings that groupbased anger directly predicted violent intentions across all four studies is worth noting since they provide further evidence for the role of anger in predicting nonnormative collective action despite other recent theorizing and findings that anger does not predict nonnormative collective action for instance tausch et al found that contempt but not anger predicted nonnormative collective action although tausch et als general findings appear to be inconsistent with our findings one of the exceptions to their findings was that anger was positively associated with support for violence by islamist groups against western military this latter finding appears to be consistent with our present findings and the observed inconsistencies between our findings and tausch et als are likely due to differences in the specific contexts in question consider that anger is an approachrelated affect such that it often promotes an effort to eliminate perceived violations of what ought to be and often constitutes an act of rectifying an injustice with this in mind anger is likely to be a more appropriate reaction in the context of perceived injustice of western foreign policy and occupation because these specific acts are more likely to evoke stronger emotional responses and move against tendencies compared to for example an increase in student tuition further research is required to clarify the role of anger in predicting nonnormative collective action in various contexts strengths limitations and future research the present research provides a new contribution to the growing body of empirical research on islamist extremism since we demonstrate empirically that the social psychological underpinnings of islamist extremism appear to be similar in muslimmajority countries and the west psychological research and social psychological theory in particular has been based predominantly on samples from western educated industrialized rich and democratic societies and has therefore neglected to represent diverse human populations given that muslim populationsparticularly those living in muslimmajority countriesrepresent hardtoreach nonweird populations a key strength of our research is our representation of this otherwise underrepresented population in social psychological research naturally there are also limitations of our research first one can argue that our measure of muslim identification may lead the respondents to think of particular muslim communities rather than a global muslim community nevertheless our logic follows a long line of social psychological research showing that the experience of group threat and discrimination leads to a common identity in order to unite the muslim population around the globe into a unified community of ummah islamist groups depict muslims and islam in general to be under constant western threat further participation in collective action becomes a means to assert ones identity in the face of injustice and leads to protest against those perceived to be responsible thus the connection between muslim identification perceptions of injustice as well as anger and violent intentions directed toward the west are all natural from the perspective that we represent muslims overall and they represent nonmuslim westerners this reasoning is also consistent with research showing that muslims in recent years have come to see themselves as a unified community which first identifies with other muslims than with other categories although there are theoretical reasons to believe that a global sense of identitybased on the perception of collective muslim sufferingmay be an underlying factor in islamist extremism we did not actually measure identification with the global ummah as such the role of a global muslim identity is somewhat speculative future research should attempt to improve upon our current studies by actually including items that specifically refer to the transnational element of muslim identity furthermore two limitations of our research are our type of measures and our means of recruiting participants specifically we assessed violent intentions with selfreports as such we cannot be certain that our model would also extend to actual extremist behaviour on the other hand intentions are generally good predictors of overt behaviour moreover if social desirability influenced the present results we would have expected to obtain different results in the western sample by extension that would have made it harder to establish a common model across the different study contexts our use of snowball sampling and facebook sampling for sample 1c and study 2 are also less than optimal for recruiting participants however given that our research topic is a particularly sensitive issue in the contexts in which we sampled from these sampling methods were the most feasible options future research should continue to sample from various hardtoreach populations in order to assess how culturally diverse or universal the proposed key predictors of extremism are finally to directly compare the predictive utility of key variables across these groups we refrained from using contextspecific measures instead we adopted an etic approach which assumes that different processes studied in one culture have significance in other cultures this approach fits with our aim to examine whether the social psychological underpinnings of islamist extremism in the west are similar to the underpinnings of islamist extremism in countries with prolonged experience of western military interventions nevertheless an etic approach may overlook specific cultural perspectives or culturally specific behavioural nuances therefore it would be relevant for future studies examining the social psychological underpinnings of islamist extremism to adopt contextspecific measures concluding remarks muslims around the world have come to see themselves as one unified group and westernled military interventions on muslimmajority countries are likely to be perceived as an attack on the group as a whole such perceived attack may trigger feelings of injustice and anger as well as violent action tendencies even in the absence of prolonged and ongoing experiences of western military interventions this research suggests that a combination of muslim identity perceived injustice and groupbased anger fuels violent intentions against western targets more importantly this recipe for hostility seems equally applicable to islamist extremism emerging in the west and in countries where people are living with the experience of western military interventions funding the author disclosed receipt of the following financial support for the research authorship andor publication of this article the research was supported by grants from the sasakawa young leaders fellowship to milan obaidi and from the marianne and marcus wallenberg foundation to robin bergh the research was also supported by riksbankens jubileumsfond orcid ids milan obaidi 1805 gulnaz anjum 7884 supplemental material supplemental material for this article is available online notes 1 in the current sample we also measured perceived groupbased relative deprivation to answer a different research question the data have not been reported before 2 the data indeed confirmed this prediction the mean of violent intentions for students from public universities was much higher than that for students from private universities 3 given the difficulty in reaching our samples sample 1b was part of a larger battery of variables collected to answer different research questions within the same surveys variables not included here concerned for example a priming manipulation need for cognitive closure and violent behavioural intentions and muslim extremism the variables for the current sample were measured before the experimental manipulation the data have not been reported before 4 this data set was previously reported in obaidi et al to answer a different research question 5 given the difficulty in reaching our samples study 2 was part of a larger battery of variables collected to answer different research questions within the same surveys variables not included here concerned for example the hexaco personality inventory openness to intellect altruism nonviolent behavioural intentions violent behavioural intentions support for violence and groupbased relative deprivation the data have not been reported before 6 specifically we measured violent behavioural intentions with two items but only one of these referred particularly to violence in defence of muslims we acknowledge that the item in question does not identify a clear target this item was directly translated from doosje et al to facilitate comparisons with other research in this area we adopted most scales as they have been used in the past rather than introducing many modifications of this kind however both items have been validated in obaidi bergh et al predicting violent intentions in defence of muslims andor islam more importantly obaidi et al examined and addressed this issue in their paper by including two additional items that specifically targeted violent intentions on behalf of ones group and they compared the results for the additional items with the two items used here their analyses showed a strong overlap between their added items and the current ones and almost identical relations with the other variables we examine here

a sense of shared muslim suffering seems to play a key role in uniting muslims around the world therefore in the current paper we hypothesized that the social psychological underpinnings of islamist extremism would be similar for muslims living in the west and muslims living in countries with prolonged and ongoing exposure to westernled military interventions across 4 studies among muslims in pakistan and afghanistan ns 425 402 and 127 and muslims living in 20 western countries n 366 we examined a path model in which groupbased anger mediated the link between muslim identification perceived injustice of western military and foreign policy and violent behaviour intentions our results indicate that regardless of whether muslims live in places with prolonged and ongoing experience of western military interventions or not the social psychological factors predicting violent islamist extremism appear to be similar we discuss implications for future theory and research

Introduction Disability is defined by the WHO [1] as a complex phenomenon that reflects a close relationship between the characteristics of the person and the environment, being determining of the sociocultural properties. According to the latest WHO results [1], 15% of the world population has some type of disability, and the Moroccan National Survey [1,2] confirms that 5.12% of its population has a diagnosis of disability, or as far as this is concerned, more than one and a half million of the total population. Motor and mental diseases are the most diagnosed, compared to the communicative and metabolic ones [2,3]. According to Morocco's State Survey [2], the situation of people with disabilities is confusing. Although there are laws in the regulatory framework that underscore and ensure the rights and inclusion of people with disabilities in their community, the reality that many of them live in is very different [3]. Therefore, actions must be taken to ensure compliance with rights and thus achieve personal and community well-being and social participation. However, despite the fact that there are measures that favor the inclusion of people with disabilities in the public sector, the state report shows that the unemployment rate among this group is five times higher than in the rest of the population [2,3]. In the educational field, 85.7% of people with disabilities has not received any kind of legal education and, due to the inadequacy of specialized health infrastructures, access to social and health services is impossible for 60.8% of the population [2,3]. As a result, the leading causes of disabilities as well as the treatments available to people with disabilities are 2 of 12 unknown [2,3]. According to the same report [2,3], more than 43% of respondents attribute the cause of their disability to evil, magical or divine origins. With regard to the normative concerning disability, over the past 50 years, parliament has made many efforts to establish laws to ensure access to rights and social participation, highlighting Law No. 97/13 of 1993 [4][5][6][7][8], which guarantees social protection and its subsequent adaptation in 2014; the accessibility law; and a labor code that ensures workers' rights [4][5][6]. In addition, the signing of the United Nations International Convention on the Rights of People with Disabilities [4][5][6]9,10] includes the rights and obligations of states to safeguard equal opportunities. Despite this, the lack of sensitivity towards this group continues to be a reality. Most of the affected people and their families do not receive any kind of social or economic assistance from governments and institutions, and it is the relatives themselves or close people who place limits both on the development of their autonomy [11], and on the performance of activities and participation in society [12,13]. This results in a situation of occupational deprivation, which is understood as a prolonged restriction of participation in significant activities due to due to outside circumstances [11,14]. In contexts where health is conceived as equity and social participation [15], the community, understood as a social network that contributes to the determination of integration and social support, gives special relevance to time to design and carry out interventions to promote the social inclusion of people with disabilities in Morocco [16]. At the same time, from Occupational Therapy , a discipline that promotes the occupational health of the entire population, it is necessary to develop a decolonizing and decolonizing theory and practice that moves away from the hegemonic academy and develops culturally-sensitive and effective interventions [17][18][19]. Therefore, the community approach to OT proposes three perspectives that, in addition to favoring the participation of all members of society in the therapeutic process, take into consideration the perspective of health as equity and social participation [20]. OT in the community arises with the aim of improving access and occupational participation of all members of the community. This approach is influenced by the Customer Centered Practice Model [21] that was born with the aim of responding to the disadvantages of the biomedical model. In this way, OT in the community requires a structural change to address the needs of clients and does not focus attention on the objectives of professionals [22]. This approach involves interventions for community development, giving particular importance to the context, barriers and policies of the community [23]. Community OT is influenced by the Community-Based Rehabilitation Model [24], which aims to promote the better distribution of community resources, it being the therapist's role to establish partnerships and negotiations with the territory's bodies, as well as to promote community development of people with disabilities [25]. Finally, community therapy is related to the Independent Living Model [26], which offers a different approach to persons with disabilities by promoting the right to equal conditions and encouraging decision-making by people who are disadvantaged [27]. As Kronenberg and Simó defend in their project "Occupational Therapy Without Borders" [13], the community approach to address the occupational problems of the general population responds to aspects that are outside the social welfare system. In this process, the therapist must acquire different roles, such as advocate, case manager and consultant, entrepreneur, supervisor, community program coordinator, researcher and teacher [28,29]. Thus, taking into account the situation of people with disabilities in northern Morocco, the approach of interventions in, with and from the community could promote awareness and reduce exclusion towards disability. This investigation had two main objectives. On the one hand, the aim of this research was to verify the effectiveness of a community based OT intervention in the volition, quality of life and perceived self-stigma of people with disabilities in the Moroccan city of Azrou. On the other hand, another main objective was to reduce the stigma of the community towards people with disabilities in Azrou. Therefore, the research question was whether a community based OT intervention was effective to improve the volition, quality of life, awareness of stigma and occupational performance of people with disabilities, as well as to reduce the stigma of society towards this group. --- Materials and Methods --- Study Design-Participants Longitudinal study conducted through the focus of working on, with and from the community and based on the development of meaningful activities. The action research process lasted 5 months, and it was carried out with two groups; the first one was composed of people with disabilities that participated in an intervention program , and the second one was formed by people without disabilities from the community where the intervention was developed. The criteria for participating in the group of people with disabilities in the research were to be a beneficiary or to be in contact with the "Happiness Without Borders Association" and to reside in Azrou or in the continuous localities. Thus, people who were not linked to the Association or who participated and collaborated with other nongovernmental entities were excluded from the study. For participating in the group of people from the community, the criteria were not having any disability and to reside in Azrou. --- Procedure The participants were recruited through convenience sampling, and the methodological design was carried out under the ethnographic approach which, according to Hammersley and Atkinson [30], is the most basic form of social research and requires direct contact with the social agents, recording experiences in a respectful way [31]. It is an approach characterized by the researcher s participation in the daily life of the people involved in the study, which is essential to know the cultural meanings of the context. Regarding the group of people with disabilities, participants were selected by the main researchers of the project and the president of HWB, considering those who regularly attended the project called "Rehabilitation and Inclusion". After this previous work, people with disabilities susceptible to intervention were informed about the objectives and procedure of the investigation, as well as the possible risks and benefits that could derive from it, after which the corresponding informed consents were signed. Access to people in the community was through their participation in local events and their presence at strategic points of the city, such as the Souk or the Mosque. They were also informed of the objectives and procedure of the research. After the recruitment of the participants from both groups, the initial evaluation was carried out, prior to the implementation of the intervention in the group of people with disabilities for 16 weeks. People in the community group did not participate in the intervention, although it was developed in their own community, and they were able to see what was being done. One month after the intervention, all variables were re-evaluated for further analysis in both groups. The Bioethics Committee of the University of Burgos approved the research , which was carried out according the ethics principles of the Helsinki Declaration [32], the Regulation 2016/679 of the European Parliament and of the Council of 27 April 2016 [33], The Organic Law 3/2008 of December 5, protection of personal data and guarantee of digital rights [34], the ethical code of OT [35,36] and the regulations established by the European Commission by the European Group on Ethics in Science and New Technologies [37]. --- Intervention Process Prior to the implementation of the intervention, volition, quality of life, awareness of stigma and other relevant variables in the ad hoc questionnaire were evaluated in the group participants with disabilities. Due to their characteristics and the conception of health as something collective, the study variables were evaluated through informants, the caregivers, usually mothers and grandmothers, who provided the information in most cases. Regarding the group of participants without disabilities, no tool adapted to the rural population of Morocco was found, so a meeting was held with 68 people from Azrou and the continuous villages in which the different ways of evaluating the stigma of society towards disability were discussed. It was decided that the AQ-27 questionnaire, despite being aimed at the population with mental illness, was the most appropriate tool after a few simple adaptations. Once adapted, the questionnaire was piloted in a sample of 50 subjects to check its validity and ensure its adaptation to the sociocultural context, to later be completed by the 42 people who made up the study group. Initial evaluations were performed in both groups, and then intervention sessions were carried out in the group of people with disabilities, from a community approach and based on the realization of significant activities focused mainly on games and leisure. The intervention lasted 16 weeks, during which one-hour sessions were held, 7 days a week. Individual and group sessions were developed, always with the help of a translator, to facilitate communication between the therapist and the participants. The sessions were elaborated, taking into account the responses of the ad hoc questionnaire, in order to consider the customs and socio-cultural characteristics of the place and the needs and interests of the participants. The intervention activities were agreed upon with the interested person and their closest circle and were planned and developed based on their significant occupations, collected through the previously administered ad hoc questionnaire. The activities were graduated according to the person s needs and were initially developed in a small and structured environment to be later generalized to real contexts, such as participating in family businesses, enjoying a space and leisure activities, or collaborating in activities religious. During the performance of these occupations, in addition to promoting inclusion in the community, individual performance skills such as motor skills, emotional skills, cognitive skills, communication skills and social skills were promoted. By holding the sessions in the community environment, the rest of the population also participated indirectly in the different sessions, which was intended to reduce the stigma of the community and promote inclusive behaviors and thoughts towards this group. One month after the end of the intervention, a second evaluation was carried out with both groups in order to conduct the subsequent analysis. --- Instruments The data were collected using several standardized scales and an ad hoc interview through participating observation method. The scales made it possible to collect specific data with good statistical value, while the ad hoc interview provided a more global view of the phenomenon studied. Relevant sociodemographic variables such as gender or age were also collected for further analysis. The entire data collection process was carried out in habitual and natural contexts with the aim of observing, listening and maintaining an informal conversation with participants during the development of daily activities and tasks, creating and annotating field notes after observation through reflections with participants. The evaluation tools used for the group of people with disabilities were the following: --- • The Volitive Questionnaire , which aims to evaluate the volition according to the Human Occupation Model, referring to one of the subsystems of the person [38]. It consists of 14 items that provide individualized and specific information about the person's motivational characteristics, activities and other circumstances that increase the person's volition, evaluated by a scoring system consisting of P = 1, D = 2, I = 3 and E = 4 [39][40][41]. Thus, it rates from 4 to 56, and higher score means higher volition. --- • The World Health Organization Quality of Life scale [42]. It allows one to know the general profile of Quality of Life, through 26 items divided into four dimensions through a Likert type scale of 5 points ranging between 26 and 130, where higher scores mean a better quality of life. --- • The Stigma Consciousness Questionnaire [43]: to know the self-stigma of people with disabilities, through 10 items with a Likert scale with 5 response options, 1 being not agree and 5 totally agree. Three items are inverse, and so they were recodified for data evaluation, so it scores from 5 to 50, where the higher scores mean the lower stigma consciousness or auto-stigma. --- • Ad hoc interview, divided into two blocks, in which the former collects information on cognitive level and occupational behavior with responses inadequate = 0 and appropriate = 1; emotional state, communication and interaction skills and social functioning with a 1-5 Likert scale; and the activities of daily life with values dependent = 0 and independent = 1; in all cases, higher scores are assimilated to better circumstances. The second block consists of four open questions translated and adapted to the cultural and linguistic needs of the country on the significant activities of the person, which was used to plan the significant activities used in the intervention. All participants of the group of people without disabilities were evaluated by the Attribution Questionnaire [44], adapted to the context. The original AQ-27 questionnaire assesses the stigmatizing attitude and beliefs towards people diagnosed with mental illness; however, for this research, questions were tailored to the context and collective to be analyzed, emphasizing stereotypes, beliefs and behaviors towards people with disabilities. It consists of 27 items distributed in 9 factors scoring between 1 and 9, where avoidance items have an inverse score and higher scores mean a higher stigmatizing attitude and beliefs towards people with disabilities [45]. Each dimension consists of 3 items and scores between 3 and 27. Scores greater than 20 are considered high, between 20 and 10 average, and less than 10 low [44]; the total score of the scale can also be considered [46]. --- Statistical Analysis A normality analysis was performed using the Kolmogorov-Smirnoff test and the Sapphire-Wilk test , which determined that the sample did not fit a normal distribution. Descriptive analysis was performed in terms of mean and standard deviation in continuous variables and percentages and frequencies in categorical variables. For the inferential analysis, Spearman correlations were performed with the quantitative variables and the Wilcoxon rank-sum test to compare the scores obtained in the pretest and in the post-test in both study groups. For statistical analysis, it was conducted using SPSS Version 25.0 software, with a set risk of 0.05 as the limit of statistical significance. --- Results --- People with Disabilities Participating in the Intervention Program Out of the total number of people with disabilities participating in the intervention program , there were 29 men and 23 women , with an average age of 12.08 years old. Most people were single , and regarding the residence area, 69.2% lived in a rural area and 30.8% in an urban area . Most had preschool studies or primary , and only four people had secondary studies and three subjects had higher education . In terms of disability, most had a physical disability , 14 people had mental disabilities , 3 people emotional , 9 mixed disability and 3 subjects of unknown type . Most participants had a primary caregiver , whether a family member or a professional. Additionally, most people moved independently and only 11 participants needed mobility aid . In addition to the main diagnosis of their disability, there were participants with addictions , family conflicts , communication difficulties and close fights . Sixteen people did not present added difficulties . In terms of disability, most had a physical disability , 14 people h mental disabilities , 3 people emotional , 9 mixed disability an subjects of unknown type . Most participants had a primary caregiver = 41; 78.8%), whether a family member or a professional. Additionally, most peo moved independently and only 11 participants needed mobility . In addition to the main diagnosis of their disability, there were participants w addictions , family conflicts , communication difficulties = 8; 15.4%) and close fights . Sixteen people did not present added difficul . In inferential analysis, the age variable was negatively correlated with volition in sure activities = -0.326, p = 0.018) and at home activities = -0.303, p = 0.02 as well as with the quality of life prior to the intervention = -0.476, p < 0.001), so t the older participants had less volition and a lower level of quality of life. Statistically significant differences were found between the scores before and af the intervention in all the independent variables studied, which are reflected in Table In inferential analysis, the age variable was negatively correlated with volition in leisure activities = -0.326, p = 0.018) and at home activities = -0.303, p = 0.029), as well as with the quality of life prior to the intervention = -0.476, p < 0.001), so that the older participants had less volition and a lower level of quality of life. Statistically significant differences were found between the scores before and after the intervention in all the independent variables studied, which are reflected in Table 1. Of the total number of people in the community who completed the AQ-27 questionnaire, 50% were men and 50% women, aged between 8 and 64 years . Twenty-five people lived in a rural area and 17 in an urban area . After inferential analysis, age did not correlate with stigmatizing attitude towards people with disabilities. Regarding the effectiveness of the intervention, significant differences were identified between the scores before and after the intervention, both in the total score of the AQ-27 scale and in each of its scores' dimensions . --- Discussion This study aims to clarify whether intervention in, from and with the community based on significant activities is effective for improving the volition, quality of life and stigma consciousness in participants with disabilities, as well as to verify if this intervention, in turn, is able to diminish society's stigmatizing attitude towards these people. A significant increase in the volition of people with disabilities was found in the three areas of activity evaluated, as well as in quality of life. For its part, the stigma consciousness of people with disabilities themselves was lower after the intervention. Likewise, the variables analyzed using the ad hoc questionnaire also provided indicative results of improvement in cognitive level, emotional status, occupational behavior, ADL, communication and interaction skills and social functioning. Regarding the stigmatizing attitude of society towards people with disabilities, a significant reduction was found after the intervention. The OT theoretical basis consider that interventions based on the performance of specific activities or occupations in certain environments promote the participation of people in these settings and improve performance in these activities [47,48]. In this research, following the axiom that the impact on participation in the ADL has a great impact on their personal, functional, social and economic life [49][50][51], it was shown that this type of intervention can improve the performance of the participants with disabilities. Furthermore, the stigmatizing attitude of society can be reduced, thereby creating opportunities for community participation for these people. Strengthening a model of socio-community inclusion for people with disabilities is a vital goal in a way that supports community inclusion, and people with disabilities can develop roles within their membership community; all this is to normalize people with disabilities for their socio-community inclusion [52]. Thus, OT intervention requires the inclusion of the community as an area of development of the person and as a context in which their occupational performance is framed and determined [53]. This study provides an intervention that is effective from this conceptualization, as the results support that such approaches can be beneficial to improve that occupational performance. Community OT has been shown to be useful in improving occupational performance in children and youth in a study with 167 participants under the age of 18, so that children receiving home and community treatment gained changes in their performance skills [54]. These findings are consistent with those obtained in this study, since improvements were demonstrated in the variables evaluated in the ad hoc questionnaire, in addition to volition. A systematic review about the effectiveness of community OT interventions, which included 12 articles published between 2007 and 2020 [55], concluded that it constitutes a consolidated line of research, but with limited objectives and research areas, so that the studies were predominantly qualitative and descriptive. In addition, the studies analyzed showed an average/low level of evidence, among which the ones that intended to reduce the risk of fall and to improve performance in the ADL were those that showed the best results [55]. Along these lines, in this study the treatment seemed to be effective in improving all the variables studied. Regarding volition, previous investigations associated this variable with greater participation in certain activities. An Australian study, involving 244 adults older than 70 years, demonstrated a significant association of volition with increased participation in physical activities in older adults living in the community [56]. Another study with adolescents with cerebral palsy demonstrated that occupational therapists can increase the motivation and will of this group through self-efficacy in interaction with environmental characteristics to promote personal causality [57]. Graff et al. [58] found in their study of 135 couples of people with dementia and their caregivers that community OT improves the mood, quality of life and health of both people with dementia and their caregivers, improvement that was significant in the follow-up after 12 weeks. Although this study does not consider the effects on caregivers, it does show similar results in terms of improving people s quality of life. Carrasco, Martín and Molero [43] found a negative relationship between stigma consciousness and quality of life, with differences depending on sex, disability type and reason for disability, in a study that included 201 people with sensory, physical and other disabilities. Another study with children with disabilities and their families in Zambia [59] concluded that in low and middle-income countries, especially in low-income communities, the stigma of disability reduces their opportunities for participation, and they advocated for community-based interventions as a viable and acceptable approach to interacting with the community and families of children with disabilities. Although it was a pilot study, families and individuals in the community reported less perceived rejection from family and peers, but the agreement that children with disabilities should be treated in the same way as other children was minor [59]. These findings are consistent with this research, as there was less awareness of stigma on the part of participating people with disabilities, and a less stigmatizing attitude on the part of the community was observed after the intervention. The provision of therapeutic services based on western practice in other types of communities causes challenges and conflicts because the differences between cultural beliefs, values and customs are significant and can be an important barrier to the development of interventions; therefore, one study concludes that it is necessary to develop an appropriate epistemology for non-western cultures that provides guidelines for successfully implementing such services tailored to the people of those communities [60]. More research about what kinds of strategies are successful in these non-western contexts through studies developed with and adapted to local populations are needed, such as this research. This study has both strengths and weaknesses. The implementation of a community intervention in a population with limited resources, and the good results in terms of the participation of both persons with disabilities and their families and the rest of the community, with the aim of improving social participation and reducing the stigma towards disability, is the greatest strength. Furthermore, the fact that there was a significant improvement in all the variables studied is encouraging and facilitates the approach of future similar lines of research in this or other communities. On the other hand, the design has methodological limitations that should be pointed out as weaknesses. The sample was reduced in people with disabilities and in the people who completed the AQ-27 questionnaire, using a non-probability sampling. In addition, there was no control group, so it could not be guaranteed that the changes that occurred were due to the intervention. Although standardized and validated tests were used to evaluate some aspects, in others it was not possible, hence the elaboration of an ad hoc questionnaire, which, despite not having the psychometric properties offered by the validated scales, provides relevant information and highlights the need to create appropriate assessment tools for non-western communities. The present research provides evidence about the importance of community interventions in populations in which people with disabilities are subject to great stigma from society and from themselves. The community perspective allows professionals to address issues involved with people s reality, generating a space for communication, dialogue and participation, and which also favors social cohesion. It is a continuous, dynamic and dialectical process that improves the living conditions of a certain community and permits the formation of non-hierarchical relationships, maintaining horizontality in power and knowledge. Future research with a larger and more representative sample is recommended, allowing the intervention to be extrapolated to other locations. --- Conclusions Most of the existing studies have been carried out from a western approach and in populations that are not closely related to the one investigated in the present study. It is necessary to carry out research in this type of population, so this study constitutes an interesting contribution by investigating aspects such as volition in the performance of different activities, quality of life and awareness of the stigma of people with disabilities. Additionally, it considers the stigmatizing attitudes of society towards these people. The intervention was positive in that it improved all the variables studied using standardized instruments, and, in relation to variables of the ad hoc questionnaire, the intervention was also effective in improving cognitive level, emotional state, occupational behavior, ADL, communication and interaction skills and social functioning. This study provides evidence that justifies community OT intervention and proposes more interventions and research in this line, which appear to be effective. In addition, it would be very convenient to replicate the results and establish studies that include a control group. ---

In Morocco, the social and environmental context influences the volition and development of meaningful activities, creating physical, personal and social barriers to the occupational performance of people with disabilities. This study develops a community Occupational Therapy program in order to verify its effectiveness in the volition, quality of life and perceived self-stigma of people with disabilities in the Moroccan city of Azrou, and to reduce the stigma of the community towards people with disabilities in the city. Data were collected from people with disabilities who participated in the program (N = 52), using the Volitional Questionnaire (VQ), The World Health Organization Quality of Life scale (WHOQOL-BREF), the Stigma Awareness Questionnaire (SCQ) and an ad hoc interview. In addition, community stigma was assessed by the Attribution Questionnaire (AQ-27) in citizens without disabilities (N = 42). Results confirmed that this intervention favors the inclusion of people with disabilities in their closest environment, improving volition and quality of life and reducing self-stigma. Furthermore, the community's stigma towards people with disabilities was also significantly reduced after the intervention.

introduction disability is defined by the who 1 as a complex phenomenon that reflects a close relationship between the characteristics of the person and the environment being determining of the sociocultural properties according to the latest who results 1 15 of the world population has some type of disability and the moroccan national survey 12 confirms that 512 of its population has a diagnosis of disability or as far as this is concerned more than one and a half million of the total population motor and mental diseases are the most diagnosed compared to the communicative and metabolic ones 23 according to moroccos state survey 2 the situation of people with disabilities is confusing although there are laws in the regulatory framework that underscore and ensure the rights and inclusion of people with disabilities in their community the reality that many of them live in is very different 3 therefore actions must be taken to ensure compliance with rights and thus achieve personal and community wellbeing and social participation however despite the fact that there are measures that favor the inclusion of people with disabilities in the public sector the state report shows that the unemployment rate among this group is five times higher than in the rest of the population 23 in the educational field 857 of people with disabilities has not received any kind of legal education and due to the inadequacy of specialized health infrastructures access to social and health services is impossible for 608 of the population 23 as a result the leading causes of disabilities as well as the treatments available to people with disabilities are 2 of 12 unknown 23 according to the same report 23 more than 43 of respondents attribute the cause of their disability to evil magical or divine origins with regard to the normative concerning disability over the past 50 years parliament has made many efforts to establish laws to ensure access to rights and social participation highlighting law no 9713 of 1993 4 5 6 7 8 which guarantees social protection and its subsequent adaptation in 2014 the accessibility law and a labor code that ensures workers rights 4 5 6 in addition the signing of the united nations international convention on the rights of people with disabilities 4 5 6 910 includes the rights and obligations of states to safeguard equal opportunities despite this the lack of sensitivity towards this group continues to be a reality most of the affected people and their families do not receive any kind of social or economic assistance from governments and institutions and it is the relatives themselves or close people who place limits both on the development of their autonomy 11 and on the performance of activities and participation in society 1213 this results in a situation of occupational deprivation which is understood as a prolonged restriction of participation in significant activities due to due to outside circumstances 1114 in contexts where health is conceived as equity and social participation 15 the community understood as a social network that contributes to the determination of integration and social support gives special relevance to time to design and carry out interventions to promote the social inclusion of people with disabilities in morocco 16 at the same time from occupational therapy a discipline that promotes the occupational health of the entire population it is necessary to develop a decolonizing and decolonizing theory and practice that moves away from the hegemonic academy and develops culturallysensitive and effective interventions 17 18 19 therefore the community approach to ot proposes three perspectives that in addition to favoring the participation of all members of society in the therapeutic process take into consideration the perspective of health as equity and social participation 20 ot in the community arises with the aim of improving access and occupational participation of all members of the community this approach is influenced by the customer centered practice model 21 that was born with the aim of responding to the disadvantages of the biomedical model in this way ot in the community requires a structural change to address the needs of clients and does not focus attention on the objectives of professionals 22 this approach involves interventions for community development giving particular importance to the context barriers and policies of the community 23 community ot is influenced by the communitybased rehabilitation model 24 which aims to promote the better distribution of community resources it being the therapists role to establish partnerships and negotiations with the territorys bodies as well as to promote community development of people with disabilities 25 finally community therapy is related to the independent living model 26 which offers a different approach to persons with disabilities by promoting the right to equal conditions and encouraging decisionmaking by people who are disadvantaged 27 as kronenberg and simó defend in their project occupational therapy without borders 13 the community approach to address the occupational problems of the general population responds to aspects that are outside the social welfare system in this process the therapist must acquire different roles such as advocate case manager and consultant entrepreneur supervisor community program coordinator researcher and teacher 2829 thus taking into account the situation of people with disabilities in northern morocco the approach of interventions in with and from the community could promote awareness and reduce exclusion towards disability this investigation had two main objectives on the one hand the aim of this research was to verify the effectiveness of a community based ot intervention in the volition quality of life and perceived selfstigma of people with disabilities in the moroccan city of azrou on the other hand another main objective was to reduce the stigma of the community towards people with disabilities in azrou therefore the research question was whether a community based ot intervention was effective to improve the volition quality of life awareness of stigma and occupational performance of people with disabilities as well as to reduce the stigma of society towards this group materials and methods study designparticipants longitudinal study conducted through the focus of working on with and from the community and based on the development of meaningful activities the action research process lasted 5 months and it was carried out with two groups the first one was composed of people with disabilities that participated in an intervention program and the second one was formed by people without disabilities from the community where the intervention was developed the criteria for participating in the group of people with disabilities in the research were to be a beneficiary or to be in contact with the happiness without borders association and to reside in azrou or in the continuous localities thus people who were not linked to the association or who participated and collaborated with other nongovernmental entities were excluded from the study for participating in the group of people from the community the criteria were not having any disability and to reside in azrou procedure the participants were recruited through convenience sampling and the methodological design was carried out under the ethnographic approach which according to hammersley and atkinson 30 is the most basic form of social research and requires direct contact with the social agents recording experiences in a respectful way 31 it is an approach characterized by the researcher s participation in the daily life of the people involved in the study which is essential to know the cultural meanings of the context regarding the group of people with disabilities participants were selected by the main researchers of the project and the president of hwb considering those who regularly attended the project called rehabilitation and inclusion after this previous work people with disabilities susceptible to intervention were informed about the objectives and procedure of the investigation as well as the possible risks and benefits that could derive from it after which the corresponding informed consents were signed access to people in the community was through their participation in local events and their presence at strategic points of the city such as the souk or the mosque they were also informed of the objectives and procedure of the research after the recruitment of the participants from both groups the initial evaluation was carried out prior to the implementation of the intervention in the group of people with disabilities for 16 weeks people in the community group did not participate in the intervention although it was developed in their own community and they were able to see what was being done one month after the intervention all variables were reevaluated for further analysis in both groups the bioethics committee of the university of burgos approved the research which was carried out according the ethics principles of the helsinki declaration 32 the regulation 2016679 of the european parliament and of the council of 27 april 2016 33 the organic law 32008 of december 5 protection of personal data and guarantee of digital rights 34 the ethical code of ot 3536 and the regulations established by the european commission by the european group on ethics in science and new technologies 37 intervention process prior to the implementation of the intervention volition quality of life awareness of stigma and other relevant variables in the ad hoc questionnaire were evaluated in the group participants with disabilities due to their characteristics and the conception of health as something collective the study variables were evaluated through informants the caregivers usually mothers and grandmothers who provided the information in most cases regarding the group of participants without disabilities no tool adapted to the rural population of morocco was found so a meeting was held with 68 people from azrou and the continuous villages in which the different ways of evaluating the stigma of society towards disability were discussed it was decided that the aq27 questionnaire despite being aimed at the population with mental illness was the most appropriate tool after a few simple adaptations once adapted the questionnaire was piloted in a sample of 50 subjects to check its validity and ensure its adaptation to the sociocultural context to later be completed by the 42 people who made up the study group initial evaluations were performed in both groups and then intervention sessions were carried out in the group of people with disabilities from a community approach and based on the realization of significant activities focused mainly on games and leisure the intervention lasted 16 weeks during which onehour sessions were held 7 days a week individual and group sessions were developed always with the help of a translator to facilitate communication between the therapist and the participants the sessions were elaborated taking into account the responses of the ad hoc questionnaire in order to consider the customs and sociocultural characteristics of the place and the needs and interests of the participants the intervention activities were agreed upon with the interested person and their closest circle and were planned and developed based on their significant occupations collected through the previously administered ad hoc questionnaire the activities were graduated according to the person s needs and were initially developed in a small and structured environment to be later generalized to real contexts such as participating in family businesses enjoying a space and leisure activities or collaborating in activities religious during the performance of these occupations in addition to promoting inclusion in the community individual performance skills such as motor skills emotional skills cognitive skills communication skills and social skills were promoted by holding the sessions in the community environment the rest of the population also participated indirectly in the different sessions which was intended to reduce the stigma of the community and promote inclusive behaviors and thoughts towards this group one month after the end of the intervention a second evaluation was carried out with both groups in order to conduct the subsequent analysis instruments the data were collected using several standardized scales and an ad hoc interview through participating observation method the scales made it possible to collect specific data with good statistical value while the ad hoc interview provided a more global view of the phenomenon studied relevant sociodemographic variables such as gender or age were also collected for further analysis the entire data collection process was carried out in habitual and natural contexts with the aim of observing listening and maintaining an informal conversation with participants during the development of daily activities and tasks creating and annotating field notes after observation through reflections with participants the evaluation tools used for the group of people with disabilities were the following • the volitive questionnaire which aims to evaluate the volition according to the human occupation model referring to one of the subsystems of the person 38 it consists of 14 items that provide individualized and specific information about the persons motivational characteristics activities and other circumstances that increase the persons volition evaluated by a scoring system consisting of p 1 d 2 i 3 and e 4 39 40 41 thus it rates from 4 to 56 and higher score means higher volition • the world health organization quality of life scale 42 it allows one to know the general profile of quality of life through 26 items divided into four dimensions through a likert type scale of 5 points ranging between 26 and 130 where higher scores mean a better quality of life • the stigma consciousness questionnaire 43 to know the selfstigma of people with disabilities through 10 items with a likert scale with 5 response options 1 being not agree and 5 totally agree three items are inverse and so they were recodified for data evaluation so it scores from 5 to 50 where the higher scores mean the lower stigma consciousness or autostigma • ad hoc interview divided into two blocks in which the former collects information on cognitive level and occupational behavior with responses inadequate 0 and appropriate 1 emotional state communication and interaction skills and social functioning with a 15 likert scale and the activities of daily life with values dependent 0 and independent 1 in all cases higher scores are assimilated to better circumstances the second block consists of four open questions translated and adapted to the cultural and linguistic needs of the country on the significant activities of the person which was used to plan the significant activities used in the intervention all participants of the group of people without disabilities were evaluated by the attribution questionnaire 44 adapted to the context the original aq27 questionnaire assesses the stigmatizing attitude and beliefs towards people diagnosed with mental illness however for this research questions were tailored to the context and collective to be analyzed emphasizing stereotypes beliefs and behaviors towards people with disabilities it consists of 27 items distributed in 9 factors scoring between 1 and 9 where avoidance items have an inverse score and higher scores mean a higher stigmatizing attitude and beliefs towards people with disabilities 45 each dimension consists of 3 items and scores between 3 and 27 scores greater than 20 are considered high between 20 and 10 average and less than 10 low 44 the total score of the scale can also be considered 46 statistical analysis a normality analysis was performed using the kolmogorovsmirnoff test and the sapphirewilk test which determined that the sample did not fit a normal distribution descriptive analysis was performed in terms of mean and standard deviation in continuous variables and percentages and frequencies in categorical variables for the inferential analysis spearman correlations were performed with the quantitative variables and the wilcoxon ranksum test to compare the scores obtained in the pretest and in the posttest in both study groups for statistical analysis it was conducted using spss version 250 software with a set risk of 005 as the limit of statistical significance results people with disabilities participating in the intervention program out of the total number of people with disabilities participating in the intervention program there were 29 men and 23 women with an average age of 1208 years old most people were single and regarding the residence area 692 lived in a rural area and 308 in an urban area most had preschool studies or primary and only four people had secondary studies and three subjects had higher education in terms of disability most had a physical disability 14 people had mental disabilities 3 people emotional 9 mixed disability and 3 subjects of unknown type most participants had a primary caregiver whether a family member or a professional additionally most people moved independently and only 11 participants needed mobility aid in addition to the main diagnosis of their disability there were participants with addictions family conflicts communication difficulties and close fights sixteen people did not present added difficulties in terms of disability most had a physical disability 14 people h mental disabilities 3 people emotional 9 mixed disability an subjects of unknown type most participants had a primary caregiver 41 788 whether a family member or a professional additionally most peo moved independently and only 11 participants needed mobility in addition to the main diagnosis of their disability there were participants w addictions family conflicts communication difficulties 8 154 and close fights sixteen people did not present added difficul in inferential analysis the age variable was negatively correlated with volition in sure activities 0326 p 0018 and at home activities 0303 p 002 as well as with the quality of life prior to the intervention 0476 p 0001 so t the older participants had less volition and a lower level of quality of life statistically significant differences were found between the scores before and af the intervention in all the independent variables studied which are reflected in table in inferential analysis the age variable was negatively correlated with volition in leisure activities 0326 p 0018 and at home activities 0303 p 0029 as well as with the quality of life prior to the intervention 0476 p 0001 so that the older participants had less volition and a lower level of quality of life statistically significant differences were found between the scores before and after the intervention in all the independent variables studied which are reflected in table 1 of the total number of people in the community who completed the aq27 questionnaire 50 were men and 50 women aged between 8 and 64 years twentyfive people lived in a rural area and 17 in an urban area after inferential analysis age did not correlate with stigmatizing attitude towards people with disabilities regarding the effectiveness of the intervention significant differences were identified between the scores before and after the intervention both in the total score of the aq27 scale and in each of its scores dimensions discussion this study aims to clarify whether intervention in from and with the community based on significant activities is effective for improving the volition quality of life and stigma consciousness in participants with disabilities as well as to verify if this intervention in turn is able to diminish societys stigmatizing attitude towards these people a significant increase in the volition of people with disabilities was found in the three areas of activity evaluated as well as in quality of life for its part the stigma consciousness of people with disabilities themselves was lower after the intervention likewise the variables analyzed using the ad hoc questionnaire also provided indicative results of improvement in cognitive level emotional status occupational behavior adl communication and interaction skills and social functioning regarding the stigmatizing attitude of society towards people with disabilities a significant reduction was found after the intervention the ot theoretical basis consider that interventions based on the performance of specific activities or occupations in certain environments promote the participation of people in these settings and improve performance in these activities 4748 in this research following the axiom that the impact on participation in the adl has a great impact on their personal functional social and economic life 49 50 51 it was shown that this type of intervention can improve the performance of the participants with disabilities furthermore the stigmatizing attitude of society can be reduced thereby creating opportunities for community participation for these people strengthening a model of sociocommunity inclusion for people with disabilities is a vital goal in a way that supports community inclusion and people with disabilities can develop roles within their membership community all this is to normalize people with disabilities for their sociocommunity inclusion 52 thus ot intervention requires the inclusion of the community as an area of development of the person and as a context in which their occupational performance is framed and determined 53 this study provides an intervention that is effective from this conceptualization as the results support that such approaches can be beneficial to improve that occupational performance community ot has been shown to be useful in improving occupational performance in children and youth in a study with 167 participants under the age of 18 so that children receiving home and community treatment gained changes in their performance skills 54 these findings are consistent with those obtained in this study since improvements were demonstrated in the variables evaluated in the ad hoc questionnaire in addition to volition a systematic review about the effectiveness of community ot interventions which included 12 articles published between 2007 and 2020 55 concluded that it constitutes a consolidated line of research but with limited objectives and research areas so that the studies were predominantly qualitative and descriptive in addition the studies analyzed showed an averagelow level of evidence among which the ones that intended to reduce the risk of fall and to improve performance in the adl were those that showed the best results 55 along these lines in this study the treatment seemed to be effective in improving all the variables studied regarding volition previous investigations associated this variable with greater participation in certain activities an australian study involving 244 adults older than 70 years demonstrated a significant association of volition with increased participation in physical activities in older adults living in the community 56 another study with adolescents with cerebral palsy demonstrated that occupational therapists can increase the motivation and will of this group through selfefficacy in interaction with environmental characteristics to promote personal causality 57 graff et al 58 found in their study of 135 couples of people with dementia and their caregivers that community ot improves the mood quality of life and health of both people with dementia and their caregivers improvement that was significant in the followup after 12 weeks although this study does not consider the effects on caregivers it does show similar results in terms of improving people s quality of life carrasco martín and molero 43 found a negative relationship between stigma consciousness and quality of life with differences depending on sex disability type and reason for disability in a study that included 201 people with sensory physical and other disabilities another study with children with disabilities and their families in zambia 59 concluded that in low and middleincome countries especially in lowincome communities the stigma of disability reduces their opportunities for participation and they advocated for communitybased interventions as a viable and acceptable approach to interacting with the community and families of children with disabilities although it was a pilot study families and individuals in the community reported less perceived rejection from family and peers but the agreement that children with disabilities should be treated in the same way as other children was minor 59 these findings are consistent with this research as there was less awareness of stigma on the part of participating people with disabilities and a less stigmatizing attitude on the part of the community was observed after the intervention the provision of therapeutic services based on western practice in other types of communities causes challenges and conflicts because the differences between cultural beliefs values and customs are significant and can be an important barrier to the development of interventions therefore one study concludes that it is necessary to develop an appropriate epistemology for nonwestern cultures that provides guidelines for successfully implementing such services tailored to the people of those communities 60 more research about what kinds of strategies are successful in these nonwestern contexts through studies developed with and adapted to local populations are needed such as this research this study has both strengths and weaknesses the implementation of a community intervention in a population with limited resources and the good results in terms of the participation of both persons with disabilities and their families and the rest of the community with the aim of improving social participation and reducing the stigma towards disability is the greatest strength furthermore the fact that there was a significant improvement in all the variables studied is encouraging and facilitates the approach of future similar lines of research in this or other communities on the other hand the design has methodological limitations that should be pointed out as weaknesses the sample was reduced in people with disabilities and in the people who completed the aq27 questionnaire using a nonprobability sampling in addition there was no control group so it could not be guaranteed that the changes that occurred were due to the intervention although standardized and validated tests were used to evaluate some aspects in others it was not possible hence the elaboration of an ad hoc questionnaire which despite not having the psychometric properties offered by the validated scales provides relevant information and highlights the need to create appropriate assessment tools for nonwestern communities the present research provides evidence about the importance of community interventions in populations in which people with disabilities are subject to great stigma from society and from themselves the community perspective allows professionals to address issues involved with people s reality generating a space for communication dialogue and participation and which also favors social cohesion it is a continuous dynamic and dialectical process that improves the living conditions of a certain community and permits the formation of nonhierarchical relationships maintaining horizontality in power and knowledge future research with a larger and more representative sample is recommended allowing the intervention to be extrapolated to other locations conclusions most of the existing studies have been carried out from a western approach and in populations that are not closely related to the one investigated in the present study it is necessary to carry out research in this type of population so this study constitutes an interesting contribution by investigating aspects such as volition in the performance of different activities quality of life and awareness of the stigma of people with disabilities additionally it considers the stigmatizing attitudes of society towards these people the intervention was positive in that it improved all the variables studied using standardized instruments and in relation to variables of the ad hoc questionnaire the intervention was also effective in improving cognitive level emotional state occupational behavior adl communication and interaction skills and social functioning this study provides evidence that justifies community ot intervention and proposes more interventions and research in this line which appear to be effective in addition it would be very convenient to replicate the results and establish studies that include a control group

in morocco the social and environmental context influences the volition and development of meaningful activities creating physical personal and social barriers to the occupational performance of people with disabilities this study develops a community occupational therapy program in order to verify its effectiveness in the volition quality of life and perceived selfstigma of people with disabilities in the moroccan city of azrou and to reduce the stigma of the community towards people with disabilities in the city data were collected from people with disabilities who participated in the program n 52 using the volitional questionnaire vq the world health organization quality of life scale whoqolbref the stigma awareness questionnaire scq and an ad hoc interview in addition community stigma was assessed by the attribution questionnaire aq27 in citizens without disabilities n 42 results confirmed that this intervention favors the inclusion of people with disabilities in their closest environment improving volition and quality of life and reducing selfstigma furthermore the communitys stigma towards people with disabilities was also significantly reduced after the intervention

Introduction Over the past century, with urbanization and industrialization, the number of migrant workers has been increasing around the world. The amount of migrant workers has reached about 250 million, according to available estimates, which would continue to increase in the future. However, various studies have shown that the welfare of migrant workers has been faced with challenges, such as mental problems, discrimination, and unfavorable social security [1,2]. The group of migrant workers has raised a lot of concerns. In fact, the number of migrant workers has been underestimated. Due to China's special system of residential registration , a large number of farmers with the characteristics of migrant workers are not included in the statistics, and they face the same dilemma as international migrant workers. According to the official statistics from the Chinese government, there are 292.51 million migrant workers in China in 2021. Of the 292.51 million migrant workers, only 133.09 million of them have fixed residences in urban areas [3], while more than half of the migrant workers live in rural villages most of the time. In addition, because of the registered residence system and other unique policy factors in China, the group of migrant workers have to engage in heavy physical and intensive work, and they are faced with hard work and living situations. For instance, they are involved with "3D" jobs that are dangerous, dirty and demanding; they are exposed to poor working conditions; they have limited access to the same welfare of the healthcare system, education, and housing, compared with the local residents [4][5][6][7][8][9]. A question arises; faced with such poor working conditions and social welfare, why are these farmers willing to travel thousands of miles from home to engage in migration work? Whether and how the migration working experience changes them? We believe that the traditional economic analysis which mainly focuses on the pursuit of economic returns can no longer reasonably explain these phenomena. In this study, we provide a robust estimation of the effects of migration working experience on a farmer's social capital, as well as the influence mechanism in rural China. The objectives of this study are two-fold. The first is to apply a mediation model to explore how migration experience affects social capital through risk attitude, household income, and ICT adoption. The second is to investigate how ICT adoption mitigates the effects of migration experience on social capital through changing risk attitudes and household income. Specifically, migration experience changes the farmers' risk attitude, increases household income and promotes ICT adoption, resulting in increasing farmers' social capital. Meanwhile, the adoption of ICTs has a substitution effect on the migration experience affecting farmers' risk attitude and household income. To our knowledge, this study is among the first to investigate the effects of migration experience on farmers' social capital, along with its mechanism in rural China, and therefore, help shed light on the issue. What is more important is that our study also has important implications for developing countries with similar characteristics of massive rural-to-urban labor migration to China. The remainder of this paper is organized as follows. In Section 2 we provide a theoretical analysis and research hypothesis, followed by the materials and methods in Section 3. Section 4 presents the estimation results. Section 5 presents a discussion, and Section 6 concludes. --- Theoretical Analysis and Research Hypothesis The existing studies have investigated the migrant workers' health conditions, and show that migrant workers endure worse mental conditions compared to local workers [10]. Similar evidence was found with internal migrants in China [11][12][13]. For example, a study examined the prevalence and the socio-demographic correlations of the mental health of migrant workers in Shanghai China and found that 25% of the male and 6% of female migrant workers could be classified as mentally unhealthy [14]. China has implemented the system of residential registration since 1958. Under this institutional arrangement, each citizen can be categorized as having an "urban" or "rural" belonging [12]. Due to the implementation of the Hukou system, public resources and social welfare are unevenly distributed between rural and urban areas [15]. In other words, urban citizens with a local Hukou enjoy better services than those who do not have Hukou. Consequently, rural-to-urban migrants do not have access to full citizenship rights and are unable to enjoy the same social, economic, and political rights [16][17][18], and are often treated as "second-class citizens", suffering from discrimination in housing, education, employment, and health care in cities [19]. Despite migrant workers being confronted with these horrible situations, still, Chinese migrant workers have seen a steady rise since rural reforms and open policies were implemented in China from 1979, with 292.51 million rural migrants in 2021 [20]. Some studies suggest that since migrants typically leave their homes to improve their economic status and increase job opportunities, this may lead to improved psychological health [21,22]. In particular, China is a country with the largest population and amount of urban-to-rural migrant workers; it is necessary to pay attention to the social welfare of this group of people. For most migrant workers, they migrate to work to find a stable employment opportunity and acquire the Hukou in urban cities, since they would be able to enjoy better public services, including education, housing, health care, and social security. Historically, very few migrant workers made it and stayed, while others would have to move periodically between the city and the countryside. For those people, the most typical and largest group of Chinese migrant workers, what has the migration working experience changed for them? Several questions arise, why do these migrant workers, namely farmers, choose to migrate to urban areas? What impact it has on migrants? How it changes farmers? Most of the existing studies are focused on the physical and mental health and well-being of migrant workers, with little knowledge on whether and how the migrant working experience changes the farmers, especially their social capital. Maslow's demand theory provides a possible theoretical explanation for the behavior of Chinese migrant workers. They know that there is little chance of them settling down in the cities for migrant work, but they still prefer to sacrifice their health and welfare and move between the cities and the countryside in cycles. Do migrant workers have other pursuits beyond economic returns and social welfare, like social approval? Although there have been several studies investigating the impact of migration on social capital, the results are unclear or even conflicting. Some literature suggest that the increasing migrant population in agricultural fields augments their social isolation because the growing competition for scarce employment opportunities dissolves social and relation bonds [23], others argue that migration experience contributes to promoting social capital [24]. Moreover, the influence mechanism remains unclear and has not yet been fully understood. Our study may contribute to explaining why a large number of farmers are still willing to engage in migration work even though they may suffer from poor working conditions and social welfare. More importantly, we have not only shown that this effect exists, but we have also shown some possible mechanisms of influence. In the process of analyzing the results of the economic model, we introduce representative cases to further prove our conclusion. Through the review of previous studies, we found the following possible influencing mechanisms, and on this basis, we proposed a research hypothesis. In general migrant workers are faced with two options, either stay and keep seeking better life prospects in cities or go back to their hometowns. For those who decide to come back, they are likely to have higher social capital than those local farmers who don't have migrant working experience. Firstly, the migration experience has a positive impact on labor income [25], and the returnees earn more than the overall wage earners with the same education and skill levels [26], and have better chances of becoming entrepreneurs [24,27]. That is, farmers with migration experience tend to make more money and become wealthier than their local counterparts, considering the wage differences between the non-agricultural sectors and agricultural sectors, and thus, enrich social capital. Meanwhile, farmers with migration experience are likely to prefer risks and be more adventurous, since migration can be seen as a kind of risk investment, and risk attitudes can produce an effect on the migration decision [28,29]. The rural-to-urban migrants and their family members are substantially less risk-averse than stayers [30]. The risk attitude, in turn, may have an impact on their social capital, since risk aversion is strongly correlated to local network clustering, that is, the probability that one has a social tie to friends of friends [31]. Particularly, in our study, risk attitude is defined as the traditional concept of economics. Risk attitude refers to people's attitudes towards risk. Specifically, it is a mental state when people are faced with positive or negative uncertainty. In other words, it is the way people choose to respond to perceptions of important uncertainty. Risk attitudes are generally divided into three types: Risk averse, Risk neutral, and Risk appetite. More importantly, the development of information and communications technologies has reshaped people's lives and behaviors. ICTs provide easier access to social support [32], multiplex stronger social network structures [33], and more complicated personal relationships [34,35]. These social networks are the fundamental resources for them to create social capital [36], especially for migrant workers [37]. Hence, farmers with migration experience are likely to access more ICTs, and thus, have higher social capital than those who do not. Based on our observation and previous studies, we established a conceptual framework, considering the role of income, risk attitude, and ICT adoption in the effects of farmers' migration working experience on their social capital. A possible mechanism is shown in Figure 1. Hence, we propose the following hypothesis: H1. Migration experience has a significantly positive effect on farmers' social capital. --- H2. The impact of migration experience on social capital is positively mediated by risk preference. --- H3. The impact of migration experience on social capital is positively mediated by household income. --- H4. The impact of migration experience on social capital is positively mediated by the adoption of information and communications technologies . H5. ICT adoption has a moderating effect, and can help mitigate the impact of migration experience on household income and farmer risk attitude. farmers' migration working experience on their social capital. A possible mechanism is shown in Figure 1. Hence, we propose the following hypothesis: H1. Migration experience has a significantly positive effect on farmers' social capital. --- H2. The impact of migration experience on social capital is positively mediated by risk preference. H3. The impact of migration experience on social capital is positively mediated by household income. --- H4. The impact of migration experience on social capital is positively mediated by the adoption of information and communications technologies . H5. ICT adoption has a moderating effect, and can help mitigate the impact of migration experience on household income and farmer risk attitude. --- Materials and Methods --- Empirical Models --- Mediation Model for Baseline Regression In order to examine the mechanism of how the migration working experience affects farmers' social capital , we employ a mediation model to explore whether farmers' income, risk attitude, and ICT adoption mediate the effect of MWE on SC. The mediating effect mainly tests the role of household income, farmer risk attitude, and ICT adoption. The three-model system is widely used and constructed to examine the mediating effects of mediators, we set up the three-model system as follows: = + + + = + + + = + + + + Here, indicates the migration working experience of the farmer ; is income, risk attitude, and ICT adoption of the farm , namely, the mediators; is a vector of other variables affecting SC such as the farmer's education level and is a random error term. Specifically, we first test the direct effects of MWE on SC without considering the three mediator variables in Equation . Then, we explore the effects of MWE on three mediator variables in Equation . The last step is to investigate the effects of MWE and --- Materials and Methods --- Empirical Models --- Mediation Model for Baseline Regression In order to examine the mechanism of how the migration working experience affects farmers' social capital , we employ a mediation model to explore whether farmers' income, risk attitude, and ICT adoption mediate the effect of MWE on SC. The mediating effect mainly tests the role of household income, farmer risk attitude, and ICT adoption. The three-model system is widely used and constructed to examine the mediating effects of mediators, we set up the three-model system as follows: SC i = γ 0 + γ 1 MWE i + γ 2 X ki + ε 1i M i = a 0 + a 1 MWE i + a 2 X ki + ε 2i (2 ) SC i = ρ 0 + ρ 1 MWE i + ρ 2 M li + ρ 3 X ki + ε 3i Here, MWE i indicates the migration working experience of the farmer i; M i is income, risk attitude, and ICT adoption of the farm i, namely, the mediators; X ki is a vector of other variables affecting SC such as the farmer's education level and ε i is a random error term. Specifically, we first test the direct effects of MWE on SC without considering the three mediator variables in Equation . Then, we explore the effects of MWE on three mediator variables in Equation . The last step is to investigate the effects of MWE and three mediator variables on SC in Equation . If we find a 1 equal to 0, ρ 2 equal to 0, or ρ 1 equal to γ 1 , then we cannot reject the null hypothesis that there is not a mediating effect. --- Moderating Effects of ICT Adoption To better understand the role of ICT adoption in the relationship among MWE, income, risk attitude, and SC, we introduce a dummy variable, ICT adoption. Both this dummy variable and its interaction with MWE are incorporated into the regression, so that: Income i = m 1 + m 2 MWE i + m 3 X ki + m 4 ICT i + m 5 MWE i × ICT i + ε 4i (4 ) Risk attitude i = n 1 + n 2 MWE i + n 3 X ki + n 4 ICT i + n 5 MWE i × ICT i + ε 5i --- Data This study utilizes a data set which was obtained by a face-to-face questionnaire survey administered by the National Agricultural and Rural Development Research Institute of China Agricultural University in 2019. Multistage sampling was employed for data collection. First, 14 provinces were chosen. Second, the towns were selected in each province based on the grain production area. Then, 1-2 villages were randomly selected from each town. Next, 15-20 farm households were chosen from each village. High-quality survey data is one of the most important advantages of our survey. From November to December 2018, the NARI recruited the most qualified interviewers, mostly students from CAU, and trained them to guarantee that they can collect appropriate data during the survey. In fact, most of the students already had sufficient experience in surveys. The survey was conducted from January to February 2019 when the university was on winter vacation. After cleansing and dropping the inconsistent and incomplete questionnaires, the final data set consists of 2863 farm households across 14 provinces, namely Inner Mongolia, Jilin, Sichuan, Anhui, Shandong, Jiangsu, Jiangxi, Hebei, Henan, Hubei, Hunan, Gansu, Liaoning, and Heilongjiang, as is shown in Figure 2. three mediator variables on SC in Equation . If we find equal to 0, equal to 0, or equal to , then we cannot reject the null hypothesis that there is not a mediating effect. --- Moderating Effects of ICT Adoption To better understand the role of ICT adoption in the relationship among MWE, income, risk attitude, and SC, we introduce a dummy variable, ICT adoption. Both this dummy variable and its interaction with MWE are incorporated into the regression, so that: = + + + + × + = + + + + × + --- Data This study utilizes a data set which was obtained by a face-to-face questionnaire survey administered by the National Agricultural and Rural Development Research Institute of China Agricultural University in 2019. Multistage sampling was employed for data collection. First, 14 provinces were chosen. Second, the towns were selected in each province based on the grain production area. Then, 1-2 villages were randomly selected from each town. Next, 15-20 farm households were chosen from each village. High-quality survey data is one of the most important advantages of our survey. From November to December 2018, the NARI recruited the most qualified interviewers, mostly students from CAU, and trained them to guarantee that they can collect appropriate data during the survey. In fact, most of the students already had sufficient experience in surveys. The survey was conducted from January to February 2019 when the university was on winter vacation. After cleansing and dropping the inconsistent and incomplete questionnaires, the final data set consists of 2863 farm households across 14 provinces, namely Inner Mongolia, Jilin, Sichuan, Anhui, Shandong, Jiangsu, Jiangxi, Hebei, Henan, Hubei, Hunan, Gansu, Liaoning, and Heilongjiang, as is shown in Figure 2. Observations from the 14 provinces are shown in Table 1. --- Variables --- Dependent variable In our study, we focus on the impact of the farmer's migration working experience on social capital and its influence mechanism. Our dependent variable is social capital , which is measured as two indicators. Social capital. The Spring Festival, namely Chinese New Year, is the most important traditional holiday in China. During the Spring Festival, people would visit and greet each other. The higher a person's social status is, the more people would come and visit. With the popularization of Internet technology, people would greet each other via phone calls, instant messaging software, and other modern technologies during the Spring Festival. Although the ways that people greet each other have changed, what's underneath remains, that is, more greetings mean stronger social capital. In our study, social capital is measured as the amount of people that the farm household received greetings from in various ways, including video calls, phone calls, WeChat, etc., during the Spring Festival. Weak ties in social capital. The structure of social capital is complex and includes family members, relatives, people in the same villages, and ordinary friends. Social relations can be categorized into two groups, strong ties and weak ties. In particular, strong ties denote social relations formed naturally and people don't have to nurture them intentionally, including relations with family members, relatives, and people in the same villages. Weak ties represent social relations that the farmer has to nurture and maintain, in our case, with ordinary friends. In our study, we measure weak ties in social capital using the percentage of the number of greetings received from ordinary friends in the total number of greetings. It is important to observe the differences between strong ties and weak ties, especially in rural China, with the special influence of village relationships in traditional culture [38]. We take into account weak ties since kinship and natural factors are excluded from weak ties in social capital. In this way, we can capture the actual social capital increased by MWE more accurately. --- Independent variables of interest We use two variables to measure migration working experience, MWE and MWE-year. The former is used for baseline regression, the latter is for robustness test. MWE. We use a dummy variable, whether the farmer has once engaged off-farm employment, to measure MWE. In our questionnaire, farmers were asked about the specific place they worked as migrant workers. At the same time, we gave a very specific definition of the distance of migration, which can be divided into four levels: outside village, outside township, outside county, and outside province. Since the differences between neighboring villages within the same town in China are relatively small, and people are most likely to engage in agricultural production in the village, we only consider the migration experience outside the town. That is to say, the experience of a farmer who migrated to the neighborhood village is not considered to have MWE. MWE-year. To provide robustness checks, we use the years that the farmer engaged in off-farm employment , to replace MWE dummy variable and rerun the regressions. --- Mediators Income. It is measured as the total income of the farm household in 2018, including agricultural income and non-agricultural income. Risk attitude. Particularly, in our study, risk attitude is defined as the traditional concept of economics. Risk attitude refers to people's attitudes towards risk. Specifically, it is a mental state when people are faced with positive or negative uncertainty. Or, in other words, the way people choose to respond to perceptions of important uncertainty. Risk attitudes are generally divided into three types: Risk averse, Risk neutral, and Risk appetite. In the survey process, we used the research methods of the most authoritative survey databases in China, such as the China Household Finance Survey , to measure the risk attitude of farmers. The survey asked the farm household head a question, "if you have 10,000 CNY to conduct financial investment, which of the following three choices do you prefer?" Choice 1 = "earn 400 CNY in the best case and no loss in the worst case", 2 = "earn 1700 CNY in the best case and loss 1000 CNY in the worst case", and 3 = "earn 9600 CNY in the best case and loss 4800 CNY in the worst case". A larger value means a higher risk preference. Information and communications technologies . We use a dummy variable, whether the farmer used a smart phone or personal computer to search for information over 4G mobile networks or the Internet, or connect people by an instant messaging software such as WeChat, to measure ICT adoption. We take WeChat as an important indicator of information technology adoption because WeChat is an important way for farmers in rural China to obtain information. WeChat integrates the RSS function and search function, so farmers can not only receive an information push, but also take the initiative to obtain information. --- Control variables Following the existing studies, we control for farm household and farmer characteristics, including the age, gender, education, and health condition of the farm household decision maker, village cadres experience, labor allocation, hilly land ratio, agricultural income ratio, etc. [39][40][41][42][43][44][45][46]. --- Descriptive Statistics A statistical description of variables is presented in Table 2. It shows that 41.4% of the farm households had off-farm work experience over 6 months, while the rest of them engaged in agricultural production most of the time. Meanwhile, the majority of farmers chose a conservative financial investment strategy. The social capital shows significant differences among the farm households, as the standard deviation is greater than the mean and the extreme value is large. The weak ties in social capital are small, which means that most of the farm households' social relations are still focused on their families or closer friends, that is, strong ties. The average age of the farm household head is over 50 years old. The average education level is primary school and junior-middle school, implying that the human capital of rural households is relatively small. The self-reported health condition is good, and the proportion of village cadres is low, reflecting the realistic constraints of the relatively low level of human capital of the interviewed farmers. Most of the household labor force is still concentrated on agricultural production, but the source of income of most families does not depend on agriculture, reflecting the limited contribution of agriculture to farmers' income. By comparing the surveyed farmers with and without MWE, as shown in Table 3, it can be found that there are significant mean differences in social capital and weak ties in social capital between the two groups: farmers with MWE have a larger number of people who connect with them during the Spring Festival. More importantly, farmers in MWE groups have higher weak ties in social capital. A lower proportion of the number of family members, relatives and local residents means they have a wider range of social contacts. This means that farmers in the MWE group have the opportunity to enhance the ability of information acquisition and factors acquisition, and improve the marginal return of factors with the role of higher social capital. --- Results --- Baseline Regression We examine the effect of MWE on SC in three steps. Firstly, we calculate the direct effect of MWE on SC. Then, analyze the mediating effect of farmers' characteristics change, that is, how the MWE affects farmers' income and risk attitude, and then affects their social capital. Finally, we talk about the influence of ICTs, on the one side ICTs have a mediation effect between MWE and SC, on the other side, ICTs also have a moderating effect on the effect of MWE on farmers' income and risk attitude. On one hand, it is clear that leaving rural areas to work in different places will provide farmers with more opportunities to make new friends, and thus, increase their social capital. An interesting phenomenon can be found in our survey, that is, the social connections of migrant workers in cities can be divided into two obvious groups. One social group is contacts from work, the other is fellow townsmen, i.e., people who work in the same city and came from the same hometown. It should be noted that fellow townsmen play an important role in the social relations among migrant workers and the friendship associations among them are extremely tight. This phenomenon is inseparable from China's traditional culture for thousands of years, just like the old Chinese saying that tears swim in the eyes when fellow townsman meet each other. Establishing social networks through fellow villagers' friendly feelings is also an efficient way for farmers to quickly adapt to the new working environment in cities. On the other hand, migration work also increases the scope of connections between farmers and their village residents and relatives. Firstly, their friends and relatives in hometowns tend to consult them in terms of agricultural production decision making, agricultural technology adoption, and even children's education. Working in the city means broader insight and richer sources of information, which can help them make more convincing and rational decisions. Secondly, consistent with the findings of previous studies, farmers who work in cities are likely to reach out to their friends and acquaintances from their hometown through social networks. The longer the farmer stays in the city and more familiar with the city, they are likely to be contacted by their friends and acquaintances from their hometown. To sum up, the empirical analysis based on the survey data at the national level shows that MWE can significantly increase farmers' social capital. The survey data also shows that the increase in farmers' social capital mainly has two sources: one is new friends made in the city due to their work, and the other is people who are still in rural areas but expect to obtain relevant information or job opportunities through them. --- Mediating Effects Our results show that MWE can increase social capital, but little is known about the influence mechanism. Here, we imply a mediation model to analyze the role of income, risk attitude and ICT adoption in the effect of MWE on SC. The estimated results are shown in Table 4. It shows that the coefficient of MWE on SC is significant and positive in columns , , , and , implying that MWE has a significantly positive effect on SC. The coefficient of MWE on farmers' income, risk attitude, and ICT adoption is significant and positive, in columns , , and , respectively, which means that IEW has a positive impact on farmers' income, risk attitude, and ICT adoption. Meanwhile, the coefficient of farmers' income, risk attitude, and ICT adoption on SC are significantly positive in columns , , and , respectively, meaning that they have significantly increased farmers' SC. The results suggest the existence of the mediating effect of income, risk attitude, and ICT adoption, and the total effect mediated by them is 21%, 16%, and 31%, respectively. As expected, migration working experience can not only directly increase the SC of farmers, but also indirectly increase the SC by increasing the farmers' income, changing their risk attitude, and promoting ICT adoption. --- Moderating Effects of ICT Adoption To examine the effect of ICT adoption on the relationship between MWE and farmers' income, we apply OLS regression on Equations and , the results are shown in Table 5. Without considering the impact of ICT adoption, MWE has a significantly positive effect on farmers' income as shown in column . After ICT and the interaction term of ICT adoption and MWE were introduced into the regression, we can see from column that ICT has significant and positive coefficients, implying that ICT adoption can significantly increase farmers' income, but the interaction term of MWE and ICT has significant and negative coefficients, implying that there is a substitution effect between MWE and ICT adoption on the effect of farmers' income. The effect of ICT adoption on the relationship between MWE and farmers' risk attitude is obviously different from income, we also apply OLS regression on Equations and , the results are shown in Table 5. The direct effect of MWE on farmers' risk attitude is significant and positive as shown in column , then we introduce ICT and the interaction term of ICT adoption and MWE into the equation, they both have significant and positive effects on farmers' risk attitude, but the coefficient of MWE changes from significant to insignificant, and the coefficient also becomes negative, what implies that MWE can increase farmers' risk preference, but ICT adoption is the core explanatory variable affecting farmers' risk attitude compared with MWE. --- The Effects of MWE on Social Capital Structure Based on the above theoretical analysis, the influence mechanism of migration working experience on social capital structure is shown in Figure 3. Table 6 reports the direct effect of MWE on farmers' weak ties in social capital . It shows that, without considering the influence of other factors, MWE can directly increase farmers' weak ties in social capital as shown in column . All mediators play the same roles on the effect of MWE on weak ties in social capital like the effect of MWE on SC, but the results of the Sobel test show that ICT adoption plays even more important role, it can explain 40% of the effect of MWE on weak ties in social capital. --- Var In order to better understand how MWE affects farmers' social capital, we take weak ties in social capital as an alternative explanatory variable to further analyze the impact of MWE and its impact mechanism. Table 6 reports the direct effect of MWE on farmers' weak ties in social capital . It shows that, without considering the influence of other factors, MWE can directly increase farmers' weak ties in social capital as shown in column . All mediators play the same roles on the effect of MWE on weak ties in social capital like the effect of MWE on SC, but the results of the Sobel test show that ICT adoption plays even more important role, it can explain 40% of the effect of MWE on weak ties in social capital. --- Robustness Check We use two methods to test the robustness of the baseline regression, one is that we use the year of migration working experience as the explanatory variable; another is that we use the propensity score matching technique to reassess the impact of MWE on SC and weak ties in social capital. --- Alternative Variable for MWE Table 7 reports the direct effect of MWE-year on farmers' SC and weak ties in social capital, only when the immigration work time of farmers in a year exceeds half a year, we count it as one year of migration working experience. This is a further strict definition, which can more accurately measure the migration working experience of farmers. The coefficients of MWE-year in both columns and are significant and positive, it means that the more years the farmers engaged in immigration work the more social capital they have. Furthermore, MWE also significantly enhances the weak tiles in social capital, meaning that the longer they engaged in off-farm work, the more tight social capital structure they have. --- Alternative Empirical Model Based on the results of OLS model, we show that MWE is significantly positively correlated with farmers' SC and weak ties in SC, and the effects are mediated by household income, farmer risk attitude, and ICT adoption. To further examine the impact of MWE on farmers' social capital, we apply a PSM technique. In our study, we use the following different matching methods, the nearest neighbor matching, caliper matching, kernel matching , and local linear regression matching methods, respectively, to estimate the average treatment effect on the treated generated by MWE for samples in the common support domain, that is, the net effect of MWE on social capital. The results of the balance test of covariates are shown in Table 8. The covariate deviation between the two groups of samples was distinguished. The results show that the covariates after PSM matching pass the balance test, which is helpful to the subsequent analysis of the social capital differences between farmers with MWE and farmers without MWE. As reported in Table 9, the PSM estimation results show that MWE has a significant causal effect on SC, which is consistent with our baseline regression results. --- Discussion --- Role of Income There is an idiom in China called "returning home with gold", which means that when you leave your hometown to work and achieve certain achievements or accumulate certain wealth, you will be respected by the people in your hometown, this concept has been deeply rooted in Chinese culture for thousands of years. Therefore, the pursuit of higher income is the core pursuit for farmers to leave their hometowns to work. Industrial and agricultural scissors differences have existed for a long time since the founding of the people's Republic of China. In 1952, China's agricultural net output value accounted for 74.7% of the industrial and agricultural net output value, and 83.5% of the employed population was engaged in agricultural production and the cottage industry. In the following decades, the unified purchase and marketing policy and the urban-rural registered residence system further expanded this income gap, this kind of economic growth competition has not only caused the growth imbalance between urban and rural areas but also caused the regional growth imbalance between the eastern coast and the central and western regions [47]. With the advancement of urbanization in China, the differences between urban and rural are enlarging and show significant regional differences. Specifically, the urban-rural gap in the eastern region is decreasing, while the urban-rural gap in the central and western regions is expanding, leading to the emergence of massive migrant workers. Most of them migrate from the central and western regions of China to the eastern region for higher income. These huge differences in remuneration between agricultural sectors and industrial sectors in China are inseparable from the evolution of urban-rural relations since the implementation of rural reform and open-up policy in 1979. Therefore, based on this historical background, migration working means a higher probability of income growth, which can improve one's prestige in the hometown. It is, therefore, easy to understand how MWE affects farmers' social capital. --- Role of Risk Attitude Previous studies have paid little attention to the impact of risk attitude on farmers' social capital. In our study, we pay attention to the role of risk attitude in the relationship between MWE and SC. MWE brings farmers additional non-agricultural income, which significantly improves their ability to resist risks and increase their risk preference. On one hand, farmers with a higher risk preference have a greater probability of adopting new agricultural technologies and are more willing to adopt new agricultural technologies methods. Agricultural production enables farmers to link with each other, since farmers tend to consult and learn from those who adopt new agricultural production technologies. There is a similar influence mechanism in the sales of agricultural products, for example, the decision to use new sales modes of agricultural products, such as ecommerce. Hence, a higher risk preference enables farmers to accumulate experience and knowledge, which can significantly affect the social capital of farmers. As such, MWE play a role by the mechanism, that is, MWE-Higher risk preference-Higher probability of technology adoption, accumulation of information, experience, and knowledge-More farmers followers-Increasing social capital. On the other hand, a higher risk preference means more job opportunities. In the early stage of China's urbanization, farmers are likely to migrate, which significantly increases income. However, with the continuous advancement of urbanization, this situation has changed, more and more farmers engage in migration work, but the homogeneity of these labor forces is rather high. That is to say, those farmers with higher risk preferences would have more information through more radical and frequent work replacement, which enables them to have stronger social networks in urban areas. As such, MWE plays a role by the mechanism: MWE-Higher risk preference-More frequent job hopping-Accumulation of information, experience, and skills-More farmers followers-Increasing social capital. --- Role of ICT Adoption Compared with income and risk attitude, the effect of ICTs on the relationship between MWE and SC is more complex. On one hand, it plays the same role as MWE and SC do. On the other hand, ICTs have significant and heterogeneous effects on income and risk attitude. For the mechanism "MWE-ICTs-SC", considering "MWE-ICTs", there are significant differences between urban and rural work and life styles. Obviously, ICTs are more widely used in cities, and farmers have to increase the frequency and intensity of ICT adoption to meet the needs of work and life. Considering "ICTs-SC", ICTs can break geographical restrictions and significantly reduce the cost of communication between people, they can communicate with family members or villagers by instant messaging software such as WeChat. What is more, functions like group chat and WeChat Moments can easily connect hundreds of people or even more. For the mechanism "MWE--Income", MWE can directly promote income, while the use of ICTs can slow down the process of MWE on income. It implies that the use of ICTs can be a substitute for migration to increase household income. From the logic of how MWE and ICTs increase household income, the results are implausible. As analyzed before, MWE plays a significant role in accessing more information, experience and knowledge through migration work. MWE has a positive impact on household income. ICTs can do the same thing since it lowers the cost of accessing information. During the field surveys, we also found that ICTs can easily break the geographical limitations among farmers, which decreases communication costs. For the mechanism "MWE--Risk attitude", MWE can directly promote farmers' risk preference, and ICT adoption can enhance the effect of MWE on risk attitude. More importantly, ICT adoption has a complete substitution effect on MWE. Based on the analysis above, although we have known the key role of ICTs, the results still exceed our expectations. To some extent, it implies that the information obtained through ICTs and migration work has the same effect on the change of farmers' risk attitude. Another possible explanation is that information brought by ICTs can provide migrant farmers with more employment information. It raises their expectations for the future, and therefore, they have higher risk preferences. --- Further Discussion of Social Capital Structure Based on China's special rural culture, we believe that the analysis of the social capital structure is a necessary extension of the discussion. Xiaotong Fei, the founder of Chinese sociology, proposed "the Pattern of Difference Sequence" of Chinese rural society. It vividly describes the interpersonal pattern of closeness in Chinese rural society, a rating-circle structure from inside to outside refers to family members, relatives, fellow villagers and friends, and it also means that the social relations expand from strong social ties to weak social ties. It likes a halo spreading on the water, extending from oneself, dividing closeness and distance according to the distance from oneself. In traditional Chinese culture, there is a natural trust between relatives and fellow villagers, this leads to heterogeneity in the social capital structure. Therefore, we use the concept of social capital structure to reinforce the effect of MWE on weak social ties. The results show that the effects of MWE on social capital are multifaceted, which not only strengthens the connection between farmers and strong social ties, but also weak social ties. About the effects on social capital structure, we also found an interesting case during our survey. Migrant workers may spend more time away from their hometowns, and they have to maintain social relations at work. Therefore, they do not have to spend much more time to maintain strong social ties than they would have to maintain weak ties. --- Conclusions In this study, based on a survey data set of 2863 farm households in 14 provinces in China, mediating effect model and moderating effect model are used to analyze the effect of migration working experience on farmers' social capital . We show that MWE has a significant positive impact on SC, which is mediated by household income, farmer risk attitude, and ICT adoption. Moreover, ICT adoption can mitigate the process of MWE affecting income and risk attitude, and have heterogeneous substitution effects. To provide robustness checks, we used the months of migration working and weak ties in social capital to replace core explanatory variables and dependent variables, respectively, and the estimation results are consistent. Our results clearly indicated that MWE can significantly enhance farmers' social capital by increasing income, promoting risk preference, and ICT adoption. Meanwhile, MWE is likely to have a strong externality, that is, one connects frequently with people who have MWE and would benefit from their accumulation of information, technologies, skills and knowledge. It is the key to how MWE enhances farmers' social capital. This study contributes to a better understanding of the phenomenon that people are willing to work as migrant workers even though they may suffer from unfair treatment and the loss of welfare. More importantly, this study has specific policy implications. It is necessary and beneficial to encourage migration, because it not only improves the welfare of migrants, but also helps improve the welfare of those who stay in close contact with them. MWE plays a similar role to "Xiangxian", a traditional Chinese cultural concept which means people of great prestige in the village. Of course, policies should be carried out by the government to guarantee the legitimate rights and interests of migrant workers, as many researchers and policymakers have noticed. The generalization of this study is subject to certain limitations. For example, limited by financial support the study is focused on migrant workers from the main provinces in China instead of national-level survey. Future studies would consider a wider coverage of provinces. Meanwhile, we focus on the group of farmers who live in the rural areas, instead of those who live the urban areas. It is unknown whether migration working experience has a significant impact on social capital for this group of migrant workers. Further studies may focus on the working conditions and the physical and psychological conditions of the group of migrant workers living in rural areas. --- Data Availability Statement: The data that support the findings of this study were obtained from the survey conducted by the National Agricultural and Rural Development Research Institute at China Agricultural University. ---

While a growing number of farmers migrate to urban sectors to engage in off-farm employment, little is known whether and how the migration working experience (MWE) changes farmers, especially their social capital. Using a survey data set with 2863 farm households in 14 provinces in China, we developed a mediation model to examine the impact of MWE on social capital, as well as the roles of household income, farmers' risk attitude, and information and communications technologies (ICTs). We show that MWE has a significantly positive impact on social capital and weak ties in social capital, which is mediated by household income, risk attitude, and ICT adoption. In particular, MWE can increase income, enhance risk preference, and promote ICT adoption, thus, leading to higher social capital. Moreover, ICTs play a moderating role in the impact of MWE on income and risk preference, that is, ICTs can decrease the impact of MWE on income, and completely substitute the impact of MWE on risk attitude. Our study provides an explanation for the reason why farmers are willing to migrate despite unfavorable working conditions they may endure in urban areas.

introduction over the past century with urbanization and industrialization the number of migrant workers has been increasing around the world the amount of migrant workers has reached about 250 million according to available estimates which would continue to increase in the future however various studies have shown that the welfare of migrant workers has been faced with challenges such as mental problems discrimination and unfavorable social security 12 the group of migrant workers has raised a lot of concerns in fact the number of migrant workers has been underestimated due to chinas special system of residential registration a large number of farmers with the characteristics of migrant workers are not included in the statistics and they face the same dilemma as international migrant workers according to the official statistics from the chinese government there are 29251 million migrant workers in china in 2021 of the 29251 million migrant workers only 13309 million of them have fixed residences in urban areas 3 while more than half of the migrant workers live in rural villages most of the time in addition because of the registered residence system and other unique policy factors in china the group of migrant workers have to engage in heavy physical and intensive work and they are faced with hard work and living situations for instance they are involved with 3d jobs that are dangerous dirty and demanding they are exposed to poor working conditions they have limited access to the same welfare of the healthcare system education and housing compared with the local residents 4 5 6 7 8 9 a question arises faced with such poor working conditions and social welfare why are these farmers willing to travel thousands of miles from home to engage in migration work whether and how the migration working experience changes them we believe that the traditional economic analysis which mainly focuses on the pursuit of economic returns can no longer reasonably explain these phenomena in this study we provide a robust estimation of the effects of migration working experience on a farmers social capital as well as the influence mechanism in rural china the objectives of this study are twofold the first is to apply a mediation model to explore how migration experience affects social capital through risk attitude household income and ict adoption the second is to investigate how ict adoption mitigates the effects of migration experience on social capital through changing risk attitudes and household income specifically migration experience changes the farmers risk attitude increases household income and promotes ict adoption resulting in increasing farmers social capital meanwhile the adoption of icts has a substitution effect on the migration experience affecting farmers risk attitude and household income to our knowledge this study is among the first to investigate the effects of migration experience on farmers social capital along with its mechanism in rural china and therefore help shed light on the issue what is more important is that our study also has important implications for developing countries with similar characteristics of massive ruraltourban labor migration to china the remainder of this paper is organized as follows in section 2 we provide a theoretical analysis and research hypothesis followed by the materials and methods in section 3 section 4 presents the estimation results section 5 presents a discussion and section 6 concludes theoretical analysis and research hypothesis the existing studies have investigated the migrant workers health conditions and show that migrant workers endure worse mental conditions compared to local workers 10 similar evidence was found with internal migrants in china 11 12 13 for example a study examined the prevalence and the sociodemographic correlations of the mental health of migrant workers in shanghai china and found that 25 of the male and 6 of female migrant workers could be classified as mentally unhealthy 14 china has implemented the system of residential registration since 1958 under this institutional arrangement each citizen can be categorized as having an urban or rural belonging 12 due to the implementation of the hukou system public resources and social welfare are unevenly distributed between rural and urban areas 15 in other words urban citizens with a local hukou enjoy better services than those who do not have hukou consequently ruraltourban migrants do not have access to full citizenship rights and are unable to enjoy the same social economic and political rights 16 17 18 and are often treated as secondclass citizens suffering from discrimination in housing education employment and health care in cities 19 despite migrant workers being confronted with these horrible situations still chinese migrant workers have seen a steady rise since rural reforms and open policies were implemented in china from 1979 with 29251 million rural migrants in 2021 20 some studies suggest that since migrants typically leave their homes to improve their economic status and increase job opportunities this may lead to improved psychological health 2122 in particular china is a country with the largest population and amount of urbantorural migrant workers it is necessary to pay attention to the social welfare of this group of people for most migrant workers they migrate to work to find a stable employment opportunity and acquire the hukou in urban cities since they would be able to enjoy better public services including education housing health care and social security historically very few migrant workers made it and stayed while others would have to move periodically between the city and the countryside for those people the most typical and largest group of chinese migrant workers what has the migration working experience changed for them several questions arise why do these migrant workers namely farmers choose to migrate to urban areas what impact it has on migrants how it changes farmers most of the existing studies are focused on the physical and mental health and wellbeing of migrant workers with little knowledge on whether and how the migrant working experience changes the farmers especially their social capital maslows demand theory provides a possible theoretical explanation for the behavior of chinese migrant workers they know that there is little chance of them settling down in the cities for migrant work but they still prefer to sacrifice their health and welfare and move between the cities and the countryside in cycles do migrant workers have other pursuits beyond economic returns and social welfare like social approval although there have been several studies investigating the impact of migration on social capital the results are unclear or even conflicting some literature suggest that the increasing migrant population in agricultural fields augments their social isolation because the growing competition for scarce employment opportunities dissolves social and relation bonds 23 others argue that migration experience contributes to promoting social capital 24 moreover the influence mechanism remains unclear and has not yet been fully understood our study may contribute to explaining why a large number of farmers are still willing to engage in migration work even though they may suffer from poor working conditions and social welfare more importantly we have not only shown that this effect exists but we have also shown some possible mechanisms of influence in the process of analyzing the results of the economic model we introduce representative cases to further prove our conclusion through the review of previous studies we found the following possible influencing mechanisms and on this basis we proposed a research hypothesis in general migrant workers are faced with two options either stay and keep seeking better life prospects in cities or go back to their hometowns for those who decide to come back they are likely to have higher social capital than those local farmers who dont have migrant working experience firstly the migration experience has a positive impact on labor income 25 and the returnees earn more than the overall wage earners with the same education and skill levels 26 and have better chances of becoming entrepreneurs 2427 that is farmers with migration experience tend to make more money and become wealthier than their local counterparts considering the wage differences between the nonagricultural sectors and agricultural sectors and thus enrich social capital meanwhile farmers with migration experience are likely to prefer risks and be more adventurous since migration can be seen as a kind of risk investment and risk attitudes can produce an effect on the migration decision 2829 the ruraltourban migrants and their family members are substantially less riskaverse than stayers 30 the risk attitude in turn may have an impact on their social capital since risk aversion is strongly correlated to local network clustering that is the probability that one has a social tie to friends of friends 31 particularly in our study risk attitude is defined as the traditional concept of economics risk attitude refers to peoples attitudes towards risk specifically it is a mental state when people are faced with positive or negative uncertainty in other words it is the way people choose to respond to perceptions of important uncertainty risk attitudes are generally divided into three types risk averse risk neutral and risk appetite more importantly the development of information and communications technologies has reshaped peoples lives and behaviors icts provide easier access to social support 32 multiplex stronger social network structures 33 and more complicated personal relationships 3435 these social networks are the fundamental resources for them to create social capital 36 especially for migrant workers 37 hence farmers with migration experience are likely to access more icts and thus have higher social capital than those who do not based on our observation and previous studies we established a conceptual framework considering the role of income risk attitude and ict adoption in the effects of farmers migration working experience on their social capital a possible mechanism is shown in figure 1 hence we propose the following hypothesis h1 migration experience has a significantly positive effect on farmers social capital h2 the impact of migration experience on social capital is positively mediated by risk preference h3 the impact of migration experience on social capital is positively mediated by household income h4 the impact of migration experience on social capital is positively mediated by the adoption of information and communications technologies h5 ict adoption has a moderating effect and can help mitigate the impact of migration experience on household income and farmer risk attitude farmers migration working experience on their social capital a possible mechanism is shown in figure 1 hence we propose the following hypothesis h1 migration experience has a significantly positive effect on farmers social capital h2 the impact of migration experience on social capital is positively mediated by risk preference h3 the impact of migration experience on social capital is positively mediated by household income h4 the impact of migration experience on social capital is positively mediated by the adoption of information and communications technologies h5 ict adoption has a moderating effect and can help mitigate the impact of migration experience on household income and farmer risk attitude materials and methods empirical models mediation model for baseline regression in order to examine the mechanism of how the migration working experience affects farmers social capital we employ a mediation model to explore whether farmers income risk attitude and ict adoption mediate the effect of mwe on sc the mediating effect mainly tests the role of household income farmer risk attitude and ict adoption the threemodel system is widely used and constructed to examine the mediating effects of mediators we set up the threemodel system as follows here indicates the migration working experience of the farmer is income risk attitude and ict adoption of the farm namely the mediators is a vector of other variables affecting sc such as the farmers education level and is a random error term specifically we first test the direct effects of mwe on sc without considering the three mediator variables in equation then we explore the effects of mwe on three mediator variables in equation the last step is to investigate the effects of mwe and materials and methods empirical models mediation model for baseline regression in order to examine the mechanism of how the migration working experience affects farmers social capital we employ a mediation model to explore whether farmers income risk attitude and ict adoption mediate the effect of mwe on sc the mediating effect mainly tests the role of household income farmer risk attitude and ict adoption the threemodel system is widely used and constructed to examine the mediating effects of mediators we set up the threemodel system as follows sc i γ 0 γ 1 mwe i γ 2 x ki ε 1i m i a 0 a 1 mwe i a 2 x ki ε 2i 2 sc i ρ 0 ρ 1 mwe i ρ 2 m li ρ 3 x ki ε 3i here mwe i indicates the migration working experience of the farmer i m i is income risk attitude and ict adoption of the farm i namely the mediators x ki is a vector of other variables affecting sc such as the farmers education level and ε i is a random error term specifically we first test the direct effects of mwe on sc without considering the three mediator variables in equation then we explore the effects of mwe on three mediator variables in equation the last step is to investigate the effects of mwe and three mediator variables on sc in equation if we find a 1 equal to 0 ρ 2 equal to 0 or ρ 1 equal to γ 1 then we cannot reject the null hypothesis that there is not a mediating effect moderating effects of ict adoption to better understand the role of ict adoption in the relationship among mwe income risk attitude and sc we introduce a dummy variable ict adoption both this dummy variable and its interaction with mwe are incorporated into the regression so that income i m 1 m 2 mwe i m 3 x ki m 4 ict i m 5 mwe i × ict i ε 4i 4 risk attitude i n 1 n 2 mwe i n 3 x ki n 4 ict i n 5 mwe i × ict i ε 5i data this study utilizes a data set which was obtained by a facetoface questionnaire survey administered by the national agricultural and rural development research institute of china agricultural university in 2019 multistage sampling was employed for data collection first 14 provinces were chosen second the towns were selected in each province based on the grain production area then 12 villages were randomly selected from each town next 1520 farm households were chosen from each village highquality survey data is one of the most important advantages of our survey from november to december 2018 the nari recruited the most qualified interviewers mostly students from cau and trained them to guarantee that they can collect appropriate data during the survey in fact most of the students already had sufficient experience in surveys the survey was conducted from january to february 2019 when the university was on winter vacation after cleansing and dropping the inconsistent and incomplete questionnaires the final data set consists of 2863 farm households across 14 provinces namely inner mongolia jilin sichuan anhui shandong jiangsu jiangxi hebei henan hubei hunan gansu liaoning and heilongjiang as is shown in figure 2 three mediator variables on sc in equation if we find equal to 0 equal to 0 or equal to then we cannot reject the null hypothesis that there is not a mediating effect moderating effects of ict adoption to better understand the role of ict adoption in the relationship among mwe income risk attitude and sc we introduce a dummy variable ict adoption both this dummy variable and its interaction with mwe are incorporated into the regression so that × × data this study utilizes a data set which was obtained by a facetoface questionnaire survey administered by the national agricultural and rural development research institute of china agricultural university in 2019 multistage sampling was employed for data collection first 14 provinces were chosen second the towns were selected in each province based on the grain production area then 12 villages were randomly selected from each town next 1520 farm households were chosen from each village highquality survey data is one of the most important advantages of our survey from november to december 2018 the nari recruited the most qualified interviewers mostly students from cau and trained them to guarantee that they can collect appropriate data during the survey in fact most of the students already had sufficient experience in surveys the survey was conducted from january to february 2019 when the university was on winter vacation after cleansing and dropping the inconsistent and incomplete questionnaires the final data set consists of 2863 farm households across 14 provinces namely inner mongolia jilin sichuan anhui shandong jiangsu jiangxi hebei henan hubei hunan gansu liaoning and heilongjiang as is shown in figure 2 observations from the 14 provinces are shown in table 1 variables dependent variable in our study we focus on the impact of the farmers migration working experience on social capital and its influence mechanism our dependent variable is social capital which is measured as two indicators social capital the spring festival namely chinese new year is the most important traditional holiday in china during the spring festival people would visit and greet each other the higher a persons social status is the more people would come and visit with the popularization of internet technology people would greet each other via phone calls instant messaging software and other modern technologies during the spring festival although the ways that people greet each other have changed whats underneath remains that is more greetings mean stronger social capital in our study social capital is measured as the amount of people that the farm household received greetings from in various ways including video calls phone calls wechat etc during the spring festival weak ties in social capital the structure of social capital is complex and includes family members relatives people in the same villages and ordinary friends social relations can be categorized into two groups strong ties and weak ties in particular strong ties denote social relations formed naturally and people dont have to nurture them intentionally including relations with family members relatives and people in the same villages weak ties represent social relations that the farmer has to nurture and maintain in our case with ordinary friends in our study we measure weak ties in social capital using the percentage of the number of greetings received from ordinary friends in the total number of greetings it is important to observe the differences between strong ties and weak ties especially in rural china with the special influence of village relationships in traditional culture 38 we take into account weak ties since kinship and natural factors are excluded from weak ties in social capital in this way we can capture the actual social capital increased by mwe more accurately independent variables of interest we use two variables to measure migration working experience mwe and mweyear the former is used for baseline regression the latter is for robustness test mwe we use a dummy variable whether the farmer has once engaged offfarm employment to measure mwe in our questionnaire farmers were asked about the specific place they worked as migrant workers at the same time we gave a very specific definition of the distance of migration which can be divided into four levels outside village outside township outside county and outside province since the differences between neighboring villages within the same town in china are relatively small and people are most likely to engage in agricultural production in the village we only consider the migration experience outside the town that is to say the experience of a farmer who migrated to the neighborhood village is not considered to have mwe mweyear to provide robustness checks we use the years that the farmer engaged in offfarm employment to replace mwe dummy variable and rerun the regressions mediators income it is measured as the total income of the farm household in 2018 including agricultural income and nonagricultural income risk attitude particularly in our study risk attitude is defined as the traditional concept of economics risk attitude refers to peoples attitudes towards risk specifically it is a mental state when people are faced with positive or negative uncertainty or in other words the way people choose to respond to perceptions of important uncertainty risk attitudes are generally divided into three types risk averse risk neutral and risk appetite in the survey process we used the research methods of the most authoritative survey databases in china such as the china household finance survey to measure the risk attitude of farmers the survey asked the farm household head a question if you have 10000 cny to conduct financial investment which of the following three choices do you prefer choice 1 earn 400 cny in the best case and no loss in the worst case 2 earn 1700 cny in the best case and loss 1000 cny in the worst case and 3 earn 9600 cny in the best case and loss 4800 cny in the worst case a larger value means a higher risk preference information and communications technologies we use a dummy variable whether the farmer used a smart phone or personal computer to search for information over 4g mobile networks or the internet or connect people by an instant messaging software such as wechat to measure ict adoption we take wechat as an important indicator of information technology adoption because wechat is an important way for farmers in rural china to obtain information wechat integrates the rss function and search function so farmers can not only receive an information push but also take the initiative to obtain information control variables following the existing studies we control for farm household and farmer characteristics including the age gender education and health condition of the farm household decision maker village cadres experience labor allocation hilly land ratio agricultural income ratio etc 39 40 41 42 43 44 45 46 descriptive statistics a statistical description of variables is presented in table 2 it shows that 414 of the farm households had offfarm work experience over 6 months while the rest of them engaged in agricultural production most of the time meanwhile the majority of farmers chose a conservative financial investment strategy the social capital shows significant differences among the farm households as the standard deviation is greater than the mean and the extreme value is large the weak ties in social capital are small which means that most of the farm households social relations are still focused on their families or closer friends that is strong ties the average age of the farm household head is over 50 years old the average education level is primary school and juniormiddle school implying that the human capital of rural households is relatively small the selfreported health condition is good and the proportion of village cadres is low reflecting the realistic constraints of the relatively low level of human capital of the interviewed farmers most of the household labor force is still concentrated on agricultural production but the source of income of most families does not depend on agriculture reflecting the limited contribution of agriculture to farmers income by comparing the surveyed farmers with and without mwe as shown in table 3 it can be found that there are significant mean differences in social capital and weak ties in social capital between the two groups farmers with mwe have a larger number of people who connect with them during the spring festival more importantly farmers in mwe groups have higher weak ties in social capital a lower proportion of the number of family members relatives and local residents means they have a wider range of social contacts this means that farmers in the mwe group have the opportunity to enhance the ability of information acquisition and factors acquisition and improve the marginal return of factors with the role of higher social capital results baseline regression we examine the effect of mwe on sc in three steps firstly we calculate the direct effect of mwe on sc then analyze the mediating effect of farmers characteristics change that is how the mwe affects farmers income and risk attitude and then affects their social capital finally we talk about the influence of icts on the one side icts have a mediation effect between mwe and sc on the other side icts also have a moderating effect on the effect of mwe on farmers income and risk attitude on one hand it is clear that leaving rural areas to work in different places will provide farmers with more opportunities to make new friends and thus increase their social capital an interesting phenomenon can be found in our survey that is the social connections of migrant workers in cities can be divided into two obvious groups one social group is contacts from work the other is fellow townsmen ie people who work in the same city and came from the same hometown it should be noted that fellow townsmen play an important role in the social relations among migrant workers and the friendship associations among them are extremely tight this phenomenon is inseparable from chinas traditional culture for thousands of years just like the old chinese saying that tears swim in the eyes when fellow townsman meet each other establishing social networks through fellow villagers friendly feelings is also an efficient way for farmers to quickly adapt to the new working environment in cities on the other hand migration work also increases the scope of connections between farmers and their village residents and relatives firstly their friends and relatives in hometowns tend to consult them in terms of agricultural production decision making agricultural technology adoption and even childrens education working in the city means broader insight and richer sources of information which can help them make more convincing and rational decisions secondly consistent with the findings of previous studies farmers who work in cities are likely to reach out to their friends and acquaintances from their hometown through social networks the longer the farmer stays in the city and more familiar with the city they are likely to be contacted by their friends and acquaintances from their hometown to sum up the empirical analysis based on the survey data at the national level shows that mwe can significantly increase farmers social capital the survey data also shows that the increase in farmers social capital mainly has two sources one is new friends made in the city due to their work and the other is people who are still in rural areas but expect to obtain relevant information or job opportunities through them mediating effects our results show that mwe can increase social capital but little is known about the influence mechanism here we imply a mediation model to analyze the role of income risk attitude and ict adoption in the effect of mwe on sc the estimated results are shown in table 4 it shows that the coefficient of mwe on sc is significant and positive in columns and implying that mwe has a significantly positive effect on sc the coefficient of mwe on farmers income risk attitude and ict adoption is significant and positive in columns and respectively which means that iew has a positive impact on farmers income risk attitude and ict adoption meanwhile the coefficient of farmers income risk attitude and ict adoption on sc are significantly positive in columns and respectively meaning that they have significantly increased farmers sc the results suggest the existence of the mediating effect of income risk attitude and ict adoption and the total effect mediated by them is 21 16 and 31 respectively as expected migration working experience can not only directly increase the sc of farmers but also indirectly increase the sc by increasing the farmers income changing their risk attitude and promoting ict adoption moderating effects of ict adoption to examine the effect of ict adoption on the relationship between mwe and farmers income we apply ols regression on equations and the results are shown in table 5 without considering the impact of ict adoption mwe has a significantly positive effect on farmers income as shown in column after ict and the interaction term of ict adoption and mwe were introduced into the regression we can see from column that ict has significant and positive coefficients implying that ict adoption can significantly increase farmers income but the interaction term of mwe and ict has significant and negative coefficients implying that there is a substitution effect between mwe and ict adoption on the effect of farmers income the effect of ict adoption on the relationship between mwe and farmers risk attitude is obviously different from income we also apply ols regression on equations and the results are shown in table 5 the direct effect of mwe on farmers risk attitude is significant and positive as shown in column then we introduce ict and the interaction term of ict adoption and mwe into the equation they both have significant and positive effects on farmers risk attitude but the coefficient of mwe changes from significant to insignificant and the coefficient also becomes negative what implies that mwe can increase farmers risk preference but ict adoption is the core explanatory variable affecting farmers risk attitude compared with mwe the effects of mwe on social capital structure based on the above theoretical analysis the influence mechanism of migration working experience on social capital structure is shown in figure 3 table 6 reports the direct effect of mwe on farmers weak ties in social capital it shows that without considering the influence of other factors mwe can directly increase farmers weak ties in social capital as shown in column all mediators play the same roles on the effect of mwe on weak ties in social capital like the effect of mwe on sc but the results of the sobel test show that ict adoption plays even more important role it can explain 40 of the effect of mwe on weak ties in social capital var in order to better understand how mwe affects farmers social capital we take weak ties in social capital as an alternative explanatory variable to further analyze the impact of mwe and its impact mechanism table 6 reports the direct effect of mwe on farmers weak ties in social capital it shows that without considering the influence of other factors mwe can directly increase farmers weak ties in social capital as shown in column all mediators play the same roles on the effect of mwe on weak ties in social capital like the effect of mwe on sc but the results of the sobel test show that ict adoption plays even more important role it can explain 40 of the effect of mwe on weak ties in social capital robustness check we use two methods to test the robustness of the baseline regression one is that we use the year of migration working experience as the explanatory variable another is that we use the propensity score matching technique to reassess the impact of mwe on sc and weak ties in social capital alternative variable for mwe table 7 reports the direct effect of mweyear on farmers sc and weak ties in social capital only when the immigration work time of farmers in a year exceeds half a year we count it as one year of migration working experience this is a further strict definition which can more accurately measure the migration working experience of farmers the coefficients of mweyear in both columns and are significant and positive it means that the more years the farmers engaged in immigration work the more social capital they have furthermore mwe also significantly enhances the weak tiles in social capital meaning that the longer they engaged in offfarm work the more tight social capital structure they have alternative empirical model based on the results of ols model we show that mwe is significantly positively correlated with farmers sc and weak ties in sc and the effects are mediated by household income farmer risk attitude and ict adoption to further examine the impact of mwe on farmers social capital we apply a psm technique in our study we use the following different matching methods the nearest neighbor matching caliper matching kernel matching and local linear regression matching methods respectively to estimate the average treatment effect on the treated generated by mwe for samples in the common support domain that is the net effect of mwe on social capital the results of the balance test of covariates are shown in table 8 the covariate deviation between the two groups of samples was distinguished the results show that the covariates after psm matching pass the balance test which is helpful to the subsequent analysis of the social capital differences between farmers with mwe and farmers without mwe as reported in table 9 the psm estimation results show that mwe has a significant causal effect on sc which is consistent with our baseline regression results discussion role of income there is an idiom in china called returning home with gold which means that when you leave your hometown to work and achieve certain achievements or accumulate certain wealth you will be respected by the people in your hometown this concept has been deeply rooted in chinese culture for thousands of years therefore the pursuit of higher income is the core pursuit for farmers to leave their hometowns to work industrial and agricultural scissors differences have existed for a long time since the founding of the peoples republic of china in 1952 chinas agricultural net output value accounted for 747 of the industrial and agricultural net output value and 835 of the employed population was engaged in agricultural production and the cottage industry in the following decades the unified purchase and marketing policy and the urbanrural registered residence system further expanded this income gap this kind of economic growth competition has not only caused the growth imbalance between urban and rural areas but also caused the regional growth imbalance between the eastern coast and the central and western regions 47 with the advancement of urbanization in china the differences between urban and rural are enlarging and show significant regional differences specifically the urbanrural gap in the eastern region is decreasing while the urbanrural gap in the central and western regions is expanding leading to the emergence of massive migrant workers most of them migrate from the central and western regions of china to the eastern region for higher income these huge differences in remuneration between agricultural sectors and industrial sectors in china are inseparable from the evolution of urbanrural relations since the implementation of rural reform and openup policy in 1979 therefore based on this historical background migration working means a higher probability of income growth which can improve ones prestige in the hometown it is therefore easy to understand how mwe affects farmers social capital role of risk attitude previous studies have paid little attention to the impact of risk attitude on farmers social capital in our study we pay attention to the role of risk attitude in the relationship between mwe and sc mwe brings farmers additional nonagricultural income which significantly improves their ability to resist risks and increase their risk preference on one hand farmers with a higher risk preference have a greater probability of adopting new agricultural technologies and are more willing to adopt new agricultural technologies methods agricultural production enables farmers to link with each other since farmers tend to consult and learn from those who adopt new agricultural production technologies there is a similar influence mechanism in the sales of agricultural products for example the decision to use new sales modes of agricultural products such as ecommerce hence a higher risk preference enables farmers to accumulate experience and knowledge which can significantly affect the social capital of farmers as such mwe play a role by the mechanism that is mwehigher risk preferencehigher probability of technology adoption accumulation of information experience and knowledgemore farmers followersincreasing social capital on the other hand a higher risk preference means more job opportunities in the early stage of chinas urbanization farmers are likely to migrate which significantly increases income however with the continuous advancement of urbanization this situation has changed more and more farmers engage in migration work but the homogeneity of these labor forces is rather high that is to say those farmers with higher risk preferences would have more information through more radical and frequent work replacement which enables them to have stronger social networks in urban areas as such mwe plays a role by the mechanism mwehigher risk preferencemore frequent job hoppingaccumulation of information experience and skillsmore farmers followersincreasing social capital role of ict adoption compared with income and risk attitude the effect of icts on the relationship between mwe and sc is more complex on one hand it plays the same role as mwe and sc do on the other hand icts have significant and heterogeneous effects on income and risk attitude for the mechanism mweictssc considering mweicts there are significant differences between urban and rural work and life styles obviously icts are more widely used in cities and farmers have to increase the frequency and intensity of ict adoption to meet the needs of work and life considering ictssc icts can break geographical restrictions and significantly reduce the cost of communication between people they can communicate with family members or villagers by instant messaging software such as wechat what is more functions like group chat and wechat moments can easily connect hundreds of people or even more for the mechanism mweincome mwe can directly promote income while the use of icts can slow down the process of mwe on income it implies that the use of icts can be a substitute for migration to increase household income from the logic of how mwe and icts increase household income the results are implausible as analyzed before mwe plays a significant role in accessing more information experience and knowledge through migration work mwe has a positive impact on household income icts can do the same thing since it lowers the cost of accessing information during the field surveys we also found that icts can easily break the geographical limitations among farmers which decreases communication costs for the mechanism mwerisk attitude mwe can directly promote farmers risk preference and ict adoption can enhance the effect of mwe on risk attitude more importantly ict adoption has a complete substitution effect on mwe based on the analysis above although we have known the key role of icts the results still exceed our expectations to some extent it implies that the information obtained through icts and migration work has the same effect on the change of farmers risk attitude another possible explanation is that information brought by icts can provide migrant farmers with more employment information it raises their expectations for the future and therefore they have higher risk preferences further discussion of social capital structure based on chinas special rural culture we believe that the analysis of the social capital structure is a necessary extension of the discussion xiaotong fei the founder of chinese sociology proposed the pattern of difference sequence of chinese rural society it vividly describes the interpersonal pattern of closeness in chinese rural society a ratingcircle structure from inside to outside refers to family members relatives fellow villagers and friends and it also means that the social relations expand from strong social ties to weak social ties it likes a halo spreading on the water extending from oneself dividing closeness and distance according to the distance from oneself in traditional chinese culture there is a natural trust between relatives and fellow villagers this leads to heterogeneity in the social capital structure therefore we use the concept of social capital structure to reinforce the effect of mwe on weak social ties the results show that the effects of mwe on social capital are multifaceted which not only strengthens the connection between farmers and strong social ties but also weak social ties about the effects on social capital structure we also found an interesting case during our survey migrant workers may spend more time away from their hometowns and they have to maintain social relations at work therefore they do not have to spend much more time to maintain strong social ties than they would have to maintain weak ties conclusions in this study based on a survey data set of 2863 farm households in 14 provinces in china mediating effect model and moderating effect model are used to analyze the effect of migration working experience on farmers social capital we show that mwe has a significant positive impact on sc which is mediated by household income farmer risk attitude and ict adoption moreover ict adoption can mitigate the process of mwe affecting income and risk attitude and have heterogeneous substitution effects to provide robustness checks we used the months of migration working and weak ties in social capital to replace core explanatory variables and dependent variables respectively and the estimation results are consistent our results clearly indicated that mwe can significantly enhance farmers social capital by increasing income promoting risk preference and ict adoption meanwhile mwe is likely to have a strong externality that is one connects frequently with people who have mwe and would benefit from their accumulation of information technologies skills and knowledge it is the key to how mwe enhances farmers social capital this study contributes to a better understanding of the phenomenon that people are willing to work as migrant workers even though they may suffer from unfair treatment and the loss of welfare more importantly this study has specific policy implications it is necessary and beneficial to encourage migration because it not only improves the welfare of migrants but also helps improve the welfare of those who stay in close contact with them mwe plays a similar role to xiangxian a traditional chinese cultural concept which means people of great prestige in the village of course policies should be carried out by the government to guarantee the legitimate rights and interests of migrant workers as many researchers and policymakers have noticed the generalization of this study is subject to certain limitations for example limited by financial support the study is focused on migrant workers from the main provinces in china instead of nationallevel survey future studies would consider a wider coverage of provinces meanwhile we focus on the group of farmers who live in the rural areas instead of those who live the urban areas it is unknown whether migration working experience has a significant impact on social capital for this group of migrant workers further studies may focus on the working conditions and the physical and psychological conditions of the group of migrant workers living in rural areas data availability statement the data that support the findings of this study were obtained from the survey conducted by the national agricultural and rural development research institute at china agricultural university

while a growing number of farmers migrate to urban sectors to engage in offfarm employment little is known whether and how the migration working experience mwe changes farmers especially their social capital using a survey data set with 2863 farm households in 14 provinces in china we developed a mediation model to examine the impact of mwe on social capital as well as the roles of household income farmers risk attitude and information and communications technologies icts we show that mwe has a significantly positive impact on social capital and weak ties in social capital which is mediated by household income risk attitude and ict adoption in particular mwe can increase income enhance risk preference and promote ict adoption thus leading to higher social capital moreover icts play a moderating role in the impact of mwe on income and risk preference that is icts can decrease the impact of mwe on income and completely substitute the impact of mwe on risk attitude our study provides an explanation for the reason why farmers are willing to migrate despite unfavorable working conditions they may endure in urban areas

Introduction In the past few years, the world has had trouble with a lack of resources and energy, as well as problems with supply and demand. The climate and environmental problems caused by energy consumption are also becoming increasingly severe [1]. It is the responsibility of every citizen to promote energy conservation. China is transitioning from a "production-oriented" to a "life-oriented" society, and the household sector's energy consumption has been increasing year over year [2]. Among them, electricity consumption, primarily from household appliances, contributes the most to energy consumption [3]. So, household electricity-saving behavior is increasingly important for resource conservation. Electricity-saving behavior is generally divided into buying electricity-saving behavior and customary electricity-saving behavior [4]. Compared with customary electricity-saving behavior, electricity-saving behavior plays a more important role. So, it is significant to persuade households to choose energy-saving products. The consumption behavior of household energy-saving products is characteristic of "one-time investment, long-term impact" [5], so there are many difficulties in persuading people to buy because they have to pay more. The country has advocated green consumption and household energy-saving products in various policies [6,7]. National policies are essential in encouraging people to purchase household energy-saving products, but it tends to work in the short term. Therefore, other forces must be combined to promote people's buying behavior. In recent years, with the rapid development of internet marketing in China, internet celebrities have become an essential force in promoting the diffusion of household energy-saving products. They have a large fan base due to their expertise and attraction, and they sell related energysaving products among their fan groups, producing significant social and commercial value. The phenomenon of internet celebrities has attracted extensive attention from scholars. However, more research still needs to be done on how internet celebrities influence fans' purchase intention. The mechanism by which internet celebrities increase their fans' purchases of household energy-saving products urgently needs further investigation. In the past, many scholars have analyzed the factors affecting consumers' intention to purchase energy-saving products from various angles. Scholars explored factors in terms of the consumers themselves, such as demography [8][9][10], ethics [11][12][13][14], attitudes, emotions, and awareness of the environment [15,16], and they also explore the factors of the external environment, such as media, policy incentives [17,18], price incentives [19], and ecological labels [20,21]. However, from the perspective of social influence, there needs to be more research on the impact of opinion leaders on the users' purchase of household energy-saving products. In the internet era, people obtain relevant information from influential people in online communities. Their values are easily influenced by influential people, thereby changing their attitudes and behaviors [22]. The closeness between users and media figures is called a "parasocial relationship", and it often has a big impact on how people decide what to buy. Although energy-saving products can have good economic and social benefits, they often cost more. So, rational persuasion alone is not enough to get people to buy these products. Instead, the close relationship between fans and internet celebrities is a big reason people buy energy-saving products that internet celebrities recommend. This study uses social cognitive theory and parasocial interaction theory as the theoretical basis to explore the mechanisms by which the expertise and attraction of internet celebrities influence the intention of fans to purchase the energy-saving products they endorse. This study introduces parasocial relationships as a mediating variable from a relational perspective to explore its mediating role. Secondly, based on the characteristics of household energy-saving products, this study explores the moderating effect of fans' green self-efficacy on the relationship between the expertise and attraction of internet celebrities and the parasocial relationships formed between them and their fans. This study has theoretical and practical contributions. In terms of theoretical contributions, the study extends the scope included in the environmental element of social cognitive theory. This study takes internet celebrities' characteristics as the external environment factor and explores its influence on fans' purchase intention of energy-saving products. Secondly, this study enriches the application scenario of parasocial interaction theory and explores the psychological mechanisms of fans' purchasing energy-saving products recommended by internet celebrities from the perspective of intimate relationships. Finally, the findings have practical implications for internet celebrities and governments attempting to urge households to purchase energy-saving products. --- Theoretical Background and Hypotheses --- The Impact of an Internet Celebrities' Expertise on the Audience's Purchase Intention Expertise refers to the degree of knowledge of a specific object in a particular field, including authority, ability, or qualification [23]. Numerous studies have shown that as external sources of information for fans in online communities, internet celebrities' expertise affects fans' attitudes and subsequent behaviors [24][25][26]. Daneshvary & Schwer also pointed out in their study that expertise is a crucial information source for internet celebrities to obtain fans' recognition and attention [27]. Internet celebrities' professional knowledge increases fans' perceived credibility, which enhances their purchasing behavior. Endorsers with more professional knowledge are more persuasive and increase fans' stickiness with the brand [28,29]. When internet celebrities have more robust expertise in the fields of environmental protection and energy conservation, their ability to promote fans' understanding of the related costs and energy-saving effects of household energy-saving products is stronger, which is more conducive to fans making better decisions. Fans tend to seek information and advice from internet celebrities when purchasing household energysaving products. With increased interaction frequency, fans form a closer relationship with internet celebrities, gradually increasing their trust and intention to purchase household energy-saving products. Therefore, we can assume: H1: Internet celebrity expertise positively influences consumers' purchase intention. --- The Relationship between Internet Celebrities 'Attraction and Fans' Purchase Intention Attraction is the first step in establishing a user relationship [30,31]. Previous research has shown that it is an important factor driving changes in user attitudes and behaviors in e-commerce and online contexts. Social cognitive theory suggests that individuals will take action plans closely related to the environment and intrinsic factors for various tasks required [32]. When users encounter problems in their daily learning work and lives, they seek help from the outside world. This study believes that when fans purchase household energy-saving products, they often want to know more about similar energysaving products, compare the advantages and disadvantages of different energy-saving products, and then make a purchase. When an internet celebrity's popularity is high, they can provide various product comparison information for fans and meet their various needs before making purchase decisions. Through continuous interaction with an internet celebrity, fans' relationships become more intimate, and their understanding of household energy-saving products deepens, which increases their intention to purchase the product. In addition to the ability of internet celebrities to help fans complete tasks related to decision points before purchasing a product, which will affect fans' intention to buy the product, the influence of the values they can bring to fans will also affect a fan's intention to buy energy-saving products. The social attraction of an influencer refers to the degree to which fans identify with its values and ideology, want to communicate with it, and establish intimate relationships with it [33], and the higher its social attraction, the higher the degree to which fans admire and respect it [34]. Therefore, when influencers are more socially attractive, fans identify more strongly with their values [35][36][37]. This study argues that when the social attraction of internet celebrities is more potent, the degree of their values about environmental and energy conservation among their fans is more profound, and the intention of fans to follow and learn from their behavior increases, in turn increasing their intention to purchase the household energy-saving products they endorse. Therefore, we can assume H2 and H3. --- H2: Internet celebrities' task attraction positively affects fans' purchase intention of household energy-saving products. H3: Internet celebrities' social attraction of Internet celebrities positively affects fans' purchase intention to purchase household energy-saving products. --- The Mediating Role of Parasocial Relationships Parasocial relationships often describe the intimate relationships between media figures and media users. The mediating role of parasocial relationships is supported by numerous scholars in the fields of vloggers, social media influencers, and so on. Aw and Chuah suggest that parasocial relationships mediate the social media influencers' content characteristics and self-serving motives [38]. Liu et al. found that a vlogger's physical and social attraction increased the audience's evaluations of the brands endorsed by the vloggers, and these relationships were mediated by the parasocial interaction between the vloggers and the audience [39]. Sakib et al. highlight vloggers' credibility and physical attraction, but not homophily, as salient source characteristics that influence parasocial interaction, reinforcing the audience's compliance intention [40]. Social Cognitive Theory emphasizes the influence of the environment on individuals, and it assumes that most people learn by observing others and then acquire cognitive changes in knowledge, skills, strategies, and attitudes [33]. In online community contexts, people often seek help from internet celebrities. In the process of communicating with them, the characteristics of the source of information affect the attitude of fans in communicating and interacting with them [41]. For example, Bansal and Voyer found that consumers prefer to seek professional advice before purchasing [42]. The more professional internet celebrities are, the more likely people are to interact with them and reach an agreement [43]. Expertise is the basic condition for an influencer to gain fans' trust when selling household energy-saving products, and it makes fans understand more comprehensive information about energy-saving products. Secondly, the ability of internet celebrities to collect information about various energy-saving products and facilitate fans' better purchasing processes makes them more reliable and credible [34], which further promotes fans' interaction and communication with them and increases their intimacy with influencers. In addition, the attraction of influencers in terms of values and ideas has an important influence on the intention of fans to interact with them. Internet celebrities with high social attraction increase their interaction with fans by promoting their recognition of their environmental protection and energy-saving values, affecting their intention to purchase related products [44][45][46]. With more interactions between fans and internet celebrities, fans feel closer to internet celebrities, which makes them less uncertain about all kinds of information about household energy-saving products and more likely to buy them [47]. When fans form parasocial relationships with internet celebrities, they recognize their professional industry and values of environmental protection, resource conservation, and other aspects, thus increasing the intention to buy household energy-saving products. Accordingly, we propose Hypotheses H4-H6. H4: Parasocial relationships play a mediating role between the expertise of internet celebrities and the purchase intention of fans. H5: Parasocial relationships play a mediating role between the task attraction of internet celebrities and the purchase intention of fans. H6: Parasocial relationships play a mediating role between the social attraction of internet celebrities and the purchase intention of fans. --- The Moderating Effect of Green Self-Efficacy The social cognitive theory is based on the idea that people's actions are affected by both their environment and themselves. When fans buy energy-saving products endorsed by internet celebrities, their characteristics will work together with fan characteristics to influence the fans' corresponding attitudes and behaviors. As a key factor in individual behavior change, green self-efficacy judges how much people value their own behavior, and it is an important motivation for behavior display, which mobilizes people's emotions, motivations, and behaviors and can influence the choice of active behavior [48]. Green self-efficacy is a concept proposed by scholars who introduced self-efficacy into the environmental field in the context of global green trends. It is a self-perception that refers specifically to an individual's self-evaluation of their ability to achieve environmental goals [49,50]. When fans have a strong sense of green self-efficacy, they believe that their energy-saving behaviors have a strong effect on the energy savings of society as a whole. They will actively seek out internet celebrities with strong expertise and attraction to interact with them in the online community context, asking them for information related to energy-saving products and interacting with them on various aspects, such as product purchase costs and energy-saving effects. Accordingly, we propose Hypotheses H7-H9. H7: Green self-efficacy plays a positive moderating role between internet celebrities' expertise and parasocial relationships. H8: Green self-efficacy plays a positive moderating role between internet celebrities' task attraction and parasocial relationships. H9: Green self-efficacy plays a positive moderating role between internet celebrities' social attraction and parasocial relationships. Based on the above analysis, the research framework is shown in Figure 1. --- Data Collection and Methodology Data Collection and Sampling This study uses a survey method. The questionnaire was distributed through the Credamo platform. Credamo is a professional questionnaire survey platform in China with more than 1.5 million subjects nationwide. Questionnaires are distributed on this platform, and random samples were selected for investigation in this study. The study also set up a screening question so that only consumers who had bought household energy-saving products recommended by internet celebrities could participate, and the rest would be stopped from filling out the questionnaire. Subjects were asked to recall an internet celebrity who had purchased household energy-saving products on their live streaming or short video platforms. Subjects who completed the questionnaire with good quality were rewarded with red packets. After eliminating invalid questionnaires, 334 valid questionnaires remained. Participant demographics are shown in Table 1. To ensure the quality of the questionnaires completed by the subjects, this study translates the developed scales drawn from foreign languages to make them fit the cultural context and cognitive habits of Chinese people. At the same time, the test questions were designed appropriately, and instructions were written to state that the questionnaire's content was for academic research purposes only. Expertise borrowing from the scale developed by Ohanian [29] and modifying it, the scale is measured by four questions: "I think the internet celebrity is knowledgeable", "The internet celebrity is an expert in the field of energy conservation and environmental protection", "The internet celebrity has extensive experience in selling household energysaving products", and "The internet celebrity is qualified to sell household energy-saving products". Social attraction was measured using the scale used by Shen et al. [50] through the questions, "I think interacting with the internet celebrity would be helpful for me to buy household energy-saving products for my home", "I can communicate with the internet celebrity in a friendly way", "I have a good time with the internet celebrity", and "I approve of the internet celebrity's values on energy-saving and environmental protection". Task attraction was measured using the scale developed by Shen et al. [51] through the questions "I would rely on an internet celebrity if I want to complete the task of purchasing household energy-saving products for my home", "the internet celebrity can meet my needs in terms of purchasing household energy-saving products for my home", "the internet celebrity makes it easier for me to complete my household energy-saving products", and "I am confident in the performance of the household energy-saving products endorsed by the internet celebrity". The parasocial relationships were assessed using a Rubin et al. [52] scale, which included the questions "I look forward to exchanging knowledge about environmental protection and energy conservation with the internet celebrity", "I follow the internet celebrity when he appears on other online community platforms", "I would like to meet the internet celebrity in person", and "I feel that I am part of that internet celebrity's 'fan base'". Green self-efficacy was based on a scale developed by Chen [53], Shen et al. [54], and others, using the questions "I feel that I can successfully practice environmental ideas", "I feel that I am capable of helping to achieve environmental goals", "I feel confident that my energy-saving behavior will make a difference to the environment", and "I feel confident that I can change environmental issues through my own efforts". The Shelton and Yang [55] scale was used to assess product purchase intention; "I would like to buy the household energy-saving products recommended by the internet celebrity", "If necessary, I would buy the household energysaving products recommended by the internet celebrity", and "I would like to recommend the household energy-saving products endorsed by the internet celebrity to my friends and relatives". --- Data Analysis and Result --- Measurement Model Analysis AMOS 25.0 was used to test the fit of the structural model. The absolute fit index of the whole model was χ2/df = 2.295 < 3, RMSEA = 0.048 < 0.05, GFI = 0.948 > 0.9, AGFI = 0.917 > 0.9, NFI = 0.958 > 0.9, TLI = 0.958 > 0.9, CFI = 0.985 > 0.9, all greater than 0.9, and all the fit indexes reached the standard. The results are shown in Table 2. In this paper, SPSS26.0 software was used to analyze the reliability of the collected data, and the results are shown in Table 2. The Cronbach s α of each latent variable was greater than 0.7, indicating that the latent variables of this questionnaire had good reliability and the questionnaire had good internal consistency and stability. The Amos 25.0 software was also used to conduct validation factor analysis on each variable, and the results are shown in Table 3. The factor loadings of each variable were all greater than 0.7, indicating that the observed variables could explain the latent variables well. The combined reliability of each variable was greater than 0.7, and the average variance extracted was greater than 0.5, indicating that this questionnaire has good convergent validity. Validity analysis was used to indicate the accuracy and validity of the measurement scale. The study used authoritative scales that have been validated several times, modified and optimized through data feedback from pre-research, and have good content validity. The results of the discriminant validity tests are shown in Table 4, which shows that the square root of AVE for each construct is greater than the correlation coefficient between itself and the other latent variables. --- Structural Model Testing Hypothesis Testing --- 1. The effects of the internet celebrities' expertise, social attraction, and task attraction on fans' intention to purchase products. The standardized results derived from Bootstrap 1000 times indicated that the effect of expertise, social attraction, and task attraction to consumer purchase intention was significant, and internet celebrities' expertise, social attraction, and task attraction have a significant positive effect on fans' intention to product purchase, Hypotheses H1-H3 hold. The results are shown in Table 5. --- 2. The mediating role of parasocial relationships. The results of the mediation effect test through the Bootstrap 1000 procedure showed that the indirect effect was significant. The direct effect was significant between internet celebrities' expertise to product purchase intention, and the proportion of the indirect effect in the total effect was 59.74%. At the same time, expertise had a significant positive effect on parasocial relationships , and parasocial relationships had a significant positive effect on fans' intention to purchase products . In summary, it can be seen that parasocial relationships produce a significant partial mediating effect between expertise and consumer product purchase intention, and hypothesis H4 holds. Similarly, the total effect of social attraction and task attraction to fans' product purchase intention was significant for indirect effects , , and the proportion of indirect effects in the total effect was 61.42% and 59.74%. Social attraction has a significant positive effect on parasocial relationships , and task attraction has a significant positive effect on parasocial relationships . In summary, parasocial relationships play a partially mediating role between social attraction, task attraction, and intention to purchase fan products. Hypotheses H5 and H6 hold. The results are shown in Table 6. --- 3. The moderating role of green self-efficacy. The moderating role of green self-efficacy was examined using latent moderated structural equations . The results show that the interaction terms of expertise and green self-efficacy and task attraction and green self-efficacy had significant effects on parasocial relationships. In contrast, the interaction term of social attraction and green self-efficacy had a non-significant effect on the parasocial relationship . In summary, it can be seen that green self-efficacy produced a positive moderating effect during the influence of internet celebrities' expertise and task attraction on parasocial relationships. However, the moderating effect during the influence of social attraction on parasocial relationships was not significant, and Hypotheses H7 and H8 were held, while H9 was not. The specific interaction pattern is shown in Figures 2 and3. --- Conclusions, Implications, and Limitations --- Conclusions This study set out to investigate the influence of internet celebrities on fans' purchase intentions for energy-saving products. The analysis was centered on the relationship between fans and internet celebrities. Using parasocial relationships from mass communication literature, this study investigated the "relationship" developed between fans and internet celebrities and the subsequent influence of that perception on energy-saving product purchase intentions. This was accomplished through a questionnaire study. Overall, the results of these studies found support for parasocial relationships as an energy-saving product diffusion management tool. This paper draws the following conclusions: First, the expertise and attraction of online celebrities have a positive impact on the consumers' intention to purchase energy-saving products in an online community context. Moreover, expertise and task attraction have a stronger effect on fans' intention to buy household energy-saving products; that is, fans are more likely to buy energy-saving products at good value through the recommendations of internet celebrities; Second, parasocial relationships mediate the relationship between online celebrities' expertise, attraction , and fans' intention to purchase household energy-saving products; Third, fans' green self-efficacy plays a positive moderating role between online celebrities' expertise, task attraction, and parasocial relationships and a less significant moderating role between online celebrities' social attraction and parasocial relationships. --- Theoretical Contributions First, based on social cognitive theory, this study investigates the factors influencing consumers' intention to purchase household energy-saving products recommended by online celebrities in an online community context, further broadening the application scenarios of social cognitive theory. Existing studies have not paid enough attention to promoting consumers' intention to purchase household energy-saving products from online celebrities. Even less research has been conducted exploring consumer behavior in this scenario based on social cognitive theory. Second, this study analyzes the mechanism of parasocial relationships between online celebrities' expertise and attraction to fans' product purchase intention, opening up the "black box" of consumer purchase and demonstrating the mediating role of parasocial relationships between online celebrities expertise and attraction and fans' intention to purchase household energy-saving products. This is part of a growing area that moves PSI from the realm of TV personalities to use as an actual sale tool. Third, this study further extends the application of self-efficacy in the environmental field. This study demonstrates that green self-efficacy interacts with the external environment, influencing fans' parasocial relationships with online celebrities. This study enriches the theory of self-efficacy. --- Practical Implications As evident in this study, internet celebrities can be an important force for household energy-saving product diffusion. In particular, it can be useful for establishing relationships with fans. Fans view internet celebrities who have expertise and attraction will likely develop PSI with them and have the same positive evaluations of energy-saving products the internet celebrities recommended. Overall, this paper has some practical implications. First, this study can promote better marketing results for internet celebrities selling energy-saving products. The findings of this study provide guidance for internet celebrities to increase their influence and better persuade their fans to buy energy-saving products, facilitating better sales for household energy-saving products. The results of this study suggest that as a new force for promoting the proliferation of energy-saving products in the internet era, internet celebrities can increase their frequency of interaction and intimacy with their fans by increasing their own expertise and attraction , thereby increasing their trust and emotional attachment to them, reducing their resistance to their persuasive intentions when selling products, and thus increasing their intention to buy the energy-saving products they recommend. This increases the intention to buy the products they recommend. Second, this study can provide new enlightenment for the government and other departments to promote people's energy-saving behavior with the help of social forces. In addition to promoting people's energy-saving behavior through policy promotion and economic subsidies, government departments should play an important role in promoting people's energy-saving behavior at the consumer end. Therefore, they can guide internet celebrities and other new forces to exert their influence, increase people's awareness of energy saving, and promote energy-saving behavior. Third, this study can provide insights for brands or suppliers of energy-saving products to expand the sales channels of their products. This study analyses the impact of the characteristics of internet celebrities on promoting people's buying behavior, which has important implications for brands and suppliers of household energy-saving products in finding suitable partners to increase brand awareness and promote product sales. --- Limitations There are also some research limitations in this study, mainly the following: First, consumer behavior in purchasing household energy-saving products is a complex process, and this study only explores the factors influencing consumers' intention to purchase household energy-saving products. There is a gap between consumers' intention to purchase and consumer purchasing behavior, influencing factors that need to be improved in the next study; Second, at present, there is not much empirical research on the influence of internet celebrities on consumers' intention to purchase household energy-saving products, and this research is only in its infancy. ---

In the past few years, internet celebrities have become a new and important way to get people to buy energy-saving products. Their psychological mechanisms for promoting fans' intention to purchase have become the focus of academic attention, but a unified conclusion has yet to be reached. This study uses online communities as a scenario, with the characteristics of influencers' expertise, social attraction, and task attraction as antecedent variables and social cognitive theory and parasocial interaction theory as the theoretical basis to explore their influence on fans' intention to purchase household energy-saving products. The study investigates the mediating role of parasocial relationships and the moderating role of fans' green self-efficacy in influencing internet celebrities' expertise and attraction of fans' parasocial relationships. The results showed that the parasocial relationships formed between fans and influencers mediated the relationship between the expertise and attraction of influencers and fans' intention to purchase energy-saving products and that "green self-efficacy" positively moderated the parasocial relationships formed between fans and internet celebrities in terms of their expertise and task attraction. The moderating effect of "green self-efficacy" on the parasocial relationships between fans and internet celebrities was insignificant.

introduction in the past few years the world has had trouble with a lack of resources and energy as well as problems with supply and demand the climate and environmental problems caused by energy consumption are also becoming increasingly severe 1 it is the responsibility of every citizen to promote energy conservation china is transitioning from a productionoriented to a lifeoriented society and the household sectors energy consumption has been increasing year over year 2 among them electricity consumption primarily from household appliances contributes the most to energy consumption 3 so household electricitysaving behavior is increasingly important for resource conservation electricitysaving behavior is generally divided into buying electricitysaving behavior and customary electricitysaving behavior 4 compared with customary electricitysaving behavior electricitysaving behavior plays a more important role so it is significant to persuade households to choose energysaving products the consumption behavior of household energysaving products is characteristic of onetime investment longterm impact 5 so there are many difficulties in persuading people to buy because they have to pay more the country has advocated green consumption and household energysaving products in various policies 67 national policies are essential in encouraging people to purchase household energysaving products but it tends to work in the short term therefore other forces must be combined to promote peoples buying behavior in recent years with the rapid development of internet marketing in china internet celebrities have become an essential force in promoting the diffusion of household energysaving products they have a large fan base due to their expertise and attraction and they sell related energysaving products among their fan groups producing significant social and commercial value the phenomenon of internet celebrities has attracted extensive attention from scholars however more research still needs to be done on how internet celebrities influence fans purchase intention the mechanism by which internet celebrities increase their fans purchases of household energysaving products urgently needs further investigation in the past many scholars have analyzed the factors affecting consumers intention to purchase energysaving products from various angles scholars explored factors in terms of the consumers themselves such as demography 8 9 10 ethics 11 12 13 14 attitudes emotions and awareness of the environment 1516 and they also explore the factors of the external environment such as media policy incentives 1718 price incentives 19 and ecological labels 2021 however from the perspective of social influence there needs to be more research on the impact of opinion leaders on the users purchase of household energysaving products in the internet era people obtain relevant information from influential people in online communities their values are easily influenced by influential people thereby changing their attitudes and behaviors 22 the closeness between users and media figures is called a parasocial relationship and it often has a big impact on how people decide what to buy although energysaving products can have good economic and social benefits they often cost more so rational persuasion alone is not enough to get people to buy these products instead the close relationship between fans and internet celebrities is a big reason people buy energysaving products that internet celebrities recommend this study uses social cognitive theory and parasocial interaction theory as the theoretical basis to explore the mechanisms by which the expertise and attraction of internet celebrities influence the intention of fans to purchase the energysaving products they endorse this study introduces parasocial relationships as a mediating variable from a relational perspective to explore its mediating role secondly based on the characteristics of household energysaving products this study explores the moderating effect of fans green selfefficacy on the relationship between the expertise and attraction of internet celebrities and the parasocial relationships formed between them and their fans this study has theoretical and practical contributions in terms of theoretical contributions the study extends the scope included in the environmental element of social cognitive theory this study takes internet celebrities characteristics as the external environment factor and explores its influence on fans purchase intention of energysaving products secondly this study enriches the application scenario of parasocial interaction theory and explores the psychological mechanisms of fans purchasing energysaving products recommended by internet celebrities from the perspective of intimate relationships finally the findings have practical implications for internet celebrities and governments attempting to urge households to purchase energysaving products theoretical background and hypotheses the impact of an internet celebrities expertise on the audiences purchase intention expertise refers to the degree of knowledge of a specific object in a particular field including authority ability or qualification 23 numerous studies have shown that as external sources of information for fans in online communities internet celebrities expertise affects fans attitudes and subsequent behaviors 24 25 26 daneshvary schwer also pointed out in their study that expertise is a crucial information source for internet celebrities to obtain fans recognition and attention 27 internet celebrities professional knowledge increases fans perceived credibility which enhances their purchasing behavior endorsers with more professional knowledge are more persuasive and increase fans stickiness with the brand 2829 when internet celebrities have more robust expertise in the fields of environmental protection and energy conservation their ability to promote fans understanding of the related costs and energysaving effects of household energysaving products is stronger which is more conducive to fans making better decisions fans tend to seek information and advice from internet celebrities when purchasing household energysaving products with increased interaction frequency fans form a closer relationship with internet celebrities gradually increasing their trust and intention to purchase household energysaving products therefore we can assume h1 internet celebrity expertise positively influences consumers purchase intention the relationship between internet celebrities attraction and fans purchase intention attraction is the first step in establishing a user relationship 3031 previous research has shown that it is an important factor driving changes in user attitudes and behaviors in ecommerce and online contexts social cognitive theory suggests that individuals will take action plans closely related to the environment and intrinsic factors for various tasks required 32 when users encounter problems in their daily learning work and lives they seek help from the outside world this study believes that when fans purchase household energysaving products they often want to know more about similar energysaving products compare the advantages and disadvantages of different energysaving products and then make a purchase when an internet celebritys popularity is high they can provide various product comparison information for fans and meet their various needs before making purchase decisions through continuous interaction with an internet celebrity fans relationships become more intimate and their understanding of household energysaving products deepens which increases their intention to purchase the product in addition to the ability of internet celebrities to help fans complete tasks related to decision points before purchasing a product which will affect fans intention to buy the product the influence of the values they can bring to fans will also affect a fans intention to buy energysaving products the social attraction of an influencer refers to the degree to which fans identify with its values and ideology want to communicate with it and establish intimate relationships with it 33 and the higher its social attraction the higher the degree to which fans admire and respect it 34 therefore when influencers are more socially attractive fans identify more strongly with their values 35 36 37 this study argues that when the social attraction of internet celebrities is more potent the degree of their values about environmental and energy conservation among their fans is more profound and the intention of fans to follow and learn from their behavior increases in turn increasing their intention to purchase the household energysaving products they endorse therefore we can assume h2 and h3 h2 internet celebrities task attraction positively affects fans purchase intention of household energysaving products h3 internet celebrities social attraction of internet celebrities positively affects fans purchase intention to purchase household energysaving products the mediating role of parasocial relationships parasocial relationships often describe the intimate relationships between media figures and media users the mediating role of parasocial relationships is supported by numerous scholars in the fields of vloggers social media influencers and so on aw and chuah suggest that parasocial relationships mediate the social media influencers content characteristics and selfserving motives 38 liu et al found that a vloggers physical and social attraction increased the audiences evaluations of the brands endorsed by the vloggers and these relationships were mediated by the parasocial interaction between the vloggers and the audience 39 sakib et al highlight vloggers credibility and physical attraction but not homophily as salient source characteristics that influence parasocial interaction reinforcing the audiences compliance intention 40 social cognitive theory emphasizes the influence of the environment on individuals and it assumes that most people learn by observing others and then acquire cognitive changes in knowledge skills strategies and attitudes 33 in online community contexts people often seek help from internet celebrities in the process of communicating with them the characteristics of the source of information affect the attitude of fans in communicating and interacting with them 41 for example bansal and voyer found that consumers prefer to seek professional advice before purchasing 42 the more professional internet celebrities are the more likely people are to interact with them and reach an agreement 43 expertise is the basic condition for an influencer to gain fans trust when selling household energysaving products and it makes fans understand more comprehensive information about energysaving products secondly the ability of internet celebrities to collect information about various energysaving products and facilitate fans better purchasing processes makes them more reliable and credible 34 which further promotes fans interaction and communication with them and increases their intimacy with influencers in addition the attraction of influencers in terms of values and ideas has an important influence on the intention of fans to interact with them internet celebrities with high social attraction increase their interaction with fans by promoting their recognition of their environmental protection and energysaving values affecting their intention to purchase related products 44 45 46 with more interactions between fans and internet celebrities fans feel closer to internet celebrities which makes them less uncertain about all kinds of information about household energysaving products and more likely to buy them 47 when fans form parasocial relationships with internet celebrities they recognize their professional industry and values of environmental protection resource conservation and other aspects thus increasing the intention to buy household energysaving products accordingly we propose hypotheses h4h6 h4 parasocial relationships play a mediating role between the expertise of internet celebrities and the purchase intention of fans h5 parasocial relationships play a mediating role between the task attraction of internet celebrities and the purchase intention of fans h6 parasocial relationships play a mediating role between the social attraction of internet celebrities and the purchase intention of fans the moderating effect of green selfefficacy the social cognitive theory is based on the idea that peoples actions are affected by both their environment and themselves when fans buy energysaving products endorsed by internet celebrities their characteristics will work together with fan characteristics to influence the fans corresponding attitudes and behaviors as a key factor in individual behavior change green selfefficacy judges how much people value their own behavior and it is an important motivation for behavior display which mobilizes peoples emotions motivations and behaviors and can influence the choice of active behavior 48 green selfefficacy is a concept proposed by scholars who introduced selfefficacy into the environmental field in the context of global green trends it is a selfperception that refers specifically to an individuals selfevaluation of their ability to achieve environmental goals 4950 when fans have a strong sense of green selfefficacy they believe that their energysaving behaviors have a strong effect on the energy savings of society as a whole they will actively seek out internet celebrities with strong expertise and attraction to interact with them in the online community context asking them for information related to energysaving products and interacting with them on various aspects such as product purchase costs and energysaving effects accordingly we propose hypotheses h7h9 h7 green selfefficacy plays a positive moderating role between internet celebrities expertise and parasocial relationships h8 green selfefficacy plays a positive moderating role between internet celebrities task attraction and parasocial relationships h9 green selfefficacy plays a positive moderating role between internet celebrities social attraction and parasocial relationships based on the above analysis the research framework is shown in figure 1 data collection and methodology data collection and sampling this study uses a survey method the questionnaire was distributed through the credamo platform credamo is a professional questionnaire survey platform in china with more than 15 million subjects nationwide questionnaires are distributed on this platform and random samples were selected for investigation in this study the study also set up a screening question so that only consumers who had bought household energysaving products recommended by internet celebrities could participate and the rest would be stopped from filling out the questionnaire subjects were asked to recall an internet celebrity who had purchased household energysaving products on their live streaming or short video platforms subjects who completed the questionnaire with good quality were rewarded with red packets after eliminating invalid questionnaires 334 valid questionnaires remained participant demographics are shown in table 1 to ensure the quality of the questionnaires completed by the subjects this study translates the developed scales drawn from foreign languages to make them fit the cultural context and cognitive habits of chinese people at the same time the test questions were designed appropriately and instructions were written to state that the questionnaires content was for academic research purposes only expertise borrowing from the scale developed by ohanian 29 and modifying it the scale is measured by four questions i think the internet celebrity is knowledgeable the internet celebrity is an expert in the field of energy conservation and environmental protection the internet celebrity has extensive experience in selling household energysaving products and the internet celebrity is qualified to sell household energysaving products social attraction was measured using the scale used by shen et al 50 through the questions i think interacting with the internet celebrity would be helpful for me to buy household energysaving products for my home i can communicate with the internet celebrity in a friendly way i have a good time with the internet celebrity and i approve of the internet celebritys values on energysaving and environmental protection task attraction was measured using the scale developed by shen et al 51 through the questions i would rely on an internet celebrity if i want to complete the task of purchasing household energysaving products for my home the internet celebrity can meet my needs in terms of purchasing household energysaving products for my home the internet celebrity makes it easier for me to complete my household energysaving products and i am confident in the performance of the household energysaving products endorsed by the internet celebrity the parasocial relationships were assessed using a rubin et al 52 scale which included the questions i look forward to exchanging knowledge about environmental protection and energy conservation with the internet celebrity i follow the internet celebrity when he appears on other online community platforms i would like to meet the internet celebrity in person and i feel that i am part of that internet celebritys fan base green selfefficacy was based on a scale developed by chen 53 shen et al 54 and others using the questions i feel that i can successfully practice environmental ideas i feel that i am capable of helping to achieve environmental goals i feel confident that my energysaving behavior will make a difference to the environment and i feel confident that i can change environmental issues through my own efforts the shelton and yang 55 scale was used to assess product purchase intention i would like to buy the household energysaving products recommended by the internet celebrity if necessary i would buy the household energysaving products recommended by the internet celebrity and i would like to recommend the household energysaving products endorsed by the internet celebrity to my friends and relatives data analysis and result measurement model analysis amos 250 was used to test the fit of the structural model the absolute fit index of the whole model was χ2df 2295 3 rmsea 0048 005 gfi 0948 09 agfi 0917 09 nfi 0958 09 tli 0958 09 cfi 0985 09 all greater than 09 and all the fit indexes reached the standard the results are shown in table 2 in this paper spss260 software was used to analyze the reliability of the collected data and the results are shown in table 2 the cronbach s α of each latent variable was greater than 07 indicating that the latent variables of this questionnaire had good reliability and the questionnaire had good internal consistency and stability the amos 250 software was also used to conduct validation factor analysis on each variable and the results are shown in table 3 the factor loadings of each variable were all greater than 07 indicating that the observed variables could explain the latent variables well the combined reliability of each variable was greater than 07 and the average variance extracted was greater than 05 indicating that this questionnaire has good convergent validity validity analysis was used to indicate the accuracy and validity of the measurement scale the study used authoritative scales that have been validated several times modified and optimized through data feedback from preresearch and have good content validity the results of the discriminant validity tests are shown in table 4 which shows that the square root of ave for each construct is greater than the correlation coefficient between itself and the other latent variables structural model testing hypothesis testing 1 the effects of the internet celebrities expertise social attraction and task attraction on fans intention to purchase products the standardized results derived from bootstrap 1000 times indicated that the effect of expertise social attraction and task attraction to consumer purchase intention was significant and internet celebrities expertise social attraction and task attraction have a significant positive effect on fans intention to product purchase hypotheses h1h3 hold the results are shown in table 5 2 the mediating role of parasocial relationships the results of the mediation effect test through the bootstrap 1000 procedure showed that the indirect effect was significant the direct effect was significant between internet celebrities expertise to product purchase intention and the proportion of the indirect effect in the total effect was 5974 at the same time expertise had a significant positive effect on parasocial relationships and parasocial relationships had a significant positive effect on fans intention to purchase products in summary it can be seen that parasocial relationships produce a significant partial mediating effect between expertise and consumer product purchase intention and hypothesis h4 holds similarly the total effect of social attraction and task attraction to fans product purchase intention was significant for indirect effects and the proportion of indirect effects in the total effect was 6142 and 5974 social attraction has a significant positive effect on parasocial relationships and task attraction has a significant positive effect on parasocial relationships in summary parasocial relationships play a partially mediating role between social attraction task attraction and intention to purchase fan products hypotheses h5 and h6 hold the results are shown in table 6 3 the moderating role of green selfefficacy the moderating role of green selfefficacy was examined using latent moderated structural equations the results show that the interaction terms of expertise and green selfefficacy and task attraction and green selfefficacy had significant effects on parasocial relationships in contrast the interaction term of social attraction and green selfefficacy had a nonsignificant effect on the parasocial relationship in summary it can be seen that green selfefficacy produced a positive moderating effect during the influence of internet celebrities expertise and task attraction on parasocial relationships however the moderating effect during the influence of social attraction on parasocial relationships was not significant and hypotheses h7 and h8 were held while h9 was not the specific interaction pattern is shown in figures 2 and3 conclusions implications and limitations conclusions this study set out to investigate the influence of internet celebrities on fans purchase intentions for energysaving products the analysis was centered on the relationship between fans and internet celebrities using parasocial relationships from mass communication literature this study investigated the relationship developed between fans and internet celebrities and the subsequent influence of that perception on energysaving product purchase intentions this was accomplished through a questionnaire study overall the results of these studies found support for parasocial relationships as an energysaving product diffusion management tool this paper draws the following conclusions first the expertise and attraction of online celebrities have a positive impact on the consumers intention to purchase energysaving products in an online community context moreover expertise and task attraction have a stronger effect on fans intention to buy household energysaving products that is fans are more likely to buy energysaving products at good value through the recommendations of internet celebrities second parasocial relationships mediate the relationship between online celebrities expertise attraction and fans intention to purchase household energysaving products third fans green selfefficacy plays a positive moderating role between online celebrities expertise task attraction and parasocial relationships and a less significant moderating role between online celebrities social attraction and parasocial relationships theoretical contributions first based on social cognitive theory this study investigates the factors influencing consumers intention to purchase household energysaving products recommended by online celebrities in an online community context further broadening the application scenarios of social cognitive theory existing studies have not paid enough attention to promoting consumers intention to purchase household energysaving products from online celebrities even less research has been conducted exploring consumer behavior in this scenario based on social cognitive theory second this study analyzes the mechanism of parasocial relationships between online celebrities expertise and attraction to fans product purchase intention opening up the black box of consumer purchase and demonstrating the mediating role of parasocial relationships between online celebrities expertise and attraction and fans intention to purchase household energysaving products this is part of a growing area that moves psi from the realm of tv personalities to use as an actual sale tool third this study further extends the application of selfefficacy in the environmental field this study demonstrates that green selfefficacy interacts with the external environment influencing fans parasocial relationships with online celebrities this study enriches the theory of selfefficacy practical implications as evident in this study internet celebrities can be an important force for household energysaving product diffusion in particular it can be useful for establishing relationships with fans fans view internet celebrities who have expertise and attraction will likely develop psi with them and have the same positive evaluations of energysaving products the internet celebrities recommended overall this paper has some practical implications first this study can promote better marketing results for internet celebrities selling energysaving products the findings of this study provide guidance for internet celebrities to increase their influence and better persuade their fans to buy energysaving products facilitating better sales for household energysaving products the results of this study suggest that as a new force for promoting the proliferation of energysaving products in the internet era internet celebrities can increase their frequency of interaction and intimacy with their fans by increasing their own expertise and attraction thereby increasing their trust and emotional attachment to them reducing their resistance to their persuasive intentions when selling products and thus increasing their intention to buy the energysaving products they recommend this increases the intention to buy the products they recommend second this study can provide new enlightenment for the government and other departments to promote peoples energysaving behavior with the help of social forces in addition to promoting peoples energysaving behavior through policy promotion and economic subsidies government departments should play an important role in promoting peoples energysaving behavior at the consumer end therefore they can guide internet celebrities and other new forces to exert their influence increase peoples awareness of energy saving and promote energysaving behavior third this study can provide insights for brands or suppliers of energysaving products to expand the sales channels of their products this study analyses the impact of the characteristics of internet celebrities on promoting peoples buying behavior which has important implications for brands and suppliers of household energysaving products in finding suitable partners to increase brand awareness and promote product sales limitations there are also some research limitations in this study mainly the following first consumer behavior in purchasing household energysaving products is a complex process and this study only explores the factors influencing consumers intention to purchase household energysaving products there is a gap between consumers intention to purchase and consumer purchasing behavior influencing factors that need to be improved in the next study second at present there is not much empirical research on the influence of internet celebrities on consumers intention to purchase household energysaving products and this research is only in its infancy

in the past few years internet celebrities have become a new and important way to get people to buy energysaving products their psychological mechanisms for promoting fans intention to purchase have become the focus of academic attention but a unified conclusion has yet to be reached this study uses online communities as a scenario with the characteristics of influencers expertise social attraction and task attraction as antecedent variables and social cognitive theory and parasocial interaction theory as the theoretical basis to explore their influence on fans intention to purchase household energysaving products the study investigates the mediating role of parasocial relationships and the moderating role of fans green selfefficacy in influencing internet celebrities expertise and attraction of fans parasocial relationships the results showed that the parasocial relationships formed between fans and influencers mediated the relationship between the expertise and attraction of influencers and fans intention to purchase energysaving products and that green selfefficacy positively moderated the parasocial relationships formed between fans and internet celebrities in terms of their expertise and task attraction the moderating effect of green selfefficacy on the parasocial relationships between fans and internet celebrities was insignificant

Introduction Seeking refuge is one of the oldest practices known to men [1]. People leave their home countries in the face of persecution for reasons of their religious beliefs, ethnic background, or their political and social activities and become refugees [2,3]. In 1951, the United Nations declared an official definition for the Status of Refugees at the United Nations Geneva Convention, which defined refugees as: outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or is unwilling to return to it" [4] Once refugees reach their destination countries, they often must endure a long, stressful, and uncertain period in detention and asylum centers [5,6]. Lack of information and unfavorable policies coupled with potential hostility towards refugees in the host country all add additional challenges to the refugee's experiences in the host country [7,8]. These intense experiences will often lead to a high prevalence of mental health distress and disorders among refugees, including depression, anxiety, anger, feelings of isolation, and post-traumatic stress disorder [8][9][10]. Mental wellbeing is not a mere absence of distress and mental disorder; rather, it is a stable and strong state of wellness, satisfaction, and contentment [10]. The WHO describes mental health as "a fundamental element of the resilience, capabilities, and positive adaptation that enable people both to cope with adversity and to reach their full potential and humanity" [11]. Resilience is "the process of negotiating, managing, and adapting to significant sources of stress or trauma" [12]. Mental wellbeing incorporates resilience as an essential part of wellness; for example, individuals' own ability to cope with stressors, be part of a community, and to be able to learn and socialize are some of the signs of mental wellbeing [13][14][15]. Additionally, studies show improvement of mental wellbeing among refugees is influenced by successful utilization of social resilience [16,17]. Social resilience is defined as an adaptive system that encompasses "individuals' and societies' capacity to acquire new strategies for survival and cultural creativity to embrace and adopt new contexts to maintain normal function without fundamental loss of identity" [18,19]. Mental wellbeing and social resilience are interconnected, as the refugees' ability to react and adapt to adverse and traumatizing experiences is associated with social relationships [19,20]. Refugee mental health and wellbeing have been addressed by previous studies with varying findings. A survey study of 4325 recently resettled adult refugees in Germany showed that the majority of participants show severe symptoms of depression, anxiety, and lower life satisfaction owing to uncertain legal status, family separation, and living in refugee housing [21]. Another recent study among asylum seekers and refugees in Germany also found that the level of mental distress was higher than that of the local population, with 46% and 45% of asylum seekers and refugees suffering from depression and anxiety, respectively [22]. Eritrean refugees make up a large number of refugees living in Germany [23]. In 2018 alone, around 10,200 Eritrean refugees reached Germany and applied for asylum [24]. Even though currently, Eritrea represents one of the highest numbers of refugees from sub-Saharan Africa, it has not actually been at war for almost two decades. Nicknamed "national slavery", most Eritrean refugees cite indefinite conscription into the national service as the main reason for fleeing the country [25]. The Eritrean national service proclamation was declared in 1994. In the beginning, every eligible citizen between the ages of 18 to 40 was expected to serve for 18 months. However, a campaign by the Eritrean government in 2002 changed the duration period of national service to indefinite [25]. Other reasons mentioned as factors for leaving Eritrea include banning all civil society organizations, lack of freedom of speech, religion and political opinion, human rights abuse, imprisonment, and forced labor [25]. --- Models for Social Resilience Different models of resilience have been developed which focus on the environment, the institutions, and societal resources for promoting refugees' social resilience and mental wellbeing. One example is the ADAPT model [26]. This model helps to understand the experience of refugees in resettlement and the effects it has on their mental health and social organization. According to the ADAPT model, individuals and societies have an innate drive to survive and adapt, but the effectiveness of these natural drives depends on the availability of social resources. According to Tay and Silove [27], the ADAPT model provides a conceptual framework to understand refugees' experiences and their collective social responses to the challenges they face. The model projects that by addressing the social dysfunction and resilience capabilities of refugees, their mental wellbeing could also be positively affected. The authors of the ADAPT model [27] have formulated five key interrelated pillars of strategies or "adaptive systems" which could be affected after experiencing forced displacement and resettlement. According to Silove [26], these five pillars represent a strong base for the development of a stable community and society. The five pillars include security and safety , interpersonal bonds and networks , access to justice and protection , social roles and maintained identities , and the availability of institutions that confer existential meaning and coherence . The ADAPT model further provides principles for policies and practices for mental wellbeing and social resilience interventions to create a holistic recovery in response to challenges faced by refugees [26]. Generally, little attention is given to refugees' resettlement challenges in the broad context of the social environment. Hence, the current study used a qualitative design to provide multidimensional information about refugee resettlement experiences; it explores the mental wellbeing and social resilience mechanisms of Eritrean refugees living in Germany. This study aimed to understand the Eritrean refugee's perceptions of their mental wellbeing, identify the social factors and conditions in Germany that may be associated with mental wellbeing and social resilience, and determine the measures taken by Eritrean refugees to adapt to the social challenges faced in the host country and examine the sources and hindrances for Eritrean refugees' development of social resilience. --- Materials and Methods --- Study Design The current study adopted a qualitative approach with a phenomenological design, as it was ideal for identifying and studying the experiences and issues from the perspective of the study participants. The phenomenological design focuses on gathering detailed individual information, perceptions, and experiences within a particular group of people to understand and describe a particular phenomenon [28]. --- Study Setting and Participants The study involved 11 male and 4 female participants. The number of participants was a result of the accessibility of participants, speed of the snowball method , availability of resources , and participants' willingness to participate. The study participants were all recruited within the state of Baden-Württemberg in Germany. Eritrean refugees between the age of 18 and 40 who came to Germany between 3 and 6 years ago were recruited, thus ensuring a source of ample post-migration experience of life in Germany as well as limiting the years spent in Germany that can affect the experience. The rationale for the age selection was that the majority of the refugees who arrive in Germany are under the age of 35 [29]. --- Sample Technique and Data Collection Tools The exponential non-discriminative snowball sampling method was the most appropriate for this study as there is no complete sampling frame from which to draw a random sample. In this sampling type, the first participant is recruited and provided multiple referrals; thereafter, the recruited participant in the research work recruits another participant until the needed number is reached [30]. The initial male participants were recruited from a local barbershop owned and managed by Eritreans, as well as from a restaurant that is frequented by local Eritrean residents. The initial female participants were recruited from a local Eritrean orthodox church community. To explore and understand the details of refugee experiences, the researcher adopted a semi-structured in-depth interview technique with open-ended questions as a data collection method. The interview guide was designed based on a preliminary literature review of the conceptual framework used for the study, i.e., the ADAPT model [26]. Participants' experiences with a focus on challenges encountered since arrival in the host country were the focus of the interviews, as well as their coping skills and self-identified resources utilized for social resilience. For mental wellbeing, no specific framework was used. Instead, we relied on the self-reflective description from the participants and adapted it to the ADOPT model framework. The interview guide was reviewed by scholars and professionals who worked in the fields of public health, anthropology, and psychology. It also went through another review by conducting two trial interviews. Based on the recommendations and advice given by the scholars and professionals and the trial interview, the guide was slightly modified to serve as an optimal basis for the communicative exploration of refugee experiences. --- Data Collection Procedures Due to the recent COVID-19 pandemic, face-to-face social interactions were prohibited during the data collection period; thus, all interviews were conducted via telephone. The researcher and all participants were able to speak and understand Tigrinya ; therefore, the interview guide was translated from English to Tigrinya by the principal researcher and Eritrean peer reviewer , and all the interviews were conducted in Tigrinya. This helped the participants express their ideas, views, and experiences with ease. Information sheets and consent forms, written in Tigrinya, were mailed to the participants before the actual dates of the interviews. Because there could have been illiterate persons, the information sheet and consent form were read out to the interviewee before the start of the interviews. All participants had given their consent to the interviews being audio recorded, analyzed, and published. --- Data Analysis Thematic analysis was used in the study to interpret and code the data. For the analysis, a systematic and iterative process was utilized. This process consisted of multiple stages: the first stage was the verbatim transcription of the interviews, and the next step was to translate the transcribed data into English. The process of translating Tigrinya to English was completed by the principal researcher with a detailed and careful assessment of each word. Necessary alterations had to be made, as the grammatical structure of Tigrinya is different from English [31]. The translated texts were later back-translated into Tigrinya by another Eritrean peer reviewer with advanced skills/proficiency in both languages to ensure the quality of the translated data. Relevant segments from the translated transcripts were condensed into codes and given the appropriate label by the researcher. NVivo software , NVivo Version 12) [32] was used for coding and analysis of the data set. The themes of the study were developed according to the five themes described in the ADAPT framework, which allowed for a unique understanding of the issues being examined here. --- Ethical Consideration The study protocol had been submitted before the start of the research, and ethical approval was obtained from the ethics committee of the medical faculty of Heidelberg University . The study was conducted under the principles described in the Declaration of Helsinki [33]. --- Results The results of the current study are presented in two sections. The first section consists of the demographic data of the participants. The second section describes the self-reported status of mental wellbeing and subsequently reports on the five pillars of the ADAPT model . Finally, hindrances and sources of social resilience are presented and summarized. --- Demographics of the Participants A total of 15 participants took part in the study, including 11 males and 4 females. Most of the participants were young males between the ages of 18 and 24. The majority of the participants were either employed or were currently enrolled in language or vocational training. Three participants had a B1 level of German language proficiency, and 11 participants either had no academic language proficiency or only had an A1 level of proficiency. One participant had a C1 level of German language proficiency. More details about the participants are shown in Table 1. --- Self-Reported Status of Mental Wellbeing When discussing their mental wellbeing, almost all the participants described their current mental wellbeing as having improved since arriving in Germany; the first years were characterized by all the participants as "distressing, shocking, and stressful". "In the beginning, it was stressful; we were suffering. My husband and I did not know anything about Germany, so everything was a shock for us." (female, [18][19][20][21][22][23][24]. Time was mentioned as a healer. With the length of the time spent in Germany, all participants reported their mental wellbeing improved. Most of the participants reported incidents of distress and depression in the first years of the resettlement process, with two of the participants taking medication for the depression they suffered. Some of the mentally stressful experiences reported by the participants are isolation and feeling of loneliness. The most common source of stress was the "language barrier"; other reasons for stress were the burden of responsibility for family back home, unemployment, and cultural differences. A unique source of stress expressed by more than half of the participants was related to receiving many official letters and contracts through the mail. Specifically, difficulty reading the letters and the quantity of the letters received were reported as the source of stress. "One thing I hate about Germany is that they have too much paperwork for little things, and they send you so many letters and that drove me crazy in the early days. I still hate it, and whenever I go to check the mail, I get stressed." --- Safety and Security Safety and security were discussed as the first part of the five pillars of the ADAPT model. Most of the participants considered German people as "law-abiding citizens" (female, [18][19][20][21][22][23][24] and the country of Germany as a "safe place to live" (male, 31-35, female, [25][26][27][28][29][30]. The perceived strict rules and regulations of the German society were considered as a positive influence on the safety of the participants, and for all the female participants, physical safety was not considered an issue in Germany, stating this: "I am safe here [ . . . ] If someone does anything to me, he will never get away with it. I feel confident about my safety here." (female, [25][26][27][28][29][30] Another topic discussed along with safety was emotional and physical security; all participants described one or more reasons to be insecure in their current lives. The most frequently mentioned insecurity was related to the residence permit. Insecure and temporary residence permits were reported as an obstacle to integration and as a source of stress by all participants. Some participants described fear of deportation when their residence permit expires; they expressed an uneasy feeling of uncertainty. Some participants were reminded of their past experiences in Eritrea when thinking about this fear. The participants recounted the insecurity they felt when they did not know when they would be taken by the military police to the national service in their home country, known locally as "gefa", as similar to the uncertainty of not knowing if they would be allowed to stay or not in Germany. " . . . Just like back home when we had to flee our homes because of "gefa" and here I had the same experience . . . " (male, [18][19][20][21][22][23][24] For most participants, safety and security were interrelated with the prospects of their future. Many participants shared a sense of hope for a good future even though the short residence permit made them feel insecure. They linked their prospects with the current opportunities opening up in Germany. The "new" life in Germany was referred to as an opportunity, a platform for a future they did not expect to have in their former hometowns. --- Interpersonal Bond Participants expressed their loss of immediate family ties after reaching Europe, mentioning how much they missed their family back home. Family support and relationship were cited as primary needs for almost all the participants. The majority of the participants expressed negative emotions and distress due to separation from family, as one participant described: "I cannot handle the stress here alone, I miss my home and my family." (male, [31][32][33][34][35]. All participants mentioned losing their social connections upon arrival in Germany, but 14 out of the 15 participants reported establishing a new relationship with other Eritrean refugees in Germany soon thereafter. The majority of the participants considered these relationships as positive concerning the benefit of socializing and interacting with Eritrean refugees. "I feel happy; I get to speak to my brothers in my own language. I enjoy the conversations we have." (male, [18][19][20][21][22][23][24] The interaction between Eritreans was viewed as a therapeutic time and stress reliever; participants reported feeling "happy" and "excited" to meet their Eritrean friends, and one participant even described meeting Eritreans as "a social medicine", Stating that "it is better than the medicine you take from doctors" (male, [25][26][27][28][29][30]. The most commonly reported benefit of maintaining interaction with a fellow Eritrean was "ease of communication". Relationships with non-Eritreans were mentioned as seeming impersonal, and most participants described their interaction with their classmates, workmates, and neighbors, who were not Eritreans, as "distant and limited" (male, [25][26][27][28][29][30]. Participants in the study also discussed the relationship with the Eritrean diaspora community, older Eritreans who have been living in Germany for decades. Communication and interaction with this group were described as "broken" or "hostile"; some participants even claimed that "the reason they received short residence permits" was due to people from the diaspora community acting as translators, and they assumed they were "lying to the immigration officers about Eritrean politics, which affects our asylum claim" . Another participant described his interaction with the diaspora community like that: "I can honestly say, I do not have a relationship with any diaspora community. Even if they see you in the streets, especially the young newcomers, they insult us. If they genuinely cared about us, they could have talked to us and discussed our problems; they are liars! To be frank, they were supposed to guide the young generation because they know everything about Germany, but instead, they made sure to create a conflict with the new generation." --- Sense of Justice Participants expressed perceived unfair treatment due to their social status as refugees and as Africans. These participants spoke of a need for understanding and compassion because "the Eritrean situation is not the same as other refugees" . Some participants asked for support and empathy from the German communities: "We Eritreans are fleeing a dictatorial regime that is killing its youth, and the Germans should know this well. They had their experiences with a dictator in the past; they fled the country back then too." Meanwhile, another reported phenomenon exemplifying a sense of justice in comparison to the past experiences of injustice was the treatment they received from members of German society. More than half of the respondents reported having been treated well within the German community. Yet, these participants also mentioned incidents of unfair treatment by some local communities. All the participants in the study reported having experienced racism and discrimination. Self-perceived discrimination was thematized by more than half of the participants. A female participant reported on her interactions with local officials: "the offices I went to have no respect for me. Either they rudely treated me, or they treated me like I am ignorant." (female, [25][26][27][28][29][30]. Another concern regarded as injustice brought up in the interviews was the immigration and asylum laws in Germany; the participants described them as violating their human rights and rights for asylum. The possibility of Eritrea being labeled as a safe country of origin after the peace agreement of 2018, and the therefore heightened probability of asylum claims from Eritrea being rejected, was reported as a source of great stress. "They should consider the Eritreans refugee's situation again. We did not escape because of war, there was no war, we fled because of the tyrant leader there. I think it even got worse after the peace agreement and people are still coming." 3.6. Role, Identity, and Culture Participants aged 30 and above mentioned the significance of family ties as vital for social roles and self-identity. The majority of the participants under the age of 30 described adapting quickly to new social roles in resettlement. The cultural difference was considered confusing and disruptive to traditional roles and self-identity. As participants explained their experiences and challenges with role shifts, they expressed fear of losing their traditional roles. Employment was mentioned as a source of stabilization of traditional roles among Eritrean refugees, as one participant explained about her husband and other Eritrean men who are unemployed: "In our culture, men need to work, and they won't feel like a man if they don't have a job. A man who stays at home all day is considered less than a man, and this is a source of stress for them they get depressed, and they start drinking . . . " (female, [18][19][20][21][22][23][24] Many participants stressed that they lost their identity when they reached Germany; they described the feeling of emptiness, and they also mentioned the feeling of confusion concerning their future roles. All participants reported losing their past credentials in the migration process. "I only had the clothes on my back and a small bag on my hand. I had no educational or vocational papers from home, and there was no way to get it because of the political situation." (female, [25][26][27][28][29][30] Losing their past accomplishments, be it educational or vocational, was perceived as identity loss and, therefore, as stressful. Most participants described the feeling of anxiety and confusion about their roles in life after resettlement. Another loss described by the participants was a phenomenon referred to by one participant as "generation loss" (male, [31][32][33][34][35]. Participants said that cultural and national identities, which were supposed to be passed on from generation to generation, were disrupted. They described the "generation gap" created by the unstable relationship with the older generation and being cut off from their home country as a reason for young Eritreans to feel they have lost or are losing their identity. --- Existential Meaning and Coherence Participants pulled meaning and coherence out of religious and traditional value systems. They described the realization of being in an unfamiliar environment as a shock that had to be processed. The "world" had to be understood anew, and their own life experience had to be given meaning. Religion helped most of the participants in that process. All the respondents reported attending religious services at some point in time. For approximately half of the participants, religion was mentioned as a source of unity and strength as well as a central part of their social lives. The second source of identity stabilization for some people is traditional values. Older aged participants regarded them as violated in resettlement. For example, four of the participants described the phenomenon of young Eritreans being sexually active before marriage, loss of respect for older aged individuals, and individualism. They voiced concerns about this kind of cultural transformation of adolescent refugees. "The underage refugees who were placed with German families, don't respect their elders and their culture, which will lead to arguments and fights. They are losing their Eritrean heritage because they are living with German families." --- Social Resilience More than half of the participant's responses saw the current social resilience among the Eritrean refugee community in Germany as weak and ineffective. "It is virtually non-existent with us here, social resilience depends on helping and assisting each other, and we are not doing that genuinely, we only pretend to care! Especially the diaspora in Germany." (female, [18][19][20][21][22][23][24] Social resilience was associated with socializing with fellow Eritreans; more than half of the participants reported difficulties finding the opportunity and appropriate location for such meetings. Some of the difficulties participants mentioned in socializing were housing location; they described being assigned housing in rural areas, which prevented them from meeting other Eritreans. Churches and traditional coffee houses were mentioned as essential sources of socialization for three male and all female participants. Although all participants liked to socialize with fellow Eritrean refugees, the current political division among Eritreans was mentioned as counter-beneficial to the social resilience of Eritrean refugees. Similarly, most of the participants reported social media as having a negative consequence rather than being a means to facilitate social resilience. They described social media's role as divisive and inciting violence amongst Eritrean refugees, providing a platform for hate speech and bullying. --- Sources and Hindrances for the Development of Social Resilience In line with the results displayed according to the ADAPT model, we identified hindrances and sources of mental wellbeing and social resilience. Hindrances have been attributed to the challenges those participants of this study faced throughout their resettlement process, concluding in negative outcomes for their mental as well as their social wellbeing. Furthermore, our study participants mentioned multiple sources for mental wellbeing and social resilience, which facilitated a positively shaped attitude toward their situation and solidified hope for their future. We visualize these hindrances and sources of social resilience in Figure 1 and Figure 2 Figure 2. Sources to mental wellbeing and social resilience . --- Discussion The result of the study suggests that the experiences of refugees after resettlement --- Discussion The result of the study suggests that the experiences of refugees after resettlement are multidimensional and complex. The findings of our study support and contradict previous studies. The post-migration experience of participants was characterized by diffi- --- Discussion The result of the study suggests that the experiences of refugees after resettlement are multidimensional and complex. The findings of our study support and contradict previous studies. The post-migration experience of participants was characterized by difficulties, adversities, and discrimination in resettlement but also innovations in integration, utilization of social support, and resources for social resilience. --- Mental Wellbeing All participants gave accounts of their self-reflective psychological experiences and challenges. They repeatedly mentioned experiencing some degree of stress and psychological distress after resettlement in Germany, echoing the finding from a previous study by Biddle [22] on recently resettled refugees in Germany. The current study revealed some conditions which were a hindrance to positive mental wellbeing for resettled refugees. Participants repeatedly mentioned the language barrier as the most common source of stress, which acted as a barrier to their integration into German society. Language difficulties were mentioned in various degrees, resulting in fewer employment opportunities, social interaction, and independence. Similarly, a study by Walther et al. [34] on refugees who resettled in Germany between 2013 and 2016 found that proficiency in the German language was associated with improved mental health. A unique finding on a source of stress in the current study is that of official documentation and letters. Some participants cited the frequency and number of letters received from local authorities, combined with the language barrier to reading the letters, as a factor for post-resettlement stress. Participants explicitly mentioned anxiety due to the accumulation of letters, missing important messages due to a lack of complete understanding of the written information, getting fined because they did not respond to letters sent to them from local authorities and constantly asking people to translate for them. The feeling of being "an outsider" is amplified for refugees with every challenging experience of the language barrier and integration [21]. As mentioned by previous studies [7,9] feelings of isolation are found to be a risk factor for mental health disorders among refugee populations. These feelings are linked to depression, sleep deprivation, thoughts of self-harm, addictions, and risky behavior [9]. By focusing on the challenges of resettlement, the current study findings were able to explore and describe the subjective experiences of post-migration stressors and the influence it has on the mental wellbeing and social resilience of Eritrean refugees. In general, the level of stress has been reported to decrease with more time spent in Germany. This can be due to multiple reasons, as the participants of the current study are mostly young adults, and so the ability of an individual to recover at this period of their life might be higher compared with older aged individuals [21]. The social environment in which Eritrean refugees find themselves influences their mental recovery as well, and acceptance and social support from local communities help to mitigate past trauma. Additionally, the challenging history of the participants and the previous experiences of migration trauma have contributed to feeling better after resettlement and being grateful for the current experiences. The feelings of hope and optimism appear to be enforced by the knowledge that things could be much worse than they currently are. Similarly, a study by McGregor [35] concludes that previous hardships faced by refugees are mitigated through feelings of appreciation for their current life circumstances. Mental wellbeing improvement was more evident in female participants, who expressed their overall satisfaction with life, confirming a report by Walther [21] on the refugee population in Germany, which stated that female refugees reported higher life satisfaction compared with male refugees. --- Safety and Security All discussions with the participants addressed the five categories of the ADAPT model in relation to social resilience to varying degrees. Various mechanisms of resilience and recovery, as well as challenges, are discussed. What facilitated the feeling of safety among participants in the study differed, but the findings show an increased sense of safety. Most participants compared Germany with Eritrea and other countries they encountered during the migration process, which increased the feeling of safety in the current host country. The general feeling of safety and security was decreased in relation to rights to remain amongst participants as a result of the uncertain and short residence permits they received, which made them question their future, some describing it as "being left in a loop". Some participants even went as far as comparing their experiences with short residence permits and the fear of deportation with a practice called "gefa" in Eritrea, which is essentially government rounding up of youth for national military service; it is known for being one of the traumatizing experiences of pre-migration for Eritrean refugees [36]. Additionally, some participants described the recent peace agreement between Eritrea and Ethiopia as a source of potential insecurity regarding their residence status in Germany. On 9 July 2018, leaders of Eritrea-Ethiopia met for a peace summit, formally ending the border conflict between both countries, which started in 1998 and continued until 2018 in a frozen conflict state of "no war, no peace" [37]. Short residence status can create a feeling of uncertainty, which hinders Eritrean refugees' integration process in Germany regarding employment, or language proficiency, confirming the conclusion of a study by Bakker et al. [38] on the adverse effects of insecure residence permits on integration and psychological wellbeing of refugees. Additionally, a lengthy unsecured residence in host countries will "foster a passive attitude towards their future" [38], creating an atmosphere that is not conducive to smooth integration and social resilience. --- Interpersonal Bond Regarding the participant's interpersonal relationship, the primary source of social interaction indicated by the participants was a relationship created with other Eritrean refugees who arrived in Germany recently, characterizing the relationship as close, full of mutual understanding, and a stress reliever. Social interaction with fellow refugees increases the sense of security and stability of individual refugees and the community as a whole and results in improved reports of mental wellbeing [39]. The positive aspect of socializing with Eritrean refugees was mostly referred to in sentimental tones that centered around nostalgic feelings of home, mother language, culture, and mutual understanding. However, the loss of close family and friends in the process of migration and resettlement was attributed as a stressor among the present study participants. Studies on the mental health and wellbeing of refugees have found that social connections and affiliations are important predictors of successful integration and foster social resilience [2,9]. In addition to the already lost relationships, the interaction with the local residents and Eritrean diaspora communities, who have been living in Germany for decades, did not materialize into meaningful relationships for our participants, making adaptation to the new society an uphill climb. The relations and interactions with the Eritrean diaspora were characterized as hostile, resentful, and suspicious. According to Hepner [40], due to the generational gap, combined with the politicizing of interactions and general miscommunication, the relationship between the newcomer Eritrean refugees and the Eritrean diaspora community has been broken. This phenomenon acted as a hindrance to the utilization of social resources and the development of social resilience. This is not to suggest that all refugees in the current study are unable to access the social resources available to them, but rather, they cannot access the optimal potential of social resources in relation to fellow ex-pats, which would make a positive difference in their integration and social resilience. --- Sense of Justice A sense of injustice before and after resettlement was repeatedly mentioned in the current study. The pre-migration injustice mainly centered around treatment by the Eritrean government, but wrongs and mistreatment committed by the Eritrean government have been reported by some participants as restored by the treatment they received after arriving in Germany. A feeling of injustice in the light of discrimination and racism is also mentioned in previous studies [10,35]. Similarly, in a follow-up study of Syrian refugees in Germany, discrimination was identified as a major risk factor for mental wellbeing [41]. These negative experiences reinforced the challenges of social resilience and adaptation to the new environment, creating a sense of being unwelcome. According to Silove [26], understanding and mitigating the sources of injustice is vital to creating an environment that enhances the process of mental health recovery during the resettlement of refugees. Refugees with short residence permits typically feel insecure about their future in the host country [5,9]. The participants in the present study echoed a similar sentiment, describing the immigration laws of Germany as unjust since it disregards their unique situation that needed to be addressed differently than that of other refugees, stating they do not see a future where they can go back to their home country anytime soon. It should be noted that this claim has been challenged by the Eritrean diaspora community in a previous study, stating that Eritrea is a safe country [40]. --- Role and Identity The findings in this study suggest a link between social role breakdown and the negative mental wellbeing and social resilience of refugees. Our participants pointed to a correlation between social roles and the level of stress expressed by the participants. In line with Sin's findings [42], the current study especially confirms that employment plays a significant role in social integration and resilience. Unemployment was seen as one of the primary role and identity breakdowns the male participants experienced during their resettlement process. To all female participants of the study, family separation was the most important source of psychological disturbance and challenged their role in the community. The hostility of the authoritarian Eritrean government towards the refugees who have fled the country makes it impossible to obtain the legal papers needed to confirm past educational and professional achievements [40]. This was seen as an obstacle to resuming their previous vocational role after resettlement. The difficulties in acquiring documentation included their civil documentation as well, mainly marriage and birth certificates, which made it very difficult to reunite with family members. According to Silove [26], oppressive regimes regularly deny individuals social rights to punish dissidents and challenge their sense of identity and control. --- Existential Meaning Religious beliefs play a key role in strengthening the social resilience of refugees; Silove [26] argues that religion solidifies the moral values and beliefs that are integral to social and mental wellbeing. The refugees in the current study reported gratitude and appreciation to God for surviving challenging migration routes and the opportunity to live and pursue their future. The role that religion plays in the social activity of the participants was apparent, especially among the female participants. Strong beliefs and religion have been noted to play a focal role in social interaction and adopting coping mechanisms for refugees resettled in a new environment [20]. A recent study on Eritrean refugees echoed similar findings on the positive role of religious faith, family support, and a vision for the future, which act as enabling factors to build resilience and social interaction [43]. Changes to traditional culture, beliefs, and values took place for the Eritrean refugees while trying to negotiate their new life in the new environment. The new lifestyle encountered by the refugees, which was constantly referred to as "the German system" by the participants of the current study, left them with cultural shock and forced them to innovate and adapt to the new environment. All participants recalled cultural shock when first arriving in Germany, but slowly they grew accustomed to living in their new home. The social and cultural adaptation has not progressed equally for every participant in the study, with more than half of the participants describing difficulties with the "German system" daily. Magnet de Saissy [14] argues rapid and forced adaptation of communities to the new environment will have an impact on the social and mental wellbeing of the individual. A source of social conflict that stood out in the present study is social media. Participants explicitly mentioned social media tools as facilitators of conflict and division for Eritrean refugees, thus acting as a hindrance to fostering social resilience among Eritrean refugees. This finding contradicted research that found social media as facilitators of positive social interaction for Eritrean and other refugees [19,35]. For most participants of the current study, leaving aside the positive aspect of communication, social media caused harm to the solidarity and social resilience of Eritrean refugees. Some consider the platforms to be a means for the political and regional division to spread among the newcomers. Therefore, this study revealed the negative role social media play among Eritrean refugees. --- Social Resilience The findings of this study demonstrated the importance of a robust social community in building and adopting a resilience mechanism. Identifying and tackling the sources of conflicts among the refugees will be essential to fostering better social interaction and mental wellbeing. Additionally, the study attests to the relevance of the ADAPT model [26] in understanding the complexity and challenging experiences of refugees after resettlement. --- Strength and Limitations of the Study Owed to restrictions due to the COVID-19 pandemic, the study data collection method was limited to a telephone interview; however, we found that this method gave a heightened sense of anonymity to the participants and freedom to speak freely and openly. Additionally, telephone interviews are hypothesized to have a decreasing effect on the social desirability bias [44]. The telephone interviews provided and encouraged an environment of open and honest discussion about culturally sensitive topics, including one's mental health. However, the absence of visual cues and communication in telephone interviews is a drawback to the natural and emotional interaction in face-to-face interviews and thus produces more restricted responses [44]. The current study was conducted in the frame of a Master's course , with the principal researcher being a young Master's student of the same national origin as the study participants. Coming from the same socio-cultural background, having a family history of migration as well , and being able to speak the study participants' language, Tigrinya, eased access to and familiarization with the study participants as well as building trust to narrate their stories and express their feelings. However, the negative impacts of the researchers' background on the study cannot be ruled out . Furthermore, some of the limitations of the study are the small sample size and the heterogeneity of the snowball sample method. With regards to the small sample size: the fact that the primary researcher had the same socio-cultural background as the study participants might have eased the initiation of the snowball sampling. Yet establishing contact and access to the sampling population, as well as creating trust, takes time. How much COVID-19 also played a role is difficult to say. However, the snowball process went rather slow, and the study had to be conducted within a certain time period . In the end, a total of 15 participants were included. The time constraints did not allow for planning the study a priori to reach theoretical saturation . However, the data were rich enough to answer the study aim, which is one aspect of saturation. Related to that, in qualitative research, numbers are not as important as the depth of the data [28]. With regards to heterogeneity, 11 male participants and 4 female participants were included. This might present a selection bias, potentially affecting the transferability of our results. Furthermore, inherent in snowball sampling is the fact that the subsequently recruited respondents are more likely to be similar to the previous participants, which could have led to a very concise data picture. Additionally, female participants being interviewed by a male interviewer could have led to a reporting bias. Sex differences can create a significant barrier to acquiring honest responses to sensitive questions [45]. In qualitative research, the researcher is seen as part of the research process, and it is acknowledged that the researcher comes with their own background, ideas, and interpretations [32]. The researcher should hence always reflect on his/her background and the ways in which this influences the analysis of the data and interpretation of findings. Although efforts were made to stay true to the participant's response, considering the researcher as only a narrator, and to keep one's own interpretations apart, it cannot be ruled out that a bias in this direction occurred. In this process, going back to the respondents to dig deeper into the meaning of some data and to clarify the respondents' view versus the researcher's interpretation might be necessary. Resource and time constraints, unfortunately, did not allow this in the current study. Despite these, the current study provides a comprehensive understanding of the current challenges for refugees to feel well and identifies hindrances and sources for better social resilience. --- Conclusions The findings of the current study can be helpful for the planning of effective and sustainable interventions. One of the ways to mitigate the challenges of refugee resettlement is by focusing on integration lessons and training on topics such as cultures and social and legal systems in Germany, referred to as the "German system" by the participants. The Federal Office for Migration and Refugees provides an integration course on various challenges refugees encounter, consisting of language courses, orientation to administrative regulations, writing emails and letters, and job interviews. The integration course should be tailored to be more culturally appropriate, putting into consideration the understanding and background of refugees. Integration course instructors should be aware of possibly different habits of thought and evaluation as well as daily life practices and experiences of their students, which will help to design the best method to deliver the courses appropriately. Additionally, due to the limited literacy possessed by Eritrean refugees, we recommend German language lessons be already provided alongside the integration courses, preferably instructors/assistant instructors with knowledge of the Tigrinya language; henceforward, they will be able to translate German words directly into Tigrinya words. Additionally, taking into consideration the lack of access to the proper credentials and documentation, the mentioned loss of past achievements by the respondents could be tackled if government services would be more open to accepting international study and working degrees and vocational training certificates or at least propose flexible ways to catch up with the requirements of the German system. Coupled with efforts to integrate the refugees into job positions, this could not only help to solve Germany's skilled labor shortage but also touch upon the mentioned feeling of isolation, as the refugees would be integrated into the "German system". Easing family identification requirements for the family reunification process could also ease the stress of isolation. By focusing on the challenges of resettlement, the current study findings were able to explore and describe the subjective experiences of post-migrations stressors and the influence it has on the mental wellbeing and social resilience of Eritrean refugees. In addressing the challenging experiences of refugee resettlement within the five pillars of the ADAPT model, the current study reveals those experiences could be turned into sources of mental wellbeing and resilience. --- Data Availability Statement: The data presented in this study are available on request from the corresponding author. ---

Mental health and social resilience play a significant role in refugees' adaptation during the resettlement process in the host country. Maintaining good mental wellbeing helps the refugees to respond to stressful experiences with healthy life choices. This study aimed to explore the mental wellbeing and social resilience of Eritrean refugees living in Germany and to identify social conditions and enablers to foster adaptation. This study employs a qualitative approach with a semi-structured, in-depth interview data collection method. Informants were identified among mostly young adult refugees living in Heidelberg, Germany, with a migration history of 3-6 years. In total, 15 informants were recruited through snowball sampling. Data were sorted and analyzed using the five pillars of the Adaptation and Development after Persecution and Trauma (ADAPT) model. The findings suggest that Eritrean refugees experienced psychological distress after resettlement in Germany; however, with time, their mental health improved. The study revealed conditions that were experienced as hindrances, as well as ones that were considered to be resources of positive mental wellbeing and social resilience for resettled refugees. Resettlement challenges described by the participants were the language barrier, discrimination, unemployment, insecure residence status, loss of family and friends, conflict within the diaspora community, and isolation. The main sources of mental wellbeing and social resilience include the feeling of being welcomed by local communities, access to social services, adopting new relationships, and educational opportunities. These experiences encouraged refugees to have a favorable view of their lives and futures and were also found to facilitate better integration and adaptation. Understanding refugee mental wellbeing and social resilience requires a multidimensional perspective. Eritrean refugees living in Germany have experienced and are still experiencing resettlement challenges, such as, for example, loss of family and friends, negative perception of the German system, loss of past achievements, or unemployment. However, they have developed adaptive and resilience mechanisms, as well, such as seeing an opportunity for a better life, adopting new roles, and accepting Germany as a "second home". In addressing those issues reported by the refugees as hindrances, these could be turned into sources of mental wellbeing and resilience.

introduction seeking refuge is one of the oldest practices known to men 1 people leave their home countries in the face of persecution for reasons of their religious beliefs ethnic background or their political and social activities and become refugees 23 in 1951 the united nations declared an official definition for the status of refugees at the united nations geneva convention which defined refugees as outside the country of his nationality and is unable or owing to such fear is unwilling to avail himself of the protection of that country or is unwilling to return to it 4 once refugees reach their destination countries they often must endure a long stressful and uncertain period in detention and asylum centers 56 lack of information and unfavorable policies coupled with potential hostility towards refugees in the host country all add additional challenges to the refugees experiences in the host country 78 these intense experiences will often lead to a high prevalence of mental health distress and disorders among refugees including depression anxiety anger feelings of isolation and posttraumatic stress disorder 8 9 10 mental wellbeing is not a mere absence of distress and mental disorder rather it is a stable and strong state of wellness satisfaction and contentment 10 the who describes mental health as a fundamental element of the resilience capabilities and positive adaptation that enable people both to cope with adversity and to reach their full potential and humanity 11 resilience is the process of negotiating managing and adapting to significant sources of stress or trauma 12 mental wellbeing incorporates resilience as an essential part of wellness for example individuals own ability to cope with stressors be part of a community and to be able to learn and socialize are some of the signs of mental wellbeing 13 14 15 additionally studies show improvement of mental wellbeing among refugees is influenced by successful utilization of social resilience 1617 social resilience is defined as an adaptive system that encompasses individuals and societies capacity to acquire new strategies for survival and cultural creativity to embrace and adopt new contexts to maintain normal function without fundamental loss of identity 1819 mental wellbeing and social resilience are interconnected as the refugees ability to react and adapt to adverse and traumatizing experiences is associated with social relationships 1920 refugee mental health and wellbeing have been addressed by previous studies with varying findings a survey study of 4325 recently resettled adult refugees in germany showed that the majority of participants show severe symptoms of depression anxiety and lower life satisfaction owing to uncertain legal status family separation and living in refugee housing 21 another recent study among asylum seekers and refugees in germany also found that the level of mental distress was higher than that of the local population with 46 and 45 of asylum seekers and refugees suffering from depression and anxiety respectively 22 eritrean refugees make up a large number of refugees living in germany 23 in 2018 alone around 10200 eritrean refugees reached germany and applied for asylum 24 even though currently eritrea represents one of the highest numbers of refugees from subsaharan africa it has not actually been at war for almost two decades nicknamed national slavery most eritrean refugees cite indefinite conscription into the national service as the main reason for fleeing the country 25 the eritrean national service proclamation was declared in 1994 in the beginning every eligible citizen between the ages of 18 to 40 was expected to serve for 18 months however a campaign by the eritrean government in 2002 changed the duration period of national service to indefinite 25 other reasons mentioned as factors for leaving eritrea include banning all civil society organizations lack of freedom of speech religion and political opinion human rights abuse imprisonment and forced labor 25 models for social resilience different models of resilience have been developed which focus on the environment the institutions and societal resources for promoting refugees social resilience and mental wellbeing one example is the adapt model 26 this model helps to understand the experience of refugees in resettlement and the effects it has on their mental health and social organization according to the adapt model individuals and societies have an innate drive to survive and adapt but the effectiveness of these natural drives depends on the availability of social resources according to tay and silove 27 the adapt model provides a conceptual framework to understand refugees experiences and their collective social responses to the challenges they face the model projects that by addressing the social dysfunction and resilience capabilities of refugees their mental wellbeing could also be positively affected the authors of the adapt model 27 have formulated five key interrelated pillars of strategies or adaptive systems which could be affected after experiencing forced displacement and resettlement according to silove 26 these five pillars represent a strong base for the development of a stable community and society the five pillars include security and safety interpersonal bonds and networks access to justice and protection social roles and maintained identities and the availability of institutions that confer existential meaning and coherence the adapt model further provides principles for policies and practices for mental wellbeing and social resilience interventions to create a holistic recovery in response to challenges faced by refugees 26 generally little attention is given to refugees resettlement challenges in the broad context of the social environment hence the current study used a qualitative design to provide multidimensional information about refugee resettlement experiences it explores the mental wellbeing and social resilience mechanisms of eritrean refugees living in germany this study aimed to understand the eritrean refugees perceptions of their mental wellbeing identify the social factors and conditions in germany that may be associated with mental wellbeing and social resilience and determine the measures taken by eritrean refugees to adapt to the social challenges faced in the host country and examine the sources and hindrances for eritrean refugees development of social resilience materials and methods study design the current study adopted a qualitative approach with a phenomenological design as it was ideal for identifying and studying the experiences and issues from the perspective of the study participants the phenomenological design focuses on gathering detailed individual information perceptions and experiences within a particular group of people to understand and describe a particular phenomenon 28 study setting and participants the study involved 11 male and 4 female participants the number of participants was a result of the accessibility of participants speed of the snowball method availability of resources and participants willingness to participate the study participants were all recruited within the state of badenwürttemberg in germany eritrean refugees between the age of 18 and 40 who came to germany between 3 and 6 years ago were recruited thus ensuring a source of ample postmigration experience of life in germany as well as limiting the years spent in germany that can affect the experience the rationale for the age selection was that the majority of the refugees who arrive in germany are under the age of 35 29 sample technique and data collection tools the exponential nondiscriminative snowball sampling method was the most appropriate for this study as there is no complete sampling frame from which to draw a random sample in this sampling type the first participant is recruited and provided multiple referrals thereafter the recruited participant in the research work recruits another participant until the needed number is reached 30 the initial male participants were recruited from a local barbershop owned and managed by eritreans as well as from a restaurant that is frequented by local eritrean residents the initial female participants were recruited from a local eritrean orthodox church community to explore and understand the details of refugee experiences the researcher adopted a semistructured indepth interview technique with openended questions as a data collection method the interview guide was designed based on a preliminary literature review of the conceptual framework used for the study ie the adapt model 26 participants experiences with a focus on challenges encountered since arrival in the host country were the focus of the interviews as well as their coping skills and selfidentified resources utilized for social resilience for mental wellbeing no specific framework was used instead we relied on the selfreflective description from the participants and adapted it to the adopt model framework the interview guide was reviewed by scholars and professionals who worked in the fields of public health anthropology and psychology it also went through another review by conducting two trial interviews based on the recommendations and advice given by the scholars and professionals and the trial interview the guide was slightly modified to serve as an optimal basis for the communicative exploration of refugee experiences data collection procedures due to the recent covid19 pandemic facetoface social interactions were prohibited during the data collection period thus all interviews were conducted via telephone the researcher and all participants were able to speak and understand tigrinya therefore the interview guide was translated from english to tigrinya by the principal researcher and eritrean peer reviewer and all the interviews were conducted in tigrinya this helped the participants express their ideas views and experiences with ease information sheets and consent forms written in tigrinya were mailed to the participants before the actual dates of the interviews because there could have been illiterate persons the information sheet and consent form were read out to the interviewee before the start of the interviews all participants had given their consent to the interviews being audio recorded analyzed and published data analysis thematic analysis was used in the study to interpret and code the data for the analysis a systematic and iterative process was utilized this process consisted of multiple stages the first stage was the verbatim transcription of the interviews and the next step was to translate the transcribed data into english the process of translating tigrinya to english was completed by the principal researcher with a detailed and careful assessment of each word necessary alterations had to be made as the grammatical structure of tigrinya is different from english 31 the translated texts were later backtranslated into tigrinya by another eritrean peer reviewer with advanced skillsproficiency in both languages to ensure the quality of the translated data relevant segments from the translated transcripts were condensed into codes and given the appropriate label by the researcher nvivo software nvivo version 12 32 was used for coding and analysis of the data set the themes of the study were developed according to the five themes described in the adapt framework which allowed for a unique understanding of the issues being examined here ethical consideration the study protocol had been submitted before the start of the research and ethical approval was obtained from the ethics committee of the medical faculty of heidelberg university the study was conducted under the principles described in the declaration of helsinki 33 results the results of the current study are presented in two sections the first section consists of the demographic data of the participants the second section describes the selfreported status of mental wellbeing and subsequently reports on the five pillars of the adapt model finally hindrances and sources of social resilience are presented and summarized demographics of the participants a total of 15 participants took part in the study including 11 males and 4 females most of the participants were young males between the ages of 18 and 24 the majority of the participants were either employed or were currently enrolled in language or vocational training three participants had a b1 level of german language proficiency and 11 participants either had no academic language proficiency or only had an a1 level of proficiency one participant had a c1 level of german language proficiency more details about the participants are shown in table 1 selfreported status of mental wellbeing when discussing their mental wellbeing almost all the participants described their current mental wellbeing as having improved since arriving in germany the first years were characterized by all the participants as distressing shocking and stressful in the beginning it was stressful we were suffering my husband and i did not know anything about germany so everything was a shock for us female 18 19 20 21 22 23 24 time was mentioned as a healer with the length of the time spent in germany all participants reported their mental wellbeing improved most of the participants reported incidents of distress and depression in the first years of the resettlement process with two of the participants taking medication for the depression they suffered some of the mentally stressful experiences reported by the participants are isolation and feeling of loneliness the most common source of stress was the language barrier other reasons for stress were the burden of responsibility for family back home unemployment and cultural differences a unique source of stress expressed by more than half of the participants was related to receiving many official letters and contracts through the mail specifically difficulty reading the letters and the quantity of the letters received were reported as the source of stress one thing i hate about germany is that they have too much paperwork for little things and they send you so many letters and that drove me crazy in the early days i still hate it and whenever i go to check the mail i get stressed safety and security safety and security were discussed as the first part of the five pillars of the adapt model most of the participants considered german people as lawabiding citizens female 18 19 20 21 22 23 24 and the country of germany as a safe place to live male 3135 female 25 26 27 28 29 30 the perceived strict rules and regulations of the german society were considered as a positive influence on the safety of the participants and for all the female participants physical safety was not considered an issue in germany stating this i am safe here if someone does anything to me he will never get away with it i feel confident about my safety here female 25 26 27 28 29 30 another topic discussed along with safety was emotional and physical security all participants described one or more reasons to be insecure in their current lives the most frequently mentioned insecurity was related to the residence permit insecure and temporary residence permits were reported as an obstacle to integration and as a source of stress by all participants some participants described fear of deportation when their residence permit expires they expressed an uneasy feeling of uncertainty some participants were reminded of their past experiences in eritrea when thinking about this fear the participants recounted the insecurity they felt when they did not know when they would be taken by the military police to the national service in their home country known locally as gefa as similar to the uncertainty of not knowing if they would be allowed to stay or not in germany just like back home when we had to flee our homes because of gefa and here i had the same experience male 18 19 20 21 22 23 24 for most participants safety and security were interrelated with the prospects of their future many participants shared a sense of hope for a good future even though the short residence permit made them feel insecure they linked their prospects with the current opportunities opening up in germany the new life in germany was referred to as an opportunity a platform for a future they did not expect to have in their former hometowns interpersonal bond participants expressed their loss of immediate family ties after reaching europe mentioning how much they missed their family back home family support and relationship were cited as primary needs for almost all the participants the majority of the participants expressed negative emotions and distress due to separation from family as one participant described i cannot handle the stress here alone i miss my home and my family male 31 32 33 34 35 all participants mentioned losing their social connections upon arrival in germany but 14 out of the 15 participants reported establishing a new relationship with other eritrean refugees in germany soon thereafter the majority of the participants considered these relationships as positive concerning the benefit of socializing and interacting with eritrean refugees i feel happy i get to speak to my brothers in my own language i enjoy the conversations we have male 18 19 20 21 22 23 24 the interaction between eritreans was viewed as a therapeutic time and stress reliever participants reported feeling happy and excited to meet their eritrean friends and one participant even described meeting eritreans as a social medicine stating that it is better than the medicine you take from doctors male 25 26 27 28 29 30 the most commonly reported benefit of maintaining interaction with a fellow eritrean was ease of communication relationships with noneritreans were mentioned as seeming impersonal and most participants described their interaction with their classmates workmates and neighbors who were not eritreans as distant and limited male 25 26 27 28 29 30 participants in the study also discussed the relationship with the eritrean diaspora community older eritreans who have been living in germany for decades communication and interaction with this group were described as broken or hostile some participants even claimed that the reason they received short residence permits was due to people from the diaspora community acting as translators and they assumed they were lying to the immigration officers about eritrean politics which affects our asylum claim another participant described his interaction with the diaspora community like that i can honestly say i do not have a relationship with any diaspora community even if they see you in the streets especially the young newcomers they insult us if they genuinely cared about us they could have talked to us and discussed our problems they are liars to be frank they were supposed to guide the young generation because they know everything about germany but instead they made sure to create a conflict with the new generation sense of justice participants expressed perceived unfair treatment due to their social status as refugees and as africans these participants spoke of a need for understanding and compassion because the eritrean situation is not the same as other refugees some participants asked for support and empathy from the german communities we eritreans are fleeing a dictatorial regime that is killing its youth and the germans should know this well they had their experiences with a dictator in the past they fled the country back then too meanwhile another reported phenomenon exemplifying a sense of justice in comparison to the past experiences of injustice was the treatment they received from members of german society more than half of the respondents reported having been treated well within the german community yet these participants also mentioned incidents of unfair treatment by some local communities all the participants in the study reported having experienced racism and discrimination selfperceived discrimination was thematized by more than half of the participants a female participant reported on her interactions with local officials the offices i went to have no respect for me either they rudely treated me or they treated me like i am ignorant female 25 26 27 28 29 30 another concern regarded as injustice brought up in the interviews was the immigration and asylum laws in germany the participants described them as violating their human rights and rights for asylum the possibility of eritrea being labeled as a safe country of origin after the peace agreement of 2018 and the therefore heightened probability of asylum claims from eritrea being rejected was reported as a source of great stress they should consider the eritreans refugees situation again we did not escape because of war there was no war we fled because of the tyrant leader there i think it even got worse after the peace agreement and people are still coming 36 role identity and culture participants aged 30 and above mentioned the significance of family ties as vital for social roles and selfidentity the majority of the participants under the age of 30 described adapting quickly to new social roles in resettlement the cultural difference was considered confusing and disruptive to traditional roles and selfidentity as participants explained their experiences and challenges with role shifts they expressed fear of losing their traditional roles employment was mentioned as a source of stabilization of traditional roles among eritrean refugees as one participant explained about her husband and other eritrean men who are unemployed in our culture men need to work and they wont feel like a man if they dont have a job a man who stays at home all day is considered less than a man and this is a source of stress for them they get depressed and they start drinking female 18 19 20 21 22 23 24 many participants stressed that they lost their identity when they reached germany they described the feeling of emptiness and they also mentioned the feeling of confusion concerning their future roles all participants reported losing their past credentials in the migration process i only had the clothes on my back and a small bag on my hand i had no educational or vocational papers from home and there was no way to get it because of the political situation female 25 26 27 28 29 30 losing their past accomplishments be it educational or vocational was perceived as identity loss and therefore as stressful most participants described the feeling of anxiety and confusion about their roles in life after resettlement another loss described by the participants was a phenomenon referred to by one participant as generation loss male 31 32 33 34 35 participants said that cultural and national identities which were supposed to be passed on from generation to generation were disrupted they described the generation gap created by the unstable relationship with the older generation and being cut off from their home country as a reason for young eritreans to feel they have lost or are losing their identity existential meaning and coherence participants pulled meaning and coherence out of religious and traditional value systems they described the realization of being in an unfamiliar environment as a shock that had to be processed the world had to be understood anew and their own life experience had to be given meaning religion helped most of the participants in that process all the respondents reported attending religious services at some point in time for approximately half of the participants religion was mentioned as a source of unity and strength as well as a central part of their social lives the second source of identity stabilization for some people is traditional values older aged participants regarded them as violated in resettlement for example four of the participants described the phenomenon of young eritreans being sexually active before marriage loss of respect for older aged individuals and individualism they voiced concerns about this kind of cultural transformation of adolescent refugees the underage refugees who were placed with german families dont respect their elders and their culture which will lead to arguments and fights they are losing their eritrean heritage because they are living with german families social resilience more than half of the participants responses saw the current social resilience among the eritrean refugee community in germany as weak and ineffective it is virtually nonexistent with us here social resilience depends on helping and assisting each other and we are not doing that genuinely we only pretend to care especially the diaspora in germany female 18 19 20 21 22 23 24 social resilience was associated with socializing with fellow eritreans more than half of the participants reported difficulties finding the opportunity and appropriate location for such meetings some of the difficulties participants mentioned in socializing were housing location they described being assigned housing in rural areas which prevented them from meeting other eritreans churches and traditional coffee houses were mentioned as essential sources of socialization for three male and all female participants although all participants liked to socialize with fellow eritrean refugees the current political division among eritreans was mentioned as counterbeneficial to the social resilience of eritrean refugees similarly most of the participants reported social media as having a negative consequence rather than being a means to facilitate social resilience they described social medias role as divisive and inciting violence amongst eritrean refugees providing a platform for hate speech and bullying sources and hindrances for the development of social resilience in line with the results displayed according to the adapt model we identified hindrances and sources of mental wellbeing and social resilience hindrances have been attributed to the challenges those participants of this study faced throughout their resettlement process concluding in negative outcomes for their mental as well as their social wellbeing furthermore our study participants mentioned multiple sources for mental wellbeing and social resilience which facilitated a positively shaped attitude toward their situation and solidified hope for their future we visualize these hindrances and sources of social resilience in figure 1 and figure 2 figure 2 sources to mental wellbeing and social resilience discussion the result of the study suggests that the experiences of refugees after resettlement discussion the result of the study suggests that the experiences of refugees after resettlement are multidimensional and complex the findings of our study support and contradict previous studies the postmigration experience of participants was characterized by diffi discussion the result of the study suggests that the experiences of refugees after resettlement are multidimensional and complex the findings of our study support and contradict previous studies the postmigration experience of participants was characterized by difficulties adversities and discrimination in resettlement but also innovations in integration utilization of social support and resources for social resilience mental wellbeing all participants gave accounts of their selfreflective psychological experiences and challenges they repeatedly mentioned experiencing some degree of stress and psychological distress after resettlement in germany echoing the finding from a previous study by biddle 22 on recently resettled refugees in germany the current study revealed some conditions which were a hindrance to positive mental wellbeing for resettled refugees participants repeatedly mentioned the language barrier as the most common source of stress which acted as a barrier to their integration into german society language difficulties were mentioned in various degrees resulting in fewer employment opportunities social interaction and independence similarly a study by walther et al 34 on refugees who resettled in germany between 2013 and 2016 found that proficiency in the german language was associated with improved mental health a unique finding on a source of stress in the current study is that of official documentation and letters some participants cited the frequency and number of letters received from local authorities combined with the language barrier to reading the letters as a factor for postresettlement stress participants explicitly mentioned anxiety due to the accumulation of letters missing important messages due to a lack of complete understanding of the written information getting fined because they did not respond to letters sent to them from local authorities and constantly asking people to translate for them the feeling of being an outsider is amplified for refugees with every challenging experience of the language barrier and integration 21 as mentioned by previous studies 79 feelings of isolation are found to be a risk factor for mental health disorders among refugee populations these feelings are linked to depression sleep deprivation thoughts of selfharm addictions and risky behavior 9 by focusing on the challenges of resettlement the current study findings were able to explore and describe the subjective experiences of postmigration stressors and the influence it has on the mental wellbeing and social resilience of eritrean refugees in general the level of stress has been reported to decrease with more time spent in germany this can be due to multiple reasons as the participants of the current study are mostly young adults and so the ability of an individual to recover at this period of their life might be higher compared with older aged individuals 21 the social environment in which eritrean refugees find themselves influences their mental recovery as well and acceptance and social support from local communities help to mitigate past trauma additionally the challenging history of the participants and the previous experiences of migration trauma have contributed to feeling better after resettlement and being grateful for the current experiences the feelings of hope and optimism appear to be enforced by the knowledge that things could be much worse than they currently are similarly a study by mcgregor 35 concludes that previous hardships faced by refugees are mitigated through feelings of appreciation for their current life circumstances mental wellbeing improvement was more evident in female participants who expressed their overall satisfaction with life confirming a report by walther 21 on the refugee population in germany which stated that female refugees reported higher life satisfaction compared with male refugees safety and security all discussions with the participants addressed the five categories of the adapt model in relation to social resilience to varying degrees various mechanisms of resilience and recovery as well as challenges are discussed what facilitated the feeling of safety among participants in the study differed but the findings show an increased sense of safety most participants compared germany with eritrea and other countries they encountered during the migration process which increased the feeling of safety in the current host country the general feeling of safety and security was decreased in relation to rights to remain amongst participants as a result of the uncertain and short residence permits they received which made them question their future some describing it as being left in a loop some participants even went as far as comparing their experiences with short residence permits and the fear of deportation with a practice called gefa in eritrea which is essentially government rounding up of youth for national military service it is known for being one of the traumatizing experiences of premigration for eritrean refugees 36 additionally some participants described the recent peace agreement between eritrea and ethiopia as a source of potential insecurity regarding their residence status in germany on 9 july 2018 leaders of eritreaethiopia met for a peace summit formally ending the border conflict between both countries which started in 1998 and continued until 2018 in a frozen conflict state of no war no peace 37 short residence status can create a feeling of uncertainty which hinders eritrean refugees integration process in germany regarding employment or language proficiency confirming the conclusion of a study by bakker et al 38 on the adverse effects of insecure residence permits on integration and psychological wellbeing of refugees additionally a lengthy unsecured residence in host countries will foster a passive attitude towards their future 38 creating an atmosphere that is not conducive to smooth integration and social resilience interpersonal bond regarding the participants interpersonal relationship the primary source of social interaction indicated by the participants was a relationship created with other eritrean refugees who arrived in germany recently characterizing the relationship as close full of mutual understanding and a stress reliever social interaction with fellow refugees increases the sense of security and stability of individual refugees and the community as a whole and results in improved reports of mental wellbeing 39 the positive aspect of socializing with eritrean refugees was mostly referred to in sentimental tones that centered around nostalgic feelings of home mother language culture and mutual understanding however the loss of close family and friends in the process of migration and resettlement was attributed as a stressor among the present study participants studies on the mental health and wellbeing of refugees have found that social connections and affiliations are important predictors of successful integration and foster social resilience 29 in addition to the already lost relationships the interaction with the local residents and eritrean diaspora communities who have been living in germany for decades did not materialize into meaningful relationships for our participants making adaptation to the new society an uphill climb the relations and interactions with the eritrean diaspora were characterized as hostile resentful and suspicious according to hepner 40 due to the generational gap combined with the politicizing of interactions and general miscommunication the relationship between the newcomer eritrean refugees and the eritrean diaspora community has been broken this phenomenon acted as a hindrance to the utilization of social resources and the development of social resilience this is not to suggest that all refugees in the current study are unable to access the social resources available to them but rather they cannot access the optimal potential of social resources in relation to fellow expats which would make a positive difference in their integration and social resilience sense of justice a sense of injustice before and after resettlement was repeatedly mentioned in the current study the premigration injustice mainly centered around treatment by the eritrean government but wrongs and mistreatment committed by the eritrean government have been reported by some participants as restored by the treatment they received after arriving in germany a feeling of injustice in the light of discrimination and racism is also mentioned in previous studies 1035 similarly in a followup study of syrian refugees in germany discrimination was identified as a major risk factor for mental wellbeing 41 these negative experiences reinforced the challenges of social resilience and adaptation to the new environment creating a sense of being unwelcome according to silove 26 understanding and mitigating the sources of injustice is vital to creating an environment that enhances the process of mental health recovery during the resettlement of refugees refugees with short residence permits typically feel insecure about their future in the host country 59 the participants in the present study echoed a similar sentiment describing the immigration laws of germany as unjust since it disregards their unique situation that needed to be addressed differently than that of other refugees stating they do not see a future where they can go back to their home country anytime soon it should be noted that this claim has been challenged by the eritrean diaspora community in a previous study stating that eritrea is a safe country 40 role and identity the findings in this study suggest a link between social role breakdown and the negative mental wellbeing and social resilience of refugees our participants pointed to a correlation between social roles and the level of stress expressed by the participants in line with sins findings 42 the current study especially confirms that employment plays a significant role in social integration and resilience unemployment was seen as one of the primary role and identity breakdowns the male participants experienced during their resettlement process to all female participants of the study family separation was the most important source of psychological disturbance and challenged their role in the community the hostility of the authoritarian eritrean government towards the refugees who have fled the country makes it impossible to obtain the legal papers needed to confirm past educational and professional achievements 40 this was seen as an obstacle to resuming their previous vocational role after resettlement the difficulties in acquiring documentation included their civil documentation as well mainly marriage and birth certificates which made it very difficult to reunite with family members according to silove 26 oppressive regimes regularly deny individuals social rights to punish dissidents and challenge their sense of identity and control existential meaning religious beliefs play a key role in strengthening the social resilience of refugees silove 26 argues that religion solidifies the moral values and beliefs that are integral to social and mental wellbeing the refugees in the current study reported gratitude and appreciation to god for surviving challenging migration routes and the opportunity to live and pursue their future the role that religion plays in the social activity of the participants was apparent especially among the female participants strong beliefs and religion have been noted to play a focal role in social interaction and adopting coping mechanisms for refugees resettled in a new environment 20 a recent study on eritrean refugees echoed similar findings on the positive role of religious faith family support and a vision for the future which act as enabling factors to build resilience and social interaction 43 changes to traditional culture beliefs and values took place for the eritrean refugees while trying to negotiate their new life in the new environment the new lifestyle encountered by the refugees which was constantly referred to as the german system by the participants of the current study left them with cultural shock and forced them to innovate and adapt to the new environment all participants recalled cultural shock when first arriving in germany but slowly they grew accustomed to living in their new home the social and cultural adaptation has not progressed equally for every participant in the study with more than half of the participants describing difficulties with the german system daily magnet de saissy 14 argues rapid and forced adaptation of communities to the new environment will have an impact on the social and mental wellbeing of the individual a source of social conflict that stood out in the present study is social media participants explicitly mentioned social media tools as facilitators of conflict and division for eritrean refugees thus acting as a hindrance to fostering social resilience among eritrean refugees this finding contradicted research that found social media as facilitators of positive social interaction for eritrean and other refugees 1935 for most participants of the current study leaving aside the positive aspect of communication social media caused harm to the solidarity and social resilience of eritrean refugees some consider the platforms to be a means for the political and regional division to spread among the newcomers therefore this study revealed the negative role social media play among eritrean refugees social resilience the findings of this study demonstrated the importance of a robust social community in building and adopting a resilience mechanism identifying and tackling the sources of conflicts among the refugees will be essential to fostering better social interaction and mental wellbeing additionally the study attests to the relevance of the adapt model 26 in understanding the complexity and challenging experiences of refugees after resettlement strength and limitations of the study owed to restrictions due to the covid19 pandemic the study data collection method was limited to a telephone interview however we found that this method gave a heightened sense of anonymity to the participants and freedom to speak freely and openly additionally telephone interviews are hypothesized to have a decreasing effect on the social desirability bias 44 the telephone interviews provided and encouraged an environment of open and honest discussion about culturally sensitive topics including ones mental health however the absence of visual cues and communication in telephone interviews is a drawback to the natural and emotional interaction in facetoface interviews and thus produces more restricted responses 44 the current study was conducted in the frame of a masters course with the principal researcher being a young masters student of the same national origin as the study participants coming from the same sociocultural background having a family history of migration as well and being able to speak the study participants language tigrinya eased access to and familiarization with the study participants as well as building trust to narrate their stories and express their feelings however the negative impacts of the researchers background on the study cannot be ruled out furthermore some of the limitations of the study are the small sample size and the heterogeneity of the snowball sample method with regards to the small sample size the fact that the primary researcher had the same sociocultural background as the study participants might have eased the initiation of the snowball sampling yet establishing contact and access to the sampling population as well as creating trust takes time how much covid19 also played a role is difficult to say however the snowball process went rather slow and the study had to be conducted within a certain time period in the end a total of 15 participants were included the time constraints did not allow for planning the study a priori to reach theoretical saturation however the data were rich enough to answer the study aim which is one aspect of saturation related to that in qualitative research numbers are not as important as the depth of the data 28 with regards to heterogeneity 11 male participants and 4 female participants were included this might present a selection bias potentially affecting the transferability of our results furthermore inherent in snowball sampling is the fact that the subsequently recruited respondents are more likely to be similar to the previous participants which could have led to a very concise data picture additionally female participants being interviewed by a male interviewer could have led to a reporting bias sex differences can create a significant barrier to acquiring honest responses to sensitive questions 45 in qualitative research the researcher is seen as part of the research process and it is acknowledged that the researcher comes with their own background ideas and interpretations 32 the researcher should hence always reflect on hisher background and the ways in which this influences the analysis of the data and interpretation of findings although efforts were made to stay true to the participants response considering the researcher as only a narrator and to keep ones own interpretations apart it cannot be ruled out that a bias in this direction occurred in this process going back to the respondents to dig deeper into the meaning of some data and to clarify the respondents view versus the researchers interpretation might be necessary resource and time constraints unfortunately did not allow this in the current study despite these the current study provides a comprehensive understanding of the current challenges for refugees to feel well and identifies hindrances and sources for better social resilience conclusions the findings of the current study can be helpful for the planning of effective and sustainable interventions one of the ways to mitigate the challenges of refugee resettlement is by focusing on integration lessons and training on topics such as cultures and social and legal systems in germany referred to as the german system by the participants the federal office for migration and refugees provides an integration course on various challenges refugees encounter consisting of language courses orientation to administrative regulations writing emails and letters and job interviews the integration course should be tailored to be more culturally appropriate putting into consideration the understanding and background of refugees integration course instructors should be aware of possibly different habits of thought and evaluation as well as daily life practices and experiences of their students which will help to design the best method to deliver the courses appropriately additionally due to the limited literacy possessed by eritrean refugees we recommend german language lessons be already provided alongside the integration courses preferably instructorsassistant instructors with knowledge of the tigrinya language henceforward they will be able to translate german words directly into tigrinya words additionally taking into consideration the lack of access to the proper credentials and documentation the mentioned loss of past achievements by the respondents could be tackled if government services would be more open to accepting international study and working degrees and vocational training certificates or at least propose flexible ways to catch up with the requirements of the german system coupled with efforts to integrate the refugees into job positions this could not only help to solve germanys skilled labor shortage but also touch upon the mentioned feeling of isolation as the refugees would be integrated into the german system easing family identification requirements for the family reunification process could also ease the stress of isolation by focusing on the challenges of resettlement the current study findings were able to explore and describe the subjective experiences of postmigrations stressors and the influence it has on the mental wellbeing and social resilience of eritrean refugees in addressing the challenging experiences of refugee resettlement within the five pillars of the adapt model the current study reveals those experiences could be turned into sources of mental wellbeing and resilience data availability statement the data presented in this study are available on request from the corresponding author

mental health and social resilience play a significant role in refugees adaptation during the resettlement process in the host country maintaining good mental wellbeing helps the refugees to respond to stressful experiences with healthy life choices this study aimed to explore the mental wellbeing and social resilience of eritrean refugees living in germany and to identify social conditions and enablers to foster adaptation this study employs a qualitative approach with a semistructured indepth interview data collection method informants were identified among mostly young adult refugees living in heidelberg germany with a migration history of 36 years in total 15 informants were recruited through snowball sampling data were sorted and analyzed using the five pillars of the adaptation and development after persecution and trauma adapt model the findings suggest that eritrean refugees experienced psychological distress after resettlement in germany however with time their mental health improved the study revealed conditions that were experienced as hindrances as well as ones that were considered to be resources of positive mental wellbeing and social resilience for resettled refugees resettlement challenges described by the participants were the language barrier discrimination unemployment insecure residence status loss of family and friends conflict within the diaspora community and isolation the main sources of mental wellbeing and social resilience include the feeling of being welcomed by local communities access to social services adopting new relationships and educational opportunities these experiences encouraged refugees to have a favorable view of their lives and futures and were also found to facilitate better integration and adaptation understanding refugee mental wellbeing and social resilience requires a multidimensional perspective eritrean refugees living in germany have experienced and are still experiencing resettlement challenges such as for example loss of family and friends negative perception of the german system loss of past achievements or unemployment however they have developed adaptive and resilience mechanisms as well such as seeing an opportunity for a better life adopting new roles and accepting germany as a second home in addressing those issues reported by the refugees as hindrances these could be turned into sources of mental wellbeing and resilience

Background The heavy and ever rising burden of non-communicable diseases in low-and middle-income countries warrants interventions to reduce their underlying risk factors, which are often linked to lifestyles. To effectively supplement nationwide policies with targeted interventions, it is important to know how these risk factors are distributed across socioeconomic segments of populations in LMICs. An estimated 73% of total deaths worldwide are attributable to NCDs [1]. In LMICs NCD-related deaths are expected to increase from about 30 million currently to 41.8 million by 2030 [2]. The Sustainable Development Goal agenda [3] aims to reduce pre-mature mortality from NCDs with one-third by 2030. Progress so far has been uneven, both across and within countries [4], and the COVID-19 pandemic is eroding earlier gains [5]. The links between lifestyle risk factors or preventable factors -tobacco use, harmful alcohol use and the combination of unhealthy diet and physical inactivity resulting in overweight -and NCDs are well documented [6][7][8]. In high income settings, lifestyle risk factors are most prevalent among those with a lower socioeconomic status [9,10]. Less is known about socioeconomic inequalities in lifestyle risk factors across LMICs [11], which limits opportunities for targeting effective interventions on those exposed to greatest risk which is an approach that is increasingly being implemented in among others healthcare facilities [12,13]. Such targeted interventions could provide an important supplement to national policies such as taxation of unhealthy foods and tobacco to reduce consumption of these goods. An important, and sometimes underappreciated aspect of these lifestyle risk factors, is the limited choice that individuals might have in adopting and changing these unhealthy lifestyles due to structural inequalities. Overweight for example, is in many cases not simply a result of a choice to consume unhealthy foods, but a result of a food environment with limited food options available [14]. Yaya et al. [15] studied women across 33 Sub Saharan African countries and found that alcohol consumption and overweight were more prevalent among the better off, while tobacco use was more concentrated in the poor segments of the population. A systematic review by Allen et al. [16] on the association between socioeconomic status and lifestyle risk factors in LMICs, included data from 75 studies conducted between 1990 and 2015. Only two studies [17,18] reported data on more than one LMIC. Hosseinpoor et al. [17] studied 48 LMICs and found that daily smoking as well as low fruit and vegetable consumption were more prevalent among those with a lower socioeconomic status. However, their data are dated and lack information on alcohol consumption and overweight. In addition, unhealthy behaviours are likely to cluster [19], and there is not much known about the prevalence of multiple lifestyle risk factors within a person or household in LMICs. In a comment on Allen et al. [16], Stringhini & Bovet [20] emphasize the lack of systematically compared data from LMICs to determine and explain socioeconomic inequality in lifestyle risk factors. This study aims to fill part of that gap by quantifying the prevalence and socioeconomic inequalities in three lifestyle risk factors -smoking, harmful alcohol use and overweight -in 9 low-income countries and 13 middle-income countries . This will help to identify policy priorities conducive to the Sustainable Development Goal of a one third reduction in deaths from NCDs by 2030. In this study, we use self-reported information on smoking, while overweight is determined by actual measured height and weight. Insights about harmful alcohol use are based on reports from a randomly selected subsample of women about alcohol use of their partner. We also extend the existing literature by studying cumulation of these unhealthy behaviours within households to determine which couples are most likely to jointly exhibit two or more of these three lifestyle risk factors. We use data from 1,278,624 adults in the Demographics and Health Surveys between 2013 and 2018. We investigate whether countries that spend more on health are less likely to exhibit large socioeconomic inequalities in lifestyle risk factors, which would be expected if several well targeted prevention programs are in place. However, it seems more likely that the better off are the first to benefit from early prevention programs, if available. We then estimate a multilevel model to associate individual characteristics with tobacco use, overweight, harmful alcohol use and the cumulation of these lifestyle risk factors within a household. --- Methods --- Data We exploit the Standard Demographic and Health Surveys containing data from nationally representative, randomly selected samples of women in reproductive age and smaller samples of randomly selected men in LMICs [21]. The DHS is comparable across countries and contains data on demographics and health behaviour. The DHS is publicly available for research purposes and the corresponding research protocols are reviewed and approved by an Institutional Review Board. Informed consent is obtained from each respondent before the start of the interview [22]. We include all Demographic and Health Surveys from 2013 onwards containing data on at least one of three unhealthy lifestyles: tobacco use, overweight and harmful alcohol use. Unfortunately, the data do not allow us to disentangle overweight into aspects related to unhealthy diet versus physical inactivity, but we are referring to the combination of these two when studying "overweight". Surveys collected before 2013 are excluded to ensure policy relevance. In case more than one DHS was fielded in the same country since 2013, we include the most recent one. This results in data from 9 LICs and 13 MICs covering a total of 1,029,182 women, as shown in Supplementary Table S1. Sample sizes range from 6116 to 699,686 women. Most countries were African , a few Asian and one Eastern European. Interviews with men were in most countries performed in every third household [18] resulting in a total sample of 249,442 men from 19 countries, with country-level sample sizes ranging from 2755 to 112,122 men as shown in Supplementary Table S1. No data were collected among men in Chad, Egypt and Tajikistan. To estimate cumulative presence of lifestyle risk factors within a household, we use data from the subset of couples where both partners were interviewed in respectively the female and male survey. Sample sizes for each of the four outcome measures are shown in Table S1. Overweight , based on height and weight measured during the interview is missing for 14% of women. Pregnant women were excluded from data collection on height and weight since BMI is not perceived an accurate measure of body composition during pregnancy [23]. Other women did not consent to have their measures taken. Harmful alcohol use is based on women's reports about alcohol consumption of their partner and was only collected among a randomly selected subsample of women via the "domestic violence" module of the DHS [18], resulting in a considerably smaller sample . Tobacco use among men was available for virtually the entire sample and information from both partners was available for 125,393 couples. Tobacco use was extremely low among women so we only included tobacco use among men. No data on husband or partner alcohol use was available for Albania, as shown in Table S1. In Egypt and Gambia less than 2 % of women indicated that their husband or partner consumed alcohol. Consequently, Albania, Egypt and Gambia are excluded in the estimation of socioeconomic inequality in husband/partner's harmful alcohol consumption. In addition to these micro level data, we use the most recent macro level information on country health expenditure as percentage of GDP [24], to proxy nationwide investments in health. --- Variables of interest The three lifestyle risk factors are operationalized as follows. Tobacco use is based on self-reported information among men about current smoking, i.e. daily, sometimes or never. Data on local smoking products were also collected but were excluded due to heterogeneity and low response rates. For ease of interpretation, tobacco use is dichotomized with 1 representing "daily" or "sometimes" and 0 otherwise. Secondly, the Body Mass Index based on weight and height measured during the interview by trained surveyors, is used to define the dichotomous variable overweight with a BMI larger than 25.0 identified as overweight [25] and 0 otherwise. Height and weight measurements were only obtained among women, not among men. Thirdly, a randomly selected subset of women was asked whether their husband or partner consumed alcohol and if yes, whether their husband or partner was never, sometimes or often drunk. Responses indicating that the partner was sometimes or often drunk were considered harmful alcohol use [1] and 0 otherwise. In addition to these three lifestyle risk factors at individual level, we also study the cumulation of these factors at household level. The cumulative presence of the three lifestyle risk factors was estimated within a household, using the couples dataset. Household behavior was dichotomized into 1 unhealthy with two or the maximum of three lifestyle risk factors present in the couple, and 0 otherwise . To proxy socioeconomic status, we use the wealth quintiles provided in the DHS. These are derived from a wealth index ranking households based on a principal component analysis on a set of variables about household dwelling characteristics and asset ownership [26] including materials used for construction of the house, types of water access, sanitation facilities and ownership of televisions and bicycles [27]. This composite measure is considered an acceptable measure of wealth in LMICs. The lowest wealth quintile represents the 20% poorest part of the population while the highest quintile reflects the 20% best off. Filmer & Pritchett [26] have shown that that this method provides plausible and defensible weights for an asset index to serve as a proxy for wealth, even though income or expenditure data are not taken into account. To acknowledge the complexity and multidimensionality of socioeconomic status we also include education and occupation in our regression analysis. Macrolevel country health expenditure is defined as the share of GDP spent on health i.e. health expenditure as % of GDP in 2020, the most recent data available [24]. We use health expenditure for all countries in our study sample for the same year, as opposed to the different data collection years, to allow for easier comparison. Ideally, we would have obtained information on spending earmarked for prevention and/or NCDs, but these are not available, to our knowledge. Our multilevel models to determine individual characteristics of those using tobacco, being overweight, using harmful levels of alcohol and the cumulation of these in couples include rural/urban household, age categories, literacy, education, occupation, wealth index, household size and number of living children. --- Analytical approach Prevalence of lifestyle risk factors The prevalence of the lifestyle risk factors for each country is calculated as a crude prevalence rate: dividing the total number of respondents with the lifestyle risk factor by the total number of respondents in the relevant study sample. For household unhealthy behaviour the presence of two or three lifestyle risk factors in couples over the total number of couples was used as the prevalence. --- Socioeconomic inequalities We measure socioeconomic inequalities in lifestyle risk factors, i.e. variation in these factors across the wealth quintiles, with a concentration index suggested by Erreygers [28] for a dichotomous variable. This is simply the scaled covariance between the lifestyle risk factor of individual i and their rank in the distribution of the wealth index: EI y ð Þ ¼ 8 cov y i ; R i ð Þð1Þ This index takes values between -1 and 1. Positive values indicate a disproportionate concentration of the lifestyle risk factor among the better off, while negative values signal a disproportionate concentration among the poor. The STATA package "conindex" [29] is used for this analysis. The micro level analyses to estimate prevalence and socioeconomic inequalities in lifestyle risk factors are performed separately for each country. --- Macro level association between inequalities and health expenditures The within country estimations of inequalities are followed by a cross-country macro level analysis determining whether countries with smaller inequalities also tend to be those with a higher percentage of GDP spent on health. We calculate the average percentage of GDP spent on health across the countries in our sample as a reference value. Any country's spending on health above the reference value is considered "high" and otherwise "low". We map each country, differentiating between low-and middle-income countries, on a four-quadrant model of socioeconomic inequality and health expenditure to identify countries with a "double disadvantage" i.e. both a skewed distribution of lifestyle risk factors towards the poor and low spending on health nationwide. This allows for identification of countries that could be prioritized by policy makers worldwide. --- Multilevel analysis We then estimate a multilevel probit model based on country fixed effects for each of the four lifestyle risk factors using the pooled set of data from all countries included in the study. Eq. 2 describes the multilevel model. y ic ¼ β 0 x i þ γ c þ ε icð2Þ where x i is the set of individual characteristics, γ c the country fixed effects and ε ic the error term. This allows us to estimate the relation between individual characteristics and lifestyle risk factors while allowing for variation in these across countries. All analyses were performed using software package STATA 15. --- Results --- Prevalence of lifestyle risk factors Table S1 in the Supplementary files shows for each country the response rate on the lifestyle risk factors. The prevalence of the lifestyle risk factors by country indicate that tobacco use is most prevalent in Armenia and Timor-Leste: respectively 59.6 and 54.4% of men reported to smoke daily or sometimes. The highest level of overweight among women is found in Egypt , followed by South Africa and Albania . There is a wide range in the prevalence of women that reported that their partner is "often or sometimes drunk", with only 1.3% in Gambia and 82.5% in Burundi. In total, the prevalence was over 50% in three countries . Only four countries had a prevalence below the 20% , all low-income countries. The prevalence of cumulative unhealthy behaviour within households is also diverse. Armenia and South Africa have the highest prevalence of unhealthy household behaviour with 50.6 and 40.4%. --- Inequalities in the distribution of lifestyle risk factors Table 2 shows the socioeconomic inequalities, based on the Erreygers Index , for each of the lifestyle risk factors. Tobacco use is in all countries concentrated among the poor, except for Nigeria where we found a pro-rich distribution. Overweight, on the other hand, is concentrated in all countries towards those with a higher socioeconomic status. Armenia is the only country without significant inequality in overweight across socioeconomic groups. Socioeconomic inequalities in harmful alcohol use is more diverse. Four countries show no wealth related inequalities in alcohol consumption. Nigeria is the only country were harmful alcohol use is most concentrated among the better off , while Chad, India, Rwanda and Togo show the strongest unequal distribution towards the poor . Accordingly, the Erreygers Indices for unhealthy household behaviour show a diverse picture. Unhealthy behaviour within a household is most concentrated among the poor in Cambodia. Only in Ethiopia, India, Nigeria and Timor-Leste significant positive Erreygers indices are reported, referring to a concentration among the better off . The last column of Table 2 shows how the country average share of GDP spend on health differs from the total average share in percentage points, indicating whether a country spends more or less than the average across these 22 LMICs. Sierra Leone spends the highest share of GDP on health , followed by Armenia and Malawi . On the other end of the spectrum, Congo, Gambia and India spend the lowest share of GDP on health, respectively 2.9, 3.3 and 3.5%. factor of interest on the horizontal axis and average percentage of GDP spent on health on the vertical axis, distinguishing between low-and middle-income countries. The dotted reference line represents the average share of GDP spent on health across the countries in our sample. The top left quadrant contains countries with relatively higher shares of health expenditure, but the corresponding lifestyle risk factor concentrated among the poor where the latter is generally deemed "unfair". --- Socioeconomic inequalities and percentage of GDP spent on health The top right quadrant consists again of countries with relatively higher shares of health expenditure, but the lifestyle risk factor is concentrated among the better-off, which might suggest that these countries do not have the highest priority when it comes to reducing lifestyle risk factors among the poor, even though there is still considerable room for improvement. The bottom right quadrant shows low shares spend on health and concentration of the lifestyle risk factor among the better off. Finally, the bottom left corner contains the countries with a "double disadvantaged" population with the share spend on health relatively low and lifestyle risk factors concentrated among the poor. Countries in this bottom left quadrant should be prioritized in policies to reduce the morbidity and mortality from NCDs. Tobacco use is mainly concentrated in the left quadrants , so among the poor . This disadvantage is especially present for middle-income countries, where the pro-poor inequality coincides with relatively low shares of GDP spent on health. While we cannot identify an overall pattern it seems that, with the exemption of Sierra Leone, a higher share of GDP spent on health is observed in countries with less inequality i.e. an concentration index closer to zero. We observe for overweight , contrary to tobacco use, a pro-rich distribution with countries spending a higher share of their GDP on health having less inequality. When mapping these countries in terms of harmful alcohol use , there are countries located in each of the four quadrants indicating that there is no strong association between the share of GDP spent on health and the socioeconomical distribution of harmful alcohol use. However, the countries at a "double disadvantaged" and thus with the most pressing need for effective interventions to reduce harmful alcohol use are Chad, Congo, India, Tanzania, Timor-Leste, Zambia and Cambodia. Figure 4 shows clustering of lifestyle risk factors in households and suggests that countries with a higher share of their GDP spent on health tend to have a pro-poor distribution of lifestyle risk factors within a household. Countries with a lower share of their GDP spent on health tend to have a pro-rich distribution of lifestyle risk factors within a household. As this figure shows the cumulative behaviour of a household, this finding should be interpreted carefully as combinations of lifestyle risk factors within a household might differ. When comparing low-versus middle-income countries, we observe that the low-income countries more frequently have a pro-poor distribution, while the middle-income countries dominantly have a pro-rich distribution of these lifestyle risk factors. We refrain from multilevel analysis here, because of the limited sample size . --- Individual characteristics and lifestyle risk factors Table 3 contains descriptive statistics of the explanatory variables used in the multilevel models on the women's, men's and couples' samples. The information in Table 3 is based on the men and women in the couples' dataset. 1 For all countries combined, we find that a bit less than one third live in an urban area and half of the women indicate not to have an occupation compared to 4.7% among men. The average age in our sample is 37 years with an average household consisting of six members. The results from the multilevel probit regression models confirm that tobacco and harmful alcohol use are concentrated among the poorer men, while overweight is concentrated among the better off women. When combining unhealthy behaviors among couples, as shown in the last column, we find that the probability of such clustering significantly increases with 0.07 among couples with women above 35 years old, compared to similar couples with a woman below 20 years old. --- Discussion This study exploits data from the Demographic and Health Survey collected across 22 low-and middle-income countries between 2013 and 2018 to analyse prevalence and socioeconomic inequality in lifestyle risk factors i.e. tobacco use, overweight and harmful alcohol use. We show that both the prevalence and the degree of socioeconomic inequality differ considerably across lifestyle risk factors and across countries. Tobacco and harmful alcohol use are largely concentrated among the poor, while overweight is heavily concentrated among the better-off in LMICs. This is contrary to findings from high income countries where all lifestyle risk factors are most prevalent among those with a lower socioeconomic status [9,10]. The largest socioeconomic inequalities across the four lifestyle risk factors were found for overweight. In developed countries low socioeconomic status is consistently associated with higher prevalence of unhealthy BMI, while our finding shows the opposite direction, in line with previous research on LMICs [17]. The largest prorich socioeconomic inequalities in overweight were observed in India, Tanzania and Zimbabwe. Some evidence suggests that obesity is a symbol of high social status in developing countries [30]. This contrast in socioeconomic inequality between high-versus low-and middle-income countries emphasizes the need to develop context specific policy interventions to tackle lifestyle risk factors. For most LMICs in our study, we find that harmful alcohol use is mostly a problem among the poor. When mapping the share of GDP spend on health in each of these countries, as well as the socioeconomic inequality in lifestyle risk factors, we identified those countries with both a low share spend on health and an inequality lifestyle risk factors distributed towards the poor as "double disadvantaged". Combining these different lifestyle risk factors, especially Zambia, Tanzania and Cambodia are at a double disadvantage and should be prioritized when implementing global policies to reduce unhealthy lifestyles among the poor. --- Limitations This study is based on cross-sectional data solely allowing us to examine associations. Our findings cannot be interpreted as causal. Furthermore, our findings are derived from large datasets and inferences about the nature of individuals cannot be deduced from inferences about the larger groups to which these individuals belong i.e. ecological fallacy. The response rates for the DHS are generally high, ranging from 97 to 99.9%. However, missing observations on lifestyle risk factors because respondents were unwilling to answer or to have their height and weight measured are a limitation to our study. This would be especially problematic when respondents from a specific socioeconomic group are less likely to provide this information, biasing our inequality estimates. However, we do not have reason to believe that this is the case. The sample of women reporting on their partner's harmful alcohol use does not suffer from this potential bias, because the sample size is lower as a result of only a randomly selected subset of women being asked to answer this question. A second limitation arises from the use of BMI as a combined proxy for diet and physical activity which were not observed in the DHS. Although BMI is an objective and reliable measure it is less informative on diet composition; we cannot identify whether the poor consume less fruit and vegetables. Measuring physical activity, both work and leisure related, would be informative to policy makers aiming to reduce overweight but the DHS does not collect this information. Furthermore, because of data limitations we could not provide information on overweight in men. A third limitation arises from the reports on alcohol use in men, which are provided by the spouse and not by the consumer himself. This is likely to bias our estimates, but it is unclear whether this leads to an over-or underestimation. When alcohol consumption is collected from the consumer himself, it is possible that people who drink excessively provide an under estimation because of a perceived social stigma. However, the spouse might also under report for the same reason and her recall bias might be larger. She could also overestimate her partner's alcohol use because she does not have complete information on his alcohol consumption, especially not when this is outside of the house. Finally, socioeconomic inequality in lifestyle risk factors could be influenced by taxation policies of which the effects could differ per country and per socioeconomic group. Further research is needed to estimate the effect of such taxation schemes on the socioeconomic distribution of lifestyle risk factors. Notwithstanding these limitations, this study provides policy relevant insights into lifestyle risk factors in LMICs based on data from over a million of adults living in more than twenty LMICs. --- Conclusions This study emphasizes the importance of lifestyle risk factors in LMICs and the socioeconomic variation therein. While tobacco and alcohol use are most prevalent among males with a low socioeconomic status, it is mainly the better off females that are overweight. We identified Zambia, Tanzania and Cambodia as the countries at a "double disadvantage", implying that priority should be given to these populations when implementing policies towards the SDG target of reducing NCDs by one third. Given the different socioeconomic distribution of lifestyle risk factors, especially overweight, the targeting of interventions to reduce the burden from these lifestyles in LMICs should not be copied from high income countries but be tailored towards the high-risk populations in these countries. Below we suggest three policy implications. --- Policy implications Consistent with findings from Yaya et al. [15] among women across 33 Sub Saharan African countries, we find that tobacco use in men is most prevalent among the poor in LMICs. For HICs, increasing the price of cigarettes has been shown to be one of the most effective strategies to reduce smoking prevalence, in particular among people with a lower socioeconomic status [31]. The World Health Organization's Framework Convention on Tobacco Control covers more than 90% of the world's population and provides its 180 collaborators to enact comprehensive, effective tobacco control measures. The findings of this study emphasize that in particular Timor-Leste, Armenia and South Africa which have the highest prevalence in tobacco use can benefit from alignment with the WHO FCTC. Second, to our knowledge, no interventions have been proven to be widely effective in sustainably reducing overweight in high income countries. So even when interventions developed in HICs, such as low caloric diets or physical activity programs, would be tailored to target the better off women in LMICs it is unlikely that these are effective. Furthermore, the food environment can limit the opportunity for the poor to switch to healthy, often more expensive, foods. As a result, overweight is not simply driven by the choice to consume unhealthy foods but can be a reflection of structural inequalities. Further research is therefore necessary to identify effective interventions to reduce overweight in LMICs. Finally, while lifestyle risk factors are generally deemed to be modifiable, support to improve lifestyles is necessary to make sustained changes. Access to this support, if even available, is likely to be smaller for those with a lower socioeconomic status. Targeting this segment of the population, for example through vouchers for support programmes or cash transfers conditional on improving behaviour are therefore likely to be most effective in reducing socioeconomic inequalities in lifestyle risk factors. Further research is necessary to determine the effectiveness of these policy suggestions, especially through a longitudinal approach to identify modifications in unhealthy behaviours over time. --- --- Abbreviations LMIC: Low-and Middle-Income Countries; EI: Erreygers Index; NCD: Noncommunicable diseases --- --- --- Ethics approval of consent to participate The DHS is publicly available for research purposes and the corresponding research protocols are reviewed and approved by ICF Institutional Review Board. Informed consent is obtained from each respondent before the start of the interview. See DHS website for more details. . --- --- Competing interests The authors declare that they have no competing interests. ---

Background: The heavy and ever rising burden of non-communicable diseases (NCDs) in low-and middle-income countries (LMICs) warrants interventions to reduce their underlying risk factors, which are often linked to lifestyles. To effectively supplement nationwide policies with targeted interventions, it is important to know how these risk factors are distributed across socioeconomic segments of populations in LMICs. This study quantifies the prevalence and socioeconomic inequalities in lifestyle risk factors in LMICs, to identify policy priorities conducive to the Sustainable Development Goal of a one third reduction in deaths from NCDs by 2030. Methods: Data from 1,278,624 adult respondents to Demographic & Health Surveys across 22 LMICs between 2013 and 2018 are used to estimate crude prevalence rates and socioeconomic inequalities in tobacco use, overweight, harmful alcohol use and the clustering of these three in a household. Inequalities are measured by a concentration index and correlated with the percentage of GDP spent on health. We estimate a multilevel model to examine associations of individual characteristics with the different lifestyle risk factors. Results: The prevalence of tobacco use among men ranges from 59.6% (Armenia) to 6.6% (Nigeria). The highest level of overweight among women is 83.7% (Egypt) while this is less than 12% in Burundi, Chad and Timor-Leste. 82.5% of women in Burundi report that their partner is "often or sometimes drunk" compared to 1.3% in Gambia. Tobacco use is concentrated among the poor, except for the low share of men smoking in Nigeria. Overweight, however, is concentrated among the better off, especially in Tanzania and Zimbabwe (Erreygers Index (EI) 0.227 and 0.232). Harmful alcohol use is more concentrated among the better off in Nigeria (EI 0.127), while Chad, Rwanda and Togo show an unequal pro-poor distribution (EI respectively -0.147, -0.210, -0.266). Cambodia exhibits the largest socioeconomic inequality in unhealthy household behaviour (EI -0.253). The multilevel analyses confirm that in LMICs, tobacco and alcohol use are largely concentrated among the poor, while overweight is concentrated among the better-off. The associations between the share of GDP spent on health and the socioeconomical distribution of lifestyle factors are multidirectional. Conclusions: This study emphasizes the importance of lifestyle risk factors in LMICs and the socioeconomic variation therein. Given the different socioeconomic patterns in lifestyle risk factors -overweight patters in LMICs differ considerably from those in high income countries-tailored interventions towards specific high-risk populations are warranted to supplement nationwide policies.

background the heavy and ever rising burden of noncommunicable diseases in lowand middleincome countries warrants interventions to reduce their underlying risk factors which are often linked to lifestyles to effectively supplement nationwide policies with targeted interventions it is important to know how these risk factors are distributed across socioeconomic segments of populations in lmics an estimated 73 of total deaths worldwide are attributable to ncds 1 in lmics ncdrelated deaths are expected to increase from about 30 million currently to 418 million by 2030 2 the sustainable development goal agenda 3 aims to reduce premature mortality from ncds with onethird by 2030 progress so far has been uneven both across and within countries 4 and the covid19 pandemic is eroding earlier gains 5 the links between lifestyle risk factors or preventable factors tobacco use harmful alcohol use and the combination of unhealthy diet and physical inactivity resulting in overweight and ncds are well documented 6 7 8 in high income settings lifestyle risk factors are most prevalent among those with a lower socioeconomic status 910 less is known about socioeconomic inequalities in lifestyle risk factors across lmics 11 which limits opportunities for targeting effective interventions on those exposed to greatest risk which is an approach that is increasingly being implemented in among others healthcare facilities 1213 such targeted interventions could provide an important supplement to national policies such as taxation of unhealthy foods and tobacco to reduce consumption of these goods an important and sometimes underappreciated aspect of these lifestyle risk factors is the limited choice that individuals might have in adopting and changing these unhealthy lifestyles due to structural inequalities overweight for example is in many cases not simply a result of a choice to consume unhealthy foods but a result of a food environment with limited food options available 14 yaya et al 15 studied women across 33 sub saharan african countries and found that alcohol consumption and overweight were more prevalent among the better off while tobacco use was more concentrated in the poor segments of the population a systematic review by allen et al 16 on the association between socioeconomic status and lifestyle risk factors in lmics included data from 75 studies conducted between 1990 and 2015 only two studies 1718 reported data on more than one lmic hosseinpoor et al 17 studied 48 lmics and found that daily smoking as well as low fruit and vegetable consumption were more prevalent among those with a lower socioeconomic status however their data are dated and lack information on alcohol consumption and overweight in addition unhealthy behaviours are likely to cluster 19 and there is not much known about the prevalence of multiple lifestyle risk factors within a person or household in lmics in a comment on allen et al 16 stringhini bovet 20 emphasize the lack of systematically compared data from lmics to determine and explain socioeconomic inequality in lifestyle risk factors this study aims to fill part of that gap by quantifying the prevalence and socioeconomic inequalities in three lifestyle risk factors smoking harmful alcohol use and overweight in 9 lowincome countries and 13 middleincome countries this will help to identify policy priorities conducive to the sustainable development goal of a one third reduction in deaths from ncds by 2030 in this study we use selfreported information on smoking while overweight is determined by actual measured height and weight insights about harmful alcohol use are based on reports from a randomly selected subsample of women about alcohol use of their partner we also extend the existing literature by studying cumulation of these unhealthy behaviours within households to determine which couples are most likely to jointly exhibit two or more of these three lifestyle risk factors we use data from 1278624 adults in the demographics and health surveys between 2013 and 2018 we investigate whether countries that spend more on health are less likely to exhibit large socioeconomic inequalities in lifestyle risk factors which would be expected if several well targeted prevention programs are in place however it seems more likely that the better off are the first to benefit from early prevention programs if available we then estimate a multilevel model to associate individual characteristics with tobacco use overweight harmful alcohol use and the cumulation of these lifestyle risk factors within a household methods data we exploit the standard demographic and health surveys containing data from nationally representative randomly selected samples of women in reproductive age and smaller samples of randomly selected men in lmics 21 the dhs is comparable across countries and contains data on demographics and health behaviour the dhs is publicly available for research purposes and the corresponding research protocols are reviewed and approved by an institutional review board informed consent is obtained from each respondent before the start of the interview 22 we include all demographic and health surveys from 2013 onwards containing data on at least one of three unhealthy lifestyles tobacco use overweight and harmful alcohol use unfortunately the data do not allow us to disentangle overweight into aspects related to unhealthy diet versus physical inactivity but we are referring to the combination of these two when studying overweight surveys collected before 2013 are excluded to ensure policy relevance in case more than one dhs was fielded in the same country since 2013 we include the most recent one this results in data from 9 lics and 13 mics covering a total of 1029182 women as shown in supplementary table s1 sample sizes range from 6116 to 699686 women most countries were african a few asian and one eastern european interviews with men were in most countries performed in every third household 18 resulting in a total sample of 249442 men from 19 countries with countrylevel sample sizes ranging from 2755 to 112122 men as shown in supplementary table s1 no data were collected among men in chad egypt and tajikistan to estimate cumulative presence of lifestyle risk factors within a household we use data from the subset of couples where both partners were interviewed in respectively the female and male survey sample sizes for each of the four outcome measures are shown in table s1 overweight based on height and weight measured during the interview is missing for 14 of women pregnant women were excluded from data collection on height and weight since bmi is not perceived an accurate measure of body composition during pregnancy 23 other women did not consent to have their measures taken harmful alcohol use is based on womens reports about alcohol consumption of their partner and was only collected among a randomly selected subsample of women via the domestic violence module of the dhs 18 resulting in a considerably smaller sample tobacco use among men was available for virtually the entire sample and information from both partners was available for 125393 couples tobacco use was extremely low among women so we only included tobacco use among men no data on husband or partner alcohol use was available for albania as shown in table s1 in egypt and gambia less than 2 of women indicated that their husband or partner consumed alcohol consequently albania egypt and gambia are excluded in the estimation of socioeconomic inequality in husbandpartners harmful alcohol consumption in addition to these micro level data we use the most recent macro level information on country health expenditure as percentage of gdp 24 to proxy nationwide investments in health variables of interest the three lifestyle risk factors are operationalized as follows tobacco use is based on selfreported information among men about current smoking ie daily sometimes or never data on local smoking products were also collected but were excluded due to heterogeneity and low response rates for ease of interpretation tobacco use is dichotomized with 1 representing daily or sometimes and 0 otherwise secondly the body mass index based on weight and height measured during the interview by trained surveyors is used to define the dichotomous variable overweight with a bmi larger than 250 identified as overweight 25 and 0 otherwise height and weight measurements were only obtained among women not among men thirdly a randomly selected subset of women was asked whether their husband or partner consumed alcohol and if yes whether their husband or partner was never sometimes or often drunk responses indicating that the partner was sometimes or often drunk were considered harmful alcohol use 1 and 0 otherwise in addition to these three lifestyle risk factors at individual level we also study the cumulation of these factors at household level the cumulative presence of the three lifestyle risk factors was estimated within a household using the couples dataset household behavior was dichotomized into 1 unhealthy with two or the maximum of three lifestyle risk factors present in the couple and 0 otherwise to proxy socioeconomic status we use the wealth quintiles provided in the dhs these are derived from a wealth index ranking households based on a principal component analysis on a set of variables about household dwelling characteristics and asset ownership 26 including materials used for construction of the house types of water access sanitation facilities and ownership of televisions and bicycles 27 this composite measure is considered an acceptable measure of wealth in lmics the lowest wealth quintile represents the 20 poorest part of the population while the highest quintile reflects the 20 best off filmer pritchett 26 have shown that that this method provides plausible and defensible weights for an asset index to serve as a proxy for wealth even though income or expenditure data are not taken into account to acknowledge the complexity and multidimensionality of socioeconomic status we also include education and occupation in our regression analysis macrolevel country health expenditure is defined as the share of gdp spent on health ie health expenditure as of gdp in 2020 the most recent data available 24 we use health expenditure for all countries in our study sample for the same year as opposed to the different data collection years to allow for easier comparison ideally we would have obtained information on spending earmarked for prevention andor ncds but these are not available to our knowledge our multilevel models to determine individual characteristics of those using tobacco being overweight using harmful levels of alcohol and the cumulation of these in couples include ruralurban household age categories literacy education occupation wealth index household size and number of living children analytical approach prevalence of lifestyle risk factors the prevalence of the lifestyle risk factors for each country is calculated as a crude prevalence rate dividing the total number of respondents with the lifestyle risk factor by the total number of respondents in the relevant study sample for household unhealthy behaviour the presence of two or three lifestyle risk factors in couples over the total number of couples was used as the prevalence socioeconomic inequalities we measure socioeconomic inequalities in lifestyle risk factors ie variation in these factors across the wealth quintiles with a concentration index suggested by erreygers 28 for a dichotomous variable this is simply the scaled covariance between the lifestyle risk factor of individual i and their rank in the distribution of the wealth index ei y ð þ ¼ 8 cov y i r i ð þð1þ this index takes values between 1 and 1 positive values indicate a disproportionate concentration of the lifestyle risk factor among the better off while negative values signal a disproportionate concentration among the poor the stata package conindex 29 is used for this analysis the micro level analyses to estimate prevalence and socioeconomic inequalities in lifestyle risk factors are performed separately for each country macro level association between inequalities and health expenditures the within country estimations of inequalities are followed by a crosscountry macro level analysis determining whether countries with smaller inequalities also tend to be those with a higher percentage of gdp spent on health we calculate the average percentage of gdp spent on health across the countries in our sample as a reference value any countrys spending on health above the reference value is considered high and otherwise low we map each country differentiating between lowand middleincome countries on a fourquadrant model of socioeconomic inequality and health expenditure to identify countries with a double disadvantage ie both a skewed distribution of lifestyle risk factors towards the poor and low spending on health nationwide this allows for identification of countries that could be prioritized by policy makers worldwide multilevel analysis we then estimate a multilevel probit model based on country fixed effects for each of the four lifestyle risk factors using the pooled set of data from all countries included in the study eq 2 describes the multilevel model y ic ¼ β 0 x i þ γ c þ ε icð2þ where x i is the set of individual characteristics γ c the country fixed effects and ε ic the error term this allows us to estimate the relation between individual characteristics and lifestyle risk factors while allowing for variation in these across countries all analyses were performed using software package stata 15 results prevalence of lifestyle risk factors table s1 in the supplementary files shows for each country the response rate on the lifestyle risk factors the prevalence of the lifestyle risk factors by country indicate that tobacco use is most prevalent in armenia and timorleste respectively 596 and 544 of men reported to smoke daily or sometimes the highest level of overweight among women is found in egypt followed by south africa and albania there is a wide range in the prevalence of women that reported that their partner is often or sometimes drunk with only 13 in gambia and 825 in burundi in total the prevalence was over 50 in three countries only four countries had a prevalence below the 20 all lowincome countries the prevalence of cumulative unhealthy behaviour within households is also diverse armenia and south africa have the highest prevalence of unhealthy household behaviour with 506 and 404 inequalities in the distribution of lifestyle risk factors table 2 shows the socioeconomic inequalities based on the erreygers index for each of the lifestyle risk factors tobacco use is in all countries concentrated among the poor except for nigeria where we found a prorich distribution overweight on the other hand is concentrated in all countries towards those with a higher socioeconomic status armenia is the only country without significant inequality in overweight across socioeconomic groups socioeconomic inequalities in harmful alcohol use is more diverse four countries show no wealth related inequalities in alcohol consumption nigeria is the only country were harmful alcohol use is most concentrated among the better off while chad india rwanda and togo show the strongest unequal distribution towards the poor accordingly the erreygers indices for unhealthy household behaviour show a diverse picture unhealthy behaviour within a household is most concentrated among the poor in cambodia only in ethiopia india nigeria and timorleste significant positive erreygers indices are reported referring to a concentration among the better off the last column of table 2 shows how the country average share of gdp spend on health differs from the total average share in percentage points indicating whether a country spends more or less than the average across these 22 lmics sierra leone spends the highest share of gdp on health followed by armenia and malawi on the other end of the spectrum congo gambia and india spend the lowest share of gdp on health respectively 29 33 and 35 factor of interest on the horizontal axis and average percentage of gdp spent on health on the vertical axis distinguishing between lowand middleincome countries the dotted reference line represents the average share of gdp spent on health across the countries in our sample the top left quadrant contains countries with relatively higher shares of health expenditure but the corresponding lifestyle risk factor concentrated among the poor where the latter is generally deemed unfair socioeconomic inequalities and percentage of gdp spent on health the top right quadrant consists again of countries with relatively higher shares of health expenditure but the lifestyle risk factor is concentrated among the betteroff which might suggest that these countries do not have the highest priority when it comes to reducing lifestyle risk factors among the poor even though there is still considerable room for improvement the bottom right quadrant shows low shares spend on health and concentration of the lifestyle risk factor among the better off finally the bottom left corner contains the countries with a double disadvantaged population with the share spend on health relatively low and lifestyle risk factors concentrated among the poor countries in this bottom left quadrant should be prioritized in policies to reduce the morbidity and mortality from ncds tobacco use is mainly concentrated in the left quadrants so among the poor this disadvantage is especially present for middleincome countries where the propoor inequality coincides with relatively low shares of gdp spent on health while we cannot identify an overall pattern it seems that with the exemption of sierra leone a higher share of gdp spent on health is observed in countries with less inequality ie an concentration index closer to zero we observe for overweight contrary to tobacco use a prorich distribution with countries spending a higher share of their gdp on health having less inequality when mapping these countries in terms of harmful alcohol use there are countries located in each of the four quadrants indicating that there is no strong association between the share of gdp spent on health and the socioeconomical distribution of harmful alcohol use however the countries at a double disadvantaged and thus with the most pressing need for effective interventions to reduce harmful alcohol use are chad congo india tanzania timorleste zambia and cambodia figure 4 shows clustering of lifestyle risk factors in households and suggests that countries with a higher share of their gdp spent on health tend to have a propoor distribution of lifestyle risk factors within a household countries with a lower share of their gdp spent on health tend to have a prorich distribution of lifestyle risk factors within a household as this figure shows the cumulative behaviour of a household this finding should be interpreted carefully as combinations of lifestyle risk factors within a household might differ when comparing lowversus middleincome countries we observe that the lowincome countries more frequently have a propoor distribution while the middleincome countries dominantly have a prorich distribution of these lifestyle risk factors we refrain from multilevel analysis here because of the limited sample size individual characteristics and lifestyle risk factors table 3 contains descriptive statistics of the explanatory variables used in the multilevel models on the womens mens and couples samples the information in table 3 is based on the men and women in the couples dataset 1 for all countries combined we find that a bit less than one third live in an urban area and half of the women indicate not to have an occupation compared to 47 among men the average age in our sample is 37 years with an average household consisting of six members the results from the multilevel probit regression models confirm that tobacco and harmful alcohol use are concentrated among the poorer men while overweight is concentrated among the better off women when combining unhealthy behaviors among couples as shown in the last column we find that the probability of such clustering significantly increases with 007 among couples with women above 35 years old compared to similar couples with a woman below 20 years old discussion this study exploits data from the demographic and health survey collected across 22 lowand middleincome countries between 2013 and 2018 to analyse prevalence and socioeconomic inequality in lifestyle risk factors ie tobacco use overweight and harmful alcohol use we show that both the prevalence and the degree of socioeconomic inequality differ considerably across lifestyle risk factors and across countries tobacco and harmful alcohol use are largely concentrated among the poor while overweight is heavily concentrated among the betteroff in lmics this is contrary to findings from high income countries where all lifestyle risk factors are most prevalent among those with a lower socioeconomic status 910 the largest socioeconomic inequalities across the four lifestyle risk factors were found for overweight in developed countries low socioeconomic status is consistently associated with higher prevalence of unhealthy bmi while our finding shows the opposite direction in line with previous research on lmics 17 the largest prorich socioeconomic inequalities in overweight were observed in india tanzania and zimbabwe some evidence suggests that obesity is a symbol of high social status in developing countries 30 this contrast in socioeconomic inequality between highversus lowand middleincome countries emphasizes the need to develop context specific policy interventions to tackle lifestyle risk factors for most lmics in our study we find that harmful alcohol use is mostly a problem among the poor when mapping the share of gdp spend on health in each of these countries as well as the socioeconomic inequality in lifestyle risk factors we identified those countries with both a low share spend on health and an inequality lifestyle risk factors distributed towards the poor as double disadvantaged combining these different lifestyle risk factors especially zambia tanzania and cambodia are at a double disadvantage and should be prioritized when implementing global policies to reduce unhealthy lifestyles among the poor limitations this study is based on crosssectional data solely allowing us to examine associations our findings cannot be interpreted as causal furthermore our findings are derived from large datasets and inferences about the nature of individuals cannot be deduced from inferences about the larger groups to which these individuals belong ie ecological fallacy the response rates for the dhs are generally high ranging from 97 to 999 however missing observations on lifestyle risk factors because respondents were unwilling to answer or to have their height and weight measured are a limitation to our study this would be especially problematic when respondents from a specific socioeconomic group are less likely to provide this information biasing our inequality estimates however we do not have reason to believe that this is the case the sample of women reporting on their partners harmful alcohol use does not suffer from this potential bias because the sample size is lower as a result of only a randomly selected subset of women being asked to answer this question a second limitation arises from the use of bmi as a combined proxy for diet and physical activity which were not observed in the dhs although bmi is an objective and reliable measure it is less informative on diet composition we cannot identify whether the poor consume less fruit and vegetables measuring physical activity both work and leisure related would be informative to policy makers aiming to reduce overweight but the dhs does not collect this information furthermore because of data limitations we could not provide information on overweight in men a third limitation arises from the reports on alcohol use in men which are provided by the spouse and not by the consumer himself this is likely to bias our estimates but it is unclear whether this leads to an overor underestimation when alcohol consumption is collected from the consumer himself it is possible that people who drink excessively provide an under estimation because of a perceived social stigma however the spouse might also under report for the same reason and her recall bias might be larger she could also overestimate her partners alcohol use because she does not have complete information on his alcohol consumption especially not when this is outside of the house finally socioeconomic inequality in lifestyle risk factors could be influenced by taxation policies of which the effects could differ per country and per socioeconomic group further research is needed to estimate the effect of such taxation schemes on the socioeconomic distribution of lifestyle risk factors notwithstanding these limitations this study provides policy relevant insights into lifestyle risk factors in lmics based on data from over a million of adults living in more than twenty lmics conclusions this study emphasizes the importance of lifestyle risk factors in lmics and the socioeconomic variation therein while tobacco and alcohol use are most prevalent among males with a low socioeconomic status it is mainly the better off females that are overweight we identified zambia tanzania and cambodia as the countries at a double disadvantage implying that priority should be given to these populations when implementing policies towards the sdg target of reducing ncds by one third given the different socioeconomic distribution of lifestyle risk factors especially overweight the targeting of interventions to reduce the burden from these lifestyles in lmics should not be copied from high income countries but be tailored towards the highrisk populations in these countries below we suggest three policy implications policy implications consistent with findings from yaya et al 15 among women across 33 sub saharan african countries we find that tobacco use in men is most prevalent among the poor in lmics for hics increasing the price of cigarettes has been shown to be one of the most effective strategies to reduce smoking prevalence in particular among people with a lower socioeconomic status 31 the world health organizations framework convention on tobacco control covers more than 90 of the worlds population and provides its 180 collaborators to enact comprehensive effective tobacco control measures the findings of this study emphasize that in particular timorleste armenia and south africa which have the highest prevalence in tobacco use can benefit from alignment with the who fctc second to our knowledge no interventions have been proven to be widely effective in sustainably reducing overweight in high income countries so even when interventions developed in hics such as low caloric diets or physical activity programs would be tailored to target the better off women in lmics it is unlikely that these are effective furthermore the food environment can limit the opportunity for the poor to switch to healthy often more expensive foods as a result overweight is not simply driven by the choice to consume unhealthy foods but can be a reflection of structural inequalities further research is therefore necessary to identify effective interventions to reduce overweight in lmics finally while lifestyle risk factors are generally deemed to be modifiable support to improve lifestyles is necessary to make sustained changes access to this support if even available is likely to be smaller for those with a lower socioeconomic status targeting this segment of the population for example through vouchers for support programmes or cash transfers conditional on improving behaviour are therefore likely to be most effective in reducing socioeconomic inequalities in lifestyle risk factors further research is necessary to determine the effectiveness of these policy suggestions especially through a longitudinal approach to identify modifications in unhealthy behaviours over time abbreviations lmic lowand middleincome countries ei erreygers index ncd noncommunicable diseases ethics approval of consent to participate the dhs is publicly available for research purposes and the corresponding research protocols are reviewed and approved by icf institutional review board informed consent is obtained from each respondent before the start of the interview see dhs website for more details competing interests the authors declare that they have no competing interests

background the heavy and ever rising burden of noncommunicable diseases ncds in lowand middleincome countries lmics warrants interventions to reduce their underlying risk factors which are often linked to lifestyles to effectively supplement nationwide policies with targeted interventions it is important to know how these risk factors are distributed across socioeconomic segments of populations in lmics this study quantifies the prevalence and socioeconomic inequalities in lifestyle risk factors in lmics to identify policy priorities conducive to the sustainable development goal of a one third reduction in deaths from ncds by 2030 methods data from 1278624 adult respondents to demographic health surveys across 22 lmics between 2013 and 2018 are used to estimate crude prevalence rates and socioeconomic inequalities in tobacco use overweight harmful alcohol use and the clustering of these three in a household inequalities are measured by a concentration index and correlated with the percentage of gdp spent on health we estimate a multilevel model to examine associations of individual characteristics with the different lifestyle risk factors results the prevalence of tobacco use among men ranges from 596 armenia to 66 nigeria the highest level of overweight among women is 837 egypt while this is less than 12 in burundi chad and timorleste 825 of women in burundi report that their partner is often or sometimes drunk compared to 13 in gambia tobacco use is concentrated among the poor except for the low share of men smoking in nigeria overweight however is concentrated among the better off especially in tanzania and zimbabwe erreygers index ei 0227 and 0232 harmful alcohol use is more concentrated among the better off in nigeria ei 0127 while chad rwanda and togo show an unequal propoor distribution ei respectively 0147 0210 0266 cambodia exhibits the largest socioeconomic inequality in unhealthy household behaviour ei 0253 the multilevel analyses confirm that in lmics tobacco and alcohol use are largely concentrated among the poor while overweight is concentrated among the betteroff the associations between the share of gdp spent on health and the socioeconomical distribution of lifestyle factors are multidirectional conclusions this study emphasizes the importance of lifestyle risk factors in lmics and the socioeconomic variation therein given the different socioeconomic patterns in lifestyle risk factors overweight patters in lmics differ considerably from those in high income countriestailored interventions towards specific highrisk populations are warranted to supplement nationwide policies

racial disparities emerge. Only three studies have examined racial differences in nocturnal BP decline among children and adolescents, two of which reported a higher prevalence of BP nondipping among African American youth . Because elevated BP during childhood persists into adulthood and predicts adult hypertension , adolescence is a critical period during which trajectories to cardiovascular risk are established. Thus, investigating race and other factors related to BP nondipping during this period of biological, social, and psychological maturation could shed light on inequalities in cardiovascular morbidity and mortality in adulthood. To fully comprehend race differences in BP nondipping, it is essential to consider socioeconomic status . Research indicates that lower SES individuals are at greater risk for nondipping, compared to higher SES individuals . Because African Americans are overrepresented in lower SES positions , racial differences in BP nondipping may be attributed in part to racial disparities in SES. Consistent with this notion are findings that years of education largely attenuated the effect of race on BP nondipping among normotensive and hypertensive adults . Moreover, being African American and low SES may interact to confer increased risk for nondipping and subsequent hypertension, as African Americans may be more vulnerable to the negative impact of lower SES environments. Indeed, only among African American adolescents from lower SES neighborhoods were perceptions of unfair treatment from others associated with higher night/day BP ratios . A primary objective of this study was to test the independent and combined effects of race and SES on night/day BP ratios in healthy African American and Caucasian adolescents. Understanding the pathways by which SES and race influence cardiovascular health is of great public health and clinical significance . From a psychosocial perspective, both lower SES and minority status are thought to lead to greater exposure to stressful circumstances and their emotional sequalae, which, in turn, may lead to elevated cardiovascular risk . However, it is also recognized that psychosocial resources -including intrapersonal, interpersonal, and cultural resources --may be important in reducing the likelihood of adverse cardiovascular consequences . These factors may be especially applicable to understanding nondipping because stressful circumstances and negative emotions are known to disturb circadian rhythms . Consistent with this perspective, a burgeoning literature finds that adults who exhibit BP nondipping have elevated scores on measures of anger, hostility, and depression , and there is preliminary evidence that suggests that African Americans may be particularly vulnerable to the toxic effects of negative emotions on the diurnal pattern of BP . Less is known about positive resources in relation to nondipping. The few available studies report that high social support and high life purpose are associated with dipping in middle-aged adults . A second aim of this study was to examine whether nondipping was associated with high levels of negative emotions and low levels of psychosocial resources among adolescents and whether accounting for these psychological factors attenuated the impact of race and SES. Poor social relationships, including the level of conflict experienced in relationships, have also been associated with BP nondipping . Conflictual interpersonal interactions with family and friends are a typical feature of adolescent life and are associated with negative emotions . Ecological momentary assessment of ongoing conflictual and unpleasant encounters throughout the day may provide a more valid representation of social relationships than global self-report measure . To date, only two ambulatory BP studies have examined interpersonal conflict by ecological momentary assessment, with conflict exhibiting positive associations with within-person fluctuations in systolic BP and diastolic BP in one study and masked hypertension in the other ; these studies did not evaluate the effects on nighttime BP or night/day ratios. A third purpose of this study was to test the associations between cumulative exposure to conflictual and unpleasant interactions throughout the day and BP nondipping. To meet study objectives, we measured ambulatory BP for 2 full days and nights during the school week in a sample of healthy African American and Caucasian high school students. The measures of nondipping were the ratios of night/day SBP and DBP measured during sleep and awake periods verified by actigraphy. At the time of BP assessment, students recorded the quality of their concurrent social interactions. Thus, our study was able to test the following hypotheses: Night/day BP ratios would be elevated among African American and low SES adolescents. Night/day ratios would be elevated among adolescents with high negative emotions and low positive resources scores, with statistical adjustment for emotions and resources attenuating any observed associations of night/day ratios and ethnicity and SES. Night/day ratios would be elevated among those who experienced conflictual, unpleasant encounters throughout the day. Furthermore, the study examined whether associations between psychosocial factors and night/day BP ratios would be stronger in African Americans, who may be more vulnerable because of their established risk for nondipping and hypertension in adulthood. --- Method Participants were 250 adolescents between the ages of 14 and 19 from an urban, integrated, public high school near Pittsburgh, PA. Participants were recruited from health classes between 2008 and 2011 for an adolescent health project designed to measure risk factors for cardiovascular disease and sleep. Exclusionary criteria for study participation included parental report of children's cardiovascular or kidney disease, usage of medication for emotional problems, diabetes or high blood pressure, as well as medication known to affect the cardiovascular system or sleep. Sixteen participants who expressed an interest in the study were ineligible to participate based on the exclusionary criteria, and seven students who signed consent forms did not actively enroll in the study. Of the 250 adolescents who enrolled in the study, two adolescents had body mass index values that fell over four standard deviations from the sample mean and were excluded from analyses. Also excluded were one adolescent who did not complete the ambulatory BP monitoring procedures and two participants who removed the BP cuff on at least one night of data collection. Six participants had missing data for family size, which precluded calculation of an imputed score for income, and four participants were missing questionnaire data. The final sample consisted of 239 adolescents. --- Measures and Procedures Overview-Participants were recruited during physical education classes in which trained staff presented the study objectives and protocol. Subsequently, parents/guardians of students who expressed an interest in the study were contacted for a screening phone interview. After obtaining signed informed consent from the parent/guardian and student, parents/guardians were interviewed regarding household SES and family history. Students were then scheduled to complete a 7-day study protocol, which included two school days and two nights of ambulatory BP monitoring , completion of a battery of psychosocial questionnaires via protected web access, a blood draw, and actigraphy. Upon completion of the study protocol, participants were compensated $100 for successful participation in the research project. Ambulatory Blood Pressure Assessment: A Spacelabs Monitor # 90217 was used to measure ambulatory BP for two days and two nights. This monitor uses the auscultatory method of BP assessment. A BP reading was taken every 30 minutes from 7:00 a.m. to 10:00 p.m. and hourly thereafter. Measurements were averaged across the night, starting when participants went to sleep and stopping when they reported awakening in daily diaries and across the remaining wake period. At least 5 readings across each night were required in order to calculate this average. Blood pressures that fell within the participant's self-reported sleep window were used to calculate average nighttime BP; BP readings that were ± 3 standard deviations from a participant's individual mean were treated as outliers and excluded. Night/day ratio was defined as the ratio of average nighttime BP to average daytime BP for SBP and DBP separately. Accordingly, a higher score represents a smaller nocturnal decline relative to daytime BP or more BP nondipping. We chose the night/day SBP and DBP ratios as our primary measures because they provide continuous measures and maximize statistical power. --- Measures Socioeconomic Status: We utilized parental education and family income as indicators of SES. These two indicators are distinct in that income is often characterized as a resource measure and education as a prestige index of SES . Parental education was the higher level of educational attainment of either mother or father or head of household, with 1= grade school; 2 = high school diploma; 3 = associate degree; and 4 = college degree, and then summarized as ≤ high school, or associate degree or higher. Family income was reported as gross annual family income in the categories of <$5,000; <$12,000; <$16,000; < $25,000; <$35,000; <$50,000; < $75,000; <$100,000; and >$100,000. To create a family size adjusted income, we first derived midpoints for the income categories, with the open ended top category being assigned a value of 50% above its lower boundary. Thereafter, income was adjusted for the square root of the household size and a log transformation was applied to reduce skewness of the distribution. Additionally, because the parents of 15 participants declined to provide information about their family income, we imputed income data by identifying families with similar structure and using the midpoint of the average income category for the comparable family constellations . The results presented below were identical to those results based on excluding those with the imputed scores. --- Assessments of Psychological Factors: Negative Emotions and Positive Resources: Four measures of negative emotions were included. The Positive and Negative Affect Schedule consisted of 10 items each measuring global positive and negative dispositional affect. Participants were asked to indicate how much they feel each affect in general ranging from 1 to 5 . Cronbach's alpha coefficient for negative affect was 0.85. Depressive symptoms were assessed using the 20-item Center for Epidemiological Studies Depression scale . Participants rated the frequency of experiencing each symptom in the past week, ranging from 1 to 4 . A sample item was "I was bothered by things that usually don't bother me." Higher scores indicated greater depressive symptoms. Cronbach's alpha coefficient for the CES-D in this sample was 0.85. Anger was measured using the Spielberger Trait Anger Scale , which consists of 10 items related to the frequency with which the emotion of anger is generally experienced in relation to situations and interactions with others. Participants characterized how they generally felt, ranging from a 1 to 4 . Sample items were, "I have a fiery temper" and "When I get frustrated, I feel like hitting someone." Higher scores indicate greater trait anger. Cronbach's alpha for trait anger was 0.87. Cynicism was assessed by 12 items from the Cook-Medley Hostility Scale . Participants designated if they believed a statement to be true or false about the ways people behave. Sample items include, "It is safer to trust nobody" and "I think most people would lie to get ahead." Higher scores indicate greater cynicism and the Cronbach's alpha in this sample was 0.55. Four measures of positive resources were included. Positive affect was derived from the Positive and Negative Affect Scale, described above; Cronbach's alpha for positive affect was 0.82. Self-esteem was measured with 10 items from the Rosenberg Self-Esteem Scale . Students characterized their agreement with statements regarding perceptions of selfworth using a scale ranging from 1 to 4 . A sample item is, "I feel that I am a person of worth, at least on an equal basis with others." Higher scores are indicative of higher self-esteem. In our sample, the Cronbach's alpha was 0.84. Optimism was measured using the 6-item Life Orientation Test-Revised . Participants characterized their agreement with each item using a scale ranging from 0 to 4 , with 2 being a neutral response. A sample optimism item is, "In uncertain times, I usually expect the best." The LOT-R overall score ranges from 0-24 and higher scores indicate greater optimism. The LOT-R showed moderate reliability; the Cronbach's alpha coefficient was 0.60. Subjective social standing was measured using the MacArthur Scale of Subjective Social Standing that was developed as a measure of people's perceptions of their placement in the social hierarchy . Using a picture of a ladder with 9 rungs, adolescents indicated where they rank relative to other students in the school based on popularity, grades, respect, etc. The youth version of the MacArthur Scale is appropriate for those grades 7 and above or children aged 12 and older. This measure was considered to be a positive sense of self, relative to other students. Principal components analysis with orthogonal varimax rotation was conducted on the scale scores from the above questionnaires. The Kaiser-Meyer-Olkin measure verified the sampling adequacy for the analysis, KMO = 0.72. Barlett's test of sphericity χ 2 = 499.45, p < .01, indicated that correlations between measures were sufficiently large. Two components had eigenvalues over Kaiser's criterion of 1 and in combination explained 55.5% of the variance. Four measures loaded > .55 on the first factor labeled Negative Emotions, and four measures loaded > .61 on the second factor, labeled Positive Resources. Each score was standardized and added together to form composites. --- Unpleasant Social Interactions: In conjunction with the daytime ambulatory BP recordings, participants reported via electronic diaries whether or not they had been engaged in a social interaction in the 10 minutes preceding each daytime BP recording. If "Yes" was indicated, participants answered two questions: "Did you have a conflict or disagreement with someone? Did you have a pleasant interaction with someone?". The responses ranged from 1 to 6 . The responses for pleasantness and conflict averaged across the total number of responses provided across the measurement period were inversely related, r= -.42. The ratings of pleasantness were reverse coded and added to the ratings of conflict to make a total combined score, labeled unpleasant interaction score, across the total number of responses provided across the measurement period; eight participants with fewer than 5 recorded interactions were not included in the analysis of this variable. --- Covariates: The covariates were age, sex, and BMI. Age and sex were determined by selfreport. BMI was derived from weight and height measured on a calibrated scale nearest 0.1 kg and 0.1 cm, respectively; because of its distribution, a square root transformation was performed. Statistical Analyses: Race and gender differences in SES, BP, negative emotions, positive resources, and unpleasant interaction scores were examined by 2 by 2 ANOVAS. To test our hypotheses, we used linear regression, with covariates of age, sex, and BMI. To meet the first aim, in separate analyses for household income and parental education, the covariates, race, and the SES variable were entered at step 1, and the interaction of race and SES at step 2. To meet the second and third aims, after entering covariates plus race and household income, negative emotions, positive resources, and unpleasant interaction scores were entered separately in the second step. The change in the betas for race and SES were evaluated as to whether they were attenuated by the introduction of the psychosocial scores. Finally, the interactions between race and each of the psychosocial scores were calculated. Significant interactions with race were further examined by conducting race-stratified regressions. For illustration only, figures show the estimated means at 1 standard deviation above and below sample mean for continuous SES and psychosocial variables. Statistical significance was set at p <.05 and were conducted with SPSS, Version 18 . --- Results --- Sample Characteristics The study sample included 239 participants, about half of whom were females, with a mean age of approximately 16 years. One hundred and thirty five participants self-reported their race as African American and 104 as Caucasian; two Hispanic participants were grouped with Caucasians. Results reported below were similar when the two Hispanic participants were removed from analyses. Approximately 22% of the adolescents were obese . Using the criterion of less than 10% decline in BP during sleep relative to daytime BP, 26% of the adolescents would be categorized as nondippers for SBP and 4% for DBP. Table 1 shows the full sample characteristics as well as race differences in characteristics. African American adolescents had higher SBP ratios and nighttime SBP and lower household income than Caucasians. African Americans had lower negative emotions and higher positive resources scores than Caucasians; each of the scales contributing to the overall factor scores differed by race as well . Only one significant interaction between race and sex emerged for BMI = 5.23, p = .02), with Caucasian males exhibiting the highest BMI . Table 2 shows the simple correlations among variables. Household income and parental education were modestly associated. Lower income was associated with higher SBP and DBP ratios. Negative emotion scores were positively correlated with SBP and DBP ratios. Additionally, negative emotions were inversely correlated with positive resources. As might be expected, adolescents who had higher negative emotion and lower positive resource scores reported more unpleasant social interactions throughout the two days of monitoring. --- Influence of Race and Socioeconomic Status on Night/Day BP ratios- The results of linear regression models testing the independent associations of race and income with BP ratios are displayed in Table 3. Larger SBP ratios were observed among African Americans than among Caucasians, whereas larger DBP ratios were associated with lower household income . Moreover, income interacted with race to predict SBP ratio. Race-stratified analyses revealed that among African American adolescents, lower income was associated with higher night/day SBP ratio , but not among Caucasians . There were no significant effects involving parental education, p's >. 25. 4 shows the results of the relations between negative emotions, positive resources, and each BP ratio, independent of variables in the base models . Only the summed negative emotions were related to SBP ratio and marginally to DBP ratio. Further, the standardized beta for the association between race and SBP ratio was not attenuated with the inclusion of negative emotions in the model, and the relationship between family income and DBP ratio was not attenuated with the inclusion of negative emotions in the model. --- Influence of Negative Emotions and Positive Resources on Night/day BP Ratios-Table Significant interactions emerged between race and negative emotions for both SBP and DBP ratios, and race and positive resources for DBP ratio . Race-stratified analyses revealed that among African Americans, higher scores on negative emotions were associated with higher night/day SBP and DBP ratios , but not among Caucasians and , respectively. Similarly, lower scores on positive resources were associated with higher DBP ratio only among African Americans , but not Caucasians . The above interactions are illustrated in Figures 2 and3 that depict the analyses of the simple slopes at one standard deviation above and below the mean. Of note, the effects of positive resources on DBP ratios among African Americans were independent of negative emotions when both were introduced into the model . Stratified analyses for African Americans showed that the inclusion of negative emotions along with the covariates of age, sex, and BMI accounted for 22% and 21% percent of the variance in SBP and DBP ratio, respectively. With the addition of positive resources in the same model as negative emotions, 23% variance in DBP ratios was explained. Influence of Unpleasant Social Interactions on Night/Day BP Ratios-Unpleasant interactions were not associated with DBP and SBP ratios. However, a significant interaction between race and unpleasant interactions was observed , with higher unpleasant interactions associated with higher SBP ratio among African Americans , but not Caucasians in racestratified analyses. Figure 4 plots the regression of race by unpleasant interaction on SBP ratio. --- Discussion The first aim of this study was to evaluate racial differences in BP nondipping in adolescents and to extend the findings by examining whether expected racial differences were independent of SES. We found that African American adolescents showed higher SBP night/day ratio than Caucasians, independent of both parental education and family income. Lower family income was associated with higher SBP ratio for African Americans only and was associated with higher DBP ratio in both African Americans and Caucasians. The blunted BP decline observed among African Americans and low income adolescents in this study is consistent with the considerable evidence on the prevalence of BP nondipping in African American and low SES adults . Taken together, the current study replicates the extant findings in the literature regarding the independent association between SES and BP dipping, and demonstrates that the association between race and night/day BP ratio in adolescents cannot be explained by racial disparities in family income. The second aim of this study was to examine whether negative emotions and positive resources would be related to BP nondipping and would attenuate the associations of race and SES. We hypothesized that adolescents who reported high negative emotions and low positive resources would exhibit higher night/day ratios. Our results showed that higher scores on the composite measure of negative emotions were associated with SBP night/day ratios. On the other hand, neither negative emotions nor positive resources explained race and SES effects on BP dipping. This relationship between negative emotions and BP dipping is in line with previous findings in adults . The finding that negative emotions did not account for demographic differences in BP is also consistent with previous research, as only one study found that hostility and anger expression explained racial differences in nocturnal decreases whereas three additional studies did not observe that individual negative emotions explained race differences in BP nondipping. We also found that race moderated the association between both negative emotions and positive resources and BP dipping. Specifically, among African Americans only, higher negative emotion scores were associated with higher SBP and DBP ratios, with each component of the negative emotions factor related . Furthermore, low positive resources, especially low positive affect and low optimism , were associated with higher DBP ratio. In contrast, negative emotions and positive resources were unrelated to nocturnal decline among Caucasian adolescents. These findings coincide with findings by Shapiro et al and Steffen et al observed in African American adults and suggest that African American adolescents may be particularly vulnerable to the effects of high levels of negative emotions and low positive resources. The third goal of this study was to evaluate the role of daily interpersonal stress in BP nondipping. We found no evidence that level of unpleasant interactions reported over two days via ecological momentary assessment mitigated the effects of either race or SES on night/day ratio. However, parallel to our findings on the moderating effects of negative emotions and positive resources, we did find that more unpleasant interactions were associated with higher SBP ratios among African American adolescents, but not among Caucasians. Taken together, these findings highlight the significance of negative emotions, positive resources, and unpleasant interactions for understanding BP nondipping among African American adolescents. One plausible explanation of race differences in the influence of these psychosocial variables could be different patterns of cardiovascular reactivity among African Americans and Caucasians, with African Americans exhibiting more alphaadrenergic response to laboratory stressors and Caucasians more beta-adrenergic reactivity . Greater vascular reactivity may accelerate stiffening of the vasculature, leading to eventual hypertension, in contrast to beta-adrenergic reactivity that may have more direct effects on atherosclerosis. Indeed, in a different sample of adolescents than the present, among African Americans, increasing negative mood states predicted greater increases in ambulatory heart rate and DBP measured across two school . Relatedly, African Americans' greater sensitivity to the effects of psychosocial factors on nocturnal BP decline could reflect diathesis stress processes , such that physiological vulnerabilities conferred by race and exposure to negative psychosocial factors interact to place African Americans on trajectories for disruptions in circadian BP regulation and later hypertension. There are several strengths of this study, including the examination of BP dipping in an adolescent sample with representation of African American and Caucasian participants, which permitted the examination of race differences. Additionally, we assessed BP over two nights, which increased the reliability of our nondipping measure compared to most studies that have examined dipping over a single 24-h period, and we utilized self-reported sleep and wake times confirmed by objective actigraphy data rather than imposing arbitrary night and day periods. Finally, we considered positive as well as negative psychosocial factors in our explorations of potential pathways leading to BP nondipping. Notwithstanding the aforementioned strengths, the findings should be interpreted in light of several limitations. First, our study did not have a broad range of SES as participants were from families of a low to middle class background from a single urban high school. Thus, the restricted family income and homogenous sample limit the generalizablity of our findings. The excellent health of the adolescent sample also limited the range of ambulatory BP. Finally, the cross-sectional design of the study does not permit inferences about causality. In summary, our findings suggest both African American and lower SES adolescents may be at risk for elevated night/day BP ratios. Further, African American adolescents who report greater negative emotions, lower positive resources, and more unpleasant social interactions, may be particularly vulnerable to having elevated night/day BP ratios. Given that the sample consisted of healthy, normotensive adolescents, it is striking that elevated night/day BP ratios were associated with race, SES, and negative emotions. Should these associations persist into adulthood, such adolescents may be at high risk for later hypertension and its complications. Interventions focused on enhancing the psychological resources of African American adolescents may reduce their risk for later hypertension. SBP night/day ratios according to family income scores . SBP night/day ratios according to negative emotion scores . DBP night/day ratios according to positive resources scores . SBP night/day ratios according to unpleasant interactions scores averaged across days . Correlations among SES, psychosocial variables, and BP ratios Standardized betas from linear regression models regressing night/day SBP and DBP ratios on race and income with adjustment for covariates Step 2: Unpleasant Interactions -0.07 0.28 0.10 0.01 1.17 -0.10 0.14 0.08 0.01 2.15 Step 3: Race x Unpleasant Interactions -0.13 0.04 0.12 0.02 4.13 -0.02 0.75 0.08 0.00 0.09 Notes: BMI = Body Mass Index, SBP=Systolic Blood Pressure; DBP=Diastolic Blood Pressure Ratio Step 2: includes the basic model illustrated in table 3, and negative emotions, positive resources, and pleasant interaction analyzed separately. Step 3 includes the basic model illustrated in table 3, and the interaction of race and negative emotions, positive resources, and unpleasant interactions analyzed separately. R 2 refers to the total variance accounted for at step, whereas ΔR 2 refers to the additional variance accounted for by the step. Ann Behav Med. Author manuscript; available in PMC 2014 October 01.

Background-Elevated nighttime blood pressure (BP) predicts hypertension and its complications in adulthood. Purpose-To assess the independent effects of race and family income on night/day BP among adolescents and to examine whether negative emotions, low positive resources, and unpleasant interactions during the day are also related.African American and Caucasian high school students (N=239) wore an ambulatory BP monitor for 48 hours, recorded quality of ongoing interpersonal interactions, and completed questionnaires. Results-African Americans and those with lower family income had higher night/day BP ratios. African Americans reporting greater negative emotions, lower positive resources, and more unpleasant interactions had higher night/day BP ratios. Conclusions-Racial differences in night BP emerge by adolescence, independent of family income. African Americans, especially those high in negative emotions and low in positive resources, may be at higher relative risk for hypertension later in life in part due to elevated night BP.

racial disparities emerge only three studies have examined racial differences in nocturnal bp decline among children and adolescents two of which reported a higher prevalence of bp nondipping among african american youth because elevated bp during childhood persists into adulthood and predicts adult hypertension adolescence is a critical period during which trajectories to cardiovascular risk are established thus investigating race and other factors related to bp nondipping during this period of biological social and psychological maturation could shed light on inequalities in cardiovascular morbidity and mortality in adulthood to fully comprehend race differences in bp nondipping it is essential to consider socioeconomic status research indicates that lower ses individuals are at greater risk for nondipping compared to higher ses individuals because african americans are overrepresented in lower ses positions racial differences in bp nondipping may be attributed in part to racial disparities in ses consistent with this notion are findings that years of education largely attenuated the effect of race on bp nondipping among normotensive and hypertensive adults moreover being african american and low ses may interact to confer increased risk for nondipping and subsequent hypertension as african americans may be more vulnerable to the negative impact of lower ses environments indeed only among african american adolescents from lower ses neighborhoods were perceptions of unfair treatment from others associated with higher nightday bp ratios a primary objective of this study was to test the independent and combined effects of race and ses on nightday bp ratios in healthy african american and caucasian adolescents understanding the pathways by which ses and race influence cardiovascular health is of great public health and clinical significance from a psychosocial perspective both lower ses and minority status are thought to lead to greater exposure to stressful circumstances and their emotional sequalae which in turn may lead to elevated cardiovascular risk however it is also recognized that psychosocial resources including intrapersonal interpersonal and cultural resources may be important in reducing the likelihood of adverse cardiovascular consequences these factors may be especially applicable to understanding nondipping because stressful circumstances and negative emotions are known to disturb circadian rhythms consistent with this perspective a burgeoning literature finds that adults who exhibit bp nondipping have elevated scores on measures of anger hostility and depression and there is preliminary evidence that suggests that african americans may be particularly vulnerable to the toxic effects of negative emotions on the diurnal pattern of bp less is known about positive resources in relation to nondipping the few available studies report that high social support and high life purpose are associated with dipping in middleaged adults a second aim of this study was to examine whether nondipping was associated with high levels of negative emotions and low levels of psychosocial resources among adolescents and whether accounting for these psychological factors attenuated the impact of race and ses poor social relationships including the level of conflict experienced in relationships have also been associated with bp nondipping conflictual interpersonal interactions with family and friends are a typical feature of adolescent life and are associated with negative emotions ecological momentary assessment of ongoing conflictual and unpleasant encounters throughout the day may provide a more valid representation of social relationships than global selfreport measure to date only two ambulatory bp studies have examined interpersonal conflict by ecological momentary assessment with conflict exhibiting positive associations with withinperson fluctuations in systolic bp and diastolic bp in one study and masked hypertension in the other these studies did not evaluate the effects on nighttime bp or nightday ratios a third purpose of this study was to test the associations between cumulative exposure to conflictual and unpleasant interactions throughout the day and bp nondipping to meet study objectives we measured ambulatory bp for 2 full days and nights during the school week in a sample of healthy african american and caucasian high school students the measures of nondipping were the ratios of nightday sbp and dbp measured during sleep and awake periods verified by actigraphy at the time of bp assessment students recorded the quality of their concurrent social interactions thus our study was able to test the following hypotheses nightday bp ratios would be elevated among african american and low ses adolescents nightday ratios would be elevated among adolescents with high negative emotions and low positive resources scores with statistical adjustment for emotions and resources attenuating any observed associations of nightday ratios and ethnicity and ses nightday ratios would be elevated among those who experienced conflictual unpleasant encounters throughout the day furthermore the study examined whether associations between psychosocial factors and nightday bp ratios would be stronger in african americans who may be more vulnerable because of their established risk for nondipping and hypertension in adulthood method participants were 250 adolescents between the ages of 14 and 19 from an urban integrated public high school near pittsburgh pa participants were recruited from health classes between 2008 and 2011 for an adolescent health project designed to measure risk factors for cardiovascular disease and sleep exclusionary criteria for study participation included parental report of childrens cardiovascular or kidney disease usage of medication for emotional problems diabetes or high blood pressure as well as medication known to affect the cardiovascular system or sleep sixteen participants who expressed an interest in the study were ineligible to participate based on the exclusionary criteria and seven students who signed consent forms did not actively enroll in the study of the 250 adolescents who enrolled in the study two adolescents had body mass index values that fell over four standard deviations from the sample mean and were excluded from analyses also excluded were one adolescent who did not complete the ambulatory bp monitoring procedures and two participants who removed the bp cuff on at least one night of data collection six participants had missing data for family size which precluded calculation of an imputed score for income and four participants were missing questionnaire data the final sample consisted of 239 adolescents measures and procedures overviewparticipants were recruited during physical education classes in which trained staff presented the study objectives and protocol subsequently parentsguardians of students who expressed an interest in the study were contacted for a screening phone interview after obtaining signed informed consent from the parentguardian and student parentsguardians were interviewed regarding household ses and family history students were then scheduled to complete a 7day study protocol which included two school days and two nights of ambulatory bp monitoring completion of a battery of psychosocial questionnaires via protected web access a blood draw and actigraphy upon completion of the study protocol participants were compensated 100 for successful participation in the research project ambulatory blood pressure assessment a spacelabs monitor 90217 was used to measure ambulatory bp for two days and two nights this monitor uses the auscultatory method of bp assessment a bp reading was taken every 30 minutes from 700 am to 1000 pm and hourly thereafter measurements were averaged across the night starting when participants went to sleep and stopping when they reported awakening in daily diaries and across the remaining wake period at least 5 readings across each night were required in order to calculate this average blood pressures that fell within the participants selfreported sleep window were used to calculate average nighttime bp bp readings that were ± 3 standard deviations from a participants individual mean were treated as outliers and excluded nightday ratio was defined as the ratio of average nighttime bp to average daytime bp for sbp and dbp separately accordingly a higher score represents a smaller nocturnal decline relative to daytime bp or more bp nondipping we chose the nightday sbp and dbp ratios as our primary measures because they provide continuous measures and maximize statistical power measures socioeconomic status we utilized parental education and family income as indicators of ses these two indicators are distinct in that income is often characterized as a resource measure and education as a prestige index of ses parental education was the higher level of educational attainment of either mother or father or head of household with 1 grade school 2 high school diploma 3 associate degree and 4 college degree and then summarized as ≤ high school or associate degree or higher family income was reported as gross annual family income in the categories of 5000 12000 16000 25000 35000 50000 75000 100000 and 100000 to create a family size adjusted income we first derived midpoints for the income categories with the open ended top category being assigned a value of 50 above its lower boundary thereafter income was adjusted for the square root of the household size and a log transformation was applied to reduce skewness of the distribution additionally because the parents of 15 participants declined to provide information about their family income we imputed income data by identifying families with similar structure and using the midpoint of the average income category for the comparable family constellations the results presented below were identical to those results based on excluding those with the imputed scores assessments of psychological factors negative emotions and positive resources four measures of negative emotions were included the positive and negative affect schedule consisted of 10 items each measuring global positive and negative dispositional affect participants were asked to indicate how much they feel each affect in general ranging from 1 to 5 cronbachs alpha coefficient for negative affect was 085 depressive symptoms were assessed using the 20item center for epidemiological studies depression scale participants rated the frequency of experiencing each symptom in the past week ranging from 1 to 4 a sample item was i was bothered by things that usually dont bother me higher scores indicated greater depressive symptoms cronbachs alpha coefficient for the cesd in this sample was 085 anger was measured using the spielberger trait anger scale which consists of 10 items related to the frequency with which the emotion of anger is generally experienced in relation to situations and interactions with others participants characterized how they generally felt ranging from a 1 to 4 sample items were i have a fiery temper and when i get frustrated i feel like hitting someone higher scores indicate greater trait anger cronbachs alpha for trait anger was 087 cynicism was assessed by 12 items from the cookmedley hostility scale participants designated if they believed a statement to be true or false about the ways people behave sample items include it is safer to trust nobody and i think most people would lie to get ahead higher scores indicate greater cynicism and the cronbachs alpha in this sample was 055 four measures of positive resources were included positive affect was derived from the positive and negative affect scale described above cronbachs alpha for positive affect was 082 selfesteem was measured with 10 items from the rosenberg selfesteem scale students characterized their agreement with statements regarding perceptions of selfworth using a scale ranging from 1 to 4 a sample item is i feel that i am a person of worth at least on an equal basis with others higher scores are indicative of higher selfesteem in our sample the cronbachs alpha was 084 optimism was measured using the 6item life orientation testrevised participants characterized their agreement with each item using a scale ranging from 0 to 4 with 2 being a neutral response a sample optimism item is in uncertain times i usually expect the best the lotr overall score ranges from 024 and higher scores indicate greater optimism the lotr showed moderate reliability the cronbachs alpha coefficient was 060 subjective social standing was measured using the macarthur scale of subjective social standing that was developed as a measure of peoples perceptions of their placement in the social hierarchy using a picture of a ladder with 9 rungs adolescents indicated where they rank relative to other students in the school based on popularity grades respect etc the youth version of the macarthur scale is appropriate for those grades 7 and above or children aged 12 and older this measure was considered to be a positive sense of self relative to other students principal components analysis with orthogonal varimax rotation was conducted on the scale scores from the above questionnaires the kaisermeyerolkin measure verified the sampling adequacy for the analysis kmo 072 barletts test of sphericity χ 2 49945 p 01 indicated that correlations between measures were sufficiently large two components had eigenvalues over kaisers criterion of 1 and in combination explained 555 of the variance four measures loaded 55 on the first factor labeled negative emotions and four measures loaded 61 on the second factor labeled positive resources each score was standardized and added together to form composites unpleasant social interactions in conjunction with the daytime ambulatory bp recordings participants reported via electronic diaries whether or not they had been engaged in a social interaction in the 10 minutes preceding each daytime bp recording if yes was indicated participants answered two questions did you have a conflict or disagreement with someone did you have a pleasant interaction with someone the responses ranged from 1 to 6 the responses for pleasantness and conflict averaged across the total number of responses provided across the measurement period were inversely related r 42 the ratings of pleasantness were reverse coded and added to the ratings of conflict to make a total combined score labeled unpleasant interaction score across the total number of responses provided across the measurement period eight participants with fewer than 5 recorded interactions were not included in the analysis of this variable covariates the covariates were age sex and bmi age and sex were determined by selfreport bmi was derived from weight and height measured on a calibrated scale nearest 01 kg and 01 cm respectively because of its distribution a square root transformation was performed statistical analyses race and gender differences in ses bp negative emotions positive resources and unpleasant interaction scores were examined by 2 by 2 anovas to test our hypotheses we used linear regression with covariates of age sex and bmi to meet the first aim in separate analyses for household income and parental education the covariates race and the ses variable were entered at step 1 and the interaction of race and ses at step 2 to meet the second and third aims after entering covariates plus race and household income negative emotions positive resources and unpleasant interaction scores were entered separately in the second step the change in the betas for race and ses were evaluated as to whether they were attenuated by the introduction of the psychosocial scores finally the interactions between race and each of the psychosocial scores were calculated significant interactions with race were further examined by conducting racestratified regressions for illustration only figures show the estimated means at 1 standard deviation above and below sample mean for continuous ses and psychosocial variables statistical significance was set at p 05 and were conducted with spss version 18 results sample characteristics the study sample included 239 participants about half of whom were females with a mean age of approximately 16 years one hundred and thirty five participants selfreported their race as african american and 104 as caucasian two hispanic participants were grouped with caucasians results reported below were similar when the two hispanic participants were removed from analyses approximately 22 of the adolescents were obese using the criterion of less than 10 decline in bp during sleep relative to daytime bp 26 of the adolescents would be categorized as nondippers for sbp and 4 for dbp table 1 shows the full sample characteristics as well as race differences in characteristics african american adolescents had higher sbp ratios and nighttime sbp and lower household income than caucasians african americans had lower negative emotions and higher positive resources scores than caucasians each of the scales contributing to the overall factor scores differed by race as well only one significant interaction between race and sex emerged for bmi 523 p 02 with caucasian males exhibiting the highest bmi table 2 shows the simple correlations among variables household income and parental education were modestly associated lower income was associated with higher sbp and dbp ratios negative emotion scores were positively correlated with sbp and dbp ratios additionally negative emotions were inversely correlated with positive resources as might be expected adolescents who had higher negative emotion and lower positive resource scores reported more unpleasant social interactions throughout the two days of monitoring influence of race and socioeconomic status on nightday bp ratios the results of linear regression models testing the independent associations of race and income with bp ratios are displayed in table 3 larger sbp ratios were observed among african americans than among caucasians whereas larger dbp ratios were associated with lower household income moreover income interacted with race to predict sbp ratio racestratified analyses revealed that among african american adolescents lower income was associated with higher nightday sbp ratio but not among caucasians there were no significant effects involving parental education ps 25 4 shows the results of the relations between negative emotions positive resources and each bp ratio independent of variables in the base models only the summed negative emotions were related to sbp ratio and marginally to dbp ratio further the standardized beta for the association between race and sbp ratio was not attenuated with the inclusion of negative emotions in the model and the relationship between family income and dbp ratio was not attenuated with the inclusion of negative emotions in the model influence of negative emotions and positive resources on nightday bp ratiostable significant interactions emerged between race and negative emotions for both sbp and dbp ratios and race and positive resources for dbp ratio racestratified analyses revealed that among african americans higher scores on negative emotions were associated with higher nightday sbp and dbp ratios but not among caucasians and respectively similarly lower scores on positive resources were associated with higher dbp ratio only among african americans but not caucasians the above interactions are illustrated in figures 2 and3 that depict the analyses of the simple slopes at one standard deviation above and below the mean of note the effects of positive resources on dbp ratios among african americans were independent of negative emotions when both were introduced into the model stratified analyses for african americans showed that the inclusion of negative emotions along with the covariates of age sex and bmi accounted for 22 and 21 percent of the variance in sbp and dbp ratio respectively with the addition of positive resources in the same model as negative emotions 23 variance in dbp ratios was explained influence of unpleasant social interactions on nightday bp ratiosunpleasant interactions were not associated with dbp and sbp ratios however a significant interaction between race and unpleasant interactions was observed with higher unpleasant interactions associated with higher sbp ratio among african americans but not caucasians in racestratified analyses figure 4 plots the regression of race by unpleasant interaction on sbp ratio discussion the first aim of this study was to evaluate racial differences in bp nondipping in adolescents and to extend the findings by examining whether expected racial differences were independent of ses we found that african american adolescents showed higher sbp nightday ratio than caucasians independent of both parental education and family income lower family income was associated with higher sbp ratio for african americans only and was associated with higher dbp ratio in both african americans and caucasians the blunted bp decline observed among african americans and low income adolescents in this study is consistent with the considerable evidence on the prevalence of bp nondipping in african american and low ses adults taken together the current study replicates the extant findings in the literature regarding the independent association between ses and bp dipping and demonstrates that the association between race and nightday bp ratio in adolescents cannot be explained by racial disparities in family income the second aim of this study was to examine whether negative emotions and positive resources would be related to bp nondipping and would attenuate the associations of race and ses we hypothesized that adolescents who reported high negative emotions and low positive resources would exhibit higher nightday ratios our results showed that higher scores on the composite measure of negative emotions were associated with sbp nightday ratios on the other hand neither negative emotions nor positive resources explained race and ses effects on bp dipping this relationship between negative emotions and bp dipping is in line with previous findings in adults the finding that negative emotions did not account for demographic differences in bp is also consistent with previous research as only one study found that hostility and anger expression explained racial differences in nocturnal decreases whereas three additional studies did not observe that individual negative emotions explained race differences in bp nondipping we also found that race moderated the association between both negative emotions and positive resources and bp dipping specifically among african americans only higher negative emotion scores were associated with higher sbp and dbp ratios with each component of the negative emotions factor related furthermore low positive resources especially low positive affect and low optimism were associated with higher dbp ratio in contrast negative emotions and positive resources were unrelated to nocturnal decline among caucasian adolescents these findings coincide with findings by shapiro et al and steffen et al observed in african american adults and suggest that african american adolescents may be particularly vulnerable to the effects of high levels of negative emotions and low positive resources the third goal of this study was to evaluate the role of daily interpersonal stress in bp nondipping we found no evidence that level of unpleasant interactions reported over two days via ecological momentary assessment mitigated the effects of either race or ses on nightday ratio however parallel to our findings on the moderating effects of negative emotions and positive resources we did find that more unpleasant interactions were associated with higher sbp ratios among african american adolescents but not among caucasians taken together these findings highlight the significance of negative emotions positive resources and unpleasant interactions for understanding bp nondipping among african american adolescents one plausible explanation of race differences in the influence of these psychosocial variables could be different patterns of cardiovascular reactivity among african americans and caucasians with african americans exhibiting more alphaadrenergic response to laboratory stressors and caucasians more betaadrenergic reactivity greater vascular reactivity may accelerate stiffening of the vasculature leading to eventual hypertension in contrast to betaadrenergic reactivity that may have more direct effects on atherosclerosis indeed in a different sample of adolescents than the present among african americans increasing negative mood states predicted greater increases in ambulatory heart rate and dbp measured across two school relatedly african americans greater sensitivity to the effects of psychosocial factors on nocturnal bp decline could reflect diathesis stress processes such that physiological vulnerabilities conferred by race and exposure to negative psychosocial factors interact to place african americans on trajectories for disruptions in circadian bp regulation and later hypertension there are several strengths of this study including the examination of bp dipping in an adolescent sample with representation of african american and caucasian participants which permitted the examination of race differences additionally we assessed bp over two nights which increased the reliability of our nondipping measure compared to most studies that have examined dipping over a single 24h period and we utilized selfreported sleep and wake times confirmed by objective actigraphy data rather than imposing arbitrary night and day periods finally we considered positive as well as negative psychosocial factors in our explorations of potential pathways leading to bp nondipping notwithstanding the aforementioned strengths the findings should be interpreted in light of several limitations first our study did not have a broad range of ses as participants were from families of a low to middle class background from a single urban high school thus the restricted family income and homogenous sample limit the generalizablity of our findings the excellent health of the adolescent sample also limited the range of ambulatory bp finally the crosssectional design of the study does not permit inferences about causality in summary our findings suggest both african american and lower ses adolescents may be at risk for elevated nightday bp ratios further african american adolescents who report greater negative emotions lower positive resources and more unpleasant social interactions may be particularly vulnerable to having elevated nightday bp ratios given that the sample consisted of healthy normotensive adolescents it is striking that elevated nightday bp ratios were associated with race ses and negative emotions should these associations persist into adulthood such adolescents may be at high risk for later hypertension and its complications interventions focused on enhancing the psychological resources of african american adolescents may reduce their risk for later hypertension sbp nightday ratios according to family income scores sbp nightday ratios according to negative emotion scores dbp nightday ratios according to positive resources scores sbp nightday ratios according to unpleasant interactions scores averaged across days correlations among ses psychosocial variables and bp ratios standardized betas from linear regression models regressing nightday sbp and dbp ratios on race and income with adjustment for covariates step 2 unpleasant interactions 007 028 010 001 117 010 014 008 001 215 step 3 race x unpleasant interactions 013 004 012 002 413 002 075 008 000 009 notes bmi body mass index sbpsystolic blood pressure dbpdiastolic blood pressure ratio step 2 includes the basic model illustrated in table 3 and negative emotions positive resources and pleasant interaction analyzed separately step 3 includes the basic model illustrated in table 3 and the interaction of race and negative emotions positive resources and unpleasant interactions analyzed separately r 2 refers to the total variance accounted for at step whereas δr 2 refers to the additional variance accounted for by the step ann behav med author manuscript available in pmc 2014 october 01

backgroundelevated nighttime blood pressure bp predicts hypertension and its complications in adulthood purposeto assess the independent effects of race and family income on nightday bp among adolescents and to examine whether negative emotions low positive resources and unpleasant interactions during the day are also relatedafrican american and caucasian high school students n239 wore an ambulatory bp monitor for 48 hours recorded quality of ongoing interpersonal interactions and completed questionnaires resultsafrican americans and those with lower family income had higher nightday bp ratios african americans reporting greater negative emotions lower positive resources and more unpleasant interactions had higher nightday bp ratios conclusionsracial differences in night bp emerge by adolescence independent of family income african americans especially those high in negative emotions and low in positive resources may be at higher relative risk for hypertension later in life in part due to elevated night bp

INTRODUCTION African Americans or Black Americans are defined by the U.S. Census Bureau as having origins from any of the Black racial groups in Africa . This includes those who only identify as Black, those who identify as Black and one or more races, and those who identify as Black and have a Hispanic/Latino ethnicity . Black Americans currently make up 13.6% of the total US population and Black women make up 12.9% of the total population of women in the U.S. . Black Americans are a diverse group and mostly consists of the descendants of enslaved Africans who were forcibly brought to the Caribbeans and Americas as early as the 16 th century. Due to the numerous and traumatic atrocities committed against Black Americans during and after slavery, 21 st century American Black women are still struggling with the need for protection against violent crimes of rape and sexual assault with many not reporting and continuing to suffer in silence as their enslaved ancestors did over 400 years ago. According to the U.S. Department of Justice as cited in The National Center on Violence Against Women in the Black Community , 1 in 5 Black women are rape --- HISTORICAL EXAMPLES --- Harriet Jacobs Harriett Jacobs was a woman born into slavery in North Carolina who endured repeated sexual assaults from her master beginning at the age of 12. After years of abuse and the threat of her children being sold, she ran away and hid in a small crawlspace at her grandmother's house for 7 years. She was finally able to escape to New York and was eventually reunited with her children. Jacobs published her autobiography, Incidents in the Life of a Slave Girl, in 1861 under the pseudonym Linda Brent detailing the events of her life including the years of sexual abuse: He was too scrupulous to sell me; but he had no scruples whatever about committing a much greater wrong against the helpless young girl placed under his guardianship, as his daughter's property. Sometimes my persecutor would ask me whether I would like to be sold. I told him I would rather be sold to anybody than to lead such a life as I did. . --- Celia Celia was an enslaved woman in Missouri who suffered repeated sexual assaults from her master over the course of 5 years which began when she was aged 14. While suffering from a difficult third pregnancy, she asked him to leave her alone. He refused and Celia killed him in an act of self-defense. After being threatened with her children being taken away she confessed to his murder and she was incarcerated, convicted, and eventually executed by hanging on December 21, 1855. Below is an excerpt from Enslaved Peoples of the Historical Slave Trade briefly summarizing her story: Celia became the cook and only female slave in the Newsom household in neighboring Calloway County. At some point on the return journey from Audrain County, seventy-year-old Newsom raped 14-year-old Celia. It immediately became apparent to Celia, however, that Robert Newsom had purchased her primarily to serve as his concubine…Court records show that over the next four years the rapes continued, and that Newsom repeatedly forced Celia to have sex with him against her will…In spite of Jameson's efforts, trial judge William Hall advised the all-White jury that they could not acquit Celia on the grounds of self-defense, and all but instructed them to find her guilty of murder in the first degree…Pregnant, ill, and having suffered from Newsom's abuse for more than five years, something inside her had simply snapped...Her case, according to the legal historian and federal Source: The National Center on Violence Against Women in the Black Community, . Black Women and Sexual Assault. Retrieved from: judge, A. Leon Higginbotham, was even more "venal and racist" than the more famous Missouri slave case, Dred Scott v. Sanford . Unlike Scott, who was ultimately freed and who died of natural causes, Higginbotham argues, Celia was executed because the Missouri courts held that "a slave woman had no virtue that the law would protect against a master's lust" (Higginbotham, 1989 p. 694 as cited in Jones & Niven,[2][3][4][5][6][7][8][9][10][11][12][13]. --- The Sexual Abuse Continues After slavery ended, during the reconstruction period, Black women continued to remain victims of sexual assault and rape at the hands of White vigilante groups such as the Ku Klux Klan who engaged in gang rape tactics of Black women . Black women were still subjected to rape at the hands of White men during the Jim Crow era to invoke fear and complacency in the Black community . Today, decades later, 1 in 4 Black girls will experience some form of sexual abuse before they reach adulthood, age 18 . Additionally, 22% of black women will experience rape in their lifetimes when compared to 18.8% of white women . Many of these victimized women do not seek medical or mental health services relating to their sexual assaults. This is due to several reasons that are unique to Black women including social stigmas and norms, financial barriers, and the need to protect Black men. Slaton & Richard provide strong evidence explaining the vulnerability of Black women as sexual victims due to their marginalized status, which makes them unwilling to disclose sexual victimization. If reported they are less likely to be believed by authority figures, and if believed, their access to community resources is limited. The need to protect Black men is a major concern in the Black community due to the continued brutality and lethal force imposed on Black males by law enforcement officers in Black communities. Thus, the accusation of rape would provide further enticement by officers to continue their rampage against them. The shift from stranger rape to acquaintance sexual victimization created a traumatic psychological impact not only on the victim, but also on the Black community which has historically had to "protect" itself from "outsiders" who could cause harm. Williams provides clinical research to support the need by Black women to protect Black men and the psychological impact of the non-disclosure due to communal protectiveness of Black males so that another Black male is not arrested and placed in prison. Zounlome et al. utilized an intersectional phenomenological approach to examine cultural barriers and their perceptions about sexual violence. They concluded that although there is information in the literature providing discussions related to sexual violence, they suggest that there is a lack of diversity in the research samples that can provide generalizability. For example, they question the perceptions of college Black women on the issue of Black sexual victimization. Their research concluded similar findings that Black college women's perceptions were like larger Black community with silence and the need the need to protect the Black male, historical racialized trauma against Black women, stereotypes about Black women and their sexuality, and continued racial injustices in American society. They concluded with the need for college campuses to provide prevention initiatives for Black women to enable them to discuss sexual victimization in a non-judgmental and safe environment. Kelley suggests that although there is research in the literature regarding Black women and sexual violence, there is limited information with discussions about their actual experiences. She notes that importance of understanding the historical and cultural context because these features shed light on why there is a tendency for them to remain silent about sexual violence when they become victims. From a Black feminist perspective, Kelley's research findings revealed that when Black women sought medical assistance resulting from sexual victimization, they considered the culturally specific and legal sanction aspects when filing police rape reports. She concluded that although these women in her study did seek medical treatment, they were reluctant to involve the police. Campbell et al. proposes that help seeking by sexual violence victims has been to seek medical treatment however, classical research promotes the thinking that intragroup allegiance may cause barriers for pursuing the issue further beyond medical treatment because the experiences of Black women are different . Kelley strongly advocates for more research on help seeking providers working with sexual violence victims as her findings occurred during the COVID-19 pandemic where many of the Black women sought medical treatment over silence. However, Kelley also suggests that her sample was drawn only from the victims who sought medical treatment. Ullman and Lorenz conducted a mixed methods study to explore the mental health care helpseeking behaviors and experiences of Black women who had been sexually assaulted. The quantitative sample consisted of 836 African American women from the Chicago metropolitan area, with 4.8% also identifying as Hispanic, who had an unwanted sexual experience when they 14 years of age or older. The qualitative sample consisted of African American women, with 19% also identifying as Hispanic, who were survivors of various forms of sexual assault including childhood sexual abuse, sexual coercion, and romantic acquaintances. The measures included interviews which were coded into positive, negative, or mixed. Interview transcripts were later summarized and analyzed to identify patterns and themes and the qualitative data revealed barriers to mental health care. These barriers included financial, social stigma, and the lack of more Black providers. Their findings concluded that although Black women have a higher risk for sexual assault than other racial/ethnic women, Black women are more reluctant to use mental health or medical services due to certain factors that are related to the chances that survivors will or will not seek mental health care in relation to their sexual assault. These intersectional factors are discrimination, gender issues, racism, and class . Although there is information in the literature on sexual assault victims however, the literature is limited with information regarding connecting factors that may cause Black women to remain silent and to not seek professional services. There are major gaps in the literature on the Black women's intersectional experiences related to sexual assaults and help seeking providers . Most of the studies provide a comparative analysis of experiences based on different racial and ethnic groups , but fail to consider intersectional factors. Only a few studies considered whether Black survivors of sexual assault sought or received professional follow up from medical and or mental health professionals . Although there is a focus on barriers that Black women face when they are victims of sexual abuse, there is limited information on strategies that can be utilized for help seeking providers working with Black victims of sexual violence. The challenges must not only be addressed, but there must be dialogue, support systems, and safe environments for the victims so that they can receive appropriate interventions. This can occur with providing effective intervention strategies to help seeking providers who may experience helplessness when working with this population. --- Application of a Theory of Human Behavior African American women have a unique history that has been passed on by generation after generation formulating major themes that are perpetuated in each generation as delineated by Slatton & Richard : 1) the social construct that Black women are strong, 2) sanctioning of intra-racial sexual assault disclosure, and 3) delegitimization of Black women as rape victims. Bandura's social learning theory is applicable when exploring this topic focused on Black women and sexual assault. Social learning theory is the belief that social behavior is learned by observing and imitating the social interactions and behaviors from the people around us and our environments. This learning can occur both directly and indirectly. "More specifically, behavior is assumed to be developed and regulated by external stimulus events, such as the influence of other individuals, and by external reinforcement, such as praise, blame, and reward" . Bandura stated that there is a shift in behavior from inner determinates to detailed external influences by individuals and or the environment. These external influences can cause responsiveness by individuals in terms of stimulus events which can cause reinforced consequences. Black women learn how and how not to react to sexual assault by listening to others in their communities and the media as Black women have historically been depicted as promiscuous and hyper sexualized . They also learn by watching how other women within the family who have been sexually assaulted are treated and how they function. Through their oral historical depictures of their rape victimizations to grandchildren and children, the knowledge is passed on intergenerationally. Environmental reinforcements are significant features in learning behaviors. One thing that is reinforced in the Black community is the notion of the strong Black woman. Many Black women are socialized to believe that they should remain strong no matter the circumstances. Washington states, "the pressure to uphold the trope of the Strong Black Woman puts us in the impossible position of having to keep going, even when we are burned out and have nothing left to give to the world or ourselves." This is often exhibited in matriarchal Black households where there is a disproportionate number of female headed households, with 64% of Black children being raised in single-parent households, primarily headed by women . Black women often see their mothers, grandmothers, aunts, and other women around them having to do everything, often with little to no help. Collins describes "a series of women-centered networks, including grandmothers, siblings, other relatives, neighbors, and even strangers, all of whom became what she calls the 'other mothers' assisting the blood mothers" . Another thing that is learned is "what happens in this house, stays in this house." This is something that is said in many Black households, and it is told to children, so they do not speak about family business outside of the home . This applies to sexual abuse as the survivor may be afraid to break this cultural norm to seek the help they need because Black women have been socialized to embrace Black values . Black women are also often taught to "protect Black men" due to the dehumanization of and historical violence perpetuated against Black males as well as the ongoing societal perceptions of Black males being aggressive and dangerous. Due to this thinking, Black boys as young as 10 are more likely to be considered older and less innocent than their White counterparts which then leads to perceptions of guilt and increased violence against them by police when accused of a crime . While Black men are not inherently violent and aggressive, according to the Blackburn Center , a national study reported 91% of Black women are sexually assaulted by Black men and 75% of those attacks are perpetrated by someone the survivor knows. Social learning theory also suggests that Black women and girls may be faced with pressure from others in the Black community not to report sexual violence as it would be seen as a betrayal. Not only does stigma from the Black community pressure Black women into not reporting, it also can lead to them not seeking mental health treatment. Washington states: In my life, upholding the Strong Black Woman stereotype has only deterred me from getting the help I needed. At one point -when I was on the brink of homelessness in January -I refused to take any time off of work because I didn't want to let my team down. I convinced myself that I needed to be "strong" and figure a way out of the situation by myself. Refusing to acknowledge how I was feeling only left me drained. Failure to disclose sexual assault or rape is due to a number of reasons including the expectation to uphold the image of the strong Black woman, stigma and fear of judgement, not believing in the effectiveness of mental health treatments , the small percentage of Black therapists, and due to a general distrust of the medical system because of past indiscretions such as the Tuskegee Experiment and Henrietta Lacks. Historically, there is a distrust in the Black community based on experiments used in scientific research without their consent. Specifically, the Tuskegee experiment conducted between 1932 ending in 1972 by the government using 600 Black men and injecting them with the syphilis virus and providing no cure for their treatment. In 1972 after public outcry the experiment was discontinued, and President Clinton issued a public apology from the nation. Similarly, Henrietta Lacks' cells were sent to John Hopkins and used experimentally, without her or her family's consent, to diagnose cervical cancer cells in humans . As a result of racialized trauma many Black women believe that prayer, the use of family members, and friends are major protective factors when dealing with mental health issues, and their belief in mental health treatment was low . Improving factors such as increased culturally competent mental health practitioners would likely increase the number of victims of sexual violence who are willing to break the chain of silence about sexual violence. However, there is an increase in need for mental health workers, and a decrease in mental health workers in the workforce with even less minority mental health workers. The Bureau of Labor Statistics suggest that 74.2% of mental health professionals are White, followed by Black or African American 7.9%, Hispanic or Latino and Unknown 6.2% . --- Risk Factors Social workers may view a strengths perspective as a very significant aspect of the clinical counseling process. However, it can be a risk factor to Black women who are victims of sexual assault. For example, the strong Black woman analogy can deter a victim from seeking professional help. Being taught to internalize the "strong enough" to cope persona enforces the need to remain silent about a sexual assault. Not only can some values present strong risk factors, but stereotypes also create barriers to obtaining professional services for Black victims of sexual assault. Wilson provides a historical background on these stereotypes stating: that Black women are perceived as lustful and promiscuous beings while White women are portrayed as models of self-respect and sexual purity . With a higher risk of sexual assault than their White counterparts , the Black female is also a victim of stereotypical nuances such as hypersexual and promiscuous and therefore, "deserving" to experience sexual attacks. This thinking that the Black victim "deserved it" and was not raped provides policy and decision makers with the suggestion that the Black female is not a rape victim and "unrapeable" because she deserved it. Beck states, "It wasn't until the Civil War when black women were actually able to come forward and call it rape. Before that time, even in the North, they would make it a lesser charge [for black women], if at all." Another risk factor is the years of oppression that Black women have faced for generations based on race as well as the health risks as sexual assault can cause physical and emotional health consequences including increased risks of depression, drug misuse, PTSD after sexual assault. Wilson concluded that Black women internalize external perspectives and view themselves as objectified individuals which results in producing mental health issues . These feelings can cause them to feel less competent, and obtaining feelings that they are responsible and deserving to be raped .There can be social drawbacks to sexual assault including name calling, isolation, and the need to constantly explain behavior. In addition to that, black women are exposed to discrimination and researchers whose focus is less about well-being and more about comparative analyses, which furthers the limited disclosure information from a victim. Thus, limiting or nullifying the professional counseling or medical services. Another relevant risk factor among Black women is impoverished conditions where they are more likely to live in poverty-stricken areas below the poverty level . West & Johnson suggest that these women struggle daily to provide the basic necessities for their children while living in areas where they may witness and also may become as a victim of sexual assault. According to Darkness to Light , a non-profit focused on child sexual abuse prevention, children in low socioeconomic households are three times as likely to be the victim of child sexual abuse and children who witness and/or are the victim of another crime are also significantly more likely to be sexually abused as well. In 2021, 30% of Black families led by single mothers were living in poverty . "Children who live with a single parent that has a live-in partner are at the highest risk of sexual abuse: they are 20 times more likely to be victims of sexual abuse than children living with both biological parents" . Holmes also adds that the risk for abuse in single parent homes was higher in the lower income groups than it was in the higher income groups and that there is an increased likelihood of predators having easier access to emotionally needy children due to the type of facilities available in these areas. Black college women are viewed as the protective factor in the black family , however, this protective factor can also become a hazardous risk factor on the college/university campus because many may "go Greek" and join a sororities they are prime victims of sexual harassment and assaults at fraternity parties and other events. Certainly, nondisclosure or delayed disclosure about sexual assault at Greek events can cause increased stress, insecurity, and in some instances dropping out of higher education. --- Culturally Sensitive Response -Effective Interventions When considering effective interventions for this population, it is significant that consideration is given to the characteristics of the survivors who are victims of rape and sexual assault. Ullman & Lorenz suggest that factors such as age, socioeconomic status, education, knowledge of the perpetrator, and support systems are essential entities that must be factored into the treatment planning process. However, even when focusing on these traits, Black rape survivors are still left with enormous mental health issues such as depression, substance abuse/misuse, alcoholism, PTSD , limited support, and suicide ideation. Although survivors are termed "survivors" because they were not murdered in the process of the rape or sexual assault, however, the quality of their survival, in many instances, is poor because many continue to suffer in silence. Kelley provides research considering the impact of COVID-19 pandemic and the increased cases of sexual assault cases. An increase in meeting perpetrators online during lockdown . Evidence also suggests that sexual violence increased during the lockdown period reporting 40% increase in rape crisis centers, with concern from the National Sexual Violence Resource Center that this increased trend will continue as over 30 million Americans are now out of work . Police organizations report that only 23% of sexual assaults were reported. The criticism was that lockdowns were hurriedly implemented to contain the virus, but there was not thought given to resources for victims of sexual violence. Therefore, their situation was unthinkable because there was no escape for them. Black women due to sociohistorical and cultural aspects along with multiple barriers face unique factors as victims of sexual assault. Thus, interventions must be effective strategies that will acknowledge these aspects and utilize them to empower and enhance daily functioning. Eliminate the pathological thought that Black women must be strong and endure the aftermath of sexual assault . Black women survivors of rape/sexual assault seek professional help at lower rates than other racial/ethnic group survivors . This can be attributed to many sociohistorical aspects such as the lack of trust of systemic mental health programs. Although, mental health programs are designed to focus on issues that survivors endure, the major issues are whether mental health workers have been properly prepared to work with these survivors and are social work programs preparing future mental health workers with an understanding of sociohistorical aspects that may impact these women as they move toward accomplishing successful treatment outcomes? The literature places the blame for Black women's continued silence on them with study after study suggesting that more of these survivors should seek mental health services. What should occur to accomplish this? There is a need to advocate for the inclusion of specific information into clinical practice curriculum about sexual assault. --- Council on Social Work Education has Figure 2: mandated that all accredited social work programs include information on specific topics . Certainly, the number of sexual assault survivors would be a strong indicator of the need to mandate that social work classes include classroom discussions about this underserved and understudied marginalized population of victims of sexual violence. However, academicians and practitioners do not have to wait for a CSWE imposed mandate. The development and design of classroom curricula can begin with the inclusion of class discussions and specific assignments to focus on sexual assault. Clinical practitioners can begin to work closely with perpetrators of sexual assault to not only discover and allow them to express their thoughts, but this would also provide a mechanism for developing more effective programs to address the needs of the survivors as well as the perpetrators who are also in need of counseling. Too often programs are designed by individuals to simply obtain data, and the data is seldom used. This strategy will allow input from the perpetrators and the survivors as well. This beginning strategy will not only remove the blame from the survivors but would stimulate mental health workers to begin to actively include sexual assault and rape into class discussions utilizing case vignettes, YouTube videos, guest speakers, Kahoot, and community projects. Each intervention level must consider the need to conceptualize the interventions with the understanding that these women have experienced not only sexual assault but many prejudicial complexities in their lives. --- Implications for Social Work Practice Davis called for action to focus on black women and sexual assault, over thirty-four years ago, identifying it as one of the "fastest growing violent crimes" in America and identifying it as an epidemic as she focused on the need to not only change laws but to understand that rape provided the essential ingredient to terrorize and exploit Black women. Crenshaw expanded on Davis' thinking with expressing the need for practitioners to shift their thinking to become more cognizant of the overlapping factors of features such as racism, gender, and values that should be considered when working with Black women survivors of sexual assault. Social work practitioners are given the ethical responsibility to work with marginalized populations. This responsibility entails the need to function from many practice levels . Clinical practitioners must engage directly with survivors in counseling . At this level of practice, the practitioner must demonstrate an awareness of sociohistorical aspects that impact the lives of Black rape survivors. This display of competence can ease the stress from the client who may be reluctant to enter the therapeutic process for fear that the "therapist does not understand." This feature at the micro level of practice is significant especially in instances where the therapist may not be Black. There are limited Black clinical practitioners in America, and thus it is important to the Black client survivor that the therapist understands the numerous barriers that Black women must endure. At the macro level of practice impacting policy and policy changes and communities. Black rape survivors who have been and continue to be unlikely to utilize mental health services may turn to the Black church as a means of support because the Black church has historically been the primary means of comfort and societal change in the Black community. African American Christianity is losing relevance among younger millennials and Gen-Zers, however, Black churches continue to have influence . What has occurred is that the Black church has become intertwined with political tenets and no longer provides the "street talk" for the community . Thus, the church, although still very essential, but less visible in social action to the community at large. This shift in proactivity by the Black church may cause many survivors to continue their silence because the pastor may not view rape and sexual assault as an "appropriate" church topic . Thus, clinical practitioners may not be able to utilize the Black church as a resource for assisting these Black women who are rape survivors because the Black church may also introduce harmful interventions such as couples counseling when the Black women may be continuously raped by the significant other or spouse. Williams & Jenkins suggest that Black churches are mixed in their views on Black women and their battered environments. They reported that few faith-based communities received domestic violence training and some views that battered women programs are anti male and keep couples apart. They note that Black women in particular use the church as a coping mechanism. But, when the church blames the victim, some victims may continue to seek pastoral counseling, but others will not and will continue in silence, leaving the practitioner with the task of advocacy for more community resources for support of these victims. It thus becomes necessary to ensure that social work practitioners are trained to work competently in the area of sexual assault, especially in the Black community. Church leaders have indicated that they are concerned about Black women and victimization, but they acknowledge that they have not been trained to sufficiently assist their congregation in this area . Social work practitioners can begin to interact with faith-based community entities to not only sensitize them about the victims, but also provide training that the ministers and church deacons can utilize within their congregations and communities. Social workers must continue or must become strong advocates for not only the increased awareness about sexual assault but also become active shareholders in the decision-making process. This can occur with continued meetings with policy and decision makers and lobbyists. American Medical Association has one of the strongest lobbying units on Capitol Hill. Social workers must establish a partnership with AMA or begin to become more involved with political entities when decisions are made about marginalized populations. This can begin on the local level with interactions with local political leaders to obtain their views. --- CONCLUSION Black women and girls continue to remain victims of sexual violence due to systemic institutionalized racial and gender based social norms and laws. They face sexual abuse at an alarmingly high rate, but the rate of reporting and seeking help is low due to a number of oppressive barriers. These barriers include social stigmas and pressure related to racial and gender discrimination, financial, and the need to protect Black men. Bandura's social learning theory could help explain the fear and it can be utilized in future research to identify ways to combat the negative learned behaviors that are still being reinforced and passed down in the Black community. More research is strongly encouraged to consider the unique aspects of Black women survivors of sexual assault. Social workers are encouraged to engage in more micro and macro level prevention and intervention strategies with Black women rape survivors. Advocacy should be extended to more research, both quantitative and qualitative, on what resources can be provided for these victims, the mechanisms that can be used to break their silence, and utilization of an intersectional approach that includes factors unique to Black women. As the church will continue to be the "backbone" of the African American community, there is also the call to action for church leaders to become proactive providers of equal protection for Black women who are victims of rape violence.

Black women in America have historically been victims of oppression, racism, and sexual assault. This victimization can be traced as far back as the forced immigration to America in Jamestown, Virginia in 1619. Forced travel bondage on slave ships highlights the institutionalized pattern, not only of their suffering from repeated rape, but also logs their victimized sufferings in silence that they had to endure then and continue to endure in 21 st century contemporary America. Black women have been socialized intergenerationally to respond in a specific manner similar to the female slaves who endured rape from ship crew members during their long voyage to the Americas. Even after slavery was legally abolished in 1865, Black women continued to endure victimizations not only due to their gender, but also due to discrimination, classism, perceptions regarding their sexuality, racism, and fear. These intersectional factors cause Black women to have become unique experiences at the hands of rapists. Thus, Black women have unique experiences as victims of rape than other individuals who are also rape victims. Any discussion of Black women and rape must be placed in a sociohistorical framework. The purpose of this article is to revisit historical underpinnings about the rape of Black women in a socialized manner that continues to hinder a silent, nonactive role, and in some instances denial of being a victim of rape. The aim is to sensitize, stimulate, and motivate action by increasing social work classroom discussions about the topic, increasing research in the area of rape of Black women utilizing an intersectional approach reviewing factors that are unique to Black women, and providing more information as a resource to enhance community awareness. Effective intervention strategies are also delineated.

introduction african americans or black americans are defined by the us census bureau as having origins from any of the black racial groups in africa this includes those who only identify as black those who identify as black and one or more races and those who identify as black and have a hispaniclatino ethnicity black americans currently make up 136 of the total us population and black women make up 129 of the total population of women in the us black americans are a diverse group and mostly consists of the descendants of enslaved africans who were forcibly brought to the caribbeans and americas as early as the 16 th century due to the numerous and traumatic atrocities committed against black americans during and after slavery 21 st century american black women are still struggling with the need for protection against violent crimes of rape and sexual assault with many not reporting and continuing to suffer in silence as their enslaved ancestors did over 400 years ago according to the us department of justice as cited in the national center on violence against women in the black community 1 in 5 black women are rape historical examples harriet jacobs harriett jacobs was a woman born into slavery in north carolina who endured repeated sexual assaults from her master beginning at the age of 12 after years of abuse and the threat of her children being sold she ran away and hid in a small crawlspace at her grandmothers house for 7 years she was finally able to escape to new york and was eventually reunited with her children jacobs published her autobiography incidents in the life of a slave girl in 1861 under the pseudonym linda brent detailing the events of her life including the years of sexual abuse he was too scrupulous to sell me but he had no scruples whatever about committing a much greater wrong against the helpless young girl placed under his guardianship as his daughters property sometimes my persecutor would ask me whether i would like to be sold i told him i would rather be sold to anybody than to lead such a life as i did celia celia was an enslaved woman in missouri who suffered repeated sexual assaults from her master over the course of 5 years which began when she was aged 14 while suffering from a difficult third pregnancy she asked him to leave her alone he refused and celia killed him in an act of selfdefense after being threatened with her children being taken away she confessed to his murder and she was incarcerated convicted and eventually executed by hanging on december 21 1855 below is an excerpt from enslaved peoples of the historical slave trade briefly summarizing her story celia became the cook and only female slave in the newsom household in neighboring calloway county at some point on the return journey from audrain county seventyyearold newsom raped 14yearold celia it immediately became apparent to celia however that robert newsom had purchased her primarily to serve as his concubine…court records show that over the next four years the rapes continued and that newsom repeatedly forced celia to have sex with him against her will…in spite of jamesons efforts trial judge william hall advised the allwhite jury that they could not acquit celia on the grounds of selfdefense and all but instructed them to find her guilty of murder in the first degree…pregnant ill and having suffered from newsoms abuse for more than five years something inside her had simply snappedher case according to the legal historian and federal source the national center on violence against women in the black community black women and sexual assault retrieved from judge a leon higginbotham was even more venal and racist than the more famous missouri slave case dred scott v sanford unlike scott who was ultimately freed and who died of natural causes higginbotham argues celia was executed because the missouri courts held that a slave woman had no virtue that the law would protect against a masters lust higginbotham 1989 p 694 as cited in jones niven 2 3 4 5 6 7 8 9 10 11 12 13 the sexual abuse continues after slavery ended during the reconstruction period black women continued to remain victims of sexual assault and rape at the hands of white vigilante groups such as the ku klux klan who engaged in gang rape tactics of black women black women were still subjected to rape at the hands of white men during the jim crow era to invoke fear and complacency in the black community today decades later 1 in 4 black girls will experience some form of sexual abuse before they reach adulthood age 18 additionally 22 of black women will experience rape in their lifetimes when compared to 188 of white women many of these victimized women do not seek medical or mental health services relating to their sexual assaults this is due to several reasons that are unique to black women including social stigmas and norms financial barriers and the need to protect black men slaton richard provide strong evidence explaining the vulnerability of black women as sexual victims due to their marginalized status which makes them unwilling to disclose sexual victimization if reported they are less likely to be believed by authority figures and if believed their access to community resources is limited the need to protect black men is a major concern in the black community due to the continued brutality and lethal force imposed on black males by law enforcement officers in black communities thus the accusation of rape would provide further enticement by officers to continue their rampage against them the shift from stranger rape to acquaintance sexual victimization created a traumatic psychological impact not only on the victim but also on the black community which has historically had to protect itself from outsiders who could cause harm williams provides clinical research to support the need by black women to protect black men and the psychological impact of the nondisclosure due to communal protectiveness of black males so that another black male is not arrested and placed in prison zounlome et al utilized an intersectional phenomenological approach to examine cultural barriers and their perceptions about sexual violence they concluded that although there is information in the literature providing discussions related to sexual violence they suggest that there is a lack of diversity in the research samples that can provide generalizability for example they question the perceptions of college black women on the issue of black sexual victimization their research concluded similar findings that black college womens perceptions were like larger black community with silence and the need the need to protect the black male historical racialized trauma against black women stereotypes about black women and their sexuality and continued racial injustices in american society they concluded with the need for college campuses to provide prevention initiatives for black women to enable them to discuss sexual victimization in a nonjudgmental and safe environment kelley suggests that although there is research in the literature regarding black women and sexual violence there is limited information with discussions about their actual experiences she notes that importance of understanding the historical and cultural context because these features shed light on why there is a tendency for them to remain silent about sexual violence when they become victims from a black feminist perspective kelleys research findings revealed that when black women sought medical assistance resulting from sexual victimization they considered the culturally specific and legal sanction aspects when filing police rape reports she concluded that although these women in her study did seek medical treatment they were reluctant to involve the police campbell et al proposes that help seeking by sexual violence victims has been to seek medical treatment however classical research promotes the thinking that intragroup allegiance may cause barriers for pursuing the issue further beyond medical treatment because the experiences of black women are different kelley strongly advocates for more research on help seeking providers working with sexual violence victims as her findings occurred during the covid19 pandemic where many of the black women sought medical treatment over silence however kelley also suggests that her sample was drawn only from the victims who sought medical treatment ullman and lorenz conducted a mixed methods study to explore the mental health care helpseeking behaviors and experiences of black women who had been sexually assaulted the quantitative sample consisted of 836 african american women from the chicago metropolitan area with 48 also identifying as hispanic who had an unwanted sexual experience when they 14 years of age or older the qualitative sample consisted of african american women with 19 also identifying as hispanic who were survivors of various forms of sexual assault including childhood sexual abuse sexual coercion and romantic acquaintances the measures included interviews which were coded into positive negative or mixed interview transcripts were later summarized and analyzed to identify patterns and themes and the qualitative data revealed barriers to mental health care these barriers included financial social stigma and the lack of more black providers their findings concluded that although black women have a higher risk for sexual assault than other racialethnic women black women are more reluctant to use mental health or medical services due to certain factors that are related to the chances that survivors will or will not seek mental health care in relation to their sexual assault these intersectional factors are discrimination gender issues racism and class although there is information in the literature on sexual assault victims however the literature is limited with information regarding connecting factors that may cause black women to remain silent and to not seek professional services there are major gaps in the literature on the black womens intersectional experiences related to sexual assaults and help seeking providers most of the studies provide a comparative analysis of experiences based on different racial and ethnic groups but fail to consider intersectional factors only a few studies considered whether black survivors of sexual assault sought or received professional follow up from medical and or mental health professionals although there is a focus on barriers that black women face when they are victims of sexual abuse there is limited information on strategies that can be utilized for help seeking providers working with black victims of sexual violence the challenges must not only be addressed but there must be dialogue support systems and safe environments for the victims so that they can receive appropriate interventions this can occur with providing effective intervention strategies to help seeking providers who may experience helplessness when working with this population application of a theory of human behavior african american women have a unique history that has been passed on by generation after generation formulating major themes that are perpetuated in each generation as delineated by slatton richard 1 the social construct that black women are strong 2 sanctioning of intraracial sexual assault disclosure and 3 delegitimization of black women as rape victims banduras social learning theory is applicable when exploring this topic focused on black women and sexual assault social learning theory is the belief that social behavior is learned by observing and imitating the social interactions and behaviors from the people around us and our environments this learning can occur both directly and indirectly more specifically behavior is assumed to be developed and regulated by external stimulus events such as the influence of other individuals and by external reinforcement such as praise blame and reward bandura stated that there is a shift in behavior from inner determinates to detailed external influences by individuals and or the environment these external influences can cause responsiveness by individuals in terms of stimulus events which can cause reinforced consequences black women learn how and how not to react to sexual assault by listening to others in their communities and the media as black women have historically been depicted as promiscuous and hyper sexualized they also learn by watching how other women within the family who have been sexually assaulted are treated and how they function through their oral historical depictures of their rape victimizations to grandchildren and children the knowledge is passed on intergenerationally environmental reinforcements are significant features in learning behaviors one thing that is reinforced in the black community is the notion of the strong black woman many black women are socialized to believe that they should remain strong no matter the circumstances washington states the pressure to uphold the trope of the strong black woman puts us in the impossible position of having to keep going even when we are burned out and have nothing left to give to the world or ourselves this is often exhibited in matriarchal black households where there is a disproportionate number of female headed households with 64 of black children being raised in singleparent households primarily headed by women black women often see their mothers grandmothers aunts and other women around them having to do everything often with little to no help collins describes a series of womencentered networks including grandmothers siblings other relatives neighbors and even strangers all of whom became what she calls the other mothers assisting the blood mothers another thing that is learned is what happens in this house stays in this house this is something that is said in many black households and it is told to children so they do not speak about family business outside of the home this applies to sexual abuse as the survivor may be afraid to break this cultural norm to seek the help they need because black women have been socialized to embrace black values black women are also often taught to protect black men due to the dehumanization of and historical violence perpetuated against black males as well as the ongoing societal perceptions of black males being aggressive and dangerous due to this thinking black boys as young as 10 are more likely to be considered older and less innocent than their white counterparts which then leads to perceptions of guilt and increased violence against them by police when accused of a crime while black men are not inherently violent and aggressive according to the blackburn center a national study reported 91 of black women are sexually assaulted by black men and 75 of those attacks are perpetrated by someone the survivor knows social learning theory also suggests that black women and girls may be faced with pressure from others in the black community not to report sexual violence as it would be seen as a betrayal not only does stigma from the black community pressure black women into not reporting it also can lead to them not seeking mental health treatment washington states in my life upholding the strong black woman stereotype has only deterred me from getting the help i needed at one point when i was on the brink of homelessness in january i refused to take any time off of work because i didnt want to let my team down i convinced myself that i needed to be strong and figure a way out of the situation by myself refusing to acknowledge how i was feeling only left me drained failure to disclose sexual assault or rape is due to a number of reasons including the expectation to uphold the image of the strong black woman stigma and fear of judgement not believing in the effectiveness of mental health treatments the small percentage of black therapists and due to a general distrust of the medical system because of past indiscretions such as the tuskegee experiment and henrietta lacks historically there is a distrust in the black community based on experiments used in scientific research without their consent specifically the tuskegee experiment conducted between 1932 ending in 1972 by the government using 600 black men and injecting them with the syphilis virus and providing no cure for their treatment in 1972 after public outcry the experiment was discontinued and president clinton issued a public apology from the nation similarly henrietta lacks cells were sent to john hopkins and used experimentally without her or her familys consent to diagnose cervical cancer cells in humans as a result of racialized trauma many black women believe that prayer the use of family members and friends are major protective factors when dealing with mental health issues and their belief in mental health treatment was low improving factors such as increased culturally competent mental health practitioners would likely increase the number of victims of sexual violence who are willing to break the chain of silence about sexual violence however there is an increase in need for mental health workers and a decrease in mental health workers in the workforce with even less minority mental health workers the bureau of labor statistics suggest that 742 of mental health professionals are white followed by black or african american 79 hispanic or latino and unknown 62 risk factors social workers may view a strengths perspective as a very significant aspect of the clinical counseling process however it can be a risk factor to black women who are victims of sexual assault for example the strong black woman analogy can deter a victim from seeking professional help being taught to internalize the strong enough to cope persona enforces the need to remain silent about a sexual assault not only can some values present strong risk factors but stereotypes also create barriers to obtaining professional services for black victims of sexual assault wilson provides a historical background on these stereotypes stating that black women are perceived as lustful and promiscuous beings while white women are portrayed as models of selfrespect and sexual purity with a higher risk of sexual assault than their white counterparts the black female is also a victim of stereotypical nuances such as hypersexual and promiscuous and therefore deserving to experience sexual attacks this thinking that the black victim deserved it and was not raped provides policy and decision makers with the suggestion that the black female is not a rape victim and unrapeable because she deserved it beck states it wasnt until the civil war when black women were actually able to come forward and call it rape before that time even in the north they would make it a lesser charge for black women if at all another risk factor is the years of oppression that black women have faced for generations based on race as well as the health risks as sexual assault can cause physical and emotional health consequences including increased risks of depression drug misuse ptsd after sexual assault wilson concluded that black women internalize external perspectives and view themselves as objectified individuals which results in producing mental health issues these feelings can cause them to feel less competent and obtaining feelings that they are responsible and deserving to be raped there can be social drawbacks to sexual assault including name calling isolation and the need to constantly explain behavior in addition to that black women are exposed to discrimination and researchers whose focus is less about wellbeing and more about comparative analyses which furthers the limited disclosure information from a victim thus limiting or nullifying the professional counseling or medical services another relevant risk factor among black women is impoverished conditions where they are more likely to live in povertystricken areas below the poverty level west johnson suggest that these women struggle daily to provide the basic necessities for their children while living in areas where they may witness and also may become as a victim of sexual assault according to darkness to light a nonprofit focused on child sexual abuse prevention children in low socioeconomic households are three times as likely to be the victim of child sexual abuse and children who witness andor are the victim of another crime are also significantly more likely to be sexually abused as well in 2021 30 of black families led by single mothers were living in poverty children who live with a single parent that has a livein partner are at the highest risk of sexual abuse they are 20 times more likely to be victims of sexual abuse than children living with both biological parents holmes also adds that the risk for abuse in single parent homes was higher in the lower income groups than it was in the higher income groups and that there is an increased likelihood of predators having easier access to emotionally needy children due to the type of facilities available in these areas black college women are viewed as the protective factor in the black family however this protective factor can also become a hazardous risk factor on the collegeuniversity campus because many may go greek and join a sororities they are prime victims of sexual harassment and assaults at fraternity parties and other events certainly nondisclosure or delayed disclosure about sexual assault at greek events can cause increased stress insecurity and in some instances dropping out of higher education culturally sensitive response effective interventions when considering effective interventions for this population it is significant that consideration is given to the characteristics of the survivors who are victims of rape and sexual assault ullman lorenz suggest that factors such as age socioeconomic status education knowledge of the perpetrator and support systems are essential entities that must be factored into the treatment planning process however even when focusing on these traits black rape survivors are still left with enormous mental health issues such as depression substance abusemisuse alcoholism ptsd limited support and suicide ideation although survivors are termed survivors because they were not murdered in the process of the rape or sexual assault however the quality of their survival in many instances is poor because many continue to suffer in silence kelley provides research considering the impact of covid19 pandemic and the increased cases of sexual assault cases an increase in meeting perpetrators online during lockdown evidence also suggests that sexual violence increased during the lockdown period reporting 40 increase in rape crisis centers with concern from the national sexual violence resource center that this increased trend will continue as over 30 million americans are now out of work police organizations report that only 23 of sexual assaults were reported the criticism was that lockdowns were hurriedly implemented to contain the virus but there was not thought given to resources for victims of sexual violence therefore their situation was unthinkable because there was no escape for them black women due to sociohistorical and cultural aspects along with multiple barriers face unique factors as victims of sexual assault thus interventions must be effective strategies that will acknowledge these aspects and utilize them to empower and enhance daily functioning eliminate the pathological thought that black women must be strong and endure the aftermath of sexual assault black women survivors of rapesexual assault seek professional help at lower rates than other racialethnic group survivors this can be attributed to many sociohistorical aspects such as the lack of trust of systemic mental health programs although mental health programs are designed to focus on issues that survivors endure the major issues are whether mental health workers have been properly prepared to work with these survivors and are social work programs preparing future mental health workers with an understanding of sociohistorical aspects that may impact these women as they move toward accomplishing successful treatment outcomes the literature places the blame for black womens continued silence on them with study after study suggesting that more of these survivors should seek mental health services what should occur to accomplish this there is a need to advocate for the inclusion of specific information into clinical practice curriculum about sexual assault council on social work education has figure 2 mandated that all accredited social work programs include information on specific topics certainly the number of sexual assault survivors would be a strong indicator of the need to mandate that social work classes include classroom discussions about this underserved and understudied marginalized population of victims of sexual violence however academicians and practitioners do not have to wait for a cswe imposed mandate the development and design of classroom curricula can begin with the inclusion of class discussions and specific assignments to focus on sexual assault clinical practitioners can begin to work closely with perpetrators of sexual assault to not only discover and allow them to express their thoughts but this would also provide a mechanism for developing more effective programs to address the needs of the survivors as well as the perpetrators who are also in need of counseling too often programs are designed by individuals to simply obtain data and the data is seldom used this strategy will allow input from the perpetrators and the survivors as well this beginning strategy will not only remove the blame from the survivors but would stimulate mental health workers to begin to actively include sexual assault and rape into class discussions utilizing case vignettes youtube videos guest speakers kahoot and community projects each intervention level must consider the need to conceptualize the interventions with the understanding that these women have experienced not only sexual assault but many prejudicial complexities in their lives implications for social work practice davis called for action to focus on black women and sexual assault over thirtyfour years ago identifying it as one of the fastest growing violent crimes in america and identifying it as an epidemic as she focused on the need to not only change laws but to understand that rape provided the essential ingredient to terrorize and exploit black women crenshaw expanded on davis thinking with expressing the need for practitioners to shift their thinking to become more cognizant of the overlapping factors of features such as racism gender and values that should be considered when working with black women survivors of sexual assault social work practitioners are given the ethical responsibility to work with marginalized populations this responsibility entails the need to function from many practice levels clinical practitioners must engage directly with survivors in counseling at this level of practice the practitioner must demonstrate an awareness of sociohistorical aspects that impact the lives of black rape survivors this display of competence can ease the stress from the client who may be reluctant to enter the therapeutic process for fear that the therapist does not understand this feature at the micro level of practice is significant especially in instances where the therapist may not be black there are limited black clinical practitioners in america and thus it is important to the black client survivor that the therapist understands the numerous barriers that black women must endure at the macro level of practice impacting policy and policy changes and communities black rape survivors who have been and continue to be unlikely to utilize mental health services may turn to the black church as a means of support because the black church has historically been the primary means of comfort and societal change in the black community african american christianity is losing relevance among younger millennials and genzers however black churches continue to have influence what has occurred is that the black church has become intertwined with political tenets and no longer provides the street talk for the community thus the church although still very essential but less visible in social action to the community at large this shift in proactivity by the black church may cause many survivors to continue their silence because the pastor may not view rape and sexual assault as an appropriate church topic thus clinical practitioners may not be able to utilize the black church as a resource for assisting these black women who are rape survivors because the black church may also introduce harmful interventions such as couples counseling when the black women may be continuously raped by the significant other or spouse williams jenkins suggest that black churches are mixed in their views on black women and their battered environments they reported that few faithbased communities received domestic violence training and some views that battered women programs are anti male and keep couples apart they note that black women in particular use the church as a coping mechanism but when the church blames the victim some victims may continue to seek pastoral counseling but others will not and will continue in silence leaving the practitioner with the task of advocacy for more community resources for support of these victims it thus becomes necessary to ensure that social work practitioners are trained to work competently in the area of sexual assault especially in the black community church leaders have indicated that they are concerned about black women and victimization but they acknowledge that they have not been trained to sufficiently assist their congregation in this area social work practitioners can begin to interact with faithbased community entities to not only sensitize them about the victims but also provide training that the ministers and church deacons can utilize within their congregations and communities social workers must continue or must become strong advocates for not only the increased awareness about sexual assault but also become active shareholders in the decisionmaking process this can occur with continued meetings with policy and decision makers and lobbyists american medical association has one of the strongest lobbying units on capitol hill social workers must establish a partnership with ama or begin to become more involved with political entities when decisions are made about marginalized populations this can begin on the local level with interactions with local political leaders to obtain their views conclusion black women and girls continue to remain victims of sexual violence due to systemic institutionalized racial and gender based social norms and laws they face sexual abuse at an alarmingly high rate but the rate of reporting and seeking help is low due to a number of oppressive barriers these barriers include social stigmas and pressure related to racial and gender discrimination financial and the need to protect black men banduras social learning theory could help explain the fear and it can be utilized in future research to identify ways to combat the negative learned behaviors that are still being reinforced and passed down in the black community more research is strongly encouraged to consider the unique aspects of black women survivors of sexual assault social workers are encouraged to engage in more micro and macro level prevention and intervention strategies with black women rape survivors advocacy should be extended to more research both quantitative and qualitative on what resources can be provided for these victims the mechanisms that can be used to break their silence and utilization of an intersectional approach that includes factors unique to black women as the church will continue to be the backbone of the african american community there is also the call to action for church leaders to become proactive providers of equal protection for black women who are victims of rape violence

black women in america have historically been victims of oppression racism and sexual assault this victimization can be traced as far back as the forced immigration to america in jamestown virginia in 1619 forced travel bondage on slave ships highlights the institutionalized pattern not only of their suffering from repeated rape but also logs their victimized sufferings in silence that they had to endure then and continue to endure in 21 st century contemporary america black women have been socialized intergenerationally to respond in a specific manner similar to the female slaves who endured rape from ship crew members during their long voyage to the americas even after slavery was legally abolished in 1865 black women continued to endure victimizations not only due to their gender but also due to discrimination classism perceptions regarding their sexuality racism and fear these intersectional factors cause black women to have become unique experiences at the hands of rapists thus black women have unique experiences as victims of rape than other individuals who are also rape victims any discussion of black women and rape must be placed in a sociohistorical framework the purpose of this article is to revisit historical underpinnings about the rape of black women in a socialized manner that continues to hinder a silent nonactive role and in some instances denial of being a victim of rape the aim is to sensitize stimulate and motivate action by increasing social work classroom discussions about the topic increasing research in the area of rape of black women utilizing an intersectional approach reviewing factors that are unique to black women and providing more information as a resource to enhance community awareness effective intervention strategies are also delineated

Background Despite efforts of international and national health authorities, immunization coverage and timeliness of vaccination against dangerous childhood diseases have been adversely affected by parental choice to decline childhood vaccination in high-income countries [1][2][3]. This led to large-scale outbreaks of vaccine preventable diseases in Europe and the US such as measles in the Netherlands, Italy, France, Germany, Switzerland and the UK over the last ten years [4]. In Switzerland, after several years with a relatively low annual incidence rate, there have been several waves of large measles epidemics since 2006 [4,5]. As a consequence of these outbreaks and increased population awareness, coverage rate for two MMR doses among 2-year old children has slightly increased since 2005 to 86% [6], which is still considerably below the WHO target of 95% coverage. Moreover, coverage rates vary strongly between language zones and cantons ranging from 50 to 93% [7]. Recent studies argue that in today's industrial countries vaccine refusal rates can only partially be explained by parents' information deficit, lack of access to facts and misinformation [8,9]. Instead recent socialscientific literature has emphasized the importance of identifying broader social, political and conceptual structures that may shape parents' immunization decisions in order to better understand reasons behind parental resistance to immunize their child [10]. Several authors see the reason behind parental hesitation to vaccinate their children as a combination of an increasing erosion of trust in stakeholders involved with vaccination and a parallel trend of an increasing personalization/ individualization of risk [9,11]. However, in the last decade several studies have also reported on vaccination refusal among social groups having "alternative" lifestyles and philosophical outlooks [12][13][14]. Streefland [15] shows that there is a trend particularly among well-educated parents in Europe and the USA to believe in keeping good health by maintaining bodily balances and gaining immunity in a natural way. In his analysis of recent anti-vaccination movements Blume [1] also points to the emerging questioning of immunization among parents who advocate holistic ideas about health, natural child birth and breast feeding. Several studies support his observation: In a study exploring how parents in Brighton were thinking about the MMR vaccine in the context of the autism-controversy raised in the UK in the 1990s, several mothers backed up their arguments against MMR vaccination with the idea of the value of acquired natural immunity through nutrition and appropriate nurturing and the particularity of individual immunity [10,13]. Arguing that "alternative" views of health and medicine seem to be finding increasing sympathy among the population at large Blume [1] calls for a better understanding of them. Until now, there has been little formal research on these trends despite their influence on health care use [16,17]. In this paper we are especially interested in better understanding the influence of parents' emerging views linked to "natural and healthy" lifestyles on their decision regarding childhood vaccination. This is particularly pertinent in Switzerland, where immunization costs are covered by insurance companies, but where vaccination coverage depends on parents' initiative to bring their children to private pediatricians for vaccination. Based on the parents' narratives we examined in particular how Swiss parents used themes around what they perceived as 'natural development' of the body and the immune system to explain their critical attitudes towards immunization against measles and other childhood diseases. --- Methods --- Study design In order to explore parents' perceptions and critical attitudes towards immunization against measles and other childhood diseases, semi-structured interviews were conducted with parents of children who had either been immunized incompletely , partially or who had not been immunized at all. We use the term vaccine hesitancy as described by Yaqub et al. [9] as all participants express critical attitudes towards vaccination but some may nonetheless vaccinate their children, although not according to the recommended schedule. In the interviews information on parents' socio-demographic status and family composition was obtained. As part of an exploratory study on factors associated with vaccination resistance, the interviews addressed parents' concepts of and attitudes towards childhood immunization, their individual experiences with vaccinations and the diseases, their perceptions of the risk, severity, and meaning of childhood diseases, their perceptions of immunization information disseminated by the media, doctors and the national health authority as well as their use of immunization services for their children. Since parents' talking about the natural development of the body and the immune system emerged strongly from the interviews, we focus particularly on how Swiss parents used these themes to explain their critical attitudes towards immunization against measles and other childhood diseases. --- Recruitment Parents were recruited from two cantons with high immunization coverage , Fribourg ) and two cantons with low immunization coverage and Vaud ) in the German and French speaking part of Switzerland [4]. To obtain a sufficient number of parents for the study different recruitment strategies were used: first, pediatricians and homeopaths working in the respective cantons were asked to inform and recruit parents. Since recruitment through this channel was difficult, participating parents were asked to provide further contacts, and finally two anti-vaccination organizations were contacted and asked for collaboration. Through this mix of purposeful sampling and snowball approach high heterogeneity among the participants was achieved. --- Data collection and analysis A total of 32 interviews were conducted with parents who had children in the age range of 0 and 16 years of age . All interviews were carried out in 2011 by a trained interviewer with a medical background in German and French. Interviews were conducted at parents' home or a place that was convenient to them. An interview guideline that was pretested outside the study setting helped to structure the interviews. The average duration of the interviews was 60 minutes. All interviews were audio-recorded and transcribed verbatim in Swiss German or French. The transcripts were analyzed with Atlas.ti using latent content analysis [18]. Text segments were coded and grouped by two independent researchers . There were no predefined coding themes; coding was entirely based on the content of the interviews. A final code catalogue was developed that guided the subsequent data analysis. The congruency of assigned codes and findings was continually compared during the data analysis process. --- Ethics and consent Before the interview, informed consent was obtained from all participants. Parents were informed about the study and their right to stop the interview at any time. They were assured confidentiality and anonymity. Pseudonyms were used to anonymize the transcripts of the interviews. The study has been approved by the Ethics Committee of Basel . The manuscript complies with the RATS guidelines for qualitative research. --- Results --- Sample characteristics Out of the 32 interviews 28 interviews were conducted with the mother, one with the father and three interviews with both parents. Parents had a mixed socio-economic status but the majority could be characterized as middleclass with many parents working in the field of medical care or education . Details on parents' age, education and income are summarized in Table 1. Most of the families had two children. None of the interviewed parents had fully immunized their lastborn child. Nine parents had not immunized their lastborn child at all. Another 23 parents had only partially immunized their children or not yet immunized their lastborn child. --- The strength of the naturally acquired immune system In the interviews, many parents built their arguments against immunization on a strong faith in the strength of the naturally acquired immune system. A mother working as acupuncturist argued for example that a strong immune system is able to cope with childhood diseases and cure them without the support of vaccines. "Our immune system is strong enough, and one should be able to overcome an illness with our own means" . Several parents supported their argument by referring to human evolution. There was a strong belief in the body's perfect functioning, which has developed over millions of years and was contrasted with the vaccines' short existence. A mother and nurse-in-training said for example, "I know it has worked for millions of years […]. I see this [vaccination] as antagonistic, because it [the vaccine] only exists for a few decades and it shall be much better than what has proved itself for millions of years; this does not make sense to me" . Parents generally described childhood diseases like measles, rubella, mumps or whooping cough as mild illnesses that many of them had gone through themselves as a child. Other childhood diseases such as polio were considered rare in Switzerland. Childhood diseases were, thus, not perceived as a threat but as part of the natural way to strengthen the body and to acquire "natural" immunity. Many parents, such as a mother working as a nurse specializing in sophrology presented diseases as meaningful and associated the experience of illness and recovery with progress in the child's development. "Well, I think that it [illness] is like a necessary passage in order to grow. Often you see that children after overcoming a childhood disease make major steps in their development, acquisitions, and this again allows a good development to overcome these illnesses" . Illness was also perceived as a signal sent by the body in the case of tiredness or weakness forcing the person to rest and slow down. Parents argued that diseases come at the right time and are a more natural way to acquire immunity than through immunization. "If one is sick, it [the body] tells us… there is a message behind. The body tells us that we need to stop, to have a rest" . The non-immunized child's health was often put in comparison with the health status of immunized children. Good health was taken as a reaffirmation. "We just really have a good feeling and we see, everything is fine with the kids, they are healthy. Healthier than other children in kindergarten, in comparison. And this is actually really a big affirmation for us that the way we are going is the right one. The right one for us" . Many parents argued that the strength of the immune system can be built up by healthy food. Moreover, breastfeeding was often mentioned as a sufficient measure to protect infants particularly in the early phase. "If one is really concerned with health, with food, with hygiene, with the whole life style, one has a natural immunity strong enough against so many things" . "I think with breast milk a baby has already sufficient antibodies. Why inject then something else at such an early stage?" . --- Immunization as an intrusion into natural bodily orders Immunization was generally perceived as artificial and as an unnecessary intrusion into the development of a natural immune system and the healthy status of the child. Many parents, such as this mother working as a theater instructor, were convinced that the natural way of acquiring immunity through diseases should not be disturbed nor forestalled by a vaccine. "I have the feeling that I don't want to meddle with it [natural immunity] and mess it up. Things exist and one has to handle them when they are there. But to treat an illness before it is there, ehm… that is something weird. It is like having a bypass operation while the heart is still strong" . Arguments against vaccination arise particularly in terms of the lower quality of vaccine-acquired immunity, the uncertainty about the bodily reactions to it, and its artificial timing. Protection through immunization was often not believed to be complete. Moreover, bodily reactions to a disease were considered different or even stronger when induced artificially compared to naturally acquired diseases. Many parents refused immunizations arguing as this mother and nurse "that one is injecting something into the body without really knowing what it triggers" . Parents expressed fears of upsetting the natural bodily order of the child or even impairing the child's body. Those having small children below one year of age were particularly worried of "overloading" the immune system of their child with combined vaccines. "I have the feeling, one can overload the immune system with it, well, simply by giving the vaccine, or … yes, weaken the body somehow, so that it does not learn anymore to work well itself" . A mother working as a commercial employee for example interpreted the sickness she observed after the immunization as a sign that her child's immune system was not able to cope with the immunization or was even further impaired by it. "With my older child I have waited for a whole year, and then I immunized him with polio, but I stopped afterwards. He reacted very strongly, he was afterwards constantly sick, well, he was permanently sick. The little one,… I have not yet vaccinated her for anything, well, I will not vaccinate anything, yes, because it does not make sense to me" . Some mothers pictorially described the combat of the body with the chemical substances of the vaccine, using notions of war and contamination. "I think one weakens the person, I say… by inserting something into the body that is something synthetic… that is nothing natural, hence, our body does automatically fight that, it does need to get used to it… and then, if one does not accept it… if the body does not accept it… They are a bit like bombs… I say for the children they are like bombs that are sent into their blood, that's it " . "Well, yes, I think it is nevertheless a type of internal contamination and it does push our immune system, doesn't it?" . A frequently raised concern was the artificial timing of the fight of the immune system with the substances of the vaccine. Even parents who planned to vaccinate their child opted for an individualized vaccination schedule and decided to postpone the vaccines "in order to allow their child to build up its immune system itself" . --- Discussion Parents' perceptions of the importance of a "natural" development of the body and the immune system emerged as a significant theme in explaining parents' critical attitudes towards the immunization of their child against measles, mumps and rubella as well as other childhood diseases in Switzerland. Rather than simply "resisting" vaccination, this group of middle-class parents, a high proportion of which worked in the health and education sectors, showed a surprisingly strong faith in and appraisal of the "natural" development and functioning of the human immune system in their arguments. Earlier studies on parents' vaccine decision-making in the UK have highlighted the close interconnection of parents' decisions on natural birth, breastfeeding and vaccination [10,13,19]. Although not referring to natural ways of delivering, the interviewed parents in Switzerland similarly depicted worldviews emphasizing a particular notion of "the natural". They repeatedly emphasized the important role of breastfeeding and healthy natural food to build up their children's immune system. The health system itself has played an important role for the last two decades in promoting breastfeeding as the best way to protect an infant from infections through public health messages [20]. This may have contributed to a local culture of vaccination [21], which goes along with the underestimation of the need to vaccinate the child for specific diseases. In addition, recent campaigns to promote the consumption of particular foods such as fruits may support perceptions that a "natural" choice is a healthier choice. In our interviews, parents perceived diseases as a natural way to build-up a robust individual immunity, health and development, similar to what Leach and Fairhead described for the UK [10]. Our results support Blume [1] as well who has stressed the importance of considering parents' ideas about holistic health and the importance of a natural life style and environment for a child's well-being in order to understand parents' vaccination decision-making. One question, which emerges from these findings, is to what extent the preference for the natural over the artificial reflects a more deeply rooted distrust in the dominant bio-medical health care system. In their recent review on reasons for vaccine hesitancy in Europe Yaqub et al. identified distrust as a key barrier to vaccination, more precisely 'distrust of doctors' , 'distrust of government sources' , and 'distrust of pharmaceutical companies' [9]. The authors stressed that vaccines per se were not mistrusted, but the institutions delivering the vaccines. In some cases the motivation of health system actors was perceived as being influenced by larger economic interests. Our study differed in this respect in that distrust in institutions did not seem to be an overruling barrier to vaccination, albeit it was observed as well. But many of the interviewed parents worked themselves in the Swiss health care system, so that it is unlikely that they are overly critical of the system. Nonetheless they decided not to follow the official recommendations for vaccination. Unlike in other studies our findings thus reveal a certain ambiguity as regards the importance of distrust of the health care system for vaccine hesitancy. Helpful for the interpretation of our findings is the conceptual distinction between trust and legitimacy. Yaqub et al. defined trust as 'ability to rely on somebody else's claims about a situation' in the absence of full information, whereas legitimacy refers to the grounds upon which truth claims are made [9]. Among our respondents vaccine hesitancy seems to originate strongly in doubts about the legitimacy of an artificial intrusion into the "natural" development of the immune system rather than merely reflecting a general distrust in the actors of the health care system. When parents question the legitimacy of prioritizing the artificial stimulation of a child's immune system over naturally acquired immunity, their uncertainty about bodily reactions to vaccinations might be part of "an increasing unease with modernity" which is paralleled by general concerns about the safety of mobile phones or environmental pollution, for example [17]. Helman postulated a general shift in the interpretation of the health-nature relationship: "In the 1970s . . . […] nature had become a threat. People were exhorted to keep it at bay, to protect themselves from the elements. In the new model, nature has come full circle and is once again valued as a positive, health-giving force . Parents' juxtaposition of naturally acquired immunity and health and their perception of vaccination as an artificial intrusion into the bodily order of the child refers well to what he described as part of a Western modern dualism endowing positive qualities to anything 'natural' and holistic as opposed to anything scientific or technical. Besides doubts about the legitimacy of interfering with a "natural" process, fears about vaccination side effects played a role as well. Similar to what has been described by other authors, parents in Switzerland feared that vaccines combining several antigens could potentially overwhelm or "contaminate" the child's immune system, even more so in the case of the still immature immune system of an infant [2,3,19]. Emily Martin described this phenomena already 20 years ago as a paradigm shift from a general concern of "disinfection" to "detoxification" [22]. Parental concerns of "overloading" their infants' immune system with vaccines in the first months of life further open up discussions about the "right" timing of vaccines. Current practice of "one size fits all" immunization plans and combined vaccines raises concerns about not meeting every individual child's needs. The rationale for recommendations as regards the timing of a specific vaccination is based on immunological and epidemiological considerations, which are usually not known to parents. Their desire for a personalized, patient-centered approach to vaccination in terms of age of the child and timing of vaccination may be accommodated with more precise information in this regard. A clear rationale for the recommended timing may motivate parents to follow the immunization schemes; in cases where flexibility is possible this could be communicated. It is further notable that despite national information campaigns, the majority of interviewed parents associated childhood diseases such as measles, rubella and mumps with mild illnesses that many of them had gone through themselves when they were children, which was reported by other studies as well [2,23]. This illustrates again the very personalized perspective of parents when judging the risks and benefits of immunization versus disease [24]. Moreover, it points to the fact that risk perception always depends on the available possibilities to counter specific threats, such as the availability of a high quality curative health system [25]. In the Swiss context, contracting an infectious disease seemed to constitute a smaller threat to these parents than the uncertainty of the child's bodily reaction to the vaccine. We limited the focus of this paper on parents talking about nature, body and health as this reflects important lifestyle concepts in Switzerland and other high-income countries, which have up to this point received little attention in public health campaigns promoting vaccination. Decision-making on immunization involves many more dimensions, including parents' understanding of their responsibility, their trust in health professionals and authorities, parents' own health history, and social relationships with other mothers and parents [13]. Moreover, the small sample of parents critical to fully immunize their children cannot be generalized to the Swiss population. Nonetheless, our results provide important insights into parental reasoning on immunization, which may help to better adapt public health and vaccination messages. --- Conclusions In the context of the Swiss health system vaccination coverage depends on parents' initiative to take their child to a private pediatrician. Our findings suggest that well-informed parents make health-related decisions for their children on the basis of their own assessment, informed by their own worldview rather than basing it on experts' recommendations alone. Unless emerging trends and lifestyles, such as the trend towards a more "natural" way of life, are addressed in vaccination campaigns, they might miss the target population. A related aspect is parents' wish for a more personalized timing of vaccinations. To satisfy the increasing parental demand for an individualized, patient-centered approach to vaccination, a more flexible immunization plan, where possible, might help to increase immunization coverage. Moreover, national vaccination campaigns need to be integrated in a meaningful way into other public health messages that promote 'natural' ways to develop the human immune system, such as exclusive breastfeeding, to avoid seemingly contradictory messages. However, most importantly, there is a need for more research on the issue. --- Competing interests The authors declare that they have no competing interests. Authors' contributions KH, SM and EZ have contributed to the conception and design of the study, and KH has collected the data. KH and KG have analyzed and interpreted the data, and all authors were involved in drafting the article or revising it critically for important intellectual content. All authors have provided approval of the final version as submitted.

Background: Despite efforts of international and national health authorities, immunization coverage and timeliness of vaccination against dangerous childhood diseases have been adversely affected by parental hesitation to vaccinate their children in high-income countries. Literature shows that social and political processes and shifts in conceptual structures, such as emerging views linked to health and 'natural' lifestyles, have shaped parents' immunization decisions. This paper investigates how Swiss parents argued along the lines of a natural development of the child to explain their critical attitudes towards immunization against measles and other childhood diseases. Methods: A total of 32 semi-structured interviews were conducted with parents of children between 0 and 16 years of age who decided not to fully immunize their children. The interviews were analyzed using qualitative content analysis and an interpretative approach. Results: Parents built their arguments against immunization on a strong faith in the strength of the naturally acquired immune system. Childhood diseases were not perceived as a threat but as part of the natural way to reinforce the body and to acquire a "natural" and thus strong immunity. Parents understood immunization as an artificial intrusion into the natural development of the immune system and feared overloading the still immature immune system of their young children and infants through current vaccination schemes. Conclusions: In the context of emerging trends towards natural lifestyles and ideas of holistic health in Switzerland and Europe, where many well-informed parents express concerns towards vaccinating their children, public vaccination strategies require reconsideration. Public immunization schedules need to acknowledge parents' wish for more flexibility and demand for an individualized patient-centered approach to immunization.

background despite efforts of international and national health authorities immunization coverage and timeliness of vaccination against dangerous childhood diseases have been adversely affected by parental choice to decline childhood vaccination in highincome countries 1 2 3 this led to largescale outbreaks of vaccine preventable diseases in europe and the us such as measles in the netherlands italy france germany switzerland and the uk over the last ten years 4 in switzerland after several years with a relatively low annual incidence rate there have been several waves of large measles epidemics since 2006 45 as a consequence of these outbreaks and increased population awareness coverage rate for two mmr doses among 2year old children has slightly increased since 2005 to 86 6 which is still considerably below the who target of 95 coverage moreover coverage rates vary strongly between language zones and cantons ranging from 50 to 93 7 recent studies argue that in todays industrial countries vaccine refusal rates can only partially be explained by parents information deficit lack of access to facts and misinformation 89 instead recent socialscientific literature has emphasized the importance of identifying broader social political and conceptual structures that may shape parents immunization decisions in order to better understand reasons behind parental resistance to immunize their child 10 several authors see the reason behind parental hesitation to vaccinate their children as a combination of an increasing erosion of trust in stakeholders involved with vaccination and a parallel trend of an increasing personalization individualization of risk 911 however in the last decade several studies have also reported on vaccination refusal among social groups having alternative lifestyles and philosophical outlooks 12 13 14 streefland 15 shows that there is a trend particularly among welleducated parents in europe and the usa to believe in keeping good health by maintaining bodily balances and gaining immunity in a natural way in his analysis of recent antivaccination movements blume 1 also points to the emerging questioning of immunization among parents who advocate holistic ideas about health natural child birth and breast feeding several studies support his observation in a study exploring how parents in brighton were thinking about the mmr vaccine in the context of the autismcontroversy raised in the uk in the 1990s several mothers backed up their arguments against mmr vaccination with the idea of the value of acquired natural immunity through nutrition and appropriate nurturing and the particularity of individual immunity 1013 arguing that alternative views of health and medicine seem to be finding increasing sympathy among the population at large blume 1 calls for a better understanding of them until now there has been little formal research on these trends despite their influence on health care use 1617 in this paper we are especially interested in better understanding the influence of parents emerging views linked to natural and healthy lifestyles on their decision regarding childhood vaccination this is particularly pertinent in switzerland where immunization costs are covered by insurance companies but where vaccination coverage depends on parents initiative to bring their children to private pediatricians for vaccination based on the parents narratives we examined in particular how swiss parents used themes around what they perceived as natural development of the body and the immune system to explain their critical attitudes towards immunization against measles and other childhood diseases methods study design in order to explore parents perceptions and critical attitudes towards immunization against measles and other childhood diseases semistructured interviews were conducted with parents of children who had either been immunized incompletely partially or who had not been immunized at all we use the term vaccine hesitancy as described by yaqub et al 9 as all participants express critical attitudes towards vaccination but some may nonetheless vaccinate their children although not according to the recommended schedule in the interviews information on parents sociodemographic status and family composition was obtained as part of an exploratory study on factors associated with vaccination resistance the interviews addressed parents concepts of and attitudes towards childhood immunization their individual experiences with vaccinations and the diseases their perceptions of the risk severity and meaning of childhood diseases their perceptions of immunization information disseminated by the media doctors and the national health authority as well as their use of immunization services for their children since parents talking about the natural development of the body and the immune system emerged strongly from the interviews we focus particularly on how swiss parents used these themes to explain their critical attitudes towards immunization against measles and other childhood diseases recruitment parents were recruited from two cantons with high immunization coverage fribourg and two cantons with low immunization coverage and vaud in the german and french speaking part of switzerland 4 to obtain a sufficient number of parents for the study different recruitment strategies were used first pediatricians and homeopaths working in the respective cantons were asked to inform and recruit parents since recruitment through this channel was difficult participating parents were asked to provide further contacts and finally two antivaccination organizations were contacted and asked for collaboration through this mix of purposeful sampling and snowball approach high heterogeneity among the participants was achieved data collection and analysis a total of 32 interviews were conducted with parents who had children in the age range of 0 and 16 years of age all interviews were carried out in 2011 by a trained interviewer with a medical background in german and french interviews were conducted at parents home or a place that was convenient to them an interview guideline that was pretested outside the study setting helped to structure the interviews the average duration of the interviews was 60 minutes all interviews were audiorecorded and transcribed verbatim in swiss german or french the transcripts were analyzed with atlasti using latent content analysis 18 text segments were coded and grouped by two independent researchers there were no predefined coding themes coding was entirely based on the content of the interviews a final code catalogue was developed that guided the subsequent data analysis the congruency of assigned codes and findings was continually compared during the data analysis process ethics and consent before the interview informed consent was obtained from all participants parents were informed about the study and their right to stop the interview at any time they were assured confidentiality and anonymity pseudonyms were used to anonymize the transcripts of the interviews the study has been approved by the ethics committee of basel the manuscript complies with the rats guidelines for qualitative research results sample characteristics out of the 32 interviews 28 interviews were conducted with the mother one with the father and three interviews with both parents parents had a mixed socioeconomic status but the majority could be characterized as middleclass with many parents working in the field of medical care or education details on parents age education and income are summarized in table 1 most of the families had two children none of the interviewed parents had fully immunized their lastborn child nine parents had not immunized their lastborn child at all another 23 parents had only partially immunized their children or not yet immunized their lastborn child the strength of the naturally acquired immune system in the interviews many parents built their arguments against immunization on a strong faith in the strength of the naturally acquired immune system a mother working as acupuncturist argued for example that a strong immune system is able to cope with childhood diseases and cure them without the support of vaccines our immune system is strong enough and one should be able to overcome an illness with our own means several parents supported their argument by referring to human evolution there was a strong belief in the bodys perfect functioning which has developed over millions of years and was contrasted with the vaccines short existence a mother and nurseintraining said for example i know it has worked for millions of years … i see this vaccination as antagonistic because it the vaccine only exists for a few decades and it shall be much better than what has proved itself for millions of years this does not make sense to me parents generally described childhood diseases like measles rubella mumps or whooping cough as mild illnesses that many of them had gone through themselves as a child other childhood diseases such as polio were considered rare in switzerland childhood diseases were thus not perceived as a threat but as part of the natural way to strengthen the body and to acquire natural immunity many parents such as a mother working as a nurse specializing in sophrology presented diseases as meaningful and associated the experience of illness and recovery with progress in the childs development well i think that it illness is like a necessary passage in order to grow often you see that children after overcoming a childhood disease make major steps in their development acquisitions and this again allows a good development to overcome these illnesses illness was also perceived as a signal sent by the body in the case of tiredness or weakness forcing the person to rest and slow down parents argued that diseases come at the right time and are a more natural way to acquire immunity than through immunization if one is sick it the body tells us… there is a message behind the body tells us that we need to stop to have a rest the nonimmunized childs health was often put in comparison with the health status of immunized children good health was taken as a reaffirmation we just really have a good feeling and we see everything is fine with the kids they are healthy healthier than other children in kindergarten in comparison and this is actually really a big affirmation for us that the way we are going is the right one the right one for us many parents argued that the strength of the immune system can be built up by healthy food moreover breastfeeding was often mentioned as a sufficient measure to protect infants particularly in the early phase if one is really concerned with health with food with hygiene with the whole life style one has a natural immunity strong enough against so many things i think with breast milk a baby has already sufficient antibodies why inject then something else at such an early stage immunization as an intrusion into natural bodily orders immunization was generally perceived as artificial and as an unnecessary intrusion into the development of a natural immune system and the healthy status of the child many parents such as this mother working as a theater instructor were convinced that the natural way of acquiring immunity through diseases should not be disturbed nor forestalled by a vaccine i have the feeling that i dont want to meddle with it natural immunity and mess it up things exist and one has to handle them when they are there but to treat an illness before it is there ehm… that is something weird it is like having a bypass operation while the heart is still strong arguments against vaccination arise particularly in terms of the lower quality of vaccineacquired immunity the uncertainty about the bodily reactions to it and its artificial timing protection through immunization was often not believed to be complete moreover bodily reactions to a disease were considered different or even stronger when induced artificially compared to naturally acquired diseases many parents refused immunizations arguing as this mother and nurse that one is injecting something into the body without really knowing what it triggers parents expressed fears of upsetting the natural bodily order of the child or even impairing the childs body those having small children below one year of age were particularly worried of overloading the immune system of their child with combined vaccines i have the feeling one can overload the immune system with it well simply by giving the vaccine or … yes weaken the body somehow so that it does not learn anymore to work well itself a mother working as a commercial employee for example interpreted the sickness she observed after the immunization as a sign that her childs immune system was not able to cope with the immunization or was even further impaired by it with my older child i have waited for a whole year and then i immunized him with polio but i stopped afterwards he reacted very strongly he was afterwards constantly sick well he was permanently sick the little one… i have not yet vaccinated her for anything well i will not vaccinate anything yes because it does not make sense to me some mothers pictorially described the combat of the body with the chemical substances of the vaccine using notions of war and contamination i think one weakens the person i say… by inserting something into the body that is something synthetic… that is nothing natural hence our body does automatically fight that it does need to get used to it… and then if one does not accept it… if the body does not accept it… they are a bit like bombs… i say for the children they are like bombs that are sent into their blood thats it well yes i think it is nevertheless a type of internal contamination and it does push our immune system doesnt it a frequently raised concern was the artificial timing of the fight of the immune system with the substances of the vaccine even parents who planned to vaccinate their child opted for an individualized vaccination schedule and decided to postpone the vaccines in order to allow their child to build up its immune system itself discussion parents perceptions of the importance of a natural development of the body and the immune system emerged as a significant theme in explaining parents critical attitudes towards the immunization of their child against measles mumps and rubella as well as other childhood diseases in switzerland rather than simply resisting vaccination this group of middleclass parents a high proportion of which worked in the health and education sectors showed a surprisingly strong faith in and appraisal of the natural development and functioning of the human immune system in their arguments earlier studies on parents vaccine decisionmaking in the uk have highlighted the close interconnection of parents decisions on natural birth breastfeeding and vaccination 101319 although not referring to natural ways of delivering the interviewed parents in switzerland similarly depicted worldviews emphasizing a particular notion of the natural they repeatedly emphasized the important role of breastfeeding and healthy natural food to build up their childrens immune system the health system itself has played an important role for the last two decades in promoting breastfeeding as the best way to protect an infant from infections through public health messages 20 this may have contributed to a local culture of vaccination 21 which goes along with the underestimation of the need to vaccinate the child for specific diseases in addition recent campaigns to promote the consumption of particular foods such as fruits may support perceptions that a natural choice is a healthier choice in our interviews parents perceived diseases as a natural way to buildup a robust individual immunity health and development similar to what leach and fairhead described for the uk 10 our results support blume 1 as well who has stressed the importance of considering parents ideas about holistic health and the importance of a natural life style and environment for a childs wellbeing in order to understand parents vaccination decisionmaking one question which emerges from these findings is to what extent the preference for the natural over the artificial reflects a more deeply rooted distrust in the dominant biomedical health care system in their recent review on reasons for vaccine hesitancy in europe yaqub et al identified distrust as a key barrier to vaccination more precisely distrust of doctors distrust of government sources and distrust of pharmaceutical companies 9 the authors stressed that vaccines per se were not mistrusted but the institutions delivering the vaccines in some cases the motivation of health system actors was perceived as being influenced by larger economic interests our study differed in this respect in that distrust in institutions did not seem to be an overruling barrier to vaccination albeit it was observed as well but many of the interviewed parents worked themselves in the swiss health care system so that it is unlikely that they are overly critical of the system nonetheless they decided not to follow the official recommendations for vaccination unlike in other studies our findings thus reveal a certain ambiguity as regards the importance of distrust of the health care system for vaccine hesitancy helpful for the interpretation of our findings is the conceptual distinction between trust and legitimacy yaqub et al defined trust as ability to rely on somebody elses claims about a situation in the absence of full information whereas legitimacy refers to the grounds upon which truth claims are made 9 among our respondents vaccine hesitancy seems to originate strongly in doubts about the legitimacy of an artificial intrusion into the natural development of the immune system rather than merely reflecting a general distrust in the actors of the health care system when parents question the legitimacy of prioritizing the artificial stimulation of a childs immune system over naturally acquired immunity their uncertainty about bodily reactions to vaccinations might be part of an increasing unease with modernity which is paralleled by general concerns about the safety of mobile phones or environmental pollution for example 17 helman postulated a general shift in the interpretation of the healthnature relationship in the 1970s … nature had become a threat people were exhorted to keep it at bay to protect themselves from the elements in the new model nature has come full circle and is once again valued as a positive healthgiving force parents juxtaposition of naturally acquired immunity and health and their perception of vaccination as an artificial intrusion into the bodily order of the child refers well to what he described as part of a western modern dualism endowing positive qualities to anything natural and holistic as opposed to anything scientific or technical besides doubts about the legitimacy of interfering with a natural process fears about vaccination side effects played a role as well similar to what has been described by other authors parents in switzerland feared that vaccines combining several antigens could potentially overwhelm or contaminate the childs immune system even more so in the case of the still immature immune system of an infant 2319 emily martin described this phenomena already 20 years ago as a paradigm shift from a general concern of disinfection to detoxification 22 parental concerns of overloading their infants immune system with vaccines in the first months of life further open up discussions about the right timing of vaccines current practice of one size fits all immunization plans and combined vaccines raises concerns about not meeting every individual childs needs the rationale for recommendations as regards the timing of a specific vaccination is based on immunological and epidemiological considerations which are usually not known to parents their desire for a personalized patientcentered approach to vaccination in terms of age of the child and timing of vaccination may be accommodated with more precise information in this regard a clear rationale for the recommended timing may motivate parents to follow the immunization schemes in cases where flexibility is possible this could be communicated it is further notable that despite national information campaigns the majority of interviewed parents associated childhood diseases such as measles rubella and mumps with mild illnesses that many of them had gone through themselves when they were children which was reported by other studies as well 223 this illustrates again the very personalized perspective of parents when judging the risks and benefits of immunization versus disease 24 moreover it points to the fact that risk perception always depends on the available possibilities to counter specific threats such as the availability of a high quality curative health system 25 in the swiss context contracting an infectious disease seemed to constitute a smaller threat to these parents than the uncertainty of the childs bodily reaction to the vaccine we limited the focus of this paper on parents talking about nature body and health as this reflects important lifestyle concepts in switzerland and other highincome countries which have up to this point received little attention in public health campaigns promoting vaccination decisionmaking on immunization involves many more dimensions including parents understanding of their responsibility their trust in health professionals and authorities parents own health history and social relationships with other mothers and parents 13 moreover the small sample of parents critical to fully immunize their children cannot be generalized to the swiss population nonetheless our results provide important insights into parental reasoning on immunization which may help to better adapt public health and vaccination messages conclusions in the context of the swiss health system vaccination coverage depends on parents initiative to take their child to a private pediatrician our findings suggest that wellinformed parents make healthrelated decisions for their children on the basis of their own assessment informed by their own worldview rather than basing it on experts recommendations alone unless emerging trends and lifestyles such as the trend towards a more natural way of life are addressed in vaccination campaigns they might miss the target population a related aspect is parents wish for a more personalized timing of vaccinations to satisfy the increasing parental demand for an individualized patientcentered approach to vaccination a more flexible immunization plan where possible might help to increase immunization coverage moreover national vaccination campaigns need to be integrated in a meaningful way into other public health messages that promote natural ways to develop the human immune system such as exclusive breastfeeding to avoid seemingly contradictory messages however most importantly there is a need for more research on the issue competing interests the authors declare that they have no competing interests authors contributions kh sm and ez have contributed to the conception and design of the study and kh has collected the data kh and kg have analyzed and interpreted the data and all authors were involved in drafting the article or revising it critically for important intellectual content all authors have provided approval of the final version as submitted

background despite efforts of international and national health authorities immunization coverage and timeliness of vaccination against dangerous childhood diseases have been adversely affected by parental hesitation to vaccinate their children in highincome countries literature shows that social and political processes and shifts in conceptual structures such as emerging views linked to health and natural lifestyles have shaped parents immunization decisions this paper investigates how swiss parents argued along the lines of a natural development of the child to explain their critical attitudes towards immunization against measles and other childhood diseases methods a total of 32 semistructured interviews were conducted with parents of children between 0 and 16 years of age who decided not to fully immunize their children the interviews were analyzed using qualitative content analysis and an interpretative approach results parents built their arguments against immunization on a strong faith in the strength of the naturally acquired immune system childhood diseases were not perceived as a threat but as part of the natural way to reinforce the body and to acquire a natural and thus strong immunity parents understood immunization as an artificial intrusion into the natural development of the immune system and feared overloading the still immature immune system of their young children and infants through current vaccination schemes conclusions in the context of emerging trends towards natural lifestyles and ideas of holistic health in switzerland and europe where many wellinformed parents express concerns towards vaccinating their children public vaccination strategies require reconsideration public immunization schedules need to acknowledge parents wish for more flexibility and demand for an individualized patientcentered approach to immunization

Introduction The coronavirus outbreak, which can also be termed as a black swan event, has disrupted the rapid economic growth of countries globally. Tracing back history, the Spanish flu of 1918 had hard hit the world which resulted in loss of lives of 50-100 million globally with India suffering the highest fatality of 18 million lives. To diminish the havoc that such a pandemic can inflict on the lives of people, the Indian Government imposed a nationwide lockdown effective 25 March 2020. The shortcoming of any lockdown is that economic activity comes to a complete standstill. Based on lack of economic activity, IMF in the World Economic Outlook projected the growth numbers for India 2020-2021 to be at 1.9%. Due to disruptions in demand and supply chains, World Bank's estimates show that Indian economic growth is likely to be in the range of 1.55% to 2.8% in 2020-2021. Growth projections forecasted by the International Monetary Fund for the global economy have been revised from 3.3% to a contraction of 3%. Along with this, health and well-being of millions of people have been at risk. Researches are being conducted in several parts of the world to discover a vaccine and possible treatment of the virus. However, the possibility and viability of this being successfully done is not very clear or visible in near future. The only possible means or option available to survive the pandemic infection and reduce the spread of the infection is to implement social distancing and live in a controlled environment. The virus has also been instrumental in sparking a huge economic crisis. It has simultaneously adversely impacted the supply, i.e. production of goods & services, and the demand, i.e. consumption, investment, exports and imports. The economic damage due to this health crisis is likely to affect more people in India than the disease. Q1 2020 has been negatively impacted by the lockdown. Q2 and Q3 are expected to be riddled with consumption levels being at an all-time low, business investments declining and exports gradually pointing downwards resulting in an adverse impact on the Indian economy. As the COVID-19 cases in India were seen to be rising, the lockdown was announced to flatten the curve of this infection and reduce the spread of this infectious disease by breaking important chains of transmission. "India chose to sacrifice its economy and save lives"-"जान है ं तो जहान है ं ". Therefore, it implied that all economic and social activities which require physical presence were either postponed or brought to a halt in its tracks. The recovery curve as being forecasted by analysts and economists is ranging from a best case scenario of "V"shaped recovery curve to "U", "W" or "L". A "V"-or "U"-shaped curve is associated with the timing and extent of stimulus provided by the Government and how companies and market structures are able to cope with decreasing demand. With the number of coronavirus cases in India on the rise, the lockdown has been extended four times and is in force till 31 May 2020, as of date. Early lockdown announced by the Government of India helped slowdown the spread of the infection in the country. However, it has raised issues of escalating inequalities 1 3 The Indian Journal of Labour Economics 64:731-747 ISLE and susceptibilities of marginalized communities within the country. This lockdown and its subsequent extensions, has resulted in disrupting life of all. The lockdown caused confinement of millions of citizens in their homes. Businesses across the length and breadth of the country were shut, and nearly all economic activity was stopped, thereby negatively impacting workforce employed in both the formal and informal sectors. Construction sites were abandoned after the announcement of lockdown. At the same time, most of the residential societies and colonies shut their gates for all but the residents. The prominent sectors which employ migrant workers who are essentially members of the informal economy, are construction and building industry, manufacturing units, trade setups, transport, and hospitality. Also, some of these migrant workers might work as domestic helpers , street vendors, workers in tiny and roadside businesses or as help in salons and gyms. As per an estimate of Centre for Monitoring Indian Economy , nearly 122 million people in India were jobless in April 2020 itself, of which a large majority are small traders and wage labourers. Thus, this precarious situation has resulted in serious crisis and dislocation for migrant workers. According to the Economic Survey of 2018-2019, the informal economy is constituted of 93% workers. Census 2011 suggests that there are 450 million internal migrants in India. The actual numbers currently are likely to be much higher than these figures. Primarily, two types of migrations are common in India: the first being longterm migration which is attributed to the resettlement of an individual or household; the second being essentially short-term or seasonal/circular migration, which implies to and fro movement between a source and destination. Approximately 175 million migrants in India are those who travel for work in the informal sector. They are the lifeline of many State economies. This pandemic and the subsequent lockdowns have forced several amongst these workers accompanied by their families, to seek shelters in government run relief camps for food and basic needs. Indian Central and State Governments have been setting up of additional relief camps for them to live. The migrant workers have been through enormous mental, financial and emotional agony in urban centres and industrial belts and are migrating back to their native villages in enormous numbers. The agony of these workers has been due to many fold reasons such as lack of jobs and livelihood, absence of social security and being stranded in an alien city and State. The absence of public transportation during the lockdown compelled these stranded migrant workers to try to travel by foot or on bicycle to cover hundreds of kilometres back to their native homes in villages. The imposing of lockdown by the Central Government has precipitated a huge "reverse migration" from the "destination" to "source" in large parts of India . As per some estimates, more than 120 to 140 million workers are on their way back to the villages. --- Review of Literature India, as a country prior to the onset of this health crisis, was already facing a decline in GDP growth and an increase in unemployment rates. There was a demand slowdown, and the lockdown further worsened the demand and supply decline in the economy. Global recession and trouble in global supply chains are further aggravating the already disrupted domestic supplies and demand. Both the formal and informal sectors would have to bear the brunt of this crisis. Coronavirus in India has caused unique challenges for the country. The large population of 1.3 billion living in diverse States with differing levels of health infrastructure, social, cultural and economic inequalities are the major reasons for this. The readiness of State Governments to deal with the virus has differed substantially. Having faced the Nipah virus in 2018, Kerala resorted to extensive testing, contact tracing, etc., to minimize the spread. Similarly, Odisha as a State has witnessed several natural disasters, and adequate measures were taken by State government to deal with it. Migration can be regarded as movement of people from one place to another for a certain period of time . The lockdown resulted in manufacturing being brought to a standstill and disruption of the supply chain due to the countries dependence on the supply of intermediate goods from China. Therefore, production was stopped even though workers and capital both were present in the cities. Further, the demand for goods and services in the economy falls, other than that for essential goods. The Domino Effect operates. To worsen the situation this segment of the population, has hardly any access to savings, resulting in worsening their misery. These workers are the ones who are migrating from the cities to the villages in the hope that at least food and essentials would be available in the village. Based on the researches conducted, it is seen that majority of the investigations related to the impact of the outbreak of pandemic belong to the health sector and economy. It is being increasingly felt that more in-depth analysis is required to understand the magnitude of the challenges that this pandemic along with a declining GDP growth rate in India has inflicted on the condition of the migrant workers, thereby impacting inequality levels in the economy. It is also imperative to analyse if the public policy measures adopted by the Government are adequate to mitigate the challenging conditions being faced by these workers or is there need for additional economic policy announcements by the Government of India. The current research aims to delve into assimilating available information in Twitter with regard to the plight of Indian migrant workers due to Covid 19 and a lower economic growth and analyse the same with the objective of: identify the responses of people with reference to challenges being faced by the migrant workers in India due to the Covid 19 pandemic and the subsequent lockdown that was imposed along with an anticipated declining economic growth; critically evaluate the policy responses announced by the Government of India to benefit the migrant workers; suggest additional economic policy measures that can be undertaken by the Government for these workers which can thereby lead to reduction in the widening economic inequality gap. The current study will give 1 3 The Indian Journal of Labour Economics 64:731-747 ISLE a bird's eye-view of the impact of Covid 19 and declining Indian growth rates on the predicament faced by migrant workers. It will also analyse the economic policy measures adopted by the Government and suggest policy changes to lessen the misery and challenges faced by these workers. --- Material and Methods Text mining assists in knowledge extraction from an unstructured pool of textual data. This tool has been accepted widely by researchers and analysts as an analytical tool for analysing data. It is machine learning and natural language processing which has enabled the process of mining data to identify patterns and topics in the text. Text mining enables researchers to extract high-quality information and evidence with the help of computational tools and techniques from a large quantity of unstructured data. This process of data analysis and theme extraction is also known as Knowledge Discovery and is supported by machine analysis of text. The process of finding knowledge in data is known as Knowledge Discovery in Databases . It has been defined by as "the non-trivial process of identifying valid, novel, potentially useful and ultimately understandable patterns in data". KDD has a multidimensional method which constitutes activities from data collection to knowledge interpretation. The present study follows the KKD process of text mining for the meta trend analysis of textual data, i.e. the compendium of tweets related to "Indian Migrant workers" to analyse the impact of Covid 19 and consequently declining economic growth on the conditions of "Migrant Workers" in India. --- Data Collection COVID 19 has proven to be a major social event which has created huge ramifications for our social system . A qualitative approach has been used to enable researchers to capture deeper meanings from the dataset. This included labelling popular terms and tweet topics, assigning meaning and themes to the topics and interpreting them to identify the latent issues generated . The researchers therefore implemented qualitative analysis, a useful method for analysing this social phenomenon. It is characterized by the systematic process of coding the data to understand the meaning and description of the social reality by identifying the inherent theme . Twitter data can be used to study attitude, trend tracking and population health. The use of social media data enables researchers to gather reports of behaviours and views that are unsolicited and unprompted by the researcher. At the same time, social media provides the opportunity to spot personal expression and human interaction in real time and on a massive scale . Twitter is one of the social networking sites being used extensively since it enables all to share and express concerns and views on topics of relevance. Trending hashtags related to the problem of migrant labour, such as #IndianMi-grantWorkers, were used as key search terms to collect Tweets on Twitter. The data were downloaded from Twitter with the help of the Twitter API Authentication Process using OAuth package of R. Tweets published between 23 March 2020 and 21 May 2020. A total of nearly 50,000 Tweets have been downloaded and are the dataset for the present study. --- Data Cleaning and Pre-processing On the downloaded data from Twitter, text mining technique was applied for the purpose of automated information extraction from unstructured text data . It is a scientific process of deriving trends from unstructured textual data, and helps gain an insight into the themes of the dataset and examine the dynamics of the study . The data noisiness was cleaned with the help of the R-Programming and statistical software. In this package R data cleaning is completed by means of the library package "tm". After removing all noise and cleaning of the data, the pre-processing of the Corpus was completed. Thereafter, it involved transforming the pre-processed text into a structured format for actual computation. --- Data Transformation On obtaining the structured cleaned "Corpus", it was transformed into a "TermDoc-umentMatrix". The TermDocumentMatrix is a mathematical matrix which helps describe the frequency of terms that occur in a structured dataset. The rows tally to documents in the structured text, while columns correspond to the terms. The goal of the TermDocumentMatrix is to characterize the topic of a document by the frequency of semantically significant terms. --- Establishing Trustworthiness In the present study, two researchers were involved in separately interpreting the clusters of tweets that have been formed using unsupervised machine learning to ensure inter-rater reliability . The researchers separately labelled the clusters and that became the theme to which that cluster represented. --- Results --- Data Mining The transformed matrix was subsequently used for analysis of data. Data analysis was done based on three models: the first being Wordcloud, second being topic modelling 1 3 The Indian Journal of Labour Economics 64:731-747 ISLE and third being sentiment analysis. "Word cloud" or tag clouds are graphical visual depictions of word frequency and provide larger visibility to those words which are more frequently used in the tweets and text. It has been defined as "the visual representation of words for a certain written content structured as per its frequency" . The study by Sinclair and Cardew-Hall states that word cloud is an initial stage for an exhaustive analysis of certain text material. Thus, post-Word cloud visualization, topic modelling of the themes and topics was done for an in-depth investigation of the tweets. Advancement in natural language processing and machine learning has led to the development of a probabilistic framework text mining approach called topic modelling. It enables researchers to establish and encapsulate electronic archives at a scale that would be impossible by human annotation and use algorithms for discovering the main themes that pervade a large and unstructured collection of documents. It uses the primary technique of latent Dirichlet allocation and is akin to discrete PCA, i.e. principal component and factor analysis. LDA and other topic models are part of the larger field of probabilistic modelling . The dataset is analysed into a few topics. The graphical representation helps understand the topics that are extracted from the tweets. The topics may contain words from several topics in different proportions, i.e. in a two topic document it can be interpreted that "Document 1 is 80% topic A and 20% topic B, while Document 2 is 35% topic A and 65% topic B". The identified topics were deliberated upon by two domain experts from the field to interpret the data. The two experts labelled these topics and identified the theme to which the topic belongs. --- Sentiment Analysis Sentiment analysis or opinion mining has been defined as "the computational study of opinions, sentiments and emotions expressed in text" . It can be regarded as a form of text analysis that helps to extract and analyse opinion oriented text to determine positive and negative views/ opinions about an event/ product/person or topic. A large mass of people express their views on various aspects freely on Twitter. Therefore, these tweets can be regarded as useful source of information to infer people's opinion on pertinent social issues. As an important method for undertaking social media research, sentiment analysis can be regarded as a computational and natural language processing-based method to scrutinize the prominent sentiments and emotions of people in the given texts . In the present study, based on the NRC Emotion Lexicon, the sentiment analysis has been done . Two sentiments and eight basic emotions that are associated with English words and languages characterize The NRC Emotion Lexicon. The "syuzhet" package in R was used to capture people's emotions in text. 1 3 ISLE --- Data Interpretation and Knowledge Discovery --- Word Cloud The word cloud consists of the most used words from the tweets which mentioned Indian Migrant labour. The prominent or keywords figuring repetitively in the tweets and communicating the sentiments of the people are represented graphically. In the graphic based on the frequency of occurrence in the text, the more prominent words appear larger in size and bold creating a visual emphasis . The image highlighted three words prominently, "India", "Migrant" and "Workers" indicating that the migrant workers have been adversely impacted in India. In terms of how these migrant workers were impacted, words like "tragedy", "horrible" "scale", "crisis" and "torturing" emerged as major terms. Additionally, in terms of help extended to the migrant workers, words such as "Shramik", "Railways", "Trains" and "buses" emerged. These terms were further explored in detail by the researchers by examining full sentences in tweets. One tweet suggested, "In India migrants are from Indian villages that work in the cities have been affected by this 1 3 The Indian Journal of Labour Economics 64:731-747 ISLE horrible tragedy". Similarly, some others are related to relief measures, "Modi Govt arranged hundreds of special trains for migrant workers!"; "Indian government arranges special trains and buses to help stranded migrant workers." --- Topic Modelling Topic modelling analysis of Twitter data was done to identify the key themes representative of public sentiment related to the migrant labourers in India. These represent the main topics or key phrases that emerged from the tweets on the social platform related to reverse migration of workers after the lockdown. The two researchers subsequently discussed the terms and sample Tweets in the five topics that emerged and categorized them into common themes. To protect the privacy and anonymity of the Twitter users of these sample Tweets, the researchers have used either excerpts of Tweets or paraphrased them in the message. Table 1 in Appendix 1 presents the results of identified five salient topics, most popular words within each topic and some sample tweets related to each topic. --- Sentiment Analysis The above plot shows that tweets are more related to trust and fear. This suggests that though there is confidence and trust in the minds of masses about tiding through this crisis with government support, however, a fear element is also present. People do have some negative feelings on Twitter. However, positive sentiments are more prominent than the negative emotions. But overall, people on Twitter are optimistic about the positive outcomes of reverse migration. The possible reason for the optimism in the masses could be that the tweets include ones related to the Rs. 20 trillion economic package announced by the Finance Minister to provide a boost to the economy. --- Discussion and Conclusion The results of the analysis highlight five major themes of discussion. On the one hand, the discussion reflects the rescue operations, help being provided and the government relief package to bring about self-reliance and self-sufficiency. On the other hand, the scale of this unforeseen tragedy and the pain due to the lockdown imposed to ensure social distancing with the aim to curb the spread of the pandemic is seen. These could be the primary factors for the shift in Prime Minister's address during the announcement of second lockdown. In the first lockdown, he emphasized the importance of-"जान है ं तो जहान है ं " , while in the second the direction that he gave to his countrymen was of "जान भी और जहान भी, दोनो है जरू री" . This indicates the desire of the government to focus on revival of economic activities and start the production and economic process in a manner that the fight against the virus is also not affected and the economy moves gradually back to normalcy with caution. --- 3 The Indian Journal of Labour Economics 64:731-747 ISLE "…a future where people care about both the aspects, follow their duties and abide by the directions of the government -this will be important for India's prosperous and healthy future," PM Narendra Modi. As seen in the topics identified, the pandemic, which initially started as a medical emergency, has now evolved into an economic calamity, with severe ramifications for all sections of society. Workers in the informal sectors have been hit very badly because of the lockdown measures implemented by the government in a bid to contain the spread of the pandemic. Majority of them have migrated back to their native villages and have no means of livelihood and no savings. It is very important to protect and help them to tide over the shock. A concentrated joint effort by the State and Central Governments working hand in hand is critical to the country successfully overcoming this crisis and restoring normalcy. Central Government has announced a major relief package to help the rehabilitation drive of migrant workers, ensuring that they become "आत् मनिर् भर", i.e. selfreliant in their native villages. These policy measures include key measures, both short term and long term, to help them ride through the present crisis. The details have been included as Appendix 2. Post the announcement of policy measures of Rs. 20 trillion announced by the Finance Minister, tweets via the hashtag "#MigrantWorker and Indian Economy" related to people's reactions on the stimulus provided for migrant workers and Indian economy was further analysed and a word cloud was created. This word cloud highlights some words prominently. "Migrant", "Administration", "Accept", "Sanctions" and "Impose". These highlight the important measures initiated by the administration to tide over the crisis. Also, other key words like "cash", "transfers", "contribution", "deserve" can be regarded as suggesting the need for providing support to the migrant workers in terms of cash by money transfers to further mitigate their woes. Full sentences related to these terms were extracted. Some of the prominent ones include, "Contribution of migrants labourers to Indian economy is humungous and they deserve better treatment and facilities", "Centre and State Govt should come together to support Migrant Workers and provide cash relief!" "A package is ready for the poor who need immediate help like migrant workers and urban and rural poor. No one will go hungry. The package is worth Rs. 1.7 trillion: Finance Minister Nirmala Sitharaman". --- Implications of Reverse Migration on Cities 1. Continuous large-scale reverse migration of labour would result in severe scarcity of semiskilled and unskilled workers in all the urban centres across the country. 2. Businesses which are operating in the organized sector would face major difficulties in resuming operations. 3. Labour-intensive sectors are likely to feel the pain to a greater extent. 4. Less supply of labour could lead to an inevitable rise in wage rates. --- Implications of Reverse Migration on the Migrant Workers 1. The desire and the ability of the migrant labour to return to work after the lockdown is lifted remains to be seen. Their decisions could be driven by a number of factors. a. Extent of pandemic-related fears in metro cities, b. Ease of mobility in the country after the lockdown is lifted. c. Having experienced the worst in cities, there is a strong realization amongst them that the cost of living in rural areas is only a third of what it is in the city. d. Some migrant workers might be owning small tracts of dry land. With small investment, this land could be turned into a productive fertile ground. The employment opportunities that are available in the rural sector and the extent to which these workers can be successfully absorbed in the agrarian sector would be dependent upon the support extended by the State Government, cropping cycles and their skill-set. --- 3 The Indian Journal of Labour Economics 64:731-747 --- ISLE In case support is provided, they could invest in fertilisers, irrigation infrastructure, transportation and other components required to grow and sell produce in their own land. An effort to help them with financial planning and investing in skill development programmes for these workers, would facilitate the integration of these migrants into the rural economies. Rashtriya Krishi Vikas Yojana, Universities of Agricultural Sciences, National Mission for Sustainable Agriculture, Krishi Vigyan Kendras and the Agriculture Skill Council of India could aid in this. --- The Way Forward In addition to the policy measures adopted by the Central Government, the States should view the demographic shift due to the reverse migration as an opportunity to revamp rural infrastructure. These workers can be productively employed in labour-intensive activities, such as small-scale agro-based industries, livestock, food and fodder processing, water management systems, nurseries and seed banks in the States. The present scenario is providing an opportunity to decongest cities. In this context, Government can take into account Mahatma Gandhi's advice to first develop the rural economy in order to make it self-sufficient. The migrant labour would then have the option of deciding whether to remain in the villages or move to the cities. However, on the flip side, 70% of India's population is dependent upon the rural economy but contributes 48% of Net domestic product, as on 2015-2016, according to the latest labour survey of 2017-2018. This suggests that the productivity of the workforce is lower in rural areas. Further, there is over dependence on agriculture, with low diversification. Therefore, creating more employment in rural areas would be tough. According to a study by RBI in 2014, the income elasticity for the agriculture sector is 0.04 during 1999-2009. This implies that to bring about an increase of 1% in employment, this sector needs to have a growth of 25%, which is quite unrealistic considering the average growth of only 3.34% in 2017-2018 based on data from Central Statistical Organization. The manufacturing and construction sectors, which constitute about 17% and 10%, respectively, of the net domestic product, can help absorb the additional labour. The estimated elasticity of manufacturing sector is 0.09 as against that of construction sectors at 1.13. Therefore, the construction sector can help absorb the migrant labour, and the State Government should provide employment opportunities in these two sectors. Increase in manufacturing activities will also help in increasing economic growth of the country. The State Governments of UP and Bihar have a tough task in hand. According to Census 2011, 23% of interstate migrants are from Uttar Pradesh and 14% are from Bihar. At the same time, rural unemployment rates of these states are at 6% and 7%, as per Periodic Labour Force Survey. These two states have the highest rates of rural poverty, as nearly 37% of India's poor live in these two states. The State Governments have initiated steps to tide over this crisis and to transform this tragedy into an opportunity. Bihar government has started skill profiling exercise for the returning migrants so that this data can be utilized by them to create employment opportunities for the utilization of their skills and development of the State. Similarly, the government of UP has also initiated steps to map details of migrants and their skillsets. The government would then provide training to them, ensure social security, employment and loan facilities for these migrants. The Central and State Governments are taking measures to respond to this challenge. A step taken by the Government in this direction is the announcement of the Garib Kalyan Rojgar Abhiyan scheme of Rs. 50,000 crore on 20 June 2020, wherein 25 different projects in 116 districts across six states will create job opportunities for these migrant workers. Thus, it is imperative on the part of policy makers at both these levels to scale up the responses as the challenges unfold. This is mandatory to minimize the damage and shock caused by this pandemic on the formal and informal sectors. This could help pave the way for a V-or U-shaped recovery for the Indian economy at large and help restart the journey back on the road to rapid economic growth that India has been treading on for more than over two decades. --- Limitations The researchers have only sampled the trending hashtag of "#IndianMigrant-Worker" and "#MigrantWorker and Indian Economy" to collect Twitter data. Some new hashtags could have become new trending terms for Twitter users over time. Another, major limitation could be that Twitter users are not the representative of the whole population. The opinions and views included in the present study are indicative of only users' opinions and reactions. Since, the non-English tweets have been removed from analysis, results could bring out a new perspective if we include tweets of Hindi and other Indian languages. --- Appendix 1 See Table 1. --- 3 The Indian Journal of Labour Economics 64:731-747 --- ISLE --- Table 1 Themes, topic components and sample tweets Theme Topic components Sample tweets within themes Rescue operation Special Train, Shramik Express, Piyush Goyal "…Shramik Special Trains is savior to Migrant Labourers who lost their livelihood due to lockdown…" "To provide relief to migrant labour, Indian Railways is ready to run "Shramik Special" trains from any District in the Country…" "…Despite all constraints and challenges, the administration has worked hard to see that migrants reach their homes safely…" "…All will be brought from 1000 trains…" Help to migrants Labourer buses, sending home "…bus for migrant workers …"; "… Day 14 of food Distribution drive…" "…volunteers prepared 1200 food-kits to support…" "…:Charan Paduka campaign for migrant labourers launched…" "…Reporter's gift of shoes to migrant goes viral…" "…distributed food packs to passengers at New Delhi railway station..." Self-reliance Economic package, atma-nirbhar "…The significant number of bold structural reforms under the #AatmaNirbharBharatPackage hold the potential…" "…States can't hire workers from UP without UP govt permission…" "…lays down stringent conditions for ensuring social security of workers from UP hired by other states…" "…Time to became #Atamnirbharbharat so that nobody have to go far away from their home to find bread and butter for their family…" Horrible Tragedy World Crisis, Scale, Tragedy "…Country facing: Pandemic, Economic Slowdown, Jobloss, Migrant Crisis…" "…The cyclone comes as tens of thousands of migrant workers continue to flee cities for their villages during India's lock…" "…India is facing crisis in many fields: coronavirus, health and economic crisis..." --- Lockdown worries Lockdown triggered, 8 weeks "…Migrant workers have been turned desperate…" "…People like to be with their loved ones in times of distress, even those who were being provided food and those who can feed themselves wanted to go back because of the fear of the unknown…" "…Redevelopment project -at a time when the Government & people of India are suffering from an unprecedented crisis…" "…the country was shut down in a couple of hours -putting millions of people through an ordeal that will be remembered for generations…" --- Appendix 2 Some of the policy measures announced by the Central Government to help them tide over this crisis are: 1. The National Disaster Management Authority has introduced the online dashboard called "National Migrant Information System ". The purpose is to monitor the movement of migrant workers and help track the migrant movement to their native places. 2. Comprehensive effort by the GOI to create a database of migrant workers spread across the country. Three primary sources are being considered for this data: relief camps/shelters as per districts, including camps run by non-government bodies and companies; from the employer's premises and also from the clusters in which they reside. This will enable the government to identify migrants who have Aadhar cards, bank accounts and are receiving the benefits of free gas cylinders. Further, this consolidated data would be segregated according to their occupations. The whole exercise would be managed by the district administrations in states with the labour commissioners. 3. The Finance Minister has announced a 65 per cent increase in allocation for MGNREGA in this fiscal. This has been initiated with an aim to help migrant workers find a means to earn their livelihood in their home states. Additional Rs 40,000 crore, has been allocated. Further, the total number of working days have been increased to 300 crore man-days. This has been initiated so that State Governments are able to provide employment to those labourers back home and also employ them during the monsoon season. Work would be provided by States in plantations, horticulture, livestock-related work, etc. 4. The government has promised a free supply of 5 kg of foodgrain per person and 1 kg channa per family per month for two months, for those migrants who are neither beneficiaries of the National Food Security Act , or NFSA, nor possess State cards. The government expects eight crore migrants to benefit from this scheme, and the Centre will spend ₹3,500 crore on this. States will be in charge of implementation and distribution. 5. The Central Government is also providing benefits under the "One Nation One Ration Card scheme". Under this scheme, the migrant workers can have access to food in States other than that of their permanent residence. 6. NABARD would provide additional refinance support of Rs. 30,000 crores to rural cooperative and regional banks for crop loan. 7. Special credit facility for street vendors of 5000 cr 8. 2.5 crore farmers would be provided Kisan Credit Card and can avail of the benefit of concessional loans that are provided through the card. These would include fisherman and animal husbandry farmers. Funding There was no outside funding or grants received that assisted in this study. --- 3 The Indian Journal of Labour Economics 64:731-747 --- ISLE ---

The Coronavirus pandemic has induced a huge economic crisis. The norms of social distancing and consequent lockdown to flatten the curve of this infection has brought economic activity across the globe to a standstill. A mass exodus of workers from major urban centres of India to their native villages started. Mental, financial and emotional agony inflicted due to job-loss, lack of job and livelihood opportunities led to this. A massive macroeconomic crisis for the country with serious ramifications has consequently exploded. The present study explores and captures the diffusion and discovery of information about the various facets of reverse migration in India using Twitter mining. Tweets provide extensive opportunities to extract social perceptions and insights relevant to migration of workers. The massive Twitter data were analysed by applying text mining technique and sentiment analysis. The results of the analysis highlight five major themes. The sentiment analysis confirms the confidence and trust in the minds of masses about tiding through this crisis with government support. The study brings out the major macroeconomic ramifications of this reverse migration. The study's findings indicate that a concentrated joint intervention by the State and Central Governments is critical for successfully tiding through this crisis and restoring normalcy. The subsequent policy measures announced by the government are being critically gauged. In addition, the authors have proposed measures to ameliorate this damage on the formal and informal sectors.

introduction the coronavirus outbreak which can also be termed as a black swan event has disrupted the rapid economic growth of countries globally tracing back history the spanish flu of 1918 had hard hit the world which resulted in loss of lives of 50100 million globally with india suffering the highest fatality of 18 million lives to diminish the havoc that such a pandemic can inflict on the lives of people the indian government imposed a nationwide lockdown effective 25 march 2020 the shortcoming of any lockdown is that economic activity comes to a complete standstill based on lack of economic activity imf in the world economic outlook projected the growth numbers for india 20202021 to be at 19 due to disruptions in demand and supply chains world banks estimates show that indian economic growth is likely to be in the range of 155 to 28 in 20202021 growth projections forecasted by the international monetary fund for the global economy have been revised from 33 to a contraction of 3 along with this health and wellbeing of millions of people have been at risk researches are being conducted in several parts of the world to discover a vaccine and possible treatment of the virus however the possibility and viability of this being successfully done is not very clear or visible in near future the only possible means or option available to survive the pandemic infection and reduce the spread of the infection is to implement social distancing and live in a controlled environment the virus has also been instrumental in sparking a huge economic crisis it has simultaneously adversely impacted the supply ie production of goods services and the demand ie consumption investment exports and imports the economic damage due to this health crisis is likely to affect more people in india than the disease q1 2020 has been negatively impacted by the lockdown q2 and q3 are expected to be riddled with consumption levels being at an alltime low business investments declining and exports gradually pointing downwards resulting in an adverse impact on the indian economy as the covid19 cases in india were seen to be rising the lockdown was announced to flatten the curve of this infection and reduce the spread of this infectious disease by breaking important chains of transmission india chose to sacrifice its economy and save livesजान है ं तो जहान है ं therefore it implied that all economic and social activities which require physical presence were either postponed or brought to a halt in its tracks the recovery curve as being forecasted by analysts and economists is ranging from a best case scenario of vshaped recovery curve to u w or l a vor ushaped curve is associated with the timing and extent of stimulus provided by the government and how companies and market structures are able to cope with decreasing demand with the number of coronavirus cases in india on the rise the lockdown has been extended four times and is in force till 31 may 2020 as of date early lockdown announced by the government of india helped slowdown the spread of the infection in the country however it has raised issues of escalating inequalities 1 3 the indian journal of labour economics 64731747 isle and susceptibilities of marginalized communities within the country this lockdown and its subsequent extensions has resulted in disrupting life of all the lockdown caused confinement of millions of citizens in their homes businesses across the length and breadth of the country were shut and nearly all economic activity was stopped thereby negatively impacting workforce employed in both the formal and informal sectors construction sites were abandoned after the announcement of lockdown at the same time most of the residential societies and colonies shut their gates for all but the residents the prominent sectors which employ migrant workers who are essentially members of the informal economy are construction and building industry manufacturing units trade setups transport and hospitality also some of these migrant workers might work as domestic helpers street vendors workers in tiny and roadside businesses or as help in salons and gyms as per an estimate of centre for monitoring indian economy nearly 122 million people in india were jobless in april 2020 itself of which a large majority are small traders and wage labourers thus this precarious situation has resulted in serious crisis and dislocation for migrant workers according to the economic survey of 20182019 the informal economy is constituted of 93 workers census 2011 suggests that there are 450 million internal migrants in india the actual numbers currently are likely to be much higher than these figures primarily two types of migrations are common in india the first being longterm migration which is attributed to the resettlement of an individual or household the second being essentially shortterm or seasonalcircular migration which implies to and fro movement between a source and destination approximately 175 million migrants in india are those who travel for work in the informal sector they are the lifeline of many state economies this pandemic and the subsequent lockdowns have forced several amongst these workers accompanied by their families to seek shelters in government run relief camps for food and basic needs indian central and state governments have been setting up of additional relief camps for them to live the migrant workers have been through enormous mental financial and emotional agony in urban centres and industrial belts and are migrating back to their native villages in enormous numbers the agony of these workers has been due to many fold reasons such as lack of jobs and livelihood absence of social security and being stranded in an alien city and state the absence of public transportation during the lockdown compelled these stranded migrant workers to try to travel by foot or on bicycle to cover hundreds of kilometres back to their native homes in villages the imposing of lockdown by the central government has precipitated a huge reverse migration from the destination to source in large parts of india as per some estimates more than 120 to 140 million workers are on their way back to the villages review of literature india as a country prior to the onset of this health crisis was already facing a decline in gdp growth and an increase in unemployment rates there was a demand slowdown and the lockdown further worsened the demand and supply decline in the economy global recession and trouble in global supply chains are further aggravating the already disrupted domestic supplies and demand both the formal and informal sectors would have to bear the brunt of this crisis coronavirus in india has caused unique challenges for the country the large population of 13 billion living in diverse states with differing levels of health infrastructure social cultural and economic inequalities are the major reasons for this the readiness of state governments to deal with the virus has differed substantially having faced the nipah virus in 2018 kerala resorted to extensive testing contact tracing etc to minimize the spread similarly odisha as a state has witnessed several natural disasters and adequate measures were taken by state government to deal with it migration can be regarded as movement of people from one place to another for a certain period of time the lockdown resulted in manufacturing being brought to a standstill and disruption of the supply chain due to the countries dependence on the supply of intermediate goods from china therefore production was stopped even though workers and capital both were present in the cities further the demand for goods and services in the economy falls other than that for essential goods the domino effect operates to worsen the situation this segment of the population has hardly any access to savings resulting in worsening their misery these workers are the ones who are migrating from the cities to the villages in the hope that at least food and essentials would be available in the village based on the researches conducted it is seen that majority of the investigations related to the impact of the outbreak of pandemic belong to the health sector and economy it is being increasingly felt that more indepth analysis is required to understand the magnitude of the challenges that this pandemic along with a declining gdp growth rate in india has inflicted on the condition of the migrant workers thereby impacting inequality levels in the economy it is also imperative to analyse if the public policy measures adopted by the government are adequate to mitigate the challenging conditions being faced by these workers or is there need for additional economic policy announcements by the government of india the current research aims to delve into assimilating available information in twitter with regard to the plight of indian migrant workers due to covid 19 and a lower economic growth and analyse the same with the objective of identify the responses of people with reference to challenges being faced by the migrant workers in india due to the covid 19 pandemic and the subsequent lockdown that was imposed along with an anticipated declining economic growth critically evaluate the policy responses announced by the government of india to benefit the migrant workers suggest additional economic policy measures that can be undertaken by the government for these workers which can thereby lead to reduction in the widening economic inequality gap the current study will give 1 3 the indian journal of labour economics 64731747 isle a birds eyeview of the impact of covid 19 and declining indian growth rates on the predicament faced by migrant workers it will also analyse the economic policy measures adopted by the government and suggest policy changes to lessen the misery and challenges faced by these workers material and methods text mining assists in knowledge extraction from an unstructured pool of textual data this tool has been accepted widely by researchers and analysts as an analytical tool for analysing data it is machine learning and natural language processing which has enabled the process of mining data to identify patterns and topics in the text text mining enables researchers to extract highquality information and evidence with the help of computational tools and techniques from a large quantity of unstructured data this process of data analysis and theme extraction is also known as knowledge discovery and is supported by machine analysis of text the process of finding knowledge in data is known as knowledge discovery in databases it has been defined by as the nontrivial process of identifying valid novel potentially useful and ultimately understandable patterns in data kdd has a multidimensional method which constitutes activities from data collection to knowledge interpretation the present study follows the kkd process of text mining for the meta trend analysis of textual data ie the compendium of tweets related to indian migrant workers to analyse the impact of covid 19 and consequently declining economic growth on the conditions of migrant workers in india data collection covid 19 has proven to be a major social event which has created huge ramifications for our social system a qualitative approach has been used to enable researchers to capture deeper meanings from the dataset this included labelling popular terms and tweet topics assigning meaning and themes to the topics and interpreting them to identify the latent issues generated the researchers therefore implemented qualitative analysis a useful method for analysing this social phenomenon it is characterized by the systematic process of coding the data to understand the meaning and description of the social reality by identifying the inherent theme twitter data can be used to study attitude trend tracking and population health the use of social media data enables researchers to gather reports of behaviours and views that are unsolicited and unprompted by the researcher at the same time social media provides the opportunity to spot personal expression and human interaction in real time and on a massive scale twitter is one of the social networking sites being used extensively since it enables all to share and express concerns and views on topics of relevance trending hashtags related to the problem of migrant labour such as indianmigrantworkers were used as key search terms to collect tweets on twitter the data were downloaded from twitter with the help of the twitter api authentication process using oauth package of r tweets published between 23 march 2020 and 21 may 2020 a total of nearly 50000 tweets have been downloaded and are the dataset for the present study data cleaning and preprocessing on the downloaded data from twitter text mining technique was applied for the purpose of automated information extraction from unstructured text data it is a scientific process of deriving trends from unstructured textual data and helps gain an insight into the themes of the dataset and examine the dynamics of the study the data noisiness was cleaned with the help of the rprogramming and statistical software in this package r data cleaning is completed by means of the library package tm after removing all noise and cleaning of the data the preprocessing of the corpus was completed thereafter it involved transforming the preprocessed text into a structured format for actual computation data transformation on obtaining the structured cleaned corpus it was transformed into a termdocumentmatrix the termdocumentmatrix is a mathematical matrix which helps describe the frequency of terms that occur in a structured dataset the rows tally to documents in the structured text while columns correspond to the terms the goal of the termdocumentmatrix is to characterize the topic of a document by the frequency of semantically significant terms establishing trustworthiness in the present study two researchers were involved in separately interpreting the clusters of tweets that have been formed using unsupervised machine learning to ensure interrater reliability the researchers separately labelled the clusters and that became the theme to which that cluster represented results data mining the transformed matrix was subsequently used for analysis of data data analysis was done based on three models the first being wordcloud second being topic modelling 1 3 the indian journal of labour economics 64731747 isle and third being sentiment analysis word cloud or tag clouds are graphical visual depictions of word frequency and provide larger visibility to those words which are more frequently used in the tweets and text it has been defined as the visual representation of words for a certain written content structured as per its frequency the study by sinclair and cardewhall states that word cloud is an initial stage for an exhaustive analysis of certain text material thus postword cloud visualization topic modelling of the themes and topics was done for an indepth investigation of the tweets advancement in natural language processing and machine learning has led to the development of a probabilistic framework text mining approach called topic modelling it enables researchers to establish and encapsulate electronic archives at a scale that would be impossible by human annotation and use algorithms for discovering the main themes that pervade a large and unstructured collection of documents it uses the primary technique of latent dirichlet allocation and is akin to discrete pca ie principal component and factor analysis lda and other topic models are part of the larger field of probabilistic modelling the dataset is analysed into a few topics the graphical representation helps understand the topics that are extracted from the tweets the topics may contain words from several topics in different proportions ie in a two topic document it can be interpreted that document 1 is 80 topic a and 20 topic b while document 2 is 35 topic a and 65 topic b the identified topics were deliberated upon by two domain experts from the field to interpret the data the two experts labelled these topics and identified the theme to which the topic belongs sentiment analysis sentiment analysis or opinion mining has been defined as the computational study of opinions sentiments and emotions expressed in text it can be regarded as a form of text analysis that helps to extract and analyse opinion oriented text to determine positive and negative views opinions about an event productperson or topic a large mass of people express their views on various aspects freely on twitter therefore these tweets can be regarded as useful source of information to infer peoples opinion on pertinent social issues as an important method for undertaking social media research sentiment analysis can be regarded as a computational and natural language processingbased method to scrutinize the prominent sentiments and emotions of people in the given texts in the present study based on the nrc emotion lexicon the sentiment analysis has been done two sentiments and eight basic emotions that are associated with english words and languages characterize the nrc emotion lexicon the syuzhet package in r was used to capture peoples emotions in text 1 3 isle data interpretation and knowledge discovery word cloud the word cloud consists of the most used words from the tweets which mentioned indian migrant labour the prominent or keywords figuring repetitively in the tweets and communicating the sentiments of the people are represented graphically in the graphic based on the frequency of occurrence in the text the more prominent words appear larger in size and bold creating a visual emphasis the image highlighted three words prominently india migrant and workers indicating that the migrant workers have been adversely impacted in india in terms of how these migrant workers were impacted words like tragedy horrible scale crisis and torturing emerged as major terms additionally in terms of help extended to the migrant workers words such as shramik railways trains and buses emerged these terms were further explored in detail by the researchers by examining full sentences in tweets one tweet suggested in india migrants are from indian villages that work in the cities have been affected by this 1 3 the indian journal of labour economics 64731747 isle horrible tragedy similarly some others are related to relief measures modi govt arranged hundreds of special trains for migrant workers indian government arranges special trains and buses to help stranded migrant workers topic modelling topic modelling analysis of twitter data was done to identify the key themes representative of public sentiment related to the migrant labourers in india these represent the main topics or key phrases that emerged from the tweets on the social platform related to reverse migration of workers after the lockdown the two researchers subsequently discussed the terms and sample tweets in the five topics that emerged and categorized them into common themes to protect the privacy and anonymity of the twitter users of these sample tweets the researchers have used either excerpts of tweets or paraphrased them in the message table 1 in appendix 1 presents the results of identified five salient topics most popular words within each topic and some sample tweets related to each topic sentiment analysis the above plot shows that tweets are more related to trust and fear this suggests that though there is confidence and trust in the minds of masses about tiding through this crisis with government support however a fear element is also present people do have some negative feelings on twitter however positive sentiments are more prominent than the negative emotions but overall people on twitter are optimistic about the positive outcomes of reverse migration the possible reason for the optimism in the masses could be that the tweets include ones related to the rs 20 trillion economic package announced by the finance minister to provide a boost to the economy discussion and conclusion the results of the analysis highlight five major themes of discussion on the one hand the discussion reflects the rescue operations help being provided and the government relief package to bring about selfreliance and selfsufficiency on the other hand the scale of this unforeseen tragedy and the pain due to the lockdown imposed to ensure social distancing with the aim to curb the spread of the pandemic is seen these could be the primary factors for the shift in prime ministers address during the announcement of second lockdown in the first lockdown he emphasized the importance ofजान है ं तो जहान है ं while in the second the direction that he gave to his countrymen was of जान भी और जहान भी दोनो है जरू री this indicates the desire of the government to focus on revival of economic activities and start the production and economic process in a manner that the fight against the virus is also not affected and the economy moves gradually back to normalcy with caution 3 the indian journal of labour economics 64731747 isle …a future where people care about both the aspects follow their duties and abide by the directions of the government this will be important for indias prosperous and healthy future pm narendra modi as seen in the topics identified the pandemic which initially started as a medical emergency has now evolved into an economic calamity with severe ramifications for all sections of society workers in the informal sectors have been hit very badly because of the lockdown measures implemented by the government in a bid to contain the spread of the pandemic majority of them have migrated back to their native villages and have no means of livelihood and no savings it is very important to protect and help them to tide over the shock a concentrated joint effort by the state and central governments working hand in hand is critical to the country successfully overcoming this crisis and restoring normalcy central government has announced a major relief package to help the rehabilitation drive of migrant workers ensuring that they become आत् मनिर् भर ie selfreliant in their native villages these policy measures include key measures both short term and long term to help them ride through the present crisis the details have been included as appendix 2 post the announcement of policy measures of rs 20 trillion announced by the finance minister tweets via the hashtag migrantworker and indian economy related to peoples reactions on the stimulus provided for migrant workers and indian economy was further analysed and a word cloud was created this word cloud highlights some words prominently migrant administration accept sanctions and impose these highlight the important measures initiated by the administration to tide over the crisis also other key words like cash transfers contribution deserve can be regarded as suggesting the need for providing support to the migrant workers in terms of cash by money transfers to further mitigate their woes full sentences related to these terms were extracted some of the prominent ones include contribution of migrants labourers to indian economy is humungous and they deserve better treatment and facilities centre and state govt should come together to support migrant workers and provide cash relief a package is ready for the poor who need immediate help like migrant workers and urban and rural poor no one will go hungry the package is worth rs 17 trillion finance minister nirmala sitharaman implications of reverse migration on cities 1 continuous largescale reverse migration of labour would result in severe scarcity of semiskilled and unskilled workers in all the urban centres across the country 2 businesses which are operating in the organized sector would face major difficulties in resuming operations 3 labourintensive sectors are likely to feel the pain to a greater extent 4 less supply of labour could lead to an inevitable rise in wage rates implications of reverse migration on the migrant workers 1 the desire and the ability of the migrant labour to return to work after the lockdown is lifted remains to be seen their decisions could be driven by a number of factors a extent of pandemicrelated fears in metro cities b ease of mobility in the country after the lockdown is lifted c having experienced the worst in cities there is a strong realization amongst them that the cost of living in rural areas is only a third of what it is in the city d some migrant workers might be owning small tracts of dry land with small investment this land could be turned into a productive fertile ground the employment opportunities that are available in the rural sector and the extent to which these workers can be successfully absorbed in the agrarian sector would be dependent upon the support extended by the state government cropping cycles and their skillset 3 the indian journal of labour economics 64731747 isle in case support is provided they could invest in fertilisers irrigation infrastructure transportation and other components required to grow and sell produce in their own land an effort to help them with financial planning and investing in skill development programmes for these workers would facilitate the integration of these migrants into the rural economies rashtriya krishi vikas yojana universities of agricultural sciences national mission for sustainable agriculture krishi vigyan kendras and the agriculture skill council of india could aid in this the way forward in addition to the policy measures adopted by the central government the states should view the demographic shift due to the reverse migration as an opportunity to revamp rural infrastructure these workers can be productively employed in labourintensive activities such as smallscale agrobased industries livestock food and fodder processing water management systems nurseries and seed banks in the states the present scenario is providing an opportunity to decongest cities in this context government can take into account mahatma gandhis advice to first develop the rural economy in order to make it selfsufficient the migrant labour would then have the option of deciding whether to remain in the villages or move to the cities however on the flip side 70 of indias population is dependent upon the rural economy but contributes 48 of net domestic product as on 20152016 according to the latest labour survey of 20172018 this suggests that the productivity of the workforce is lower in rural areas further there is over dependence on agriculture with low diversification therefore creating more employment in rural areas would be tough according to a study by rbi in 2014 the income elasticity for the agriculture sector is 004 during 19992009 this implies that to bring about an increase of 1 in employment this sector needs to have a growth of 25 which is quite unrealistic considering the average growth of only 334 in 20172018 based on data from central statistical organization the manufacturing and construction sectors which constitute about 17 and 10 respectively of the net domestic product can help absorb the additional labour the estimated elasticity of manufacturing sector is 009 as against that of construction sectors at 113 therefore the construction sector can help absorb the migrant labour and the state government should provide employment opportunities in these two sectors increase in manufacturing activities will also help in increasing economic growth of the country the state governments of up and bihar have a tough task in hand according to census 2011 23 of interstate migrants are from uttar pradesh and 14 are from bihar at the same time rural unemployment rates of these states are at 6 and 7 as per periodic labour force survey these two states have the highest rates of rural poverty as nearly 37 of indias poor live in these two states the state governments have initiated steps to tide over this crisis and to transform this tragedy into an opportunity bihar government has started skill profiling exercise for the returning migrants so that this data can be utilized by them to create employment opportunities for the utilization of their skills and development of the state similarly the government of up has also initiated steps to map details of migrants and their skillsets the government would then provide training to them ensure social security employment and loan facilities for these migrants the central and state governments are taking measures to respond to this challenge a step taken by the government in this direction is the announcement of the garib kalyan rojgar abhiyan scheme of rs 50000 crore on 20 june 2020 wherein 25 different projects in 116 districts across six states will create job opportunities for these migrant workers thus it is imperative on the part of policy makers at both these levels to scale up the responses as the challenges unfold this is mandatory to minimize the damage and shock caused by this pandemic on the formal and informal sectors this could help pave the way for a vor ushaped recovery for the indian economy at large and help restart the journey back on the road to rapid economic growth that india has been treading on for more than over two decades limitations the researchers have only sampled the trending hashtag of indianmigrantworker and migrantworker and indian economy to collect twitter data some new hashtags could have become new trending terms for twitter users over time another major limitation could be that twitter users are not the representative of the whole population the opinions and views included in the present study are indicative of only users opinions and reactions since the nonenglish tweets have been removed from analysis results could bring out a new perspective if we include tweets of hindi and other indian languages appendix 1 see table 1 3 the indian journal of labour economics 64731747 isle table 1 themes topic components and sample tweets theme topic components sample tweets within themes rescue operation special train shramik express piyush goyal …shramik special trains is savior to migrant labourers who lost their livelihood due to lockdown… to provide relief to migrant labour indian railways is ready to run shramik special trains from any district in the country… …despite all constraints and challenges the administration has worked hard to see that migrants reach their homes safely… …all will be brought from 1000 trains… help to migrants labourer buses sending home …bus for migrant workers … … day 14 of food distribution drive… …volunteers prepared 1200 foodkits to support… …charan paduka campaign for migrant labourers launched… …reporters gift of shoes to migrant goes viral… …distributed food packs to passengers at new delhi railway station selfreliance economic package atmanirbhar …the significant number of bold structural reforms under the aatmanirbharbharatpackage hold the potential… …states cant hire workers from up without up govt permission… …lays down stringent conditions for ensuring social security of workers from up hired by other states… …time to became atamnirbharbharat so that nobody have to go far away from their home to find bread and butter for their family… horrible tragedy world crisis scale tragedy …country facing pandemic economic slowdown jobloss migrant crisis… …the cyclone comes as tens of thousands of migrant workers continue to flee cities for their villages during indias lock… …india is facing crisis in many fields coronavirus health and economic crisis lockdown worries lockdown triggered 8 weeks …migrant workers have been turned desperate… …people like to be with their loved ones in times of distress even those who were being provided food and those who can feed themselves wanted to go back because of the fear of the unknown… …redevelopment project at a time when the government people of india are suffering from an unprecedented crisis… …the country was shut down in a couple of hours putting millions of people through an ordeal that will be remembered for generations… appendix 2 some of the policy measures announced by the central government to help them tide over this crisis are 1 the national disaster management authority has introduced the online dashboard called national migrant information system the purpose is to monitor the movement of migrant workers and help track the migrant movement to their native places 2 comprehensive effort by the goi to create a database of migrant workers spread across the country three primary sources are being considered for this data relief campsshelters as per districts including camps run by nongovernment bodies and companies from the employers premises and also from the clusters in which they reside this will enable the government to identify migrants who have aadhar cards bank accounts and are receiving the benefits of free gas cylinders further this consolidated data would be segregated according to their occupations the whole exercise would be managed by the district administrations in states with the labour commissioners 3 the finance minister has announced a 65 per cent increase in allocation for mgnrega in this fiscal this has been initiated with an aim to help migrant workers find a means to earn their livelihood in their home states additional rs 40000 crore has been allocated further the total number of working days have been increased to 300 crore mandays this has been initiated so that state governments are able to provide employment to those labourers back home and also employ them during the monsoon season work would be provided by states in plantations horticulture livestockrelated work etc 4 the government has promised a free supply of 5 kg of foodgrain per person and 1 kg channa per family per month for two months for those migrants who are neither beneficiaries of the national food security act or nfsa nor possess state cards the government expects eight crore migrants to benefit from this scheme and the centre will spend ₹3500 crore on this states will be in charge of implementation and distribution 5 the central government is also providing benefits under the one nation one ration card scheme under this scheme the migrant workers can have access to food in states other than that of their permanent residence 6 nabard would provide additional refinance support of rs 30000 crores to rural cooperative and regional banks for crop loan 7 special credit facility for street vendors of 5000 cr 8 25 crore farmers would be provided kisan credit card and can avail of the benefit of concessional loans that are provided through the card these would include fisherman and animal husbandry farmers funding there was no outside funding or grants received that assisted in this study 3 the indian journal of labour economics 64731747 isle

the coronavirus pandemic has induced a huge economic crisis the norms of social distancing and consequent lockdown to flatten the curve of this infection has brought economic activity across the globe to a standstill a mass exodus of workers from major urban centres of india to their native villages started mental financial and emotional agony inflicted due to jobloss lack of job and livelihood opportunities led to this a massive macroeconomic crisis for the country with serious ramifications has consequently exploded the present study explores and captures the diffusion and discovery of information about the various facets of reverse migration in india using twitter mining tweets provide extensive opportunities to extract social perceptions and insights relevant to migration of workers the massive twitter data were analysed by applying text mining technique and sentiment analysis the results of the analysis highlight five major themes the sentiment analysis confirms the confidence and trust in the minds of masses about tiding through this crisis with government support the study brings out the major macroeconomic ramifications of this reverse migration the studys findings indicate that a concentrated joint intervention by the state and central governments is critical for successfully tiding through this crisis and restoring normalcy the subsequent policy measures announced by the government are being critically gauged in addition the authors have proposed measures to ameliorate this damage on the formal and informal sectors

INTRODUCTION People with chronic kidney disease are immersed in a series of life changes that influence the way they think and act. In addition to the physical damage caused by kidney disease, patients suffer psychological pain and abrupt modifications to their daily lives . This series of problems tends to worsen in the final stages of this disease when patients must initiate haemodialysis. Living with a chronic disease forces the suff ers to centralize their activities around the illness and its treatment, since the haemodialysis that guarantees the adequate physiological conditions requires regular weekly sessions . The resulting phenomenon causes concern and daily confrontations, which also lead suff erers to incorporate knowledge that assumes a dynamic form anchored on beliefs and perceptions. These beliefs in relation to the disease help patients experience illness in a singular manner and consequently manage their care . Furthermore, the experience of illness brings new encumbrances to kidney disease patients and the possibility to voice their judgement on how to cope and live with these problems. A study on the representations of chronic kidney disease reveals the intensity of losses, suff ering and anguish experienced by these patients, and highlights the significance of illness and the indivisibility between care practices and the psycho-aff ective and social relationships in their lives . Social representations have also been useful for investigating the perceptions of care and adherence to treatment of haemodialysis patients . An understanding of the representational and consensual universe of people who experience the fi nal stages of chronic kidney disease should help these patients express their needs and receive specifi c healthcare. This understanding allows them to defi ne their desires, diffi culties, attitudes and emotions in relation to the disease process. Knowledge of the representations of kidney disease and its infl uence on the various aspects of the elaborate and shared experience should support an understanding on how these people perceive the illness and how care and care practices to control this disease can become a part of their daily lives . The guiding question was: What are the social representations of people with chronic kidney disease on the illness process? To answer this question, the aim of this study is to describe the social representations of people with chronic kidney disease undergoing haemodialysis on the illness process. --- METHOD This is a descriptive study based on the qualitative approach, anchored on the Social Representations Theory created by Serge Moscovici that defi nes social representations as forms of practical knowledge by means of common sense. These representations establish an order that guides individuals in their social and material world, and enables the consequent communication among members of the same group . The Social Representations Theory addresses an object that is socially shared by a group and confers meaning to collective and individual experiences. It also articulates the practices and helps sustain the social identity of a group. Consequently, the SRT involves, as a criterion, the existence of an object or something that is being investigated, and the existence of a subject, something that represents the investigated object . In the case of this study, the subjects are people with diagnosed chronic kidney disease and the object is the renal illness. The study scenario was a healthcare organization, in the hospital and out-patient environment, that provides renal replacement therapy in the municipality of Ponta Grossa . The organization is considered a benchmark in healthcare for chronic kidney disease among users of the Unifi ed Health System , health plans and private patients. The patients who use the haemodialysis service also come from surrounding municipalities and regions. Of the 100 patients with diagnosed chronic kidney disease, 23 were included in the study because they fully met the criterion of inclusion. These 23 patients were between the ages of 18 and 60, both sexes, had been undergoing haemodialysis for more than one year, and were aware of their acts and eager to participate in the study. Those who did not meet the criterion for inclusion were excluded. The participants were selected with the help of healthcare professionals of the haemodialysis service. Data were collected by means of individual semi-structured interviews recorded on an audio device at the nephrology service, in a private room, from February to November 2012. The duration of the interviews was between 20 and 30 minutes. The interview script was previously tested and recreated using closed questions related to participant characterization, such as age, sex, marital status, schooling, profession, and time of haemodialysis. The script also had open questions based on the discovery of the disease and emotions in relation to the diagnosis and the resulting life changes. The interviews were transcribed and submitted to category content analysis in three stages: pre-analysis, analysis unit selection and categorization . The interview scripts were then read repeatedly to better understand the content and identify the emerging meaning units. These units were organized, interpreted and analysed based on the respective statements that revealed the meaning and perception of the individuals who had chronic kidney disease and were undergoing haemodialysis. In observance to the ethical and legal aspects of the National Health Council , the research project was submitted to the Ethics Committee of the Health Sciences Sector at the Universidade Federal do Paraná , and approved under protocol CEP/SD nº 1216.141.11.09. Prior to conducting the interviews, the script was presented to each subject, together with the objectives, method, risks and benefi ts of the study. The patients subsequently signed an informed consent statement to participate in the study. In order to respect the commitment of protecting the privacy of each participant, they were identifi ed with the letter "P" and the order of the interviews, namely 1 to 23. This study was extracted from the master´s dissertation, "The Social Representations of Chronic Kidney Disease" . --- RESULTS AND DISCUSSION A total of 16 women and 7 men with an average age of 40 participated in this study. The predominant age range was 41 to 50 years, corresponding to 8 participants. In terms of schooling, 1 participant was illiterate, 17 had fi nished primary school, 4 had fi nished secondary school and only 1 had a university degree. Of the participants, 11 were married or lived with a partner, 4 were separated/divorced and 8 were single. In relation to profession/occupation, 8 were on sick pay, 5 had a remunerated activity and 5 were unemployed and did not receive any social security benefi t, 4 were on permanent disability retirement and 1 was a home worker. In terms of time doing haemodialysis, there was a significant variation: the patient with the longest time had been doing haemodialysis for 25 years, and the patient with the least time had been doing haemodialysis for 1 year. --- The meaning of kidney disease: the awareness of fi nitude The discovery of the diagnosis was very particular and accompanied by representations that were anchored on the relationship of losses, consensually manifested by the participants, due to the insidious disease process. This caused insecurity and established new parameters of liv-ing by introducing a new reality with negative feelings and the image of suff ering that is usually related to this disease, in addition to the despair, fear and approximation with death. Kidney disease is thus characterized as being something unimaginable and feared, and as a condition that demands special treatment. It also represents a barrier in the living process that alters the lifestyle and the social role of suff erers. Based on the long-term impact of the disease on the patients' lives and normal daily activities, they also expressed concern, discomfort and sadness. At this point, the ignored evokes fear because it threatens the sense of order and control over the world that is present in human subjectivity . This is the reason people create the social representations of something that is familiar and therefore make the object less threatening. Normally, the problem can be overcome when it is integrated to the mental and physical world of these individuals, which makes this diffi culty richer and possibly unequal. The unknown is formed by points of tension from the symbolic universe of a society and has the power to threaten the sense of order and control individuals have over themselves and their world . This tension allows the construction of social representations that will establish an intermediation between the cognitive system of people and the social reality. Additionally, the meaning of treatment implies the self-recognition of suff ering and limitations, possibly determined by the previous knowledge of these participants, related to the invasive and permanent nature of haemodialysis. The suff ering is greater when they receive the news of the loss of kidney function, as CKD starts off as a silent disease: the suff erers do not feel pain and continue urinating, which leads to the false impression that their kidneys are still functioning . The uncertainty in relation to the future, and the fear and panic will increase when people that have chronic kidney disease realize that they have defi nitively lost kidney function, which leads to abrupt changes, since Renal Replacement Therapy is immediate. At this point, the disease stops being imaginary, a possibility, and becomes a reality. The materialization of the death image associated to kidney disease projects a feeling of loss, at-tached to the memories of distance and rupture of the family ties. --- I panicked, I couldn´t stop thinking about my daughter. If I die, who I'm going to leave her with. Concerns with the ruptured family ties expressed in this study, related to the possibility of death and the diagnosis of the disease, characterise a crushing reality in which these individuals review their relationships and responsibilities. The family is aff ected by the disease and may represent real fears that are proportional to the seriousness of the disease. The family must defi ne strategies to cope with the impositions of chronic kidney disease . The family is a greater good that serves as a source of support and carries a substantial importance in the process of coping with the disease and its consequences, since it is part of the insertion context of these individuals. This is one of the aspects that has the greatest repercussions on the rupture of the rules of reciprocity. It somehow helps these patients to review the chronic status of their disease and infl uences the experience of the disease and the pursuit for coping mechanisms. The interruption in the normal course of their lives incurs intense emotional reactions, such as "despair" marked by the shift in their social role. The serious impact caused by chronic kidney disease in their productive life and the diffi culty of maintaining a home causes concerns that permeate these representations, indicating their potential deleterious eff ects on the emotional lives of these individuals. --- I had to sell everything to pay for part of my treatment. Now I work to survive, I can't provide extra comfort for my family. The fact that they are confronted with this situation interrupts the fl ow of their routines, which makes their experience with the disease more confl icting. In this case, these individuals tend to distance themselves from their own emotions, which are perceived as hostile and potentially destructive due to the burden of the psychological suff ering. --- I worked in the fi elds, helped my family, now I can't work anymore, I'm not strong enough. I lost my job, I lost my happiness. The patients acknowledge and appreciate their jobs because they satisfy their survival needs and their realiza-tion, and because they performed activities that granted them pleasure and contentment. Another aspect related to employment is the fear of depending on their families or vice versa. When these patients provide for their families, the diagnosis causes anguish and suff ering, which can extend their denial of the disease in order to fl ee from the situation. This fi nding is similar to the results of a study conducted with a population of chronic renal patients, which showed that the restrictions in relation to work causes these individuals to lose their autonomy and fi nancial independence. It also showed that, in some cases, the responsibility of supporting a family is transferred to another person, which also results in fi nancial insecurity due to the loss of employment or an early retirement . Moreover, when these individuals fi nd themselves in a stable clinical condition, they cannot get another job because they spend hours in dialysis therapy. Many of these patients, however, lose their primary source of income and have diffi culty in fi nancially supporting themselves and their families . This can lead to individual consequences, such as a loss of self-worth due to the interrupted professional activities. It is believed that the chronicity connected to people with chronic kidney disease, based on the treatment and loss of employment, leads to possible individual and collective changes of life, values, beliefs, habits and knowledge. This provides a culture that relates having chronic kidney disease with being closer to death; the culture of being the bearer of a social stigma and, therefore, marginalized and discredited . Analysis of the processes that form the social representations of chronic kidney disease showed that the awareness of fi nitude was associated to the prelude of death as a threat -in addition to losing a life, a family and a job. In fact, the representation of the renal disease process is perceived as being something bad and unpleasant, and as something that aff ects these people and incapacitates them; that reveals the diff erence and interrupts their projects of life. --- Survival: the visible in chronic kidney disease Chronic kidney disease was represented with the image of the "kidney that dries" and was associated to the perception of an initially silent trajectory with the awareness of chronicity. This idea is anchored on a concept that is still not fully understood by these individuals, and on an appreciation that is sometimes confusing, multifaceted, but determining. The term "kidney that dries" often consists in a resource that helps healthcare professionals communication the new condition and support the process of building a new identity after the diagnosis. The doctor told me my kidneys were dry. The kidney disease started off really silently. I'm not sure, I don't quite know how to put it, a kidney problem that has no cure. The kidney does not fi lter the blood, the kidney dries. Withal, the perception of the disease as being silent was not consistent. For some of the patients, it was subordinated to the appearance and exacerbation of symptoms and complications, such as high blood pressure. For others, the change of living habits represented a visible and possible routine in relation to the disease, since even when they were faced with the limitations, they managed to incorporate the new condition and continue to live their lives. --- I don't let the disease aff ect my life, but it does change a lot of things in my life and in the lives of my family members. My life changed a lot [...] but I continue, there' s no other way, I can't turn back the clock. The meaning of renal chronicity was based on the image of the disease as a silent enemy, whose manifestations and the exacerbation of organic symptoms are tied to the regularity of haemodialysis. People that do haemodialysis need access to healthcare services to receive this treatment; they need strict dietary and medication control, and work-related restrictions that are directly connected to the context of disease and their personal, family and social lives . However, the need for treatment may interfere with their life plans in terms of time spent, and lead to symptoms like discouragement, tiredness and lack of energy . An understanding of the new routine, that is visible in light of renal disease, is associated to the presence of the machine as a guarantee of life. Elements that represent the disease, such as hope and tiredness, coexist with the duality in terms of the diffi culties they have in accepting the treatment routine and their need to survive. This duality implies the aggregation between physical suff ering and psychological pain . --- It' s tiring to depend on a machine to live, but I always come, I'm never absent because it' s the only hope I have. I don't like being here. Being connected to this machine makes me suff er, I can't move properly, my arm hurts. I only come to clean my blood and live longer, survive. I can't die now. Here, death is very present in the expression "to survive". People also depend on family ties to find a reason to keep living their lives when confronted with renal chronicity. Consequently, the apprehension of the meanings of the machine, and the restriction and limitations with which they must now live, are gradually interwoven with the representations of loss of freedom, imprisonment and the stigma of the disease itself. The machine allows the maintenance of life. On the other hand, for some, it is a sign of difference due to the marks on their body. The partnership of these individuals with the machine produces an ambiguity of emotions that can lead to the duality rage and gratitude, since they depend on the machine to maintain their lives . The representation of loss of freedom and imprisonment refers to the stress they experience on a daily basis when they internalize the treatment in their lives and the impossibility of detaching from this treatment, since therapeutic failure would shorten their lives. The impact of this condition can lead people to other limitations in their social lives, such as leisure and travelling, in addition to changes in their body image. --- [...] I don't like the fi stula because it marks my body. I don't like it when people look and whisper. The marks take on an even greater signifi cance in the lives of these patients because they make them diff erent to the rest of society, that is unaware of the characteristics of the disease. Depending on haemodialysis also has an impact on the lives of these patients. In addition to the perceptible physical changes that result from the disease, they must suff er the discomfort of the clinical condition and the routine of dialysis therapy. The procedures to create a point of access of dialysis, such as catheters and fistulas, produce a significant impact on the patients' body image, and they feel different to others and unattractive . The visible alterations of the body of a chronic kidney disease sufferer caused by the treatment and the new condition lead to a permanent lifestyle transformation. In this case, the meaning of the body is intimately related to the construction of subjectivity, influenced by the social context and personal history. Consequently, the representations that people with chronic kidney disease have in relation to these marks aff ect and guide the way they respond emotionally and behaviourally to these marks. This is especially important because it is believed that the experience of chronic kidney disease before and after dialysis determines their position in relation to the health-sickness process. --- CONCLUSIONS It is considered that acknowledging oneself as a person that is experiencing chronic kidney disease, with haemodialysis, means to live with a negative role of losses and the explicit threat of death, in addition to subjecting oneself to the changes and necessary adaptations resulting from the disease. This fact aff ects the construction of singular social representations related to the meaning of being sick, which is associated to the constant and often painful transformations that vary according to the individuality and life changes of each patient. The awareness of fi nitude represented, to the interviewed individuals, sadness, failure and interrupted life plans due to the interruption of their professional activities. Some of these patients also acknowledged and valued their jobs because they met their survival needs and involved activities that gave them pleasure and satisfaction. The description of the social representations of chronic kidney disease suggests a multidimensional vision of the impact on the daily lives of these individuals. These elements emphasize the isolation and the stigma associated to the change of social role. From this perspective, this study remains open and future research is therefore important to re-evaluate the impact of these changes, especially in relation to the interaction between the individual experience and the social position. There is also a need to consider the broader context, since the investigation in question has limitations due to the application of interviews to adults only, which characterizes a type of representation that could be altered in studies among other age groups. In addition to the high technology therapy provided for people with kidney disease, the representations that are based on family and social ties of these individuals should also be considered, since they are determining factors for the provision of care for this population.

Representações sociais sobre o adoecimento de pessoas com doença renal crônica Representaciones sociales de la enfermedad de las personas con enfermedad renal crónica a Nurse. Master of Nursing Practice from the Universidade Federal do Paraná (UFPR). Professor of the

introduction people with chronic kidney disease are immersed in a series of life changes that influence the way they think and act in addition to the physical damage caused by kidney disease patients suffer psychological pain and abrupt modifications to their daily lives this series of problems tends to worsen in the final stages of this disease when patients must initiate haemodialysis living with a chronic disease forces the suff ers to centralize their activities around the illness and its treatment since the haemodialysis that guarantees the adequate physiological conditions requires regular weekly sessions the resulting phenomenon causes concern and daily confrontations which also lead suff erers to incorporate knowledge that assumes a dynamic form anchored on beliefs and perceptions these beliefs in relation to the disease help patients experience illness in a singular manner and consequently manage their care furthermore the experience of illness brings new encumbrances to kidney disease patients and the possibility to voice their judgement on how to cope and live with these problems a study on the representations of chronic kidney disease reveals the intensity of losses suff ering and anguish experienced by these patients and highlights the significance of illness and the indivisibility between care practices and the psychoaff ective and social relationships in their lives social representations have also been useful for investigating the perceptions of care and adherence to treatment of haemodialysis patients an understanding of the representational and consensual universe of people who experience the fi nal stages of chronic kidney disease should help these patients express their needs and receive specifi c healthcare this understanding allows them to defi ne their desires diffi culties attitudes and emotions in relation to the disease process knowledge of the representations of kidney disease and its infl uence on the various aspects of the elaborate and shared experience should support an understanding on how these people perceive the illness and how care and care practices to control this disease can become a part of their daily lives the guiding question was what are the social representations of people with chronic kidney disease on the illness process to answer this question the aim of this study is to describe the social representations of people with chronic kidney disease undergoing haemodialysis on the illness process method this is a descriptive study based on the qualitative approach anchored on the social representations theory created by serge moscovici that defi nes social representations as forms of practical knowledge by means of common sense these representations establish an order that guides individuals in their social and material world and enables the consequent communication among members of the same group the social representations theory addresses an object that is socially shared by a group and confers meaning to collective and individual experiences it also articulates the practices and helps sustain the social identity of a group consequently the srt involves as a criterion the existence of an object or something that is being investigated and the existence of a subject something that represents the investigated object in the case of this study the subjects are people with diagnosed chronic kidney disease and the object is the renal illness the study scenario was a healthcare organization in the hospital and outpatient environment that provides renal replacement therapy in the municipality of ponta grossa the organization is considered a benchmark in healthcare for chronic kidney disease among users of the unifi ed health system health plans and private patients the patients who use the haemodialysis service also come from surrounding municipalities and regions of the 100 patients with diagnosed chronic kidney disease 23 were included in the study because they fully met the criterion of inclusion these 23 patients were between the ages of 18 and 60 both sexes had been undergoing haemodialysis for more than one year and were aware of their acts and eager to participate in the study those who did not meet the criterion for inclusion were excluded the participants were selected with the help of healthcare professionals of the haemodialysis service data were collected by means of individual semistructured interviews recorded on an audio device at the nephrology service in a private room from february to november 2012 the duration of the interviews was between 20 and 30 minutes the interview script was previously tested and recreated using closed questions related to participant characterization such as age sex marital status schooling profession and time of haemodialysis the script also had open questions based on the discovery of the disease and emotions in relation to the diagnosis and the resulting life changes the interviews were transcribed and submitted to category content analysis in three stages preanalysis analysis unit selection and categorization the interview scripts were then read repeatedly to better understand the content and identify the emerging meaning units these units were organized interpreted and analysed based on the respective statements that revealed the meaning and perception of the individuals who had chronic kidney disease and were undergoing haemodialysis in observance to the ethical and legal aspects of the national health council the research project was submitted to the ethics committee of the health sciences sector at the universidade federal do paraná and approved under protocol cepsd nº 12161411109 prior to conducting the interviews the script was presented to each subject together with the objectives method risks and benefi ts of the study the patients subsequently signed an informed consent statement to participate in the study in order to respect the commitment of protecting the privacy of each participant they were identifi ed with the letter p and the order of the interviews namely 1 to 23 this study was extracted from the master´s dissertation the social representations of chronic kidney disease results and discussion a total of 16 women and 7 men with an average age of 40 participated in this study the predominant age range was 41 to 50 years corresponding to 8 participants in terms of schooling 1 participant was illiterate 17 had fi nished primary school 4 had fi nished secondary school and only 1 had a university degree of the participants 11 were married or lived with a partner 4 were separateddivorced and 8 were single in relation to professionoccupation 8 were on sick pay 5 had a remunerated activity and 5 were unemployed and did not receive any social security benefi t 4 were on permanent disability retirement and 1 was a home worker in terms of time doing haemodialysis there was a significant variation the patient with the longest time had been doing haemodialysis for 25 years and the patient with the least time had been doing haemodialysis for 1 year the meaning of kidney disease the awareness of fi nitude the discovery of the diagnosis was very particular and accompanied by representations that were anchored on the relationship of losses consensually manifested by the participants due to the insidious disease process this caused insecurity and established new parameters of living by introducing a new reality with negative feelings and the image of suff ering that is usually related to this disease in addition to the despair fear and approximation with death kidney disease is thus characterized as being something unimaginable and feared and as a condition that demands special treatment it also represents a barrier in the living process that alters the lifestyle and the social role of suff erers based on the longterm impact of the disease on the patients lives and normal daily activities they also expressed concern discomfort and sadness at this point the ignored evokes fear because it threatens the sense of order and control over the world that is present in human subjectivity this is the reason people create the social representations of something that is familiar and therefore make the object less threatening normally the problem can be overcome when it is integrated to the mental and physical world of these individuals which makes this diffi culty richer and possibly unequal the unknown is formed by points of tension from the symbolic universe of a society and has the power to threaten the sense of order and control individuals have over themselves and their world this tension allows the construction of social representations that will establish an intermediation between the cognitive system of people and the social reality additionally the meaning of treatment implies the selfrecognition of suff ering and limitations possibly determined by the previous knowledge of these participants related to the invasive and permanent nature of haemodialysis the suff ering is greater when they receive the news of the loss of kidney function as ckd starts off as a silent disease the suff erers do not feel pain and continue urinating which leads to the false impression that their kidneys are still functioning the uncertainty in relation to the future and the fear and panic will increase when people that have chronic kidney disease realize that they have defi nitively lost kidney function which leads to abrupt changes since renal replacement therapy is immediate at this point the disease stops being imaginary a possibility and becomes a reality the materialization of the death image associated to kidney disease projects a feeling of loss attached to the memories of distance and rupture of the family ties i panicked i couldn´t stop thinking about my daughter if i die who im going to leave her with concerns with the ruptured family ties expressed in this study related to the possibility of death and the diagnosis of the disease characterise a crushing reality in which these individuals review their relationships and responsibilities the family is aff ected by the disease and may represent real fears that are proportional to the seriousness of the disease the family must defi ne strategies to cope with the impositions of chronic kidney disease the family is a greater good that serves as a source of support and carries a substantial importance in the process of coping with the disease and its consequences since it is part of the insertion context of these individuals this is one of the aspects that has the greatest repercussions on the rupture of the rules of reciprocity it somehow helps these patients to review the chronic status of their disease and infl uences the experience of the disease and the pursuit for coping mechanisms the interruption in the normal course of their lives incurs intense emotional reactions such as despair marked by the shift in their social role the serious impact caused by chronic kidney disease in their productive life and the diffi culty of maintaining a home causes concerns that permeate these representations indicating their potential deleterious eff ects on the emotional lives of these individuals i had to sell everything to pay for part of my treatment now i work to survive i cant provide extra comfort for my family the fact that they are confronted with this situation interrupts the fl ow of their routines which makes their experience with the disease more confl icting in this case these individuals tend to distance themselves from their own emotions which are perceived as hostile and potentially destructive due to the burden of the psychological suff ering i worked in the fi elds helped my family now i cant work anymore im not strong enough i lost my job i lost my happiness the patients acknowledge and appreciate their jobs because they satisfy their survival needs and their realization and because they performed activities that granted them pleasure and contentment another aspect related to employment is the fear of depending on their families or vice versa when these patients provide for their families the diagnosis causes anguish and suff ering which can extend their denial of the disease in order to fl ee from the situation this fi nding is similar to the results of a study conducted with a population of chronic renal patients which showed that the restrictions in relation to work causes these individuals to lose their autonomy and fi nancial independence it also showed that in some cases the responsibility of supporting a family is transferred to another person which also results in fi nancial insecurity due to the loss of employment or an early retirement moreover when these individuals fi nd themselves in a stable clinical condition they cannot get another job because they spend hours in dialysis therapy many of these patients however lose their primary source of income and have diffi culty in fi nancially supporting themselves and their families this can lead to individual consequences such as a loss of selfworth due to the interrupted professional activities it is believed that the chronicity connected to people with chronic kidney disease based on the treatment and loss of employment leads to possible individual and collective changes of life values beliefs habits and knowledge this provides a culture that relates having chronic kidney disease with being closer to death the culture of being the bearer of a social stigma and therefore marginalized and discredited analysis of the processes that form the social representations of chronic kidney disease showed that the awareness of fi nitude was associated to the prelude of death as a threat in addition to losing a life a family and a job in fact the representation of the renal disease process is perceived as being something bad and unpleasant and as something that aff ects these people and incapacitates them that reveals the diff erence and interrupts their projects of life survival the visible in chronic kidney disease chronic kidney disease was represented with the image of the kidney that dries and was associated to the perception of an initially silent trajectory with the awareness of chronicity this idea is anchored on a concept that is still not fully understood by these individuals and on an appreciation that is sometimes confusing multifaceted but determining the term kidney that dries often consists in a resource that helps healthcare professionals communication the new condition and support the process of building a new identity after the diagnosis the doctor told me my kidneys were dry the kidney disease started off really silently im not sure i dont quite know how to put it a kidney problem that has no cure the kidney does not fi lter the blood the kidney dries withal the perception of the disease as being silent was not consistent for some of the patients it was subordinated to the appearance and exacerbation of symptoms and complications such as high blood pressure for others the change of living habits represented a visible and possible routine in relation to the disease since even when they were faced with the limitations they managed to incorporate the new condition and continue to live their lives i dont let the disease aff ect my life but it does change a lot of things in my life and in the lives of my family members my life changed a lot but i continue there s no other way i cant turn back the clock the meaning of renal chronicity was based on the image of the disease as a silent enemy whose manifestations and the exacerbation of organic symptoms are tied to the regularity of haemodialysis people that do haemodialysis need access to healthcare services to receive this treatment they need strict dietary and medication control and workrelated restrictions that are directly connected to the context of disease and their personal family and social lives however the need for treatment may interfere with their life plans in terms of time spent and lead to symptoms like discouragement tiredness and lack of energy an understanding of the new routine that is visible in light of renal disease is associated to the presence of the machine as a guarantee of life elements that represent the disease such as hope and tiredness coexist with the duality in terms of the diffi culties they have in accepting the treatment routine and their need to survive this duality implies the aggregation between physical suff ering and psychological pain it s tiring to depend on a machine to live but i always come im never absent because it s the only hope i have i dont like being here being connected to this machine makes me suff er i cant move properly my arm hurts i only come to clean my blood and live longer survive i cant die now here death is very present in the expression to survive people also depend on family ties to find a reason to keep living their lives when confronted with renal chronicity consequently the apprehension of the meanings of the machine and the restriction and limitations with which they must now live are gradually interwoven with the representations of loss of freedom imprisonment and the stigma of the disease itself the machine allows the maintenance of life on the other hand for some it is a sign of difference due to the marks on their body the partnership of these individuals with the machine produces an ambiguity of emotions that can lead to the duality rage and gratitude since they depend on the machine to maintain their lives the representation of loss of freedom and imprisonment refers to the stress they experience on a daily basis when they internalize the treatment in their lives and the impossibility of detaching from this treatment since therapeutic failure would shorten their lives the impact of this condition can lead people to other limitations in their social lives such as leisure and travelling in addition to changes in their body image i dont like the fi stula because it marks my body i dont like it when people look and whisper the marks take on an even greater signifi cance in the lives of these patients because they make them diff erent to the rest of society that is unaware of the characteristics of the disease depending on haemodialysis also has an impact on the lives of these patients in addition to the perceptible physical changes that result from the disease they must suff er the discomfort of the clinical condition and the routine of dialysis therapy the procedures to create a point of access of dialysis such as catheters and fistulas produce a significant impact on the patients body image and they feel different to others and unattractive the visible alterations of the body of a chronic kidney disease sufferer caused by the treatment and the new condition lead to a permanent lifestyle transformation in this case the meaning of the body is intimately related to the construction of subjectivity influenced by the social context and personal history consequently the representations that people with chronic kidney disease have in relation to these marks aff ect and guide the way they respond emotionally and behaviourally to these marks this is especially important because it is believed that the experience of chronic kidney disease before and after dialysis determines their position in relation to the healthsickness process conclusions it is considered that acknowledging oneself as a person that is experiencing chronic kidney disease with haemodialysis means to live with a negative role of losses and the explicit threat of death in addition to subjecting oneself to the changes and necessary adaptations resulting from the disease this fact aff ects the construction of singular social representations related to the meaning of being sick which is associated to the constant and often painful transformations that vary according to the individuality and life changes of each patient the awareness of fi nitude represented to the interviewed individuals sadness failure and interrupted life plans due to the interruption of their professional activities some of these patients also acknowledged and valued their jobs because they met their survival needs and involved activities that gave them pleasure and satisfaction the description of the social representations of chronic kidney disease suggests a multidimensional vision of the impact on the daily lives of these individuals these elements emphasize the isolation and the stigma associated to the change of social role from this perspective this study remains open and future research is therefore important to reevaluate the impact of these changes especially in relation to the interaction between the individual experience and the social position there is also a need to consider the broader context since the investigation in question has limitations due to the application of interviews to adults only which characterizes a type of representation that could be altered in studies among other age groups in addition to the high technology therapy provided for people with kidney disease the representations that are based on family and social ties of these individuals should also be considered since they are determining factors for the provision of care for this population

representações sociais sobre o adoecimento de pessoas com doença renal crônica representaciones sociales de la enfermedad de las personas con enfermedad renal crónica a nurse master of nursing practice from the universidade federal do paraná ufpr professor of the

Introduction It is complex for social entrepreneurs to convince potential supporters, resource providers, and investors in a pitch situation since many are not familiar with the concept . Social entrepreneurship combines potentially contradicting elements of social and commercial logics in unprecedented ways to address social problems and it creates positive impact for society . Previous research has focused on various aspects that influence the process of resource mobilization such as signaling the competences of the founding team , the network that the entrepreneur is embedded in and the social competence of the founder . A recent turn toward linguistics has called attention to the role of pitching and storytelling in the entrepreneurial process. In this study, we explore how social entrepreneurs present their venture to the audience in a pitch situation. In doing so, we intend to shed light on the specific dilemmas and tensions that social entrepreneurs face. Zacharakis et al. found that early stage investors are to some extent intuitive decision makers. This may apply even more to the context of social entrepreneurship since the decision to support social entrepreneurs could also be a gut decision instead of a purely analytical one . The existing research on pitches by social entrepreneurs is limited . Two studies on social ventures that presented on the online micro-lending platform Kiva offer contradictory findings on the question of whether business or social discourse in the pitches tends to convince potential funders . While the nascent field of impact investing and resource mobilization for social entrepreneurship is attracting increasing scholarly attention , we do not yet fully understand how social entrepreneurs pitch and how resource providers react to those pitches. While there is a presumption that the motivation to support and invest in socially oriented ventures is likely to be an ethical act to serve a larger social cause , we know little about how such processes unfold. Specifically, current research falls short in investigating the dialogic nature of a social entrepreneur's pitch . Texts are often constructed with co-authorship where others are asking questions or giving comments . Intertextuality captures the idea that every utterance is inevitably linked to what has been said before . The text of a pitch is thus constructed as a mosaic of quotations since any text is the absorption and transformation of others . Creating such a mosaic is a process by which different words, phrases, and speech acts are selected and combined when constructing the meaning of a phenomenon such as social entrepreneurship. We presently lack an understanding of how a pitch is connected to macro-discourses and how the audience may intentionally or unintentionally co-author the texts produced . Adopting a practice approach to social entrepreneurship , we analyzed videotapes of 12 and 37 of pitches by social entrepreneurs , their audiences and the interaction between both groups in the subsequent Q&A sessions. The main contribution of our paper is that it advances our understanding of social entrepreneurial pitching as a dialogic process in which both presenters and their audience draw from larger discourses. This interdiscursive perspective allows us to highlight the power dynamics involved in the construction of social entrepreneurship in pitch situations. Our study offers two key contributions to the literature. First, we offer detailed insights into the discourses social entrepreneurs and their audience mobilize in pitch situations. We highlight how powerful gatekeepers predominantly drew on a business discourse offering a "taken-for-granted" understanding of what social entrepreneurship is which goes largely uncontested. Second, we highlight how aligning their presentations with the powerful business discourse has enabling and constraining effects for social entrepreneurs. --- Pitching in Social Entrepreneurship --- Storytelling and Resource Mobilization in Social Entrepreneurship Resources such as financial, physical, human, as well as intangible resources are central to venture creation . Since social entrepreneurship as a concept is new to many providers of resources and does not conform with well-known categories of business or not-for-profit , founders still have to do significantly more convincing. Social entrepreneurship is defined as individuals and organizations that "use a business logic in a novel and entrepreneurial way to improve the situation of segments of the population that are excluded, marginalized, or suffering and are themselves not capable of changing this situation." . Even though the term itself was coined more than two decades ago , resource providers have discovered the field only recently and many investors face uncertainty in a fragmented field that still lacks standards and oversight. Early research on impact investing suggests that often the audience of social entrepreneurial pitches is torn between an ideal-typical charity logic and an investment logic . Hehenberger et al. show how a dominant "field ideology" has emerged among experts in impact investing, which emphasizes "head" over "heart" decisions, impact measurement over storytelling, tools over needs of beneficiaries, and picking the best over nurturing the social entrepreneurial ecosystem. Despite these significant advances, our knowledge about the pitch process itself as well as the interaction between social entrepreneurs and their audience remains limited. Such an audience may consist of actors as diverse as wealthy private individuals or investment advisors , representatives of venture capital funds, institutional asset owners , supporting organizations, foundations, and other experts in the field of social entrepreneurship. A recent turn in entrepreneurship research has shifted the focus from entrepreneurial characteristics to entrepreneurial behaviors . In this research stream of entrepreneurial behavior, a group of authors investigates the role of stories in resource mobilization . Storytelling has been suggested to be of specific importance for social ventures . While research on "live pitches" in social entrepreneurship is scarce, evidence from studies on texts of crowdfunding presentations is also "meager" and "inconsistent" . Using a different text analysis dictionary led to contradictory results in two studies on the same crowd-based micro-lending platform . Thus, to date we lack a coherent understanding of the discourses used in social entrepreneurial pitch situations. We need to learn more about the discourses social entrepreneurs draw upon in live pitches, which may differ from the presentation of a start-up to "laypersons" on an online crowdfunding platform. --- Pitches in the Entrepreneurial Process Research on pitches in commercial entrepreneurship found the pitch to be a critical component in the funding vetting process conducted by resource providers. A pitch is often the initial introduction to and presentation of the venture to potential investors and resource providers . Resource providers use this forum to evaluate both the potential of the venture and the entrepreneur's capabilities to lead and grow the venture . It provides a critical opportunity for the entrepreneur to articulate the venture's business propositions to create interest . If resource providers form negative impressions of the entrepreneur's abilities to lead the venture during these presentations, it is improbable that access to funding will later be secured . In pitches, connecting with the audience is especially important in the process of mobilizing resources as it helps to frame the nature of the business in such a way that its potential value becomes believable . For example, Allison et al. found that characterizing the venture as a personal dream in a pitch narrative positively influenced inexperienced, first-time funders. Moderate accounts of narcissistic rhetoric enhance crowdfunding performance; however, the impact of narcissistic rhetoric becomes detrimental to performance when used extensively . Drawing on text, speech, and video metadata of crowdfunding campaigns, Kaminski and Hopp found that linguistic styles that aim to trigger excitement or are aimed at inclusiveness are better predictors of campaign success than firm-level determinants. While we know from existing research about the pivotal role of pitches in the entrepreneurial process , "the interactions between entrepreneurs and different resource provider audiences'" in live pitch situations of social entrepreneurs warrants further scholarly attention . --- Intertextuality To date, it remains unclear how social entrepreneurs and their audience connect the texts that they produce in pitch situations to larger discourses. Work on discursive devices , interaction analysis or psychonarratology take readership and response into account and point toward the dialogic nature of texts where "readership and interpretation are as important as structure or authorship" . The notion of intertextuality holds that every utterance is inevitably linked to what has been said before in other texts . All utterances are populated and constituted by snatches of others' utterances, more or less explicitly . Besides capturing the idea that each text connects to earlier texts, intertextuality furthermore draws on a social connection between the author and the reader. To communicate effectively, speakers have to draw on "commonplaces" : "the more the communicators' cultural worlds overlap, the more effective their communication is" . Intertextuality also highlights the anticipation of reading . Consequently, social entrepreneurs are consciously or unconsciously influenced by the audience they address. The existing research on storytelling in the entrepreneurial process has not sufficiently accounted for intertextuality, that is, the role the audience plays in co-producing texts in pitches. This study aims to expand the existing work by analyzing the discourses that social entrepreneurs and their audience employ in live pitches. Therefore, we ask: What discursive repertoire do social entrepreneurs and their audience draw upon in pitch situations? --- Methodology To analyze the dynamic and interactive processes that occurred between the presenters and audience in real-time, we chose a qualitative research design . We studied live events at popular incubators to explore how social entrepreneurs pitch and how the audience reacts to these pitches. Our research was guided by a focus on 1 3 the "doing" of social entrepreneurs and their audiences in line with previous research that has conceptualized social entrepreneurship not as an inherently ethical concept "per se" but calls to investigate the concrete practices at play . According to the entrepreneurship-as-practice literature, those practices encompass the meaning-making, identity-forming and order-producing actions performed by multiple actors in the entrepreneurial process . We videotaped the pitches and the subsequent Q&A sessions to capture the multitude of human actions and interactions which unfold so quickly that they would otherwise have been lost . These videos provided a detailed and permanent record of the events from a perspective that captured both the presenters and their audience. --- Data Collection I: Research Setting We were initially guided by our general interest in pitches by social entrepreneurs. For this reason, we conducted a first study in an incubator in Switzerland in 2013. In that setting, we had the unique opportunity to record live pitches on video and conduct interviews with social entrepreneurs and jury members. The Swiss incubator was founded in 2011 in Zurich and pursued the following mission: "we are committed to creating a thriving innovation ecosystem where people across organizations, cultures, and generations work together to solve the great challenges of our time." The pitches that we filmed took place at the end of a 6-month training program for social entrepreneurs. The pitches lasted approximately 10-15 min, followed by a 10-min Q&A session with questions from the jury. The jury consisted of three members from the incubator team, among whom was a university professor. This event was a unique opportunity to gain first insights into live pitches and the discourses that the teams drew upon. However, the data collection at this pitch event presented us with a decisive disadvantage: Although the pitches were evaluated by the jury, this evaluation had few to no direct consequences for the founders. For this reason, we approached a large incubator in Germany for an additional data collection and were granted access to the selection process there 2 weeks later. We were thus able to include pitches where the teams were then either given access to resources or not. --- Data Collection I: Sources of Data In total, we videotaped 12 pitches and the subsequent Q&A sessions. The interaction of the audience with the presenters was especially important for our research design, as it allowed us to investigate co-authorship and the dialogic nature of the production of texts . Additionally, we conducted 15 interviews during the pitching event . The interviews with the three jury members lasted about 60 min and were tape-recorded, the informal interviews with each presenter team about 10-15 min. We asked the jury members to explain their written evaluations of the pitches and which parts of the pitch they remembered best. In the short interviews with the presenters, we asked how the teams had prepared for the pitches and why they had decided to present their start-up in the precise manner in which they did. The recorded interviews and the pitches were transcribed verbatim. The questionnaire that the jury and the other presenters filled out asked them to evaluate the pitch according to the following criteria: comprehensibility, innovation and effectiveness of the idea, expertise and credibility of the founders, financial viability, and feasibility. While the survey did not meet scientific requirements, we were surprised by the results, which showed how negatively the jury and the other presenters rated "social impact stories" compared to pitches framed around a business discourse. After finding only partial confirmation and inconclusive explanations of this finding in the interviews, we collected additional data to gain more insights. --- Data Collection II: Research Setting In our data collection II, we videotaped 37 live pitches in four pitching events at one incubator organization in Germany. The incubator was originally founded in 1994 to guide marginalized young adults in starting up their own business and becoming self-employed. In 2011, they expanded their program and started an incubator for social entrepreneurs. The organization's mission is to "foster social equality and promotion inclusion through the support of social start-ups." At the time of data collection, the incubator had 90 employees and offices in eight German cities. To be accepted to the program and receive a scholarship, a start-up must apply and then present their business idea in a pitch. Each start-up has five minutes to present their idea and seven minutes for discussion with the jury and the audience. All pitching events are public; thus, approximately 20-50 interested individuals attend and also ask questions. However, the majority of questions are asked by members of the jury. The jury decides which start-ups will be awarded the "social impact start" scholarship. Once a start-up is accepted, it can take advantage of several services including the use of a co-working space, coaching and mentoring, legal consulting and access to a network of investors. Taken together, the basic services that the incubator offers to their scholarship holders correspond to a total value of approximately 20,000 Euros. Each pitching event that we attended consisted of a different composition of jury members; however, two members were part of the jury in all four pitching events observed. Jury members included, for example, representatives from a government-owned German development bank and a leading organization to support social entrepreneurship as well as from commercial start-up incubators. In addition, successful commercial entrepreneurs, a head of CSR from a German car manufacturer, a marketing director of a large firm, the chief digital officer at a multinational IT company, a private impact investor and a journalist from a national newspaper rounded out the jury. A number of jury members either directly invested in start-ups or supported start-ups in the process of resource mobilization while the program was running and beyond. To be invited to the pitching event, the founders submit a short written application that is checked for comprehensiveness and consistency by a team from the incubator. A staff member of the incubator, who is also a member of the jury, conducts a short informal interview with the applicants. However, the other jury members decide without prior information solely based on the pitch and the subsequent Q&A session. --- Data Collection II: Sources of Data We attended four pitching events, two in Berlin and two in Hamburg, and collected data on 37 social start-ups. All pitches, including the seven-minute follow-up interaction between start-up and jury or audience, were videotaped. Furthermore, we collected all presentation slides and handouts created by the start-ups to support their talk. As a third source of data, we conducted in-depth interviews with three jury members from the incubator, including the organization's founder, to deepen our initial understanding of the audience's discourses gained from the question-and-answer sessions of the pitches. The interviews lasted on average 60 min. In those interviews, we asked how a typical pitch unfolded and what elements determined a successful pitch, including examples. We then discussed several pitches with them and asked them to elaborate on why they were accepted into the program or not. We also asked our intervieweees to explain their evaluation of the pitch. In addition, we had informal conversations with social entrepreneurs and jury members right before or after the pitches, during coffee breaks, and after the events. In the four pitching events that we attended, 37 individuals and teams presented their ideas. Twenty-two were accepted to the program, and 15 were rejected. In each of the four events, the start-up that convinced the highest number of audience members received the "audience award": "Soccer for Everyone" in Berlin in February, "Fair Handbags" in Hamburg in May, "Urban Bees" in Berlin in June, and "Blindmap" in Hamburg in August . In early 2020, 7 years after the pitches, we conducted an internet search to determine whether the start-ups from the second data collection were still alive . Eighteen ventures were still active. One venture still existed, but a commercial mission had replaced the social mission. Of the 23 "winners" that had entered the program, 10 were still alive in 2020 . Of the 15 rejected start-up teams, 8 were still active-even though they had not received support from the incubator. Interestingly, only two of the four start-ups that had received the "audience award" survived. --- Data Analysis We transcribed the text of all pitches and the respective Q&A sessions as well as the interviews verbatim, resulting in 370 pages of text. Informed by grounded theory , we began our analysis with a fine-grained reading of the data and wrote "story sheets" for each pitch. The videotapes allowed us to watch and rewatch each pitch and subsequent Q&A session numerous times during data analysis. We first coded the text authored by the jury and the audience and the text produced by the pitchers each individually using the coding software MAXQDA. The cross-case analysis of both incubators in Germany and Switzerland allowed us to identify the key themes of audience and pitchers. We aggregated the themes into two broader discourses, namely business and social. We were surprised to discover how the first-order codes of "using a business language" were similar for both groups. Interestingly, though, we found differences in how social entrepreneurs and their audience mobilized the social discourse. For example, our data show how the concepts of beneficiary, fair remuneration, and scaling a solution to a social problem were almost exclusively used by pitchers. For each discourse, we identified concepts, objects, and subject positions . Concepts are the very means through which social entrepreneurs and their audience make sense of phenomena such as a start-up. They constitute the vocabulary necessary for meaning-making. Discourses not only describe but also construct objects such as a new social venture. Different discourses may produce different objects, thus offering differing and even contradicting conceptualizations of one and the same start-up . Discourses also construct subject positions for the actors involved, as they "give the subject different, and possibly contradicting, positions from which to speak" . Such positions determine which social roles and functions as well as their affordances can legitimately be adopted within each discourse. For example, some social entrepreneurs may emerge as business people and others as social changemakers. In mobilizing a specific discourse, powerful actors shape our understanding of social entrepreneurship, which in turn reflects their power to do so . In this sense, discourses are performative; they accomplish things . We held focus-group-like presentations of our findings with team members from both incubators to clarify our observations. After completing data collection, the first author became a member of the German incubator's jury to deepen her contextual knowledge on the selection processes. We also used the interview data to challenge our findings, to learn more about the way the presenters prepared for the pitches and about the invisible reactions of the audience to the presentations. --- Findings Based on our analysis, we highlight the similarities and the differences between the texts produced by social entrepreneurs and their audience in pitch situations. In drawing on prior texts, both groups mobilized elements of larger discourses-albeit in different ways. We show how they "borrow" concepts, objects, and subject positions from a business and social discourse. --- Discourses in Social Entrepreneurial Pitches We elucidate how pitchers and their audience select bits and pieces from prior texts, giving their language an intertextual dimension, whether or not the speakers intended to do so. Our analysis suggests that in the actual pitch situations, the questions and comments of the audience drew to a large extent on the discursive repertoire of the business discourse. The presentations of most social entrepreneurs, in contrast, involved elements of both the business and the social discourse. --- The Business Discourse of Social Entrepreneurs and Their Audience The business discourse is based on a managerialist ideology that emphasizes profit-maximizing strategies, efficiency and profit . The main concepts of the business discourse include a unique selling proposition, customer, pricing, marketing, and commercial growth. In addition, the financial viability of the business model was a popular concept used by the audience and, to a small extent, some social entrepreneurs. "How are you going to finance that?" was the most frequently asked question during the Q&A sessions. In responding to the question, social entrepreneurs were forced to elaborate on their business model. Some were well equipped to answer those questions by drawing on a business vocabulary; others struggled. A member of the jury explained his reaction to the pitches as follows: I'm a businessman and -to be honest -I'm looking for people with business acumen who can make things happen. If it cannot be financed, it remains a naive illusion. [observation, pitch event]. In contrast, many social entrepreneurs did not refer to a "business model" at all in their pitches. Those who did emphasized revenue streams and financing options. The founder of LoveClothes later explained her choice not to use "business language" as follows: The term "entrepreneur" was new to me. I have never written a business plan. To be honest, I don't even know exactly what it is. I studied international labor rights. I live and breathe for the cause and want to empower the seamstresses in India. [interview, social entrepreneur] Although the pitch was evaluated negatively and there were some critical queries about the financial viability by the jury, the start-up was accepted in the end. It still existed and was operating successfully in 2020. In contrast, a jury member stressed the importance of solid business models: Between us, there are the tree huggers in social entrepreneurship. They celebrate themselves so much, and you see little progress. We think like business people, and when I speak out in favor of a social enterprise, it's not because a few naive do-gooders think they have a good idea. The thing has to finance itself. Period. [interview, jury member]. Associated with such business thinking was the concept of a unique selling proposition to the paying customer. Social entrepreneurs highlighted the unique features of the product or service and how it differed from existing offers: "We see an added value in our offer in contrast to others because the features of the IT solution are unique." [pitch]. The startup Medical Backpack, for example, elaborated in-depth on the viability of their business model and their unique selling proposition. They presented their product as more 1 3 efficient than existing solutions. The audience reacted very positively to this aspect, congratulating the founders on their unique idea: "This is truly a unique product." [comment, jury member] Directly after the Q&A session, in which many questions focused on the unique selling proposition of Medical Backpack, the next team-before their actual pitch-repeated the same concept: "We differentiate ourselves from other offerings […]." Interestingly, the audience members used in their questions on the unique selling proposition the term "competitor" to refer to other offers: "Who are your competitors?" [audience question]. The notion of "competitor" portrays social entrepreneurs as trying to compete with others, for example by making bigger sales. The term was rarely used by social entrepreneurs, and if at all, in answers to jury questions. In addition, we identified the notion of "customer" as a key concept in the business discourse: It is very important to me that they have an idea of what the customer looks like. Who's buying this and why? The worm must taste good to the fish, not to the angler, or the story won't pay off. [interview, jury member]. In the presentation by Blindmap, the founders explained how one of the team members belonged to their customer group and had inside knowledge of their needs. The start-up Sustainability Game presented extensive research on their potential customers including a number of informative figures and statistics. Similarly, the team from "Emissionfree Food" stated: Let's look at our primary customers. Our customers are adults between 25 and 45 years, they possess a smartphone, and they live in German-or English-speaking countries. This would be 78 million. Out of those 78 million, 80% say climate change is a serious or very serious problem. This means we may have 62 million potential customers. [pitch] Many start-ups explicitly referred to customers, whereas other social entrepreneurs did not address the concept of customer at all during their pitch. The pitchers mostly spoke about the needs and expectations of customers; the audiences' questions revolved around the number and characteristics of customers and their ability to pay. Many pitchers also made use of other concepts originating in the business discourse, for example, marketing, addressing topics such as how to present and advertise the product or service. One team described their sales channels as follows: "We plan to work with classic retailers, and, of course, organic supermarkets are at the top of our list." [pitch]. One of the jury members also emphasized the importance of marketing targeted toward the paying customer: They must be able to demonstrate where they want to get the paying customer. How do they plan to advertise and sell the products or services? [interview, jury member]. Unlike the social entrepreneurs' presentations, the audience questions were often targeted at "sales" or "sales channels." Some pitchers had difficulty responding. Furthermore, jury members asked questions about the pricing if the concept had not been mentioned in the pitch: "Can you tell us more about the price? […] How does this cover your costs?" The audience repeatedly emphasized the important of a pricing strategy and whether it matched the costs and the willingness to pay. Pricing was much less referred to by the social entrepreneurs, or only when asked about it. In addition, the concept of commercial growth was frequently referred to in pitches and the Q&A sessions: "You have to identify new markets to be successful." [comment, jury member]. The start-up Blindmap explained their strategy for revenue growth as follows: Our next challenge is to gain automation. As M. explained, we are currently doing everything manually. With each successive step, we want to automate everything so that our maps will become more and more affordable. This has a large impact on our business model. Our maps need to be financed. [pitch]. The audience asked about the potential for growth in revenues and sales while some social entrepreneurs also mentioned how they planned to grow the business beyond the core. The founder of LoveClothes was very skeptical about growth as such: I don't want investors who will reduce our impact and only want a quick profit. If anything, we will grow organically: Slowly and steadily. [interview, social entrepreneur] These concepts of the business discourse used by the pitchers and their audience bring an object into being, namely the social start-up as a business. The social cause that the venture aims to address is framed as a business opportunity rather than as a societal challenge: "We saw a market here." [pitch]. Urban Vegan Farming chose not to speak about the problem but rather focus on the business opportunity: We observe a trend that hip, urban people want to feel a connection to their food. This is our target group. We offer harvesting stations; we create a world of experience and a meeting place. [pitch]. Instead of describing the various sustainability problems of the food industry, the founders illustrated the untapped market potential that they wanted to address with their offer. Thus, they presented the opportunity in a social problem. The jury rated their pitch as very convincing in the questionnaire. In the interview, the presenters explained their choice as follows: This is supposed to be a business. We need to convince potential investors of our business model and our potential. […] We have learned to stop boring people with our litanies about the scandalous food industry. No one wants to hear that. Some people know that and the others do not want to hear about it. [interview, presenter] In line with a business ideology of profit-maximizing strategies and an emphasis on efficiency, conceptualizing the start-up as a business also included the conviction that a market-based solution is superior: There is a significant difference between the work public agencies or nonprofits do. The laws of the market ensure that social enterprises are efficient. [interview, jury member] The subject position as a legitimate position to speak from in the business discourse portrays the social entrepreneur mainly as an entrepreneur, i.e., as a person who takes risks and makes money: This is our co-working space, where our entrepreneurs really take off. For example, Alpha, they just made a six-figure sum with a crowdfunding campaign. [observation, employee from Impact Lab guides the jury members through their office space] Founders described themselves as a "business person" with "strong implementation skills." Their audience voiced how social entrepreneurs should be "entrepreneurs" and "self-starters." --- Social Discourse of Social Entrepreneurs and Their Audience In contrast, the social discourse centers on the main goal of the start-up: working toward a social mission. In the Q&A sessions, only a small fraction of the questions by the audience referred to concepts of the social discourse. Social entrepreneurs drew to varying degrees on the language and concepts of this discourse. Firmly rooted in a social ideology, the social discourse is shaped by values such as justice, inclusion, and responsibility and emphasizes social impact . A central concept is the notion of the theory of change and social impact, that is, how and why a desired social change is expected to happen. To our surprise, only a few questions of the jury referred to the concept and if so, then only to the reach of the offer. By contrast, many social entrepreneurs explained the social or environmental problem they intended to address in detail, e.g., the challenge of improving the lives of disadvantaged groups or fighting climate change: "This is challenging. How can I present such a complex problem in such a short time?" [pitch]. The description and analysis of the problem ranged from stories the social entrepreneurs had experienced to more abstract presentations of facts and figures. The social cause is framed as a problem that needs to be addressed, emphasizing the drive of the venture for social change. A central part of the pitch was describing the solution idea for the problem, i.e., how the founders planned to achieve the intended social impact. The pitchers explained how their innovative idea would bring about social change, promote justice, and responsibility and foster the inclusion of beneficiaries. For example, the founder of Children's Bus explained her theory of change as follows: I know, it's challenging to explain such a complex social problem in 60 seconds, but I'll try. […] And I am going to run a small restaurant on the bus to finance the trips. [pitch] Also, social entrepreneurs used the notion of value-added for society ["Gesellschaftlicher Mehrwert" in German] to describe the potential impact of a venture: If we stop hooligans from becoming violent, we save the government money. We contribute to peace and security and show these people a new way. [pitch]. The founders of Children's Bus, Multi-Generation house, Local Community, and World Music Concerts used their pitch time exclusively drawing on the social discourse and received unfavorable feedback from the jury members, who questioned "the lack of a business model." However, in a few cases the "theory of change" was explicitly questioned by the audience: "How are you going to work with the kids?" [audience question]. Other concepts that formed an inherent part of the social discourse included beneficiary, fair remuneration, reaching beneficiaries, and scaling. In the social discourse, the concept of a beneficiary was used instead of customer. While the term customer in the business discourse is associated with a certain "willingness to pay," the concept of beneficiary puts the in-depth knowledge of the needs of a marginalized population center stage: Annett is 14 years old and grew up in one of the biggest slums in Kibera . Every month when she has her menstruation, she is afraid to ask her father for money because money is always scarce. This leads to Annett not going to school when she has her period for fear of bleeding through her clothes and embarrassing herself. Annett is not an isolated case. Every month, more than a billion women struggle to afford pads. Out of fear of embarrassment, they stay away from school or work. UNICEF and UNDP state that menstruation is the main reason why girls do not go to school regularly. [pitch] Even though the start-up made it clear that their idea is a menstrual product primarily for use in developing countries to help women in need, the first question from the audience was: I'd be interested to know, I know this from the US and I think it's also available in Denmark. What is the growth potential in Germany? [audience question] In almost all pitches, the beneficiaries were explicitly mentioned, and often presented in detail using figurative language and introducing a specific persona. In the social discourse, the beneficiary is portrayed as a disadvantaged and/ or marginalized person who needs help and support and who deserves justice. In some instances, the terms "client" or "patient" was also used. In contrast, the characteristics of beneficiaries were almost never a topic during the Q&A sessions. The term itself was not used at all. An incubator staff member commented on our observations as follows: One aspect that many on the jury pay far too little attention to is that we should be looking for founders who know their stuff. You don't just turn a jobless migrant into an entrepreneur overnight. That would be naive. Social change does not happen like that. [interview, jury member] This is interesting since the concept of beneficiary could be viewed as less empowering than customer . Thus, the term beneficiary could actually undermine key values of the social discourse ifself such as inclusion and responsibility. Reaching the beneficiaries was another key concept of the social discourse. In contrast to the marketing concept of the business discourse, the notion of reaching the beneficiaries is concerned with the accessibility of their offer and ways to include beneficiaries to increase the social impact. It was not a frequent topic in the pitches, but the few who referred to reaching the beneficiaries described how they planned to tailor their offer to meet the needs of the target group: "Our App will be easy to use. The gamification will allow users to have fun." [pitch]. The founder of "Multi-Generation house" explained their choice to dress up with an old curtain over her head as the "soul of the building which attracts people from all age groups" as follows: "That's where we come from. We see the spirit of the building. That's what invites different people." We got the impression that the founder felt right at home in her costume as the "soul of the building." Several jury members, however, made disparaging remarks about it and missed "a business perspective." In the pitch, the team of "Multi-Generation house" had detailed their track record of how they had consistently brought very different people together. However, as with the vast majority of pitches, the topic was not addressed by the audience in the Q&A sessions. One exception was as an audience member who asked after the pitch of Children's Bus: "Why should the children want to join your activities?" [audience question] to point to the number of users needed for success. Some social entrepreneurs drew on the concept of fair remuneration in their pitches -but it was also never addressed in the Q&A. A comprehensive pricing model was concerned with setting a price that would allow for sustainable production and fair wages: Our price should reflect the true costs. We do not want somebody else to pay the price. [pitch] Finally, the concept of scaling was used by pitchers to depict a vision of how the new idea could be replicated by others in different contexts or expanded to other countries to grow its social impact: "This project could be implemented in any city" [pitch]. Unlike commercial growth, the notion of scaling is about spreading the word about a solution to a social problem without any immediate profit interest. Thus, the "scalability" refers to the possibility to grow and adapt the idea in other contexts to meet greater needs in future, and it is an often-quoted concept used by supporting organizations in social entrepreneurship. However, no audience question referred to the concept. These concepts from the social discourse bring an object into being, namely the social impact as the key feature of the start-up, emphasizing the development of fresh ideas that meet social needs more effectively than existing solutions. The view of social entrepreneurship as an ethical concept draws on an ideology which emphasizes social impact, justice, inclusion, and responsibility. A jury member described his preference as follows: To me, financing, marketing, that's completely uninteresting at the time of the pitch. You can address that, but you don't have to. The innovation is important. What is important is the social impact. So what is the problem I want to solve? [interview, jury member] The rest of the audience co-constructed a slightly different picture of a business with social side effects: It's a great product and I believe there is a market. […] And I think people will benefit. [comment, audience] The subject position as a legitimate position to speak from sees social entrepreneurs as activists and changemakers: "Our vision is the reintegration of former forced prostitutes back into society with the help of fashion." [pitch]. In an interview, a social entrepreneur described herself as a "deeply moral person" and as a social innovator: I want to change the way we look at others. Each person has unique talents -and can give something that no one else has to give. Every person has unique talents and abilities. My aim is to value strengths and not to judge people by their weaknesses. [interview, presenter]. The audience emphasized how social entrepreneurs should bring new ideas to the table: "What's new about this approach?" [audience question]. --- Separating, Mixing, and Combining Business and Social Discourse Most social entrepreneurs included elements of the business and the social discourse in their presentations. Some drew to a large extent on the business, and others put more emphasis on the social discourse. A third group scarcely referred to either of the two discourses. One presenter described her dilemma in preparing for their pitch as follows: It's a difficult choice. You just have so little time. We thought it over and rehearsed it very well beforehand. The problem is, which points should we address? I wrote my master's thesis on [social problem], so I can already say a lot about that, you know? But there is also -let's say -a certain community here, so... they want to know where the start-up capital comes from and so on. That's a certain way of thinking, yes. [interview, social entrepreneur] Our analysis finds that social entrepreneurs use different ways to separate, mix, or combine the business and social discourse in their pitches. The first group of presenters clearly split the "business" and the "social" part of their presentation, as indicated, for example, by the titles on their slides: "The problem," "The solution," "Monetization" [slides pitch presentation]. The second group of pitchers mixed the two discourseseven potentially contradicting concepts. For example, a founder spoke about the "target group," the "beneficiary," and the "customer" while referring to the same group of people. The start-up "Live your Dreams" ironically picked up elements of a business discourse to explain their social mission: "Our customers: Dreamers and Storytellers." [slides pitch presentation]. In several instances, we observed such a use of business vocabulary, which resembled the use of buzzwords without a deeper connection to the rest of the text. Paradoxically, one start-up was expressly fighting against "capitalism" as their ideological opponent; however, they told their anti-capitalism story by drawing on business concepts and a managerialist vocabulary, ignoring apparent contradictions. A third group set out to combine and thus reconcile potentially contradictory elements of both discourses. The start-up "Upcycling Design" explained how their idea integrates both ideologies: We are split into two things. Idealism meets realism. We started with our company and said we'd make money and do something social. […] We know our customers. […] Our marketing strategy […]. There is a demand for sustainable products, and it is a trend in the market. Our revenue model […] We wish to include our producers and empower them. It is our way to contribute. It's about self-realization and recognition for the producers. They can generate an additional income and this is how. […] Our offer is unique since there is no competitor that we know of and because we support our producers and educate our customers. […] On the next slide, this is our business model, and we combine it with idealism. [pitch] In a story that the audience described as "coherent," the pitchers combined elements of the business discourse with elements of the social discourse . Unlike those who mixed the discourses, potential contradictions between the two discourses in this example did not become apparent in the presentation or were turned into mutually reinforcing combinations as, for example, the idea of "sell by educating, educate by selling." After their pitch, there was an unusually high number of questions, and the Q&A session was extended. All but one of the questions asked by the audience related to the business discourse. --- Discussion Our analysis advances prior research on entrepreneurial pitching by offering a sorely needed intertextual perspective that highlights the discursive repertoire social entrepreneurs and their audience mobilize. The conventional view would be to see social entrepreneurs who are trying to a convince a jury which in turn is seeking to choose the best. Such a view would be limited because it does not capture how gatekeepers define what a social entrepreneur is in that moment. We highlight the nuances of the potentially contradicting discourses that social entrepreneurs choose from and how those connect to the discursive repertoire that their audience uses. Our detailed analysis of 49 videotaped pitches revealed that many social entrepreneurs align their text-intentionally or not-with the audience's dominant discourse. Others predominantly focused on social impact stories while neglecting the business discourse except when they had to answer questions from the audience. --- Uncertainty and Power in Social Entrepreneurial Pitching Despite important advances in research and practice , the concept of social entrepreneurship is still contested. Actors in the field and investors face uncertainty in light of the different understandings and definitions of the term . In the absence of clear selection criteria, the jury members in our study were largely left on their own to collectively make sense of the presentations. Borrowing from what they knew, they asked questions within the realm of the business discourse familiar to them. Some social entrepreneurs attempted to distance themselves from the powerful business discourse and-in drawing primarily on the social discourse-acted as if they were independent from the audience's judgements. However, the jury members forced those presenters into the discursive space of the business discourse in the Q&A sessions. In our study, gatekeepers exercised subtle and nuanced forms of power by normalizing our understanding of what social entrepreneurs are supposed to say and do. In focusing their questioning of the pitchers predominantly on business aspects, they offer a "taken-for-granted" understanding of what social entrepreneurship is , which goes largely uncontested; representing the ultimate exercise of power . Our study extends the existing research on the behavior, gesture and language of entrepreneurs since it also deals with the language their audience uses. We offer a critical perspective on the role of gatekeepers, who control access to resources or own financial assets and are more familiar with a business discourse. Thus, the business-oriented field ideology of impact investing plays an active role in shaping and influencing the fragmented concept of social entrepreneurship . In our case, the jury members decide which social enterprises are legitimate and gain access to resources . In such situations, the extent to which the gatekeepers themselves are dependent on social entrepreneurs can readily be forgotten. Previous research has suggested that the "content of entrepreneurial stories must align with the audience's interests and normative beliefs" . Bourdieu calls this alignment of interests "commonplaces," something the audience and the author have in common. Research in this field has investigated this connection, for example, in the context of journalists who reproduce commonly held ideas and ideologies to gain the attention of their audience or how entrepreneurs adapt their dress to fit the specific audience they are addressing . Our analysis extends current research since we elucidate the dialogic nature of texts including pitchers and their audience. We highlight the intertextual reproduction of the business-driven "field ideology" of their audience which seemed to be a process through which entrepreneurs could connect and engage on the basis of a common language and shared concepts. For example, in a few instances, social entrepreneurs repeated words or phrases they had heard from the jury just a few minutes earlier. We show how some social entrepreneurs opened a shared space with their audience by mostly mobilizing the business discourse, which was familiar to the jury. Others resisted-intentionally or not-and were rather forced into this space by audience questions. --- The Discursive De-construction of the "Social" in Social Entrepreneurship The concept of social entrepreneurship emphasizes the creation of positive social impact for society . Existing research has mainly viewed social entrepreneurship as being "at the service of the common good, thus exhibiting a thoroughly synergetic relationship with ethics" . However, our data suggest that powerful gatekeepers in the social entrepreneurship community construct a more business-dominated view on how to solve complex societal challenges that has important implications for the distribution of resources for start-ups. Interestingly, experts on the social or environmental challenges that the social entrepreneurs wanted to address were absent from the jury. The jury made decisions on ventures working in the field of female empowerment, education, health, or crime prevention without involving professionals in the respective area. If "success" in the field of social entrepreneurship is constructed primarily in business terms , the original social purpose will be backgrounded. Thus, while social entrepreneurs have been argued not to be inherently moral beings who do the right thing in contrast to the rest , the same may apply to their supporters and investors. Therefore, we argue that gatekeepers may need to re-focus their attention on categories of "social success," e.g., the theory of change, the quality of programs, the satisfaction of beneficiaries, and the social change accomplished . Thus, our study offers a fresh view on the practice of social entrepreneurship as a movement in which gatekeepers and investors may-unintentionally-suppress the social discourse that they intend to support. Our study points to a specific ethical dilemma for social entrepreneurs themselves: Which discourses should they align their presentation with? Our study elucidates how social entrepreneurs have to juggle the tension between emphasizing one discourse or another within the tight time limit given. Including both discourses in the presentation resulted in being able to go less in depth. Some social entrepreneurs used the discourses sequentially and separately, others mixed them while ignoring apparent contradicitions, and a third group attempted to hide contradictions or find mutually reinforcing combinations. Some social entrepreneurs felt uncomfortable with a business discourse they were not familiar with, but were nevertheless maneuvered into that discursive space by the audience in the Q&A session. Thus, the question arises as to the consequences of such a push toward the business discourse. Conformity with the powerful business discourse enables the pitching team to disguise potential contradictions and conflicts inherent in many hybrid enterprises . By actively hiding the complexity of hybridity, business stories helped the presenters simplify reality and create convincing cause-and-effect chains. Our findings illustrate how the social impact logic is "repackaged" in business vocabulary . In business-oriented pitches, serving beneficiaries and aiming for a social-mission-oriented goal were turned into stories of attracting customers and pursuing commercial growth. Such rationalism implies that by applying managerialist practices and an entrepreneurial mindset to social issues, complex realities may appear well-ordered and manageable to the audience . The subject position entrepreneur offered the social entrepreneurs a simple, unequivocally legitimate position to speak from. Such "entrepreneurial stories" seemed to have resonated with a business-oriented audience since the discursive repertoire was familiar to them. In contrast, social impact stories enabled presenters to emphasize the problem, their solution to it and their inherent intrinsic motivation, which may appeal more to the emotions and gut feeling of their audience. On the other hand, the adoption of the available concepts and "ready-made" elements of the business discourse may also constrain the social entrepreneurial community in important ways. The business discourse offers only a limited repertoire, and the hiding of the "social" may suppress critical alternative voices and draw an overly optimistic picture of the extent to which business solutions can succeed in solving complex social and environmental problems . Only in a few, rare cases did social entrepreneurs succeeded in combining both discourses and apparently seamlessly hid potential contradicitions between the two-as, for example, the start-up "Upcycling Design." Our study extends the existing research on the introduction of the market discourse in the social sector and its predominance in social entrepreneurship , which has detrimental effects for relationships to constituents . We illustrate how social entrepreneurs who resist attempts to determine who they should be as their way of practicing ethics may not be able to easily connect with powerful business-oriented gatekeepers and investors. If social entrepreneurs-responding to such pressures-try to sell their ideas in a business "outfit," will this inevitably lead to a degradation of their social mission? What impact may such an attempt have on the identity of social entrepreneurs since they have been found to draw their legitimacy as activists, guardians, or even entrepreneurs primarily from a sense of social morality rather than from the business discourse directly ? --- Managerial Implications Our study offers important managerial implications. Our findings illustrate how social entrepreneurs need to be able to present themselves in different ways to different audiences. Business-oriented stakeholders expect the appropriate information on business models, customers, pricing, marketing, etc.. However, this is not necessarily the content that may be of interest for other audiences such as beneficiaries, or stakeholders from the social sector. Our study elucidates how social entrepreneurs need to meet the expectations of their audience and thus may need to communicate differently depending on the respective target group, much like a chameleon. Impact investors need to be mindful of the importance of assessing the social impact of a venture. This is not a trivial task and they may need to draw on the expertise of professionals in the relevant subject area, for example the integration of marginalized people or the rehabilitation of juvenile offenders. --- Conclusion Our study highlights the discursive repertoire that social entrepreneurs and their audiences draw upon in pitching situations. Our analysis of video material from live pitches shows how-paradoxically-a strong focus on the impact story may prevent social entrepreneurs from entering a shared discursive space with their business-oriented audience. The intertextual perspective allows us to better understand the power dynamics between the pitcher and their audience. We highlight how the intertextual reproduction of a larger discourse contained both enabling and constraining elements. In so doing, our study points to a crucial dilemma for social entrepreneurs: Should they intentionally "dress up" as a business if that helps to connect to gatekeepers and potential investors? Although our study is based on rich data from interviews, observations, and videotaped pitches in three different cities in Germany and Switzerland, some dynamics may play out differently in social entrepreneurship communities in other countries. For example, pitching for resources in developing countries and among impoverished entrepreneurs may have different characteristics . While we acknowledge the limited generalizability of our findings, we maintain that our study sheds light on important processes that often unfold "behind closed doors." Our unique data access enabled us to conduct real-time observations of live pitches, however, this setting also has limitations. Future research needs to explore which discourse is more successful in convincing impact investors. Also, our research design did not allow us to control for the influence of other "variables." For example, future research is needed to take other important aspects such as gender into account or to investigate how the audience's perception of the moral intensity of the social problem may influence their preference for a business or social discursive repertoire. Future research is also needed to illustrate how intertextuality plays out in other pitch situations and contexts. Such analysis could also elaborate on taboos or what is left unsaid by the entrepreneurs. In addition to our focus on language, it would be worthwhile to apply a visual ethnographic approach and explore how social entrepreneurs manage and manipulate visual symbols in pitches. Finally, if gatekeepers emphasize a business discourse to the detriment of the social in pitch situations, it would be crucial to understand what happens in the later process. For example, will such differences lead to misunderstandings and conflicts over means and ends between an investor and investee? --- Appendix See Tables 1,2, and 3. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This study explores the discourse of social entrepreneurs and their audiences in pitch situations. Adopting a practice perspective on social entrepreneurship, we videotaped 49 pitches by social entrepreneurs at five different events in two incubators in Germany and Switzerland. Our analysis of the start-ups' pitches and the audience's questions and comments as well as of interview data elucidates the nuances of social and business discourse that social entrepreneurs and their audiences draw upon. Our analysis shows how many social entrepreneurs mobilize a discursive repertoire that is familiar to their businessoriented audience while others predominantly draw on a social discourse. We identify separating, mixing, and combining as key strategies that allow social entrepreneurs to dance between the two. We discuss how the intertextual reproduction of concepts, objects, and subject positions contains both enabling and constraining elements, which results in an ethical dilemma for social entrepreneurs: Should they re-package their social impact story in a business discourse to connect with their audience?

introduction it is complex for social entrepreneurs to convince potential supporters resource providers and investors in a pitch situation since many are not familiar with the concept social entrepreneurship combines potentially contradicting elements of social and commercial logics in unprecedented ways to address social problems and it creates positive impact for society previous research has focused on various aspects that influence the process of resource mobilization such as signaling the competences of the founding team the network that the entrepreneur is embedded in and the social competence of the founder a recent turn toward linguistics has called attention to the role of pitching and storytelling in the entrepreneurial process in this study we explore how social entrepreneurs present their venture to the audience in a pitch situation in doing so we intend to shed light on the specific dilemmas and tensions that social entrepreneurs face zacharakis et al found that early stage investors are to some extent intuitive decision makers this may apply even more to the context of social entrepreneurship since the decision to support social entrepreneurs could also be a gut decision instead of a purely analytical one the existing research on pitches by social entrepreneurs is limited two studies on social ventures that presented on the online microlending platform kiva offer contradictory findings on the question of whether business or social discourse in the pitches tends to convince potential funders while the nascent field of impact investing and resource mobilization for social entrepreneurship is attracting increasing scholarly attention we do not yet fully understand how social entrepreneurs pitch and how resource providers react to those pitches while there is a presumption that the motivation to support and invest in socially oriented ventures is likely to be an ethical act to serve a larger social cause we know little about how such processes unfold specifically current research falls short in investigating the dialogic nature of a social entrepreneurs pitch texts are often constructed with coauthorship where others are asking questions or giving comments intertextuality captures the idea that every utterance is inevitably linked to what has been said before the text of a pitch is thus constructed as a mosaic of quotations since any text is the absorption and transformation of others creating such a mosaic is a process by which different words phrases and speech acts are selected and combined when constructing the meaning of a phenomenon such as social entrepreneurship we presently lack an understanding of how a pitch is connected to macrodiscourses and how the audience may intentionally or unintentionally coauthor the texts produced adopting a practice approach to social entrepreneurship we analyzed videotapes of 12 and 37 of pitches by social entrepreneurs their audiences and the interaction between both groups in the subsequent q a sessions the main contribution of our paper is that it advances our understanding of social entrepreneurial pitching as a dialogic process in which both presenters and their audience draw from larger discourses this interdiscursive perspective allows us to highlight the power dynamics involved in the construction of social entrepreneurship in pitch situations our study offers two key contributions to the literature first we offer detailed insights into the discourses social entrepreneurs and their audience mobilize in pitch situations we highlight how powerful gatekeepers predominantly drew on a business discourse offering a takenforgranted understanding of what social entrepreneurship is which goes largely uncontested second we highlight how aligning their presentations with the powerful business discourse has enabling and constraining effects for social entrepreneurs pitching in social entrepreneurship storytelling and resource mobilization in social entrepreneurship resources such as financial physical human as well as intangible resources are central to venture creation since social entrepreneurship as a concept is new to many providers of resources and does not conform with wellknown categories of business or notforprofit founders still have to do significantly more convincing social entrepreneurship is defined as individuals and organizations that use a business logic in a novel and entrepreneurial way to improve the situation of segments of the population that are excluded marginalized or suffering and are themselves not capable of changing this situation even though the term itself was coined more than two decades ago resource providers have discovered the field only recently and many investors face uncertainty in a fragmented field that still lacks standards and oversight early research on impact investing suggests that often the audience of social entrepreneurial pitches is torn between an idealtypical charity logic and an investment logic hehenberger et al show how a dominant field ideology has emerged among experts in impact investing which emphasizes head over heart decisions impact measurement over storytelling tools over needs of beneficiaries and picking the best over nurturing the social entrepreneurial ecosystem despite these significant advances our knowledge about the pitch process itself as well as the interaction between social entrepreneurs and their audience remains limited such an audience may consist of actors as diverse as wealthy private individuals or investment advisors representatives of venture capital funds institutional asset owners supporting organizations foundations and other experts in the field of social entrepreneurship a recent turn in entrepreneurship research has shifted the focus from entrepreneurial characteristics to entrepreneurial behaviors in this research stream of entrepreneurial behavior a group of authors investigates the role of stories in resource mobilization storytelling has been suggested to be of specific importance for social ventures while research on live pitches in social entrepreneurship is scarce evidence from studies on texts of crowdfunding presentations is also meager and inconsistent using a different text analysis dictionary led to contradictory results in two studies on the same crowdbased microlending platform thus to date we lack a coherent understanding of the discourses used in social entrepreneurial pitch situations we need to learn more about the discourses social entrepreneurs draw upon in live pitches which may differ from the presentation of a startup to laypersons on an online crowdfunding platform pitches in the entrepreneurial process research on pitches in commercial entrepreneurship found the pitch to be a critical component in the funding vetting process conducted by resource providers a pitch is often the initial introduction to and presentation of the venture to potential investors and resource providers resource providers use this forum to evaluate both the potential of the venture and the entrepreneurs capabilities to lead and grow the venture it provides a critical opportunity for the entrepreneur to articulate the ventures business propositions to create interest if resource providers form negative impressions of the entrepreneurs abilities to lead the venture during these presentations it is improbable that access to funding will later be secured in pitches connecting with the audience is especially important in the process of mobilizing resources as it helps to frame the nature of the business in such a way that its potential value becomes believable for example allison et al found that characterizing the venture as a personal dream in a pitch narrative positively influenced inexperienced firsttime funders moderate accounts of narcissistic rhetoric enhance crowdfunding performance however the impact of narcissistic rhetoric becomes detrimental to performance when used extensively drawing on text speech and video metadata of crowdfunding campaigns kaminski and hopp found that linguistic styles that aim to trigger excitement or are aimed at inclusiveness are better predictors of campaign success than firmlevel determinants while we know from existing research about the pivotal role of pitches in the entrepreneurial process the interactions between entrepreneurs and different resource provider audiences in live pitch situations of social entrepreneurs warrants further scholarly attention intertextuality to date it remains unclear how social entrepreneurs and their audience connect the texts that they produce in pitch situations to larger discourses work on discursive devices interaction analysis or psychonarratology take readership and response into account and point toward the dialogic nature of texts where readership and interpretation are as important as structure or authorship the notion of intertextuality holds that every utterance is inevitably linked to what has been said before in other texts all utterances are populated and constituted by snatches of others utterances more or less explicitly besides capturing the idea that each text connects to earlier texts intertextuality furthermore draws on a social connection between the author and the reader to communicate effectively speakers have to draw on commonplaces the more the communicators cultural worlds overlap the more effective their communication is intertextuality also highlights the anticipation of reading consequently social entrepreneurs are consciously or unconsciously influenced by the audience they address the existing research on storytelling in the entrepreneurial process has not sufficiently accounted for intertextuality that is the role the audience plays in coproducing texts in pitches this study aims to expand the existing work by analyzing the discourses that social entrepreneurs and their audience employ in live pitches therefore we ask what discursive repertoire do social entrepreneurs and their audience draw upon in pitch situations methodology to analyze the dynamic and interactive processes that occurred between the presenters and audience in realtime we chose a qualitative research design we studied live events at popular incubators to explore how social entrepreneurs pitch and how the audience reacts to these pitches our research was guided by a focus on 1 3 the doing of social entrepreneurs and their audiences in line with previous research that has conceptualized social entrepreneurship not as an inherently ethical concept per se but calls to investigate the concrete practices at play according to the entrepreneurshipaspractice literature those practices encompass the meaningmaking identityforming and orderproducing actions performed by multiple actors in the entrepreneurial process we videotaped the pitches and the subsequent q a sessions to capture the multitude of human actions and interactions which unfold so quickly that they would otherwise have been lost these videos provided a detailed and permanent record of the events from a perspective that captured both the presenters and their audience data collection i research setting we were initially guided by our general interest in pitches by social entrepreneurs for this reason we conducted a first study in an incubator in switzerland in 2013 in that setting we had the unique opportunity to record live pitches on video and conduct interviews with social entrepreneurs and jury members the swiss incubator was founded in 2011 in zurich and pursued the following mission we are committed to creating a thriving innovation ecosystem where people across organizations cultures and generations work together to solve the great challenges of our time the pitches that we filmed took place at the end of a 6month training program for social entrepreneurs the pitches lasted approximately 1015 min followed by a 10min q a session with questions from the jury the jury consisted of three members from the incubator team among whom was a university professor this event was a unique opportunity to gain first insights into live pitches and the discourses that the teams drew upon however the data collection at this pitch event presented us with a decisive disadvantage although the pitches were evaluated by the jury this evaluation had few to no direct consequences for the founders for this reason we approached a large incubator in germany for an additional data collection and were granted access to the selection process there 2 weeks later we were thus able to include pitches where the teams were then either given access to resources or not data collection i sources of data in total we videotaped 12 pitches and the subsequent q a sessions the interaction of the audience with the presenters was especially important for our research design as it allowed us to investigate coauthorship and the dialogic nature of the production of texts additionally we conducted 15 interviews during the pitching event the interviews with the three jury members lasted about 60 min and were taperecorded the informal interviews with each presenter team about 1015 min we asked the jury members to explain their written evaluations of the pitches and which parts of the pitch they remembered best in the short interviews with the presenters we asked how the teams had prepared for the pitches and why they had decided to present their startup in the precise manner in which they did the recorded interviews and the pitches were transcribed verbatim the questionnaire that the jury and the other presenters filled out asked them to evaluate the pitch according to the following criteria comprehensibility innovation and effectiveness of the idea expertise and credibility of the founders financial viability and feasibility while the survey did not meet scientific requirements we were surprised by the results which showed how negatively the jury and the other presenters rated social impact stories compared to pitches framed around a business discourse after finding only partial confirmation and inconclusive explanations of this finding in the interviews we collected additional data to gain more insights data collection ii research setting in our data collection ii we videotaped 37 live pitches in four pitching events at one incubator organization in germany the incubator was originally founded in 1994 to guide marginalized young adults in starting up their own business and becoming selfemployed in 2011 they expanded their program and started an incubator for social entrepreneurs the organizations mission is to foster social equality and promotion inclusion through the support of social startups at the time of data collection the incubator had 90 employees and offices in eight german cities to be accepted to the program and receive a scholarship a startup must apply and then present their business idea in a pitch each startup has five minutes to present their idea and seven minutes for discussion with the jury and the audience all pitching events are public thus approximately 2050 interested individuals attend and also ask questions however the majority of questions are asked by members of the jury the jury decides which startups will be awarded the social impact start scholarship once a startup is accepted it can take advantage of several services including the use of a coworking space coaching and mentoring legal consulting and access to a network of investors taken together the basic services that the incubator offers to their scholarship holders correspond to a total value of approximately 20000 euros each pitching event that we attended consisted of a different composition of jury members however two members were part of the jury in all four pitching events observed jury members included for example representatives from a governmentowned german development bank and a leading organization to support social entrepreneurship as well as from commercial startup incubators in addition successful commercial entrepreneurs a head of csr from a german car manufacturer a marketing director of a large firm the chief digital officer at a multinational it company a private impact investor and a journalist from a national newspaper rounded out the jury a number of jury members either directly invested in startups or supported startups in the process of resource mobilization while the program was running and beyond to be invited to the pitching event the founders submit a short written application that is checked for comprehensiveness and consistency by a team from the incubator a staff member of the incubator who is also a member of the jury conducts a short informal interview with the applicants however the other jury members decide without prior information solely based on the pitch and the subsequent q a session data collection ii sources of data we attended four pitching events two in berlin and two in hamburg and collected data on 37 social startups all pitches including the sevenminute followup interaction between startup and jury or audience were videotaped furthermore we collected all presentation slides and handouts created by the startups to support their talk as a third source of data we conducted indepth interviews with three jury members from the incubator including the organizations founder to deepen our initial understanding of the audiences discourses gained from the questionandanswer sessions of the pitches the interviews lasted on average 60 min in those interviews we asked how a typical pitch unfolded and what elements determined a successful pitch including examples we then discussed several pitches with them and asked them to elaborate on why they were accepted into the program or not we also asked our intervieweees to explain their evaluation of the pitch in addition we had informal conversations with social entrepreneurs and jury members right before or after the pitches during coffee breaks and after the events in the four pitching events that we attended 37 individuals and teams presented their ideas twentytwo were accepted to the program and 15 were rejected in each of the four events the startup that convinced the highest number of audience members received the audience award soccer for everyone in berlin in february fair handbags in hamburg in may urban bees in berlin in june and blindmap in hamburg in august in early 2020 7 years after the pitches we conducted an internet search to determine whether the startups from the second data collection were still alive eighteen ventures were still active one venture still existed but a commercial mission had replaced the social mission of the 23 winners that had entered the program 10 were still alive in 2020 of the 15 rejected startup teams 8 were still activeeven though they had not received support from the incubator interestingly only two of the four startups that had received the audience award survived data analysis we transcribed the text of all pitches and the respective q a sessions as well as the interviews verbatim resulting in 370 pages of text informed by grounded theory we began our analysis with a finegrained reading of the data and wrote story sheets for each pitch the videotapes allowed us to watch and rewatch each pitch and subsequent q a session numerous times during data analysis we first coded the text authored by the jury and the audience and the text produced by the pitchers each individually using the coding software maxqda the crosscase analysis of both incubators in germany and switzerland allowed us to identify the key themes of audience and pitchers we aggregated the themes into two broader discourses namely business and social we were surprised to discover how the firstorder codes of using a business language were similar for both groups interestingly though we found differences in how social entrepreneurs and their audience mobilized the social discourse for example our data show how the concepts of beneficiary fair remuneration and scaling a solution to a social problem were almost exclusively used by pitchers for each discourse we identified concepts objects and subject positions concepts are the very means through which social entrepreneurs and their audience make sense of phenomena such as a startup they constitute the vocabulary necessary for meaningmaking discourses not only describe but also construct objects such as a new social venture different discourses may produce different objects thus offering differing and even contradicting conceptualizations of one and the same startup discourses also construct subject positions for the actors involved as they give the subject different and possibly contradicting positions from which to speak such positions determine which social roles and functions as well as their affordances can legitimately be adopted within each discourse for example some social entrepreneurs may emerge as business people and others as social changemakers in mobilizing a specific discourse powerful actors shape our understanding of social entrepreneurship which in turn reflects their power to do so in this sense discourses are performative they accomplish things we held focusgrouplike presentations of our findings with team members from both incubators to clarify our observations after completing data collection the first author became a member of the german incubators jury to deepen her contextual knowledge on the selection processes we also used the interview data to challenge our findings to learn more about the way the presenters prepared for the pitches and about the invisible reactions of the audience to the presentations findings based on our analysis we highlight the similarities and the differences between the texts produced by social entrepreneurs and their audience in pitch situations in drawing on prior texts both groups mobilized elements of larger discoursesalbeit in different ways we show how they borrow concepts objects and subject positions from a business and social discourse discourses in social entrepreneurial pitches we elucidate how pitchers and their audience select bits and pieces from prior texts giving their language an intertextual dimension whether or not the speakers intended to do so our analysis suggests that in the actual pitch situations the questions and comments of the audience drew to a large extent on the discursive repertoire of the business discourse the presentations of most social entrepreneurs in contrast involved elements of both the business and the social discourse the business discourse of social entrepreneurs and their audience the business discourse is based on a managerialist ideology that emphasizes profitmaximizing strategies efficiency and profit the main concepts of the business discourse include a unique selling proposition customer pricing marketing and commercial growth in addition the financial viability of the business model was a popular concept used by the audience and to a small extent some social entrepreneurs how are you going to finance that was the most frequently asked question during the q a sessions in responding to the question social entrepreneurs were forced to elaborate on their business model some were well equipped to answer those questions by drawing on a business vocabulary others struggled a member of the jury explained his reaction to the pitches as follows im a businessman and to be honest im looking for people with business acumen who can make things happen if it cannot be financed it remains a naive illusion observation pitch event in contrast many social entrepreneurs did not refer to a business model at all in their pitches those who did emphasized revenue streams and financing options the founder of loveclothes later explained her choice not to use business language as follows the term entrepreneur was new to me i have never written a business plan to be honest i dont even know exactly what it is i studied international labor rights i live and breathe for the cause and want to empower the seamstresses in india interview social entrepreneur although the pitch was evaluated negatively and there were some critical queries about the financial viability by the jury the startup was accepted in the end it still existed and was operating successfully in 2020 in contrast a jury member stressed the importance of solid business models between us there are the tree huggers in social entrepreneurship they celebrate themselves so much and you see little progress we think like business people and when i speak out in favor of a social enterprise its not because a few naive dogooders think they have a good idea the thing has to finance itself period interview jury member associated with such business thinking was the concept of a unique selling proposition to the paying customer social entrepreneurs highlighted the unique features of the product or service and how it differed from existing offers we see an added value in our offer in contrast to others because the features of the it solution are unique pitch the startup medical backpack for example elaborated indepth on the viability of their business model and their unique selling proposition they presented their product as more 1 3 efficient than existing solutions the audience reacted very positively to this aspect congratulating the founders on their unique idea this is truly a unique product comment jury member directly after the q a session in which many questions focused on the unique selling proposition of medical backpack the next teambefore their actual pitchrepeated the same concept we differentiate ourselves from other offerings … interestingly the audience members used in their questions on the unique selling proposition the term competitor to refer to other offers who are your competitors audience question the notion of competitor portrays social entrepreneurs as trying to compete with others for example by making bigger sales the term was rarely used by social entrepreneurs and if at all in answers to jury questions in addition we identified the notion of customer as a key concept in the business discourse it is very important to me that they have an idea of what the customer looks like whos buying this and why the worm must taste good to the fish not to the angler or the story wont pay off interview jury member in the presentation by blindmap the founders explained how one of the team members belonged to their customer group and had inside knowledge of their needs the startup sustainability game presented extensive research on their potential customers including a number of informative figures and statistics similarly the team from emissionfree food stated lets look at our primary customers our customers are adults between 25 and 45 years they possess a smartphone and they live in germanor englishspeaking countries this would be 78 million out of those 78 million 80 say climate change is a serious or very serious problem this means we may have 62 million potential customers pitch many startups explicitly referred to customers whereas other social entrepreneurs did not address the concept of customer at all during their pitch the pitchers mostly spoke about the needs and expectations of customers the audiences questions revolved around the number and characteristics of customers and their ability to pay many pitchers also made use of other concepts originating in the business discourse for example marketing addressing topics such as how to present and advertise the product or service one team described their sales channels as follows we plan to work with classic retailers and of course organic supermarkets are at the top of our list pitch one of the jury members also emphasized the importance of marketing targeted toward the paying customer they must be able to demonstrate where they want to get the paying customer how do they plan to advertise and sell the products or services interview jury member unlike the social entrepreneurs presentations the audience questions were often targeted at sales or sales channels some pitchers had difficulty responding furthermore jury members asked questions about the pricing if the concept had not been mentioned in the pitch can you tell us more about the price … how does this cover your costs the audience repeatedly emphasized the important of a pricing strategy and whether it matched the costs and the willingness to pay pricing was much less referred to by the social entrepreneurs or only when asked about it in addition the concept of commercial growth was frequently referred to in pitches and the q a sessions you have to identify new markets to be successful comment jury member the startup blindmap explained their strategy for revenue growth as follows our next challenge is to gain automation as m explained we are currently doing everything manually with each successive step we want to automate everything so that our maps will become more and more affordable this has a large impact on our business model our maps need to be financed pitch the audience asked about the potential for growth in revenues and sales while some social entrepreneurs also mentioned how they planned to grow the business beyond the core the founder of loveclothes was very skeptical about growth as such i dont want investors who will reduce our impact and only want a quick profit if anything we will grow organically slowly and steadily interview social entrepreneur these concepts of the business discourse used by the pitchers and their audience bring an object into being namely the social startup as a business the social cause that the venture aims to address is framed as a business opportunity rather than as a societal challenge we saw a market here pitch urban vegan farming chose not to speak about the problem but rather focus on the business opportunity we observe a trend that hip urban people want to feel a connection to their food this is our target group we offer harvesting stations we create a world of experience and a meeting place pitch instead of describing the various sustainability problems of the food industry the founders illustrated the untapped market potential that they wanted to address with their offer thus they presented the opportunity in a social problem the jury rated their pitch as very convincing in the questionnaire in the interview the presenters explained their choice as follows this is supposed to be a business we need to convince potential investors of our business model and our potential … we have learned to stop boring people with our litanies about the scandalous food industry no one wants to hear that some people know that and the others do not want to hear about it interview presenter in line with a business ideology of profitmaximizing strategies and an emphasis on efficiency conceptualizing the startup as a business also included the conviction that a marketbased solution is superior there is a significant difference between the work public agencies or nonprofits do the laws of the market ensure that social enterprises are efficient interview jury member the subject position as a legitimate position to speak from in the business discourse portrays the social entrepreneur mainly as an entrepreneur ie as a person who takes risks and makes money this is our coworking space where our entrepreneurs really take off for example alpha they just made a sixfigure sum with a crowdfunding campaign observation employee from impact lab guides the jury members through their office space founders described themselves as a business person with strong implementation skills their audience voiced how social entrepreneurs should be entrepreneurs and selfstarters social discourse of social entrepreneurs and their audience in contrast the social discourse centers on the main goal of the startup working toward a social mission in the q a sessions only a small fraction of the questions by the audience referred to concepts of the social discourse social entrepreneurs drew to varying degrees on the language and concepts of this discourse firmly rooted in a social ideology the social discourse is shaped by values such as justice inclusion and responsibility and emphasizes social impact a central concept is the notion of the theory of change and social impact that is how and why a desired social change is expected to happen to our surprise only a few questions of the jury referred to the concept and if so then only to the reach of the offer by contrast many social entrepreneurs explained the social or environmental problem they intended to address in detail eg the challenge of improving the lives of disadvantaged groups or fighting climate change this is challenging how can i present such a complex problem in such a short time pitch the description and analysis of the problem ranged from stories the social entrepreneurs had experienced to more abstract presentations of facts and figures the social cause is framed as a problem that needs to be addressed emphasizing the drive of the venture for social change a central part of the pitch was describing the solution idea for the problem ie how the founders planned to achieve the intended social impact the pitchers explained how their innovative idea would bring about social change promote justice and responsibility and foster the inclusion of beneficiaries for example the founder of childrens bus explained her theory of change as follows i know its challenging to explain such a complex social problem in 60 seconds but ill try … and i am going to run a small restaurant on the bus to finance the trips pitch also social entrepreneurs used the notion of valueadded for society gesellschaftlicher mehrwert in german to describe the potential impact of a venture if we stop hooligans from becoming violent we save the government money we contribute to peace and security and show these people a new way pitch the founders of childrens bus multigeneration house local community and world music concerts used their pitch time exclusively drawing on the social discourse and received unfavorable feedback from the jury members who questioned the lack of a business model however in a few cases the theory of change was explicitly questioned by the audience how are you going to work with the kids audience question other concepts that formed an inherent part of the social discourse included beneficiary fair remuneration reaching beneficiaries and scaling in the social discourse the concept of a beneficiary was used instead of customer while the term customer in the business discourse is associated with a certain willingness to pay the concept of beneficiary puts the indepth knowledge of the needs of a marginalized population center stage annett is 14 years old and grew up in one of the biggest slums in kibera every month when she has her menstruation she is afraid to ask her father for money because money is always scarce this leads to annett not going to school when she has her period for fear of bleeding through her clothes and embarrassing herself annett is not an isolated case every month more than a billion women struggle to afford pads out of fear of embarrassment they stay away from school or work unicef and undp state that menstruation is the main reason why girls do not go to school regularly pitch even though the startup made it clear that their idea is a menstrual product primarily for use in developing countries to help women in need the first question from the audience was id be interested to know i know this from the us and i think its also available in denmark what is the growth potential in germany audience question in almost all pitches the beneficiaries were explicitly mentioned and often presented in detail using figurative language and introducing a specific persona in the social discourse the beneficiary is portrayed as a disadvantaged and or marginalized person who needs help and support and who deserves justice in some instances the terms client or patient was also used in contrast the characteristics of beneficiaries were almost never a topic during the q a sessions the term itself was not used at all an incubator staff member commented on our observations as follows one aspect that many on the jury pay far too little attention to is that we should be looking for founders who know their stuff you dont just turn a jobless migrant into an entrepreneur overnight that would be naive social change does not happen like that interview jury member this is interesting since the concept of beneficiary could be viewed as less empowering than customer thus the term beneficiary could actually undermine key values of the social discourse ifself such as inclusion and responsibility reaching the beneficiaries was another key concept of the social discourse in contrast to the marketing concept of the business discourse the notion of reaching the beneficiaries is concerned with the accessibility of their offer and ways to include beneficiaries to increase the social impact it was not a frequent topic in the pitches but the few who referred to reaching the beneficiaries described how they planned to tailor their offer to meet the needs of the target group our app will be easy to use the gamification will allow users to have fun pitch the founder of multigeneration house explained their choice to dress up with an old curtain over her head as the soul of the building which attracts people from all age groups as follows thats where we come from we see the spirit of the building thats what invites different people we got the impression that the founder felt right at home in her costume as the soul of the building several jury members however made disparaging remarks about it and missed a business perspective in the pitch the team of multigeneration house had detailed their track record of how they had consistently brought very different people together however as with the vast majority of pitches the topic was not addressed by the audience in the q a sessions one exception was as an audience member who asked after the pitch of childrens bus why should the children want to join your activities audience question to point to the number of users needed for success some social entrepreneurs drew on the concept of fair remuneration in their pitches but it was also never addressed in the q a a comprehensive pricing model was concerned with setting a price that would allow for sustainable production and fair wages our price should reflect the true costs we do not want somebody else to pay the price pitch finally the concept of scaling was used by pitchers to depict a vision of how the new idea could be replicated by others in different contexts or expanded to other countries to grow its social impact this project could be implemented in any city pitch unlike commercial growth the notion of scaling is about spreading the word about a solution to a social problem without any immediate profit interest thus the scalability refers to the possibility to grow and adapt the idea in other contexts to meet greater needs in future and it is an oftenquoted concept used by supporting organizations in social entrepreneurship however no audience question referred to the concept these concepts from the social discourse bring an object into being namely the social impact as the key feature of the startup emphasizing the development of fresh ideas that meet social needs more effectively than existing solutions the view of social entrepreneurship as an ethical concept draws on an ideology which emphasizes social impact justice inclusion and responsibility a jury member described his preference as follows to me financing marketing thats completely uninteresting at the time of the pitch you can address that but you dont have to the innovation is important what is important is the social impact so what is the problem i want to solve interview jury member the rest of the audience coconstructed a slightly different picture of a business with social side effects its a great product and i believe there is a market … and i think people will benefit comment audience the subject position as a legitimate position to speak from sees social entrepreneurs as activists and changemakers our vision is the reintegration of former forced prostitutes back into society with the help of fashion pitch in an interview a social entrepreneur described herself as a deeply moral person and as a social innovator i want to change the way we look at others each person has unique talents and can give something that no one else has to give every person has unique talents and abilities my aim is to value strengths and not to judge people by their weaknesses interview presenter the audience emphasized how social entrepreneurs should bring new ideas to the table whats new about this approach audience question separating mixing and combining business and social discourse most social entrepreneurs included elements of the business and the social discourse in their presentations some drew to a large extent on the business and others put more emphasis on the social discourse a third group scarcely referred to either of the two discourses one presenter described her dilemma in preparing for their pitch as follows its a difficult choice you just have so little time we thought it over and rehearsed it very well beforehand the problem is which points should we address i wrote my masters thesis on social problem so i can already say a lot about that you know but there is also lets say a certain community here so they want to know where the startup capital comes from and so on thats a certain way of thinking yes interview social entrepreneur our analysis finds that social entrepreneurs use different ways to separate mix or combine the business and social discourse in their pitches the first group of presenters clearly split the business and the social part of their presentation as indicated for example by the titles on their slides the problem the solution monetization slides pitch presentation the second group of pitchers mixed the two discourseseven potentially contradicting concepts for example a founder spoke about the target group the beneficiary and the customer while referring to the same group of people the startup live your dreams ironically picked up elements of a business discourse to explain their social mission our customers dreamers and storytellers slides pitch presentation in several instances we observed such a use of business vocabulary which resembled the use of buzzwords without a deeper connection to the rest of the text paradoxically one startup was expressly fighting against capitalism as their ideological opponent however they told their anticapitalism story by drawing on business concepts and a managerialist vocabulary ignoring apparent contradictions a third group set out to combine and thus reconcile potentially contradictory elements of both discourses the startup upcycling design explained how their idea integrates both ideologies we are split into two things idealism meets realism we started with our company and said wed make money and do something social … we know our customers … our marketing strategy … there is a demand for sustainable products and it is a trend in the market our revenue model … we wish to include our producers and empower them it is our way to contribute its about selfrealization and recognition for the producers they can generate an additional income and this is how … our offer is unique since there is no competitor that we know of and because we support our producers and educate our customers … on the next slide this is our business model and we combine it with idealism pitch in a story that the audience described as coherent the pitchers combined elements of the business discourse with elements of the social discourse unlike those who mixed the discourses potential contradictions between the two discourses in this example did not become apparent in the presentation or were turned into mutually reinforcing combinations as for example the idea of sell by educating educate by selling after their pitch there was an unusually high number of questions and the q a session was extended all but one of the questions asked by the audience related to the business discourse discussion our analysis advances prior research on entrepreneurial pitching by offering a sorely needed intertextual perspective that highlights the discursive repertoire social entrepreneurs and their audience mobilize the conventional view would be to see social entrepreneurs who are trying to a convince a jury which in turn is seeking to choose the best such a view would be limited because it does not capture how gatekeepers define what a social entrepreneur is in that moment we highlight the nuances of the potentially contradicting discourses that social entrepreneurs choose from and how those connect to the discursive repertoire that their audience uses our detailed analysis of 49 videotaped pitches revealed that many social entrepreneurs align their textintentionally or notwith the audiences dominant discourse others predominantly focused on social impact stories while neglecting the business discourse except when they had to answer questions from the audience uncertainty and power in social entrepreneurial pitching despite important advances in research and practice the concept of social entrepreneurship is still contested actors in the field and investors face uncertainty in light of the different understandings and definitions of the term in the absence of clear selection criteria the jury members in our study were largely left on their own to collectively make sense of the presentations borrowing from what they knew they asked questions within the realm of the business discourse familiar to them some social entrepreneurs attempted to distance themselves from the powerful business discourse andin drawing primarily on the social discourseacted as if they were independent from the audiences judgements however the jury members forced those presenters into the discursive space of the business discourse in the q a sessions in our study gatekeepers exercised subtle and nuanced forms of power by normalizing our understanding of what social entrepreneurs are supposed to say and do in focusing their questioning of the pitchers predominantly on business aspects they offer a takenforgranted understanding of what social entrepreneurship is which goes largely uncontested representing the ultimate exercise of power our study extends the existing research on the behavior gesture and language of entrepreneurs since it also deals with the language their audience uses we offer a critical perspective on the role of gatekeepers who control access to resources or own financial assets and are more familiar with a business discourse thus the businessoriented field ideology of impact investing plays an active role in shaping and influencing the fragmented concept of social entrepreneurship in our case the jury members decide which social enterprises are legitimate and gain access to resources in such situations the extent to which the gatekeepers themselves are dependent on social entrepreneurs can readily be forgotten previous research has suggested that the content of entrepreneurial stories must align with the audiences interests and normative beliefs bourdieu calls this alignment of interests commonplaces something the audience and the author have in common research in this field has investigated this connection for example in the context of journalists who reproduce commonly held ideas and ideologies to gain the attention of their audience or how entrepreneurs adapt their dress to fit the specific audience they are addressing our analysis extends current research since we elucidate the dialogic nature of texts including pitchers and their audience we highlight the intertextual reproduction of the businessdriven field ideology of their audience which seemed to be a process through which entrepreneurs could connect and engage on the basis of a common language and shared concepts for example in a few instances social entrepreneurs repeated words or phrases they had heard from the jury just a few minutes earlier we show how some social entrepreneurs opened a shared space with their audience by mostly mobilizing the business discourse which was familiar to the jury others resistedintentionally or notand were rather forced into this space by audience questions the discursive deconstruction of the social in social entrepreneurship the concept of social entrepreneurship emphasizes the creation of positive social impact for society existing research has mainly viewed social entrepreneurship as being at the service of the common good thus exhibiting a thoroughly synergetic relationship with ethics however our data suggest that powerful gatekeepers in the social entrepreneurship community construct a more businessdominated view on how to solve complex societal challenges that has important implications for the distribution of resources for startups interestingly experts on the social or environmental challenges that the social entrepreneurs wanted to address were absent from the jury the jury made decisions on ventures working in the field of female empowerment education health or crime prevention without involving professionals in the respective area if success in the field of social entrepreneurship is constructed primarily in business terms the original social purpose will be backgrounded thus while social entrepreneurs have been argued not to be inherently moral beings who do the right thing in contrast to the rest the same may apply to their supporters and investors therefore we argue that gatekeepers may need to refocus their attention on categories of social success eg the theory of change the quality of programs the satisfaction of beneficiaries and the social change accomplished thus our study offers a fresh view on the practice of social entrepreneurship as a movement in which gatekeepers and investors mayunintentionallysuppress the social discourse that they intend to support our study points to a specific ethical dilemma for social entrepreneurs themselves which discourses should they align their presentation with our study elucidates how social entrepreneurs have to juggle the tension between emphasizing one discourse or another within the tight time limit given including both discourses in the presentation resulted in being able to go less in depth some social entrepreneurs used the discourses sequentially and separately others mixed them while ignoring apparent contradicitions and a third group attempted to hide contradictions or find mutually reinforcing combinations some social entrepreneurs felt uncomfortable with a business discourse they were not familiar with but were nevertheless maneuvered into that discursive space by the audience in the q a session thus the question arises as to the consequences of such a push toward the business discourse conformity with the powerful business discourse enables the pitching team to disguise potential contradictions and conflicts inherent in many hybrid enterprises by actively hiding the complexity of hybridity business stories helped the presenters simplify reality and create convincing causeandeffect chains our findings illustrate how the social impact logic is repackaged in business vocabulary in businessoriented pitches serving beneficiaries and aiming for a socialmissionoriented goal were turned into stories of attracting customers and pursuing commercial growth such rationalism implies that by applying managerialist practices and an entrepreneurial mindset to social issues complex realities may appear wellordered and manageable to the audience the subject position entrepreneur offered the social entrepreneurs a simple unequivocally legitimate position to speak from such entrepreneurial stories seemed to have resonated with a businessoriented audience since the discursive repertoire was familiar to them in contrast social impact stories enabled presenters to emphasize the problem their solution to it and their inherent intrinsic motivation which may appeal more to the emotions and gut feeling of their audience on the other hand the adoption of the available concepts and readymade elements of the business discourse may also constrain the social entrepreneurial community in important ways the business discourse offers only a limited repertoire and the hiding of the social may suppress critical alternative voices and draw an overly optimistic picture of the extent to which business solutions can succeed in solving complex social and environmental problems only in a few rare cases did social entrepreneurs succeeded in combining both discourses and apparently seamlessly hid potential contradicitions between the twoas for example the startup upcycling design our study extends the existing research on the introduction of the market discourse in the social sector and its predominance in social entrepreneurship which has detrimental effects for relationships to constituents we illustrate how social entrepreneurs who resist attempts to determine who they should be as their way of practicing ethics may not be able to easily connect with powerful businessoriented gatekeepers and investors if social entrepreneursresponding to such pressurestry to sell their ideas in a business outfit will this inevitably lead to a degradation of their social mission what impact may such an attempt have on the identity of social entrepreneurs since they have been found to draw their legitimacy as activists guardians or even entrepreneurs primarily from a sense of social morality rather than from the business discourse directly managerial implications our study offers important managerial implications our findings illustrate how social entrepreneurs need to be able to present themselves in different ways to different audiences businessoriented stakeholders expect the appropriate information on business models customers pricing marketing etc however this is not necessarily the content that may be of interest for other audiences such as beneficiaries or stakeholders from the social sector our study elucidates how social entrepreneurs need to meet the expectations of their audience and thus may need to communicate differently depending on the respective target group much like a chameleon impact investors need to be mindful of the importance of assessing the social impact of a venture this is not a trivial task and they may need to draw on the expertise of professionals in the relevant subject area for example the integration of marginalized people or the rehabilitation of juvenile offenders conclusion our study highlights the discursive repertoire that social entrepreneurs and their audiences draw upon in pitching situations our analysis of video material from live pitches shows howparadoxicallya strong focus on the impact story may prevent social entrepreneurs from entering a shared discursive space with their businessoriented audience the intertextual perspective allows us to better understand the power dynamics between the pitcher and their audience we highlight how the intertextual reproduction of a larger discourse contained both enabling and constraining elements in so doing our study points to a crucial dilemma for social entrepreneurs should they intentionally dress up as a business if that helps to connect to gatekeepers and potential investors although our study is based on rich data from interviews observations and videotaped pitches in three different cities in germany and switzerland some dynamics may play out differently in social entrepreneurship communities in other countries for example pitching for resources in developing countries and among impoverished entrepreneurs may have different characteristics while we acknowledge the limited generalizability of our findings we maintain that our study sheds light on important processes that often unfold behind closed doors our unique data access enabled us to conduct realtime observations of live pitches however this setting also has limitations future research needs to explore which discourse is more successful in convincing impact investors also our research design did not allow us to control for the influence of other variables for example future research is needed to take other important aspects such as gender into account or to investigate how the audiences perception of the moral intensity of the social problem may influence their preference for a business or social discursive repertoire future research is also needed to illustrate how intertextuality plays out in other pitch situations and contexts such analysis could also elaborate on taboos or what is left unsaid by the entrepreneurs in addition to our focus on language it would be worthwhile to apply a visual ethnographic approach and explore how social entrepreneurs manage and manipulate visual symbols in pitches finally if gatekeepers emphasize a business discourse to the detriment of the social in pitch situations it would be crucial to understand what happens in the later process for example will such differences lead to misunderstandings and conflicts over means and ends between an investor and investee appendix see tables 12 and 3 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

this study explores the discourse of social entrepreneurs and their audiences in pitch situations adopting a practice perspective on social entrepreneurship we videotaped 49 pitches by social entrepreneurs at five different events in two incubators in germany and switzerland our analysis of the startups pitches and the audiences questions and comments as well as of interview data elucidates the nuances of social and business discourse that social entrepreneurs and their audiences draw upon our analysis shows how many social entrepreneurs mobilize a discursive repertoire that is familiar to their businessoriented audience while others predominantly draw on a social discourse we identify separating mixing and combining as key strategies that allow social entrepreneurs to dance between the two we discuss how the intertextual reproduction of concepts objects and subject positions contains both enabling and constraining elements which results in an ethical dilemma for social entrepreneurs should they repackage their social impact story in a business discourse to connect with their audience

Kenya National Bureau of Statistics -KNBS established that Kenya's birth rate decreased from five kids per woman in the year 2003 to four in 2014. This is because of a spike in contraception use from 39.3% of married women in the year 2003 to 58.3% in 2014. As a result of improved FP usage and reduced fertility, the rate of population plummeted from 2.9% to 2.2 % between 2009 and 2019. However, according to Ministry of Health , the uptake of FP among married women of procreative age in Bomet County is about 47.5 percent, still low compared to the national rate of 55%. KNBS affirms that the crude birth rate in the county is 26.2 per 1,000 population; the mean number of children born by women is 5.7%, which is higher than Kenya's figure of 5%. This research, therefore, sought to examine socio-cultural factors that influence men's participation in FP in Bomet County, Kenya. --- Statement of the Problem Kenya was among the first countries in Africa to adopt a population strategy, yet the uptake of FP among women, especially those residing in rural areas, remains low. The uptake of FP among married women of procreative age in Bomet County is low compared to national FP use and other counties. This is despite the support FP is given in the area. The county has one community outreach funded by Tenwek Mission Hospital and another outreach supported by Beyond Zero mobile clinic, which supports FP initiatives. FP in the county is also enhanced by two NGOs: the World Bank and Marie Stopes. Moreover, the county has many public FP facilities that offer FP services. Therefore, this called for interrogation of socio-cultural factors that influence men's participation in FP in the county. --- Objectives of the Study The general objective of the study was to examine the socio-cultural factors that influence men's participation in FP in Bomet County, Kenya. The specific objectives of the study were to: • Assess the influence of large families on men's participation in FP in Bomet County, Kenya. • Examine the influence of sex preference on men's participation in FP in Bomet County, Kenya. • Determine the influence of religious faith on men's participation in FP in Bomet County, Kenya. --- Theoretical Framework This research was guided by the Social Dominance Theory as proposed by Sidanius and Pratto . There are four sources of gendered influence within the social domination school of thought: consensual ideologies, resource control, social obligation and force. In a patriarchal culture governed by sexism, religious traditions, and an entrenched societal belief structure, these bases of gendered power may be a prism to examine how they impact women's and men's use of contraceptives. Although these four bases can be distinguished, they are intertwined and can complement one another. Gender roles, traditions, stereotypes, and all other views or assumptions about men and women that are commonly agreed upon in a society or community are referred to as consensual ideologies. Women are always placed in a lesser status than men due to this. These mutually beneficial theories reduce women's influence in heterosexual relationships, potentially resulting in their inability to negotiate or regulate their fertility through contraception. Patriarchal philosophies, when combined with biblical scripts, support men and sanctify male superiority in the home. Men and women behave differently when it comes to contraception and decision-making because of the unbalanced gender relations in the household. Resource control refers to the control over economic resources, for example, wages and assets, which, worldwide, traditionally benefit men over women. The role of social and systemic disparity in women's subordination is highlighted by resource management. Women are frequently economically dependent on their male partners due to unequal access to resources. This renders contraceptives such as condoms difficult to use or dangerous to negotiate. Social obligations are sometimes gender controlled, with the emphasis on marriages and caregiving as causes of disparity between men and women. Responsibilities to others are inevitable social duties . Women, rather than males, have more obligations in most countries, including becoming mothers or meeting the needs and desires of others. Married women may find it more difficult to consider contraceptive use because they feel compelled to bear children as part of their marital and maternal roles. As a result, the more live children a mother has, the more likely she will use contraceptives; thus, women who have given birth to many children are more likely to adopt contraception. Force is a type of gendered power that aids in establishing a dominance hierarchy in society between men and women. Some psycho-social studies blame common power imbalances for women's abuse; they have shaped male-female relationships. A power imbalance between men and women triggers inequality and gender-based violence in the public sphere; it has also generated numerous incidents of violence in private male-female relationships, especially within the family. Women's levels of superiority in marriages are attributed to their histories of spouse brutality and harassment within their marriages. --- Research Methodology --- Research Design A descriptive survey research design was adopted in the research. It entails acquiring information from one or many groups of people about their outlooks, thoughts and past experiences by asking them questions and recording their responses. For Kothari , which supported the research findings. The descriptive survey research design also enabled the collection of both quantitative and qualitative data. --- Study Site This research was done in Bomet County, Kenya. The county has five sub-counties: Chepalungu, Bomet Central, Konoin, Sotik and Bomet East . There are five wards, 66 locations, and 177 sub-locations within the subcounties. Bomet County has a total population of 875,666 people, with 434,287 males and 441,379 females. Kericho borders it to the North, Nyamira to the West, Narok to the South, and Nakuru to the North-East. It covers a total area of 22,037.4 square kilometres. The main economic activity in Bomet County is agriculture, with dairy farming and tea farming leading. Pineapples, Irish potatoes, maize, beans, cabbages, bananas and onions are all cultivated for commercial and subsistence purposes. The county is well endowed with health facilities where women can seek FP services. They include: Tenwek Mission Hospital, which is in Category 6-B, and two Level 5 hospitals: Longisa County Referral Hospital and Kaplong Mission Hospital. Further, the county has three Level 4 hospitals, 19 health centres, 107 dispensaries and 39 community units. Moreover, the World Bank and Marie Stopes International promote FP in the county . --- Sampling Procedure This research employed a multi-stage cluster sampling method. The clusters in this research included subcounties, wards, locations, sub-locations and households. As a result, a five-stage cluster sampling procedure was used. In the first level, Bomet Central and Sotik Sub-counties were chosen on the basis of their population; the two have the highest population. The latter has 227,380 residents and 47,315 households, while the former has 173,758 residents and 38,259 households . The remaining stages employed simple random sampling with a 10%-30% criterion to survey the participating wards, areas, and sub-locations. Mugenda and Mugenda assert that a sample frame can contain about 10% and 30% of a sample frame in an analogous environment. --- Table 1:Multi-stage Cluster Sampling Procedure Source: Author, 2023 The sampling of the households was drawn from the list of the number of households in the sub-locations . Households were randomly selected; the study considered every 10 th household with a married man aged between 18-60 years and a married woman aged between 18 and 45 years. --- Sample Size The sample size for the study was estimated using the simplified method by Yamane , which estimates sample sizes with a confidence level of 95%, a level of precision of 0.05 and a population size of 25,671 households as follows: Where: n is the sample size, N is the population size , E is the level of precision Applying the formula to the sample above n = 25,671 1 + 25,671 2 =394 The male household heads filled out the questionnaires. Further, the number of married women who participated in the FGDs comprised 20 % of the sample size . Kothari posits that a sample size ranging from 10% to 30% is a good representation of the entire population. Therefore, a sample of 78 married women participated in the FGDs. The married men who participated in the study were 316. --- Sub-county The sample size was 316 married men +78 married women = 394 Additionally, twelve KIIs were included in the study. Therefore, the total sample size was 406 respondents. --- Study Findings The purpose of the study was to examine socio-cultural factors that influence men's participation in FP in Bomet County. The study found out that preference for large families, son preference and religious factors determine contraceptive uptake among both men and women in the county. --- Influence of Family Size Preference on Men's Participation in FP The study sought to establish whether or not family size influenced men's participation in FP. Therefore, the respondents were asked to state the number of children they preferred. The findings are shown in figure 1 below. --- Figure 1: Influence of Family Size Preference on Men's Participation in FP As indicated in Figure 1, respondents preferred to have four to six children. Large families were preferred in the community for various reasons. A male household head note that: Having many children is seen as a blessing to the family. Moreover, many children are a source of cheap labour and wealth. Culturally, you are not regarded as a 'real man' in our community when you decide to have only one or two children. You earn respect from the society and especially fellow men when you are seen to control a large family. Many children are also a source of happiness and they keep the house 'warm.' One of the community elders had this to comment: The Kalenjin culture values many children; they are regarded as a source of wealth and respect. A family gains wealth through receiving bride wealth. Although some of the people in the community still believe in this, times have changed and some families are opting to have few children. The aspect of having few children has not been received well by all the members of the community because of external influences such as pressure from extended family members, for instance, parents-in-law, as well as societal pressure to have many children. The naming of children after their ancestors is also a great obstacle since it is still practiced in the community. This forces couples to have many children. A health practitioner affirmed the above sentiments by noting that: Although we encourage women in this community to use contraceptives, the cultural barrier is one of the main impediments. Women are influenced by their fellow women and their extended family members to have many children. Barrenness The findings revealed that many children in the community were seen as blessings from God; the more children one had, the more blessed they were considered. Children were also regarded as a source of cheap labour and wealth. Labour was divided according to gender and those families who had many children, especially both boys and girls, were advantaged in terms of labour provision. Additionally, girls were seen as a source of wealth to the family; bride wealth would be paid to their families once they were married off. These discouraged couples from using contraceptives. The research found out that a man who controlled a large family was respected and accorded leadership roles in the community. This implied that a man's strength was measured in terms of the size of the family he controlled and one was considered 'a real man' if he controlled and provided for a large family. Furthermore, barrenness was considered to be shameful to the family. Therefore, couples would have children immediately after marriage to avoid stigmatization. These cultural practices made men limit their wives' contraceptive use to meet societal expectations. The research further established that the naming culture practiced in the community obligated couples to have many children since those whose children were named after their ancestors were respected. This indicated that children safeguarded the continuity of family and community. The society, as a means of socialization, placed childbearing responsibility upon the women; once born, the child belonged to the man. The discussion above indicated that cultural factors did not promote the uptake of contraceptives among the couples in the study area. According to Social Dominance Theory by Sidanius and Pratoo , social obligations usually work as a basis of gender power which centres on the provisions of care and relationships as causes of inequality between men and women. Caregiving and childbearing are categorised as women's responsibilities in many societies. Such social obligations usually disable women from making decisions on contraceptive use. In SSA, women are expected to give birth immediately after marriage as a way of fulfilling their roles as mothers and wives. Thus, women are not in a position to negotiate contraceptive utilization since they socio-culturally feel obligated to give birth because it is their marital and maternal responsibility. --- Influence of Sex Preference on Men's Participation in Family Planning Sex preference was regarded as a crucial factor that influenced the uptake of FP methods by men and their partners. In order to achieve this objective, the study asked respondents to indicate their sex preference since men had a preference as was concerned. The findings are shown in figure 2 below. --- Figure 2: Influence of Sex Preference on Men's Participation in FP As demonstrated in figure 2, respondents preferred sons to daughters. This implied that sex preference was one of the barriers to men's engagement in FP; sons were valued in the community for various reasons. One of the respondents noted that: Our community values sons; they are the ones who carry the family name, thus continuing with family lineage. One is considered 'man enough' when he has sired a boy. A man is never respected by his peers and the community when he only has daughters, so he is forced to marry another woman to bear him a son. I have five daughters and I discourage my wife from using FP in the hope that we will have a son since a family is not complete without one. Moreover, a son will inherit family property and the name and will take care of his parents during old age, unlike girls who will be married off. In the women FGD , a respondent asserted that: Sons are valued in the Kipsigis community since they inherit the family name and property. A woman who has not had a son is not respected, whether in the family or in the society; the husband is encouraged to remarry. This discourages most women from using contraceptives. Sex preference remains one of the main barriers to contraception uptake among women in this community. Traditionally, boys are more valued than girls since they inherit the family name and property; as for girls, they are expected to be married. Many women avoid using contraceptives if they have not given birth to a son; this, they believe, increases their chances of giving birth to one. Women fear being stigmatized and chased away from their families for having daughters only. The preceding sentiment revealed that sons were preferred in the community for the continuity of the family name. They also took care of their parents during old age and inherited family property. Additionally, men who had sired sons were respected in the society, unlike those who had daughters only. Culturally, a woman was not referred to as a "legal" wife till she gave birth to a son. Finally, the absence of a son led to wrangles among the couples. From the above statements, it is clear that sons were preferred in the community. It was important for a man to have a son who would inherit his name and property. According to the Kipsigis culture, daughters do not inherit their father's name and property since they should be married off and migrate from their home; hence, those who do not have sons were looked down upon since they could not contribute to the continuity of family lineage. Therefore, women who had not given birth to a son were discouraged by their husbands from using contraceptives till they had one. The research findings revealed that men who did not have sons were encouraged to remarry. This is because men who had daughters only were not valued in the society. Men with sons were accorded much respect in the family; they were viewed as 'ideal' within the Kipsigis community. The lack of a son led to family misunderstandings. Women were often blamed and stigmatized for the absence of a son in the family. Biologically, the sex of a child is actually determined more by the male than the female. Yet culturally, it is the woman who is blamed. This also stirred family wrangles. As such, women avoided the use of FP methods till they got a son. A son ensured one was not stigmatized and left out in sharing the family property in case of the husband's death. Moreover, women have to have subsequent pregnancies in the likely hope of giving birth to a son to dissuade the man from marrying a second wife. These endanger women's lives since most of such pregnancies are unplanned. The research findings implied that sex preference negatively influenced contraceptive uptake in the community. The need arises to educate men and women on the importance of both sexes to the family. This corroborates the findings of Begum, Grossman and Islam , who point out that sex preference is one of the major factors that influence contraceptive uptake among women. Women start using FP once they have given birth to a son. Preference for sons is a socio-cultural norm in most societies since they inherit the family name and property. The study findings in figure 2 demonstrated that 25% of the participants preferred girls for various reasons. One of the respondents stated: In today's society, some parents do not have issues concerning the gender of their children. I prefer girls since they are more responsible than boys. Moreover, a parent gets wealth by receiving the bride's wealth when the daughters are married off. All children are equal and they should be treated so in order to contribute meaningfully to societal development. The above sentiments demonstrate that some men prefer girls to boys. Girls were preferred since they were seen to be more responsible than boys and were a source of wealth when they were married off. A man who had many daughters was regarded as potentially rich upon receiving bride wealth after the daughters were married. Civic education would help the community realize more sustainable ways of being wealthy than waiting for bride-wealth. If anything, mismanagement of such bride-wealth cannot guarantee one becoming wealthy in life. --- Influence of Religious Faith on Men's Participation in FP In order to examine the influence of religious faith on men's participation in FP, the researcher asked the respondents to state whether or not their religious beliefs influenced their participation in FP. Further, the respondents were tasked to state the FP methods accepted by their religious faith and those not accepted. They were also required to give reasons why FP methods were accepted in their religion or why they were disallowed. The results are shown in figure 3 As depicted in figure 3, the majority of the respondents felt that their religious faith influenced their uptake of FP. Religion plays a significant role in influencing peoples' behaviour, perceptions and attitudes towards FP. One of the respondents stated that: I am a Protestant, specifically of the Church of God. I strongly believe in the biblical teachings. The primary goal of marriage is to have children as many as we can since these are the blessings that God gives us to make our families complete and happy. It is a sin to go against God's purpose of marriage and so I discourage my wife from using contraceptives. One of the pastors from noted that: Marriage was ordained by God and he blesses us with children. It is evil to use FP since it is not indicated anywhere in the Bible. The Bible instructs us in the book of Genesis 1:28, which says, "God blessed them and said unto them, be fruitful and multiply, replenish the earth and subdue it. Have dominion over the fish of the sea, the fowl of the air, and over a living thing that moves upon the earth. The sentiments raised above indicated that some of the Protestants believed that the primary goal of marriage was to have children. Secondly, contraceptive use was discouraged since children are regarded as blessings from God and it is sinful to go against God's will. Thirdly, marriage was ordained by God and was meant for procreation purposes. Finally, the Bible instructs Christians to be fruitful, multiply and fill the earth. This implied that members of the community who were Christians adhered to these biblical teachings on the use of contraceptives. The study established that children were regarded as blessings; hence, FP utilization among couples was discouraged. The Bible instructs the Christians to multiply and fill the earth, which denotes that they are co-creators with God. Some Protestants, therefore, discouraged FP utilization since they wanted to abide by God's commands. Therefore, Christian beliefs in relation to contraceptive use negatively influenced the uptake of contraceptives in the community. As postulated in Social Dominance Theory by Sidanius and Pratto , religion significantly shapes contraceptive uptake and fertility regulation. Religious beliefs shape the behaviour of an individual, which, in turn, influences FP utilization. Religion imposes sanctions on contraception use, which impacts an individual's fertility behaviour. These study findings are in line with those of Sinai, Omoluabi, Jimoh and Jurczynska who observe that Christians believe that children are gifts from God; therefore, reproduction should not be limited through contraceptive use. Hence, the respondents did not feel empowered to utilize FP because of such beliefs. Some of the Protestant churches, for instance, African Inland Church and African Gospel Church , left their followers to decide whether to use FP or not. A religious leader from AIC noted: The Bible does not specifically teach on FP. It is only in the book of Genesis that the Bible instructs us to be fruitful and fill the earth. Rarely do I teach my congregation about FP issues; they often make personal choices in regard to it. I'm ready to engage my congregants on FP issues if the government involves the religious leaders. The sentiments presented above indicate that some Protestant churches were not keen to teach their followers about contraceptive use. They regarded it as a personal issue that is left in the hands of believers so that they make their own decisions. The research established that the Catholic Church encouraged its followers to use the natural FP methods but did not accept the use of artificial FP methods. A --- The opinion voiced above indicated that the Catholic Church encouraged the utilization of NFP methods. Secondly, marriage is believed to be ordained by God and its chief purpose is love and companionship with children fueling the love in marriage. Finally, there were barriers that limited the adoption of artificial methods among couples. This denoted that the Catholic Church advised its congregants to adopt natural FP methods since they do not have any side effects, unlike artificial ones. Adoption of the natural FP methods was not fully successful among couples since it required the cooperation of both partners, which at times was not possible in case one partner was alcoholic. The research found out that the Catholic Church discouraged the use of artificial FP methods since they prevented couples from having children as instructed by God. The use of artificial methods was regarded as sinful since it went against the purpose of marriage, which is to be co-creators with God. These study findings concur with those of Ignaciuk and Kelly , who argue that the Catholic Church does not allow the utilization of artificial FP methods since they are viewed as being against God's law of creation. Only NFP methods are permissible within the church; they include withdrawal , calendar and breastfeeding methods. From the preceding sentiments, it is clear that religious beliefs and teachings influenced the adoption of FP methods among the Protestants and the Catholics in the community. However, some respondents regarded FP as a personal choice; hence, their religion did not impact their contraceptive uptake. Indeed, a respondent in the women FGD indicated that: Even though the church instructs that using contraception is sinful, we have no option but to use it because of the current hard economic times. Most women bear the burden of providing for their children, so they must be wise enough to use contraceptives. Giving birth to many children nowadays is a burden. It is evident that women chose to use contraceptives, citing the hard economic times. In addition, women were left to bear the burden of providing for their families, constraining them to limit their family size. This implied that religion did not really significantly influence contraceptive use among some women in the society because of the change in the gender roles. Some men had abandoned their roles of providing for their families to women, thus forcing them to have few children whom they could easily provide for. The above findings concur with those of Kok, Tolani, Mtonga, Salamba, Mwabungulu, Munthali, Smet and Chinsakaso , who established that, despite the influence and pressure to have large families, most women do not support unregulated childbearing since they understand the impacts of high fertility. Women comprehended that having a large family was costly and it kept them stuck in poverty. --- Conclusion and Recommendations Based on the study findings, it is pertinent that socio-cultural factors limit men's participation in FP issues. Cultural factors such as the desire to have large families and son preferences discouraged couples from adopting FP methods. Large families were preferred since children were regarded as a source of wealth and cheap labour. Sons were preferred since they inherited family names and property. They also take care of their parents during old age since girls are supposed to be married off. Additionally, religious factors somehow influenced men's involvement in FP since children were regarded as blessings from God. Based on the research findings, the study proposes the following recommendations: • Civic education of men on FP issues to increase their level of participation in FP, • Involving external partners on FP, • Adoption of gender-inclusive FP policies and

According to the World Health Organization -WHO (2020), contraceptive use is a crucial public health issue both in developed and developing countries. The United Nations Population Fund-UNFPA (2020) avers that FP is central to the advancement of gender equality. While there has been an increase in contraceptive uptake globally in recent decades, sub-Sahara Africa (SSA) has continued to record low contraceptive rates uptake at 28%. Globally, 77% of women of reproductive age have access to FP. However, only 56% of women in developing countries who are interested in avoiding pregnancy are presently using a modern FP method (United Nations Department of Economic and Social Affairs, 2020). Male involvement in FP is more than encouraging more men to use condoms and embrace vasectomy. It also entails inspiring men to support their partners' and peers' adoption of FP methods and influencing policymakers to develop malerelated programs. Further, it includes all national program undertakings that increase awareness, prevalence and acceptability of FP methods among men. The primary role of FP is to enable men and women to space their pregnancies and plan their families by adopting modern contraceptives (Shekhar, Bhar & Singh, 2019). According to Shattnawi, Khader, Al-Sheyab, Alyahya, Halasa-Rappel and Prince (2021), religion and culture are significant determinants of family size in Jordan. Some religious teachings discourage the use of FP and contraceptives by couples. Besides, preference for male children and large families immensely influence FP decisions. Additionally, familial pressure from in-laws and husbands strongly discourages FP utilization. Additionally, Khanna, Chandra, Singh and Mehra (2018) assert that among Indians, women face a lot of pressure from extended family members to prove their fertility immediately after marriage. This is due to prevalent social norms as well as expectations associated with early birth taken as a sign of a healthy union. Preference for sons influences contraceptive uptake since they provide security to the families and inherit family property. Bornstein, Gipson, Failing, Banda and Norris (2020) in Malawi conclude that men's capability to sire children exudes masculinity and strength; hence, infertility is a challenge to their masculinity. Without children, men's status, marriages and fatherhood is jeopardized. Men who cannot impregnate their partners are often ridiculed by their family members and the community. Thus, men avoid contraceptive use and discourage their partners from utilizing them; they need to demonstrate their fatherhood through subsequent pregnancies. Kassim and Ndumbaro (2022) argue that in Tanzania, contraceptive uptake is hampered by a desire for big families since many children are regarded as a source of prestige. This limits men's involvement in FP issues.

kenya national bureau of statistics knbs established that kenyas birth rate decreased from five kids per woman in the year 2003 to four in 2014 this is because of a spike in contraception use from 393 of married women in the year 2003 to 583 in 2014 as a result of improved fp usage and reduced fertility the rate of population plummeted from 29 to 22 between 2009 and 2019 however according to ministry of health the uptake of fp among married women of procreative age in bomet county is about 475 percent still low compared to the national rate of 55 knbs affirms that the crude birth rate in the county is 262 per 1000 population the mean number of children born by women is 57 which is higher than kenyas figure of 5 this research therefore sought to examine sociocultural factors that influence mens participation in fp in bomet county kenya statement of the problem kenya was among the first countries in africa to adopt a population strategy yet the uptake of fp among women especially those residing in rural areas remains low the uptake of fp among married women of procreative age in bomet county is low compared to national fp use and other counties this is despite the support fp is given in the area the county has one community outreach funded by tenwek mission hospital and another outreach supported by beyond zero mobile clinic which supports fp initiatives fp in the county is also enhanced by two ngos the world bank and marie stopes moreover the county has many public fp facilities that offer fp services therefore this called for interrogation of sociocultural factors that influence mens participation in fp in the county objectives of the study the general objective of the study was to examine the sociocultural factors that influence mens participation in fp in bomet county kenya the specific objectives of the study were to • assess the influence of large families on mens participation in fp in bomet county kenya • examine the influence of sex preference on mens participation in fp in bomet county kenya • determine the influence of religious faith on mens participation in fp in bomet county kenya theoretical framework this research was guided by the social dominance theory as proposed by sidanius and pratto there are four sources of gendered influence within the social domination school of thought consensual ideologies resource control social obligation and force in a patriarchal culture governed by sexism religious traditions and an entrenched societal belief structure these bases of gendered power may be a prism to examine how they impact womens and mens use of contraceptives although these four bases can be distinguished they are intertwined and can complement one another gender roles traditions stereotypes and all other views or assumptions about men and women that are commonly agreed upon in a society or community are referred to as consensual ideologies women are always placed in a lesser status than men due to this these mutually beneficial theories reduce womens influence in heterosexual relationships potentially resulting in their inability to negotiate or regulate their fertility through contraception patriarchal philosophies when combined with biblical scripts support men and sanctify male superiority in the home men and women behave differently when it comes to contraception and decisionmaking because of the unbalanced gender relations in the household resource control refers to the control over economic resources for example wages and assets which worldwide traditionally benefit men over women the role of social and systemic disparity in womens subordination is highlighted by resource management women are frequently economically dependent on their male partners due to unequal access to resources this renders contraceptives such as condoms difficult to use or dangerous to negotiate social obligations are sometimes gender controlled with the emphasis on marriages and caregiving as causes of disparity between men and women responsibilities to others are inevitable social duties women rather than males have more obligations in most countries including becoming mothers or meeting the needs and desires of others married women may find it more difficult to consider contraceptive use because they feel compelled to bear children as part of their marital and maternal roles as a result the more live children a mother has the more likely she will use contraceptives thus women who have given birth to many children are more likely to adopt contraception force is a type of gendered power that aids in establishing a dominance hierarchy in society between men and women some psychosocial studies blame common power imbalances for womens abuse they have shaped malefemale relationships a power imbalance between men and women triggers inequality and genderbased violence in the public sphere it has also generated numerous incidents of violence in private malefemale relationships especially within the family womens levels of superiority in marriages are attributed to their histories of spouse brutality and harassment within their marriages research methodology research design a descriptive survey research design was adopted in the research it entails acquiring information from one or many groups of people about their outlooks thoughts and past experiences by asking them questions and recording their responses for kothari which supported the research findings the descriptive survey research design also enabled the collection of both quantitative and qualitative data study site this research was done in bomet county kenya the county has five subcounties chepalungu bomet central konoin sotik and bomet east there are five wards 66 locations and 177 sublocations within the subcounties bomet county has a total population of 875666 people with 434287 males and 441379 females kericho borders it to the north nyamira to the west narok to the south and nakuru to the northeast it covers a total area of 220374 square kilometres the main economic activity in bomet county is agriculture with dairy farming and tea farming leading pineapples irish potatoes maize beans cabbages bananas and onions are all cultivated for commercial and subsistence purposes the county is well endowed with health facilities where women can seek fp services they include tenwek mission hospital which is in category 6b and two level 5 hospitals longisa county referral hospital and kaplong mission hospital further the county has three level 4 hospitals 19 health centres 107 dispensaries and 39 community units moreover the world bank and marie stopes international promote fp in the county sampling procedure this research employed a multistage cluster sampling method the clusters in this research included subcounties wards locations sublocations and households as a result a fivestage cluster sampling procedure was used in the first level bomet central and sotik subcounties were chosen on the basis of their population the two have the highest population the latter has 227380 residents and 47315 households while the former has 173758 residents and 38259 households the remaining stages employed simple random sampling with a 10 30 criterion to survey the participating wards areas and sublocations mugenda and mugenda assert that a sample frame can contain about 10 and 30 of a sample frame in an analogous environment table 1multistage cluster sampling procedure source author 2023 the sampling of the households was drawn from the list of the number of households in the sublocations households were randomly selected the study considered every 10 th household with a married man aged between 1860 years and a married woman aged between 18 and 45 years sample size the sample size for the study was estimated using the simplified method by yamane which estimates sample sizes with a confidence level of 95 a level of precision of 005 and a population size of 25671 households as follows where n is the sample size n is the population size e is the level of precision applying the formula to the sample above n 25671 1 25671 2 394 the male household heads filled out the questionnaires further the number of married women who participated in the fgds comprised 20 of the sample size kothari posits that a sample size ranging from 10 to 30 is a good representation of the entire population therefore a sample of 78 married women participated in the fgds the married men who participated in the study were 316 subcounty the sample size was 316 married men 78 married women 394 additionally twelve kiis were included in the study therefore the total sample size was 406 respondents study findings the purpose of the study was to examine sociocultural factors that influence mens participation in fp in bomet county the study found out that preference for large families son preference and religious factors determine contraceptive uptake among both men and women in the county influence of family size preference on mens participation in fp the study sought to establish whether or not family size influenced mens participation in fp therefore the respondents were asked to state the number of children they preferred the findings are shown in figure 1 below figure 1 influence of family size preference on mens participation in fp as indicated in figure 1 respondents preferred to have four to six children large families were preferred in the community for various reasons a male household head note that having many children is seen as a blessing to the family moreover many children are a source of cheap labour and wealth culturally you are not regarded as a real man in our community when you decide to have only one or two children you earn respect from the society and especially fellow men when you are seen to control a large family many children are also a source of happiness and they keep the house warm one of the community elders had this to comment the kalenjin culture values many children they are regarded as a source of wealth and respect a family gains wealth through receiving bride wealth although some of the people in the community still believe in this times have changed and some families are opting to have few children the aspect of having few children has not been received well by all the members of the community because of external influences such as pressure from extended family members for instance parentsinlaw as well as societal pressure to have many children the naming of children after their ancestors is also a great obstacle since it is still practiced in the community this forces couples to have many children a health practitioner affirmed the above sentiments by noting that although we encourage women in this community to use contraceptives the cultural barrier is one of the main impediments women are influenced by their fellow women and their extended family members to have many children barrenness the findings revealed that many children in the community were seen as blessings from god the more children one had the more blessed they were considered children were also regarded as a source of cheap labour and wealth labour was divided according to gender and those families who had many children especially both boys and girls were advantaged in terms of labour provision additionally girls were seen as a source of wealth to the family bride wealth would be paid to their families once they were married off these discouraged couples from using contraceptives the research found out that a man who controlled a large family was respected and accorded leadership roles in the community this implied that a mans strength was measured in terms of the size of the family he controlled and one was considered a real man if he controlled and provided for a large family furthermore barrenness was considered to be shameful to the family therefore couples would have children immediately after marriage to avoid stigmatization these cultural practices made men limit their wives contraceptive use to meet societal expectations the research further established that the naming culture practiced in the community obligated couples to have many children since those whose children were named after their ancestors were respected this indicated that children safeguarded the continuity of family and community the society as a means of socialization placed childbearing responsibility upon the women once born the child belonged to the man the discussion above indicated that cultural factors did not promote the uptake of contraceptives among the couples in the study area according to social dominance theory by sidanius and pratoo social obligations usually work as a basis of gender power which centres on the provisions of care and relationships as causes of inequality between men and women caregiving and childbearing are categorised as womens responsibilities in many societies such social obligations usually disable women from making decisions on contraceptive use in ssa women are expected to give birth immediately after marriage as a way of fulfilling their roles as mothers and wives thus women are not in a position to negotiate contraceptive utilization since they socioculturally feel obligated to give birth because it is their marital and maternal responsibility influence of sex preference on mens participation in family planning sex preference was regarded as a crucial factor that influenced the uptake of fp methods by men and their partners in order to achieve this objective the study asked respondents to indicate their sex preference since men had a preference as was concerned the findings are shown in figure 2 below figure 2 influence of sex preference on mens participation in fp as demonstrated in figure 2 respondents preferred sons to daughters this implied that sex preference was one of the barriers to mens engagement in fp sons were valued in the community for various reasons one of the respondents noted that our community values sons they are the ones who carry the family name thus continuing with family lineage one is considered man enough when he has sired a boy a man is never respected by his peers and the community when he only has daughters so he is forced to marry another woman to bear him a son i have five daughters and i discourage my wife from using fp in the hope that we will have a son since a family is not complete without one moreover a son will inherit family property and the name and will take care of his parents during old age unlike girls who will be married off in the women fgd a respondent asserted that sons are valued in the kipsigis community since they inherit the family name and property a woman who has not had a son is not respected whether in the family or in the society the husband is encouraged to remarry this discourages most women from using contraceptives sex preference remains one of the main barriers to contraception uptake among women in this community traditionally boys are more valued than girls since they inherit the family name and property as for girls they are expected to be married many women avoid using contraceptives if they have not given birth to a son this they believe increases their chances of giving birth to one women fear being stigmatized and chased away from their families for having daughters only the preceding sentiment revealed that sons were preferred in the community for the continuity of the family name they also took care of their parents during old age and inherited family property additionally men who had sired sons were respected in the society unlike those who had daughters only culturally a woman was not referred to as a legal wife till she gave birth to a son finally the absence of a son led to wrangles among the couples from the above statements it is clear that sons were preferred in the community it was important for a man to have a son who would inherit his name and property according to the kipsigis culture daughters do not inherit their fathers name and property since they should be married off and migrate from their home hence those who do not have sons were looked down upon since they could not contribute to the continuity of family lineage therefore women who had not given birth to a son were discouraged by their husbands from using contraceptives till they had one the research findings revealed that men who did not have sons were encouraged to remarry this is because men who had daughters only were not valued in the society men with sons were accorded much respect in the family they were viewed as ideal within the kipsigis community the lack of a son led to family misunderstandings women were often blamed and stigmatized for the absence of a son in the family biologically the sex of a child is actually determined more by the male than the female yet culturally it is the woman who is blamed this also stirred family wrangles as such women avoided the use of fp methods till they got a son a son ensured one was not stigmatized and left out in sharing the family property in case of the husbands death moreover women have to have subsequent pregnancies in the likely hope of giving birth to a son to dissuade the man from marrying a second wife these endanger womens lives since most of such pregnancies are unplanned the research findings implied that sex preference negatively influenced contraceptive uptake in the community the need arises to educate men and women on the importance of both sexes to the family this corroborates the findings of begum grossman and islam who point out that sex preference is one of the major factors that influence contraceptive uptake among women women start using fp once they have given birth to a son preference for sons is a sociocultural norm in most societies since they inherit the family name and property the study findings in figure 2 demonstrated that 25 of the participants preferred girls for various reasons one of the respondents stated in todays society some parents do not have issues concerning the gender of their children i prefer girls since they are more responsible than boys moreover a parent gets wealth by receiving the brides wealth when the daughters are married off all children are equal and they should be treated so in order to contribute meaningfully to societal development the above sentiments demonstrate that some men prefer girls to boys girls were preferred since they were seen to be more responsible than boys and were a source of wealth when they were married off a man who had many daughters was regarded as potentially rich upon receiving bride wealth after the daughters were married civic education would help the community realize more sustainable ways of being wealthy than waiting for bridewealth if anything mismanagement of such bridewealth cannot guarantee one becoming wealthy in life influence of religious faith on mens participation in fp in order to examine the influence of religious faith on mens participation in fp the researcher asked the respondents to state whether or not their religious beliefs influenced their participation in fp further the respondents were tasked to state the fp methods accepted by their religious faith and those not accepted they were also required to give reasons why fp methods were accepted in their religion or why they were disallowed the results are shown in figure 3 as depicted in figure 3 the majority of the respondents felt that their religious faith influenced their uptake of fp religion plays a significant role in influencing peoples behaviour perceptions and attitudes towards fp one of the respondents stated that i am a protestant specifically of the church of god i strongly believe in the biblical teachings the primary goal of marriage is to have children as many as we can since these are the blessings that god gives us to make our families complete and happy it is a sin to go against gods purpose of marriage and so i discourage my wife from using contraceptives one of the pastors from noted that marriage was ordained by god and he blesses us with children it is evil to use fp since it is not indicated anywhere in the bible the bible instructs us in the book of genesis 128 which says god blessed them and said unto them be fruitful and multiply replenish the earth and subdue it have dominion over the fish of the sea the fowl of the air and over a living thing that moves upon the earth the sentiments raised above indicated that some of the protestants believed that the primary goal of marriage was to have children secondly contraceptive use was discouraged since children are regarded as blessings from god and it is sinful to go against gods will thirdly marriage was ordained by god and was meant for procreation purposes finally the bible instructs christians to be fruitful multiply and fill the earth this implied that members of the community who were christians adhered to these biblical teachings on the use of contraceptives the study established that children were regarded as blessings hence fp utilization among couples was discouraged the bible instructs the christians to multiply and fill the earth which denotes that they are cocreators with god some protestants therefore discouraged fp utilization since they wanted to abide by gods commands therefore christian beliefs in relation to contraceptive use negatively influenced the uptake of contraceptives in the community as postulated in social dominance theory by sidanius and pratto religion significantly shapes contraceptive uptake and fertility regulation religious beliefs shape the behaviour of an individual which in turn influences fp utilization religion imposes sanctions on contraception use which impacts an individuals fertility behaviour these study findings are in line with those of sinai omoluabi jimoh and jurczynska who observe that christians believe that children are gifts from god therefore reproduction should not be limited through contraceptive use hence the respondents did not feel empowered to utilize fp because of such beliefs some of the protestant churches for instance african inland church and african gospel church left their followers to decide whether to use fp or not a religious leader from aic noted the bible does not specifically teach on fp it is only in the book of genesis that the bible instructs us to be fruitful and fill the earth rarely do i teach my congregation about fp issues they often make personal choices in regard to it im ready to engage my congregants on fp issues if the government involves the religious leaders the sentiments presented above indicate that some protestant churches were not keen to teach their followers about contraceptive use they regarded it as a personal issue that is left in the hands of believers so that they make their own decisions the research established that the catholic church encouraged its followers to use the natural fp methods but did not accept the use of artificial fp methods a the opinion voiced above indicated that the catholic church encouraged the utilization of nfp methods secondly marriage is believed to be ordained by god and its chief purpose is love and companionship with children fueling the love in marriage finally there were barriers that limited the adoption of artificial methods among couples this denoted that the catholic church advised its congregants to adopt natural fp methods since they do not have any side effects unlike artificial ones adoption of the natural fp methods was not fully successful among couples since it required the cooperation of both partners which at times was not possible in case one partner was alcoholic the research found out that the catholic church discouraged the use of artificial fp methods since they prevented couples from having children as instructed by god the use of artificial methods was regarded as sinful since it went against the purpose of marriage which is to be cocreators with god these study findings concur with those of ignaciuk and kelly who argue that the catholic church does not allow the utilization of artificial fp methods since they are viewed as being against gods law of creation only nfp methods are permissible within the church they include withdrawal calendar and breastfeeding methods from the preceding sentiments it is clear that religious beliefs and teachings influenced the adoption of fp methods among the protestants and the catholics in the community however some respondents regarded fp as a personal choice hence their religion did not impact their contraceptive uptake indeed a respondent in the women fgd indicated that even though the church instructs that using contraception is sinful we have no option but to use it because of the current hard economic times most women bear the burden of providing for their children so they must be wise enough to use contraceptives giving birth to many children nowadays is a burden it is evident that women chose to use contraceptives citing the hard economic times in addition women were left to bear the burden of providing for their families constraining them to limit their family size this implied that religion did not really significantly influence contraceptive use among some women in the society because of the change in the gender roles some men had abandoned their roles of providing for their families to women thus forcing them to have few children whom they could easily provide for the above findings concur with those of kok tolani mtonga salamba mwabungulu munthali smet and chinsakaso who established that despite the influence and pressure to have large families most women do not support unregulated childbearing since they understand the impacts of high fertility women comprehended that having a large family was costly and it kept them stuck in poverty conclusion and recommendations based on the study findings it is pertinent that sociocultural factors limit mens participation in fp issues cultural factors such as the desire to have large families and son preferences discouraged couples from adopting fp methods large families were preferred since children were regarded as a source of wealth and cheap labour sons were preferred since they inherited family names and property they also take care of their parents during old age since girls are supposed to be married off additionally religious factors somehow influenced mens involvement in fp since children were regarded as blessings from god based on the research findings the study proposes the following recommendations • civic education of men on fp issues to increase their level of participation in fp • involving external partners on fp • adoption of genderinclusive fp policies and

according to the world health organization who 2020 contraceptive use is a crucial public health issue both in developed and developing countries the united nations population fundunfpa 2020 avers that fp is central to the advancement of gender equality while there has been an increase in contraceptive uptake globally in recent decades subsahara africa ssa has continued to record low contraceptive rates uptake at 28 globally 77 of women of reproductive age have access to fp however only 56 of women in developing countries who are interested in avoiding pregnancy are presently using a modern fp method united nations department of economic and social affairs 2020 male involvement in fp is more than encouraging more men to use condoms and embrace vasectomy it also entails inspiring men to support their partners and peers adoption of fp methods and influencing policymakers to develop malerelated programs further it includes all national program undertakings that increase awareness prevalence and acceptability of fp methods among men the primary role of fp is to enable men and women to space their pregnancies and plan their families by adopting modern contraceptives shekhar bhar singh 2019 according to shattnawi khader alsheyab alyahya halasarappel and prince 2021 religion and culture are significant determinants of family size in jordan some religious teachings discourage the use of fp and contraceptives by couples besides preference for male children and large families immensely influence fp decisions additionally familial pressure from inlaws and husbands strongly discourages fp utilization additionally khanna chandra singh and mehra 2018 assert that among indians women face a lot of pressure from extended family members to prove their fertility immediately after marriage this is due to prevalent social norms as well as expectations associated with early birth taken as a sign of a healthy union preference for sons influences contraceptive uptake since they provide security to the families and inherit family property bornstein gipson failing banda and norris 2020 in malawi conclude that mens capability to sire children exudes masculinity and strength hence infertility is a challenge to their masculinity without children mens status marriages and fatherhood is jeopardized men who cannot impregnate their partners are often ridiculed by their family members and the community thus men avoid contraceptive use and discourage their partners from utilizing them they need to demonstrate their fatherhood through subsequent pregnancies kassim and ndumbaro 2022 argue that in tanzania contraceptive uptake is hampered by a desire for big families since many children are regarded as a source of prestige this limits mens involvement in fp issues

Introduction Women are widely acknowledged as a foundation of the rural economic framework, constituting an equal share of global agricultural producers [1] They concurrently fulfill multidimensional roles including familial nurturing, elderly care, cooking responsibilities, household management, and sociopolitical governance despite their substantial and dedicated involvement in agricultural pursuits [2][3][4]. In the contemporary global agrarian landscape, women constitute a significant workforce, accounting for 43 percent of the total labor force [5]. Within the distinct context of Bangladesh's national economy, the agricultural sector holds a prominent and crucial role, akin to other developing nations. Delineated as one of the central economic strongholds, this sector contributes approximately 23 percent to the country's gross domestic product [6]. Pertinently, women constitute an indispensable cohort within the rural agricultural labor force of the nation, and the involvement of women in rural areas of Bangladesh in the agriculture sector has increased from 54% in 2013 to 60% in 2017 [7]. Within the domain of agriculture, like many other sectors, the primacy of information has become increasingly pronounced, assuming a vital role in the operational paradigm [8]. As a result, ICT has a significant impact on the growth of agriculture [9], enabling farmers to acclimatize knowledge and information, thus constituting a central axis that empowers their responsiveness to emergent prospects capable of enhancing agricultural productivity [10]. In this context, information communication technologies have emerged as a vanguard, holding considerable promise for catalyzing the developmental trajectory of countries in the Global South [11]. In the specific case of Bangladesh, ICT has emerged as a transformative tool that has the potential to enhance various dimensions of women's participation in agriculture and to enhance sustainable livelihoods [12]. Primarily, ICT platforms have facilitated access to crucial agricultural information and knowledge resources for women farmers in Bangladesh. Through mobile applications, online platforms, and SMS services, women farmers are now equipped with real-time data about weather forecasts and pest management [13]. However, historically, the gendered exclusion of women from the information and communication technology domain has been conspicuous. This exclusion has manifested itself as ICT becoming predominantly male-centered, characterized by disparities in accessibility and availability, often intertwined with economic power dynamics. Simultaneously, a pronounced gender disparity persists in access to essential resources such as land, energy, technology, loans, pesticides, and fertilizers. Moreover, women confront significant hurdles in accessing training, information, public services, social protection, and markets, as highlighted by García [14]. A recent investigation conducted by the International Telecommunication Union established a tangible correlation between conspicuous gender gaps in mobile phone ownership and the limited adoption of the Internet among females. Only 19% of women in least developed countries used the Internet in 2020, compared to 86 percent in the developed world [15]. Exemplifying this dynamic, the GSMA's Mobile Gender Gap Report for the year 2023 underscores the mobile phone ownership gender divide in Bangladesh, revealing a substantial dichotomy. Remarkably, approximately 67 percent of adult women in Bangladesh own mobile phones; however, a mere 21 percent engage with the Internet. This stark incongruity designates Bangladesh as a prominent epicenter of the mobile ownership gender gap phenomenon, corroborating its standing as one of the most pronounced cases globally [16]. The root of this phenomenon can be traced to a Marxist perspective, which emphasizes the genderbased division of labor and how it perpetuates gender disparities. This issue is further exacerbated by the deeply ingrained cultural perception that associates technology with masculinity. Within this societal framework, technology reflects and reinforces the prevalent male dominance [17][18][19]. In spite of having these challenges, agriculture has emerged as a potent avenue for empowering women, as explicated by Kabeer [20], as the expansion of women's capabilities in three crucial dimensions: resources, agency, and wellbeing outcomes. However, the journey toward empowerment for rural women in Bangladesh, particularly those living in poverty, is fraught with multifaceted challenges. These challenges include poverty, inequality, inadequate infrastructure, restricted access to education and information, and deeply rooted social factors, prominently the patriarchal structure. Nevertheless, the introduction of information and communication technology has catalyzed a significant transformation in the lives of rural Bangladeshi women farmers. Among the transformative elements, the accessibility of smartphones stands out as a potent tool that has improved their access to vital information and communication opportunities. This accessibility has, in turn, mitigated vulnerabilities and enhanced livelihood prospects. ICT has also facilitated improved access to agricultural extension services and local markets, ultimately empowering women and advancing their agency, as elucidated by Biswas et al. [12]. The recognition of information and communication technology's capacity to enhance agricultural productivity has garnered extensive acknowledgment within scholarly discourse. The revitalizing potential of information and communication technology within agriculture is undeniable, as evidenced by its far-reaching impact on the sustainable livelihoods of women farmers [12]. This happened with the deployment of ICT for augmenting the capabilities, knowledge, and skills of women farmers, collectively referred to as human capital. These investments in human capital have yielded substantial dividends, resulting in the development of social, financial, physical, and political capital. Consequently, women's roles have transcended the confines of their households, bestowing upon them significant importance in the broader societal context. Further, the emergence of digital platforms has facilitated unprecedented knowledge exchange and networking opportunities among experts from diverse regions [21]. While fostering innovation, this global connectivity simultaneously introduces challenges that influence local and indigenous knowledge, particularly agroecological knowledge dynamics. However, this fundamental imperative requires a thorough investigation of the predominant ICT adoption by women farmers. Unfortunately, these concerns often receive limited attention in scholarly domains. Based upon these concerns, this study aimed to identify the impacts of ICT on the livelihoods of women farmers and uncover the challenges impeding their sustainability. To achieve these objectives, we conducted a study within the context of ICT users at South Kharibari village in Dimla Upazila. This study employed a mixed research approach, encompassing both qualitative and quantitative methods, to comprehensively explore the nuances of ICT usage for agricultural purposes among women farmers. This study emphasizes the importance of considering invaluable insights derived from indigenous and local agricultural knowledge to successfully integrate ICT to improve women's livelihoods. It seeks to achieve a harmonious synergy between modern technological interventions and the time-tested wisdom embedded within traditional knowledge systems. Such an approach could enhance the efficacy and sustainability of ICT-driven agricultural advancements, fostering a more holistic and contextually relevant renovation. --- Conceptual Framework for Understanding the Impacts of ICT on Women's Livelihoods The adoption of the sustainable livelihood framework provides a complete analytical foundation for this study. The concept of "sustainable rural livelihoods" has progressively assumed a central role in the discourse on rural development, poverty alleviation, and environmental stewardship. Livelihoods, within this framework, represent a composite of capabilities, assets-encompassing both tangible and intangible elements-and activities requisite for sustaining one's means of subsistence. Importantly, a livelihood attains sustainability when it exhibits the capacity to effectively endure and improve from various stressors and shocks while concurrently preserving or enhancing its inherent capabilities and assets, all without compromising the integrity of the natural resource base [22,23]. Those individuals who find themselves unable to effectively cope with short-term changes or adapt to longer-term shifts in livelihood strategies inevitably fall into the category of vulnerability and are less likely to realize sustainable livelihoods [22]. Within the specific context of this study, women emerge as a vulnerable demographic concerning access to information and communication technology and other essential resources. They encounter formidable obstacles when seeking access to training, information, public services, social protection, and markets. This vulnerability is intricately tied to the existence of structural barriers, prominently exemplified by the entrenched patriarchal social structure within society . The emergence of information and communication technology stands out as a transformative catalyst, significantly augmenting women's capacity to engage in various livelihood strategies . This ability to pursue diverse livelihood strategies is contingent upon the possession of foundational material and social assets. Drawing upon an economic analogy, these resources underpin livelihoods, functioning as the "capital" base from which an array of productive streams emanate, thereby constructing and sustaining livelihoods. --- level. However, the Sustainable Livelihood Framework provides a nuanced and comprehensive understanding of how ICT adoption empowers women within the agricultural sector, encompassing personal and social transformations, economic gains, and political empowerment. This framework places women as active agents of change, contributing to the development of sustainable rural livelihoods while transcending the barriers imposed by traditional gender norms and structural inequalities Figure 1. Sustainable Livelihood Framework modified from DFID [24]. Figure 1. Sustainable Livelihood Framework modified from DFID [24]. Human capital encompasses various capacities that enable individuals to pursue diverse livelihood strategies and contribute to community objectives [24]. This includes a spectrum of attributes such as skills, knowledge, labor capabilities, and physical health, all of which are essential for the effective pursuit of livelihood strategies [22]. Social capital revolves around the concept of social resources, including networks, social ties, affiliations, and associations that individuals can leverage when engaged in livelihood strategies that require coordinated actions [22]. Financial capital constitutes various economic assets, including cash, credit/debt, savings, and other financial resources, all of which are indispensable for the pursuit of livelihood strategies [22]. Physical capital includes tangible goods and objects that support individuals' livelihoods, including vehicles, homes, tools, and work-related assets [25]. Political capital serves as a testament to women's empowerment, highlighting their heightened awareness of rights, roles, and active participation in addressing societal issues and injustices. This dimension emphasizes their engagement in challenging detrimental customs and combating violence against women, as well as their increased involvement in decision-making processes, both within the family unit and at the societal level. However, the Sustainable Livelihood Framework provides a nuanced and comprehensive understanding of how ICT adoption empowers women within the agricultural sector, encompassing personal and social transformations, economic gains, and political empowerment. This framework places women as active agents of change, contributing to the development of sustainable rural livelihoods while transcending the barriers imposed by traditional gender norms and structural inequalities . --- Materials and Methods --- Study Area This research was undertaken within the South Khoribari village, located in the Dimla upazila of Nilphamari District in Northwestern Bangladesh . The study site exemplifies the characteristics of a prototypical char land, a term denoting "sandbars that emerge as islands within the river channel or as attached land to the riverbanks" [26,27]. The population of this area totals approximately 3500 individuals, with a substantial proportion of the villagers actively engaged in agricultural pursuits [27]. Noteworthy is the direct and active participation of women in agricultural pursuits, alongside their concurrent management of household responsibilities. Additionally, in select households, women assume the complete mantle of agricultural responsibilities, while male members of these families are occupied in diverse occupational pursuits in other regions of the country. with a substantial proportion of the villagers actively engaged in agricultural pursuits [27]. Noteworthy is the direct and active participation of women in agricultural pursuits, alongside their concurrent management of household responsibilities. Additionally, in select households, women assume the complete mantle of agricultural responsibilities, while male members of these families are occupied in diverse occupational pursuits in other regions of the country. --- Data Collection and Analysis The research was conducted among the beneficiaries of Oxfam's PROTIC project employing a mixed research approach, referring to the use of two or more methods in a --- Data Collection and Analysis The research was conducted among the beneficiaries of Oxfam's PROTIC project employing a mixed research approach, referring to the use of two or more methods in a single research, including qualitative and quantitative approaches to increase the accuracy and level of confidence [28][29][30][31] at South Kharibari village of Dimla upazila located on the Teesta river basin of Northwestern Bangladesh. Data were collected from women farmers provided with ICT equipment, including smartphones, Internet, and online supports through household surveys and focus group discussion from October 2019 to January 2020. In 2015, a targeted intervention involving the provisioning of ICT support was implemented for a cohort of 100 woman-headed households by Oxfam Bangladesh in collaboration with Monash University. Oxfam provided mobile phones , monthly Internet services , and training to the women who were known as animators. The selection of animators was involved in satisfying a set of three specific criteria. These criteria included the status of heading a family by a female, the presence of a disability within the individual, and a correspondence with the prevailing economic profile observed within the broader demographic composition of the village populace [13,27]. These women farmers were furnished with ICT resources to facilitate their access to essential agricultural information encompassing aspects such as crop cultivation, water manage-ment, and weather forecasts. The dissemination of this information was facilitated through diverse communication channels, including mobile phone short message service , outbound dial , interactive voice response , applications, and call center services specializing in agriculture and agrometeorology, incorporating early warning systems into their operational framework. The adoption of these services empowered women farmers to proactively mitigate potential losses and detriments incurred by unforeseen meteorological events such as floods, dense fog, abrupt rainfall, crop afflictions, and pest incursions, thus enhancing their adaptive capacities and bolstering agricultural productivity [13]. In order to comprehensively evaluate the impacts of information and communication technology on the livelihoods of women farmers, a systematic approach was adopted to gather insights acquired from five years of ICT usage. This process encompassed several vital stages, commencing with a stakeholders' consultation involving women farmers who had benefited from ICT support. This initial consultation served a dual purpose: firstly, to obtain a preliminary understanding of the effects of ICT on rural women's livelihoods; secondly, to refine and finalize the subsequent household survey questionnaire. Following the stakeholders' consultation, a semistructured questionnaire was designed to address the research questions and was subsequently utilized in a comprehensive household survey involving 42 women farmers. The data collected from the household survey formed a foundational layer upon which additional validation and context enrichment were achieved through three distinct focus group discussions . These FGDs were instrumental in corroborating the insights from the household survey and delving into the multifaceted dimensions of changes that transpired over the preceding five years. Moreover, the FGDs served an additional critical purpose of unearthing the diverse challenges of integrating ICT in rural areas. Each FGD, consisting of 12 to 15 women participants, was conducted under the guidance of a skilled facilitator, accompanied by an assistant responsible for accurately recording the discussions. The selection of respondents for both the household surveys and FGDs was deliberately differentiated, contributing to a holistic and well-rounded perspective on the subject matter. The data obtained from the focus group discussions were precisely documented through recordings and comprehensive notes, and underwent subsequent transcription into textual format. These textual data were thoroughly analyzed through traditional qualitative data analysis software, specifically N-Vivo, a recognized tool in this field, hailing from Melbourne, Australia. This analytical process was grounded in an inductive approach, enabling the systematic identification and extraction of noteworthy emergent themes inherent within the FGD data. Concurrently, the data stemming from the household surveys followed a distinct analytical trajectory. Leveraging computer software, specifically Microsoft Excel, the data from the household surveys underwent thorough analysis. --- Results --- Implications of ICT on Livelihoods The findings of our study demonstrate that the integration of ICT, such as smartphones, Internet services, and mobile applications, along with the provision of relevant training programs, enhanced the skills, knowledge, and capabilities in the field of agriculture. This implies a positive impact on the development of human capital in this agriculture. The influence of human capital extends to other dimensions, including social, financial, physical, and political capital . The findings of our study demonstrate that the integration of ICT, such as smartphones, Internet services, and mobile applications, along with the provision of relevant training programs, enhanced the skills, knowledge, and capabilities in the field of agriculture. This implies a positive impact on the development of human capital in this agriculture. The influence of human capital extends to other dimensions, including social, financial, physical, and political capital . ICT enabled women to buy land with money which they women saved 25 17 ICT turned women key earners in family 29 13 ICT made women aware of their rights and roles in society 40 02 ICT ensured women's participation in rural arbitration 26 16 ICT made women aware of preventing social issues 42 00 --- Human Capital The study revealed that within the domain of women involved in agricultural pursuits, the deliberate utilization of information and communication technology tools, specifically smartphones, in combination with the provision of relevant training on their usage and access to the Internet, has exhibited a vital capacity to enhance knowledge and competencies which is referred to as human capital [32]. The utilization of Internet resources has emerged as a transforming factor for women, serving as a crucial catalyst for empowerment. Engaging in capacity-building programs and seminars focused on successfully deploying information and communication technology has facilitated persons in improving their knowledge and understanding of agriculture, resulting in a deeper comprehension of the agricultural domain. The reliance on diverse technological avenues, including social media platforms, mobile applications, and call centers, enhances women's knowledge and skills in agricultural settings. ICT has concomitantly bolstered women's self-confidence, amplifying their decision-making processes and communication proficiencies. One FGD respondent expressed her transformative experience, noting, "I couldn't move, the touch of ICT equipment taught me to move, I couldn't say, the use of ICT gave me language and I couldn't see, ICT gave me sight. The use of ICT has changed my life." In the same way, the household data show that 100% of the respondents claimed that the ICT support and its training have improved their knowledge and skills in the agricultural sector and they can now effectively utilize them in this sector. --- Social Capital The field data revealed that the advancement of the utilization of ICT has exerted a transformative influence on societal connectivity, particularly among ICT users. During the emerging stages of the project, individuals sought assistance from nongovernmental organizations to access ICT support. However, their current approach utilizes government-sponsored applications such as Krishoker Janala to access pertinent information to address agrarian challenges. Adopting ICT equipment has yielded positive outcomes for women, leading to augmented self-confidence, heightened productivity, heightened interaction with governmental and nongovernmental entities , and enriched domain knowledge in agroproduction. Additionally, this cohort actively disseminates their accrued knowledge to fellow women farmers within their local community. These interwoven networks, structured organizational involvements, relationships rooted in trust, and reciprocal exchanges established by ICT interventions are referred to as social capital [32]. Reflecting upon this transformation, FGD respondents commented, "Earlier we got information from the NGO supported services but now we get them using GO oriented services." They further elaborated, "Not only we alone, our neighbors are also getting helped to solve the problem in cultivation, rearing livestock and farming fishes by our acquired knowledge." Similarly to the FGD respondents, 34 respondents of the household survey expressed that notable improvements in cooperation, trust, and reciprocal relationships among neighboring individuals are visible in the community. These findings underscore instances where neighboring farmers, when confronted with challenges in their agricultural practices, proactively extend assistance to ameliorate the difficulties faced by their neighbors. Furthermore, in the realm of information and communication technology , users who receive preemptive notifications regarding impending food shortages or other extreme natural events through diverse applications exhibit a discernible tendency to disseminate this crucial information to their neighboring peers selectively. This dissemination practice indicates an augmented sense of trust nurtured within the village community, cultivating a more resilient social fabric. --- Financial Capital The adeptness demonstrated by women in employing Internet-enabled cell phones has yielded tangible advantages in mitigating the risks of natural adversities, such as floods and excessive rain during the rainy season and dense fog in winter, as well as the detrimental impact of pests on crop production. The cultivation of knowledge pertaining to these challenges has culminated in augmented agricultural output, facilitated by insights into impending natural disasters, judicious employment of insecticides and fertilizers, tailored problem-solving strategies for crop cultivation, and the adept management of crops through smartphone applications. This augmented productivity has been directly mirrored in increased income levels and financial comforts. FGD respondents illustrate this transformative change, recounting, "Few years back, we faced a great financial loss due to the less production of maize and other money making crops because of the harmful insects. Potatoes were damaged due to fog. We did not know what to do. We faced a great financial crisis due to the damages of crops by floods, rains, fogs and insect's attack. But now we are aware of the insects and weather due to digital apps and early warning systems. We are being informed through SMS and phone calls in some cases. We are producing double crops as we produced before." Financial losses resulting from natural events have been minimized with the supports of ICT equipment that brought economic solvency. On the other hand, as this area is on the riverbank and in an erosion-prone area, farmers, particularly women farmers, did not receive any financial loans either from microfinance organizations or financial organization, because those organizations considered the women farmers economically vulnerable and they might fail to repay the loans. As women are financially empowered, which augments the financial prominence of women within both familial and societal spheres trust between village women and nongovernmental organizations , this has streamlined access to microfinance institutions and loans. This economic gain from minimizing the crop losses of extreme natural events and microfinance institutions is termed as financial capital [33]. Our household survey data revealed a similar finding to that obtained through FGDs. A total of 34 respondents claimed that the use of ICT reduces the chances of crop destruction or damage, resulting in financial gains. --- Physical Capital Physical capital embodies basic infrastructures including sanitation, energy, transport, communications, housing, and the means and equipment of production [34]. In the context of cultivation and agroproduction, land constitutes an indispensable prerequisite. However, a significant proportion of women farmers lacked personal landholdings for cultivation prior to their involvement in the project. These land deficiencies stemmed from factors such as river erosion and financial constraints, which hindered their ability to procure land. One of the FGD respondents appropriately encapsulates this situation, stating, "I have nothing of my own except my house. Even my husband cultivated crops in the land leased from other persons. However, crop production often faced setbacks due to adverse weather, pest infestations, and flooding." As financial empowerment gradually takes root after the usage of ICT, there emerges a burgeoning interest among women to acquire land holdings. Utilizing their newfound financial prominence, women are investing in the purchase of agricultural land, while concurrently channeling surplus income into the construction of residences for improved living conditions. An FGD respondent presented testimony, "Eight years ago, my land was swept away by river erosion, leaving me without any personal property. Since then, I have managed to acquire a new plot of land using my hard-earned income, which I had saved from the proceeds of my agricultural activities." Notably, by mitigating vulnerabilities to crop damage and destruction brought about by natural forces, the strategic integration of information and communication technology has engendered a tangible enhancement in the financial stability of women farmers. This enhanced stability, in turn, has prompted a notable proportion, precisely 25 women, to proactively engage in savings practices, thereby paving the way for more secure economic trajectories. Utilizing their savings, these economically empowered women have made major investments in acquiring land for both housing and crop cultivation purposes . Moreover, they spent money saved for renting mercenaries to accelerate their agricultural activities. These salient developments are categorized as examples of physical capital [34,35]. --- Political Capital Engagement with diverse government organizations and nongovernment organizations has facilitated a nuanced understanding among women regarding their familial and societal roles, rights, and obligations. This newfound awareness has translated into active participation in remedying injustices and eradicating violence targeting women and girls, both within the familial and broader social contexts. Their agency is prominently demonstrated by their crucial involvement in addressing prevalent customs such as child marriage and the deeply rooted dowry system, which were widely prevalent in the village around six to seven years ago. A participant in the focus group discussion embodies this profound transformation, articulating, "Just five years ago, child marriage and dowry were pervasive occurrences. I myself was wed at the tender age of 14, with my family bestowing a dowry upon my husband's family. However, we have since gained a heightened awareness of these detrimental societal norms, and we now unite in fervent protest against them." All the respondents of FGD then echoed, "Our collective voice also vehemently opposes acts of violence directed towards women." Within the familial sphere, decision-making dynamics have undergone a notable shift, culminating in the equitable prioritization of women's opinions alongside those of men. A FGD respondent claimed that "My family earlier thought that 'Woman is inferior to man and she has no power. Man holds all the power in family and society. Women were born to perform household chores. She will take care of my father, mother, and children, nothing else. Why should I listen to her? What value does her opinion hold? Man is to earn, and woman is to cook.' Now, my husband understands the value of my works. He prioritizes my opinions." Eleven additional participants in the focus group discussion corroborated her assertion by recounting similar occurrences. This acknowledgment of women's agency within both family and society has been fundamentally bolstered by their substantial financial and economic contributions within the familial unit. Furthermore, this recognition has transcended into the political domain, signifying an important transformation in their societal standing, which is labeled as political capital [36]. The heightened awareness has galvanized their participation in various social mobilizations, exemplified by their collective resistance against deeply entrenched practices such as child marriage, dowry systems, and diverse forms of violence perpetrated against women, encompassing physical and psychological dimensions. Moreover, this proactive stance has manifested in their active involvement in rural arbitration processes, underscoring a palpable departure from the scenario witnessed five years ago. Our household surveys reflect the similar implications of ICT for enhancing the political capital. It shows that ICT made women aware of their rights and responsibilities in the society, which enhanced their active participation in rural arbitration and enlarged acceptance in decision-making processes in the family. However, the introduction and implementation of ICT initiatives within the South Kharibari village have been directed towards augmenting human capital through a strategic emphasis on skill enhancement and capacity building. This concerted effort has fostered an enabling environment that empowers women within the community. The process of transforming nonproductive women into productive contributors involves a multifaceted approach encompassing the augmentation of capacities, skills, and knowledge. In this endeavor, the exploration of social capital, complementing the strides in human capital, often entails the establishment of robust networks that link women with diverse entities, including government organizations and nongovernment organizations . A profound consequence of this holistic approach is discernible financial progress, which, in turn, has spurred an upsurge in women's investments in settlement and land purchasing, leveraging their self-earned resources. This financial empowerment translates into an elevated stature within the familial framework, positioning these women as pivotal stakeholders in the decision-making processes that significantly shape family dynamics. Furthermore, women's roles extend beyond the confines of their households, assuming a profound significance in the broader societal context. Their active involvement in curbing instances of violence and injustice targeted at them stands as a testament to their agency. This engagement extends to proactive efforts in combating entrenched practices such as dowry and child marriage, reflecting their commitment to effecting transformative change within their community. --- ICT, Women, and Agriculture: Challenges for Sustainability ICT has generated a visibly positive influence on the livelihoods of female agrarian practitioners, rectifying the challenges inherent to crop cultivation due to natural adversities, such as droughts, floods, excessive fog, and heavy rainfall. Nonetheless, this technological intervention has concurrently engendered certain challenges within the purview of local women farmers. Our empirical inquiry, rooted in survey data, reveals a significant assertion made by 71 percent of respondents, affirming their substantial reliance on ICT. When confronted with impediments to optimal crop production, these women have consistently turned to ICT-enabled solutions to ameliorate the prevailing challenges. Particularly, antecedent to the extensive acclimatization of ICT into their operational settings, these farmers traditionally drew upon intergenerational agroecological knowledge to address and mitigate such challenges. Evident from our findings is the revitalized impact of excessive ICT reliance, which has hastened distinct shifts of traditional agroecological knowledge in conceptions and operational modalities within the agricultural domain. This assertion is substantiated by a participant in a focal group discussion : "My spouse and I engaged in agricultural practices based on our personal expertise prior to the advent of ICT. After the commencement of its utilization, my complete focus was directed towards the management of agricultural techniques, encompassing the preparedness for flood, high rain, and pest control. I have lacked confidence in my past expertise and knowledge within the agroproduction process." Furthermore, despite receiving training in the utilization of ICT in agriculture, a number of woman farmers encounter difficulties in effectively utilizing these tools. This issue can primarily be attributed to the prevailing lack of literacy among these women. This literacy gap, in turn, leads to a situation where the comprehension and proper application of ICT tools remain elusive. When farmers were provided informative messages alerting them to potential attack of insects and natural occurrences such as floods, and heavy rainfall, these women depend on their school-going children to verbally convey and elucidate the contents of the messages. These children effectively function as intermediaries, undertaking the role of information translators for their parents. However, this translation process is conducted without any formal training or guidelines, thereby introducing the possibility of misinterpretation or incomplete conveyance of the message's essence. Consequently, this reliance on untrained intermediaries engenders a set of challenges within the domain of agricultural practices. The inherent lack of proper training and guidance in message translation leads to the potential distortion of critical information. This distortion, in turn, has cascading effects on the decision-making processes of farmers, impeding the effective execution of agricultural strategies for preparing against natural events and insects. As reasoned by an FGD respondent, "My partial educational level prevents me from comprehending the textual communications received from service providers. Consequently, I habitually engage my daughter or another proficient reader to assist me in perusing these messages. However, instances arise wherein the conveyed content proves challenging for them to convey with optimal clarity." All surveyed households unanimously asserted that financial constraints act as significant barriers to accessing ICT and its associated services. As claimed by FGD respondents, "We, one hundred women farmers, were equipped with smartphones and received comprehensive training for operating. The initiative also encompassed provisions for monthly Internet connectivity. Consequently, a notable increase in technological utilization was observed amongst the participants. However, it is worth highlighting that financial constraint affects the acquisition of smartphones for the people who are not included in the project. In several instances, the acquisition necessitates a monetary outlay equivalent to the cumulative earnings of two to three months. This financial strain considerably complicates the procurement of high-cost mobile devices. Furthermore, it is imperative to highlight that the ongoing utilization of these devices is contingent upon consistent access to the Internet, which experiences an additional cost exceeding 200 taka per month. For impoverished rural inhabitants, these financial burdens engender substantial challenges to purchase a phone along with internet." Two cases have come to light involving individuals who were beneficiaries of ICT support but, unfortunately, their phones were damaged. As a result of this, they were unable to avail further ICT assistance from the sponsoring organization due to the loss of their devices. Regrettably, they have been unable to make progress in enhancing their skills through ICT, and their limited incomes have posed a barrier to acquiring replacement mobile phones. --- Discussion This study aimed to investigate the impacts of information and communication technology on the livelihoods of women farmers, as well as to identify the challenges that hinder their sustainability. The results of the research indicate that ICT has a substantial impact on the development of sustainable livelihoods among women farmers in the study area. This study provides evidence to support the findings of prior studies. For example, Biswas et al. [12], Sarker et al. [37], and Tithi et al. [13] investigated the effect of information and communication technology on the livelihoods of women cultivators. Our research revealed that the implications of ICT are comprehended through the facilitation of capital accumulation processes, including human, social, financial, physical, and political capital. The study's findings suggest that ICT has had multifaceted impacts on the livelihoods of women farmers. It has not only enhanced the economic wellbeing of women farmers but has also fostered the creation of networks and the sharing of knowledge among farmers, both men and women, who occupy similar socioeconomic positions within their respective communities. Furthermore, our study shows that ICT plays a substantial role as a catalyst in promoting women's social, economic, and political empowerment. These findings align with prior research, exemplified by Biswas et al. [12]. Despite its commendable noteworthy contributions to enhance the wellbeing of rural women farmers, ICT has concurrently given rise to some intricate challenges. Throughout history, the diffusion of farming knowledge has primarily occurred orally and experimentally. This approach has not only imparted valuable information but also nurtured strong interpersonal bonds and a sense of togetherness within communities. Various investigators have been involved in debates about the nature of farmers' experiments, contending that they differ fundamentally from formal scientific trials. These distinctions are rooted in unique categories and backgrounds that deviate from the conventions of Western science, as supported by Chambers and Jiggins [38], Salas [39], Kronik [40], and Saad [41]. Salas [39] emphasized the community aspect of knowledge creation, stating that it is a collaborative endeavor involving the entire community rather than an individual pursuit. However, our study discovered an intriguing observation: the persistent reliance on digital resources has considerably diminished the necessity for direct interactions and direct knowledge sharing within the community. This shift has led to a decline in the eminence of indigenous knowledge networks within the local community. As a result, the once-vibrant exchanges of traditional wisdom are gradually fading, potentially impacting the cohesion and richness of the community's collective knowledge. Furthermore, ICT also influenced farming decisions by favoring certain high-yield crops or commercial varieties, ignoring the historically existing intergenerational cropping practices. As claimed by the FGD respondents, maize cultivation has become popular in the areas over the last couple of years, replacing their popular traditional multicropping practices, including jute and wheat. For augmenting the maize production, as Tithi et al., [13] mentioned, an app, "Bhutta" , was developed rather than emphasizing the traditional crop production. However, field data revealed that the digital platforms have overlooked the cultivation of diverse indigenous crops adapted to local environments for many years. This shift towards monoculture farming may accelerate the loss of traditional plant varieties and associated knowledge of their cultivation and utilization. One of the greatest challenges in designing applications for developing communities is that potential users may have limited literacy [42]. As reported by Banglapedia, the average literacy rate of Dimla upazila is 36.2% [43]. As mentioned by Sarker et al. [37] at the outset of the project, the challenges included the limited functional literacy among women and their unfamiliarity with the capabilities of smartphones. Our study reveals that women farmers who lack literacy struggle to use these tools. They use their children as intermediates, but their lack of formal training and guidance led to misinterpretation and incomplete message transmission, influencing decision making and impeding effective agricultural measures against natural disasters and insects. The involvement of people in ICT is dependent upon factors such as socioeconomic status, education, and resources, which is termed the "digital divide" [44]. Moreover, the statistic indicates that women's access to mobile phones and the Internet is very limited in Bangladesh [16]. In light of the research findings, it becomes evident that financial limitations impose formidable barriers that inhibit agrarian stakeholders from unfolding the potential of ICT, resulting from its considerable associated costs. Additionally, a consensus emerged from the discourse within focus group discussions whereby respondents uniformly verified the conspicuous absence of personal mobile communication devices among a number of woman farmers residing within the village, thereby aggravating their inability to even contemplate venturing into the realm of Internet accessibility. The study, however, acknowledges the positive implications of ICT on the livelihoods of rural farmers. It emphasizes the effective integration and institutionalization of ICT services to ensure the long-term sustainability of these positive impacts obtained. The study suggests that in the institutionalization process of ICT supports, women's indigenous agroecological knowledge should be taken into consideration. This study also suggests that ICT support should be centered on the popular traditional multicropping practices; rather focusing on commercial monocrop production practices. --- Conclusions The findings of the study brought to light the substantial role that ICT plays in enriching the livelihoods of women farmers residing in the study area. This is achieved through the facilitation of diverse forms of capital, encompassing human, social, financial, physical, and political capital, by establishing an enabling environment and alleviating impoverishment among women farmers. On the contrary, the disappearance of agroecological knowledge, displacement of traditional cropping by high-yielding varieties, illiteracy, and financial constraints of buying ICT equipment creates serious obstacles for its sustainability dimensions. In order to effectively integrate ICT into rural communities, it is of utmost importance to incorporate invaluable indigenous and local agroecological knowledge. This approach combines modern technological interventions with traditional

Rural agrarian societies, like Bangladesh, rely substantially on women as primary contributors to crop production. Their involvement covers a broad spectrum, from the first stage of seed sowing to the ultimate phase of marketing agricultural products. Information and communication technology (ICT) in agriculture could be a transformative tool for women's agricultural involvement. Despite the inherent challenges associated with ICT adoption, it has emerged as an effective catalyst for improving the livelihoods of rural women in Bangladesh. This study investigates the impacts of ICT on the livelihoods of rural women. This study concurrently addresses the challenges that infringe upon its sustainability. The study was conducted within Oxfam Bangladesh's ICT interventions implemented upon the women farmers in Dimla Upazila, Nilphamari, Bangladesh. We employed a mixed-methods research approach to examine the multilayered impacts of ICT on women farmers' livelihoods. Our findings indicate that ICT support has improved the livelihoods of rural women through a comprehensive capital-building process encompassing human capital, social capital, financial capital, physical capital, and political capital, facilitated by creating an enabling environment. The study also unfolded several challenges stemming from aspects of ICT integration, including the disappearance of indigenous agroecological knowledge and the disruption of traditional multicropping practices. In light of the study's outcomes, a key recommendation emerges, emphasizing the importance of integrating indigenous agroecological knowledge in the widescale implementation of ICT initiatives. Acknowledging and accommodating indigenous knowledge can enhance the sustainability of ICT-driven livelihood enhancements for rural women in Bangladesh.

introduction women are widely acknowledged as a foundation of the rural economic framework constituting an equal share of global agricultural producers 1 they concurrently fulfill multidimensional roles including familial nurturing elderly care cooking responsibilities household management and sociopolitical governance despite their substantial and dedicated involvement in agricultural pursuits 2 3 4 in the contemporary global agrarian landscape women constitute a significant workforce accounting for 43 percent of the total labor force 5 within the distinct context of bangladeshs national economy the agricultural sector holds a prominent and crucial role akin to other developing nations delineated as one of the central economic strongholds this sector contributes approximately 23 percent to the countrys gross domestic product 6 pertinently women constitute an indispensable cohort within the rural agricultural labor force of the nation and the involvement of women in rural areas of bangladesh in the agriculture sector has increased from 54 in 2013 to 60 in 2017 7 within the domain of agriculture like many other sectors the primacy of information has become increasingly pronounced assuming a vital role in the operational paradigm 8 as a result ict has a significant impact on the growth of agriculture 9 enabling farmers to acclimatize knowledge and information thus constituting a central axis that empowers their responsiveness to emergent prospects capable of enhancing agricultural productivity 10 in this context information communication technologies have emerged as a vanguard holding considerable promise for catalyzing the developmental trajectory of countries in the global south 11 in the specific case of bangladesh ict has emerged as a transformative tool that has the potential to enhance various dimensions of womens participation in agriculture and to enhance sustainable livelihoods 12 primarily ict platforms have facilitated access to crucial agricultural information and knowledge resources for women farmers in bangladesh through mobile applications online platforms and sms services women farmers are now equipped with realtime data about weather forecasts and pest management 13 however historically the gendered exclusion of women from the information and communication technology domain has been conspicuous this exclusion has manifested itself as ict becoming predominantly malecentered characterized by disparities in accessibility and availability often intertwined with economic power dynamics simultaneously a pronounced gender disparity persists in access to essential resources such as land energy technology loans pesticides and fertilizers moreover women confront significant hurdles in accessing training information public services social protection and markets as highlighted by garcía 14 a recent investigation conducted by the international telecommunication union established a tangible correlation between conspicuous gender gaps in mobile phone ownership and the limited adoption of the internet among females only 19 of women in least developed countries used the internet in 2020 compared to 86 percent in the developed world 15 exemplifying this dynamic the gsmas mobile gender gap report for the year 2023 underscores the mobile phone ownership gender divide in bangladesh revealing a substantial dichotomy remarkably approximately 67 percent of adult women in bangladesh own mobile phones however a mere 21 percent engage with the internet this stark incongruity designates bangladesh as a prominent epicenter of the mobile ownership gender gap phenomenon corroborating its standing as one of the most pronounced cases globally 16 the root of this phenomenon can be traced to a marxist perspective which emphasizes the genderbased division of labor and how it perpetuates gender disparities this issue is further exacerbated by the deeply ingrained cultural perception that associates technology with masculinity within this societal framework technology reflects and reinforces the prevalent male dominance 17 18 19 in spite of having these challenges agriculture has emerged as a potent avenue for empowering women as explicated by kabeer 20 as the expansion of womens capabilities in three crucial dimensions resources agency and wellbeing outcomes however the journey toward empowerment for rural women in bangladesh particularly those living in poverty is fraught with multifaceted challenges these challenges include poverty inequality inadequate infrastructure restricted access to education and information and deeply rooted social factors prominently the patriarchal structure nevertheless the introduction of information and communication technology has catalyzed a significant transformation in the lives of rural bangladeshi women farmers among the transformative elements the accessibility of smartphones stands out as a potent tool that has improved their access to vital information and communication opportunities this accessibility has in turn mitigated vulnerabilities and enhanced livelihood prospects ict has also facilitated improved access to agricultural extension services and local markets ultimately empowering women and advancing their agency as elucidated by biswas et al 12 the recognition of information and communication technologys capacity to enhance agricultural productivity has garnered extensive acknowledgment within scholarly discourse the revitalizing potential of information and communication technology within agriculture is undeniable as evidenced by its farreaching impact on the sustainable livelihoods of women farmers 12 this happened with the deployment of ict for augmenting the capabilities knowledge and skills of women farmers collectively referred to as human capital these investments in human capital have yielded substantial dividends resulting in the development of social financial physical and political capital consequently womens roles have transcended the confines of their households bestowing upon them significant importance in the broader societal context further the emergence of digital platforms has facilitated unprecedented knowledge exchange and networking opportunities among experts from diverse regions 21 while fostering innovation this global connectivity simultaneously introduces challenges that influence local and indigenous knowledge particularly agroecological knowledge dynamics however this fundamental imperative requires a thorough investigation of the predominant ict adoption by women farmers unfortunately these concerns often receive limited attention in scholarly domains based upon these concerns this study aimed to identify the impacts of ict on the livelihoods of women farmers and uncover the challenges impeding their sustainability to achieve these objectives we conducted a study within the context of ict users at south kharibari village in dimla upazila this study employed a mixed research approach encompassing both qualitative and quantitative methods to comprehensively explore the nuances of ict usage for agricultural purposes among women farmers this study emphasizes the importance of considering invaluable insights derived from indigenous and local agricultural knowledge to successfully integrate ict to improve womens livelihoods it seeks to achieve a harmonious synergy between modern technological interventions and the timetested wisdom embedded within traditional knowledge systems such an approach could enhance the efficacy and sustainability of ictdriven agricultural advancements fostering a more holistic and contextually relevant renovation conceptual framework for understanding the impacts of ict on womens livelihoods the adoption of the sustainable livelihood framework provides a complete analytical foundation for this study the concept of sustainable rural livelihoods has progressively assumed a central role in the discourse on rural development poverty alleviation and environmental stewardship livelihoods within this framework represent a composite of capabilities assetsencompassing both tangible and intangible elementsand activities requisite for sustaining ones means of subsistence importantly a livelihood attains sustainability when it exhibits the capacity to effectively endure and improve from various stressors and shocks while concurrently preserving or enhancing its inherent capabilities and assets all without compromising the integrity of the natural resource base 2223 those individuals who find themselves unable to effectively cope with shortterm changes or adapt to longerterm shifts in livelihood strategies inevitably fall into the category of vulnerability and are less likely to realize sustainable livelihoods 22 within the specific context of this study women emerge as a vulnerable demographic concerning access to information and communication technology and other essential resources they encounter formidable obstacles when seeking access to training information public services social protection and markets this vulnerability is intricately tied to the existence of structural barriers prominently exemplified by the entrenched patriarchal social structure within society the emergence of information and communication technology stands out as a transformative catalyst significantly augmenting womens capacity to engage in various livelihood strategies this ability to pursue diverse livelihood strategies is contingent upon the possession of foundational material and social assets drawing upon an economic analogy these resources underpin livelihoods functioning as the capital base from which an array of productive streams emanate thereby constructing and sustaining livelihoods level however the sustainable livelihood framework provides a nuanced and comprehensive understanding of how ict adoption empowers women within the agricultural sector encompassing personal and social transformations economic gains and political empowerment this framework places women as active agents of change contributing to the development of sustainable rural livelihoods while transcending the barriers imposed by traditional gender norms and structural inequalities figure 1 sustainable livelihood framework modified from dfid 24 figure 1 sustainable livelihood framework modified from dfid 24 human capital encompasses various capacities that enable individuals to pursue diverse livelihood strategies and contribute to community objectives 24 this includes a spectrum of attributes such as skills knowledge labor capabilities and physical health all of which are essential for the effective pursuit of livelihood strategies 22 social capital revolves around the concept of social resources including networks social ties affiliations and associations that individuals can leverage when engaged in livelihood strategies that require coordinated actions 22 financial capital constitutes various economic assets including cash creditdebt savings and other financial resources all of which are indispensable for the pursuit of livelihood strategies 22 physical capital includes tangible goods and objects that support individuals livelihoods including vehicles homes tools and workrelated assets 25 political capital serves as a testament to womens empowerment highlighting their heightened awareness of rights roles and active participation in addressing societal issues and injustices this dimension emphasizes their engagement in challenging detrimental customs and combating violence against women as well as their increased involvement in decisionmaking processes both within the family unit and at the societal level however the sustainable livelihood framework provides a nuanced and comprehensive understanding of how ict adoption empowers women within the agricultural sector encompassing personal and social transformations economic gains and political empowerment this framework places women as active agents of change contributing to the development of sustainable rural livelihoods while transcending the barriers imposed by traditional gender norms and structural inequalities materials and methods study area this research was undertaken within the south khoribari village located in the dimla upazila of nilphamari district in northwestern bangladesh the study site exemplifies the characteristics of a prototypical char land a term denoting sandbars that emerge as islands within the river channel or as attached land to the riverbanks 2627 the population of this area totals approximately 3500 individuals with a substantial proportion of the villagers actively engaged in agricultural pursuits 27 noteworthy is the direct and active participation of women in agricultural pursuits alongside their concurrent management of household responsibilities additionally in select households women assume the complete mantle of agricultural responsibilities while male members of these families are occupied in diverse occupational pursuits in other regions of the country with a substantial proportion of the villagers actively engaged in agricultural pursuits 27 noteworthy is the direct and active participation of women in agricultural pursuits alongside their concurrent management of household responsibilities additionally in select households women assume the complete mantle of agricultural responsibilities while male members of these families are occupied in diverse occupational pursuits in other regions of the country data collection and analysis the research was conducted among the beneficiaries of oxfams protic project employing a mixed research approach referring to the use of two or more methods in a data collection and analysis the research was conducted among the beneficiaries of oxfams protic project employing a mixed research approach referring to the use of two or more methods in a single research including qualitative and quantitative approaches to increase the accuracy and level of confidence 28 29 30 31 at south kharibari village of dimla upazila located on the teesta river basin of northwestern bangladesh data were collected from women farmers provided with ict equipment including smartphones internet and online supports through household surveys and focus group discussion from october 2019 to january 2020 in 2015 a targeted intervention involving the provisioning of ict support was implemented for a cohort of 100 womanheaded households by oxfam bangladesh in collaboration with monash university oxfam provided mobile phones monthly internet services and training to the women who were known as animators the selection of animators was involved in satisfying a set of three specific criteria these criteria included the status of heading a family by a female the presence of a disability within the individual and a correspondence with the prevailing economic profile observed within the broader demographic composition of the village populace 1327 these women farmers were furnished with ict resources to facilitate their access to essential agricultural information encompassing aspects such as crop cultivation water management and weather forecasts the dissemination of this information was facilitated through diverse communication channels including mobile phone short message service outbound dial interactive voice response applications and call center services specializing in agriculture and agrometeorology incorporating early warning systems into their operational framework the adoption of these services empowered women farmers to proactively mitigate potential losses and detriments incurred by unforeseen meteorological events such as floods dense fog abrupt rainfall crop afflictions and pest incursions thus enhancing their adaptive capacities and bolstering agricultural productivity 13 in order to comprehensively evaluate the impacts of information and communication technology on the livelihoods of women farmers a systematic approach was adopted to gather insights acquired from five years of ict usage this process encompassed several vital stages commencing with a stakeholders consultation involving women farmers who had benefited from ict support this initial consultation served a dual purpose firstly to obtain a preliminary understanding of the effects of ict on rural womens livelihoods secondly to refine and finalize the subsequent household survey questionnaire following the stakeholders consultation a semistructured questionnaire was designed to address the research questions and was subsequently utilized in a comprehensive household survey involving 42 women farmers the data collected from the household survey formed a foundational layer upon which additional validation and context enrichment were achieved through three distinct focus group discussions these fgds were instrumental in corroborating the insights from the household survey and delving into the multifaceted dimensions of changes that transpired over the preceding five years moreover the fgds served an additional critical purpose of unearthing the diverse challenges of integrating ict in rural areas each fgd consisting of 12 to 15 women participants was conducted under the guidance of a skilled facilitator accompanied by an assistant responsible for accurately recording the discussions the selection of respondents for both the household surveys and fgds was deliberately differentiated contributing to a holistic and wellrounded perspective on the subject matter the data obtained from the focus group discussions were precisely documented through recordings and comprehensive notes and underwent subsequent transcription into textual format these textual data were thoroughly analyzed through traditional qualitative data analysis software specifically nvivo a recognized tool in this field hailing from melbourne australia this analytical process was grounded in an inductive approach enabling the systematic identification and extraction of noteworthy emergent themes inherent within the fgd data concurrently the data stemming from the household surveys followed a distinct analytical trajectory leveraging computer software specifically microsoft excel the data from the household surveys underwent thorough analysis results implications of ict on livelihoods the findings of our study demonstrate that the integration of ict such as smartphones internet services and mobile applications along with the provision of relevant training programs enhanced the skills knowledge and capabilities in the field of agriculture this implies a positive impact on the development of human capital in this agriculture the influence of human capital extends to other dimensions including social financial physical and political capital the findings of our study demonstrate that the integration of ict such as smartphones internet services and mobile applications along with the provision of relevant training programs enhanced the skills knowledge and capabilities in the field of agriculture this implies a positive impact on the development of human capital in this agriculture the influence of human capital extends to other dimensions including social financial physical and political capital ict enabled women to buy land with money which they women saved 25 17 ict turned women key earners in family 29 13 ict made women aware of their rights and roles in society 40 02 ict ensured womens participation in rural arbitration 26 16 ict made women aware of preventing social issues 42 00 human capital the study revealed that within the domain of women involved in agricultural pursuits the deliberate utilization of information and communication technology tools specifically smartphones in combination with the provision of relevant training on their usage and access to the internet has exhibited a vital capacity to enhance knowledge and competencies which is referred to as human capital 32 the utilization of internet resources has emerged as a transforming factor for women serving as a crucial catalyst for empowerment engaging in capacitybuilding programs and seminars focused on successfully deploying information and communication technology has facilitated persons in improving their knowledge and understanding of agriculture resulting in a deeper comprehension of the agricultural domain the reliance on diverse technological avenues including social media platforms mobile applications and call centers enhances womens knowledge and skills in agricultural settings ict has concomitantly bolstered womens selfconfidence amplifying their decisionmaking processes and communication proficiencies one fgd respondent expressed her transformative experience noting i couldnt move the touch of ict equipment taught me to move i couldnt say the use of ict gave me language and i couldnt see ict gave me sight the use of ict has changed my life in the same way the household data show that 100 of the respondents claimed that the ict support and its training have improved their knowledge and skills in the agricultural sector and they can now effectively utilize them in this sector social capital the field data revealed that the advancement of the utilization of ict has exerted a transformative influence on societal connectivity particularly among ict users during the emerging stages of the project individuals sought assistance from nongovernmental organizations to access ict support however their current approach utilizes governmentsponsored applications such as krishoker janala to access pertinent information to address agrarian challenges adopting ict equipment has yielded positive outcomes for women leading to augmented selfconfidence heightened productivity heightened interaction with governmental and nongovernmental entities and enriched domain knowledge in agroproduction additionally this cohort actively disseminates their accrued knowledge to fellow women farmers within their local community these interwoven networks structured organizational involvements relationships rooted in trust and reciprocal exchanges established by ict interventions are referred to as social capital 32 reflecting upon this transformation fgd respondents commented earlier we got information from the ngo supported services but now we get them using go oriented services they further elaborated not only we alone our neighbors are also getting helped to solve the problem in cultivation rearing livestock and farming fishes by our acquired knowledge similarly to the fgd respondents 34 respondents of the household survey expressed that notable improvements in cooperation trust and reciprocal relationships among neighboring individuals are visible in the community these findings underscore instances where neighboring farmers when confronted with challenges in their agricultural practices proactively extend assistance to ameliorate the difficulties faced by their neighbors furthermore in the realm of information and communication technology users who receive preemptive notifications regarding impending food shortages or other extreme natural events through diverse applications exhibit a discernible tendency to disseminate this crucial information to their neighboring peers selectively this dissemination practice indicates an augmented sense of trust nurtured within the village community cultivating a more resilient social fabric financial capital the adeptness demonstrated by women in employing internetenabled cell phones has yielded tangible advantages in mitigating the risks of natural adversities such as floods and excessive rain during the rainy season and dense fog in winter as well as the detrimental impact of pests on crop production the cultivation of knowledge pertaining to these challenges has culminated in augmented agricultural output facilitated by insights into impending natural disasters judicious employment of insecticides and fertilizers tailored problemsolving strategies for crop cultivation and the adept management of crops through smartphone applications this augmented productivity has been directly mirrored in increased income levels and financial comforts fgd respondents illustrate this transformative change recounting few years back we faced a great financial loss due to the less production of maize and other money making crops because of the harmful insects potatoes were damaged due to fog we did not know what to do we faced a great financial crisis due to the damages of crops by floods rains fogs and insects attack but now we are aware of the insects and weather due to digital apps and early warning systems we are being informed through sms and phone calls in some cases we are producing double crops as we produced before financial losses resulting from natural events have been minimized with the supports of ict equipment that brought economic solvency on the other hand as this area is on the riverbank and in an erosionprone area farmers particularly women farmers did not receive any financial loans either from microfinance organizations or financial organization because those organizations considered the women farmers economically vulnerable and they might fail to repay the loans as women are financially empowered which augments the financial prominence of women within both familial and societal spheres trust between village women and nongovernmental organizations this has streamlined access to microfinance institutions and loans this economic gain from minimizing the crop losses of extreme natural events and microfinance institutions is termed as financial capital 33 our household survey data revealed a similar finding to that obtained through fgds a total of 34 respondents claimed that the use of ict reduces the chances of crop destruction or damage resulting in financial gains physical capital physical capital embodies basic infrastructures including sanitation energy transport communications housing and the means and equipment of production 34 in the context of cultivation and agroproduction land constitutes an indispensable prerequisite however a significant proportion of women farmers lacked personal landholdings for cultivation prior to their involvement in the project these land deficiencies stemmed from factors such as river erosion and financial constraints which hindered their ability to procure land one of the fgd respondents appropriately encapsulates this situation stating i have nothing of my own except my house even my husband cultivated crops in the land leased from other persons however crop production often faced setbacks due to adverse weather pest infestations and flooding as financial empowerment gradually takes root after the usage of ict there emerges a burgeoning interest among women to acquire land holdings utilizing their newfound financial prominence women are investing in the purchase of agricultural land while concurrently channeling surplus income into the construction of residences for improved living conditions an fgd respondent presented testimony eight years ago my land was swept away by river erosion leaving me without any personal property since then i have managed to acquire a new plot of land using my hardearned income which i had saved from the proceeds of my agricultural activities notably by mitigating vulnerabilities to crop damage and destruction brought about by natural forces the strategic integration of information and communication technology has engendered a tangible enhancement in the financial stability of women farmers this enhanced stability in turn has prompted a notable proportion precisely 25 women to proactively engage in savings practices thereby paving the way for more secure economic trajectories utilizing their savings these economically empowered women have made major investments in acquiring land for both housing and crop cultivation purposes moreover they spent money saved for renting mercenaries to accelerate their agricultural activities these salient developments are categorized as examples of physical capital 3435 political capital engagement with diverse government organizations and nongovernment organizations has facilitated a nuanced understanding among women regarding their familial and societal roles rights and obligations this newfound awareness has translated into active participation in remedying injustices and eradicating violence targeting women and girls both within the familial and broader social contexts their agency is prominently demonstrated by their crucial involvement in addressing prevalent customs such as child marriage and the deeply rooted dowry system which were widely prevalent in the village around six to seven years ago a participant in the focus group discussion embodies this profound transformation articulating just five years ago child marriage and dowry were pervasive occurrences i myself was wed at the tender age of 14 with my family bestowing a dowry upon my husbands family however we have since gained a heightened awareness of these detrimental societal norms and we now unite in fervent protest against them all the respondents of fgd then echoed our collective voice also vehemently opposes acts of violence directed towards women within the familial sphere decisionmaking dynamics have undergone a notable shift culminating in the equitable prioritization of womens opinions alongside those of men a fgd respondent claimed that my family earlier thought that woman is inferior to man and she has no power man holds all the power in family and society women were born to perform household chores she will take care of my father mother and children nothing else why should i listen to her what value does her opinion hold man is to earn and woman is to cook now my husband understands the value of my works he prioritizes my opinions eleven additional participants in the focus group discussion corroborated her assertion by recounting similar occurrences this acknowledgment of womens agency within both family and society has been fundamentally bolstered by their substantial financial and economic contributions within the familial unit furthermore this recognition has transcended into the political domain signifying an important transformation in their societal standing which is labeled as political capital 36 the heightened awareness has galvanized their participation in various social mobilizations exemplified by their collective resistance against deeply entrenched practices such as child marriage dowry systems and diverse forms of violence perpetrated against women encompassing physical and psychological dimensions moreover this proactive stance has manifested in their active involvement in rural arbitration processes underscoring a palpable departure from the scenario witnessed five years ago our household surveys reflect the similar implications of ict for enhancing the political capital it shows that ict made women aware of their rights and responsibilities in the society which enhanced their active participation in rural arbitration and enlarged acceptance in decisionmaking processes in the family however the introduction and implementation of ict initiatives within the south kharibari village have been directed towards augmenting human capital through a strategic emphasis on skill enhancement and capacity building this concerted effort has fostered an enabling environment that empowers women within the community the process of transforming nonproductive women into productive contributors involves a multifaceted approach encompassing the augmentation of capacities skills and knowledge in this endeavor the exploration of social capital complementing the strides in human capital often entails the establishment of robust networks that link women with diverse entities including government organizations and nongovernment organizations a profound consequence of this holistic approach is discernible financial progress which in turn has spurred an upsurge in womens investments in settlement and land purchasing leveraging their selfearned resources this financial empowerment translates into an elevated stature within the familial framework positioning these women as pivotal stakeholders in the decisionmaking processes that significantly shape family dynamics furthermore womens roles extend beyond the confines of their households assuming a profound significance in the broader societal context their active involvement in curbing instances of violence and injustice targeted at them stands as a testament to their agency this engagement extends to proactive efforts in combating entrenched practices such as dowry and child marriage reflecting their commitment to effecting transformative change within their community ict women and agriculture challenges for sustainability ict has generated a visibly positive influence on the livelihoods of female agrarian practitioners rectifying the challenges inherent to crop cultivation due to natural adversities such as droughts floods excessive fog and heavy rainfall nonetheless this technological intervention has concurrently engendered certain challenges within the purview of local women farmers our empirical inquiry rooted in survey data reveals a significant assertion made by 71 percent of respondents affirming their substantial reliance on ict when confronted with impediments to optimal crop production these women have consistently turned to ictenabled solutions to ameliorate the prevailing challenges particularly antecedent to the extensive acclimatization of ict into their operational settings these farmers traditionally drew upon intergenerational agroecological knowledge to address and mitigate such challenges evident from our findings is the revitalized impact of excessive ict reliance which has hastened distinct shifts of traditional agroecological knowledge in conceptions and operational modalities within the agricultural domain this assertion is substantiated by a participant in a focal group discussion my spouse and i engaged in agricultural practices based on our personal expertise prior to the advent of ict after the commencement of its utilization my complete focus was directed towards the management of agricultural techniques encompassing the preparedness for flood high rain and pest control i have lacked confidence in my past expertise and knowledge within the agroproduction process furthermore despite receiving training in the utilization of ict in agriculture a number of woman farmers encounter difficulties in effectively utilizing these tools this issue can primarily be attributed to the prevailing lack of literacy among these women this literacy gap in turn leads to a situation where the comprehension and proper application of ict tools remain elusive when farmers were provided informative messages alerting them to potential attack of insects and natural occurrences such as floods and heavy rainfall these women depend on their schoolgoing children to verbally convey and elucidate the contents of the messages these children effectively function as intermediaries undertaking the role of information translators for their parents however this translation process is conducted without any formal training or guidelines thereby introducing the possibility of misinterpretation or incomplete conveyance of the messages essence consequently this reliance on untrained intermediaries engenders a set of challenges within the domain of agricultural practices the inherent lack of proper training and guidance in message translation leads to the potential distortion of critical information this distortion in turn has cascading effects on the decisionmaking processes of farmers impeding the effective execution of agricultural strategies for preparing against natural events and insects as reasoned by an fgd respondent my partial educational level prevents me from comprehending the textual communications received from service providers consequently i habitually engage my daughter or another proficient reader to assist me in perusing these messages however instances arise wherein the conveyed content proves challenging for them to convey with optimal clarity all surveyed households unanimously asserted that financial constraints act as significant barriers to accessing ict and its associated services as claimed by fgd respondents we one hundred women farmers were equipped with smartphones and received comprehensive training for operating the initiative also encompassed provisions for monthly internet connectivity consequently a notable increase in technological utilization was observed amongst the participants however it is worth highlighting that financial constraint affects the acquisition of smartphones for the people who are not included in the project in several instances the acquisition necessitates a monetary outlay equivalent to the cumulative earnings of two to three months this financial strain considerably complicates the procurement of highcost mobile devices furthermore it is imperative to highlight that the ongoing utilization of these devices is contingent upon consistent access to the internet which experiences an additional cost exceeding 200 taka per month for impoverished rural inhabitants these financial burdens engender substantial challenges to purchase a phone along with internet two cases have come to light involving individuals who were beneficiaries of ict support but unfortunately their phones were damaged as a result of this they were unable to avail further ict assistance from the sponsoring organization due to the loss of their devices regrettably they have been unable to make progress in enhancing their skills through ict and their limited incomes have posed a barrier to acquiring replacement mobile phones discussion this study aimed to investigate the impacts of information and communication technology on the livelihoods of women farmers as well as to identify the challenges that hinder their sustainability the results of the research indicate that ict has a substantial impact on the development of sustainable livelihoods among women farmers in the study area this study provides evidence to support the findings of prior studies for example biswas et al 12 sarker et al 37 and tithi et al 13 investigated the effect of information and communication technology on the livelihoods of women cultivators our research revealed that the implications of ict are comprehended through the facilitation of capital accumulation processes including human social financial physical and political capital the studys findings suggest that ict has had multifaceted impacts on the livelihoods of women farmers it has not only enhanced the economic wellbeing of women farmers but has also fostered the creation of networks and the sharing of knowledge among farmers both men and women who occupy similar socioeconomic positions within their respective communities furthermore our study shows that ict plays a substantial role as a catalyst in promoting womens social economic and political empowerment these findings align with prior research exemplified by biswas et al 12 despite its commendable noteworthy contributions to enhance the wellbeing of rural women farmers ict has concurrently given rise to some intricate challenges throughout history the diffusion of farming knowledge has primarily occurred orally and experimentally this approach has not only imparted valuable information but also nurtured strong interpersonal bonds and a sense of togetherness within communities various investigators have been involved in debates about the nature of farmers experiments contending that they differ fundamentally from formal scientific trials these distinctions are rooted in unique categories and backgrounds that deviate from the conventions of western science as supported by chambers and jiggins 38 salas 39 kronik 40 and saad 41 salas 39 emphasized the community aspect of knowledge creation stating that it is a collaborative endeavor involving the entire community rather than an individual pursuit however our study discovered an intriguing observation the persistent reliance on digital resources has considerably diminished the necessity for direct interactions and direct knowledge sharing within the community this shift has led to a decline in the eminence of indigenous knowledge networks within the local community as a result the oncevibrant exchanges of traditional wisdom are gradually fading potentially impacting the cohesion and richness of the communitys collective knowledge furthermore ict also influenced farming decisions by favoring certain highyield crops or commercial varieties ignoring the historically existing intergenerational cropping practices as claimed by the fgd respondents maize cultivation has become popular in the areas over the last couple of years replacing their popular traditional multicropping practices including jute and wheat for augmenting the maize production as tithi et al 13 mentioned an app bhutta was developed rather than emphasizing the traditional crop production however field data revealed that the digital platforms have overlooked the cultivation of diverse indigenous crops adapted to local environments for many years this shift towards monoculture farming may accelerate the loss of traditional plant varieties and associated knowledge of their cultivation and utilization one of the greatest challenges in designing applications for developing communities is that potential users may have limited literacy 42 as reported by banglapedia the average literacy rate of dimla upazila is 362 43 as mentioned by sarker et al 37 at the outset of the project the challenges included the limited functional literacy among women and their unfamiliarity with the capabilities of smartphones our study reveals that women farmers who lack literacy struggle to use these tools they use their children as intermediates but their lack of formal training and guidance led to misinterpretation and incomplete message transmission influencing decision making and impeding effective agricultural measures against natural disasters and insects the involvement of people in ict is dependent upon factors such as socioeconomic status education and resources which is termed the digital divide 44 moreover the statistic indicates that womens access to mobile phones and the internet is very limited in bangladesh 16 in light of the research findings it becomes evident that financial limitations impose formidable barriers that inhibit agrarian stakeholders from unfolding the potential of ict resulting from its considerable associated costs additionally a consensus emerged from the discourse within focus group discussions whereby respondents uniformly verified the conspicuous absence of personal mobile communication devices among a number of woman farmers residing within the village thereby aggravating their inability to even contemplate venturing into the realm of internet accessibility the study however acknowledges the positive implications of ict on the livelihoods of rural farmers it emphasizes the effective integration and institutionalization of ict services to ensure the longterm sustainability of these positive impacts obtained the study suggests that in the institutionalization process of ict supports womens indigenous agroecological knowledge should be taken into consideration this study also suggests that ict support should be centered on the popular traditional multicropping practices rather focusing on commercial monocrop production practices conclusions the findings of the study brought to light the substantial role that ict plays in enriching the livelihoods of women farmers residing in the study area this is achieved through the facilitation of diverse forms of capital encompassing human social financial physical and political capital by establishing an enabling environment and alleviating impoverishment among women farmers on the contrary the disappearance of agroecological knowledge displacement of traditional cropping by highyielding varieties illiteracy and financial constraints of buying ict equipment creates serious obstacles for its sustainability dimensions in order to effectively integrate ict into rural communities it is of utmost importance to incorporate invaluable indigenous and local agroecological knowledge this approach combines modern technological interventions with traditional

rural agrarian societies like bangladesh rely substantially on women as primary contributors to crop production their involvement covers a broad spectrum from the first stage of seed sowing to the ultimate phase of marketing agricultural products information and communication technology ict in agriculture could be a transformative tool for womens agricultural involvement despite the inherent challenges associated with ict adoption it has emerged as an effective catalyst for improving the livelihoods of rural women in bangladesh this study investigates the impacts of ict on the livelihoods of rural women this study concurrently addresses the challenges that infringe upon its sustainability the study was conducted within oxfam bangladeshs ict interventions implemented upon the women farmers in dimla upazila nilphamari bangladesh we employed a mixedmethods research approach to examine the multilayered impacts of ict on women farmers livelihoods our findings indicate that ict support has improved the livelihoods of rural women through a comprehensive capitalbuilding process encompassing human capital social capital financial capital physical capital and political capital facilitated by creating an enabling environment the study also unfolded several challenges stemming from aspects of ict integration including the disappearance of indigenous agroecological knowledge and the disruption of traditional multicropping practices in light of the studys outcomes a key recommendation emerges emphasizing the importance of integrating indigenous agroecological knowledge in the widescale implementation of ict initiatives acknowledging and accommodating indigenous knowledge can enhance the sustainability of ictdriven livelihood enhancements for rural women in bangladesh

uptake is vastly different when comparing people with learning disabilities and those without learning disabilities , with the largest difference in uptake being for cervical and breast cancer screening . Research has highlighted multiple barriers to decision-making and access to cervical and breast cancer screening by women with learning disabilities , including mobility issues, communication difficulties , fear and being embarrassed about going to screening , family carer and paid care workers may lack understanding cancer and having poor health literacy . Even with these known barriers to cancer screening, uptake remains consistently lower than the general population . Even with the acknowledgement of the range of barriers that WwLD face in deciding to attend and then access cervical and/or breast cancer screening, there is a need to identify the most influential factors that can facilitate or hinder WwLD. Research to date tends to involve WwLD alone or their carers , with very few accounting for all their perspectives in the same study . The combined perspectives on factors that influence access can then be utilised to make recommendation for policy and cancer screening practice to limit the inequalities faced by WwLD. Due to this, this research aimed to further understand the range of knowledge, attitudes towards and decision-making around cervical and breast cancer screening in WwLD, family carers and paid carers. --- | METHODS Approval to complete a Q methodology study was received from a university and the Health Research Authority. The following subsections explain the methods used to employ the Q methodology study. --- | Identifying a concourse and developing the Q-set A concourse consists of the range of possible opinions regarding the topic in question that can be written or spoken about a topic that can be contested and debated . A concourse is usually identified through interviews, focus groups and conducting literature reviews . For this study, the results of a systematic review were collated with reports and websites. From this, 128 statements were identified . The concourse is then synthesised to develop a set of statements called a Q-set . The Q-set aims to cover the full range of opinions in the concourse and tends to range from 20 to 100 statements . The Q-set was developed through thematically clustering the concourse statements together, based on if they had a similar meaning. All authors were involved in this process. Based on this, 28 statements were developed . Each Q-set statement started with 'Women with a learning disability …', to provide consistency and allowed the WwLD to think about themselves or other WwLD if they had not attended cancer screening previously. --- | Specifying the participants Participants were identified using purposive sampling of three non-NHS day centre providers, an NHS Foundation Trust and a GP practice in the North-East of England. Gatekeepers in each location initially identified WwLD as meeting a set of inclusion criteria . One co-author acted as a gatekeeper for one site and was the only author who had any involvement in identifying eligible participants. The gatekeepers discussed the study with the WwLD, using an information sheet . If WwLD were interested in taking part, they were either given the researcher's details or their contact information was passed onto the researcher . The WwLD were also asked if they were happy for their family or paid care workers to be contacted to take part. If so, the WwLD provided their details. Family carers and paid care workers were provided with information by the researcher , or information was sent to the WwLD to then pass on. Written informed consent was obtained from all participants. --- | Administering the Q-sort and analysis The fourth step was to administer the Q-sort. This is the process where participants rank-order the Q-set, based on their preferences or feelings towards the Q-set statements . The researcher was present during all data collection activities. To complete the Q-sort, a specific grid was developed . The grid ranged from À4 to +4 with 28 spaces for each Q-set statement. Participants started by sorting the Q-set into three piles , each pile was taken in turn and the cards were sorted onto the Q-grid to indicate the participant's level of agreement, or disagreement, with the card. The sorting process was completed under a forced-choice condition, where participants were required to place a specific number of statements under each column of the Q-grid. This instruction can make the sorting process a more manageable conceptual task, where participants can carefully consider all statements concerning each other . However, participants could place cards outside the predetermined grid structure, if they strongly felt that the remaining spaces did not reflect their views. Following the Q-sort, each participant completed a brief post-Q-sort interview to explain their reasons for the card placement and to understand their experiences of screening. All Q-sorts were audio recorded and transcribed by KS. The final step was to analyse the Q-sorts and interpret the output. The Q-sorts were input onto PQMethod . The sorts were analysed using principal component analysis with varimax rotation. This maximised the variance and provided the best mathematical solution or best fit . The correlation matrix generated is subjected to the varimax rotation to optimise the separation between factors and clarified the factor structure . A factor array was also produced, which represents a 'mean' Q-sort of the shared viewpoint of participants; this can then be interpreted . Framework analysis was completed, so the authors could interpret the factor arrays. To complete the framework analysis, a Microsoft Excel spreadsheet was developed. The spreadsheet replicated the +4, +3, À3 and À4 columns of the factor array. Quotes from the transcripts were identified to understand the reasons behind the card placement on the grid. The researcher interpreted the meaning of the factors and discussed the interpretation in detail with co-authors and two independent Q methodologists for sense checking. --- | RESULTS A total of 13 WwLD, three family carers and five paid care workers took part . Ages ranged from 20 to 69 . A two-factor solution accounting for 46% of the variance and that explained the views of 19 participants was chosen . Two WwLD did not load significantly onto either factor and were classed as 'null loaders'. Their views indicate a different and unique viewpoint to others. Factor arrays are presented in Table 1 , with the polar ends of the factors shown in Figure 1. In the results that follow, statements will be identified in brackets by . T A B L E 1 Placement of each Q-set --- | Factor 1: Personal choice and ownership Factor 1 accounted for 28% of the total variance, with the Q-sorts of 11 WwLD and two paid care workers defining this factor. This factor highlights a narrative of personal choice and WwLD having ownership over their healthcare decision, including whether to attend cervical and breast cancer screening or not. 'I would feel more comfortable with a lady nurse, and not a man' . However, it should be noted that not everyone agreed with this; for instance, one WwLD highlighted she would prefer a man to complete the screening as her doctor is male and there was an element of trust. --- | Factor 2: Protecting versus enablement Factor 2 accounted for 18% of the total variance, with the Q-sorts of three family carers and three paid care workers loading heavily onto this factor. The protectiveness of family carers and paid care workers to support WwLD in deciding to attend cancer screening is clear. However, this protection goes hand in hand with enablement. Family carers and paid care workers discuss multiple methods that can support WwLD. They also highlighted how changing or amending their perceptions and beliefs could greatly support WwLD to make an informed decision to attend a screening or not. Participants that aligned to this factor perceived that WwLD need the support of paid care workers and family carers as well as nurses and doctors to support them in deciding to attend cervical and breast cancer screening or not. Specifically, WwLD rely on them to help and support them in being aware of cancer screening (3: +3). This emphasises the need for multiple parties to be involved in supporting WwLD; however, a family carer did highlight how there was a specific reliance on them as a family to support WwLD: 'once that letter comes it's just it's up to us to explain to them' . It was also noted the importance of healthcare professionals knowing about how to support and help WwLD: Because it comes up with every aspect of somebody WwLD decide to attend cancer screening or not and then feel supported throughout the screening process. --- | Items of consensus across Factors 1 and 2 Across both factors, there were eight consensus statements. The consensus statements will be identified in brackets by (statement number: ranking in Factor 1, ranking in Factor 2). All participants perceived that WwLD 'do not attend cancer screening because they are scared' ; 'need to know the symptoms of cancer' ; need to attend cervical cancer screening even when they are not sexually active ; are not 'asked about what can help them attend cancer screening' ; 'would like a female nurse to complete their screening' ; 'find screening painful' and do not 'know about what will happen in the screening appointment before they go' . Participants held a neutral perspective to the statement, WwLD 'speak to paid carers more than their family about their health' , indicating that WwLD will speak to either their family or paid carers, regarding their health. --- | Null loaders As mentioned previously, two participants were classed as 'null loaders'. This indicated that they may hold a different perspective to the WwLD, family carers and paid care workers who load onto one of the two factors. Due to this difference in perspective, the views of both participants were not included in the final factor analysis. Some key differences between these two participants' perspectives and that of the other participants were their preference for a male to do the screening --- | DISCUSSION This study aimed to understand the knowledge of, attitudes towards and decision-making around cervical and breast cancer screening in WwLD, family carers and paid carers. From completing a Q methodology study, two accounts were identified that reflect the attitudes and perspectives relating to WwLD accessing cervical and breast cancer screening. Factor 1 highlighted that WwLD should have ownership over their healthcare decisions, including whether to attend cervical and breast cancer screening or not and that this was their decision to make. NHS England them and how they can be supported to make their own decision to access cancer screening services can aid in the screening services becoming more person-centred and flexible , as opposed to being a 'one size fits all' system . This supports research, which also identified WwLD are fearful of the mammogram exam and find breast cancer screening painful as well as the pain attributed to the speculum and taking of cells during cervical cancer screening . However, other populations of women including women with physical disabilities and women of Black African origin . However, WwLD should be supported to make an informed decision to attend cancer screening or not, and their sexual status should not be considered as an eligibility criterion . Factor 2 highlighted the protectiveness of family carers and paid care workers to support WwLD to decide to attend cancer screening. Research by Willis highlighted that family and paid carers found it difficult to explain health problems and different tests that have been completed for the person. If this is the case, supporting WwLD understand screening and may not be easy for family and paid carers . In 2019/2020, 104,723 adults with learning disabilities were living in their own homes or with their families in England , and for those who do not live at home, various family members are typically involved in their lives and may provide care and support alongside paid carers ; this indicates the reliance and input family and paid carers could have in supporting WwLD. --- | Study limitations Viewpoints may not be generalisable, given the small sample and that the sample were White British. This may mean that the factors reported may not account for those of WwLD, family carers or paid carers from other cultures. In addition, only one male took part; therefore, the perspectives of males who are in relationships with WwLD or male carers are missing. --- | Clinical implications For WwLD to make an informed decision, and then be supported to access cervical and breast cancer screening, reasonable adjustments should be identified and implemented throughout the cancer screening pathway. Proactively identifying the needs of WwLD before the invitation to attend cervical and breast cancer screening can help implement adjustments based on the WwLD needs. However, this requires WwLD to be 'flagged' as having learning disabilities to the screening programmes, so adjustments can be made. For instance, offering a desensitisation appointment so the WwLD is familiar with the environment and equipment. Similarly, support for family carers and paid carers to ensure their perspectives are informed by evidence, rather than personal thoughts, so they can support WwLD before they are invited to screening. --- | CONCLUSIONS The findings from this study highlight multiple factors that may influence decision-making and subsequent uptake of WwLD to cervical and breast cancer screening. This included using easy-read documentation throughout the screening process and inviting WwLD to attend cancer screening, ensuring WwLD know the symptoms of cancer and ensuring carers are informed and supportive of WwLD decisions. Specific clinical implications have been identified, including offering reasonable adjustments throughout the cancer screening pathway from invitation through to receiving the results. --- DATA AVAILABILITY STATEMENT The data are available on request from the authors. --- ORCID --- Kate Sykes https://orcid.org/0000-0002-2942-7193 Grant J. McGeechan https://orcid.org/0000-0002-3994-8507 Emma L. Giles https://orcid.org/0000-0002-2166-3300 --- CONFLICT OF INTEREST None declared. --- SUPPORTING INFORMATION Additional supporting information can be found online in the Supporting Information section at the end of this article.

Objectives: To understand knowledge of, attitudes towards and decision-making around cervical and breast cancer screening in women with learning disabilities, family carers and paid carers. Methods: A Q methodology study involving 13 women with learning disabilities, three family carers and five paid care workers, from the North-East of England. A Q-sort of 28 statements was completed with all participants completing a post-Q-sort interview to understand the reason behind the card placements. Factor analysis was completed using PQMethod and interpreted using framework analysis. Results: Factor 1, named 'Personal choice and ownership', explores how women with learning disabilities want to be supported to make their own decision to attend cancer screening and explored their preferred support needs. Factor 2, named 'Protecting vs. enablement', portrayed the battle family carers and paid care workers felt to protect women with learning disabilities from harm, whilst feeling that they were supporting women with learning disabilities to decide to attend cancer screening. Eight consensus statements were identified indicating a shared perspective. Conclusions: Cancer screening services should ensure that women with learning disabilities are supported to make informed decisions to attend cancer screening and then be further supported throughout the cancer pathway.

uptake is vastly different when comparing people with learning disabilities and those without learning disabilities with the largest difference in uptake being for cervical and breast cancer screening research has highlighted multiple barriers to decisionmaking and access to cervical and breast cancer screening by women with learning disabilities including mobility issues communication difficulties fear and being embarrassed about going to screening family carer and paid care workers may lack understanding cancer and having poor health literacy even with these known barriers to cancer screening uptake remains consistently lower than the general population even with the acknowledgement of the range of barriers that wwld face in deciding to attend and then access cervical andor breast cancer screening there is a need to identify the most influential factors that can facilitate or hinder wwld research to date tends to involve wwld alone or their carers with very few accounting for all their perspectives in the same study the combined perspectives on factors that influence access can then be utilised to make recommendation for policy and cancer screening practice to limit the inequalities faced by wwld due to this this research aimed to further understand the range of knowledge attitudes towards and decisionmaking around cervical and breast cancer screening in wwld family carers and paid carers methods approval to complete a q methodology study was received from a university and the health research authority the following subsections explain the methods used to employ the q methodology study identifying a concourse and developing the qset a concourse consists of the range of possible opinions regarding the topic in question that can be written or spoken about a topic that can be contested and debated a concourse is usually identified through interviews focus groups and conducting literature reviews for this study the results of a systematic review were collated with reports and websites from this 128 statements were identified the concourse is then synthesised to develop a set of statements called a qset the qset aims to cover the full range of opinions in the concourse and tends to range from 20 to 100 statements the qset was developed through thematically clustering the concourse statements together based on if they had a similar meaning all authors were involved in this process based on this 28 statements were developed each qset statement started with women with a learning disability … to provide consistency and allowed the wwld to think about themselves or other wwld if they had not attended cancer screening previously specifying the participants participants were identified using purposive sampling of three nonnhs day centre providers an nhs foundation trust and a gp practice in the northeast of england gatekeepers in each location initially identified wwld as meeting a set of inclusion criteria one coauthor acted as a gatekeeper for one site and was the only author who had any involvement in identifying eligible participants the gatekeepers discussed the study with the wwld using an information sheet if wwld were interested in taking part they were either given the researchers details or their contact information was passed onto the researcher the wwld were also asked if they were happy for their family or paid care workers to be contacted to take part if so the wwld provided their details family carers and paid care workers were provided with information by the researcher or information was sent to the wwld to then pass on written informed consent was obtained from all participants administering the qsort and analysis the fourth step was to administer the qsort this is the process where participants rankorder the qset based on their preferences or feelings towards the qset statements the researcher was present during all data collection activities to complete the qsort a specific grid was developed the grid ranged from à4 to 4 with 28 spaces for each qset statement participants started by sorting the qset into three piles each pile was taken in turn and the cards were sorted onto the qgrid to indicate the participants level of agreement or disagreement with the card the sorting process was completed under a forcedchoice condition where participants were required to place a specific number of statements under each column of the qgrid this instruction can make the sorting process a more manageable conceptual task where participants can carefully consider all statements concerning each other however participants could place cards outside the predetermined grid structure if they strongly felt that the remaining spaces did not reflect their views following the qsort each participant completed a brief postqsort interview to explain their reasons for the card placement and to understand their experiences of screening all qsorts were audio recorded and transcribed by ks the final step was to analyse the qsorts and interpret the output the qsorts were input onto pqmethod the sorts were analysed using principal component analysis with varimax rotation this maximised the variance and provided the best mathematical solution or best fit the correlation matrix generated is subjected to the varimax rotation to optimise the separation between factors and clarified the factor structure a factor array was also produced which represents a mean qsort of the shared viewpoint of participants this can then be interpreted framework analysis was completed so the authors could interpret the factor arrays to complete the framework analysis a microsoft excel spreadsheet was developed the spreadsheet replicated the 4 3 à3 and à4 columns of the factor array quotes from the transcripts were identified to understand the reasons behind the card placement on the grid the researcher interpreted the meaning of the factors and discussed the interpretation in detail with coauthors and two independent q methodologists for sense checking results a total of 13 wwld three family carers and five paid care workers took part ages ranged from 20 to 69 a twofactor solution accounting for 46 of the variance and that explained the views of 19 participants was chosen two wwld did not load significantly onto either factor and were classed as null loaders their views indicate a different and unique viewpoint to others factor arrays are presented in table 1 with the polar ends of the factors shown in figure 1 in the results that follow statements will be identified in brackets by t a b l e 1 placement of each qset factor 1 personal choice and ownership factor 1 accounted for 28 of the total variance with the qsorts of 11 wwld and two paid care workers defining this factor this factor highlights a narrative of personal choice and wwld having ownership over their healthcare decision including whether to attend cervical and breast cancer screening or not i would feel more comfortable with a lady nurse and not a man however it should be noted that not everyone agreed with this for instance one wwld highlighted she would prefer a man to complete the screening as her doctor is male and there was an element of trust factor 2 protecting versus enablement factor 2 accounted for 18 of the total variance with the qsorts of three family carers and three paid care workers loading heavily onto this factor the protectiveness of family carers and paid care workers to support wwld in deciding to attend cancer screening is clear however this protection goes hand in hand with enablement family carers and paid care workers discuss multiple methods that can support wwld they also highlighted how changing or amending their perceptions and beliefs could greatly support wwld to make an informed decision to attend a screening or not participants that aligned to this factor perceived that wwld need the support of paid care workers and family carers as well as nurses and doctors to support them in deciding to attend cervical and breast cancer screening or not specifically wwld rely on them to help and support them in being aware of cancer screening 3 3 this emphasises the need for multiple parties to be involved in supporting wwld however a family carer did highlight how there was a specific reliance on them as a family to support wwld once that letter comes its just its up to us to explain to them it was also noted the importance of healthcare professionals knowing about how to support and help wwld because it comes up with every aspect of somebody wwld decide to attend cancer screening or not and then feel supported throughout the screening process items of consensus across factors 1 and 2 across both factors there were eight consensus statements the consensus statements will be identified in brackets by statement number ranking in factor 1 ranking in factor 2 all participants perceived that wwld do not attend cancer screening because they are scared need to know the symptoms of cancer need to attend cervical cancer screening even when they are not sexually active are not asked about what can help them attend cancer screening would like a female nurse to complete their screening find screening painful and do not know about what will happen in the screening appointment before they go participants held a neutral perspective to the statement wwld speak to paid carers more than their family about their health indicating that wwld will speak to either their family or paid carers regarding their health null loaders as mentioned previously two participants were classed as null loaders this indicated that they may hold a different perspective to the wwld family carers and paid care workers who load onto one of the two factors due to this difference in perspective the views of both participants were not included in the final factor analysis some key differences between these two participants perspectives and that of the other participants were their preference for a male to do the screening discussion this study aimed to understand the knowledge of attitudes towards and decisionmaking around cervical and breast cancer screening in wwld family carers and paid carers from completing a q methodology study two accounts were identified that reflect the attitudes and perspectives relating to wwld accessing cervical and breast cancer screening factor 1 highlighted that wwld should have ownership over their healthcare decisions including whether to attend cervical and breast cancer screening or not and that this was their decision to make nhs england them and how they can be supported to make their own decision to access cancer screening services can aid in the screening services becoming more personcentred and flexible as opposed to being a one size fits all system this supports research which also identified wwld are fearful of the mammogram exam and find breast cancer screening painful as well as the pain attributed to the speculum and taking of cells during cervical cancer screening however other populations of women including women with physical disabilities and women of black african origin however wwld should be supported to make an informed decision to attend cancer screening or not and their sexual status should not be considered as an eligibility criterion factor 2 highlighted the protectiveness of family carers and paid care workers to support wwld to decide to attend cancer screening research by willis highlighted that family and paid carers found it difficult to explain health problems and different tests that have been completed for the person if this is the case supporting wwld understand screening and may not be easy for family and paid carers in 20192020 104723 adults with learning disabilities were living in their own homes or with their families in england and for those who do not live at home various family members are typically involved in their lives and may provide care and support alongside paid carers this indicates the reliance and input family and paid carers could have in supporting wwld study limitations viewpoints may not be generalisable given the small sample and that the sample were white british this may mean that the factors reported may not account for those of wwld family carers or paid carers from other cultures in addition only one male took part therefore the perspectives of males who are in relationships with wwld or male carers are missing clinical implications for wwld to make an informed decision and then be supported to access cervical and breast cancer screening reasonable adjustments should be identified and implemented throughout the cancer screening pathway proactively identifying the needs of wwld before the invitation to attend cervical and breast cancer screening can help implement adjustments based on the wwld needs however this requires wwld to be flagged as having learning disabilities to the screening programmes so adjustments can be made for instance offering a desensitisation appointment so the wwld is familiar with the environment and equipment similarly support for family carers and paid carers to ensure their perspectives are informed by evidence rather than personal thoughts so they can support wwld before they are invited to screening conclusions the findings from this study highlight multiple factors that may influence decisionmaking and subsequent uptake of wwld to cervical and breast cancer screening this included using easyread documentation throughout the screening process and inviting wwld to attend cancer screening ensuring wwld know the symptoms of cancer and ensuring carers are informed and supportive of wwld decisions specific clinical implications have been identified including offering reasonable adjustments throughout the cancer screening pathway from invitation through to receiving the results data availability statement the data are available on request from the authors orcid kate sykes grant j mcgeechan emma l giles conflict of interest none declared supporting information additional supporting information can be found online in the supporting information section at the end of this article

objectives to understand knowledge of attitudes towards and decisionmaking around cervical and breast cancer screening in women with learning disabilities family carers and paid carers methods a q methodology study involving 13 women with learning disabilities three family carers and five paid care workers from the northeast of england a qsort of 28 statements was completed with all participants completing a postqsort interview to understand the reason behind the card placements factor analysis was completed using pqmethod and interpreted using framework analysis results factor 1 named personal choice and ownership explores how women with learning disabilities want to be supported to make their own decision to attend cancer screening and explored their preferred support needs factor 2 named protecting vs enablement portrayed the battle family carers and paid care workers felt to protect women with learning disabilities from harm whilst feeling that they were supporting women with learning disabilities to decide to attend cancer screening eight consensus statements were identified indicating a shared perspective conclusions cancer screening services should ensure that women with learning disabilities are supported to make informed decisions to attend cancer screening and then be further supported throughout the cancer pathway

Introduction Food is a part and necessity of every person's daily life [1]. Therefore, from a health and policy point of view, it is necessary to investigate what people eat and their opinions about individual foods. Unhealthy eating is a problem in many countries [2,3], and if national governments need to develop action programs to promote healthy eating, a thorough understanding of consumer attitudes, experiences, and behaviors regarding healthy foods is needed. One way to obtain such information is through social media analysis [4]. Social media is now a part of many individuals' everyday lives. Increasingly, users spend more time on these platforms, and create active and passive digital footprints through their interactions with other platform users [5]. These data have a strong research potential in many areas, especially considering that understanding people's communication on social media is essential for understanding their attitudes, experiences, behaviors, and values [6,7]. In the field of food, studies have already analyzed social network data in the context of farmers' markets [8], organic food [9], undergraduate students' food choices [10], food sharing [11], and food security [12]. At present, social networks are used by around 3.6 billion people worldwide, and it has been predicted that more than 4.41 billion people will use social networks in 2025 [13]. When comparing this predicted number of social network users with the predicted global population for 2025 [14], this indicates that approximately 54% of the planet's population will use social networks by 2025. This is therefore a pertinent source of data with the potential to increase both the number of users and shared content. The aims of this study as to identify the main topic associated with healthy food on the Twitter social network. --- Theoretical Background The increase in the number of people with obesity is a global trend [15][16][17]. Many studies have underlined the association between obesity and health problems, such as cardiovascular disease [18,19], metabolic diseases [20,21], cancer [22,23], and a higher risk of severe COVID-19 [24][25][26][27]. Although obesity has been considered as primarily a problem in Western countries, urbanization is setting the stage for an obesity epidemic in Asia [28][29][30], in some African countries such as Sudan [31], and in India [32], and is thus becoming a global problem [16,33]. Food environments and dietary patterns are closely linked to obesity [34], and food is also reflected in our way of life, culture, and well-being. For these reasons, there is now a significant interest in public health [1]. Healthy foods are an important determinant of good health [35,36], while unhealthy eating can lead to significant health risks [37][38][39]. Understanding the factors that influence the food choices and eating behaviors of consumers is essential for tackling this issue [40]. Previous studies have revealed that customers' food selection process is greatly influenced by their social environment, including friends and the shopping environment [41][42][43][44][45]. Furthermore, two key studies reported that social networks have an important impact on consumers' shopping behavior [45,46]. Social networks have now become environments in which users can independently create and share content. By 2025, a predicted 4.41 billion people will use social networks [13], which is half the global population. Since young adults have widely adopted social media, health researchers are looking for ways to leverage this engagement with social media to deliver interventions and health promotion campaigns [46]. The global problem with obesity and healthy problems are so central reasons why many studies focus on the use of social networks and health issues [47]. because, social media has the potential to exchange information related to healthy behaviors [48,49]. Based on the above analysis of communication on social networks about the subject of food could help us to gain a deeper understanding of consumer behaviors and attitudes [50] when it comes to healthy food. --- Social Media and Food Behavior Social media can influence consumer behavior, such as choosing food and shopping behavior, which has been shown in following studies. Fleming-Milici and Harris [51] identified adolescents' social media engagement with food/beverage brands. Simeon and Scarpato [52] reported the negative effects of gathering information on social networks, which tend to homogenize consumption and decrease consumers' sustainability awareness. Social networks can be searched for recipes [53] and information on diets [54], and can be a good source of dietary information, such as food reviews [52] or advice for feeding young children [55]. Thus, social media can influence what food consumers buy and eat [53,56], and can be used as a policy measure to improve food literacy [57,58], and encourage healthy eating and a healthier lifestyle in general [10]. Indeed, some studies have investigated how social media can be used to promote health issues, such as nutrition interventions for adolescents and young adults [59] or health issues during the Covid-19 pandemic [60]. --- Social Media Analysis Social networks and social media are highly interrelated concepts. An example is the Twitter platform, which is a social medium that is built on users' social networks. On the Twitter platform, users create messages called "tweets". The tweet can have a maximum of 280 characters . In order for Twitter to function as a social medium, where content will be shared by millions of users, it is first necessary to create this network of users through their mutual relations, which is the essence of the social network. Two basic areas of research are used in area of social media, as follows: social network analysis is the process of examining social structures using network theory and graph theory [61]. Social network analysis represents a network of people as graphs and examines their connections. The nodes in this network represent people, and the edges connecting the two nodes represent the relationships between them [62]-for example, who has the most friends, who people follow the most or segmentation of users, on the basis of their political affiliation [63,64]; and social media analysis, the goal of social media analysis is to monitor, analyze, and represent data from social media that offer useful information on patterns of behavior [65]. For example extracting human feelings through the unstructured text-sentiment analysis [66], or analyzing what people write in relation to a particular event [67]. When analyzing data from social media, we can focus on analyzing the structure of users of a platform using social network analysis , or on analyzing the content of the communication using social media analysis . Social media analysis thus helps us to gain deeper insights into social, cultural, and environmental issues [50]. Data from the social network Twitter have shown to be a suitable source of knowledge about food-related consumer behaviors [68][69][70]. These data can provide scientists with a vast amount of information on individuals' opinions, moods, activities [71], and experiences [72]. --- Materials and Methods The data analysis was based on the Knowledge Discovery in Databases process [73], and was modified to the requirements of social media data analysis with a focus on hashtags . The hashtag is a specific part of the message text that begins with a "#" character. In social media, the hashtag has two primary functions, firstly to filter posts, where the algorithms of social networks display an archive of messages related to this hashtag based on a specific hashtag [74]. The second function of hashtags is the possibility to express experience, attitudes, opinions, and values via social media [6,7,75,76], in areas that the user wants to emphasize on social networks. For example, emphasize that the food I put on social media is vegan through the hashtag #vegan. This procedure has already been used in research focusing on farmers' markets [8], organic foods [9], sustainability [77], gamification [78], and corporate social responsibility [79]. The data analysis process consisted of five steps, as follows: 1. The Twitter API [80] was used to obtain messages from communications on the social network Twitter. The data were recorded between 1 January 2019 and 31 December 2020. The software captured messages that used the hashtag #healthyfood. During that period, 666,178 Tweets of 168,134 unique users were captured. This dataset contains all messages that contained the hashtag #healhtyfood in the monitored period, which users sent to the Twitter social network. --- 2. Content filtration: As our analysis only focused on hashtags, all words that were not preceded by the hashtag symbol were removed. This led to a dataset that consisted purely of hashtags . --- 3. Content transformation: Subsequently, all letters were transformed into lower-case letters to prevent potential duplicates . A further correction was made to break up strings of connected hashtags, e.g., "#vegan#organic" was converted to "#vegan; #organic". The dataset was imported into Gephi 0.9.2, where a hashtag network was created based on hashtag interdependence . Gephi is an open-source leading visualization and exploration software for graphs and networks [81]. To use social network analysis methods, it was necessary to create a network of hashtags based on the rule: Nodes = Hashtags and Edges = their representation in one report. For example-Message: "I love homemade cooking #healthyfood #homemade #cooking" 3 Nodes are inserted into the graph and edges are created between these hashtags -see Figure 2. If the following message contains the text: "These cookies are wonderful, if you want, I can share my #healthyfood #recipe to you", the hashtag #recipe will be inserted into the graph, which will be connected only with the hashtag #healthyfood, which already in the chart exists from the last report. For the #healthyfood hashtag, the frequency value changes from 1 to 2. --- 1. Hashtag reduction: To detect communities is necessary to process a hashtag reduction that removes micro-communities. A large number of micro-communities is caused by an extensive number of hashtags that contain local hashtags, for example, farmers' markets in the Czech Republic-Prague Dejvice-#farmersmarketpraguedejvice #applefromfarmersmarketpraguedejvice or hashtags created by the users themselves #nameandsurname. --- 2. Data mining: The following methods were used to describe the network: Frequency: The frequency is a value that expresses the hashtag frequency within a network. Eigenvector centrality: This is an extension of degree centrality, which measures the influence of hashtags in a network. The value is calculated based on the premise that connections to hashtags with high values have a greater influence than links with hashtags of similar or lower values. A high eigenvector centrality score means that a hashtag is connected to many hashtags with a high value, and was calculated as follows: x v = 1 λ ∑ t∈M x t = 1 λ ∑ t∈G a v,t x t where M denotes a set of adjacent nodes, and λ is a largest eigen value. Eigenvector x can be expressed by Equation , as follows: Ax = λx This value was used to identify important hashtags for community analysis . Modularity and community analysis: The most complex networks contain nodes that are mutually interconnected to a larger extent than they are connected to the rest of the network. Groups of such nodes are called communities [82]. Modularity represents an index that identifies the cohesion of communities within a given network [83]. The idea is to identify node communities that are mutually interconnected to a greater degree than other nodes. Networks with high modularity show strong links between nodes inside modules but weaker links between nodes in different modules [84]. The component analysis then identifies the number of different components in the network based on the modularity detection analysis [85], as follows: ∆Q = ∑ in +2k i,in 2m - ∑ tot +k i 2m 2 - ∑ in 2m - ∑ tot 2m 2 (3 ) where ∑in is the sum of weighted links inside the community, ∑tot is the sum of weighted links incident to hashtags in a community, k i is the sum of weighted links incident to hashtag i, k i,in is the sum of weighted links going from i to hashtags in a community, and m normalizing factor is the sum of weighted links for the whole graph. Visualization of the network: The goal of network visualization is to identify individual communities and their mutually position. After importing the data into the Gephi program, the visualization of the network is concentrated in the basic square without visualizing the different relationships between individual hashtags. This visualization is unsatisfactory in terms of identifying communities and their mutual positions, but does not affect the analysis of hashtag-level and network-wide characteristics. In the field of visualization, it is possible to use the ForceAtlas2 algorithm. ForceAtlas2 is an improved version of the ForceAtlas algorithm, which focuses on large networks. This method is based on the visual representation of reduced samples to define network communities and their types [86]. The advantage over ForceAtlas is its speed and ease of computing. The ideal number of hashtags is 10,000-100,000 [26]. --- Results and Discussion First, a basic analysis was performed based on the frequency of occurrence of individual hashtags in 2019 and 2020 . The analysis of the top 15 hashtags revealed that the frequency of the use of all hashtags except #recipe increased from 2019 to 2020 . A basic analysis of the frequency of the use of individual hashtags in 2020 revealed that the hashtag #healthylifestyle was the most used hashtag in connection with the hashtag #healthyfood. According to Bektas et al. [87], healthy eating is one of the dimensions of a healthy lifestyle, as is nutrition and physical activity. This hashtag was also very often used in conjunction with the hashtag #healthyfood in 2020 and was thus the 5th most used hashtag. A weight loss area has also been identified in connection with healthy food-the #weightloss hashtag and #diet . This area may be associated with obesity. The study by Karami et al. [88] focused on analyzing the characteristics of the general public's opinions regarding understanding public health opinions on social media as expressed on Twitter, which showed a notable correlation between diet and obesity was determined. As we mentioned in the introduction, obesity is a worldwide problem [15][16][17], and there is an association between obesity and health problems [21,22,27]. Weight loss is considered to be the cornerstone of treatment for obese people [89,90]. Here it is important to draw attention to the perception of oneself on social networks [91]. Thus, weight loss may not be associated with obesity but may be connected with the need to get a figure in the underweight area [92]. For this reason, it is advisable to analyze the area separately with a focus on the #weightloss area. Other important hashtags used in connection with #healthyfood were #vegan and #vegetarian . This connection confirms many previous studies that have identified health-related reasons as one of the main motivations for following both a vegan diet [93][94][95] and a vegetarian diet [96,97]. Other categories of hashtags that were often used in connection with the #healthyfood hashtag in 2020 were #recipe , #cooking , and #homemade . The high frequency of these hashtags may be related to the lifestyle changes caused by governmentally mandated lockdowns in 2020 that led to people being forced to cook a significant proportion of their food at home [98,99]. Many parents had to provide home-based meals for their children and, according to a study by Phlippe et al. [100], many parents observed changes in diet; for example, boredom led to increased consumption and emotional overeating. Laguna et al. [98] also identified changes in food purchases during the 2020 lockdown, whereby consumers bought more fruits and vegetables and fewer pastries and desserts for health reasons. This can be related to the frequent use of the hashtag #recipe , as people often search for and share recipes on the social networks [53]. The most common hashtags used in connection with the hashtag #healthyfood were #vegan , #homemade , and #organic . --- Community Analysis The community analysis extrapolated the following five communities: Active lifestyle, Influencer, Diets, Recipes, and Health problems . The largest community was that focused on an "Active lifestyle". This community contained hashtags that were associated with areas such as healthy lifestyle, fitness, healthy living, nutrition, healthy eating, wellness, and lifestyle. The second-largest community was the "Influencer" community, in which people shared foods they considered healthy. This community contained hashtags such as #foodporn, #delicious, #yummy, and #foodlover. Hashtags focused on homemade, cooking, and food blogger are likely to be related to food cooked and shared with other people via Twitter, and these users can be considered as food bloggers . Influencer marketing is built on building trust between the influencer and the follower, to whom the influencer then passes on their knowledge, experience, attitudes, opinions, and values via social media [4,7,75,76]. The smaller third community was focused on "Diets", which included areas such as vegan, organic, vegetarian, plant-based, gluten-free, sugar-free, wholefood, and clean eating. The field of organic food was separately analyzed in the previous research [9], which identified a high connection in the communication of organic food with healthy food and vegan food. For the whole diet community, it is necessary to draw attention to its high connection in the active lifestyle, see Figure 3, which again leads to the question of the extent to which people consider vegan a diet in terms of the absence of certain foods and to what extent vegan in terms of lifestyle. The last, very small community is the community focused on "Health problems", which included areas such as high blood pressure, blood pressure, hypertension, and diabetes. As already mentioned, healthy food affects health [35], including the issues mentioned in this community, such as diabetes [101] and hypertension [102]. The frequent use of social media to address health problems has also been confirmed by Korda and Itani [103]. --- Visual Analysis Visualization of the network was performed to gain an insight into the polarity of individual communities. The value of modularity was low , which means that hashtags were interconnected both within communities and between communities. As seen in Figure 2, the "Diets" community was more closely linked to the "Active lifestyle" community than to the "Influencer" community. The community with a focus on "Recipes" was relatively evenly distributed among all communities, except for the "Health problems" community, which was relatively isolated from the other communities. In terms of food characteristics, the most commonly used hashtag in connection with the hashtag #healthyfood was #vegan, which refers to the vegan diet. Vegans eat no animal products, while vegetarians do not eat animals [104]. As mentioned in the theoretical background, previous studies have shown that vegan and vegetarian diets are expanding societal phenomena, particularly in Western developed countries [105,106]. Previous work has shown that the number of consumers who lean toward vegan and vegetarian diets continues to grow [107]; moreover, veganism has exhibited a greater increase in a shorter time period [108]. According to one study [109], veganism is not only a diet, but also a lifestyle; veganism can be considered as a broader involvement in cognitive and behavioral aspects of social worlds. Following this, further studies should also directly focus an analysis on the area of #healthylifestyle and #healthyliving. A comparison of the results from healthy living and healthy lifestyle area would provide important information about the relationship between healthy food and lifestyle. When comparing the time evolution of hashtags in both studies, it could be defined by how lifestyle affects healthy eating. It is thus a matter of opinion as to whether veganism is considered as a "diet", which is the position of Lemale [110] and Lederer [111], or as a lifestyle, as it has been described by Costa [109]. --- Study Limitations Finally, some limitations of our study deserve attention. First of all, like other social media analyses, this study focuses only on one social network [8,9,68,77,78,112] and on English keywords. Twitter is specific to a maximum message limit of 280 characters and also focuses on text. Instagram, on the other hand, is limited to 2200 characters, which can provide other information. Second, this study did not deal with the geolocation of sending messages. In the following studies, it would be appropriate to focus on the use of geolocation in the report to obtain other important conclusions. This limitation results in the impossibility of verifying the proportionality of the representation of individual regions in the data set. Third, the study analyzes the current situation and does not deal with predictions for the future. In our future research, we will focus on using artificial intelligence to predict trends in social network communication. --- Future Research The results of this study opened many important questions for further research through both quantitative and qualitative methods. The present research identified main values/characteristics, that Twitter users express in the healthy food area through hashtags. In future research, it will be necessary to focus on these identified areas: healthy lifestyle, vegan, vegetarian, plant-based, gluten-free, sugarfree, wholefood, and clean eating. Since the healthy food issue is a very complex area, it will be appropriate to focus research on both the analysis of individual areas separately and the analysis of their interconnectedness. To broaden our understanding of the healthy food area, it is also necessary for researchers to focus on other social networks, such as Instagram, TikTok, Yandex, and Facebook. These results may be important for understanding the common areas that connect the individual characteristics. These interfaces are important for media communication and understanding of the common values of social network users in the monitored area. Like other studies [7,8,64,70,71,102], these results are analyzed from a global perspective. In the following research, it would be useful to find out whether regional differences in food perception can be found, or whether differences can be found, for example, between Europe and the US, or whether it is possible to create new regional segmentation, based segmentation of users with the reverse assignment of location. In other words, as Khokhar and Serajuddin [113] points out that categorization by developed and developing countries, for example, is obsolete. Subsequent research could create a map of perceptions of individual food characteristics across regions. Another important area identified by this study is the connection between healthy food and healthy lifestyle . Based on this, further studies can focus on vegan, vegetarian, or gluten-free areas and focus on understanding whether these areas are considered by people to be "more healthy food", such as [9], or it is a way of life that is not only based on one's own health, but also on the protection of nature and animals, where people avoid the use of animals in any context, including food, clothing, sport, and entertainment [114]. This understanding is important both in terms of marketing communication of product manufacturers and in understanding these trends on social networks in the field of healthy food. A weight loss area has also been identified in connection with healthy food, which may or may not be associated with obesity. Here it is important to draw attention to the perception of oneself on social networks [115]. Thus, weight loss may not be associated with obesity but may be connected with the need to get a figure in the underweight area [91]. For this reason, it is advisable to analyze the area separately with a focus on the #weightloss area. --- Conclusions Consumer behavior is a dynamic system, whereby consumers interact with producers, farmers, traders, retailers, industries, governments, and a series of other actors [92], and must, therefore, be monitored in terms of understanding people's perceptions and identifying the current situation. Social media, which is used by more people every year, has substantial research potential for basic quantitative analyses, which can be followed up by qualitative research. The present study identified new research questions and fundamental information that could be used as a basis for the following analysis in the field of Public Health and Policy. We found that the #healthylifestyle and #healthyliving hashtags were the most commonly used hashtags in conjunction with the #healthyfood hashtag. This is an important finding that identifies that people on social networks connect food with lifestyle, which is not just about nutrition, but about the way a person lives. The "Influencer" community, with a focus on influencer marketing, was the secondlargest community in the present study. Influencer marketing has a large impact on customer behavior [116]. Influencer marketing is built on building trust between the influencer and the follower, to whom the influencer passes on their knowledge, experience, attitudes, opinions, and values via social media [4,7,75,76]. As this was identified as the second-largest community, people interested in the area of healthy food may be strongly influenced by influencers. Based on the analysis of the social network Twitter, with a focus on healthy food through the hashtag #healthyfood, the three basic characteristics of food that were most communicated in 2020 were vegan, homemade, and organic. This is an important finding because it indicates how social network users perceive healthy food. These results confirm previous research [117][118][119] that has reported that people perceive vegan food, organic food, and homemade food as the healthiest types of food. Another important finding is the identification of a t difference in the use of the vegan hashtag , which expresses the rejection of the use of animal products, and vegetarian , which expresses only the rejection of eating animals [104]. Another characteristic associated with healthy food was organic. This is a continuously growing trend, which confirms previous studies [120,121]. According to an analysis of the social network Instagram [9], #organicfood is most often associated with the hashtag #organic and, subsequently, with the hashtag #healthyfood. Organic is an important characteristic of food that users communicate on social networks. To summarize, we found that users most commonly associate healthy food with a healthy lifestyle, fitness, nutrition and diet. Foods associated with this hashtag were vegan, homemade, and organic. The community analysis extrapolated the following five communities: Active lifestyle, Influencer, Diets, Recipes, and Health problems. Based on these results, it is possible to identify lifestyle as an important element in the field of healthy eating. In the following studies, it is necessary to focus separately on individual topics that have been identified as the most commonly associated with healthy food and to make a comparison within other social networks like Facebook, Instagram, and TikTok. --- Data Availability Statement: All data used in this study can be downloaded via the Twitter API [80]. --- --- Author Contributions: Conceptualization: L.K.S. and L.P.; methodology: L.P.; validation: L.K.S.; formal analysis: L.K.S. and L.P.; resources: L.P.; data curation: L.P.; writing-original draft preparation: L.K.S.; writing-review and editing: R.K. and L.P.; project administration: L.P. and R.K. All authors have read and agreed to the published version of the manuscript. Funding: This study was supported by the Internal Grant Agency of FEM CULS in Prague, registration no. 2020B0004-Use of artificial intelligence to predict communication on social networks. Institutional Review Board Statement: Ethical review and approval are not required in this study because the information-gathering process focused on tweets and personal information were excluded via data collection. Username was coded to unique ID for identification of a number of users, but no identifiable private information was collected, following the ethical guidelines and definitions of "studies that are not human subjects research". Informed Consent Statement: Not applicable.

Online social networks have become an everyday aspect of many people's lives. Users spend more and more time on these platforms and, through their interactions on social media platforms, they create active and passive digital footprints. These data have a strong potential in many research areas; indeed, understanding people's communication on social media is essential for understanding their attitudes, experiences, behaviors and values. Researchers have found that the use of social networking sites impacts eating behavior; thus, analyzing social network data is important for understanding the meaning behind expressions used in the context of healthy food. This study performed a communication analysis of data from the social network Twitter, which included 666,178 messages posted by 168,134 individual users. These data comprised all tweets that used the #healthyfood hashtag between 2019 and 2020 on Twitter. The results revealed that users most commonly associate healthy food with a healthy lifestyle, diet, and fitness. Foods associated with this hashtag were vegan, homemade, and organic. Given that people change their behavior according to other people's behavior on social networks, these data could be used to identify current and future associations with current and future perceptions of healthy food characteristics.

introduction food is a part and necessity of every persons daily life 1 therefore from a health and policy point of view it is necessary to investigate what people eat and their opinions about individual foods unhealthy eating is a problem in many countries 23 and if national governments need to develop action programs to promote healthy eating a thorough understanding of consumer attitudes experiences and behaviors regarding healthy foods is needed one way to obtain such information is through social media analysis 4 social media is now a part of many individuals everyday lives increasingly users spend more time on these platforms and create active and passive digital footprints through their interactions with other platform users 5 these data have a strong research potential in many areas especially considering that understanding peoples communication on social media is essential for understanding their attitudes experiences behaviors and values 67 in the field of food studies have already analyzed social network data in the context of farmers markets 8 organic food 9 undergraduate students food choices 10 food sharing 11 and food security 12 at present social networks are used by around 36 billion people worldwide and it has been predicted that more than 441 billion people will use social networks in 2025 13 when comparing this predicted number of social network users with the predicted global population for 2025 14 this indicates that approximately 54 of the planets population will use social networks by 2025 this is therefore a pertinent source of data with the potential to increase both the number of users and shared content the aims of this study as to identify the main topic associated with healthy food on the twitter social network theoretical background the increase in the number of people with obesity is a global trend 15 16 17 many studies have underlined the association between obesity and health problems such as cardiovascular disease 1819 metabolic diseases 2021 cancer 2223 and a higher risk of severe covid19 24 25 26 27 although obesity has been considered as primarily a problem in western countries urbanization is setting the stage for an obesity epidemic in asia 28 29 30 in some african countries such as sudan 31 and in india 32 and is thus becoming a global problem 1633 food environments and dietary patterns are closely linked to obesity 34 and food is also reflected in our way of life culture and wellbeing for these reasons there is now a significant interest in public health 1 healthy foods are an important determinant of good health 3536 while unhealthy eating can lead to significant health risks 37 38 39 understanding the factors that influence the food choices and eating behaviors of consumers is essential for tackling this issue 40 previous studies have revealed that customers food selection process is greatly influenced by their social environment including friends and the shopping environment 41 42 43 44 45 furthermore two key studies reported that social networks have an important impact on consumers shopping behavior 4546 social networks have now become environments in which users can independently create and share content by 2025 a predicted 441 billion people will use social networks 13 which is half the global population since young adults have widely adopted social media health researchers are looking for ways to leverage this engagement with social media to deliver interventions and health promotion campaigns 46 the global problem with obesity and healthy problems are so central reasons why many studies focus on the use of social networks and health issues 47 because social media has the potential to exchange information related to healthy behaviors 4849 based on the above analysis of communication on social networks about the subject of food could help us to gain a deeper understanding of consumer behaviors and attitudes 50 when it comes to healthy food social media and food behavior social media can influence consumer behavior such as choosing food and shopping behavior which has been shown in following studies flemingmilici and harris 51 identified adolescents social media engagement with foodbeverage brands simeon and scarpato 52 reported the negative effects of gathering information on social networks which tend to homogenize consumption and decrease consumers sustainability awareness social networks can be searched for recipes 53 and information on diets 54 and can be a good source of dietary information such as food reviews 52 or advice for feeding young children 55 thus social media can influence what food consumers buy and eat 5356 and can be used as a policy measure to improve food literacy 5758 and encourage healthy eating and a healthier lifestyle in general 10 indeed some studies have investigated how social media can be used to promote health issues such as nutrition interventions for adolescents and young adults 59 or health issues during the covid19 pandemic 60 social media analysis social networks and social media are highly interrelated concepts an example is the twitter platform which is a social medium that is built on users social networks on the twitter platform users create messages called tweets the tweet can have a maximum of 280 characters in order for twitter to function as a social medium where content will be shared by millions of users it is first necessary to create this network of users through their mutual relations which is the essence of the social network two basic areas of research are used in area of social media as follows social network analysis is the process of examining social structures using network theory and graph theory 61 social network analysis represents a network of people as graphs and examines their connections the nodes in this network represent people and the edges connecting the two nodes represent the relationships between them 62 for example who has the most friends who people follow the most or segmentation of users on the basis of their political affiliation 6364 and social media analysis the goal of social media analysis is to monitor analyze and represent data from social media that offer useful information on patterns of behavior 65 for example extracting human feelings through the unstructured textsentiment analysis 66 or analyzing what people write in relation to a particular event 67 when analyzing data from social media we can focus on analyzing the structure of users of a platform using social network analysis or on analyzing the content of the communication using social media analysis social media analysis thus helps us to gain deeper insights into social cultural and environmental issues 50 data from the social network twitter have shown to be a suitable source of knowledge about foodrelated consumer behaviors 68 69 70 these data can provide scientists with a vast amount of information on individuals opinions moods activities 71 and experiences 72 materials and methods the data analysis was based on the knowledge discovery in databases process 73 and was modified to the requirements of social media data analysis with a focus on hashtags the hashtag is a specific part of the message text that begins with a character in social media the hashtag has two primary functions firstly to filter posts where the algorithms of social networks display an archive of messages related to this hashtag based on a specific hashtag 74 the second function of hashtags is the possibility to express experience attitudes opinions and values via social media 677576 in areas that the user wants to emphasize on social networks for example emphasize that the food i put on social media is vegan through the hashtag vegan this procedure has already been used in research focusing on farmers markets 8 organic foods 9 sustainability 77 gamification 78 and corporate social responsibility 79 the data analysis process consisted of five steps as follows 1 the twitter api 80 was used to obtain messages from communications on the social network twitter the data were recorded between 1 january 2019 and 31 december 2020 the software captured messages that used the hashtag healthyfood during that period 666178 tweets of 168134 unique users were captured this dataset contains all messages that contained the hashtag healhtyfood in the monitored period which users sent to the twitter social network 2 content filtration as our analysis only focused on hashtags all words that were not preceded by the hashtag symbol were removed this led to a dataset that consisted purely of hashtags 3 content transformation subsequently all letters were transformed into lowercase letters to prevent potential duplicates a further correction was made to break up strings of connected hashtags eg vegan organic was converted to vegan organic the dataset was imported into gephi 092 where a hashtag network was created based on hashtag interdependence gephi is an opensource leading visualization and exploration software for graphs and networks 81 to use social network analysis methods it was necessary to create a network of hashtags based on the rule nodes hashtags and edges their representation in one report for examplemessage i love homemade cooking healthyfood homemade cooking 3 nodes are inserted into the graph and edges are created between these hashtags see figure 2 if the following message contains the text these cookies are wonderful if you want i can share my healthyfood recipe to you the hashtag recipe will be inserted into the graph which will be connected only with the hashtag healthyfood which already in the chart exists from the last report for the healthyfood hashtag the frequency value changes from 1 to 2 1 hashtag reduction to detect communities is necessary to process a hashtag reduction that removes microcommunities a large number of microcommunities is caused by an extensive number of hashtags that contain local hashtags for example farmers markets in the czech republicprague dejvice farmersmarketpraguedejvice applefromfarmersmarketpraguedejvice or hashtags created by the users themselves nameandsurname 2 data mining the following methods were used to describe the network frequency the frequency is a value that expresses the hashtag frequency within a network eigenvector centrality this is an extension of degree centrality which measures the influence of hashtags in a network the value is calculated based on the premise that connections to hashtags with high values have a greater influence than links with hashtags of similar or lower values a high eigenvector centrality score means that a hashtag is connected to many hashtags with a high value and was calculated as follows x v 1 λ ∑ t∈m x t 1 λ ∑ t∈g a vt x t where m denotes a set of adjacent nodes and λ is a largest eigen value eigenvector x can be expressed by equation as follows ax λx this value was used to identify important hashtags for community analysis modularity and community analysis the most complex networks contain nodes that are mutually interconnected to a larger extent than they are connected to the rest of the network groups of such nodes are called communities 82 modularity represents an index that identifies the cohesion of communities within a given network 83 the idea is to identify node communities that are mutually interconnected to a greater degree than other nodes networks with high modularity show strong links between nodes inside modules but weaker links between nodes in different modules 84 the component analysis then identifies the number of different components in the network based on the modularity detection analysis 85 as follows ∆q ∑ in 2k iin 2m ∑ tot k i 2m 2 ∑ in 2m ∑ tot 2m 2 3 where ∑in is the sum of weighted links inside the community ∑tot is the sum of weighted links incident to hashtags in a community k i is the sum of weighted links incident to hashtag i k iin is the sum of weighted links going from i to hashtags in a community and m normalizing factor is the sum of weighted links for the whole graph visualization of the network the goal of network visualization is to identify individual communities and their mutually position after importing the data into the gephi program the visualization of the network is concentrated in the basic square without visualizing the different relationships between individual hashtags this visualization is unsatisfactory in terms of identifying communities and their mutual positions but does not affect the analysis of hashtaglevel and networkwide characteristics in the field of visualization it is possible to use the forceatlas2 algorithm forceatlas2 is an improved version of the forceatlas algorithm which focuses on large networks this method is based on the visual representation of reduced samples to define network communities and their types 86 the advantage over forceatlas is its speed and ease of computing the ideal number of hashtags is 10000100000 26 results and discussion first a basic analysis was performed based on the frequency of occurrence of individual hashtags in 2019 and 2020 the analysis of the top 15 hashtags revealed that the frequency of the use of all hashtags except recipe increased from 2019 to 2020 a basic analysis of the frequency of the use of individual hashtags in 2020 revealed that the hashtag healthylifestyle was the most used hashtag in connection with the hashtag healthyfood according to bektas et al 87 healthy eating is one of the dimensions of a healthy lifestyle as is nutrition and physical activity this hashtag was also very often used in conjunction with the hashtag healthyfood in 2020 and was thus the 5th most used hashtag a weight loss area has also been identified in connection with healthy foodthe weightloss hashtag and diet this area may be associated with obesity the study by karami et al 88 focused on analyzing the characteristics of the general publics opinions regarding understanding public health opinions on social media as expressed on twitter which showed a notable correlation between diet and obesity was determined as we mentioned in the introduction obesity is a worldwide problem 15 16 17 and there is an association between obesity and health problems 212227 weight loss is considered to be the cornerstone of treatment for obese people 8990 here it is important to draw attention to the perception of oneself on social networks 91 thus weight loss may not be associated with obesity but may be connected with the need to get a figure in the underweight area 92 for this reason it is advisable to analyze the area separately with a focus on the weightloss area other important hashtags used in connection with healthyfood were vegan and vegetarian this connection confirms many previous studies that have identified healthrelated reasons as one of the main motivations for following both a vegan diet 93 94 95 and a vegetarian diet 9697 other categories of hashtags that were often used in connection with the healthyfood hashtag in 2020 were recipe cooking and homemade the high frequency of these hashtags may be related to the lifestyle changes caused by governmentally mandated lockdowns in 2020 that led to people being forced to cook a significant proportion of their food at home 9899 many parents had to provide homebased meals for their children and according to a study by phlippe et al 100 many parents observed changes in diet for example boredom led to increased consumption and emotional overeating laguna et al 98 also identified changes in food purchases during the 2020 lockdown whereby consumers bought more fruits and vegetables and fewer pastries and desserts for health reasons this can be related to the frequent use of the hashtag recipe as people often search for and share recipes on the social networks 53 the most common hashtags used in connection with the hashtag healthyfood were vegan homemade and organic community analysis the community analysis extrapolated the following five communities active lifestyle influencer diets recipes and health problems the largest community was that focused on an active lifestyle this community contained hashtags that were associated with areas such as healthy lifestyle fitness healthy living nutrition healthy eating wellness and lifestyle the secondlargest community was the influencer community in which people shared foods they considered healthy this community contained hashtags such as foodporn delicious yummy and foodlover hashtags focused on homemade cooking and food blogger are likely to be related to food cooked and shared with other people via twitter and these users can be considered as food bloggers influencer marketing is built on building trust between the influencer and the follower to whom the influencer then passes on their knowledge experience attitudes opinions and values via social media 477576 the smaller third community was focused on diets which included areas such as vegan organic vegetarian plantbased glutenfree sugarfree wholefood and clean eating the field of organic food was separately analyzed in the previous research 9 which identified a high connection in the communication of organic food with healthy food and vegan food for the whole diet community it is necessary to draw attention to its high connection in the active lifestyle see figure 3 which again leads to the question of the extent to which people consider vegan a diet in terms of the absence of certain foods and to what extent vegan in terms of lifestyle the last very small community is the community focused on health problems which included areas such as high blood pressure blood pressure hypertension and diabetes as already mentioned healthy food affects health 35 including the issues mentioned in this community such as diabetes 101 and hypertension 102 the frequent use of social media to address health problems has also been confirmed by korda and itani 103 visual analysis visualization of the network was performed to gain an insight into the polarity of individual communities the value of modularity was low which means that hashtags were interconnected both within communities and between communities as seen in figure 2 the diets community was more closely linked to the active lifestyle community than to the influencer community the community with a focus on recipes was relatively evenly distributed among all communities except for the health problems community which was relatively isolated from the other communities in terms of food characteristics the most commonly used hashtag in connection with the hashtag healthyfood was vegan which refers to the vegan diet vegans eat no animal products while vegetarians do not eat animals 104 as mentioned in the theoretical background previous studies have shown that vegan and vegetarian diets are expanding societal phenomena particularly in western developed countries 105106 previous work has shown that the number of consumers who lean toward vegan and vegetarian diets continues to grow 107 moreover veganism has exhibited a greater increase in a shorter time period 108 according to one study 109 veganism is not only a diet but also a lifestyle veganism can be considered as a broader involvement in cognitive and behavioral aspects of social worlds following this further studies should also directly focus an analysis on the area of healthylifestyle and healthyliving a comparison of the results from healthy living and healthy lifestyle area would provide important information about the relationship between healthy food and lifestyle when comparing the time evolution of hashtags in both studies it could be defined by how lifestyle affects healthy eating it is thus a matter of opinion as to whether veganism is considered as a diet which is the position of lemale 110 and lederer 111 or as a lifestyle as it has been described by costa 109 study limitations finally some limitations of our study deserve attention first of all like other social media analyses this study focuses only on one social network 89687778112 and on english keywords twitter is specific to a maximum message limit of 280 characters and also focuses on text instagram on the other hand is limited to 2200 characters which can provide other information second this study did not deal with the geolocation of sending messages in the following studies it would be appropriate to focus on the use of geolocation in the report to obtain other important conclusions this limitation results in the impossibility of verifying the proportionality of the representation of individual regions in the data set third the study analyzes the current situation and does not deal with predictions for the future in our future research we will focus on using artificial intelligence to predict trends in social network communication future research the results of this study opened many important questions for further research through both quantitative and qualitative methods the present research identified main valuescharacteristics that twitter users express in the healthy food area through hashtags in future research it will be necessary to focus on these identified areas healthy lifestyle vegan vegetarian plantbased glutenfree sugarfree wholefood and clean eating since the healthy food issue is a very complex area it will be appropriate to focus research on both the analysis of individual areas separately and the analysis of their interconnectedness to broaden our understanding of the healthy food area it is also necessary for researchers to focus on other social networks such as instagram tiktok yandex and facebook these results may be important for understanding the common areas that connect the individual characteristics these interfaces are important for media communication and understanding of the common values of social network users in the monitored area like other studies 78647071102 these results are analyzed from a global perspective in the following research it would be useful to find out whether regional differences in food perception can be found or whether differences can be found for example between europe and the us or whether it is possible to create new regional segmentation based segmentation of users with the reverse assignment of location in other words as khokhar and serajuddin 113 points out that categorization by developed and developing countries for example is obsolete subsequent research could create a map of perceptions of individual food characteristics across regions another important area identified by this study is the connection between healthy food and healthy lifestyle based on this further studies can focus on vegan vegetarian or glutenfree areas and focus on understanding whether these areas are considered by people to be more healthy food such as 9 or it is a way of life that is not only based on ones own health but also on the protection of nature and animals where people avoid the use of animals in any context including food clothing sport and entertainment 114 this understanding is important both in terms of marketing communication of product manufacturers and in understanding these trends on social networks in the field of healthy food a weight loss area has also been identified in connection with healthy food which may or may not be associated with obesity here it is important to draw attention to the perception of oneself on social networks 115 thus weight loss may not be associated with obesity but may be connected with the need to get a figure in the underweight area 91 for this reason it is advisable to analyze the area separately with a focus on the weightloss area conclusions consumer behavior is a dynamic system whereby consumers interact with producers farmers traders retailers industries governments and a series of other actors 92 and must therefore be monitored in terms of understanding peoples perceptions and identifying the current situation social media which is used by more people every year has substantial research potential for basic quantitative analyses which can be followed up by qualitative research the present study identified new research questions and fundamental information that could be used as a basis for the following analysis in the field of public health and policy we found that the healthylifestyle and healthyliving hashtags were the most commonly used hashtags in conjunction with the healthyfood hashtag this is an important finding that identifies that people on social networks connect food with lifestyle which is not just about nutrition but about the way a person lives the influencer community with a focus on influencer marketing was the secondlargest community in the present study influencer marketing has a large impact on customer behavior 116 influencer marketing is built on building trust between the influencer and the follower to whom the influencer passes on their knowledge experience attitudes opinions and values via social media 477576 as this was identified as the secondlargest community people interested in the area of healthy food may be strongly influenced by influencers based on the analysis of the social network twitter with a focus on healthy food through the hashtag healthyfood the three basic characteristics of food that were most communicated in 2020 were vegan homemade and organic this is an important finding because it indicates how social network users perceive healthy food these results confirm previous research 117 118 119 that has reported that people perceive vegan food organic food and homemade food as the healthiest types of food another important finding is the identification of a t difference in the use of the vegan hashtag which expresses the rejection of the use of animal products and vegetarian which expresses only the rejection of eating animals 104 another characteristic associated with healthy food was organic this is a continuously growing trend which confirms previous studies 120121 according to an analysis of the social network instagram 9 organicfood is most often associated with the hashtag organic and subsequently with the hashtag healthyfood organic is an important characteristic of food that users communicate on social networks to summarize we found that users most commonly associate healthy food with a healthy lifestyle fitness nutrition and diet foods associated with this hashtag were vegan homemade and organic the community analysis extrapolated the following five communities active lifestyle influencer diets recipes and health problems based on these results it is possible to identify lifestyle as an important element in the field of healthy eating in the following studies it is necessary to focus separately on individual topics that have been identified as the most commonly associated with healthy food and to make a comparison within other social networks like facebook instagram and tiktok data availability statement all data used in this study can be downloaded via the twitter api 80 author contributions conceptualization lks and lp methodology lp validation lks formal analysis lks and lp resources lp data curation lp writingoriginal draft preparation lks writingreview and editing rk and lp project administration lp and rk all authors have read and agreed to the published version of the manuscript funding this study was supported by the internal grant agency of fem culs in prague registration no 2020b0004use of artificial intelligence to predict communication on social networks institutional review board statement ethical review and approval are not required in this study because the informationgathering process focused on tweets and personal information were excluded via data collection username was coded to unique id for identification of a number of users but no identifiable private information was collected following the ethical guidelines and definitions of studies that are not human subjects research informed consent statement not applicable

online social networks have become an everyday aspect of many peoples lives users spend more and more time on these platforms and through their interactions on social media platforms they create active and passive digital footprints these data have a strong potential in many research areas indeed understanding peoples communication on social media is essential for understanding their attitudes experiences behaviors and values researchers have found that the use of social networking sites impacts eating behavior thus analyzing social network data is important for understanding the meaning behind expressions used in the context of healthy food this study performed a communication analysis of data from the social network twitter which included 666178 messages posted by 168134 individual users these data comprised all tweets that used the healthyfood hashtag between 2019 and 2020 on twitter the results revealed that users most commonly associate healthy food with a healthy lifestyle diet and fitness foods associated with this hashtag were vegan homemade and organic given that people change their behavior according to other peoples behavior on social networks these data could be used to identify current and future associations with current and future perceptions of healthy food characteristics

BACKGROUND Despite the call to improve the cardiovascular health of all Americans, 1 little is known about how best to adapt cardiovascular health promotion for minority communities. A statement on cardiovascular disparities highlighted the importance of addressing cultural beliefs and practices when designing interventions because of their effect on patients' preferences, behaviors, and health care utilization. 2 One way to address cultural beliefs and practices in health interventions is to develop culturally targeted messages, which segment audiences based on cultural characteristics. [3][4][5] Segmenting populations into subgroups by their cultural characteristics may enhance receptivity to, acceptance of, and salience of health messages being presented. The most common forms of cultural targeting are matching the intervention messages to the observable, surface characteristics of culture, such as language, dress, or foods. 6 While this is important, because it increases audience interest and initial receptivity to messages, targeting the surface characteristics of culture is unlikely to result in behavior change. 6 Others, building on anthropological and sociological theory, have suggested that health promotion interventions are more likely to impact behavior change when interventions target the deeper structures of culture, such as the target groups' explanatory models about the causes of health and illness 7 and their unique facilitators and barriers to behavior change. The EM is used to understand differences in the explanation of illness and disease. EMs are based on the patient's perspective 7,8 and are influenced by people's social and cultural contexts and prior experiences. [9][10][11] The type of EMs held by patients influences receptivity to health promotion messages, 5,12 health behaviors, 13 and what course of treatment an individual follows. 14 Previously, we reported on U.S. South Asians' EMs of CHD, as well as their knowledge and attitudes about CHD prevention. [15][16][17] South Asians, who are the second fastest growing racial/ethnic group in the U.S., suffer higher rates of CHD compared to other racial/ethnic groups. [18][19][20][21][22][23][24] A majority of South Asians are immigrants and may have different explanations for what causes CHD, which could impact their willingness to change behavior. Our prior research, which took place in a medically underserved South Asian community, found that South Asians' EMs of CHD differed from the biomedical model which underlies most CHD prevention messages. 16 Although South Asians' EMs did include unhealthy diet and physical inactivity, their EMs emphasized stress as the root cause of CHD. When asked how one can prevent CHD, few talked about controlling cholesterol or blood pressure, but 40 % mentioned reducing stress. 15 In addition, the majority of South Asians interviewed believed that heart attacks are not preventable. 15 These formative research findings were integrated with theoretical construct commonly used in behavioral, 25 communication, 5,26,27 and learning sciences 28,29 to develop a culturally targeted, multimedia coronary heart disease patient education program for medically underserved South Asians. The first version of the PEP had six modules that were designed to increase South Asians': 1) perceived susceptibility to CHD; 2) knowledge about modifiable risk factors; 3) belief that CHD is preventable; 3) behavioral intention to get screened for modifiable risk factors; and 4) behavioral intention to improve lifestyle behaviors. The present study was designed to qualitatively assess South Asians' reactions to the first two modules of the PEP and describe how emergent themes were used to revise the intervention. The lessons from this community and culture-centered process can be used to guide the dissemination and implementation of culturally targeted health interventions for diverse communities and have potential to be applied across other health conditions. --- METHODS --- PEP Development and Conceptual Framework The PEP was designed for use either in a primary care or community-based settings where it can be used with individuals or groups and accessed via the internet, a clinic kiosk, a link within an electronic medical record, or even as a DVD available for patients to take home. The six multimedia modules, approximately 5 minutes each, were designed to deliver actionable CHD prevention education promoting a healthy lifestyle and screening for clinical risk factors. The modules are in English and Hindi and include graphics, animation, photographs, and brief text reinforcing visually presented concepts. The spoken audio was narrated by a bilingual, female narrator. The modules are not interactive, but rather, introduce a limited number of concepts that can be followed by clinic staff or a community worker leading a brief goal-setting session with patients to reinforce learning and help patients initiate heart healthy behaviors. The research team, which was comprised of two primary care physicians, a communications expert, a registered dietician, a multimedia design expert, and a bicultural research assistant, used formative research on South Asians' EMs, [15][16][17] CHD prevention guidelines, 30 and multiple theoretical and practical considerations in the design of the PEP. We briefly review the theoretical and practical considerations below. --- Health Behavior Theory The PEP was designed to increase South Asians' perceived risk of CHD and perceived benefits of prevention because these constructs, from the Health Belief Model, were hypothesized to be important mediators of enacting a particular CHD prevention behavior. [31][32][33] The messages also addressed attitudes, subjective norms, and perceived behavioral control, which are constructs from the Theory of Planned Behavior, 25,34 because our formative work suggested that these constructs were influencing CHD prevention behaviors in South Asians. [15][16][17] --- Communication Theory The message content and structure were developed with attention to communication theories related to framing, 27 use of affective strategies , 35 and cultural targeting. 5,36,37 The PEP opened with a fear appeal message and later in the video, included positive, gain-framed messages because evidence suggests that these strategies are more effective at increasing self-efficacy and behavioral intent to engage in CHD screening behaviors. 27 Culturally targeted communication strategies 5,36,37 included incorporating the surface and deep structures of culture. --- Learning Theory The research team designed the PEP using adult learning and education principles, 28 as well as cognitive factors 'best practices,' 29 that have been shown to increase comprehension of health information in patients across education and literacy levels. To lessen the demands of the PEP on patients' working memory , we: used plain language and avoided jargon; minimized the number of new concepts introduced simultaneously; presented new information in a sequential manner so that the learner could more effectively use stored material in learning new information; chunked information into manageable pieces; and avoided distracting, 'offmessage' information. These features allow learners to more fully apply their cognitive abilities to acquiring and remembering new information. 38,39 In this paper, we describe the use of focus groups and interviews to obtain qualitative feedback and refine the first two modules of the culturally targeted PEP. These modules, "What is Heart Disease," and "Three Things to Talk to Your Doctor About," were designed to increase South Asians' perceived susceptibility to CHD, knowledge about the causes of CHD, belief that that CHD is preventable, awareness of prevention through screening for clinical risk factors, and intention to get screened for cholesterol, diabetes, and hypertension. --- Study Design and Participants Seven focus groups and 13 individual interviews were conducted between September and November 2009, with a total of 57 adults. A combination of focus groups and individual interviews were used because of participants' availability. Participants were recruited from a federally qualified health center and two community centers that provide non-health care related services for South Asian immigrants in Chicago, Illinois. The FQHC and community centers are located in densely populated residential areas, with a large population of recent South Asian immigrants who are medically underserved and have lower incomes and education levels than the general U.S. South Asian population. 40 This study was limited to Hindi and English-speaking adults who self-identified as Asian Indian or Pakistani because these are by far the largest South Asian subgroups in Chicago. 40 Study flyers were distributed at the recruitment sites; staff at the FHQC and the community organizations organized the focus group sessions and also helped recruit clients for individual interviews. Participants were encouraged to inform their friends and family members about the study. Participants received $25 for their participation. The study protocol was approved by the institutional review board of {unnamed} university. --- Interview Guide and Procedures Prior to each focus group or individual interview, participants engaged in the informed consent process with a trained research assistant and completed a one-page demographic questionnaire. Participants were shown the entire module and then surveyed about their reactions to the video using a brief quantitative questionnaire. A semistructured interview guide was developed by the study investigators to help elicit participants' reactions to the messages and design of the PEP. The same interview guide was used in focus groups and individual interviews. Participants were asked to describe their initial reactions to the video, what they learned, whether any sections were unclear, and their likes and dislikes. The focus group moderator then showed short segments or images from the videos' key points and asked participants to describe, in their own words, what was being shown. They were then asked about their reaction to the segment, including if they agreed with the message in the segment, the clarity of the segment, and how it could be improved. Finally, participants were asked about their affective response to the video and if they felt motivated to get screened or change any behaviors. Focus groups lasted between 60 and 90 minutes and interviews lasted between 30 and 45 minutes. --- Analysis The focus groups and individual interviews were recorded, transcribed verbatim, and translated by the research assistant who conducted the focus groups and interviews, using a procedural manual from our earlier studies. 16,17 Hindi words that were unique and had no English equivalent were not translated. The research team discussed the translation and meaning of key words and phrases in the transcripts to ensure cultural equivalence. Transcripts were analyzed using latent content and constant comparative techniques 41 through which three of the study authors independently assessed participant responses for focal themes before convening to compare and compile their findings. Through consensus, the coders constructed an overarching categorical system to describe the themes pertaining to cultural targeting of messages and to conceptual constructs underlying messages; specifically, coders focused on themes relating to the use of a targeted impact statement to increase perceived susceptibility to CHD, EMs of CHD, perceived benefits of screening for modifiable risk factors, and perceived behavioral control related to CHD prevention. The coders then returned to the data to assess independently the adequacy of the categorical system and the need for additional codes that were not initially captured. The team reconvened to discuss the major conceptual themes that emerged from the transcripts and to reconcile discrepancies. Through this process, the team codified an inventory of the community's knowledge and issues related to CHD etiology, prevention, and screening. The team then reviewed the transcripts together and selected exemplars to demonstrate the major conceptual themes through discussion and consensus. --- RESULTS --- Sample Characteristics The average age of participants was 53 years, 74 % were women, and all were immigrants . Three Hindi focus groups and four English focus groups were conducted. Of the 13 individual interviews, eight were in Hindi and five in English based on participants' language preferences. --- Targeted Impact Message and Perceived Susceptibility The introductory module of the PEP opened with a targeted impact statement, "Heart attack is the number one killer of Asian Indians and Pakistanis." This statement was designed to capture the audience's attention and increase their perceived susceptibility to CHD. Community members had a vigorous and mostly negative reaction to this statement . For example, one Hindi-speaking man said: "Is this a bold attack? That is how it looks if we target a community and say this. Unless it is fully based on statistical data then its fine, but maybe you want to mild it a little bit, ." Others agreed, saying that the statement was too strong and direct, and that it would turn people off from the rest of the message. Several respondents also said that the statement lacked credibility because it was not supported by any statistics. Participants said that they did not understand why the video was targeting South Asians because people from all communities have heart disease . One participant suggested using the phrase, "Heart attack is the number killer for everyone, ." Participants' feedback prompted us to modify the opening statement . In subsequent focus groups, participants had a much more positive response to the modified opening statement. Specifically, they said that the statement seemed more factual and captured their attention, without "scaring them too much" or "offending" them. --- Community Heterogeneity and Perceived Risk In our prior research, South Asian women were less likely to perceive themselves at risk for CHD compared to men. 16 To increase women's perception of CHD risk, the original PEP opened with an image of an older South Asian woman with her daughter and granddaughter . Participants said this picture was too personal and disconnected from the narration. Even more important, participants felt strongly that the images in the video should capture the heterogeneity of the community, with regards to gender, age, and body type . Several said that the message of the picture and the narration should be, "A heart attack can happen to any one of us." Based on these suggestions, a diverse montage of Asian Indians and Pakistanis was added as the opening image . The modified picture and statement were received much more positively in subsequent focus groups and interviews, where participants said, "You can establish a connection. There are many people here of different age groups, and it says that anybody can get a heart attack, does not matter young or old, man or woman, ." --- Stress and Explanatory Models of CHD Previously, we found that South Asians believed that chronic stress or stressful events cause heart disease and heart attacks. 15,16 Many described experiences where a family member received bad news and then had a heart attack. Because these beliefs may impact perceived behavioral control related to CHD prevention, the PEP included messages to change these beliefs. The PEP showed a picture of blood vessels clogging and the narration, "Many people believe that stress or bad news cause heart attacks. The truth is that heart attacks are caused by the blood vessels getting clogged, slowly, over time." After viewing the PEP, participants were unconvinced and confirmed our prior findings that the beliefs about stress causing CHD are widespread . For example, one participant said, "You are trying to address the myth here, but it is deeply rooted in people's mind. Just one sentence is not going to take it away, ." People also spoke about how these beliefs were rooted in their experiences and were reinforced by physicians back in India . Several community members suggested that the PEP should acknowledge that stress can influence the development of CHD, while also discussing the importance of other risk factors. Participants also said the PEP should include information on stress management as part of CHD prevention . In addition to changing the message in the introductory module , we developed a separate module on how stress can affect cardiovascular health, along with strategies for stress management. --- Perceived Benefits of Screening and Behavioral Control In our formative research, a majority of South Asians said that heart attacks are not preventable and very few talked about CHD prevention through screening and treatment for clinical risk factors such as high cholesterol, blood pressure, and diabetes. 15,16 There was also a common belief that vegetarians cannot have high cholesterol. 16 This is particularly salient in a community with a large number of Hindus who traditionally do not eat meat. In order to increase the community's knowledge and perceived behavioral control related to cholesterol, the narration said, "Everyone's body makes cholesterol and your body can make too much cholesterol. Even if you are a vegetarian you can still have high cholesterol because your body can make too much cholesterol." Participants had a positive response to this message, saying it made them realize that they should get screened . A typical reaction was, "Your body makes cholesterol? Oh my God, I am producing my own junk. I didn't realize that the body can make it ." Participants said that the messages did make them want to get screened; however, several participants also mentioned that in this community, lack of health insurance was the main barrier to screening . To address this barrier and increase perceived behavioral control, the revised PEP included an information screen on neighborhood FQHCs and other low-cost health centers. --- DISCUSSION Although there is a growing literature on culturally targeted health interventions for African American and Latino communities, 4,[42][43][44] far less is known about the development process and how diverse communities react to such interventions. 45 We used a community and culture-centered approach to develop and revise a multimedia, culturally targeted CHD PEP for medically underserved U.S. South Asians. The user perspectives in this study highlight the ways in which a community's EMs, daily lived experiences, and socio-economic context can influence responses to culturally targeted CHD prevention messages. There are several key lessons that can be applied across diverse settings and to other conditions. This study uncovered the tension that often exists between the biomedical model and a community's EMs. Because the research team felt it was critical for South Asians to understand that screening for and controlling clinical risk factors are central to CHD prevention, the initial version of the PEP emphasized clinical risk factors and downplayed the community's EMs of stress causing CHD. This approach was not effective at engaging community members, who said that if the messages tried to negate their EMs about stress and CHD, the messages would be less credible. The focus groups revealed that EMs are deeply-ingrained and often reflect the psychosocial and experiential factors that influence health and behavior change. A recent study found that a narrative-based intervention, utilizing a Health Belief Model and delivered via an interactive DVD, improved blood pressure control in African-American patients with uncontrolled hypertension. 44 Although ours is not a story-telling intervention, the PEP was developed using formative data on EMs and incorporated South Asians' beliefs about CHD. Health education interventions that explicitly incorporate patients' EMs, delivered via narratives or other sources, may be more effective at initiating health behavior change because the messages are perceived as more credible and because they acknowledge the multiple causal pathways that influence the health of the target community. Many studies have found that patients, especially those from vulnerable populations, implicate stress as an underlying cause of CHD 46,47 and risk factors, such as hypertension 48,49 and diabetes. 43,50,51 In some cases, these beliefs influence behavioral control and behaviors, such as adherence to medication. 52,53 Based on the community's feedback, the revised PEP incorporated South Asians' EMs about stress and CHD, while also provided clear and actionable information about the importance of controlling clinical and lifestyle risk factors. This strategy can be used for addressing the disconnect that exists between lay EMs and the biomedical model that underlies most health promotion messages. We also developed an additional module, "Take Care of Your Stress and Tension," that talks about the inter-connectedness between stress, diet, and physical activity and provides advice on coping strategies. Our findings, and others, suggest that culturally targeted health communication must not only engage the biomedical model, but must also engage the EMs that facilitate or inhibit behavior change in the target community. 54 Studies are needed to answer the questions of whether CHD Almost everyone knows someone who has had a heart attack. Have you ever wondered why they had a heart attack?" Figure 2. Modified opening picture in PEP. Narrator: "Heart attack is the number one killer of people around the world. Studies show that Asian Indians and Pakistanis are more likely to have heart attacks than people from other communities. Almost everyone knows someone who has had a heart attack. Have you ever wondered why they had a heart attack?" interventions that incorporate community members' EMs about stress are more effective than interventions based solely on a biomedical model and whether the effect varies across settings and conditions. We also found that there may be unintended consequences to fear appeals that use targeted impact statements. Others have suggested that culturally targeted impact messages are more likely to increase the target audience's attentiveness and receptivity compared to non-targeted health promotion messages because they send the message that, "this problem affects people like you." 37,55 However, in the present study, the opening message elicited a strong, negative affective response from community members and diverted their attention from the remainder of the PEP. South Asians said they felt that they were being unfairly targeted since heart disease is prevalent in many communities; they also said the language in the message was too direct and felt like a "bold attack." Another study also found that African Americans had negative reactions to targeted colon cancer screening messages, 55 and that they rejected health risk messages that were perceived as "too threatening." African Americans had a more positive affective response to messages that emphasized progress in disparities compared to messages that solely emphasize the disparity. 55 Some minority communities may be wary of targeted health messages due to prior experiences with discrimination 56 or stigma. 57 In our formative work, South Asians described feelings of social isolation and difficulties associated with immigration, 58 and these factors could have contributed to the feeling that their community was being 'singled-out.' Another possible explanation is that South Asian societies and languages are less direct than many Western societies and languages. 59 This difference in communication style should be considered when designing messages for South Asians and other communities where social interactions and language are less direct. 45,60 Future studies should explore how framing, 61 affective strategies, 35 and language influence responses to health messages across diverse populations and cultures. Another important theme that emerged during the discussions was that the PEP did not capture the target populations' heterogeneity. Community members said that the messages were not speaking to all of them. In health research, data aggregation often leads to a loss of the heterogeneity within racial/ethnic groups. 62,63 A similar situation can occur when culturally targeted health message segment their audience based on race/ethnicity. 45 There is significant socio-demographic and behavioral heterogeneity within these racial/ethnic segments, and health communication interventions need to identify messaging strategies that speak to the diversity within any given group. Community members' input also highlighted the importance of economic barriers on their perceived behavioral control related to screening for CHD risk factors. Even though participants found the messages about getting screened for cholesterol, high blood pressure, and diabetes to be effective at changing their knowledge and attitudes, they said that lack of insurance and access to health care were key barriers to getting screened. Numerous studies have shown that lack of insurance and access to health care are barriers to preventive and screening services. 64,65 In addition to addressing health beliefs, knowledge, and attitudes, health communication messages for medically underserved communities may have more of an influence on perceived behavioral control if the messages also address the economic and structural barriers to healthy behaviors. This study has several strengths, including the use of multiple focus groups and individual interviews in English and Hindi and the use of a bilingual and bicultural research assistant with prior experience conducting qualitative research in this community. The study also has important limitations. First, these findings cannot be generalized beyond the population examined in this study. This was a convenience sample of Asian Indians and Pakistanis from one medically underserved, urban community with a high proportion of recent immigrants. These findings were not intended to capture the perceptions of all U.S. South Asians, but are useful in generating hypotheses that can be tested in future research. The majority of participants were also women, and we may not have captured important differences between South Asian men's and women's reactions to the CHD messages. In addition, despite the moderator's effort to ensure that everyone in the focus groups had a chance to speak, the group setting could have led to bias related to social desirability and outspoken participants dominating the conversation. Therefore, the focus groups may not have captured the full range of opinions among all participants. The key lessons that emerged in this process can be used to guide the development of effective health promotion messages in partnership with diverse communities. First, formative research should be done to understand the EMs that may be influencing health and disease prevention within a particular community; second, health promotion interventions can navigate the tensions that may exist between the community's EM and the biomedical model by incorporating the community's EMs into targeted messages; third, communities and cultures are not monolithic, and messages must reflect the heterogeneity within a target community; fourth, culturally targeted interventions should also address the economic and structural barriers that impact health behaviors; and finally, it is hard to predict how communities will react to culturally targeted health messages, and thus, full engagement of the community in every phase of message design is critical and ideally, should be an iterative process. --- Conflict of Interest: The authors declare that they do not have a conflict of interest.

Little is known about how best to target cardiovascular health promotion messages to minorities. This study describes key lessons that emerged from a community and culture-centered approach to developing a multimedia, coronary heart disease (CHD) patient education program (PEP) for medically underserved South Asian immigrants. METHODS: The prototype PEP integrated the surface structures (e.g. language) and deeper structures (e.g. explanatory models (EMs), values) of South Asians' socio-cultural context. Seven focus groups and 13 individual interviews were used to investigate South Asians' reactions and obtain qualitative feedback after viewing the culturally targeted PEP. Qualitative data were organized into emergent thematic constructs. RESULTS: Participants (n=56) mean age was 51 years and 48 % were Hindi speakers. Community members had a strong, negative reaction to some of the targeted messages, "This statement is a bold attack. You are pinpointing one community." Other important themes emerged from focus groups and interviews about the PEP: 1) it did not capture the community's heterogeneity; 2) did not sufficiently incorporate South Asians' EMs of CHD; and 3) did not address economic barriers to CHD prevention. Feedback was used to revise the PEP. CONCLUSION: A community and culture-centered approach to developing cardiovascular health promotion messages revealed tensions between the researcher's vantage point of "cultural targeting" and the community's perceptions and reactions to these messages. Engaging communities in every phase of message design, incorporating their EMs, recognizing community heterogeneity, and addressing economic and structural barriers, are critical steps to ensuring that health promotion messages reach their intended audience and achieve true cultural appropriateness.

background despite the call to improve the cardiovascular health of all americans 1 little is known about how best to adapt cardiovascular health promotion for minority communities a statement on cardiovascular disparities highlighted the importance of addressing cultural beliefs and practices when designing interventions because of their effect on patients preferences behaviors and health care utilization 2 one way to address cultural beliefs and practices in health interventions is to develop culturally targeted messages which segment audiences based on cultural characteristics 3 4 5 segmenting populations into subgroups by their cultural characteristics may enhance receptivity to acceptance of and salience of health messages being presented the most common forms of cultural targeting are matching the intervention messages to the observable surface characteristics of culture such as language dress or foods 6 while this is important because it increases audience interest and initial receptivity to messages targeting the surface characteristics of culture is unlikely to result in behavior change 6 others building on anthropological and sociological theory have suggested that health promotion interventions are more likely to impact behavior change when interventions target the deeper structures of culture such as the target groups explanatory models about the causes of health and illness 7 and their unique facilitators and barriers to behavior change the em is used to understand differences in the explanation of illness and disease ems are based on the patients perspective 78 and are influenced by peoples social and cultural contexts and prior experiences 9 10 11 the type of ems held by patients influences receptivity to health promotion messages 512 health behaviors 13 and what course of treatment an individual follows 14 previously we reported on us south asians ems of chd as well as their knowledge and attitudes about chd prevention 15 16 17 south asians who are the second fastest growing racialethnic group in the us suffer higher rates of chd compared to other racialethnic groups 18 19 20 21 22 23 24 a majority of south asians are immigrants and may have different explanations for what causes chd which could impact their willingness to change behavior our prior research which took place in a medically underserved south asian community found that south asians ems of chd differed from the biomedical model which underlies most chd prevention messages 16 although south asians ems did include unhealthy diet and physical inactivity their ems emphasized stress as the root cause of chd when asked how one can prevent chd few talked about controlling cholesterol or blood pressure but 40 mentioned reducing stress 15 in addition the majority of south asians interviewed believed that heart attacks are not preventable 15 these formative research findings were integrated with theoretical construct commonly used in behavioral 25 communication 52627 and learning sciences 2829 to develop a culturally targeted multimedia coronary heart disease patient education program for medically underserved south asians the first version of the pep had six modules that were designed to increase south asians 1 perceived susceptibility to chd 2 knowledge about modifiable risk factors 3 belief that chd is preventable 3 behavioral intention to get screened for modifiable risk factors and 4 behavioral intention to improve lifestyle behaviors the present study was designed to qualitatively assess south asians reactions to the first two modules of the pep and describe how emergent themes were used to revise the intervention the lessons from this community and culturecentered process can be used to guide the dissemination and implementation of culturally targeted health interventions for diverse communities and have potential to be applied across other health conditions methods pep development and conceptual framework the pep was designed for use either in a primary care or communitybased settings where it can be used with individuals or groups and accessed via the internet a clinic kiosk a link within an electronic medical record or even as a dvd available for patients to take home the six multimedia modules approximately 5 minutes each were designed to deliver actionable chd prevention education promoting a healthy lifestyle and screening for clinical risk factors the modules are in english and hindi and include graphics animation photographs and brief text reinforcing visually presented concepts the spoken audio was narrated by a bilingual female narrator the modules are not interactive but rather introduce a limited number of concepts that can be followed by clinic staff or a community worker leading a brief goalsetting session with patients to reinforce learning and help patients initiate heart healthy behaviors the research team which was comprised of two primary care physicians a communications expert a registered dietician a multimedia design expert and a bicultural research assistant used formative research on south asians ems 15 16 17 chd prevention guidelines 30 and multiple theoretical and practical considerations in the design of the pep we briefly review the theoretical and practical considerations below health behavior theory the pep was designed to increase south asians perceived risk of chd and perceived benefits of prevention because these constructs from the health belief model were hypothesized to be important mediators of enacting a particular chd prevention behavior 31 32 33 the messages also addressed attitudes subjective norms and perceived behavioral control which are constructs from the theory of planned behavior 2534 because our formative work suggested that these constructs were influencing chd prevention behaviors in south asians 15 16 17 communication theory the message content and structure were developed with attention to communication theories related to framing 27 use of affective strategies 35 and cultural targeting 53637 the pep opened with a fear appeal message and later in the video included positive gainframed messages because evidence suggests that these strategies are more effective at increasing selfefficacy and behavioral intent to engage in chd screening behaviors 27 culturally targeted communication strategies 53637 included incorporating the surface and deep structures of culture learning theory the research team designed the pep using adult learning and education principles 28 as well as cognitive factors best practices 29 that have been shown to increase comprehension of health information in patients across education and literacy levels to lessen the demands of the pep on patients working memory we used plain language and avoided jargon minimized the number of new concepts introduced simultaneously presented new information in a sequential manner so that the learner could more effectively use stored material in learning new information chunked information into manageable pieces and avoided distracting offmessage information these features allow learners to more fully apply their cognitive abilities to acquiring and remembering new information 3839 in this paper we describe the use of focus groups and interviews to obtain qualitative feedback and refine the first two modules of the culturally targeted pep these modules what is heart disease and three things to talk to your doctor about were designed to increase south asians perceived susceptibility to chd knowledge about the causes of chd belief that that chd is preventable awareness of prevention through screening for clinical risk factors and intention to get screened for cholesterol diabetes and hypertension study design and participants seven focus groups and 13 individual interviews were conducted between september and november 2009 with a total of 57 adults a combination of focus groups and individual interviews were used because of participants availability participants were recruited from a federally qualified health center and two community centers that provide nonhealth care related services for south asian immigrants in chicago illinois the fqhc and community centers are located in densely populated residential areas with a large population of recent south asian immigrants who are medically underserved and have lower incomes and education levels than the general us south asian population 40 this study was limited to hindi and englishspeaking adults who selfidentified as asian indian or pakistani because these are by far the largest south asian subgroups in chicago 40 study flyers were distributed at the recruitment sites staff at the fhqc and the community organizations organized the focus group sessions and also helped recruit clients for individual interviews participants were encouraged to inform their friends and family members about the study participants received 25 for their participation the study protocol was approved by the institutional review board of unnamed university interview guide and procedures prior to each focus group or individual interview participants engaged in the informed consent process with a trained research assistant and completed a onepage demographic questionnaire participants were shown the entire module and then surveyed about their reactions to the video using a brief quantitative questionnaire a semistructured interview guide was developed by the study investigators to help elicit participants reactions to the messages and design of the pep the same interview guide was used in focus groups and individual interviews participants were asked to describe their initial reactions to the video what they learned whether any sections were unclear and their likes and dislikes the focus group moderator then showed short segments or images from the videos key points and asked participants to describe in their own words what was being shown they were then asked about their reaction to the segment including if they agreed with the message in the segment the clarity of the segment and how it could be improved finally participants were asked about their affective response to the video and if they felt motivated to get screened or change any behaviors focus groups lasted between 60 and 90 minutes and interviews lasted between 30 and 45 minutes analysis the focus groups and individual interviews were recorded transcribed verbatim and translated by the research assistant who conducted the focus groups and interviews using a procedural manual from our earlier studies 1617 hindi words that were unique and had no english equivalent were not translated the research team discussed the translation and meaning of key words and phrases in the transcripts to ensure cultural equivalence transcripts were analyzed using latent content and constant comparative techniques 41 through which three of the study authors independently assessed participant responses for focal themes before convening to compare and compile their findings through consensus the coders constructed an overarching categorical system to describe the themes pertaining to cultural targeting of messages and to conceptual constructs underlying messages specifically coders focused on themes relating to the use of a targeted impact statement to increase perceived susceptibility to chd ems of chd perceived benefits of screening for modifiable risk factors and perceived behavioral control related to chd prevention the coders then returned to the data to assess independently the adequacy of the categorical system and the need for additional codes that were not initially captured the team reconvened to discuss the major conceptual themes that emerged from the transcripts and to reconcile discrepancies through this process the team codified an inventory of the communitys knowledge and issues related to chd etiology prevention and screening the team then reviewed the transcripts together and selected exemplars to demonstrate the major conceptual themes through discussion and consensus results sample characteristics the average age of participants was 53 years 74 were women and all were immigrants three hindi focus groups and four english focus groups were conducted of the 13 individual interviews eight were in hindi and five in english based on participants language preferences targeted impact message and perceived susceptibility the introductory module of the pep opened with a targeted impact statement heart attack is the number one killer of asian indians and pakistanis this statement was designed to capture the audiences attention and increase their perceived susceptibility to chd community members had a vigorous and mostly negative reaction to this statement for example one hindispeaking man said is this a bold attack that is how it looks if we target a community and say this unless it is fully based on statistical data then its fine but maybe you want to mild it a little bit others agreed saying that the statement was too strong and direct and that it would turn people off from the rest of the message several respondents also said that the statement lacked credibility because it was not supported by any statistics participants said that they did not understand why the video was targeting south asians because people from all communities have heart disease one participant suggested using the phrase heart attack is the number killer for everyone participants feedback prompted us to modify the opening statement in subsequent focus groups participants had a much more positive response to the modified opening statement specifically they said that the statement seemed more factual and captured their attention without scaring them too much or offending them community heterogeneity and perceived risk in our prior research south asian women were less likely to perceive themselves at risk for chd compared to men 16 to increase womens perception of chd risk the original pep opened with an image of an older south asian woman with her daughter and granddaughter participants said this picture was too personal and disconnected from the narration even more important participants felt strongly that the images in the video should capture the heterogeneity of the community with regards to gender age and body type several said that the message of the picture and the narration should be a heart attack can happen to any one of us based on these suggestions a diverse montage of asian indians and pakistanis was added as the opening image the modified picture and statement were received much more positively in subsequent focus groups and interviews where participants said you can establish a connection there are many people here of different age groups and it says that anybody can get a heart attack does not matter young or old man or woman stress and explanatory models of chd previously we found that south asians believed that chronic stress or stressful events cause heart disease and heart attacks 1516 many described experiences where a family member received bad news and then had a heart attack because these beliefs may impact perceived behavioral control related to chd prevention the pep included messages to change these beliefs the pep showed a picture of blood vessels clogging and the narration many people believe that stress or bad news cause heart attacks the truth is that heart attacks are caused by the blood vessels getting clogged slowly over time after viewing the pep participants were unconvinced and confirmed our prior findings that the beliefs about stress causing chd are widespread for example one participant said you are trying to address the myth here but it is deeply rooted in peoples mind just one sentence is not going to take it away people also spoke about how these beliefs were rooted in their experiences and were reinforced by physicians back in india several community members suggested that the pep should acknowledge that stress can influence the development of chd while also discussing the importance of other risk factors participants also said the pep should include information on stress management as part of chd prevention in addition to changing the message in the introductory module we developed a separate module on how stress can affect cardiovascular health along with strategies for stress management perceived benefits of screening and behavioral control in our formative research a majority of south asians said that heart attacks are not preventable and very few talked about chd prevention through screening and treatment for clinical risk factors such as high cholesterol blood pressure and diabetes 1516 there was also a common belief that vegetarians cannot have high cholesterol 16 this is particularly salient in a community with a large number of hindus who traditionally do not eat meat in order to increase the communitys knowledge and perceived behavioral control related to cholesterol the narration said everyones body makes cholesterol and your body can make too much cholesterol even if you are a vegetarian you can still have high cholesterol because your body can make too much cholesterol participants had a positive response to this message saying it made them realize that they should get screened a typical reaction was your body makes cholesterol oh my god i am producing my own junk i didnt realize that the body can make it participants said that the messages did make them want to get screened however several participants also mentioned that in this community lack of health insurance was the main barrier to screening to address this barrier and increase perceived behavioral control the revised pep included an information screen on neighborhood fqhcs and other lowcost health centers discussion although there is a growing literature on culturally targeted health interventions for african american and latino communities 4 42 43 44 far less is known about the development process and how diverse communities react to such interventions 45 we used a community and culturecentered approach to develop and revise a multimedia culturally targeted chd pep for medically underserved us south asians the user perspectives in this study highlight the ways in which a communitys ems daily lived experiences and socioeconomic context can influence responses to culturally targeted chd prevention messages there are several key lessons that can be applied across diverse settings and to other conditions this study uncovered the tension that often exists between the biomedical model and a communitys ems because the research team felt it was critical for south asians to understand that screening for and controlling clinical risk factors are central to chd prevention the initial version of the pep emphasized clinical risk factors and downplayed the communitys ems of stress causing chd this approach was not effective at engaging community members who said that if the messages tried to negate their ems about stress and chd the messages would be less credible the focus groups revealed that ems are deeplyingrained and often reflect the psychosocial and experiential factors that influence health and behavior change a recent study found that a narrativebased intervention utilizing a health belief model and delivered via an interactive dvd improved blood pressure control in africanamerican patients with uncontrolled hypertension 44 although ours is not a storytelling intervention the pep was developed using formative data on ems and incorporated south asians beliefs about chd health education interventions that explicitly incorporate patients ems delivered via narratives or other sources may be more effective at initiating health behavior change because the messages are perceived as more credible and because they acknowledge the multiple causal pathways that influence the health of the target community many studies have found that patients especially those from vulnerable populations implicate stress as an underlying cause of chd 4647 and risk factors such as hypertension 4849 and diabetes 435051 in some cases these beliefs influence behavioral control and behaviors such as adherence to medication 5253 based on the communitys feedback the revised pep incorporated south asians ems about stress and chd while also provided clear and actionable information about the importance of controlling clinical and lifestyle risk factors this strategy can be used for addressing the disconnect that exists between lay ems and the biomedical model that underlies most health promotion messages we also developed an additional module take care of your stress and tension that talks about the interconnectedness between stress diet and physical activity and provides advice on coping strategies our findings and others suggest that culturally targeted health communication must not only engage the biomedical model but must also engage the ems that facilitate or inhibit behavior change in the target community 54 studies are needed to answer the questions of whether chd almost everyone knows someone who has had a heart attack have you ever wondered why they had a heart attack figure 2 modified opening picture in pep narrator heart attack is the number one killer of people around the world studies show that asian indians and pakistanis are more likely to have heart attacks than people from other communities almost everyone knows someone who has had a heart attack have you ever wondered why they had a heart attack interventions that incorporate community members ems about stress are more effective than interventions based solely on a biomedical model and whether the effect varies across settings and conditions we also found that there may be unintended consequences to fear appeals that use targeted impact statements others have suggested that culturally targeted impact messages are more likely to increase the target audiences attentiveness and receptivity compared to nontargeted health promotion messages because they send the message that this problem affects people like you 3755 however in the present study the opening message elicited a strong negative affective response from community members and diverted their attention from the remainder of the pep south asians said they felt that they were being unfairly targeted since heart disease is prevalent in many communities they also said the language in the message was too direct and felt like a bold attack another study also found that african americans had negative reactions to targeted colon cancer screening messages 55 and that they rejected health risk messages that were perceived as too threatening african americans had a more positive affective response to messages that emphasized progress in disparities compared to messages that solely emphasize the disparity 55 some minority communities may be wary of targeted health messages due to prior experiences with discrimination 56 or stigma 57 in our formative work south asians described feelings of social isolation and difficulties associated with immigration 58 and these factors could have contributed to the feeling that their community was being singledout another possible explanation is that south asian societies and languages are less direct than many western societies and languages 59 this difference in communication style should be considered when designing messages for south asians and other communities where social interactions and language are less direct 4560 future studies should explore how framing 61 affective strategies 35 and language influence responses to health messages across diverse populations and cultures another important theme that emerged during the discussions was that the pep did not capture the target populations heterogeneity community members said that the messages were not speaking to all of them in health research data aggregation often leads to a loss of the heterogeneity within racialethnic groups 6263 a similar situation can occur when culturally targeted health message segment their audience based on raceethnicity 45 there is significant sociodemographic and behavioral heterogeneity within these racialethnic segments and health communication interventions need to identify messaging strategies that speak to the diversity within any given group community members input also highlighted the importance of economic barriers on their perceived behavioral control related to screening for chd risk factors even though participants found the messages about getting screened for cholesterol high blood pressure and diabetes to be effective at changing their knowledge and attitudes they said that lack of insurance and access to health care were key barriers to getting screened numerous studies have shown that lack of insurance and access to health care are barriers to preventive and screening services 6465 in addition to addressing health beliefs knowledge and attitudes health communication messages for medically underserved communities may have more of an influence on perceived behavioral control if the messages also address the economic and structural barriers to healthy behaviors this study has several strengths including the use of multiple focus groups and individual interviews in english and hindi and the use of a bilingual and bicultural research assistant with prior experience conducting qualitative research in this community the study also has important limitations first these findings cannot be generalized beyond the population examined in this study this was a convenience sample of asian indians and pakistanis from one medically underserved urban community with a high proportion of recent immigrants these findings were not intended to capture the perceptions of all us south asians but are useful in generating hypotheses that can be tested in future research the majority of participants were also women and we may not have captured important differences between south asian mens and womens reactions to the chd messages in addition despite the moderators effort to ensure that everyone in the focus groups had a chance to speak the group setting could have led to bias related to social desirability and outspoken participants dominating the conversation therefore the focus groups may not have captured the full range of opinions among all participants the key lessons that emerged in this process can be used to guide the development of effective health promotion messages in partnership with diverse communities first formative research should be done to understand the ems that may be influencing health and disease prevention within a particular community second health promotion interventions can navigate the tensions that may exist between the communitys em and the biomedical model by incorporating the communitys ems into targeted messages third communities and cultures are not monolithic and messages must reflect the heterogeneity within a target community fourth culturally targeted interventions should also address the economic and structural barriers that impact health behaviors and finally it is hard to predict how communities will react to culturally targeted health messages and thus full engagement of the community in every phase of message design is critical and ideally should be an iterative process conflict of interest the authors declare that they do not have a conflict of interest

little is known about how best to target cardiovascular health promotion messages to minorities this study describes key lessons that emerged from a community and culturecentered approach to developing a multimedia coronary heart disease chd patient education program pep for medically underserved south asian immigrants methods the prototype pep integrated the surface structures eg language and deeper structures eg explanatory models ems values of south asians sociocultural context seven focus groups and 13 individual interviews were used to investigate south asians reactions and obtain qualitative feedback after viewing the culturally targeted pep qualitative data were organized into emergent thematic constructs results participants n56 mean age was 51 years and 48 were hindi speakers community members had a strong negative reaction to some of the targeted messages this statement is a bold attack you are pinpointing one community other important themes emerged from focus groups and interviews about the pep 1 it did not capture the communitys heterogeneity 2 did not sufficiently incorporate south asians ems of chd and 3 did not address economic barriers to chd prevention feedback was used to revise the pep conclusion a community and culturecentered approach to developing cardiovascular health promotion messages revealed tensions between the researchers vantage point of cultural targeting and the communitys perceptions and reactions to these messages engaging communities in every phase of message design incorporating their ems recognizing community heterogeneity and addressing economic and structural barriers are critical steps to ensuring that health promotion messages reach their intended audience and achieve true cultural appropriateness

Introduction HIV persists as a serious public health issue for Hispanic/Latina women in the US [1][2][3]. The likelihood of being diagnosed with HIV in her lifetime is significantly higher for Latinas than for non-Latina white women in the US [1][2][3]. Poverty, unemployment, low education, discrimination, and barriers to healthcare access increase Latinas' risk for HIV infection [4]. One fourth of Latinas in the US live under the poverty line, and over half are near poverty levels [5]. One in five Latinas ages 25-29 year has not graduated from high school as compared to one in 12 women from all other ethnic/racial groups [6]. One of the most disadvantaged and underserved groups of adult Latinas are seasonal workers. Latina seasonal workers are defined in this study as individuals who work or whose spouse/partner works in agriculture at a location within 75 miles of their home [7,8]. LSW are economically disadvantaged in the US with approximately 75% living below the poverty level [9]. Areas in the South and areas with a high concentration of Latinos, such as South Florida, are significantly impacted by the HIV epidemic [10]. However, there are few studies implementing and evaluating HIV prevention interventions for this at-risk population. Miami-Dade County is the epicenter of the HIV epidemic in the US, with an incidence four times the national average [11]. Among adults diagnosed with HIV in 2017, Latinos accounted for 59% of cases in Miami Dade County [12]. MDC's HIV epidemic predominantly affects men, with only 26% of people living with HIV being women. However, in Homestead, Florida City, Naranja and vicinity areas, where the majority of residents are LSW, 44% of people living with HIV are female [13]. Further, 85% of women reported heterosexual sex as the mode of HIV transmission [13]. HIV prevention strategies for underserved Latinas, such as seasonal workers, should consider cultural norms, cultural values, and socialization contexts, which influence Latinas' risk for HIV [14]. Social network-based interventions address these considerations by incorporating cultural norms and values such as personalismo and socialization contexts [15]; using link-tracing designs to recruit from high risk populations, build trust with intervention participants, and increase participation rates; and providing an opportunity for members of disenfranchised communities to serve as leaders, health intervention champions, and positive role models [16]. Despite these advantages of social network-based interventions, there are currently no HIV prevention education programs for LSW that incorporate social network approaches. The present study PROGRESO EN SALUD , designed to address this need, evaluated two interventions based on social network recruitment approaches to increase: cognitive factors , behavioral factors , and communication factors regarding HIV . --- Materials and Methods The longitudinal PROGRESO study consisted of a total of three visits over a 12-months period. We recruited and enrolled 261 LSW in Miami Dade County-Florida . The first enrollment occurred in June 2015, the last enrollment in April 2016, and the last follow-up in February 2017. Eligibility criteria included: identifying as a female age 18 years or older, living in a seasonal worker community, being able to speak and understand Spanish, reporting at least one episode of condomless sex, reporting consumption of alcohol or other drugs three months prior to the baseline interview, reporting likely to remain in the general geographic area for the next two years, and being able to understand and provide written informed consent. We guided the structure of this paper using the Consolidated Standards of Reporting Trials 2010 guidelines [17]. Using community-based participatory research approaches, we identified a community partner located in a Latino seasonal working community in South Florida to implement this study. Recruitment and intervention procedures were designed to incorporate Latino cultural values such as personalismo and collectivism. The cultural value of personalismo refers to a preference for friendship with close individuals with similar sociodemographic characteristics , suggesting a preference for familiarity in these relationships [15]. Thus, personalismo was incorporated into the social network recruitment and configuration of the sample in a way that reflected the preference for holding conversations about sensitive topics, such as HIV prevention, only after establishing friendships based on trust, support, and empathy [18,19]. The pre-implementation phases included the following activities in accordance with the Consolidated Framework for Implementation Research domains: revising the intervention kit material; assessing the available resources and cost of implementation; developing the program budget; identifying appropriate setting, space, and equipment with the collaborating community partner; assessing staff's capacity to conduct the intervention; training staff members using the VOICES manual on leading skill-building sessions, condom use, negotiation skills, and evaluation tools for program implementation; identifying and developing adequate and innovative methods to recruit Latina seasonal workers at risk for HIV; identifying and hiring members from the community with adequate skills to perform small group facilitation and recruitment of participants; implementing the human subjects protection training with all personnel involved in the program; establishing recruitment partnerships with over 30 local/state health officials and private and public organizations working with the seasonal worker community; implementing a qualitative study to gain specific information regarding this community; and developing an adaptation of the intervention implementation using a community-based participatory research approach [20]. Our partnering community-based organization played a key role in all phases of the study, including delivery of the intervention and data collection. Study participants were recruited at locations where seasonal workers are known to reside, including trailer parks, dormitory-style housing, apartment buildings, motels, duplexes, neighborhoods of single/duplex housing, and seasonal workplaces in the Homestead/Florida City area . Members from our community partner identified twenty seed individuals, the "Latina leaders". Seeds were respected women in the seasonal worker community who had the ability to reach many peers. The first ten enrolled seeds were assigned to VOICES and the last ten seeds to HEALTHY. Recruitment procedures incorporated the cultural value of collectivism. In Latino communities, collectivism is a cultural orientation that values close, nurturing, and supportive interpersonal relationships over individualistic behaviors and attitudes. According to this orientation, a person is seen as part of a family and broader community of friends and acquaintances and should accept responsibility for this role [21]. Consistent with collectivism values, in both interventions, we provided Latina leader seeds with instructions on how to promote interactions and conversations about HIV prevention within their social networks, so that underserved Latinas in their community could support one another. We implemented a link-tracing or social network respondent-driven sampling design to configure groups of 13 participants, an adequate number for a social network-based intervention. Each seed was asked to invite three friends, . The first-order friends were further asked to invite three of their own friends [22]. As a result, for each seed, a network of 13 actors was recruited in three respondent-driven waves, with wave one including the seed, wave two including three first-order friends, and wave three including nine second-order friends. All participants in the seeds' chain received the same intervention. Seeds were asked to have all members of their social network contact the project coordinator. If any invited friend declined participation, the seed/friend was asked to invite a substitute friend until a social network of 13 actors was formed. Members from our community partner checked that participants were not part of two social networks. These types of word-of-mouth recruitment strategies incorporating Latino cultural values have been shown to successfully work in similar populations and settings, and they differed from recruitment strategies of the original VOICES intervention, which recruited participants from waiting rooms of HIV and sexually transmitted infections clinics [23]. --- The Adapted VOICES Intervention VOICES is a video-based intervention that is grounded in the Theory of Reasoned Action [24]. According to the Theory of Reasoned Action, human behaviors are guided by two factors: a person's attitudes, beliefs, and experiences; and how a person believes others think he or she should act in a given circumstance . VOICES is a US Centers for Disease Control and Prevention High Impact Prevention Program which helps bridge the gap between HIV/STI prevention research and practice [25][26][27][28][29][30]. The original VOICES is a single session, video-based program for the prevention of HIV and other sexually transmitted diseases. VOICES was designed to encourage condom use and improve condom negotiation skills among heterosexual African American and Latino men and women, aged 18 years and older, who are at very high risk for HIV and other STIs [25][26][27][28][29][30]. VOICES has been adapted to specific populations such as individuals in correctional settings and men who have sex with men [26], but has not been previously adapted to Latina seasonal workers. In our adapted version of VOICES, we provided Latina Leaders with additional instructions on how to promote interactions and conversations about HIV prevention within their friendship networks. At time points of three months and nine months after the intervention session, Latina Leaders met with the individuals from their network to discuss HIV/STI prevention, either as a group, in a single session, or via individual home visits depending on the participants' availability. The Latina Leaders were given three HIV/STI informational pamphlets in Spanish to guide conversations each time. These pamphlets were also distributed to each member of her social network. A detailed description of the cultural adaption and the integration of social networks approaches in VOICES is described in Table S1, and additional information can be found elsewhere [7,31]. --- The HEALTHY Intervention The HEALTHY intervention aimed to increase participants' awareness of HIV-specific health issues. Teaching topics included general HIV prevention and risk reduction strategies such as condom use, avoidance of over-the-counter medication, and HIV communication. In addition, Lay Health Advisors spoke about other general health strategies such as hygiene and healthy living in crowded conditions. HEALTHY was similar to VOICES in dosage, as it consisted of one session that lasted approximately three hours. Moreover, similar quality control provisions were used for the HEALTHY condition, particularly regarding fidelity. HEALTHY did not incorporate a video. We developed, culturally adapted, and pre-tested flip-chart posters with large graphical representations used by our Project Coordinator and Lay Health Advisor to provide information and promote discussion surrounding health topics. Seeds were neither asked nor discouraged from promoting conversations around HIV prevention with others in their social networks. --- Assessments At baseline, participants completed a structured individual face-to-face interview in Spanish using computer assisted personal interviewing software in a private office of the collaborating community agency. Interviews were performed by six trained bilingual Latinas. The questionnaire was originally developed in English then translated into Spanish and back-translated to English to ensure the integrity of the instrument and language translation competencies. The instrument was pilot tested twice with a total of 10 participants to confirm that the content and language would be clear to participants. Our Lay Health Advisor performed retention activities via phone calls and home visits. Follow-up assessment interviews were similar to baseline assessments and were repeated at 6 months and 12 months post-intervention. These assessments collected information on cognitive factors , behavioral factors , and communication factors regarding HIV . Interviewers discussed the importance of informed consent and obtained written consent from all participants. Both interventions included one health promotion session that lasted approximately three hours. Participant incentives were the following: a bag lunch and $40 for the baseline interview; $40 for attending the intervention; $50 for taking the 6-months interview; and $55 for taking the 12-months interview. In addition, seed individuals received $10 for each participant they referred and who participated in the interviews, $10 for each member of their group who attended the intervention, and $10 for each group member with whom they discussed the informational materials at three-and nine-months post intervention . The interventions were audio-recorded to assess the fidelity of the implementation. This study was approved by the Institutional Review Board of Florida International University, and study staff received informed consent from participants prior to data collection. --- Measures Condom use was assessed with four items regarding the frequency of condom use during vaginal and anal sex in the past 30 days, with a primary sex partner and/or casual sexual partner . Questions were measured on a scale from 1 to 4 . The four questions about frequency of condom use were combined into a single ordinal variable indicating the least frequent level of condom use with any partner. For example, if the participant reported "never" using a condom for vaginal or anal sex with a primary sex partner and "sometimes" using a condom for vaginal or anal sex with a casual sex partner, that person's condom use was coded as "never". Female condom use was assessed by asking, "Have you used female condoms?" . HIV testing was assessed by asking, "Have you been tested for HIV during the past 6 months?" Reports of HIV testing at the 6-months and 12-months follow-up interviews were combined into a single binary variable to assess HIV testing any time during the 12-months post intervention. Talk with friends about HIV prevention was assessed with the following two questions: "Have you talked with your friends about ways to convince your partner to use condoms?" and "Have you talked with your friends about ways to have sex with a condom?" Response options ranged on a five-point scale from 4 to 0 . The total score was calculated by summing the scores from the two items , with a higher score representing a higher frequency of communication with friends regarding HIV prevention. HIV knowledge was assessed with 18 true/false items from the validated HIV Knowledge Questionnaire [14]. Assigning 1 point to each correct answer, the total score indicated the number of items answered correctly . A higher score indicated a higher level of HIV-related knowledge. Participants' condom use self-efficacy was assessed with a seven-item four-point Likert-type scale [32]. Items evaluated self-efficacy by measuring respondents' agreement with statements such as, "It would be easy to make my partner use a condom", with possible responses ranging from 1 to 4 . The score from items with statements that did not reflect positive condom use self-efficacy were reversed. The total score was calculated by summing the scores from the seven items , with a higher score representing a higher level of self-efficacy for HIV prevention strategies. Further information about this measure can be found elsewhere [7]. Adequate knowledge of condom use was measured using a five item, five-point Likert-type scale including items such as "You remember to hold the base of the condom when you take the condom off ", with responses ranging from 0 to 4 . The total score was calculated by summing the scores from the five items , with a higher score representing a higher level of correct use of condoms [7,31]. Intentions to negotiate safe sex with male partner was measured with four items . Response options ranged on a four-point scale from 4 to 1 . The total score was calculated by summing the scores from the four items , with a higher score representing a higher intention to negotiate safe sex with male partner. --- Data Analysis Descriptive statistics at baseline included proportions for categorical variables, and means and standard deviations for continuous variables. Socio-demographic differences between participants who completed the study and those who were lost to follow-up were assessed using chi-square and one-way analysis of variance tests. Analyses were performed by intention to treat. Because each participant contributed three values , generalized estimating equations models were used to estimate the effects, properly adjusted for non-independent contributions of both social network interventions [33,34]. The GEE method is a robust and extensively used method that assesses the time trend in repeated measurements, addressing random, missing, and misspecification of the true correlation structure. Gaussian family multivariate models were calculated addressing exchangeable working correlations with the package geepack [34]. Both individual-level and cluster-level covariates were included in these models. In order to address multiple comparison bias, separate models were performed for each outcome. Models were controlled for variable time. We estimated beta coefficients, p values, and 95% confidence intervals. Effect sizes were assessed using the R 2 . An α = 0.05 was used throughout the analysis. Analyses were performed using the R software environment. --- Results A total of 192 participants completed the 6-months follow-up assessment, and 197 participants completed the 12-months follow-up assessment. Sample demographics, presented in Table 1, indicate that there were no significant differences between participants from VOICES and HEALTHY. Loss to follow-up. There were no significant differences between participants who completed the 12-months survey and those who did not in terms of age = 0.012, p = 0.914), education = 3.84, p = 0.698), marital status (X 2 = 3.90, p = 0.564), country of origin = 1.21, p = 0.271), income = 0.049, p = 0.825), or having health insurance (X 2 = 3.70, p = 0.055) . --- Cognitive Factors HIV knowledge. Generalized estimating equation models showed that the HIV knowledge trajectory improved significantly between baseline and the 6-months follow-up and between baseline and the 6-months and 12-months follow-ups . Results also showed that the HIV knowledge trajectories were statistically significantly higher for HEALTHY than VOICES . Condom use self-efficacy trajectory also improved significantly between baseline and the 6-months follow-up and between baseline and the 6-months and 12-months follow-ups . Condom use self-efficacy trajectories were statistically significantly higher for HEALTHY than VOICES interventions . The trajectory for adequate condom use knowledge improved significantly between baseline and the 6-months follow-up and between baseline and the 6-months and 12-months follow-ups . We found no statistically significant intervention effects for adequate condom use knowledge. --- Behavioral Factors Changes before this program and during the implementation of the program were calculated for condom use, female condom use, and HIV testing . A significant condom use trajectory was found between baseline and the 6-months follow-up and between baseline and the 6-months and 12-months follow-ups . At baseline, 35% of VOICES participants reported using a condom during sexual intercourse in the past 30 days compared to 53% at the 6-months follow-up and 52% at the 12-months follow-up. At baseline, 34% of HEALTHY participants reported using a condom during sexual intercourse in the past 30 days compared to 49% at the 6-months follow-up and 44% at the 12-months follow-up . The trajectory of female condom use was significant between baseline and the 6-months follow-up and between baseline and the 6-months and 12-months follow-ups . At baseline, 9% of VOICES participants reported using a female condom compared to 52% at the 6-months and 12-months follow-ups. At baseline, 11% of HEALTHY participants reported using a female condom compared to 14% at the 6-months follow-up and 18% at the 12-months follow-up. We compared HIV testing at baseline and combined answers from the 6-months and 12-months follow-ups. A significant change was found for HIV testing . We found no statistically significant intervention effects for any of the three behavioral factors. --- Communication Factors The trajectory of having conversations with friends about HIV prevention was significant between baseline and the 6-months follow-up and between baseline and the 6-months and 12-months follow-ups . The trajectory for intention to negotiate safe sex with male partner was only significant between baseline and the 6-months follow-up . We found no statistically significant intervention effects for these two communication factors. --- Discussion This study aimed to evaluate two social network-adapted HIV interventions. The 261 LSW participants were recruited through friendship networks and received either the social network adapted VOICES or HEALTHY intervention. Both interventions led to significant changes over time in cognitive factors , behavioral factors , and communication factors . Overall, both interventions were equally effective with the exception that HEALTHY had a higher effect on HIV knowledge and condom use self-efficacy. --- Discussion This study aimed to evaluate two social network-adapted HIV interventions. The 261 LSW participants were recruited through friendship networks and received either the social network adapted VOICES or HEALTHY intervention. Both interventions led to significant changes over time in cognitive factors , behavioral factors , and communication factors . Overall, both interventions were equally effective with the exception that HEALTHY had a higher effect on HIV knowledge and condom use self-efficacy. Our findings strengthen the evidence base supporting the utility of link-tracing recruitment designs to recruit from previously unengaged populations. Link-tracing recruitment designs have positive effects on HIV prevention outcomes, including sustained benefits 12-months after the implementation of the intervention session. Our results suggest that existing best practice interventions widely used to address health care concerns affecting Latinas can be enhanced by incorporating social network recruitment approaches to improve cognitive, behavioral, and communication factors. This study also supports the literature suggesting that interventions incorporating social networks can have positive effects on HIV prevention and treatment outcomes, including sustained benefits beyond study periods [35]. Knowledge and behaviors can spread through social ties and interactions via several different mechanisms such as persuasion, communication of norms, modeling, information, support, and social pressure [36,37]. Social networks can amplify diffusion beyond single dyads or pairs of individuals [38][39][40]. As a result, changes in the cognitive factors, behavioral factors, and communication factors of one network "actor" can cascade within and between social networks, producing behavioral changes in the population-at-large. Such cascades offer the prospect of increasing the cost-effectiveness and reach of public health programs that incorporate social network data and analyses, especially in low-resource settings [41,42]. We believe the network-based approach, which incorporated Latino cultural values, was instrumental in the success of both interventions. The incorporation of personalismo in using a link-tracing design recruitment allowed for the recruitment of groups of underserved Latina participants who were friends or who had a friend in common. The incorporation of this social network recruitment strategy promoted participants' engagement. Participants from both intervention groups reported that they communicated among themselves via phone calls to remind each other about attending the intervention or scheduling an interview, and in some cases when a seed could not personally contact one member of her network, contact was made by their mutual friends, usually via social media. Participants reported being interested in participating in these interventions not only for their personal benefit, but also to allow their friends to benefit from the intervention. For instance, some participants gave their program incentives to other participants who could not afford transportation to the intervention. Our social network-based approach, incorporating Latino cultural values, created a social environment that allowed Latina participants to feel comfortable discussing sensitive topics, collaborate among themselves, and develop social capital. Our findings should be interpreted within the context of the research limitations. First, we cannot attribute with certainty that the differences between interventions is due to the interventions' effects. The study results could be due to unknown innate differences between the two groups, as a higher proportion of participants in the HEALTHY intervention reported having been tested for HIV at baseline. Nevertheless, the use of GEE models supports the effects of findings being due to the intervention differences [43][44][45]. Second, the study depended on self-reported measures of sensitive information, such as sexual behavior; thus, social desirability and recall bias may have exaggerated the effects of both interventions away from the null. However, as these biases were observed in both groups, we believe they are accounted for in our GEE model. Additionally, care was taken to hire experienced Latina interviewers trained in culturally-appropriate interviewing techniques for data collection. Third, given that our interventions were conducted with a unique population of Latinas, future studies that replicate the aforementioned methods in other regions of the United States and/or with different Latino populations may yield different results. Fourth, this study cannot assess whether the VOICES or HEALTHY intervention was better than usual practice. An important limitation is that we did not include a usual practice control because the study focused on understanding whether it was feasible to implement social network-based interventions in the LSW community and assessing the potential efficacy of these interventions. --- Conclusions Future adaptations of HIV-prevention interventions, including VOICES and HEALTHY should also incorporate biomedical prevention strategies, such as HIV pre-exposure prophylaxis . The United States Food and Drug Administration approved the use of the anti-retroviral combination of tenofovir and emtricitabine for PrEP in July 2012, in tandem with our program's design [46]. As a result, the present study did not incorporate PrEP education into the intervention components. PrEP has been shown to reduce HIV transmission in sexually active heterosexual adults by up to 60% and for individuals who take PrEP daily, the HIV transmission rate is reduced up to 99% [47][48][49][50]. Many underserved communities are unaware of the existence and/or efficacy of PrEP [51][52][53][54]. Innovative strategies are needed for dissemination of PrEP information to women at risk for HIV in a way that is believable and empowering [54]. In future work, we plan to adapt the social network approach used to include PrEP knowledge and uptake among LSW at risk for HIV infection. Future research is needed to support our promising findings, suggesting that social network methods can be incorporated into effective HIV prevention interventions for LSW and women from other communities. --- Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/16/22/4530/s1, Table S1: Original and adapted core components of VOICES, Figure S2 ---

Background: Miami-Dade County, where many Latina seasonal workers reside and work, has the highest incidence of the human immunodeficiency virus (HIV) in the US: a rate four times the national average. Despite this disproportionate risk for HIV, there are no HIV prevention interventions that aim to decrease HIV among Latina seasonal workers. Methods: The PROGRESO EN SALUD study compared the outcomes of two interventions adapted to include a social network component (VOICES and HEALTHY). Recruitment used a social network respondent-driven sampling design in which each seed was asked to recruit three friends, and those friends were asked to recruit three friends, for a total of twenty groups of 13 friends. We collected data at baseline, and 6 months and 12 months post intervention completion. We used generalized estimating equation models, properly adjusted for non-independent contributions of both social network interventions, to estimate the effects. Gaussian family multivariate models were calculated, addressing exchangeable working correlations, including both individual-level and cluster-level covariates in these models. Results: A total of 261 Latina seasonal workers participated in either the HEALTHY or the VOICES intervention. There were significant changes over time in cognitive factors (HIV knowledge, condom use self-efficacy, and adequate knowledge of condom use), behavioral factors (condom use, female condom use, and HIV testing), and communication factors (talking with friends about HIV prevention and intention to negotiate safe sex with male partners). Discussion: This study supports the literature suggesting that interventions incorporating social networks can have positive effects on HIV prevention and treatment outcomes, including sustained benefits beyond study periods.

introduction hiv persists as a serious public health issue for hispaniclatina women in the us 1 2 3 the likelihood of being diagnosed with hiv in her lifetime is significantly higher for latinas than for nonlatina white women in the us 1 2 3 poverty unemployment low education discrimination and barriers to healthcare access increase latinas risk for hiv infection 4 one fourth of latinas in the us live under the poverty line and over half are near poverty levels 5 one in five latinas ages 2529 year has not graduated from high school as compared to one in 12 women from all other ethnicracial groups 6 one of the most disadvantaged and underserved groups of adult latinas are seasonal workers latina seasonal workers are defined in this study as individuals who work or whose spousepartner works in agriculture at a location within 75 miles of their home 78 lsw are economically disadvantaged in the us with approximately 75 living below the poverty level 9 areas in the south and areas with a high concentration of latinos such as south florida are significantly impacted by the hiv epidemic 10 however there are few studies implementing and evaluating hiv prevention interventions for this atrisk population miamidade county is the epicenter of the hiv epidemic in the us with an incidence four times the national average 11 among adults diagnosed with hiv in 2017 latinos accounted for 59 of cases in miami dade county 12 mdcs hiv epidemic predominantly affects men with only 26 of people living with hiv being women however in homestead florida city naranja and vicinity areas where the majority of residents are lsw 44 of people living with hiv are female 13 further 85 of women reported heterosexual sex as the mode of hiv transmission 13 hiv prevention strategies for underserved latinas such as seasonal workers should consider cultural norms cultural values and socialization contexts which influence latinas risk for hiv 14 social networkbased interventions address these considerations by incorporating cultural norms and values such as personalismo and socialization contexts 15 using linktracing designs to recruit from high risk populations build trust with intervention participants and increase participation rates and providing an opportunity for members of disenfranchised communities to serve as leaders health intervention champions and positive role models 16 despite these advantages of social networkbased interventions there are currently no hiv prevention education programs for lsw that incorporate social network approaches the present study progreso en salud designed to address this need evaluated two interventions based on social network recruitment approaches to increase cognitive factors behavioral factors and communication factors regarding hiv materials and methods the longitudinal progreso study consisted of a total of three visits over a 12months period we recruited and enrolled 261 lsw in miami dade countyflorida the first enrollment occurred in june 2015 the last enrollment in april 2016 and the last followup in february 2017 eligibility criteria included identifying as a female age 18 years or older living in a seasonal worker community being able to speak and understand spanish reporting at least one episode of condomless sex reporting consumption of alcohol or other drugs three months prior to the baseline interview reporting likely to remain in the general geographic area for the next two years and being able to understand and provide written informed consent we guided the structure of this paper using the consolidated standards of reporting trials 2010 guidelines 17 using communitybased participatory research approaches we identified a community partner located in a latino seasonal working community in south florida to implement this study recruitment and intervention procedures were designed to incorporate latino cultural values such as personalismo and collectivism the cultural value of personalismo refers to a preference for friendship with close individuals with similar sociodemographic characteristics suggesting a preference for familiarity in these relationships 15 thus personalismo was incorporated into the social network recruitment and configuration of the sample in a way that reflected the preference for holding conversations about sensitive topics such as hiv prevention only after establishing friendships based on trust support and empathy 1819 the preimplementation phases included the following activities in accordance with the consolidated framework for implementation research domains revising the intervention kit material assessing the available resources and cost of implementation developing the program budget identifying appropriate setting space and equipment with the collaborating community partner assessing staffs capacity to conduct the intervention training staff members using the voices manual on leading skillbuilding sessions condom use negotiation skills and evaluation tools for program implementation identifying and developing adequate and innovative methods to recruit latina seasonal workers at risk for hiv identifying and hiring members from the community with adequate skills to perform small group facilitation and recruitment of participants implementing the human subjects protection training with all personnel involved in the program establishing recruitment partnerships with over 30 localstate health officials and private and public organizations working with the seasonal worker community implementing a qualitative study to gain specific information regarding this community and developing an adaptation of the intervention implementation using a communitybased participatory research approach 20 our partnering communitybased organization played a key role in all phases of the study including delivery of the intervention and data collection study participants were recruited at locations where seasonal workers are known to reside including trailer parks dormitorystyle housing apartment buildings motels duplexes neighborhoods of singleduplex housing and seasonal workplaces in the homesteadflorida city area members from our community partner identified twenty seed individuals the latina leaders seeds were respected women in the seasonal worker community who had the ability to reach many peers the first ten enrolled seeds were assigned to voices and the last ten seeds to healthy recruitment procedures incorporated the cultural value of collectivism in latino communities collectivism is a cultural orientation that values close nurturing and supportive interpersonal relationships over individualistic behaviors and attitudes according to this orientation a person is seen as part of a family and broader community of friends and acquaintances and should accept responsibility for this role 21 consistent with collectivism values in both interventions we provided latina leader seeds with instructions on how to promote interactions and conversations about hiv prevention within their social networks so that underserved latinas in their community could support one another we implemented a linktracing or social network respondentdriven sampling design to configure groups of 13 participants an adequate number for a social networkbased intervention each seed was asked to invite three friends the firstorder friends were further asked to invite three of their own friends 22 as a result for each seed a network of 13 actors was recruited in three respondentdriven waves with wave one including the seed wave two including three firstorder friends and wave three including nine secondorder friends all participants in the seeds chain received the same intervention seeds were asked to have all members of their social network contact the project coordinator if any invited friend declined participation the seedfriend was asked to invite a substitute friend until a social network of 13 actors was formed members from our community partner checked that participants were not part of two social networks these types of wordofmouth recruitment strategies incorporating latino cultural values have been shown to successfully work in similar populations and settings and they differed from recruitment strategies of the original voices intervention which recruited participants from waiting rooms of hiv and sexually transmitted infections clinics 23 the adapted voices intervention voices is a videobased intervention that is grounded in the theory of reasoned action 24 according to the theory of reasoned action human behaviors are guided by two factors a persons attitudes beliefs and experiences and how a person believes others think he or she should act in a given circumstance voices is a us centers for disease control and prevention high impact prevention program which helps bridge the gap between hivsti prevention research and practice 25 26 27 28 29 30 the original voices is a single session videobased program for the prevention of hiv and other sexually transmitted diseases voices was designed to encourage condom use and improve condom negotiation skills among heterosexual african american and latino men and women aged 18 years and older who are at very high risk for hiv and other stis 25 26 27 28 29 30 voices has been adapted to specific populations such as individuals in correctional settings and men who have sex with men 26 but has not been previously adapted to latina seasonal workers in our adapted version of voices we provided latina leaders with additional instructions on how to promote interactions and conversations about hiv prevention within their friendship networks at time points of three months and nine months after the intervention session latina leaders met with the individuals from their network to discuss hivsti prevention either as a group in a single session or via individual home visits depending on the participants availability the latina leaders were given three hivsti informational pamphlets in spanish to guide conversations each time these pamphlets were also distributed to each member of her social network a detailed description of the cultural adaption and the integration of social networks approaches in voices is described in table s1 and additional information can be found elsewhere 731 the healthy intervention the healthy intervention aimed to increase participants awareness of hivspecific health issues teaching topics included general hiv prevention and risk reduction strategies such as condom use avoidance of overthecounter medication and hiv communication in addition lay health advisors spoke about other general health strategies such as hygiene and healthy living in crowded conditions healthy was similar to voices in dosage as it consisted of one session that lasted approximately three hours moreover similar quality control provisions were used for the healthy condition particularly regarding fidelity healthy did not incorporate a video we developed culturally adapted and pretested flipchart posters with large graphical representations used by our project coordinator and lay health advisor to provide information and promote discussion surrounding health topics seeds were neither asked nor discouraged from promoting conversations around hiv prevention with others in their social networks assessments at baseline participants completed a structured individual facetoface interview in spanish using computer assisted personal interviewing software in a private office of the collaborating community agency interviews were performed by six trained bilingual latinas the questionnaire was originally developed in english then translated into spanish and backtranslated to english to ensure the integrity of the instrument and language translation competencies the instrument was pilot tested twice with a total of 10 participants to confirm that the content and language would be clear to participants our lay health advisor performed retention activities via phone calls and home visits followup assessment interviews were similar to baseline assessments and were repeated at 6 months and 12 months postintervention these assessments collected information on cognitive factors behavioral factors and communication factors regarding hiv interviewers discussed the importance of informed consent and obtained written consent from all participants both interventions included one health promotion session that lasted approximately three hours participant incentives were the following a bag lunch and 40 for the baseline interview 40 for attending the intervention 50 for taking the 6months interview and 55 for taking the 12months interview in addition seed individuals received 10 for each participant they referred and who participated in the interviews 10 for each member of their group who attended the intervention and 10 for each group member with whom they discussed the informational materials at threeand ninemonths post intervention the interventions were audiorecorded to assess the fidelity of the implementation this study was approved by the institutional review board of florida international university and study staff received informed consent from participants prior to data collection measures condom use was assessed with four items regarding the frequency of condom use during vaginal and anal sex in the past 30 days with a primary sex partner andor casual sexual partner questions were measured on a scale from 1 to 4 the four questions about frequency of condom use were combined into a single ordinal variable indicating the least frequent level of condom use with any partner for example if the participant reported never using a condom for vaginal or anal sex with a primary sex partner and sometimes using a condom for vaginal or anal sex with a casual sex partner that persons condom use was coded as never female condom use was assessed by asking have you used female condoms hiv testing was assessed by asking have you been tested for hiv during the past 6 months reports of hiv testing at the 6months and 12months followup interviews were combined into a single binary variable to assess hiv testing any time during the 12months post intervention talk with friends about hiv prevention was assessed with the following two questions have you talked with your friends about ways to convince your partner to use condoms and have you talked with your friends about ways to have sex with a condom response options ranged on a fivepoint scale from 4 to 0 the total score was calculated by summing the scores from the two items with a higher score representing a higher frequency of communication with friends regarding hiv prevention hiv knowledge was assessed with 18 truefalse items from the validated hiv knowledge questionnaire 14 assigning 1 point to each correct answer the total score indicated the number of items answered correctly a higher score indicated a higher level of hivrelated knowledge participants condom use selfefficacy was assessed with a sevenitem fourpoint likerttype scale 32 items evaluated selfefficacy by measuring respondents agreement with statements such as it would be easy to make my partner use a condom with possible responses ranging from 1 to 4 the score from items with statements that did not reflect positive condom use selfefficacy were reversed the total score was calculated by summing the scores from the seven items with a higher score representing a higher level of selfefficacy for hiv prevention strategies further information about this measure can be found elsewhere 7 adequate knowledge of condom use was measured using a five item fivepoint likerttype scale including items such as you remember to hold the base of the condom when you take the condom off with responses ranging from 0 to 4 the total score was calculated by summing the scores from the five items with a higher score representing a higher level of correct use of condoms 731 intentions to negotiate safe sex with male partner was measured with four items response options ranged on a fourpoint scale from 4 to 1 the total score was calculated by summing the scores from the four items with a higher score representing a higher intention to negotiate safe sex with male partner data analysis descriptive statistics at baseline included proportions for categorical variables and means and standard deviations for continuous variables sociodemographic differences between participants who completed the study and those who were lost to followup were assessed using chisquare and oneway analysis of variance tests analyses were performed by intention to treat because each participant contributed three values generalized estimating equations models were used to estimate the effects properly adjusted for nonindependent contributions of both social network interventions 3334 the gee method is a robust and extensively used method that assesses the time trend in repeated measurements addressing random missing and misspecification of the true correlation structure gaussian family multivariate models were calculated addressing exchangeable working correlations with the package geepack 34 both individuallevel and clusterlevel covariates were included in these models in order to address multiple comparison bias separate models were performed for each outcome models were controlled for variable time we estimated beta coefficients p values and 95 confidence intervals effect sizes were assessed using the r 2 an α 005 was used throughout the analysis analyses were performed using the r software environment results a total of 192 participants completed the 6months followup assessment and 197 participants completed the 12months followup assessment sample demographics presented in table 1 indicate that there were no significant differences between participants from voices and healthy loss to followup there were no significant differences between participants who completed the 12months survey and those who did not in terms of age 0012 p 0914 education 384 p 0698 marital status x 2 390 p 0564 country of origin 121 p 0271 income 0049 p 0825 or having health insurance x 2 370 p 0055 cognitive factors hiv knowledge generalized estimating equation models showed that the hiv knowledge trajectory improved significantly between baseline and the 6months followup and between baseline and the 6months and 12months followups results also showed that the hiv knowledge trajectories were statistically significantly higher for healthy than voices condom use selfefficacy trajectory also improved significantly between baseline and the 6months followup and between baseline and the 6months and 12months followups condom use selfefficacy trajectories were statistically significantly higher for healthy than voices interventions the trajectory for adequate condom use knowledge improved significantly between baseline and the 6months followup and between baseline and the 6months and 12months followups we found no statistically significant intervention effects for adequate condom use knowledge behavioral factors changes before this program and during the implementation of the program were calculated for condom use female condom use and hiv testing a significant condom use trajectory was found between baseline and the 6months followup and between baseline and the 6months and 12months followups at baseline 35 of voices participants reported using a condom during sexual intercourse in the past 30 days compared to 53 at the 6months followup and 52 at the 12months followup at baseline 34 of healthy participants reported using a condom during sexual intercourse in the past 30 days compared to 49 at the 6months followup and 44 at the 12months followup the trajectory of female condom use was significant between baseline and the 6months followup and between baseline and the 6months and 12months followups at baseline 9 of voices participants reported using a female condom compared to 52 at the 6months and 12months followups at baseline 11 of healthy participants reported using a female condom compared to 14 at the 6months followup and 18 at the 12months followup we compared hiv testing at baseline and combined answers from the 6months and 12months followups a significant change was found for hiv testing we found no statistically significant intervention effects for any of the three behavioral factors communication factors the trajectory of having conversations with friends about hiv prevention was significant between baseline and the 6months followup and between baseline and the 6months and 12months followups the trajectory for intention to negotiate safe sex with male partner was only significant between baseline and the 6months followup we found no statistically significant intervention effects for these two communication factors discussion this study aimed to evaluate two social networkadapted hiv interventions the 261 lsw participants were recruited through friendship networks and received either the social network adapted voices or healthy intervention both interventions led to significant changes over time in cognitive factors behavioral factors and communication factors overall both interventions were equally effective with the exception that healthy had a higher effect on hiv knowledge and condom use selfefficacy discussion this study aimed to evaluate two social networkadapted hiv interventions the 261 lsw participants were recruited through friendship networks and received either the social network adapted voices or healthy intervention both interventions led to significant changes over time in cognitive factors behavioral factors and communication factors overall both interventions were equally effective with the exception that healthy had a higher effect on hiv knowledge and condom use selfefficacy our findings strengthen the evidence base supporting the utility of linktracing recruitment designs to recruit from previously unengaged populations linktracing recruitment designs have positive effects on hiv prevention outcomes including sustained benefits 12months after the implementation of the intervention session our results suggest that existing best practice interventions widely used to address health care concerns affecting latinas can be enhanced by incorporating social network recruitment approaches to improve cognitive behavioral and communication factors this study also supports the literature suggesting that interventions incorporating social networks can have positive effects on hiv prevention and treatment outcomes including sustained benefits beyond study periods 35 knowledge and behaviors can spread through social ties and interactions via several different mechanisms such as persuasion communication of norms modeling information support and social pressure 3637 social networks can amplify diffusion beyond single dyads or pairs of individuals 38 39 40 as a result changes in the cognitive factors behavioral factors and communication factors of one network actor can cascade within and between social networks producing behavioral changes in the populationatlarge such cascades offer the prospect of increasing the costeffectiveness and reach of public health programs that incorporate social network data and analyses especially in lowresource settings 4142 we believe the networkbased approach which incorporated latino cultural values was instrumental in the success of both interventions the incorporation of personalismo in using a linktracing design recruitment allowed for the recruitment of groups of underserved latina participants who were friends or who had a friend in common the incorporation of this social network recruitment strategy promoted participants engagement participants from both intervention groups reported that they communicated among themselves via phone calls to remind each other about attending the intervention or scheduling an interview and in some cases when a seed could not personally contact one member of her network contact was made by their mutual friends usually via social media participants reported being interested in participating in these interventions not only for their personal benefit but also to allow their friends to benefit from the intervention for instance some participants gave their program incentives to other participants who could not afford transportation to the intervention our social networkbased approach incorporating latino cultural values created a social environment that allowed latina participants to feel comfortable discussing sensitive topics collaborate among themselves and develop social capital our findings should be interpreted within the context of the research limitations first we cannot attribute with certainty that the differences between interventions is due to the interventions effects the study results could be due to unknown innate differences between the two groups as a higher proportion of participants in the healthy intervention reported having been tested for hiv at baseline nevertheless the use of gee models supports the effects of findings being due to the intervention differences 43 44 45 second the study depended on selfreported measures of sensitive information such as sexual behavior thus social desirability and recall bias may have exaggerated the effects of both interventions away from the null however as these biases were observed in both groups we believe they are accounted for in our gee model additionally care was taken to hire experienced latina interviewers trained in culturallyappropriate interviewing techniques for data collection third given that our interventions were conducted with a unique population of latinas future studies that replicate the aforementioned methods in other regions of the united states andor with different latino populations may yield different results fourth this study cannot assess whether the voices or healthy intervention was better than usual practice an important limitation is that we did not include a usual practice control because the study focused on understanding whether it was feasible to implement social networkbased interventions in the lsw community and assessing the potential efficacy of these interventions conclusions future adaptations of hivprevention interventions including voices and healthy should also incorporate biomedical prevention strategies such as hiv preexposure prophylaxis the united states food and drug administration approved the use of the antiretroviral combination of tenofovir and emtricitabine for prep in july 2012 in tandem with our programs design 46 as a result the present study did not incorporate prep education into the intervention components prep has been shown to reduce hiv transmission in sexually active heterosexual adults by up to 60 and for individuals who take prep daily the hiv transmission rate is reduced up to 99 47 48 49 50 many underserved communities are unaware of the existence andor efficacy of prep 51 52 53 54 innovative strategies are needed for dissemination of prep information to women at risk for hiv in a way that is believable and empowering 54 in future work we plan to adapt the social network approach used to include prep knowledge and uptake among lsw at risk for hiv infection future research is needed to support our promising findings suggesting that social network methods can be incorporated into effective hiv prevention interventions for lsw and women from other communities supplementary materials the following are available online at table s1 original and adapted core components of voices figure s2

background miamidade county where many latina seasonal workers reside and work has the highest incidence of the human immunodeficiency virus hiv in the us a rate four times the national average despite this disproportionate risk for hiv there are no hiv prevention interventions that aim to decrease hiv among latina seasonal workers methods the progreso en salud study compared the outcomes of two interventions adapted to include a social network component voices and healthy recruitment used a social network respondentdriven sampling design in which each seed was asked to recruit three friends and those friends were asked to recruit three friends for a total of twenty groups of 13 friends we collected data at baseline and 6 months and 12 months post intervention completion we used generalized estimating equation models properly adjusted for nonindependent contributions of both social network interventions to estimate the effects gaussian family multivariate models were calculated addressing exchangeable working correlations including both individuallevel and clusterlevel covariates in these models results a total of 261 latina seasonal workers participated in either the healthy or the voices intervention there were significant changes over time in cognitive factors hiv knowledge condom use selfefficacy and adequate knowledge of condom use behavioral factors condom use female condom use and hiv testing and communication factors talking with friends about hiv prevention and intention to negotiate safe sex with male partners discussion this study supports the literature suggesting that interventions incorporating social networks can have positive effects on hiv prevention and treatment outcomes including sustained benefits beyond study periods

Introduction Moral reasoning concerns what people ought to do, which involves forming moral judgments in social or other situations . Researchers have extensively studied moral reasoning for investigating moral developments in groups organized by elements of social identity, based on genders , age , and profession . These laboratory experiments are primarily conducted using questionnaires and hypothetical social situations that make the conflicts between moral principles stark. However, real-life situations are nuanced and complex, and often present a wide variety of comparatively low-stakes decisions. Social media provide an opportunity to assess the perception of normal social situations, such as understanding others' decisions on morality of behaviors . In this work, we study in-the-wild moral reasoning by examining a popular subcommunity of Reddit called /r/AmITheAsshole . 1 In AITA, a user is decided by majority vote from the commenters. The post involves three parties -I, my parents, and my sister. Commenters provide judgments and reasons about whether the author's behavior was inappropriate. thor) post interpersonal conflicts seeking others' opinions on whether their behaviors were appropriate. AITA defines a few verdict codes, such as NTA indicate authors' behaviors are appropriate, whereas YTA indicate authors' behaviors are inappropriate. Other community members may comment on a post to provide moral judgments and other moral assessment) and the reasoning. Figure 1 shows a post along with comments on it. Each comment includes a predefined community code along with an explanation for it. A verdict of a post is decided by the top-voted comment's verdict. Recent works focus on predicting verdicts of the posts and comments . Another line of work analyzes the community using statistical methods . However, to the best of our knowledge, no empirical work has conducted a systematic analysis to understand the reasoning implicit in the comments. This paper focuses on the commonsense aspects of moral reasoning. We apply Natu- ral Language Processing tools to investigate how the authors' and commenters' social factors shape their distributions and affect moral reasoning. We extract authors' social factors from the posts. These include authors' self-reported genders and posts' topics. Here, we regard a post topic as a part of the author's social factors because the topic provides social information about the author, such as whether the author has had conflicts in marriage. As in previous work, we focus on authors' self-reported genders, not the genders of others involved . For commenters' social factors as proxies of their interests, we leverage the subreddits in which they participate . Extracting social factors from social media submissions has been extensively studied from various viewpoints, such as language bias and contentious conversations . The contextual content in the reasoning can determine the verdict. For instance, in Figure 2, the phrase low empathy refers to the author's behavior and determines a YTA verdict. With a large corpus, these verdict-determining factors would accumulate and reveal the common elements implicit in reasoning about specific social situations. Therefore, we reformulate our task as building a computational predict-then-extract model for categorizing the common elements of the moral reasoning embedded in the comments. Figure 3 describes our research pipeline. Our proposed method involves predicting reasoning and extracting the rationales, categorizing them by meaning similarities, and analyzing their associations with the abovementioned factors. Prediction As discussed above, we distinguish the ratio-nales that refer to authors from those that refer to others. Therefore, we consider the meaning and syntactic features in references to various parties. Specifically, we build a dual-channel context-feature extractor to obtain the global and local context features of sentences in the original post. We evaluate our method in terms of its prediction performance. Extraction We apply the rationalization process to extract rationales from the reasoning. The selected rationales are small but sufficient parts of the input texts that accurately identify the most important information actually used by a neural model. Unlike previous works, we assume no human annotated labels for rationales on social media data. Therefore, we follow Jiang and Wilson to "weakly" label rationales using a domain-related lexicon, the Moral Foundation Theory . We then evaluate multiple methods to select plausible rationales. Categorization and Analysis We apply k-means clustering on the embedding vectors of the rationales and categorize their meaning commonality using a meaning analysis system. Finally, we perform finegrained analysis on the resulting meaning clusters. --- Findings and Contributions To the best of our knowledge, this is the first study to explore moral reasoning in AITA. Through 51,803 posts and 3,675,452 comments, we find meaning commonalities associated with the authors' and commenters' social factors. For example, female authors attract moral judgments expressing angry and egoism in work -related scenarios, while politics and sensible are less likely present in such judgments. In addition, in safety-related situations, comments about judgment of appearance are more prevalent for female authors, whereas physical/mental are less likely to appear in the judgments. Moreover, commenters interested in the art and music subreddits express more emotions such as worry, concern, and confident, than those interested in news and politics. Our proposed model shows a 3% improvement in all averaged scores over finetuned BERT in predicting verdicts of the reasoning. Moreover, our experiments demonstrate that with additional domain knowledge improve a rationale's plausibility. The results indicate that our framework is effective in automatically understanding multiparty online discourses. Our framework is applicable in categorizing dynamic and unpredictable online discourse. For instance, the framework can be applied in automated tools, such as for moderating rule-violating comments. We have released our data and supplementary material. 2 We will release our code once the paper is published. --- Related Work Moral Reasoning in Social Psychology Moral reasoning has long been studied. Bussey and Maughan find that moral decisions by males are typically based on law-andorder reasoning, while those by females are made from an emotional perspective. Walker observe that participants' discussions about moral situations show clear age developmental trends over a two-year period. Wood et al. report that individualism and egoism have a stronger influence on the moral reasoning on business ethics by professionals than by students. However, these studies do not provide a comprehensive understanding of moral reasoning on social media. Morality in Social Media Social media helps ground descriptive ethics. Zhou, Smith, and Lee profile linguistic features and show that the use of the first-person passive voice in a post correlates with receiving a negative judgment. Nguyen et al. give a taxonomy of the structure of moral discussions. Lourie, Bras, and Choi predict morality using social norms collected from AITA. Forbes et al. extract Rules of Thumb from moral judgments of one-liner scenarios. Emelin et al. study social reasoning by constructing a crowdsourced dataset including moral actions, intentions, and consequences. Jiang et al. predict moral judgments on one-line natural language snippets from a wider range of possibilities. Ziems et al. build conversational agents to understand morality in dialogue systems. Genders, Topics, and User Factors Gender differences are often relevant. De Choudhury et al. reveal significant differences between the mental health contents and topics shared by female and male users. De Candia et al. find young and male authors are likelier to receive negative judgments in AITA and society-relevant posts are likelier to receive negative moral judgments than romancerelevant posts in AITA. Ferrer et al. find Reddit post topics are gender-biased; for instance, judgment of appearances-related posts are associated with females while power-related posts are associated with males. Collecting personal information by using users' submissions on online platforms is a common method to explore social media data, such as investigating conversation divisiveness through Reddit . --- Data Reddit discussion structure is of a tree rooted at an initial post; comments reply to the root or to other comments. Definitions We adopt definitions from Guimaraes and Weikum to describe instances in our dataset. A post refers to the starting point in a discussion. 2 https://zenodo.org/record/7850027#.ZEGCCnaZM2w A top-level comment refers to a comment that directly replies to a post. We focus on top-level comments because other comments in AITA may not include judgments and reasoning based on the posts. --- Collection of Posts and Comments We require a large-scared corpus with relevant posts and comments. Previous datasets are either nonpublic or insufficient for our purposes . Therefore, we collected our dataset using PushShift API3 and Reddit API. 4 We scraped over 351,067 posts and the corresponding 10.3M top-level comments from AITA, spanning from its founding in June 2013 to November 2021. We collected these submissions by applying rule-based filters following the aforementioned previous works to ensure their relevance and avoid discrepancies between data from Reddit and archived data from PushShift. We excluded deleted posts and comments because they may violate AITA rules, such as including fake content to solicit outrage. We also exclude posts and comments submitted by deleted accounts and moderators. We selected posts that have at least ten top-level comments to ensure quality. We selected top-level comments that have a predefined code indicating the judgment and fifteen or more characters representing the reasoning. Reddit allows users to give positive and negative feedback to submissions in the form of upvotes and downvotes. Therefore, posts and comments in our dataset are associated with a score5 representing the accumulated differences between upvotes and downvotes. Extraction of Comments' Verdicts The judgments are predefined codes: YTA , NTA , ESH , NAH , and INFO . Some comments use short phrases as codes . Therefore, we applied regular expressions to match such variants. We resolved multiple matches by selecting the second match when there is a transition word such as but. And, we reversed the extracted codes in judgments containing negations such as I do not think using regular expression. We removed sentences marked with >, which indicates a quotation. To evaluate the labeling process, we checked a random sample of 500 submissions. We found 5% false positives and 6% false negatives. Following Lourie, Bras, and Choi , we assigned labels to comments with YTA as 1, NTA as 0, and discard all other instances. --- Comment Corpus Our corpus selection criteria require that selected comments: have scores higher than 100, have a token length between 20 and 200, have commenters who were previously awarded by a flair , and replied to posts that contain authors' self-reported genders. A flair is awarded by AITA and represents how many times a user's judgments have become the most upvoted comments, thus, reflecting the commenter's reputation. As a result, our corpus includes 51,803 posts and 120,760 out of 3,675,452 total comments that belong to the selected posts. The label distribution of NTA to YTA is 60-40. We randomly selected 45,505 instances labeled as 0 and all instances labeled as 1. We split our corpus as 80/10/10 for training, development, and testing. --- Method This section introduces the processes of extracting social factors, verdicts, and rationales. There are two advantages to use rationalization for summarising common patterns of moral reasoning: it can be trained with neural networks in an unsupervised manner ,6 and it provides appropriate rationales for social media data . --- Extraction of Topics, Genders, and Interests We adopt Nguyen et al.'s topic model to identify topics for posts in our corpus. Then, we use regular expressions to extract authors' selfreported genders. We leverage commenters' participation on Reddit to proxy their interests. Topic Modeling for Posts' Topics Latent Dirichlet Allocation is widely applied for clustering text. Nguyen et al. find 47 named topics in AITA posts via LDA models. These topics are associated with clusters of words sorted by the probability of belonging to that topic. We found that our corpus and Nguyen et al.'s corpus have 34,098 posts in common, and the rest 17,705 posts were submitted after April 2020 . We follow their method to assign each post the topic that has the highest prior probability. Authors' Genders Extracting demographics from social submissions using regular expressions is common in analyzing Reddit data, such as in exploring contentious conversations . Gender and age are not typically available on Reddit, allowing for anonymous posting. Fortunately, the social media template for posting gender and age, e.g., [25f] enables us to use regular expressions to extract the information. Note that authors typically report the demographic information of multiple parties in the situation described, such as I [25f] and my wife [25m]. Therefore, we extract authors' self-reported genders by filtering first-person pronouns . Besides, we consider gendered alternatives where available; for example, male can be estimated by \b\b) and female by \b). We do not match nonbinary genders because we do not have ground truth labels for nonbinary targets. As a result, we find the female/male split of 90-10 in our dataset We took a random sample of 300 submissions to evaluate the regular expression. We found that gender extracted using our regular expression matches the manually labeled one 94% of the time. Commenters' Interests Following De Candia et al. , we proxy commenters' interests via the subreddits they participated in by making at least one submission within a six-month period based on the timestamp of the comment found in our corpus. We focus on the commenters because they have made quality judgments. We chose a six-month window based on users' prolificity, as defined by Beel et al. , considering a user prolific if they submit more than 25 times in their interested subreddit. We manually checked 100 users and found that a six-month period makes users more prolific than four, eight, and twelve months. We discard deleted user accounts, which restricts our analysis to 46,519 commenters with 104,915 comments. Unlike De Candia et al.'s work, we map the collected subreddits following Reddit's predefined subreddit categories. 7 Commenters may have interests in various categories. Therefore, we set their interest as their most frequently submitted subreddit. --- Predicting Verdicts then Extracting Rationales We now introduce the rationalization process, followed by how our predict-then-extract model operates. Introduction to Rationalization Process Given a pretrained model M, each instance is of the form of , where x = [x i ] are the input tokens and y ∈ {0, 1} is the binary label. The rationalization process outputs a predicted ŷ with a binary mask z = [z i ] ∈ {0, 1} of input length, indicating which tokens are used to make the decision . The tokens masked with ones are called rationales , and considered accurate explanations of the model's decisions and can be Figure 4: Soft rationalization is a three-phased process. The predictor outputs ŷ and importance scores s. The binarizer assigns masks to tokens z. The classifier predicts unmasked tokens; it predicts y again to evaluate a rationale's accuracy. used alone to make correct predictions . Binarization methods are hard and soft according to . Hard selection uses the Bernoulli distribution to sample binary masks ). In contrast, soft selection outputs multivariable distributions over tokens derived from features, e.g., self-attention values. We adopt soft selection because hard selection faces performance limitations and soft selection is more appropriate when there is no ground truth of rationales . Prediction then Extraction Figure 4 illustrates the architecture of a soft rationalization model. 8 The predictor in Figure 4 is a standard text classification module that predicts a verdict. We omit the last classifier module because we need the rationales instead of accurately predicting y. The importance scores z are computed via feature-scoring methods using the parameters learned during training. Therefore, the extracted rationales can capture the most salient contextual information used by a neural model when predicting a verdict. Our experiments aim to empirically collect plausible rationales for categorizing the commonality of moral reasoning reflected in social media, instead of building an accurate predictor or improving the rationalization extraction performance . Figure 5 shows our predictor. We first weakly label tokens that appear in the moral lexicon. We then obtain embeddings of input instances by adopting the pretrained bert-base-uncased model using Huggingface. 9 Next, we prepare global and local representations of a sentence by a stacked Bidirectional LSTM and a Syntactic Graph Convolutional Network . Then, we feed the concatenated final hidden representation vectors into a fully connected prediction network. The prediction network uses softmax to output the probabilities of a 8 Compared to Lei, Barzilay, and Jaakkola we simplify the names of encoder as predictor and generator as binarizer. And we name extractor as binarizer. 9 https://huggingface.co/ particular verdict. We adopt cross-entropy in the network to measure loss. Global context features are multidimensional embeddings encoded using BERT , which maps a token into a vector based on its context. We adopt the pretrained bert-base-uncased model from Huggingface to obtain embeddings. To obtain extended contexts, we use a Bidirectional LSTM . We compute the hidden states by passing the BERT-encoded embeddings to a stacked BiLSTM: ← -- h g,i ; --→ h g,i = BiLSTM, i = 1, 2, where S represents the encoding output of the last layer of BERT and i denotes the direction. We compute the global context representations h g,1 and h g,2 by averaging the hidden outputs in both directions. Local context features are obtained using a Syntactic Graph Convolutional Network , representing the local syntactic context of each token. We capture words and phrases modifying the parties in input instances by using dependency graphs, which are obtained by applying the Stanford dependency parser using Spacy. 10 The dependency graphs are composed of vertices and directed edges , which capture the complex syntactic relationships between tokens. SGCN operates on directed dependency graphs based on Graph Convolutional Network . GCN is a multilayer message propagation-based graph neural network. Given a vertex v in G and its neighbors N , the vertex representation of v on the layer is: h j+1 v = u∈N W j h j u + b j , where W j ∈ R d j+1 ×d j and b j ∈ R d j+1 are trainable parameters, and d j+1 and d j denote latent feature dimensions of the and the j layers, respectively. SGCN improves GCN by considering the directionality of edges, separating parameters for dependency labels, and applying edgewise gating . Edgewise gating can select impactful neighbors by controlling the gates for message propagation through edges. Therefore, the SGCN module takes word embeddings and syntactic relations to compute local representations. The local representation for a vertex v is: h j+1 v = u∈N g j u,v , where j represents a layer, g is the gate on the jth layer to select impactful neighbors u ∈ N of v, W is the weight, and b represents bias. For each sentence, we use a pooling layer to convert tokens' local representations into a single hidden vector. Domain knowledge is used to weakly label rationales, following . Such unsupervised rationalization favors informative tokens to optimize losses. However, our dataset's highly informative and frequent tokens such as gendered words may not determine the verdict. Therefore, we use the popular psychological theory, Moral Foundation Theory , to effectively select moral rationales. MFT refines morality into five broad domains: care/harm, fairness/cheating, loyalty/betrayal, authority/subversion, and sanctity/degradation. We adopt the extended version of the MFT lexicon , containing 2,041 unique words, to label comments in our corpus. We reprocess the input instances and generate weak labels for rationales z d = [z i d ] ∈ {0, 1} , where z i d = 1 if x i is in the lexicon. We include a loss term L d =i |a i |z i d for the soft selection process , where a i denotes the attention weight for token z i . The term L d lowers the loss when the tokens selected by feature-scoring methods are morality-related; otherwise, it has no effect. For prediction loss, we apply cross-entropy to optimize the network by calculating L using the last hidden layer's output. Combining the loss items, the objective of our model is: arg min L + λL d , where λ controls the weight of domain knowledge loss. --- Experiments and Results We now evaluate of our predict-then-extract model. For extraction performance, we first adopt multiple features scoring methods from previous works, followed by verifying the plausibility of the extracted rationales. --- Experimental Settings Baseline Methods for Prediction We evaluate these machine learning models: the state-of-art transformer model BERT , Logistic Regression , Random Forest , and Support Vector Machine . For LR, we use the lengths of the instances as a baseline model. For traditional machine learning methods, we use GloVe , a text encoder that maps a word into a low-dimensional embedding vector, for textual classification to generate vector representations. For BERT baseline, we apply the "Obtain Representations" and "Prediction Network" modules as shown in Figure 5. We feed CLS representations generated from the embedding layer into the prediction network instead of passing them through the BiLSTM and SGCN networks. Feature Scoring Methods for Extraction We use random selection as a baseline and multiple feature-scoring methods to compute importance scores s: • Random : Randomly allocate importance scores. • Attention : Normalized attention weights . • Scaled Attention : Attention weights multiplied by the corresponding gradients . • Integrated Gradients : The integral of the gradients from the baseline to the original input . • Flexible : A flexible instance-level rationale selection method , under which each instance selects different scoring methods and lengths of rationales. We compare only the above methods because they yield better performance than others, e.g., . Evaluation Metrics for Rationales' Plausibility For prediction, we use macro F1-scores. For extraction, we adopt metrics from previous works : • reverse-Macro F1 : The performance of M in predicting y when using full input and rationale-reduced input. The predicted label with full input is used as the gold standard. Masking rationales should drop the prediction performance; lower is better. • Normalized Sufficiency : Reversed and normalized differences between predicting full input text and rationales: max -p)); higher is better. To avoid overfitting, we regularize the prediction network using the Dropout technique; at each fully connected layer, we apply a Dropout level of d = 0.5. Finally, the prediction network output is fed into the last neural network of two units; with softmax to obtain probability distributions of the verdicts. We train five epochs for all the transformer-based models. All the experiments are implemented from Huggingface. --- Results The prediction performance of a model indicates its ability to distinguish commenters' evaluations of the various parties' behaviors. The extraction performance of a model indicates the plausibility of the rationales it generates. --- Performance of Predicting Verdicts We use five-fold stratified cross-validation for the aforementioned classifiers. For the transformer-based models, we ran each model with five epochs. The reported performance score averages are shown in Table 2. The scores with domain knowledge are calculated with λ = 0.1, which yields the best performance. We observe that neural models outperform traditional machine learning models. The Global-Local-Domain method shows an average of 3% improvement among all the scores compared to a finetuned BERT. We are unable to compare our results with Botzer, Gu, and Weninger because of different research purposes and lack of their dataset and experimental details. Performance of Extracting Rationales Table 3 illustrates the performance of various feature-scoring methods with and without weakly supervision through domain knowledge. We experiment on two scored token-selection methods : selecting the K highest scoring tokens for each instance and selecting highest overall K-gram scoring tokens in the span of input tokens. We adopt TopK for further analysis because it yields the best performance. Although Table 2 shows that considering domain knowledge may not improve prediction performance for all neural models , we observe that using the instance-level rationale extraction method with domain knowledge improves a rationale's plausibility. Combining the results of Table 2 and Table 3, we use Global-Local-Domain to predict and the FLX featurescoring method to extract appropriate rationales. --- Analysis We leverage the 17,808 identified rationales from the 18,202 instances of our corpus's development and test sets as a lexicon. We apply this lexicon on the total 3,675,452 comments in our corpus. We introduce how we identify and cluster the extracted rationales' meanings. Then, we perform a finegrained analysis to investigate how the clusters are associated with the authors' and commenters' social factors. 4: Examples of meaning clusters embedded in moral reasoning for topic-specific posts. Italics show the words that are common between the topics of the same cluster. The results indicate that words used in comments are different based on posts' topics. In addition, adverbs used in Evaluation: Good/Bad are more prevalent than adjectives used in Judgment of Appearance. --- Clustering and Tagging We apply pretrained GloVe embeddings to cluster the meaning similarities of rationales . After manually checking the clustered results, we select GloVe embeddings as they provide more detailed and informative clusters than other embedding methods, such as word2vec . We exclude the rationales that have negative dependencies in the original sentences to avoid ambiguity. To aggregate the most similar embeddings into clusters, we employ the well-known k-means clustering algorithm. We tag the resulting clusters with USAS, 11 a framework for automatic meaning analysis and tagging of text, which is based on McArthur's Longman Lexicon of Contemporary English . We use this lexicon to name the tags. Because 11 http://ucrel.lancs.ac.uk/usas/ the generated rationales contain phrases and words, we filter the phrases composed of words belonging to the same USAS categories, such as extremely awful. We discard clusters of pronouns and prepositions. As a result, we find 86 unique meaning clusters in our dataset. --- Associations between Comments and Factors We measure the Odds Ratio to assess the associations between posts' topics, authors' genders, and meaning clusters. For commenters' interests, we apply linear regression to compute their effects on the judgments. Figure 6 and Table 4 report the results. --- Personal belongings 1.87 roommates The odds ratio values of authors' gender and meaning clusters in different topics. An odds ratio greater than one indicates the category is more likely to appears in the comments when the posters are females compared to males. And an odds ratio smaller than one indicates the opposite. -1.0 -0.5 0.0 0.5 1.0 ×10 -4 Happy/sad:Happy Regression results for the effects of the proxied commenters' interests. An effect that is greater than zero indicates positive effect. And an effect smaller than zero indicates the opposite. 4, we also observe distinct preferences for word usage to convey identical meanings even among categories with similar gender effects, suggesting nuanced and context-specific usage of language in moral reasoning. However, the Evaluation: Good/bad category shows controversial effects, showing biases towards females in safety but towards males in work, indicating polarizing opinions. Interestingly, the most contentious topics, such as relationships , do not show typical gender biases in our analysis. This could be due to the fact that commenters have specific evaluation standards in different moral scenarios. We find distinctive gender effects in work and safety . In such topics, words in Sensible and Law&order are less likely used in comments towards female authors, and words related to Judgement of appearance are more likely to be. The observation can be explained by the reflection of the persistent societal pressure on women to conform to certain beauty standards . Moreover, commenters use different adjectives, verbs, and nouns to emphasize their concerns based on a given situation, while employing similar adverbs to express their emotions. For instance, the adjectives, verbs, and nouns used in Judgment of appearance for work and safety are dissimilar, whereas the adverbs employed in Evaluation: Good/Bad are common. --- Commenters' Interests Matter We now investigate how the commenters' interests affect their moral reasoning. There are eighteen categories of subreddits that the commenters participated in : lifestyle, science, locations, technology, hobbies and interests, law, adult and NSFW, business, social science and humanities, music, sports, entertainment, news and politics, gaming, architecture, art, travel, and education. These categories exhibit high popularity and diversity. For example, news and politics includes subreddits, such as r/PoliticalHumor and r/antiwork, each with over a million users and lifestyle includes r/baking and r/relationships . The proxied commenters' interests are confounded with each other. Therefore, we investigate them simultaneously to measure the causal effects of their interests. We use an Ordinary Least Square , model12 which is a common method for analyzing social variables . The following model captures the linear effects: b = β 0 + β i x i + ϵ i , i ≤ n, where x i denotes the frequency of the ith cluster appearing in judgments b, β represents the constant effect of x i , n is the total number of clusters, and ϵ i ∼ N is normally distributed noise centered at 0. Figure 6b shows the effects of the interest categories on emotion-relevant clusters. We observe that some categories such as Sports and Lifestyle are likelier to positively affect optimistic clusters Happy/sad:Happy than neutral clusters such as Music. In addition, Gaming and Science positively affect using Obligation and Necessity words, such as would, should, and must. Conversely, Social Science and Humanities and Entertainment have a negative effect. The results may be explained by the distinctive personality traits of the social groups the commenters belong to. For example, commenters interested in Art are the most likely to use worry, concern, and confident words and commenters interested in Music are the least likely to use Happy/sad:Happy words. A possible explanation may be that personalities of people interested in art are more emotionally sensitive than others . --- Discussion and Conclusion Our research introduces a new framework for analyzing language on social media platforms. We focus on judgments of social situations and examine how social factors, such as a poster's gender and a commenter's interests, influence the distributions of common elements in the language used in comments. We employ NLP tools and a predict-then-extract model to collect these common elements. Our study demonstrates that the language used in moral reasoning on AITA is influenced by users' social factors. For instance, consistent gender effects are observed in the Calm/Violent/Angry category in education and marriage, with posts authored by males more likely to receive such comments. Interestingly, our analysis reveals nuanced word usage within identical clusters, with verbs such as "kick" and "spitting" being frequently used in the Calm/Violent/Angry category in marriage, whereas adjectives such as "picky" and "mortified" were more common in education. Conversely, the Evaluation: Good/bad category in work and safety elicited conflicting opinions. Our observations corroborate social psychology findings . For example, comments about Judgment of Appearance in work and safety exhibit prevalence for female authors, which indicate the societal pressure on women to conform to beauty standards . Moreover, commenters interested in Music and Art are likelier to express emotions, which may be caused by their personalities . Overall, these findings highlight the context-specific and nuanced nature of language usage in moral reasoning on social media platforms, and contribute to a better understanding of the influence of social factors on language use. Broader Perspectives Our research presents a novel framework for analyzing language usage in online media, which has practical implications for the design of monitoring systems to identify biased submissions in specific communities. This framework can assist commenters in reconsidering their comments and moderators in flagging concerning comments. In addition, the proposed methods can explain why a submission is considered biased and can inform the design of better features to educate new community members about problematic aspects of their submissions. Our findings align with social psychology research and shed light on societal pressures, such as the gendered pressure on appearance in work and safety contexts. Additionally, our study reveals the impact of personal interests on language use. These broader perspectives suggest potential implications for the development of more effective communication strategies online and underscore the need for further research exploring the relationship between language use and social factors in moral reasoning. Limitations and Future Work Our empirical method inherently shares limitations with observational studies, e.g., susceptibility to bias and confounding. There is a limit to how much we can tease apart social factors of the posters and commenters. We acknowledge some of the boundaries are unclear. For example, we treat genders as a social factors, but do the genders also affect posters' writing styles? In addition to our single dataset analysis on AITA, there may be potential for further exploration on other data sets such as the r/relationship_advice subreddit. Additionally, creating new datasets with crowd-sourced moral judgments could be beneficial in expanding the scope of analysis. Although our prediction model takes into account the syntactic relations of input sentences, it is possible for some parties mentioned in a post to be background characters rather than active participants. Moreover, the rationales we extract are not validated with ground-truth labels, mainly due to the complexity of the instances in our dataset. In future work, we plan to leverage our framework to construct annotation guidelines to obtain human-evaluated clusters for analysis. Ethics Statements Reddit is a prominent social media platform. We scrape data from a subreddit using Reddit's publicly available official API and PushShift API, a widely used platform that ingests Reddit's official API data and collates the data into public data dumps. None of the commenters' information was saved during our analysis. The human evaluation mentioned, such as the evaluation of com-ments' labels, was performed by the authors of this paper and colleagues. One potential negative outcome of this research is that it may reinforce stereotypes and biases that already exist. Additionally, the research may not generalize to all populations, and may not account for other factors such as age, culture, and education that could be influencing moral reasoning on social media.

Moral reasoning reflects how people acquire and apply moral rules in particular situations. With social interactions increasingly happening online, social media data provides an unprecedented opportunity to assess in-the-wild moral reasoning. We investigate the commonsense aspects of morality empirically using data from a Reddit subcommunity (i.e., a subreddit) where an author may describe their behavior in a situation to seek comments about whether that behavior was appropriate. A situation may decide other users' comments to provide judgments and reasoning. We focus on the novel problem of understanding the moral reasoning implicit in user comments about the propriety of an author's behavior. Specifically, we explore associations between the common elements of the indicated reasoning and the extractable social factors. Our results suggest that a moral response depends on the author's gender and the topic of a post. Typical situations and behaviors include expressing anger emotion and using sensible words (e.g., f-ck, hell, and damn) in work -related situations. Moreover, we find that commonly expressed reasons also depend on commenters' interests.

introduction moral reasoning concerns what people ought to do which involves forming moral judgments in social or other situations researchers have extensively studied moral reasoning for investigating moral developments in groups organized by elements of social identity based on genders age and profession these laboratory experiments are primarily conducted using questionnaires and hypothetical social situations that make the conflicts between moral principles stark however reallife situations are nuanced and complex and often present a wide variety of comparatively lowstakes decisions social media provide an opportunity to assess the perception of normal social situations such as understanding others decisions on morality of behaviors in this work we study inthewild moral reasoning by examining a popular subcommunity of reddit called ramitheasshole 1 in aita a user is decided by majority vote from the commenters the post involves three parties i my parents and my sister commenters provide judgments and reasons about whether the authors behavior was inappropriate thor post interpersonal conflicts seeking others opinions on whether their behaviors were appropriate aita defines a few verdict codes such as nta indicate authors behaviors are appropriate whereas yta indicate authors behaviors are inappropriate other community members may comment on a post to provide moral judgments and other moral assessment and the reasoning figure 1 shows a post along with comments on it each comment includes a predefined community code along with an explanation for it a verdict of a post is decided by the topvoted comments verdict recent works focus on predicting verdicts of the posts and comments another line of work analyzes the community using statistical methods however to the best of our knowledge no empirical work has conducted a systematic analysis to understand the reasoning implicit in the comments this paper focuses on the commonsense aspects of moral reasoning we apply natu ral language processing tools to investigate how the authors and commenters social factors shape their distributions and affect moral reasoning we extract authors social factors from the posts these include authors selfreported genders and posts topics here we regard a post topic as a part of the authors social factors because the topic provides social information about the author such as whether the author has had conflicts in marriage as in previous work we focus on authors selfreported genders not the genders of others involved for commenters social factors as proxies of their interests we leverage the subreddits in which they participate extracting social factors from social media submissions has been extensively studied from various viewpoints such as language bias and contentious conversations the contextual content in the reasoning can determine the verdict for instance in figure 2 the phrase low empathy refers to the authors behavior and determines a yta verdict with a large corpus these verdictdetermining factors would accumulate and reveal the common elements implicit in reasoning about specific social situations therefore we reformulate our task as building a computational predictthenextract model for categorizing the common elements of the moral reasoning embedded in the comments figure 3 describes our research pipeline our proposed method involves predicting reasoning and extracting the rationales categorizing them by meaning similarities and analyzing their associations with the abovementioned factors prediction as discussed above we distinguish the rationales that refer to authors from those that refer to others therefore we consider the meaning and syntactic features in references to various parties specifically we build a dualchannel contextfeature extractor to obtain the global and local context features of sentences in the original post we evaluate our method in terms of its prediction performance extraction we apply the rationalization process to extract rationales from the reasoning the selected rationales are small but sufficient parts of the input texts that accurately identify the most important information actually used by a neural model unlike previous works we assume no human annotated labels for rationales on social media data therefore we follow jiang and wilson to weakly label rationales using a domainrelated lexicon the moral foundation theory we then evaluate multiple methods to select plausible rationales categorization and analysis we apply kmeans clustering on the embedding vectors of the rationales and categorize their meaning commonality using a meaning analysis system finally we perform finegrained analysis on the resulting meaning clusters findings and contributions to the best of our knowledge this is the first study to explore moral reasoning in aita through 51803 posts and 3675452 comments we find meaning commonalities associated with the authors and commenters social factors for example female authors attract moral judgments expressing angry and egoism in work related scenarios while politics and sensible are less likely present in such judgments in addition in safetyrelated situations comments about judgment of appearance are more prevalent for female authors whereas physicalmental are less likely to appear in the judgments moreover commenters interested in the art and music subreddits express more emotions such as worry concern and confident than those interested in news and politics our proposed model shows a 3 improvement in all averaged scores over finetuned bert in predicting verdicts of the reasoning moreover our experiments demonstrate that with additional domain knowledge improve a rationales plausibility the results indicate that our framework is effective in automatically understanding multiparty online discourses our framework is applicable in categorizing dynamic and unpredictable online discourse for instance the framework can be applied in automated tools such as for moderating ruleviolating comments we have released our data and supplementary material 2 we will release our code once the paper is published related work moral reasoning in social psychology moral reasoning has long been studied bussey and maughan find that moral decisions by males are typically based on lawandorder reasoning while those by females are made from an emotional perspective walker observe that participants discussions about moral situations show clear age developmental trends over a twoyear period wood et al report that individualism and egoism have a stronger influence on the moral reasoning on business ethics by professionals than by students however these studies do not provide a comprehensive understanding of moral reasoning on social media morality in social media social media helps ground descriptive ethics zhou smith and lee profile linguistic features and show that the use of the firstperson passive voice in a post correlates with receiving a negative judgment nguyen et al give a taxonomy of the structure of moral discussions lourie bras and choi predict morality using social norms collected from aita forbes et al extract rules of thumb from moral judgments of oneliner scenarios emelin et al study social reasoning by constructing a crowdsourced dataset including moral actions intentions and consequences jiang et al predict moral judgments on oneline natural language snippets from a wider range of possibilities ziems et al build conversational agents to understand morality in dialogue systems genders topics and user factors gender differences are often relevant de choudhury et al reveal significant differences between the mental health contents and topics shared by female and male users de candia et al find young and male authors are likelier to receive negative judgments in aita and societyrelevant posts are likelier to receive negative moral judgments than romancerelevant posts in aita ferrer et al find reddit post topics are genderbiased for instance judgment of appearancesrelated posts are associated with females while powerrelated posts are associated with males collecting personal information by using users submissions on online platforms is a common method to explore social media data such as investigating conversation divisiveness through reddit data reddit discussion structure is of a tree rooted at an initial post comments reply to the root or to other comments definitions we adopt definitions from guimaraes and weikum to describe instances in our dataset a post refers to the starting point in a discussion 2 a toplevel comment refers to a comment that directly replies to a post we focus on toplevel comments because other comments in aita may not include judgments and reasoning based on the posts collection of posts and comments we require a largescared corpus with relevant posts and comments previous datasets are either nonpublic or insufficient for our purposes therefore we collected our dataset using pushshift api3 and reddit api 4 we scraped over 351067 posts and the corresponding 103m toplevel comments from aita spanning from its founding in june 2013 to november 2021 we collected these submissions by applying rulebased filters following the aforementioned previous works to ensure their relevance and avoid discrepancies between data from reddit and archived data from pushshift we excluded deleted posts and comments because they may violate aita rules such as including fake content to solicit outrage we also exclude posts and comments submitted by deleted accounts and moderators we selected posts that have at least ten toplevel comments to ensure quality we selected toplevel comments that have a predefined code indicating the judgment and fifteen or more characters representing the reasoning reddit allows users to give positive and negative feedback to submissions in the form of upvotes and downvotes therefore posts and comments in our dataset are associated with a score5 representing the accumulated differences between upvotes and downvotes extraction of comments verdicts the judgments are predefined codes yta nta esh nah and info some comments use short phrases as codes therefore we applied regular expressions to match such variants we resolved multiple matches by selecting the second match when there is a transition word such as but and we reversed the extracted codes in judgments containing negations such as i do not think using regular expression we removed sentences marked with which indicates a quotation to evaluate the labeling process we checked a random sample of 500 submissions we found 5 false positives and 6 false negatives following lourie bras and choi we assigned labels to comments with yta as 1 nta as 0 and discard all other instances comment corpus our corpus selection criteria require that selected comments have scores higher than 100 have a token length between 20 and 200 have commenters who were previously awarded by a flair and replied to posts that contain authors selfreported genders a flair is awarded by aita and represents how many times a users judgments have become the most upvoted comments thus reflecting the commenters reputation as a result our corpus includes 51803 posts and 120760 out of 3675452 total comments that belong to the selected posts the label distribution of nta to yta is 6040 we randomly selected 45505 instances labeled as 0 and all instances labeled as 1 we split our corpus as 801010 for training development and testing method this section introduces the processes of extracting social factors verdicts and rationales there are two advantages to use rationalization for summarising common patterns of moral reasoning it can be trained with neural networks in an unsupervised manner 6 and it provides appropriate rationales for social media data extraction of topics genders and interests we adopt nguyen et als topic model to identify topics for posts in our corpus then we use regular expressions to extract authors selfreported genders we leverage commenters participation on reddit to proxy their interests topic modeling for posts topics latent dirichlet allocation is widely applied for clustering text nguyen et al find 47 named topics in aita posts via lda models these topics are associated with clusters of words sorted by the probability of belonging to that topic we found that our corpus and nguyen et als corpus have 34098 posts in common and the rest 17705 posts were submitted after april 2020 we follow their method to assign each post the topic that has the highest prior probability authors genders extracting demographics from social submissions using regular expressions is common in analyzing reddit data such as in exploring contentious conversations gender and age are not typically available on reddit allowing for anonymous posting fortunately the social media template for posting gender and age eg 25f enables us to use regular expressions to extract the information note that authors typically report the demographic information of multiple parties in the situation described such as i 25f and my wife 25m therefore we extract authors selfreported genders by filtering firstperson pronouns besides we consider gendered alternatives where available for example male can be estimated by bb and female by b we do not match nonbinary genders because we do not have ground truth labels for nonbinary targets as a result we find the femalemale split of 9010 in our dataset we took a random sample of 300 submissions to evaluate the regular expression we found that gender extracted using our regular expression matches the manually labeled one 94 of the time commenters interests following de candia et al we proxy commenters interests via the subreddits they participated in by making at least one submission within a sixmonth period based on the timestamp of the comment found in our corpus we focus on the commenters because they have made quality judgments we chose a sixmonth window based on users prolificity as defined by beel et al considering a user prolific if they submit more than 25 times in their interested subreddit we manually checked 100 users and found that a sixmonth period makes users more prolific than four eight and twelve months we discard deleted user accounts which restricts our analysis to 46519 commenters with 104915 comments unlike de candia et als work we map the collected subreddits following reddits predefined subreddit categories 7 commenters may have interests in various categories therefore we set their interest as their most frequently submitted subreddit predicting verdicts then extracting rationales we now introduce the rationalization process followed by how our predictthenextract model operates introduction to rationalization process given a pretrained model m each instance is of the form of where x x i are the input tokens and y ∈ 0 1 is the binary label the rationalization process outputs a predicted ŷ with a binary mask z z i ∈ 0 1 of input length indicating which tokens are used to make the decision the tokens masked with ones are called rationales and considered accurate explanations of the models decisions and can be figure 4 soft rationalization is a threephased process the predictor outputs ŷ and importance scores s the binarizer assigns masks to tokens z the classifier predicts unmasked tokens it predicts y again to evaluate a rationales accuracy used alone to make correct predictions binarization methods are hard and soft according to hard selection uses the bernoulli distribution to sample binary masks in contrast soft selection outputs multivariable distributions over tokens derived from features eg selfattention values we adopt soft selection because hard selection faces performance limitations and soft selection is more appropriate when there is no ground truth of rationales prediction then extraction figure 4 illustrates the architecture of a soft rationalization model 8 the predictor in figure 4 is a standard text classification module that predicts a verdict we omit the last classifier module because we need the rationales instead of accurately predicting y the importance scores z are computed via featurescoring methods using the parameters learned during training therefore the extracted rationales can capture the most salient contextual information used by a neural model when predicting a verdict our experiments aim to empirically collect plausible rationales for categorizing the commonality of moral reasoning reflected in social media instead of building an accurate predictor or improving the rationalization extraction performance figure 5 shows our predictor we first weakly label tokens that appear in the moral lexicon we then obtain embeddings of input instances by adopting the pretrained bertbaseuncased model using huggingface 9 next we prepare global and local representations of a sentence by a stacked bidirectional lstm and a syntactic graph convolutional network then we feed the concatenated final hidden representation vectors into a fully connected prediction network the prediction network uses softmax to output the probabilities of a 8 compared to lei barzilay and jaakkola we simplify the names of encoder as predictor and generator as binarizer and we name extractor as binarizer 9 particular verdict we adopt crossentropy in the network to measure loss global context features are multidimensional embeddings encoded using bert which maps a token into a vector based on its context we adopt the pretrained bertbaseuncased model from huggingface to obtain embeddings to obtain extended contexts we use a bidirectional lstm we compute the hidden states by passing the bertencoded embeddings to a stacked bilstm ← h gi → h gi bilstm i 1 2 where s represents the encoding output of the last layer of bert and i denotes the direction we compute the global context representations h g1 and h g2 by averaging the hidden outputs in both directions local context features are obtained using a syntactic graph convolutional network representing the local syntactic context of each token we capture words and phrases modifying the parties in input instances by using dependency graphs which are obtained by applying the stanford dependency parser using spacy 10 the dependency graphs are composed of vertices and directed edges which capture the complex syntactic relationships between tokens sgcn operates on directed dependency graphs based on graph convolutional network gcn is a multilayer message propagationbased graph neural network given a vertex v in g and its neighbors n the vertex representation of v on the layer is h j1 v u∈n w j h j u b j where w j ∈ r d j1 ×d j and b j ∈ r d j1 are trainable parameters and d j1 and d j denote latent feature dimensions of the and the j layers respectively sgcn improves gcn by considering the directionality of edges separating parameters for dependency labels and applying edgewise gating edgewise gating can select impactful neighbors by controlling the gates for message propagation through edges therefore the sgcn module takes word embeddings and syntactic relations to compute local representations the local representation for a vertex v is h j1 v u∈n g j uv where j represents a layer g is the gate on the jth layer to select impactful neighbors u ∈ n of v w is the weight and b represents bias for each sentence we use a pooling layer to convert tokens local representations into a single hidden vector domain knowledge is used to weakly label rationales following such unsupervised rationalization favors informative tokens to optimize losses however our datasets highly informative and frequent tokens such as gendered words may not determine the verdict therefore we use the popular psychological theory moral foundation theory to effectively select moral rationales mft refines morality into five broad domains careharm fairnesscheating loyaltybetrayal authoritysubversion and sanctitydegradation we adopt the extended version of the mft lexicon containing 2041 unique words to label comments in our corpus we reprocess the input instances and generate weak labels for rationales z d z i d ∈ 0 1 where z i d 1 if x i is in the lexicon we include a loss term l d i a i z i d for the soft selection process where a i denotes the attention weight for token z i the term l d lowers the loss when the tokens selected by featurescoring methods are moralityrelated otherwise it has no effect for prediction loss we apply crossentropy to optimize the network by calculating l using the last hidden layers output combining the loss items the objective of our model is arg min l λl d where λ controls the weight of domain knowledge loss experiments and results we now evaluate of our predictthenextract model for extraction performance we first adopt multiple features scoring methods from previous works followed by verifying the plausibility of the extracted rationales experimental settings baseline methods for prediction we evaluate these machine learning models the stateofart transformer model bert logistic regression random forest and support vector machine for lr we use the lengths of the instances as a baseline model for traditional machine learning methods we use glove a text encoder that maps a word into a lowdimensional embedding vector for textual classification to generate vector representations for bert baseline we apply the obtain representations and prediction network modules as shown in figure 5 we feed cls representations generated from the embedding layer into the prediction network instead of passing them through the bilstm and sgcn networks feature scoring methods for extraction we use random selection as a baseline and multiple featurescoring methods to compute importance scores s • random randomly allocate importance scores • attention normalized attention weights • scaled attention attention weights multiplied by the corresponding gradients • integrated gradients the integral of the gradients from the baseline to the original input • flexible a flexible instancelevel rationale selection method under which each instance selects different scoring methods and lengths of rationales we compare only the above methods because they yield better performance than others eg evaluation metrics for rationales plausibility for prediction we use macro f1scores for extraction we adopt metrics from previous works • reversemacro f1 the performance of m in predicting y when using full input and rationalereduced input the predicted label with full input is used as the gold standard masking rationales should drop the prediction performance lower is better • normalized sufficiency reversed and normalized differences between predicting full input text and rationales max p higher is better to avoid overfitting we regularize the prediction network using the dropout technique at each fully connected layer we apply a dropout level of d 05 finally the prediction network output is fed into the last neural network of two units with softmax to obtain probability distributions of the verdicts we train five epochs for all the transformerbased models all the experiments are implemented from huggingface results the prediction performance of a model indicates its ability to distinguish commenters evaluations of the various parties behaviors the extraction performance of a model indicates the plausibility of the rationales it generates performance of predicting verdicts we use fivefold stratified crossvalidation for the aforementioned classifiers for the transformerbased models we ran each model with five epochs the reported performance score averages are shown in table 2 the scores with domain knowledge are calculated with λ 01 which yields the best performance we observe that neural models outperform traditional machine learning models the globallocaldomain method shows an average of 3 improvement among all the scores compared to a finetuned bert we are unable to compare our results with botzer gu and weninger because of different research purposes and lack of their dataset and experimental details performance of extracting rationales table 3 illustrates the performance of various featurescoring methods with and without weakly supervision through domain knowledge we experiment on two scored tokenselection methods selecting the k highest scoring tokens for each instance and selecting highest overall kgram scoring tokens in the span of input tokens we adopt topk for further analysis because it yields the best performance although table 2 shows that considering domain knowledge may not improve prediction performance for all neural models we observe that using the instancelevel rationale extraction method with domain knowledge improves a rationales plausibility combining the results of table 2 and table 3 we use globallocaldomain to predict and the flx featurescoring method to extract appropriate rationales analysis we leverage the 17808 identified rationales from the 18202 instances of our corpuss development and test sets as a lexicon we apply this lexicon on the total 3675452 comments in our corpus we introduce how we identify and cluster the extracted rationales meanings then we perform a finegrained analysis to investigate how the clusters are associated with the authors and commenters social factors 4 examples of meaning clusters embedded in moral reasoning for topicspecific posts italics show the words that are common between the topics of the same cluster the results indicate that words used in comments are different based on posts topics in addition adverbs used in evaluation goodbad are more prevalent than adjectives used in judgment of appearance clustering and tagging we apply pretrained glove embeddings to cluster the meaning similarities of rationales after manually checking the clustered results we select glove embeddings as they provide more detailed and informative clusters than other embedding methods such as word2vec we exclude the rationales that have negative dependencies in the original sentences to avoid ambiguity to aggregate the most similar embeddings into clusters we employ the wellknown kmeans clustering algorithm we tag the resulting clusters with usas 11 a framework for automatic meaning analysis and tagging of text which is based on mcarthurs longman lexicon of contemporary english we use this lexicon to name the tags because 11 the generated rationales contain phrases and words we filter the phrases composed of words belonging to the same usas categories such as extremely awful we discard clusters of pronouns and prepositions as a result we find 86 unique meaning clusters in our dataset associations between comments and factors we measure the odds ratio to assess the associations between posts topics authors genders and meaning clusters for commenters interests we apply linear regression to compute their effects on the judgments figure 6 and table 4 report the results personal belongings 187 roommates the odds ratio values of authors gender and meaning clusters in different topics an odds ratio greater than one indicates the category is more likely to appears in the comments when the posters are females compared to males and an odds ratio smaller than one indicates the opposite 10 05 00 05 10 ×10 4 happysadhappy regression results for the effects of the proxied commenters interests an effect that is greater than zero indicates positive effect and an effect smaller than zero indicates the opposite 4 we also observe distinct preferences for word usage to convey identical meanings even among categories with similar gender effects suggesting nuanced and contextspecific usage of language in moral reasoning however the evaluation goodbad category shows controversial effects showing biases towards females in safety but towards males in work indicating polarizing opinions interestingly the most contentious topics such as relationships do not show typical gender biases in our analysis this could be due to the fact that commenters have specific evaluation standards in different moral scenarios we find distinctive gender effects in work and safety in such topics words in sensible and lawℴ are less likely used in comments towards female authors and words related to judgement of appearance are more likely to be the observation can be explained by the reflection of the persistent societal pressure on women to conform to certain beauty standards moreover commenters use different adjectives verbs and nouns to emphasize their concerns based on a given situation while employing similar adverbs to express their emotions for instance the adjectives verbs and nouns used in judgment of appearance for work and safety are dissimilar whereas the adverbs employed in evaluation goodbad are common commenters interests matter we now investigate how the commenters interests affect their moral reasoning there are eighteen categories of subreddits that the commenters participated in lifestyle science locations technology hobbies and interests law adult and nsfw business social science and humanities music sports entertainment news and politics gaming architecture art travel and education these categories exhibit high popularity and diversity for example news and politics includes subreddits such as rpoliticalhumor and rantiwork each with over a million users and lifestyle includes rbaking and rrelationships the proxied commenters interests are confounded with each other therefore we investigate them simultaneously to measure the causal effects of their interests we use an ordinary least square model12 which is a common method for analyzing social variables the following model captures the linear effects b β 0 β i x i ϵ i i ≤ n where x i denotes the frequency of the ith cluster appearing in judgments b β represents the constant effect of x i n is the total number of clusters and ϵ i ∼ n is normally distributed noise centered at 0 figure 6b shows the effects of the interest categories on emotionrelevant clusters we observe that some categories such as sports and lifestyle are likelier to positively affect optimistic clusters happysadhappy than neutral clusters such as music in addition gaming and science positively affect using obligation and necessity words such as would should and must conversely social science and humanities and entertainment have a negative effect the results may be explained by the distinctive personality traits of the social groups the commenters belong to for example commenters interested in art are the most likely to use worry concern and confident words and commenters interested in music are the least likely to use happysadhappy words a possible explanation may be that personalities of people interested in art are more emotionally sensitive than others discussion and conclusion our research introduces a new framework for analyzing language on social media platforms we focus on judgments of social situations and examine how social factors such as a posters gender and a commenters interests influence the distributions of common elements in the language used in comments we employ nlp tools and a predictthenextract model to collect these common elements our study demonstrates that the language used in moral reasoning on aita is influenced by users social factors for instance consistent gender effects are observed in the calmviolentangry category in education and marriage with posts authored by males more likely to receive such comments interestingly our analysis reveals nuanced word usage within identical clusters with verbs such as kick and spitting being frequently used in the calmviolentangry category in marriage whereas adjectives such as picky and mortified were more common in education conversely the evaluation goodbad category in work and safety elicited conflicting opinions our observations corroborate social psychology findings for example comments about judgment of appearance in work and safety exhibit prevalence for female authors which indicate the societal pressure on women to conform to beauty standards moreover commenters interested in music and art are likelier to express emotions which may be caused by their personalities overall these findings highlight the contextspecific and nuanced nature of language usage in moral reasoning on social media platforms and contribute to a better understanding of the influence of social factors on language use broader perspectives our research presents a novel framework for analyzing language usage in online media which has practical implications for the design of monitoring systems to identify biased submissions in specific communities this framework can assist commenters in reconsidering their comments and moderators in flagging concerning comments in addition the proposed methods can explain why a submission is considered biased and can inform the design of better features to educate new community members about problematic aspects of their submissions our findings align with social psychology research and shed light on societal pressures such as the gendered pressure on appearance in work and safety contexts additionally our study reveals the impact of personal interests on language use these broader perspectives suggest potential implications for the development of more effective communication strategies online and underscore the need for further research exploring the relationship between language use and social factors in moral reasoning limitations and future work our empirical method inherently shares limitations with observational studies eg susceptibility to bias and confounding there is a limit to how much we can tease apart social factors of the posters and commenters we acknowledge some of the boundaries are unclear for example we treat genders as a social factors but do the genders also affect posters writing styles in addition to our single dataset analysis on aita there may be potential for further exploration on other data sets such as the rrelationshipadvice subreddit additionally creating new datasets with crowdsourced moral judgments could be beneficial in expanding the scope of analysis although our prediction model takes into account the syntactic relations of input sentences it is possible for some parties mentioned in a post to be background characters rather than active participants moreover the rationales we extract are not validated with groundtruth labels mainly due to the complexity of the instances in our dataset in future work we plan to leverage our framework to construct annotation guidelines to obtain humanevaluated clusters for analysis ethics statements reddit is a prominent social media platform we scrape data from a subreddit using reddits publicly available official api and pushshift api a widely used platform that ingests reddits official api data and collates the data into public data dumps none of the commenters information was saved during our analysis the human evaluation mentioned such as the evaluation of comments labels was performed by the authors of this paper and colleagues one potential negative outcome of this research is that it may reinforce stereotypes and biases that already exist additionally the research may not generalize to all populations and may not account for other factors such as age culture and education that could be influencing moral reasoning on social media

moral reasoning reflects how people acquire and apply moral rules in particular situations with social interactions increasingly happening online social media data provides an unprecedented opportunity to assess inthewild moral reasoning we investigate the commonsense aspects of morality empirically using data from a reddit subcommunity ie a subreddit where an author may describe their behavior in a situation to seek comments about whether that behavior was appropriate a situation may decide other users comments to provide judgments and reasoning we focus on the novel problem of understanding the moral reasoning implicit in user comments about the propriety of an authors behavior specifically we explore associations between the common elements of the indicated reasoning and the extractable social factors our results suggest that a moral response depends on the authors gender and the topic of a post typical situations and behaviors include expressing anger emotion and using sensible words eg fck hell and damn in work related situations moreover we find that commonly expressed reasons also depend on commenters interests

Introduction The consumption of sufficient amounts of fruit and vegetables underpins an overall healthy diet. Increased consumption of fruit and vegetables has been shown to reduce the risk for several major chronic diseases such as cancer, 1 diabetes 2 and heart disease. [3][4][5] In addition, diets consisting of more nutrient-rich foods such as fruits are associated with lower body weight, less weight gain, and reduced obesity rates.6 -8 Prior studies have identified a variety of determinants associated with fruit and vegetable consumption 9 including individual demographic and socioeconomic factors , 10, 11 eating behaviors,12 environmental and social influences, including access to healthy foods13 -15 and social capital. 10,16,17 Social capital is considered to be a social resource [18][19][20] that provides social support 17 and benefits. 21 According to Bourdieu, social capital is defined as "the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition. 22 Portes explained how social capital functions in three ways: as a normative influence, as a source of familial and extrafamilial social support. 23 Research finds that stronger social networks and social norms contributed to a greater change in fruit and vegetable consumption;16 and individuals with more social support had healthier diets. 24 An intervention measured the influence of social context on fruit and vegetable consumption and found social ties and social norms to be important. 16 Poortinga found a relationship between social support, social capital and daily fruit and vegetable consumption.17 Individuals who were lacking in social support were less likely to consume at least five servings daily. Analysis demonstrated individuals with higher levels of social capital on the community level were more likely to consume two to five servings of fruit and vegetables daily. Both social capital and fruit and vegetable intake had positive and significant effects on self-rated health.17 Most Americans do not achieve the recommended levels of fruit and vegetable intake. [25][26][27] In rural areas, individuals also are not meeting the recommendations for fruit and vegetable intake [28][29][30][31][32] and consuming even fewer servings than the national average. 33 Approximately 20% of the American population resides in rural areas. 34 However, few U.S. studies have focused on eating behaviors for rural residents 24,35 or the determinants of fruit and vegetable consumption in small-town, rural areas or rural agricultural communities. 29, 30 , 32 , 36 -38 Research findings indicate that a higher frequency of sugar-sweetened beverage consumption among rural residents was associated with a higher body mass index . 35 Results from a study of rural adolescents found an association between a higher Healthy Eating Index score and higher levels of social support; the HEI incorporated items for fruit and vegetable, fast food, and soda consumption. 24 The classification of rural areas across a Rural-Urban continuum of six categories recognizes the complexity of rurality. 38 The official U.S. Census Bureau defines rural areas as areas with fewer than 2500 residents. 39 Generally, food sources are not evenly distributed in many rural areas, where residents experience loss of grocery stores and greater travel distances to obtain food. 40,41 Rural areas are unique and require targeted research and interventions to address health disparities. 42 Many rural areas are geographically isolated; rural residents typically are poorer, less educated, older, and have lower access to health care services than those living in urban areas. 31,42 In addition, social factors, such as social support and social capital, have been identified as determinants for health in rural areas. [43][44][45] Studies show social capital36 , 46 and fruit and vegetable consumption47 -50 vary between rural and urban areas, and variations in social capital may contribute to differences in fruit and vegetable intake between rural and urban areas. We identified no studies that considered individual and contextual factors as influences on fruit and vegetable intake for individuals living in rural areas. This analysis uses an ecological perspective to consider individual level influences such as healthy and unhealthy eating behaviors and socioeconomic characteristics and influences of the social environment conceptualized as social capital . Thus, the purpose of this paper is to simultaneously examine demographic and socioeconomic characteristics, social capital, and eating behaviors to understand their association with fruit and vegetable consumption in a large sample of rural adults. --- Methods --- Sample and Study Design This study used data from adult participants in the 2006 Brazos Valley Health Assessment who resided in one of the six rural counties in the Brazos Valley region of Texas. The BVHA was developed through a collaboration among local and regional academic and community-based organizations for the following purposes: to identify factors influencing health status, to recognize health-related issues and needs of the local community, to locate resources within the region, and finally, to produce a source of reliable information that may be utilized in developing effective solutions to identified health-related problems. 51 Approximately 3500 respondents were identified with a response rate of 73.8% . More than 1500 adults who resided in the six rural counties were recruited for the BVHA by a professional independent survey research firm into a large community assessment through random digit dialing and follow-up mailed survey; detailed methodology has been previously described.51 , 52 Within a subsample of rural adults , 1220 respondents had complete responses for demographic and sociodemographic characteristics, social capital, and nutrition items. These responses were retained for the analytic sample . The Texas A&M University Institutional Review board approved the study protocol and all participants provided written informed consent. --- Measures Fruit and vegetable intake-Fruit and vegetable intakes were separately measured by a validated, self-reported two-item screener.53 , 54 One item asked participants to report the number of servings of fruit usually consumed each day; the second item targeted the number of servings of vegetables consumed daily. A combined fruit and vegetable intake variable was calculated as the total of both fruit and vegetable intakes. This summed measure was constructed as the chief dependent variable because an increase in combined fruit and vegetable intake is a common goal among interventions. 55 Furthermore, many public health recommendations combine fruit and vegetable intake.56 -58 Eating behaviors-Eating behaviors were selected based on prior community-based work in North Carolina and included consumption of fast food, sugar-sweetened beverages, and breakfast meals.59 , 60 Weekly fast food consumption , daily sugar-sweetened beverage consumption or glasses of sweet tea do you drink on an average day?"), and weekly consumption of regular breakfasts were determined from the mailed survey. Social capital-A standardized social capital index was created from survey items originally developed by Burdine et al.61 using an iterated principal factor method . This scale focuses on the extrafamilial dimension of social capital as identified by Portes.23 Previously, this scale has only been used for analytic purposes in the context of this health assessment and a dissertation. 62 Respondents were asked to rate six items on a five point scale: "Strongly Agree" to "Strongly Disagree." The first item was a positive statement, followed by five negative statements. The first item was reverse coded for the following index construction. Factor loadings for the social capital items are in parentheses: "If there is a problem in my community, the people who live here work together to get it resolved . People in the community where I live are only out for themselves . I am afraid when I am out alone after dark in my community . In my community, a small group of people have all the power . I feel like an outsider in my community . There is nothing I can do to solve problems in my community when they happen ." The eigenvalue for one factor was 2.5. Chronbach's α was 0.79, indicating the index had a good internal consistency. A social capital index was developed by dividing the score by the square of the eigenvalue. A three level categorical index was constructed based on the quartile distribution: high social capital , medium social capital , and low social capital .63 Demographic and socioeconomic characteristics-The BVHA provided data on age, gender, household income, highest level of education completed, marital status, household composition, length of residence in the same county, and employment status. --- Statistical analysis STATA version 11 was used to generate descriptive statistics and linear regression models; p < 0.05 was considered statistically significant. Descriptive statistics were estimated for demographic and socioeconomic status items; social capital; daily fruit and vegetable intake; weekly fast food consumption; daily sugar-sweetened beverage consumption; and weekly consumption of regular breakfast meals. The analysis process included determining bivariate correlations between the dependent variable, fruit and vegetable intake, and SES variables, social capital, and other eating behaviors in addition to building a multivariate regression model. Correlations between individual and environmental determinants and intake were calculated using X 2 statistics. For the regression model, variables that were associated with fruit and vegetable intake were included. Backward elimination was used to create the multivariate linear regression model used to describe the relationship of demographics and SES, social capital, and eating behaviors with fruit and vegetable intake. --- Results --- Sample characteristics Sample characteristics are presented in Table 1. Rural respondents ranged in age from 18 to 90 years . Most respondents were women. Approximately 18% of the sample was below the poverty level. This value falls within the 14 to 22% range for poverty level reported in 2006 for rural counties in the Brazos Valley.64 Approximately 17% were low income. Non-Hispanic whites composed approximately 81% of the respondents. This value is higher than the 57 to 77% range reported in 2008 for the rural counties of the Brazos Valley. 64 Approximately 48% of respondents over the age of 25 had completed high school . This value falls below the 67 to 74% range reported in 2000 for rural counties in the Brazos Valley. 64 Overall, the BVHA respondents did not consume the recommended five to nine servings of fruit and vegetables. More than 35% consumed less than three servings of fruit and vegetables per day. In addition, approximately 35% of respondents in rural areas consumed at least two sugar-sweetened beverages, including nondiet soda and sweet tea, daily. Approximately 74% consumed fast food at least once per week, ranging from one to five occurrences. Regular breakfasts were consumed at least once per week by roughly 81% of respondents, ranging from one to five breakfasts per week. --- Multivariable regression models of fruit and vegetable intake Results of the regression model are shown in Table 2. Age, gender, and education were statistically significant in the model for intake of fruit and vegetables among rural residents. Age was positively associated with fruit and vegetable intake, with older respondents consuming greater amounts of fruit and vegetables, though intakes fell below recommended levels. Being a woman or having completed more education levels was associated with greater fruit and vegetable consumption. Social capital was also statistically significant. Respondents reporting higher levels of higher social capital consumed more fruit and vegetables. Lower fruit and vegetable intake was associated with more frequent daily sugarsweetened beverage consumption, though this relationship was relatively weak. Conversely, eating a regular breakfast was strongly associated with increased fruit and vegetable intake. Fast food consumption was not significant in this analysis of fruit and vegetable intake. --- Discussion Rural residents, and Americans in general, are not meeting recommendations for consumption of fruit and vegetables, [25][26][27]33 but only a limited number of studies have focused on the determinants of fruit and vegetable consumption areas among rural adults. 29,30,36 This study examined the influence of demographics, socioeconomic status, social capital, and eating behaviors on fruit and vegetable consumption for a large rural sample to contribute new findings to the literature on fruit and vegetable intake. Evidence from this study indicates that fruit and vegetable consumption is better understood in context with the consideration of other eating behaviors. Specifically, these results indicate eating a regular breakfast increased consumption of fruit and vegetables, while consumption of sugarsweetened beverages decreased fruit and vegetable intake. This analysis found eating a regular breakfast was significantly associated with fruit and vegetable intake and suggests consumption of fruit and vegetables is part of an overall healthy diet, including eating regular breakfasts. The nutrition literature demonstrates regular breakfast consumption, especially of breakfast cereals, promotes better nutrition and healthy weight. 65 Additional research shows individuals who eat more fruit and vegetables engage in other healthy behaviors, such as exercise and not smoking, 66,67 and a Swedish study demonstrates having an irregular breakfast is related to other unhealthy behaviors such as eating fewer fruits and vegetables, drinking more soft drinks, and smoking. 68 For unhealthy eating behaviors, results indicate a negative association between both weekly fast food consumption, daily consumption of sugar-sweetened beverages and fruit and vegetable intake. Analysis showed the relationship between drinking sugar-sweetened beverages and eating fruit and vegetables to be statistically significant. However, after controlling for sugar-sweetened beverage consumption, fast food was not an influence on fruit and vegetable intake. Both coefficients for the two unhealthy eating behaviors were relatively small. Other studies also suggest a possible displacement of healthier foods, including fruit and vegetables, as the intake of unhealthy foods, such as fast food and nondiet soft drinks, increases. [69][70][71] The importance of individual, social, and contextual factors to understanding fruit and vegetable consumption is supported by other studies. 9 This analysis illustrates how individual determinants such as age, gender, and education, are associated with consumption of fruit and vegetables. Results indicated income had a negative relationship with fruit and vegetable consumption, though in the model, education displaced income as a significant covariate. Several studies have shown similar findings for being female and older 25,57,72 and better educated. 27,73,74 Although neither income level was significantly associated with fruit and vegetable intake, there was a more pronounced relationship between being lower income and eating fewer fruits and vegetables. Research indicates individuals who are low income have more food insecurity than those at poverty level who can access food and nutrition assistance resources. 75 In addition, social capital was statistically significant in the model as an influence on fruit and vegetable intake. Two studies discussed the importance of the social environment on fruit and vegetable intake and provided some evidence indicating a positive relationship between either social support or social capital and fruit and vegetable intake. 16,17 However, only one of these studies produced significant findings for the positive influence of social capital on consuming at least five servings of fruit and vegetables a day. 17 This analysis found social capital to be a highly significant influence on fruit and vegetable intake which further distinguishes these findings. Social capital represents a social resource that arises from the collective social functioning of a specific social context. [18][19][20] It is possible these measures of social capital indicate the level of social support 17 and benefits accruing from social support 21 that influence fruit and vegetable consumption. These results are supported by previous work showing a positive association between social capital and fruit and vegetable intake. 16,17 Although this study contributes new knowledge, it is worth noting a few limitations in this analysis. Recruitment efforts sought a representative sample for the Brazos Valley population; however, the analytical sample was over-represented in terms of age, gender, ethnicity and education. For example, rural respondents were older than the average age of adults living in Brazos Valley. Also, the population is roughly 50% women, while our sample was almost 75% women. Both racial minorities and high school graduates were underrepresented in our sample. The underrepresentation of minority groups may explain the absence of any significant association between racial category and fruit and vegetable intake. Furthermore, the underrepresentation of high school graduates may impact our estimates of the role of education in fruit and vegetable intake. Due to the cross-sectional nature of the data, causality cannot be inferred. No claims can be made suggesting that individual, environmental or behavioral determinants cause individuals to eat more or less fruit and vegetables. In addition, eating behavior data were collected using a self-report, self-administered method and as a result, there may be measurement error. There were limitations in the questions on eating behaviors. For example, definitions were not provided for fast food and regular breakfast meal; and the question on sugar-sweetened beverages did not specifically mention sugar-sweetened beverages in addition to regular soda and sweet tea. --- Conclusions & Applications Notwithstanding the limitations, this study contributes unique findings related to fruit and vegetable consumption in rural areas, specifically how other healthy and unhealthy behaviors influence intake. Results provide additional context for understanding fruit and vegetable intake and should be considered in efforts to improve nutrition and health in rural areas. --- Conceptual model for relationships between determinants and fruit and vegetable intake

Few studies have focused on determinants of fruit and vegetable intake in rural areas. This study examined the relationship between demographics, socioeconomic status, social capital, eating behaviors, and fruit and vegetable intake for a large rural sample. Data from 1220 rural adults participating in the 2006 Brazos Valley Community Health Assessment Survey were used. Multivariable regression results demonstrated eating a regular breakfast (p-value ≤ 0.001) was positively and drinking sugar-sweetened beverages (p-value = 0.010) was negatively associated with fruit and vegetable intake. Being female, older, and having higher levels of education and social capital were associated with consuming more fruit and vegetables. This analysis provides evidence that contextual aspects are important for understanding fruit and vegetable intake in rural areas.

introduction the consumption of sufficient amounts of fruit and vegetables underpins an overall healthy diet increased consumption of fruit and vegetables has been shown to reduce the risk for several major chronic diseases such as cancer 1 diabetes 2 and heart disease 3 4 5 in addition diets consisting of more nutrientrich foods such as fruits are associated with lower body weight less weight gain and reduced obesity rates6 8 prior studies have identified a variety of determinants associated with fruit and vegetable consumption 9 including individual demographic and socioeconomic factors 10 11 eating behaviors12 environmental and social influences including access to healthy foods13 15 and social capital 101617 social capital is considered to be a social resource 18 19 20 that provides social support 17 and benefits 21 according to bourdieu social capital is defined as the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition 22 portes explained how social capital functions in three ways as a normative influence as a source of familial and extrafamilial social support 23 research finds that stronger social networks and social norms contributed to a greater change in fruit and vegetable consumption16 and individuals with more social support had healthier diets 24 an intervention measured the influence of social context on fruit and vegetable consumption and found social ties and social norms to be important 16 poortinga found a relationship between social support social capital and daily fruit and vegetable consumption17 individuals who were lacking in social support were less likely to consume at least five servings daily analysis demonstrated individuals with higher levels of social capital on the community level were more likely to consume two to five servings of fruit and vegetables daily both social capital and fruit and vegetable intake had positive and significant effects on selfrated health17 most americans do not achieve the recommended levels of fruit and vegetable intake 25 26 27 in rural areas individuals also are not meeting the recommendations for fruit and vegetable intake 28 29 30 31 32 and consuming even fewer servings than the national average 33 approximately 20 of the american population resides in rural areas 34 however few us studies have focused on eating behaviors for rural residents 2435 or the determinants of fruit and vegetable consumption in smalltown rural areas or rural agricultural communities 29 30 32 36 38 research findings indicate that a higher frequency of sugarsweetened beverage consumption among rural residents was associated with a higher body mass index 35 results from a study of rural adolescents found an association between a higher healthy eating index score and higher levels of social support the hei incorporated items for fruit and vegetable fast food and soda consumption 24 the classification of rural areas across a ruralurban continuum of six categories recognizes the complexity of rurality 38 the official us census bureau defines rural areas as areas with fewer than 2500 residents 39 generally food sources are not evenly distributed in many rural areas where residents experience loss of grocery stores and greater travel distances to obtain food 4041 rural areas are unique and require targeted research and interventions to address health disparities 42 many rural areas are geographically isolated rural residents typically are poorer less educated older and have lower access to health care services than those living in urban areas 3142 in addition social factors such as social support and social capital have been identified as determinants for health in rural areas 43 44 45 studies show social capital36 46 and fruit and vegetable consumption47 50 vary between rural and urban areas and variations in social capital may contribute to differences in fruit and vegetable intake between rural and urban areas we identified no studies that considered individual and contextual factors as influences on fruit and vegetable intake for individuals living in rural areas this analysis uses an ecological perspective to consider individual level influences such as healthy and unhealthy eating behaviors and socioeconomic characteristics and influences of the social environment conceptualized as social capital thus the purpose of this paper is to simultaneously examine demographic and socioeconomic characteristics social capital and eating behaviors to understand their association with fruit and vegetable consumption in a large sample of rural adults methods sample and study design this study used data from adult participants in the 2006 brazos valley health assessment who resided in one of the six rural counties in the brazos valley region of texas the bvha was developed through a collaboration among local and regional academic and communitybased organizations for the following purposes to identify factors influencing health status to recognize healthrelated issues and needs of the local community to locate resources within the region and finally to produce a source of reliable information that may be utilized in developing effective solutions to identified healthrelated problems 51 approximately 3500 respondents were identified with a response rate of 738 more than 1500 adults who resided in the six rural counties were recruited for the bvha by a professional independent survey research firm into a large community assessment through random digit dialing and followup mailed survey detailed methodology has been previously described51 52 within a subsample of rural adults 1220 respondents had complete responses for demographic and sociodemographic characteristics social capital and nutrition items these responses were retained for the analytic sample the texas a m university institutional review board approved the study protocol and all participants provided written informed consent measures fruit and vegetable intakefruit and vegetable intakes were separately measured by a validated selfreported twoitem screener53 54 one item asked participants to report the number of servings of fruit usually consumed each day the second item targeted the number of servings of vegetables consumed daily a combined fruit and vegetable intake variable was calculated as the total of both fruit and vegetable intakes this summed measure was constructed as the chief dependent variable because an increase in combined fruit and vegetable intake is a common goal among interventions 55 furthermore many public health recommendations combine fruit and vegetable intake56 58 eating behaviorseating behaviors were selected based on prior communitybased work in north carolina and included consumption of fast food sugarsweetened beverages and breakfast meals59 60 weekly fast food consumption daily sugarsweetened beverage consumption or glasses of sweet tea do you drink on an average day and weekly consumption of regular breakfasts were determined from the mailed survey social capitala standardized social capital index was created from survey items originally developed by burdine et al61 using an iterated principal factor method this scale focuses on the extrafamilial dimension of social capital as identified by portes23 previously this scale has only been used for analytic purposes in the context of this health assessment and a dissertation 62 respondents were asked to rate six items on a five point scale strongly agree to strongly disagree the first item was a positive statement followed by five negative statements the first item was reverse coded for the following index construction factor loadings for the social capital items are in parentheses if there is a problem in my community the people who live here work together to get it resolved people in the community where i live are only out for themselves i am afraid when i am out alone after dark in my community in my community a small group of people have all the power i feel like an outsider in my community there is nothing i can do to solve problems in my community when they happen the eigenvalue for one factor was 25 chronbachs α was 079 indicating the index had a good internal consistency a social capital index was developed by dividing the score by the square of the eigenvalue a three level categorical index was constructed based on the quartile distribution high social capital medium social capital and low social capital 63 demographic and socioeconomic characteristicsthe bvha provided data on age gender household income highest level of education completed marital status household composition length of residence in the same county and employment status statistical analysis stata version 11 was used to generate descriptive statistics and linear regression models p 005 was considered statistically significant descriptive statistics were estimated for demographic and socioeconomic status items social capital daily fruit and vegetable intake weekly fast food consumption daily sugarsweetened beverage consumption and weekly consumption of regular breakfast meals the analysis process included determining bivariate correlations between the dependent variable fruit and vegetable intake and ses variables social capital and other eating behaviors in addition to building a multivariate regression model correlations between individual and environmental determinants and intake were calculated using x 2 statistics for the regression model variables that were associated with fruit and vegetable intake were included backward elimination was used to create the multivariate linear regression model used to describe the relationship of demographics and ses social capital and eating behaviors with fruit and vegetable intake results sample characteristics sample characteristics are presented in table 1 rural respondents ranged in age from 18 to 90 years most respondents were women approximately 18 of the sample was below the poverty level this value falls within the 14 to 22 range for poverty level reported in 2006 for rural counties in the brazos valley64 approximately 17 were low income nonhispanic whites composed approximately 81 of the respondents this value is higher than the 57 to 77 range reported in 2008 for the rural counties of the brazos valley 64 approximately 48 of respondents over the age of 25 had completed high school this value falls below the 67 to 74 range reported in 2000 for rural counties in the brazos valley 64 overall the bvha respondents did not consume the recommended five to nine servings of fruit and vegetables more than 35 consumed less than three servings of fruit and vegetables per day in addition approximately 35 of respondents in rural areas consumed at least two sugarsweetened beverages including nondiet soda and sweet tea daily approximately 74 consumed fast food at least once per week ranging from one to five occurrences regular breakfasts were consumed at least once per week by roughly 81 of respondents ranging from one to five breakfasts per week multivariable regression models of fruit and vegetable intake results of the regression model are shown in table 2 age gender and education were statistically significant in the model for intake of fruit and vegetables among rural residents age was positively associated with fruit and vegetable intake with older respondents consuming greater amounts of fruit and vegetables though intakes fell below recommended levels being a woman or having completed more education levels was associated with greater fruit and vegetable consumption social capital was also statistically significant respondents reporting higher levels of higher social capital consumed more fruit and vegetables lower fruit and vegetable intake was associated with more frequent daily sugarsweetened beverage consumption though this relationship was relatively weak conversely eating a regular breakfast was strongly associated with increased fruit and vegetable intake fast food consumption was not significant in this analysis of fruit and vegetable intake discussion rural residents and americans in general are not meeting recommendations for consumption of fruit and vegetables 25 26 27 33 but only a limited number of studies have focused on the determinants of fruit and vegetable consumption areas among rural adults 293036 this study examined the influence of demographics socioeconomic status social capital and eating behaviors on fruit and vegetable consumption for a large rural sample to contribute new findings to the literature on fruit and vegetable intake evidence from this study indicates that fruit and vegetable consumption is better understood in context with the consideration of other eating behaviors specifically these results indicate eating a regular breakfast increased consumption of fruit and vegetables while consumption of sugarsweetened beverages decreased fruit and vegetable intake this analysis found eating a regular breakfast was significantly associated with fruit and vegetable intake and suggests consumption of fruit and vegetables is part of an overall healthy diet including eating regular breakfasts the nutrition literature demonstrates regular breakfast consumption especially of breakfast cereals promotes better nutrition and healthy weight 65 additional research shows individuals who eat more fruit and vegetables engage in other healthy behaviors such as exercise and not smoking 6667 and a swedish study demonstrates having an irregular breakfast is related to other unhealthy behaviors such as eating fewer fruits and vegetables drinking more soft drinks and smoking 68 for unhealthy eating behaviors results indicate a negative association between both weekly fast food consumption daily consumption of sugarsweetened beverages and fruit and vegetable intake analysis showed the relationship between drinking sugarsweetened beverages and eating fruit and vegetables to be statistically significant however after controlling for sugarsweetened beverage consumption fast food was not an influence on fruit and vegetable intake both coefficients for the two unhealthy eating behaviors were relatively small other studies also suggest a possible displacement of healthier foods including fruit and vegetables as the intake of unhealthy foods such as fast food and nondiet soft drinks increases 69 70 71 the importance of individual social and contextual factors to understanding fruit and vegetable consumption is supported by other studies 9 this analysis illustrates how individual determinants such as age gender and education are associated with consumption of fruit and vegetables results indicated income had a negative relationship with fruit and vegetable consumption though in the model education displaced income as a significant covariate several studies have shown similar findings for being female and older 255772 and better educated 277374 although neither income level was significantly associated with fruit and vegetable intake there was a more pronounced relationship between being lower income and eating fewer fruits and vegetables research indicates individuals who are low income have more food insecurity than those at poverty level who can access food and nutrition assistance resources 75 in addition social capital was statistically significant in the model as an influence on fruit and vegetable intake two studies discussed the importance of the social environment on fruit and vegetable intake and provided some evidence indicating a positive relationship between either social support or social capital and fruit and vegetable intake 1617 however only one of these studies produced significant findings for the positive influence of social capital on consuming at least five servings of fruit and vegetables a day 17 this analysis found social capital to be a highly significant influence on fruit and vegetable intake which further distinguishes these findings social capital represents a social resource that arises from the collective social functioning of a specific social context 18 19 20 it is possible these measures of social capital indicate the level of social support 17 and benefits accruing from social support 21 that influence fruit and vegetable consumption these results are supported by previous work showing a positive association between social capital and fruit and vegetable intake 1617 although this study contributes new knowledge it is worth noting a few limitations in this analysis recruitment efforts sought a representative sample for the brazos valley population however the analytical sample was overrepresented in terms of age gender ethnicity and education for example rural respondents were older than the average age of adults living in brazos valley also the population is roughly 50 women while our sample was almost 75 women both racial minorities and high school graduates were underrepresented in our sample the underrepresentation of minority groups may explain the absence of any significant association between racial category and fruit and vegetable intake furthermore the underrepresentation of high school graduates may impact our estimates of the role of education in fruit and vegetable intake due to the crosssectional nature of the data causality cannot be inferred no claims can be made suggesting that individual environmental or behavioral determinants cause individuals to eat more or less fruit and vegetables in addition eating behavior data were collected using a selfreport selfadministered method and as a result there may be measurement error there were limitations in the questions on eating behaviors for example definitions were not provided for fast food and regular breakfast meal and the question on sugarsweetened beverages did not specifically mention sugarsweetened beverages in addition to regular soda and sweet tea conclusions applications notwithstanding the limitations this study contributes unique findings related to fruit and vegetable consumption in rural areas specifically how other healthy and unhealthy behaviors influence intake results provide additional context for understanding fruit and vegetable intake and should be considered in efforts to improve nutrition and health in rural areas conceptual model for relationships between determinants and fruit and vegetable intake

few studies have focused on determinants of fruit and vegetable intake in rural areas this study examined the relationship between demographics socioeconomic status social capital eating behaviors and fruit and vegetable intake for a large rural sample data from 1220 rural adults participating in the 2006 brazos valley community health assessment survey were used multivariable regression results demonstrated eating a regular breakfast pvalue ≤ 0001 was positively and drinking sugarsweetened beverages pvalue 0010 was negatively associated with fruit and vegetable intake being female older and having higher levels of education and social capital were associated with consuming more fruit and vegetables this analysis provides evidence that contextual aspects are important for understanding fruit and vegetable intake in rural areas

Introduction Eliminating poverty is a global challenge. When reframed in terms of human development, poverty is a constraint that denies individuals human agency in multiple parts of their lives [1]. In 2015, the United Nations claimed that the Millennium Development Goals had succeeded in reducing global poverty levels by half . Nonetheless, global poverty and hunger remain serious problems [2]. The World Bank reported that 689 million people lived in extreme poverty in 2017, and the COVID-19 pandemic may have further pushed about 150 million people into extreme poverty between 2020 and 2021 [3]. Over the past decades, countries at different levels of development have contributed to global poverty reduction. Numerous anti-poverty strategies and programs have been established, and they are a fundamental component of welfare policies in both developed and developing countries [4]. For example, the Europe 2020 strategy includes "Promoting Social Inclusion and Combating Poverty" as one of its 10 integrated guidelines, aiming to lift 20 million people out of poverty and social exclusion by 2020 [5]. In Mexico, Oportunidades, founded in 2002, was, until 2014, Mexico's main conditional cash transfer program to alleviate poverty. It aimed to break the transmission of poverty to the next generation through investments in human capital, beginning in rural areas and then expanding to urban areas. In 2014, the program was renamed Prospera [6]. Brazil is different from Mexico. BPC and Bolsa Familia are the two most prominent anti-poverty programs. They are among the biggest in the world, and, from the beginning, they have covered both urban and rural areas [7]. India also has a long history of direct and targeted interventions to fight poverty through workfare schemes and subsidized food and farm inputs. The main objective of the National Rural Employment Guarantee Scheme is to enhance the livelihood security of farmers by providing 100 days of guaranteed wage employment to every household in unskilled manual work [8]. In Pakistan, the poverty incidence is very high, and the government implemented the Social Safety Net Program , Pakistan Poverty Alleviation Fund , and many other microfinance schemes to reduce poverty [9]. Thanks to these strategies, many countries and regions have seen significant reductions in the number of people living in poverty. These experiences and lessons are also worthy of learning and study by various countries and regions to better meet the challenges they face. However, while important progress has been made in global poverty reduction efforts, challenges remain for some emerging economies: for example, implementing targeted transfers creates new policy challenges [10]. In addition, climate change, natural disasters, and social risks will also exacerbate uncertainties in the development of world society and pose great challenges to global poverty reduction. Based on building a community with a shared future for humankind, working together to eradicate poverty is in line with global common interests and is a common mission and goal of all humankind. Over the past 40 years, China has made significant progress towards its poverty alleviation goals; the rural population under the current poverty line has decreased by 739.9 million [11]. Providing China's successful practical experience as a reference for other developing countries and regions and, thus, for achieving the Sustainable Development Goals , is undoubtedly a main way for China to make a greater contribution to humanity. In 1980, the Ningxia Hui Autonomous Region moved the entire population from the arid mountainous areas in the south to the easy-to-farm plains in the north using the "Diaozhuang resettlement". It solved the food and clothing problems of 280,000 people and achieved good socioeconomic benefits. In 2001, China's former State Planning Commission formally introduced the concept of "anti-poverty relocation and settlement". According to "China's Rural Poverty Alleviation and Development Program ", China aimed to carry out pilot policies according to the principle of "government guidance and voluntary relocation of farmers" over the following 10 years, but the overall scale of relocation was relatively small. In 2011, China gradually established a policy system for "anti-poverty relocation and settlement" with the goal of "moving out, stabilizing, developing and getting rich", marked by the "Outline of Poverty Alleviation and Development in Rural China " and the "Twelfth Five-Year Plan for Relocation to Poverty Alleviation", changing the government from a facilitator to a leader. After 2015, poverty governance began to enter the stage of targeted poverty alleviation, relocation, and settlement as one of the basic means. It was also in this year that China launched the anti-poverty relocation and settlement program , which aimed to lift the poor out of poverty and achieve sustainable livelihood. In 2016, the "National 13th Five-Year Plan for Antipoverty Relocation and Settlement" proposed to relocate and resettle 10 million poor people within five years to meet their basic needs, broaden income channels, and improve living standards, so as to fundamentally solve the problem of poverty alleviation and ultimately achieve common prosperity for everyone. In 2020, China officially announced that 98.99 million impoverished rural residents living under the current poverty line were lifted out of poverty. All 832 impoverished counties and 128,000 impoverished villages have been removed from the poverty list, eliminating overall regional poverty. Compared with the traditional relief type , relocation and settlement highlight the characteristics of the development style . Improving the production and living conditions at the relocation site can not only help farmers escape poverty and become rich, but also relieve the tension between the ecological environment and social development in the out-migrating area. With the end of the massive relocation in 2020, the ARSP has entered the post-support stage to achieve "stability, employment, and gradually being able to get rich" for farmers. Judging from the literature, livelihood has been the object of research and policies [12,13]. Livelihood reconstruction should be a core process in the planning, implementation and post-implementation stages [14]. Thus, what exactly is the impact of the ARSP on the livelihood of farmers? The answer to this question is the key to strengthening the targeting of policies in the post-support stage. Existing studies have discussed the issue mainly in terms of the links between livelihood sustainability and environmental protection [15], the links between migration and livelihood [16], well-being and ecosystem dependence [17], livelihood capital [18], livelihood strategy choices [19], livelihood resilience [20], and risk resistance capacity [21]. Further, some studies have begun to draw on the geographic school of thought to identify the spatial distribution of poverty, finding that there is a clear spatial poverty trap in rural China [22,23]. One study revealed the impact of spatial externality on rural poverty from the perspective of public expenditure fluctuation [24], where a spatial scale effect was found to exist in regional poverty features and in the impact of geographical capital on regional poverty [25]. These studies have valuable implications for us. However, there are also two shortcomings. On the one hand, although numerous studies have been conducted on the relationship between anti-poverty policies and livelihood, only a few qualitative studies exist on the topic. These quantitative studies are analyzed mainly with the help of objective-level measurable indicators, but these may ignore, to some extent, the influence of some subjective-level non-quantifiable indicators . Inspired by James C. Scott, we can think of the ARSP as a social project to transform the productive and living environments of villages and poor people. To avoid the failure of the state perspective, it is not enough to rely on the top-down state perspective in policy formulation and evaluation of the ARSP. Therefore, it is necessary to combine this with a bottom-up perspective of farmers . On the other hand, although researchers have noted the importance of spatial factors in understanding poverty, they have been limited to analyzing the association between the two at the macro level. On the contrary, they have not focused on the micro level to understand the changes in and reconfiguration of farmers' livelihood from a spatial perspective, especially in the context of the ARSP. Overall, this article fills the literature gap by using an explanatory framework of livelihood space to assess the impact of the ARSP on farmers' livelihood in four dimensions: production, residential, social interactions, and institutions, and provide a basis for relevant policies. The structure of the article is as follows. The first section is the introduction. Firstly, a brief review of national and regional experiences in poverty reduction is presented around the topic of global poverty. Secondly, the basic information surrounding China's poverty reduction policies is highlighted. Finally, a literature review is used to identify the research gaps and put forward research propositions. The second section is the framework. The spatial perspective of poverty research and the concept of geographical capital are briefly described, on the basis of which the analytical framework of livelihood space is constructed and deconstructed. The third section is the methodology. The study area, research methodology, specific implementation process, and data sources are presented in more detail. The fourth section is the findings. The impacts and performance of production space, residential space, social interaction space, and institutional space are analyzed and interpreted in relation to the research data. The fifth section is the discussion. It mainly connects and compares the findings with those of previous studies and provides insights into the differences found in this paper. The sixth section is the conclusion. The significance of this study is again clarified, and several specific policy recommendations are made based on the findings. --- Framework In the 1950s, the early school of new economic geography believed that economic backwardness and poverty were closely related to the geographical environment. By the 1990s, the spatial perspective began to be introduced into poverty research. Increasingly, geographers have put poverty back on the map by pointing to its intricate spatial manifestations [26]. One study found that poverty became more concentrated in space [27]. This spatial concentration of poverty due to geographic factors is called the "SPT" [28]. The SPT is a persistent state of poverty caused by location characteristics or high migration costs [29], which is usually distributed in areas with poor ecological environments and a lack of infrastructure and public services. The notion of geographical capital usefully highlights the importance of the spatial patterning of disadvantage [30]. Over time, environmental, economic, social, and cultural factors other than natural resources have gradually been incorporated into the category "geographical capital". Meanwhile, researchers have also begun to focus on comprehensive poverty and identify it based on the multiple dimensions of the economy, society, and policy [31]. The spatial turn in poverty studies is instructive for studying the ARSP. Spatial poverty theory emphasizes that space is one of the poverty-causing factors, and that a poor and closed geographical environment can compress the livelihood space of poor people, restrict their production and lifestyle, and lead to a homogeneous economic structure and weaker development capacity. According to this logic, the path of poverty reduction is to improve or rebuild livelihood space. The ARSP is a way to escape the SPT by moving poor people living in areas with "bad soil and water conditions which can't afford households' life" to resettle in places with better natural resources. At the same time, the rich connotation of geographical capital shows that poverty may be reflected in potential social exclusion and lack of opportunities, in addition to low income levels. Therefore, when assessing the impact of the ARSP on farmers' livelihood, it is important to consider the impact of institutional and social indicators, in addition to focusing on some clear and simple monetary indicators . Research has confirmed that poverty rates can be reduced by empowering families in political, economic, and social aspects [32]. In conclusion, the concept of geographical capital can help us to better identify the needs and barriers of farmers to improve their livelihood space, and then adapt policies according to the actual situation to avoid the misalignment between policy supply and farmers' needs. Many studies have developed frameworks for livelihood space. One study divided the livelihood space of migrants into economic space, policy space, public service space, and living space [33]. In another study, the authors constructed a quality evaluation index system for farmers' livelihood space from the four dimensions of life, production, society, and institution [34]. Referring to existing research results, we divided the livelihood space of farmers into production space, residential space, social interaction space, and institutional space . Production space refers to the functional area and capacity of farmers to engage in productive activities. The analysis indicators include the rate of non-farm employment and the level of household savings. Residential space refers to the area where families live daily. The analysis indicators include housing area and the accessibility of infrastructure and public service facilities. Social interaction space refers to the space constructed by farmers through social networks. The analysis indicators include the objects and frequency of social interactions. Institutional space refers to the institutional environment. The analysis indicators include the administrative settings and work content of the community and village. These four dimensions are not completely separate, but are interconnected and mutually influential. community and village. These four dimensions are not completely separate, but are connected and mutually influential. For production space, the ARSP attempts to fundamentally help poor people cape poverty through a series of measures. Objectively speaking, it creates favorable ditions for widening production space. However, the non-agricultural resettlement m also breaks the original production order, and the yard economy-which is an impo part of daily production-disappears, causing production skills to become ineffectiv the same time, the mismatch between the industrial structure of the resettlement are the demographic structure of the village also hinders the expansion of production s In terms of residential space, due to relocation, farmers will move from dilapidated galows into spacious buildings, public service facilities in the resettlement area wi come more centralized, and accessibility will be further enhanced. In terms of social action space, relocation will tear up farmers' original social network, but it will also grate them on a larger scale. In addition, the change in production space also simul ously promotes a shift in social relationship ties from blood and geographical ties to k and interest ties. For institutional space, relocation will break the original administr division, and several villages will be concentrated and resettled in the same commu turning farmers from villagers into community residents. Meanwhile, the ARSP, as a ernment-led intervention, has a campaign-style character in practice, and the commu have more complex governance issues, which pose new requirements for the constru of institutional space. --- Methodology --- Case Study Area Nanshan village is located in the mountainous area in the north of Laohu t Dongping County, Shandong Province, China . For the basic information a the village, please refer to Table 1. In 2016, Shandong Province issued "The 13th Five Plan for Poverty Alleviation Relocation and Resettlement in Shandong Province" plan proposed to implement the ARSP in 4 cities and 6 counties , 16 villages, and 15,748 pe accounting for about 40% of the total relocation population in the province. Among population, the relocation population of Laohu town was 41,405 people. For production space, the ARSP attempts to fundamentally help poor people to escape poverty through a series of measures. Objectively speaking, it creates favorable conditions for widening production space. However, the non-agricultural resettlement mode also breaks the original production order, and the yard economy-which is an important part of daily production-disappears, causing production skills to become ineffective. At the same time, the mismatch between the industrial structure of the resettlement area and the demographic structure of the village also hinders the expansion of production space. In terms of residential space, due to relocation, farmers will move from dilapidated bungalows into spacious buildings, public service facilities in the resettlement area will become more centralized, and accessibility will be further enhanced. In terms of social interaction space, relocation will tear up farmers' original social network, but it will also integrate them on a larger scale. In addition, the change in production space also simultaneously promotes a shift in social relationship ties from blood and geographical ties to karma and interest ties. For institutional space, relocation will break the original administrative division, and several villages will be concentrated and resettled in the same community, turning farmers from villagers into community residents. Meanwhile, the ARSP, as a governmentled intervention, has a campaign-style character in practice, and the communities have more complex governance issues, which pose new requirements for the construction of institutional space. --- Methodology --- Case Study Area Nanshan village is located in the mountainous area in the north of Laohu town, Dongping County, Shandong Province, China . For the basic information about the village, please refer to Table 1. In 2016, Shandong Province issued "The 13th Five-Year Plan for Poverty Alleviation Relocation and Resettlement in Shandong Province". The plan proposed to implement the ARSP in 4 cities and 6 counties , plan and build 39 concentrated settlements, and resettle a total of 39,834 people. Dongping was one of the counties that underwent the most heavy-duty poverty alleviation in Shandong Province, involving a total of 5 townships , 16 villages, and 15,748 people, accounting for about 40% of the total relocation population in the province. Among this population, the relocation population of Laohu town was 41,405 people. In 2017, Nanshan village completed the relocation of the whole village, primarily into Binan community According to "The Old House Demolition Compensation Incentives of The Laohu Town Nanshan Village", villagers who were born in, moved to, or lived in Nanshan village long before 31 December 2016 received CNY 18,000 and 40 m 2 of resettlement housing per capita . At the same time, the main house, gates, and courtyard walls within the relocation area were valued for compensation and demolition. Compensation proceeds were used for housing replacement, refunds were issued for any overpayment, or a supplemental payment was offered for any deficiency. Currently, Nanshan village has completed the relocation, and all compensation and incentives have been issued according to the policy. In 2017, Nanshan village completed the relocation of the whole village, primari Binan community According to "The Old House Demo Compensation Incentives of The Laohu Town Nanshan Village", villagers who wer in, moved to, or lived in Nanshan village long before 31 December 2016 received 18,000 and 40 m 2 of resettlement housing per capita (excluding the storage room ar the same time, the main house, gates, and courtyard walls within the relocation area valued for compensation and demolition. Compensation proceeds were used for ho replacement, refunds were issued for any overpayment, or a supplemental paymen offered for any deficiency. Currently, Nanshan village has completed the relocatio all compensation and incentives have been issued according to the policy. We also felt the impact of the ARSP on farmers' livelihood during the field su Before the relocation, Nanshan village was located in a mountainous area with poor conservancy conditions which was far from the market town, and the income source mainly drought-tolerant crops such as corn, cotton, and millet. Overall, the living tions of farmers were poor, and their income and living standards were low. Aft relocation, farmers moved into spacious and bright buildings . Howeve to various reasons, such as a loss of agricultural income, lack of work skills, an wages, more people chose to go out to work. To address this situ the local government has been actively developing industrial parks and providin ployment training to help rural families achieve sustainable livelihood. We also felt the impact of the ARSP on farmers' livelihood during the field survey. Before the relocation, Nanshan village was located in a mountainous area with poor water conservancy conditions which was far from the market town, and the income sources were mainly drought-tolerant crops such as corn, cotton, and millet. Overall, the living conditions of farmers were poor, and their income and living standards were low. After the relocation, farmers moved into spacious and bright buildings . However, due to various reasons, such as a loss of agricultural income, lack of work skills, and low wages, more people chose to go out to work. To address this situation, the local government has been actively developing industrial parks and providing employment training to help rural families achieve sustainable livelihood. --- Material Collection and Process This article is a qualitative study, aiming to assess the impact of relocation on farmers' livelihood from four aspects: production, livelihood, social interaction, and institutions. We conducted a field survey in Nanshan village between February and June 2022. For material collection, this study used the semi-structured interview and semi-par-Scheme 1. Resettlement houses and garment-processing plants in the industrial park. Source: This picture was taken in 2022 by the authors. --- Material Collection and Process This article is a qualitative study, aiming to assess the impact of relocation on farmers' livelihood from four aspects: production, livelihood, social interaction, and institutions. We conducted a field survey in Nanshan village between February and June 2022. For material collection, this study used the semi-structured interview and semiparticipatory observation methods. The snowball sampling method was used for sampling, which ensured the randomness of the sample selection. The demographics of the interviewees are shown in the Table 2. The outline of the interview was set based on research experience and the relevant literature . The semi-structured interview method is flexible and can obtain a high amount of information while stimulating the initiative of both sides of the interview, which places a higher demand on the researchers' control and guidance ability. In addition, although the semi-participatory observation method provides a shallow understanding of the problem and the observed information is more scattered, this information still verifies and complements the formal interview. Are professional services such as psychological adaptation provided? --- Object Before entering the field, we used personal connections to establish contact with the director of the Laohu town relocation office . After explaining the research intentions and gaining her trust and permission, she gave us a panoramic introduction to the ARSP in Laohu town. After that, she helped us to contact the officials of the community and village. Moreover, we interviewed four farmers. The interview sites were located in their homes or the fields, since familiar and safe environments can appropriately reduce respondents' concerns and communication pressure. With the interviewees' consent, the interview audio was recorded and compiled into text on the same day, with the initials replacing the actual name of the interviewee. During this period, we also carefully observed the decoration and furnishings of the farmers' homes, so we could quickly understand their living standards. Sometimes, we participated in their chat and carefully observed the chat topics and attitudes. The data sources and statistics on the ARSP in this section were provided by the Laohu town relocation office, Binan community, and Nanshan village. --- Findings 4.1. The Expansion and Shrinkage of Production Space Show Stratified Characteristics at the Age and Economic Levels The ARSP is a "double-edged sword". At the macro level, relocation has moved people out of the SPT. The centralized resettlement mode and the post-support polices have further optimized the production environment of farmers, which has contributed to the expansion of production space to a certain extent. At the micro level, before the relocation, the farming radius was small, the courtyard areas were large, the production autonomy was strong, and farmers mainly engaged in agriculture and livestock breeding. Since the relocation, the original production space has shown a shrinking trend and faced problems such as long farming distances and the disappearance of vegetable plots. At the same time, although the idea of non-agricultural resettlement has allowed the remaining young labor force to enter the labor market, the sources of income have gradually been diversified. However, changes in the macro-production environment also force them to change production methods and habits, and their original production skills are useless. In other words, agriculture is mainly being squeezed out of local livelihoods due to economic, environmental, and social changes [35]. In addition, with the aggravation of aging and population outflow, the area of abandoned land is also increasing, which is the reality of the transformation of farmers' production space after the relocation. However, from the perspective of the heterogeneity of personal livelihood capital, it is found that the internal impact of this external environmental change on individual production space shows the characteristic of being highly differentiated. That is, the degree of profit and loss of production space due to the ARSP varies from person to person, showing stratification effects among farmers at the age and economic levels. The first effect is age stratification. Affected by poor farming conditions, the limited absorption capacity of the community's labor market, and low labor remuneration levels, more than half of the young labor force in the village has outflowed. The existing population of the village is mainly the elderly, women, and children. On the contrary, the laborintensive industries represented by clothing and weaving in the nearby industrial parks are mainly for women under 45 , which means that people who exceed the age requirements have no work. The elderly who can still work can only continue to farm , and their living expenses mostly rely on pension insurance and the support of other family members. As the interviewee Z.C.H. said, "We used to live in the mountains, where farming was our main source of livelihood, but the water conditions were not good, so we had to rely on natural conditions to live. Now, most young people choose to go out to work; the family is left with the old, the sick and disabled, and the elderly, who have no income and do not go to the workers' homes when they are old. The elderly still have to rely on farming. At present, the land has not been transferred out, coupled with the land away from the community, it takes a long time to go back and forth" . The second effect is economic stratification. Taking farmers' household savings level as an example, we found that this indicator directly affects the freedom to choose units and broaden the space for future production. With a high level of household savings, farmers can not only live in spacious houses but also use geographical advantages to enrich income-generating channels, rather than choosing a relatively compact apartment type to avoid being indebted. The study found that farmers with a comparative advantage in non-agricultural sectors could benefit from relocation to nearby towns [36]. The interviewee L.N.S. told us, "The current relocation policy is a per capita subsidy of 18,000 yuan, and the house is compensated according to the standard of 300 or 580 yuan/m 2 . Generally, 80% of farmers can live in new houses with only these compensations. Taking me as an example, there were a total of two houses before the relocation, with a total compensation of 170,000 yuan, coupled with a subsidy for five people. After purchasing a new house of 100 m 2 , 80,000 was left, which I can use for other things. However, farmers with small house areas and few family members may need to pay in some money when purchasing houses" . --- The Improvement of Residential Space Is Uneven among the Physical and Social Groups Residential space is where farmers live daily. It can be divided into physical and social aspects. The former relates mainly to the construction of community infrastructure and public service facilities, which is also an important measure to solve the problem of "Two assurances and three guarantees" for farmers. The former site of Nanshan village was in a mountainous area, where the production and living conditions were poor, and the daily medical treatment, schooling, and travel of farmers were inconvenient. Since the relocation, the infrastructure of the resettlement community has been completed, the gap between urban and rural public service levels is narrowing, and the distance to schools, hospitals, markets, and bus stations has been shortened to an average of about 3.5 km. The accessibility of life space plays a different role in promoting the development of farmers [37]. At the same time, optimizing the community living environment also provides health protection for the lives of farmers. "Here is cleaner and healthier than before" is the simplest cognition and expression of their new "home". In this regard, the interviewee D.M.L. said, "The original living conditions were not good, and young people were unwilling to continue living there after work. Nowadays, the community environment is much better than before. Special property companies are in the community, and people in public welfare positions are responsible for cleaning work. Going out is also much more convenient, as schools, supermarkets, and township hospitals are only a few hundred meters away" . The latter mainly refers to the daily lifestyle and habits of farmers. As far as the rural community is concerned, the living pattern may become a perspective to examine the changes in lifestyles and habits. Before the relocation, their living pattern was mainly a scattered and independent bungalow courtyard with a shed for raising poultry, with a sizeable total use area, providing conditions for developing the courtyard economy. At the same time, farmers had almost zero cost for food, drink, and fuel. However, the resettlement community has a unified design, comprising high-rise buildings with fixed units and a limited area, and the original living space has been further compressed. Moreover, tap water and natural gas have increased the cost of living. According to a relocation household, an older man in the community weighed the water in the toilet tank and calculated that it would cost about CNY 0.05 to flush the toilet once. Therefore, to save money, some older people subjectively control the number of times they use the toilet per day, accumulate several uses before washing, and even use the open ground near the community . Over an extended period, the sanitary conditions in farmers' homes will gradually deteriorate. In addition, there are conflicts between traditional living habits and the order of modern life, such as cooking by burning firewood and "growing vegetable by destroying green belts". From the perspective of the analytical framework of "spatial change-social adaptation", the ARSP has significantly improved the physical level of residential space through spatial relocation and reconstruction, as well as the social level. The interviewee W.S. said, "It's good to relocate into the community, but I lost a source of income, and the cost of living increased. For example, I used to find branches in the wild about cooking, drink water without paying, grow vegetables and grain by myself, and keep a few chickens and ducks in captivity to ensure meat and eggs. But not now; the property company does not allow wood burning, and captive poultry is not allowed. Now the young, healthy people can go to farming, but the older ones cannot; in this situation, it has to rely on buying food and drink" . --- Expanding Social Interaction Space Coexists with the Self-Isolation of Social Interaction in the Short Term Although the relocation has microscopically broken the original living pattern, torn the long-established neighborhood relationship, and distanced relationships with relatives and friends, the centralized resettlement mode means that farmers are regrouped on a larger scale. At the same time, changes in production and residential space also provide opportunities for them to expand their social interaction space, such as entering the nearby industrial parks to work and participating in recreational activities. The social relationship ties have gradually changed from blood and geographical to business and interests. Ideally, concentrated residence increases the number of potential contacts, objects, and opportunities to chat more and engage in conversations. During the survey, we learned that, because the reservoir resettlement villages in Binan community belong to landless resettlement villages, they sometimes have contact with farmers from Nanshan village for the purchase of cemetery plots. This increases the probability of communication and familiarity between farmers and is conducive to reproducing their social capital. In short, from a macro point of view, the overall scale of social interaction space has gradually expanded since the relocation. However, our research found that the natural pattern of farmers' social interaction space seems different. The current resident population in the village can be divided into two types. One is continued farmers, who still live a farming life of "awake with the sunrise and rest with the sunset", and workers, who also go out early and return late. The other is those who stay at home, mainly the elderly and women who take care of the family, whose social interaction during the day is generally distributed in the corridor of the village building or the nearby shed, likely in the evening. They rarely go through several buildings to villages or other places in the community, except for going to the square to see a play one or two times per month. Unlike the village society that has heard about chickens and dogs, the current apartment-style housing emphasizes the privacy of personal life. The stairs and anti-theft doors have become the "roadblock" for farmers' interactions. In fact, farmers have fewer cross-village social activities due to factors such as livelihood differences and housing segregation, and even the frequency of interaction with village households is lower than before. In short, since the relocation, farmers' social scope and social network have not been significantly extended with time but are still relatively closed. That is, social interaction tends to cause self-isolation in the short term. According to the actual situation, there are two causes of self-isolation. First, farmers in the same village have substantial homogeneity in living habits and cultural psychology, the interpersonal relationships formed in the village society are stable, social trust and recognition are high, and the villagers are more inclined to communicate with each other. At the same time, this interaction is also conducive to maintaining the "sense of place", which can be seen from the gossip of farmers. The survey found that their topics of daily chatting included memories of previous life, worries about current life, and discussions on current policies, in addition to chewing the fat and discussing new things in the community. Second, in addition to the above differences and housing distinctions, this also includes the heterogeneity of communication objects and the sense of relative deprivation caused by policy differences. Reservoir resettlements can receive a per capita relocation subsidy of CNY 25,000 and a post-assistance subsidy of CNY 600 per capita per year before 30 June 2026. For some farmers, policy differences are a topic to talk about after dinner, but the relative deprivation caused by them also hinders communication between them. --- The Institutional Space Faces the Double Squeeze of "Campaign-Style Relocation" and "Normalizing Management" Institutional space is an essential guarantee for reconstructing livelihood space. However, this survey found that institutional space faces a double squeeze. The first is the squeeze brought by "Campaign-style relocation". This double squeeze leads to governance dilemmas such as difficulties in social integration, insecure sustainable livelihoods, and tight service resources [38]. This is mainly reflected in three aspects: the scale of relocation, the depth of mobilization, and the intensity of resource integration. Specifically, traces of "Campaign-style relocation" can be seen in Nanshan village and Binan community in the relocation mobilization and housing selection. Regarding the relocation scene, X.S.J., the party branch secretary of Nanshan village, recalled the following: "At that time, the village committee members went door-to-door in two classes to visit and carrying out ideological work. Results showed that 70% of farmers were willing to relocate, and when they chose a house, the proportionality value reached more than 90%. They did not move partly because they could not make the decision alone, and partly because their house size and family size were small, so they received very little compensation and would have had to take extra money to live in a new house. After a demolition, these people also came along, and now all relocated. Everyone calculated their account, found that the result was very suitable, so they decided to move" . W.C.Y., the secretary of Binan community, described the scene of the housing selection at that time. He said the following: "When the house was divided, it was intended to let everyone draw lots, but one-third of them did not want to come. Later we thought of a way for people unwilling to relocate to live in the original place, but whoever comes first can choose the house first, and the house number is optional. Later, the vast majority came to choose, and the remaining people felt no need to consume anymore. Some people come to the line two days in advance and sleep in the line at night" . Judging from the results, the short-term effects of "Campaign-style relocation" are remarkable and take full advantage of the benefits of the socialist system with Chinese characteristics. However, it faces challenges in adapting to the livelihood of farmers, demolishing old houses, and supplying public services in the resettlement community [39]. At the same time, as a product of forced institutional changes, "fragmentation" and "transition" are its core characteristics. Further, from the analysis framework of "Institution and Life", there are also conflicts and tensions between "daily life" and "institutional creation" within this type of community [40]. The second is the squeeze brought by "Normalizing management". Before the relocation, the "administrative district" was always an intermediary between townships and villages. An "Administrative district" is a quasi-administrative organization between townships and administrative villages. Currently, the administrative district of Shandong Province is the most complete and standardized. After the relocation, although the community nominally replaced the "administrative district", the functions and status of the two were the same. Farmers still referred to the party secretary of Binan community as the "administrative district" secretary. From the content point of view, the current township communities and villages continue the previous "Normalizing management" relationship. "Normalizing management" is mainly reflected in the following three aspects. The first aspect is the regularization of community and village committee staffing. For example, community officials include a party secretary, director, and instructor; village officials include a party branch secretary and accountant. The second aspect is the regularization of working funds. The community has no independent economic rights. Nanshan village has neither a fixed collective income nor additional office expenses. The third aspect is the normalization of work content. The daily work is still based on the assigned tasks of the higher-level government departments. On the contrary, less attention is paid to the unique problems in the transitional stage, such as culture, psychological adaptation, and professional service supply. In short, the resettlement community still follows a "management logic" related to the nature of targeted anti-poverty work. At the same time, there is also a lack of institutional response to the "fragmentation" and "transition" in the community service system. This may expose farmers to the risk of exclusion and marginalization due to a lack of identity, participation, and special demand expression channels. --- Discussion Based on qualitative work in Nanshan village, this paper draws on the framework of livelihood space to examine the impact of the ARSP on the livelihood of farmers from four dimensions: production, residential, social interaction, and institutions. The results show that livelihood space is a composite system of livelihood practices and that the impact of relocation on livelihood is multidimensional and deep. Our findings are in accordance with recent studies indicating that relocation has various negative socioeconomic impacts on livelihood, leading to significant impoverishment risks [41]. The ARSP destroyed the stable production structure and order while transferring farmers out of the SPT. Further analysis indicates that the impact has stratified characteristics in terms of age and the level of household savings. Older people are more likely to see these challenges due to the disappearance of income and vegetable plots. Farmers with high levels of household savings are more likely to see the opportunities because they can use compensation and geographical advantages to conduct business for asset accumulation. A study on the migration of Bangladeshi fishermen also expressed a similar perspective. That is, the results of immigration are highly differentiated. For poorer fishermen, immigration is a way to cope with shocks, and fishermen with better resources can use it for asset accumulation [42]. This study also found that, although the government has been trying to build industrial parks and carry out skills training, migrant work is still the main source of income for farmers. Combined with the results of the interviews, the reason is not just the lack of employment opportunities [43]. It may also be related to low wages, a long tradition of migrant work, and occupational prejudice . The evidence shows that the transformation of farmers' lifestyles and habits shows hysteresis compared to community building. Adaptation is a process that may take years to complete, as it is not a short-term process. Meanwhile, this study found that farmers' social interactions are characterized by self-segregation and that the objects of interaction are highly homogeneous in the short term. A study found that urban-rural interface residents attempt to realize their social and cultural aspirations of reproducing kampung ways of life characterized by dense social networks and common practices such as mutual aid [44]. This provides an idea to explain our findings, but it does not seem to be sufficient. We also found that apartment-style housing discourages social interaction among households. Usually, it is found that the space in front of houses as a de facto veranda is used for social interaction [45]. However, we do not know how long this trend of self-segregation will continue. Nonetheless, in any case, we believe that this trend will gradually weaken, as it was seen during this research that farmers interact with other residents for reasons such as land transactions and work. Finally, the current study concluded that the construction and management of the community has been led by the government from the time of the relocation to the present. This is substantively justified in practice because relocation involves extensive social mobilization and a variety of complex issues, and governance arrangements appear to generally strengthen the enforcement capacity of political institutions [46]. However, with the completion of the relocation task, will the continuation of this normalizing management mode be conducive to achieving sustainable livelihoods for farmers? This is a question worth discussing. Resettlement communities, similar to urban-rural interfaces, are characterized by a "rural-urban" transition, where the living style, travel patterns, and production and living systems will gradually change to urban. This is both an opportunity and a challenge for communities and farmers, as many urbanized services are already far beyond the capacity and scope of resettlement communities and villages. Moreover, it is certainly more difficult for communities and villages to apply political pressure on the government to tackle problems [47]. Generally speaking, the government tends to provide urban services to dense urban areas rather than to more dispersed urban-rural interfaces [48]. In this case, implementing a change from management to governance is necessary. Governance includes the actions of the government , private sector , and civil society [49], but the government and its various forms still plays a central and key role. The limitations of this study include the following aspects. First of all, the logical structure of the framework and the measurement indicators of each dimension may need to be further analyzed and revised. Secondly, this study also used a single methodology and a small sample size. The relationship between the ARSP and livelihood is complex, and not all impacts can be presented using qualitative materials. Further research should attempt to construct a system of indicators for measuring livelihood space. --- Conclusions The ARSP is an important means of poverty reduction in China and has thus far helped 10 million poor people escape poverty completely. Moreover, the pressure on the regional ecological environment has been effectively alleviated. In the later stage of the support, the focus and difficulty have concerned understanding methods to help farmers build sustainable livelihoods and prevent any return to poverty. Against this background, assessing the impact of the ARSP on farmers' livelihood and providing a basis for policies are of positive significance for completing the second half of this article on poverty alleviation and relocation, telling the Chinese story well, and providing a reference for other developing countries and regions. Although this was an area-specific study representing only the rural areas of Shandong Province, China, our findings provide insights into achieving sustainable livelihoods for farmers from a livelihood space perspective. We hereby propose the following policy recommendations based on our study: Promote the simultaneous construction of resettlement areas and industrial parks in combination with local social conditions and rural revitalization planning, by introducing diversified industries to absorb labor and help farmers achieve highquality employment locally. Meanwhile, allow farmers with a low economic status to pay for houses in installments; Improve the construction of community infrastructure or properly transform the spatial layout to weaken the impact of spatial isolation on the social interaction of farmers; Help farmers to develop new social capital via, for example, the establishment of various interest and cooperative organizations; Engage more actors in community governance according to the needs of community governance, to strengthen the capacity to provide public services, especially professional services. --- Data Availability Statement: Not applicable. Sustainability 2023, 15, 8604 ---

To better promote the new anti-poverty strategy and serve as a reference for poverty alleviation in other developing countries and regions, this paper discussed the impact of the antipoverty relocation and settlement program (ARSP) on the livelihood of farmers from the perspective of livelihood space. Existing research focuses on quantitative research on the relationship between relocation and livelihood, but lacks a perspective that combines livelihood and space. In this study, Nanshan village was selected as the research area, using the semi-structured interview and the semi-participatory observation methods to obtain the original materials, and the snowball sampling method was used to determine the interviewees. This study found that the ARSP has a more significant effect on the expansion of production space of young people and farmers with high household savings; meanwhile, by changing the traditional folk house layout, the non-agricultural resettlement mode also forces farmers to adapt to urbanized living, which is a slow process. Affected by factors such as housing segregation and cultural elements, farmers' social interactions show the characteristics of self-isolation in the short term. However, the evidence shows that this trend is declining; after the relocation, the village was incorporated into the community jurisdiction. Similar to urban-rural interfaces, with the transformation from rural to urban, it is difficult for the normalizing management mode and service supply capacity of communities to meet the growing demand for urbanized services of farmers. The clarification of the above impact provides a basis for future relocation community governance and policies.

introduction eliminating poverty is a global challenge when reframed in terms of human development poverty is a constraint that denies individuals human agency in multiple parts of their lives 1 in 2015 the united nations claimed that the millennium development goals had succeeded in reducing global poverty levels by half nonetheless global poverty and hunger remain serious problems 2 the world bank reported that 689 million people lived in extreme poverty in 2017 and the covid19 pandemic may have further pushed about 150 million people into extreme poverty between 2020 and 2021 3 over the past decades countries at different levels of development have contributed to global poverty reduction numerous antipoverty strategies and programs have been established and they are a fundamental component of welfare policies in both developed and developing countries 4 for example the europe 2020 strategy includes promoting social inclusion and combating poverty as one of its 10 integrated guidelines aiming to lift 20 million people out of poverty and social exclusion by 2020 5 in mexico oportunidades founded in 2002 was until 2014 mexicos main conditional cash transfer program to alleviate poverty it aimed to break the transmission of poverty to the next generation through investments in human capital beginning in rural areas and then expanding to urban areas in 2014 the program was renamed prospera 6 brazil is different from mexico bpc and bolsa familia are the two most prominent antipoverty programs they are among the biggest in the world and from the beginning they have covered both urban and rural areas 7 india also has a long history of direct and targeted interventions to fight poverty through workfare schemes and subsidized food and farm inputs the main objective of the national rural employment guarantee scheme is to enhance the livelihood security of farmers by providing 100 days of guaranteed wage employment to every household in unskilled manual work 8 in pakistan the poverty incidence is very high and the government implemented the social safety net program pakistan poverty alleviation fund and many other microfinance schemes to reduce poverty 9 thanks to these strategies many countries and regions have seen significant reductions in the number of people living in poverty these experiences and lessons are also worthy of learning and study by various countries and regions to better meet the challenges they face however while important progress has been made in global poverty reduction efforts challenges remain for some emerging economies for example implementing targeted transfers creates new policy challenges 10 in addition climate change natural disasters and social risks will also exacerbate uncertainties in the development of world society and pose great challenges to global poverty reduction based on building a community with a shared future for humankind working together to eradicate poverty is in line with global common interests and is a common mission and goal of all humankind over the past 40 years china has made significant progress towards its poverty alleviation goals the rural population under the current poverty line has decreased by 7399 million 11 providing chinas successful practical experience as a reference for other developing countries and regions and thus for achieving the sustainable development goals is undoubtedly a main way for china to make a greater contribution to humanity in 1980 the ningxia hui autonomous region moved the entire population from the arid mountainous areas in the south to the easytofarm plains in the north using the diaozhuang resettlement it solved the food and clothing problems of 280000 people and achieved good socioeconomic benefits in 2001 chinas former state planning commission formally introduced the concept of antipoverty relocation and settlement according to chinas rural poverty alleviation and development program china aimed to carry out pilot policies according to the principle of government guidance and voluntary relocation of farmers over the following 10 years but the overall scale of relocation was relatively small in 2011 china gradually established a policy system for antipoverty relocation and settlement with the goal of moving out stabilizing developing and getting rich marked by the outline of poverty alleviation and development in rural china and the twelfth fiveyear plan for relocation to poverty alleviation changing the government from a facilitator to a leader after 2015 poverty governance began to enter the stage of targeted poverty alleviation relocation and settlement as one of the basic means it was also in this year that china launched the antipoverty relocation and settlement program which aimed to lift the poor out of poverty and achieve sustainable livelihood in 2016 the national 13th fiveyear plan for antipoverty relocation and settlement proposed to relocate and resettle 10 million poor people within five years to meet their basic needs broaden income channels and improve living standards so as to fundamentally solve the problem of poverty alleviation and ultimately achieve common prosperity for everyone in 2020 china officially announced that 9899 million impoverished rural residents living under the current poverty line were lifted out of poverty all 832 impoverished counties and 128000 impoverished villages have been removed from the poverty list eliminating overall regional poverty compared with the traditional relief type relocation and settlement highlight the characteristics of the development style improving the production and living conditions at the relocation site can not only help farmers escape poverty and become rich but also relieve the tension between the ecological environment and social development in the outmigrating area with the end of the massive relocation in 2020 the arsp has entered the postsupport stage to achieve stability employment and gradually being able to get rich for farmers judging from the literature livelihood has been the object of research and policies 1213 livelihood reconstruction should be a core process in the planning implementation and postimplementation stages 14 thus what exactly is the impact of the arsp on the livelihood of farmers the answer to this question is the key to strengthening the targeting of policies in the postsupport stage existing studies have discussed the issue mainly in terms of the links between livelihood sustainability and environmental protection 15 the links between migration and livelihood 16 wellbeing and ecosystem dependence 17 livelihood capital 18 livelihood strategy choices 19 livelihood resilience 20 and risk resistance capacity 21 further some studies have begun to draw on the geographic school of thought to identify the spatial distribution of poverty finding that there is a clear spatial poverty trap in rural china 2223 one study revealed the impact of spatial externality on rural poverty from the perspective of public expenditure fluctuation 24 where a spatial scale effect was found to exist in regional poverty features and in the impact of geographical capital on regional poverty 25 these studies have valuable implications for us however there are also two shortcomings on the one hand although numerous studies have been conducted on the relationship between antipoverty policies and livelihood only a few qualitative studies exist on the topic these quantitative studies are analyzed mainly with the help of objectivelevel measurable indicators but these may ignore to some extent the influence of some subjectivelevel nonquantifiable indicators inspired by james c scott we can think of the arsp as a social project to transform the productive and living environments of villages and poor people to avoid the failure of the state perspective it is not enough to rely on the topdown state perspective in policy formulation and evaluation of the arsp therefore it is necessary to combine this with a bottomup perspective of farmers on the other hand although researchers have noted the importance of spatial factors in understanding poverty they have been limited to analyzing the association between the two at the macro level on the contrary they have not focused on the micro level to understand the changes in and reconfiguration of farmers livelihood from a spatial perspective especially in the context of the arsp overall this article fills the literature gap by using an explanatory framework of livelihood space to assess the impact of the arsp on farmers livelihood in four dimensions production residential social interactions and institutions and provide a basis for relevant policies the structure of the article is as follows the first section is the introduction firstly a brief review of national and regional experiences in poverty reduction is presented around the topic of global poverty secondly the basic information surrounding chinas poverty reduction policies is highlighted finally a literature review is used to identify the research gaps and put forward research propositions the second section is the framework the spatial perspective of poverty research and the concept of geographical capital are briefly described on the basis of which the analytical framework of livelihood space is constructed and deconstructed the third section is the methodology the study area research methodology specific implementation process and data sources are presented in more detail the fourth section is the findings the impacts and performance of production space residential space social interaction space and institutional space are analyzed and interpreted in relation to the research data the fifth section is the discussion it mainly connects and compares the findings with those of previous studies and provides insights into the differences found in this paper the sixth section is the conclusion the significance of this study is again clarified and several specific policy recommendations are made based on the findings framework in the 1950s the early school of new economic geography believed that economic backwardness and poverty were closely related to the geographical environment by the 1990s the spatial perspective began to be introduced into poverty research increasingly geographers have put poverty back on the map by pointing to its intricate spatial manifestations 26 one study found that poverty became more concentrated in space 27 this spatial concentration of poverty due to geographic factors is called the spt 28 the spt is a persistent state of poverty caused by location characteristics or high migration costs 29 which is usually distributed in areas with poor ecological environments and a lack of infrastructure and public services the notion of geographical capital usefully highlights the importance of the spatial patterning of disadvantage 30 over time environmental economic social and cultural factors other than natural resources have gradually been incorporated into the category geographical capital meanwhile researchers have also begun to focus on comprehensive poverty and identify it based on the multiple dimensions of the economy society and policy 31 the spatial turn in poverty studies is instructive for studying the arsp spatial poverty theory emphasizes that space is one of the povertycausing factors and that a poor and closed geographical environment can compress the livelihood space of poor people restrict their production and lifestyle and lead to a homogeneous economic structure and weaker development capacity according to this logic the path of poverty reduction is to improve or rebuild livelihood space the arsp is a way to escape the spt by moving poor people living in areas with bad soil and water conditions which cant afford households life to resettle in places with better natural resources at the same time the rich connotation of geographical capital shows that poverty may be reflected in potential social exclusion and lack of opportunities in addition to low income levels therefore when assessing the impact of the arsp on farmers livelihood it is important to consider the impact of institutional and social indicators in addition to focusing on some clear and simple monetary indicators research has confirmed that poverty rates can be reduced by empowering families in political economic and social aspects 32 in conclusion the concept of geographical capital can help us to better identify the needs and barriers of farmers to improve their livelihood space and then adapt policies according to the actual situation to avoid the misalignment between policy supply and farmers needs many studies have developed frameworks for livelihood space one study divided the livelihood space of migrants into economic space policy space public service space and living space 33 in another study the authors constructed a quality evaluation index system for farmers livelihood space from the four dimensions of life production society and institution 34 referring to existing research results we divided the livelihood space of farmers into production space residential space social interaction space and institutional space production space refers to the functional area and capacity of farmers to engage in productive activities the analysis indicators include the rate of nonfarm employment and the level of household savings residential space refers to the area where families live daily the analysis indicators include housing area and the accessibility of infrastructure and public service facilities social interaction space refers to the space constructed by farmers through social networks the analysis indicators include the objects and frequency of social interactions institutional space refers to the institutional environment the analysis indicators include the administrative settings and work content of the community and village these four dimensions are not completely separate but are interconnected and mutually influential community and village these four dimensions are not completely separate but are connected and mutually influential for production space the arsp attempts to fundamentally help poor people cape poverty through a series of measures objectively speaking it creates favorable ditions for widening production space however the nonagricultural resettlement m also breaks the original production order and the yard economywhich is an impo part of daily productiondisappears causing production skills to become ineffectiv the same time the mismatch between the industrial structure of the resettlement are the demographic structure of the village also hinders the expansion of production s in terms of residential space due to relocation farmers will move from dilapidated galows into spacious buildings public service facilities in the resettlement area wi come more centralized and accessibility will be further enhanced in terms of social action space relocation will tear up farmers original social network but it will also grate them on a larger scale in addition the change in production space also simul ously promotes a shift in social relationship ties from blood and geographical ties to k and interest ties for institutional space relocation will break the original administr division and several villages will be concentrated and resettled in the same commu turning farmers from villagers into community residents meanwhile the arsp as a ernmentled intervention has a campaignstyle character in practice and the commu have more complex governance issues which pose new requirements for the constru of institutional space methodology case study area nanshan village is located in the mountainous area in the north of laohu t dongping county shandong province china for the basic information a the village please refer to table 1 in 2016 shandong province issued the 13th five plan for poverty alleviation relocation and resettlement in shandong province plan proposed to implement the arsp in 4 cities and 6 counties 16 villages and 15748 pe accounting for about 40 of the total relocation population in the province among population the relocation population of laohu town was 41405 people for production space the arsp attempts to fundamentally help poor people to escape poverty through a series of measures objectively speaking it creates favorable conditions for widening production space however the nonagricultural resettlement mode also breaks the original production order and the yard economywhich is an important part of daily productiondisappears causing production skills to become ineffective at the same time the mismatch between the industrial structure of the resettlement area and the demographic structure of the village also hinders the expansion of production space in terms of residential space due to relocation farmers will move from dilapidated bungalows into spacious buildings public service facilities in the resettlement area will become more centralized and accessibility will be further enhanced in terms of social interaction space relocation will tear up farmers original social network but it will also integrate them on a larger scale in addition the change in production space also simultaneously promotes a shift in social relationship ties from blood and geographical ties to karma and interest ties for institutional space relocation will break the original administrative division and several villages will be concentrated and resettled in the same community turning farmers from villagers into community residents meanwhile the arsp as a governmentled intervention has a campaignstyle character in practice and the communities have more complex governance issues which pose new requirements for the construction of institutional space methodology case study area nanshan village is located in the mountainous area in the north of laohu town dongping county shandong province china for the basic information about the village please refer to table 1 in 2016 shandong province issued the 13th fiveyear plan for poverty alleviation relocation and resettlement in shandong province the plan proposed to implement the arsp in 4 cities and 6 counties plan and build 39 concentrated settlements and resettle a total of 39834 people dongping was one of the counties that underwent the most heavyduty poverty alleviation in shandong province involving a total of 5 townships 16 villages and 15748 people accounting for about 40 of the total relocation population in the province among this population the relocation population of laohu town was 41405 people in 2017 nanshan village completed the relocation of the whole village primarily into binan community according to the old house demolition compensation incentives of the laohu town nanshan village villagers who were born in moved to or lived in nanshan village long before 31 december 2016 received cny 18000 and 40 m 2 of resettlement housing per capita at the same time the main house gates and courtyard walls within the relocation area were valued for compensation and demolition compensation proceeds were used for housing replacement refunds were issued for any overpayment or a supplemental payment was offered for any deficiency currently nanshan village has completed the relocation and all compensation and incentives have been issued according to the policy in 2017 nanshan village completed the relocation of the whole village primari binan community according to the old house demo compensation incentives of the laohu town nanshan village villagers who wer in moved to or lived in nanshan village long before 31 december 2016 received 18000 and 40 m 2 of resettlement housing per capita excluding the storage room ar the same time the main house gates and courtyard walls within the relocation area valued for compensation and demolition compensation proceeds were used for ho replacement refunds were issued for any overpayment or a supplemental paymen offered for any deficiency currently nanshan village has completed the relocatio all compensation and incentives have been issued according to the policy we also felt the impact of the arsp on farmers livelihood during the field su before the relocation nanshan village was located in a mountainous area with poor conservancy conditions which was far from the market town and the income source mainly droughttolerant crops such as corn cotton and millet overall the living tions of farmers were poor and their income and living standards were low aft relocation farmers moved into spacious and bright buildings howeve to various reasons such as a loss of agricultural income lack of work skills an wages more people chose to go out to work to address this situ the local government has been actively developing industrial parks and providin ployment training to help rural families achieve sustainable livelihood we also felt the impact of the arsp on farmers livelihood during the field survey before the relocation nanshan village was located in a mountainous area with poor water conservancy conditions which was far from the market town and the income sources were mainly droughttolerant crops such as corn cotton and millet overall the living conditions of farmers were poor and their income and living standards were low after the relocation farmers moved into spacious and bright buildings however due to various reasons such as a loss of agricultural income lack of work skills and low wages more people chose to go out to work to address this situation the local government has been actively developing industrial parks and providing employment training to help rural families achieve sustainable livelihood material collection and process this article is a qualitative study aiming to assess the impact of relocation on farmers livelihood from four aspects production livelihood social interaction and institutions we conducted a field survey in nanshan village between february and june 2022 for material collection this study used the semistructured interview and semiparscheme 1 resettlement houses and garmentprocessing plants in the industrial park source this picture was taken in 2022 by the authors material collection and process this article is a qualitative study aiming to assess the impact of relocation on farmers livelihood from four aspects production livelihood social interaction and institutions we conducted a field survey in nanshan village between february and june 2022 for material collection this study used the semistructured interview and semiparticipatory observation methods the snowball sampling method was used for sampling which ensured the randomness of the sample selection the demographics of the interviewees are shown in the table 2 the outline of the interview was set based on research experience and the relevant literature the semistructured interview method is flexible and can obtain a high amount of information while stimulating the initiative of both sides of the interview which places a higher demand on the researchers control and guidance ability in addition although the semiparticipatory observation method provides a shallow understanding of the problem and the observed information is more scattered this information still verifies and complements the formal interview are professional services such as psychological adaptation provided object before entering the field we used personal connections to establish contact with the director of the laohu town relocation office after explaining the research intentions and gaining her trust and permission she gave us a panoramic introduction to the arsp in laohu town after that she helped us to contact the officials of the community and village moreover we interviewed four farmers the interview sites were located in their homes or the fields since familiar and safe environments can appropriately reduce respondents concerns and communication pressure with the interviewees consent the interview audio was recorded and compiled into text on the same day with the initials replacing the actual name of the interviewee during this period we also carefully observed the decoration and furnishings of the farmers homes so we could quickly understand their living standards sometimes we participated in their chat and carefully observed the chat topics and attitudes the data sources and statistics on the arsp in this section were provided by the laohu town relocation office binan community and nanshan village findings 41 the expansion and shrinkage of production space show stratified characteristics at the age and economic levels the arsp is a doubleedged sword at the macro level relocation has moved people out of the spt the centralized resettlement mode and the postsupport polices have further optimized the production environment of farmers which has contributed to the expansion of production space to a certain extent at the micro level before the relocation the farming radius was small the courtyard areas were large the production autonomy was strong and farmers mainly engaged in agriculture and livestock breeding since the relocation the original production space has shown a shrinking trend and faced problems such as long farming distances and the disappearance of vegetable plots at the same time although the idea of nonagricultural resettlement has allowed the remaining young labor force to enter the labor market the sources of income have gradually been diversified however changes in the macroproduction environment also force them to change production methods and habits and their original production skills are useless in other words agriculture is mainly being squeezed out of local livelihoods due to economic environmental and social changes 35 in addition with the aggravation of aging and population outflow the area of abandoned land is also increasing which is the reality of the transformation of farmers production space after the relocation however from the perspective of the heterogeneity of personal livelihood capital it is found that the internal impact of this external environmental change on individual production space shows the characteristic of being highly differentiated that is the degree of profit and loss of production space due to the arsp varies from person to person showing stratification effects among farmers at the age and economic levels the first effect is age stratification affected by poor farming conditions the limited absorption capacity of the communitys labor market and low labor remuneration levels more than half of the young labor force in the village has outflowed the existing population of the village is mainly the elderly women and children on the contrary the laborintensive industries represented by clothing and weaving in the nearby industrial parks are mainly for women under 45 which means that people who exceed the age requirements have no work the elderly who can still work can only continue to farm and their living expenses mostly rely on pension insurance and the support of other family members as the interviewee zch said we used to live in the mountains where farming was our main source of livelihood but the water conditions were not good so we had to rely on natural conditions to live now most young people choose to go out to work the family is left with the old the sick and disabled and the elderly who have no income and do not go to the workers homes when they are old the elderly still have to rely on farming at present the land has not been transferred out coupled with the land away from the community it takes a long time to go back and forth the second effect is economic stratification taking farmers household savings level as an example we found that this indicator directly affects the freedom to choose units and broaden the space for future production with a high level of household savings farmers can not only live in spacious houses but also use geographical advantages to enrich incomegenerating channels rather than choosing a relatively compact apartment type to avoid being indebted the study found that farmers with a comparative advantage in nonagricultural sectors could benefit from relocation to nearby towns 36 the interviewee lns told us the current relocation policy is a per capita subsidy of 18000 yuan and the house is compensated according to the standard of 300 or 580 yuanm 2 generally 80 of farmers can live in new houses with only these compensations taking me as an example there were a total of two houses before the relocation with a total compensation of 170000 yuan coupled with a subsidy for five people after purchasing a new house of 100 m 2 80000 was left which i can use for other things however farmers with small house areas and few family members may need to pay in some money when purchasing houses the improvement of residential space is uneven among the physical and social groups residential space is where farmers live daily it can be divided into physical and social aspects the former relates mainly to the construction of community infrastructure and public service facilities which is also an important measure to solve the problem of two assurances and three guarantees for farmers the former site of nanshan village was in a mountainous area where the production and living conditions were poor and the daily medical treatment schooling and travel of farmers were inconvenient since the relocation the infrastructure of the resettlement community has been completed the gap between urban and rural public service levels is narrowing and the distance to schools hospitals markets and bus stations has been shortened to an average of about 35 km the accessibility of life space plays a different role in promoting the development of farmers 37 at the same time optimizing the community living environment also provides health protection for the lives of farmers here is cleaner and healthier than before is the simplest cognition and expression of their new home in this regard the interviewee dml said the original living conditions were not good and young people were unwilling to continue living there after work nowadays the community environment is much better than before special property companies are in the community and people in public welfare positions are responsible for cleaning work going out is also much more convenient as schools supermarkets and township hospitals are only a few hundred meters away the latter mainly refers to the daily lifestyle and habits of farmers as far as the rural community is concerned the living pattern may become a perspective to examine the changes in lifestyles and habits before the relocation their living pattern was mainly a scattered and independent bungalow courtyard with a shed for raising poultry with a sizeable total use area providing conditions for developing the courtyard economy at the same time farmers had almost zero cost for food drink and fuel however the resettlement community has a unified design comprising highrise buildings with fixed units and a limited area and the original living space has been further compressed moreover tap water and natural gas have increased the cost of living according to a relocation household an older man in the community weighed the water in the toilet tank and calculated that it would cost about cny 005 to flush the toilet once therefore to save money some older people subjectively control the number of times they use the toilet per day accumulate several uses before washing and even use the open ground near the community over an extended period the sanitary conditions in farmers homes will gradually deteriorate in addition there are conflicts between traditional living habits and the order of modern life such as cooking by burning firewood and growing vegetable by destroying green belts from the perspective of the analytical framework of spatial changesocial adaptation the arsp has significantly improved the physical level of residential space through spatial relocation and reconstruction as well as the social level the interviewee ws said its good to relocate into the community but i lost a source of income and the cost of living increased for example i used to find branches in the wild about cooking drink water without paying grow vegetables and grain by myself and keep a few chickens and ducks in captivity to ensure meat and eggs but not now the property company does not allow wood burning and captive poultry is not allowed now the young healthy people can go to farming but the older ones cannot in this situation it has to rely on buying food and drink expanding social interaction space coexists with the selfisolation of social interaction in the short term although the relocation has microscopically broken the original living pattern torn the longestablished neighborhood relationship and distanced relationships with relatives and friends the centralized resettlement mode means that farmers are regrouped on a larger scale at the same time changes in production and residential space also provide opportunities for them to expand their social interaction space such as entering the nearby industrial parks to work and participating in recreational activities the social relationship ties have gradually changed from blood and geographical to business and interests ideally concentrated residence increases the number of potential contacts objects and opportunities to chat more and engage in conversations during the survey we learned that because the reservoir resettlement villages in binan community belong to landless resettlement villages they sometimes have contact with farmers from nanshan village for the purchase of cemetery plots this increases the probability of communication and familiarity between farmers and is conducive to reproducing their social capital in short from a macro point of view the overall scale of social interaction space has gradually expanded since the relocation however our research found that the natural pattern of farmers social interaction space seems different the current resident population in the village can be divided into two types one is continued farmers who still live a farming life of awake with the sunrise and rest with the sunset and workers who also go out early and return late the other is those who stay at home mainly the elderly and women who take care of the family whose social interaction during the day is generally distributed in the corridor of the village building or the nearby shed likely in the evening they rarely go through several buildings to villages or other places in the community except for going to the square to see a play one or two times per month unlike the village society that has heard about chickens and dogs the current apartmentstyle housing emphasizes the privacy of personal life the stairs and antitheft doors have become the roadblock for farmers interactions in fact farmers have fewer crossvillage social activities due to factors such as livelihood differences and housing segregation and even the frequency of interaction with village households is lower than before in short since the relocation farmers social scope and social network have not been significantly extended with time but are still relatively closed that is social interaction tends to cause selfisolation in the short term according to the actual situation there are two causes of selfisolation first farmers in the same village have substantial homogeneity in living habits and cultural psychology the interpersonal relationships formed in the village society are stable social trust and recognition are high and the villagers are more inclined to communicate with each other at the same time this interaction is also conducive to maintaining the sense of place which can be seen from the gossip of farmers the survey found that their topics of daily chatting included memories of previous life worries about current life and discussions on current policies in addition to chewing the fat and discussing new things in the community second in addition to the above differences and housing distinctions this also includes the heterogeneity of communication objects and the sense of relative deprivation caused by policy differences reservoir resettlements can receive a per capita relocation subsidy of cny 25000 and a postassistance subsidy of cny 600 per capita per year before 30 june 2026 for some farmers policy differences are a topic to talk about after dinner but the relative deprivation caused by them also hinders communication between them the institutional space faces the double squeeze of campaignstyle relocation and normalizing management institutional space is an essential guarantee for reconstructing livelihood space however this survey found that institutional space faces a double squeeze the first is the squeeze brought by campaignstyle relocation this double squeeze leads to governance dilemmas such as difficulties in social integration insecure sustainable livelihoods and tight service resources 38 this is mainly reflected in three aspects the scale of relocation the depth of mobilization and the intensity of resource integration specifically traces of campaignstyle relocation can be seen in nanshan village and binan community in the relocation mobilization and housing selection regarding the relocation scene xsj the party branch secretary of nanshan village recalled the following at that time the village committee members went doortodoor in two classes to visit and carrying out ideological work results showed that 70 of farmers were willing to relocate and when they chose a house the proportionality value reached more than 90 they did not move partly because they could not make the decision alone and partly because their house size and family size were small so they received very little compensation and would have had to take extra money to live in a new house after a demolition these people also came along and now all relocated everyone calculated their account found that the result was very suitable so they decided to move wcy the secretary of binan community described the scene of the housing selection at that time he said the following when the house was divided it was intended to let everyone draw lots but onethird of them did not want to come later we thought of a way for people unwilling to relocate to live in the original place but whoever comes first can choose the house first and the house number is optional later the vast majority came to choose and the remaining people felt no need to consume anymore some people come to the line two days in advance and sleep in the line at night judging from the results the shortterm effects of campaignstyle relocation are remarkable and take full advantage of the benefits of the socialist system with chinese characteristics however it faces challenges in adapting to the livelihood of farmers demolishing old houses and supplying public services in the resettlement community 39 at the same time as a product of forced institutional changes fragmentation and transition are its core characteristics further from the analysis framework of institution and life there are also conflicts and tensions between daily life and institutional creation within this type of community 40 the second is the squeeze brought by normalizing management before the relocation the administrative district was always an intermediary between townships and villages an administrative district is a quasiadministrative organization between townships and administrative villages currently the administrative district of shandong province is the most complete and standardized after the relocation although the community nominally replaced the administrative district the functions and status of the two were the same farmers still referred to the party secretary of binan community as the administrative district secretary from the content point of view the current township communities and villages continue the previous normalizing management relationship normalizing management is mainly reflected in the following three aspects the first aspect is the regularization of community and village committee staffing for example community officials include a party secretary director and instructor village officials include a party branch secretary and accountant the second aspect is the regularization of working funds the community has no independent economic rights nanshan village has neither a fixed collective income nor additional office expenses the third aspect is the normalization of work content the daily work is still based on the assigned tasks of the higherlevel government departments on the contrary less attention is paid to the unique problems in the transitional stage such as culture psychological adaptation and professional service supply in short the resettlement community still follows a management logic related to the nature of targeted antipoverty work at the same time there is also a lack of institutional response to the fragmentation and transition in the community service system this may expose farmers to the risk of exclusion and marginalization due to a lack of identity participation and special demand expression channels discussion based on qualitative work in nanshan village this paper draws on the framework of livelihood space to examine the impact of the arsp on the livelihood of farmers from four dimensions production residential social interaction and institutions the results show that livelihood space is a composite system of livelihood practices and that the impact of relocation on livelihood is multidimensional and deep our findings are in accordance with recent studies indicating that relocation has various negative socioeconomic impacts on livelihood leading to significant impoverishment risks 41 the arsp destroyed the stable production structure and order while transferring farmers out of the spt further analysis indicates that the impact has stratified characteristics in terms of age and the level of household savings older people are more likely to see these challenges due to the disappearance of income and vegetable plots farmers with high levels of household savings are more likely to see the opportunities because they can use compensation and geographical advantages to conduct business for asset accumulation a study on the migration of bangladeshi fishermen also expressed a similar perspective that is the results of immigration are highly differentiated for poorer fishermen immigration is a way to cope with shocks and fishermen with better resources can use it for asset accumulation 42 this study also found that although the government has been trying to build industrial parks and carry out skills training migrant work is still the main source of income for farmers combined with the results of the interviews the reason is not just the lack of employment opportunities 43 it may also be related to low wages a long tradition of migrant work and occupational prejudice the evidence shows that the transformation of farmers lifestyles and habits shows hysteresis compared to community building adaptation is a process that may take years to complete as it is not a shortterm process meanwhile this study found that farmers social interactions are characterized by selfsegregation and that the objects of interaction are highly homogeneous in the short term a study found that urbanrural interface residents attempt to realize their social and cultural aspirations of reproducing kampung ways of life characterized by dense social networks and common practices such as mutual aid 44 this provides an idea to explain our findings but it does not seem to be sufficient we also found that apartmentstyle housing discourages social interaction among households usually it is found that the space in front of houses as a de facto veranda is used for social interaction 45 however we do not know how long this trend of selfsegregation will continue nonetheless in any case we believe that this trend will gradually weaken as it was seen during this research that farmers interact with other residents for reasons such as land transactions and work finally the current study concluded that the construction and management of the community has been led by the government from the time of the relocation to the present this is substantively justified in practice because relocation involves extensive social mobilization and a variety of complex issues and governance arrangements appear to generally strengthen the enforcement capacity of political institutions 46 however with the completion of the relocation task will the continuation of this normalizing management mode be conducive to achieving sustainable livelihoods for farmers this is a question worth discussing resettlement communities similar to urbanrural interfaces are characterized by a ruralurban transition where the living style travel patterns and production and living systems will gradually change to urban this is both an opportunity and a challenge for communities and farmers as many urbanized services are already far beyond the capacity and scope of resettlement communities and villages moreover it is certainly more difficult for communities and villages to apply political pressure on the government to tackle problems 47 generally speaking the government tends to provide urban services to dense urban areas rather than to more dispersed urbanrural interfaces 48 in this case implementing a change from management to governance is necessary governance includes the actions of the government private sector and civil society 49 but the government and its various forms still plays a central and key role the limitations of this study include the following aspects first of all the logical structure of the framework and the measurement indicators of each dimension may need to be further analyzed and revised secondly this study also used a single methodology and a small sample size the relationship between the arsp and livelihood is complex and not all impacts can be presented using qualitative materials further research should attempt to construct a system of indicators for measuring livelihood space conclusions the arsp is an important means of poverty reduction in china and has thus far helped 10 million poor people escape poverty completely moreover the pressure on the regional ecological environment has been effectively alleviated in the later stage of the support the focus and difficulty have concerned understanding methods to help farmers build sustainable livelihoods and prevent any return to poverty against this background assessing the impact of the arsp on farmers livelihood and providing a basis for policies are of positive significance for completing the second half of this article on poverty alleviation and relocation telling the chinese story well and providing a reference for other developing countries and regions although this was an areaspecific study representing only the rural areas of shandong province china our findings provide insights into achieving sustainable livelihoods for farmers from a livelihood space perspective we hereby propose the following policy recommendations based on our study promote the simultaneous construction of resettlement areas and industrial parks in combination with local social conditions and rural revitalization planning by introducing diversified industries to absorb labor and help farmers achieve highquality employment locally meanwhile allow farmers with a low economic status to pay for houses in installments improve the construction of community infrastructure or properly transform the spatial layout to weaken the impact of spatial isolation on the social interaction of farmers help farmers to develop new social capital via for example the establishment of various interest and cooperative organizations engage more actors in community governance according to the needs of community governance to strengthen the capacity to provide public services especially professional services data availability statement not applicable sustainability 2023 15 8604

to better promote the new antipoverty strategy and serve as a reference for poverty alleviation in other developing countries and regions this paper discussed the impact of the antipoverty relocation and settlement program arsp on the livelihood of farmers from the perspective of livelihood space existing research focuses on quantitative research on the relationship between relocation and livelihood but lacks a perspective that combines livelihood and space in this study nanshan village was selected as the research area using the semistructured interview and the semiparticipatory observation methods to obtain the original materials and the snowball sampling method was used to determine the interviewees this study found that the arsp has a more significant effect on the expansion of production space of young people and farmers with high household savings meanwhile by changing the traditional folk house layout the nonagricultural resettlement mode also forces farmers to adapt to urbanized living which is a slow process affected by factors such as housing segregation and cultural elements farmers social interactions show the characteristics of selfisolation in the short term however the evidence shows that this trend is declining after the relocation the village was incorporated into the community jurisdiction similar to urbanrural interfaces with the transformation from rural to urban it is difficult for the normalizing management mode and service supply capacity of communities to meet the growing demand for urbanized services of farmers the clarification of the above impact provides a basis for future relocation community governance and policies

A range of studies links higher testosterone to specialized "life-history strategies" centered around prolific short-term and nonmonogamous partnering . Traits facilitating these effects include risk taking and impulsivity, and are accompanied by a range of "antisocial" behaviors, reactive aggression, as well as lower empathy. Consistent with this diminished prosocial capacity, recent cross-sectional evidence from the nationally representative NHANES indicates negative linkages of men's testosterone with cooperative, supportive relationships beyond the intimate partnership . In other words, the well-documented underinvestment in monogamous partners or in parenting care, among men with elevated testosterone, may be paralleled by a lack of investment in strong social relationships in general . While theory predicts similar patterns among women, their testosterone-sociality linkages remain unexplored. Moreover, causal direction in associations of testosterone with social relationships remains unclear. Both clinical and an older sociological literature appear to assume hormones are exogenous to social processes-such that any connection between the two is in the form of hormonal causation . In contrast, recent studies indicate behavioral and relational modulation of testosterone levels, suggesting that close ties may prospectively lower testosterone . In turn, a large and growing literature indicates women's network ties have consistent associations with a range of better outcomes in late life, including physical and mental health . Thus, predictors of these crucial social resources become important to explore. While studies have yielded a large number of "risk factors," none have examined hormones. Moreover, testosterone also has deep physiological linkages with multiple health dimensions in late life . If this sex steroid does indeed influence network outcomes, therefore, it may also confound previously published associations of social ties with behaviors and health conditions . Conversely, as discussed below, any influence of a woman's egocentric web of relationships on her testosterone levels would have serious implications for the vast literature on testosterone's apparent effects on sexual health . The current study filled these gaps by examining linkages of older women's salivary testosterone with their social ties, as well as potential causal direction in such associations. Specifically, it used data from the first two waves of the National Social Life, Health and Aging Project -a national probability sample of older U.S. adults-along with autoregressive cross-lagged panel models to simultaneously address reciprocal influences of women's testosterone on their social relationships and vice versa. The latter included one structural indicator of a nurturant relational contextthe proportion of kin in one's egocentric network-as well as two indicators of tie strength: perceived support from friends and family, and closeness to network members. It was conjectured that kin proportion, as a stable compositional feature, would be driven by a range of factors other than hormones. Thus, any linkage with testosterone would more likely follow a social modulation than hormonal causation pattern. In contrast, closeness to and perceived support from one's social alters could take either form. Two research questions were examined: do older women's elevated testosterone levels predict their network kin proportion and tie strength? And are these effects bidirectional? --- Testosterone and Social Relationships Explanatory models of testosterone-prosociality linkages derive from the "challenge hypothesis." The original version of this conceptual framework concentrated on species differences in mating and social propensities. Among monogamous species, it also addressed temporal changes in them, catalyzed by testosterone . Briefly, the model proposes that this sex hormone may facilitate a trade-off between mating and parenting effort. Thus, rather than stable relationships and parental care, those with higher testosterone may invest in shortterm and promiscuous mating strategies . These patterns may begin early in life, such that an individual is gradually channeled into a sexual career marked by more risky and frequent partnering. Behaviors associated with such an orientation may include a range of antisocial activities, all of which can be viewed as putting shorterterm goals before longer-term ones-as also aggression, dominance, status striving, and a general lowering of social empathy. Rather than having a "localized" association with sexuality, in other words, high testosterone might be linked more generally to life trajectories marked by less norm conformity and higher interpersonal conflict. As noted, clinical as well as an older sociological literature appears to assume hormonal causation with these associations, such that testosterone lowers prosocial propensities and heightens promiscuity . In contrast, a newer "social modulation" model suggests the inverse-that is, that "exposure" to a stable and high-quality partnership, and constrained sexual opportunities, may prospectively lower testosterone . Similarly, behaviors such as wielding power may also raise testosterone , while participating in emotionally supportive relationships may lower it . Per evolutionary logic, continuously high testosterone levels and their associated behaviors are suboptimal, since they elevate survival costs as well as reproductive ones . In monogamous species, such costs are controlled by maintaining testosterone at lower baseline levels, and making this hormone responsive to environmental cues . Far from being a static and exogenous biological factor, in other words, testosterone levels are in large part a dynamic outcome of a changing social context. Thus, for instance, testosterone rises when competition or interaction with sexually desirable partners is imminent. Human mating systems have been described as involving mild polygamy, together with high parental care, such that testosterone shows substantial ecological responsiveness . More constrained exposure to arousal-inducing social signals, therefore, may prospectively lower testosterone. In other words, while testosterone's linkages with sexualized life trajectories and associated behaviors seem clear, causal direction at a given stage of the life course does not. Human literature on the challenge hypothesis has largely focused on men, with far fewer studies examining women's patterns . A new generation of scholarship, rooted in feminist biological theory, is beginning to fill these gaps . Importantly, it finds that while there is similarity across genders in linkages of testosterone to behaviors, there is also considerable variation. These differences may apply not simply to the relative strength of associations, but also to the specific behaviors or ecological factors tied to this sex steroid among women or men. Evolved functions, social roles, and/or sociocultural experiences related to femininity and masculinity are all speculated to play a role. For instance, certain activities may be testosteroneenhancing for men but not women, because only the former have been taught to value them as competitive . Beyond the challenge hypothesis, a new Steroid/Peptide Theory of Social Bonds addresses these same testosterone-prosociality-partnership interconnections-uniting testosterone and oxytocin in a single model, and explicitly focusing on women's patterns ). The framework divides intimacy into sexual and nurturant subtypes. Both types increase oxytocin. However, only sexual intimacy is linked to elevated testosterone. Nurturant intimacy, in contrast, may have negative associations with it. Importantly, such an orientation of testosterone along a nurturance-competition gradient, in this theoretical model, applies to social relationships in general, beyond the pair bond. Current biological literature also assumes any social or relational modulation is due to spontaneous psychobiological downregulation of testosterone in nurturant, noncompetitive contexts where empathy and dampening of aggression are more needed . In turn, evolutionary kin selection theory strongly indicates networks rich in relatives are more likely than any other to provide precisely such an environment . The model, one of the main evolutionary explanations for altruism, predicts behavior to maximize the fitness of one's relatives, even at a cost to one's own survival and reproduction. However, a longstanding network literature indicates a second potential mechanism through which such kin-centered contexts can influence testosterone-social control of antisocial behaviors. Embeddedness in a dense network of "stakeholders," such as concerned family members, can serve as a crucial source of control over one's counter-normative activities . Indeed, such relational inhibition may be gender-specific-such as enforcement of norms that proscribe older women's but not men's sexuality . If so, such network composition may also dampen the former's testosterone-although, as a structural feature of one's web of relationships, it is less likely than tie strength to be influenced by testosterone levels. Overall, then, rather than a gender-neutral framework, building theory on hormonesociality linkages requires careful attention to factors that may be specifically important to one gender or the other. Despite these clear and potentially conflicting theoretical predictions, no empirical analyses yet exist on linkages of women's testosterone with their social ties. Accordingly, the current study examined three conjectures. To test social modulation, it was hypothesized that: Hypothesis 1. Women's higher network kin proportions will predict their lower testosterone. Hypothesis 2. Women's stronger social ties will predict their lower testosterone. Similarly, the inverse hormonal causation conjecture led to the following hypothesis: Hypothesis 3. Women's elevated testosterone will predict their weaker social ties. In the second wave , 2,261 of these individuals were reinterviewed. The total analytic sample for the current study was comprised of 1,162 of these women. As described below, IPA weights were used to adjust for across-wave attrition. --- Method --- Procedure An in-person questionnaire was administered in either English or Spanish by a field interviewer in the participant's home. Most interviewers were experienced personnel given further training by NORC at the University of Chicago, and remained with the project throughout the survey period. In addition to self-report, data included assessments of physical and sensory function, height and weight, and salivary, blood, and vaginal mucosal samples-all collected at the time of interview by nonmedically trained interviewers. Participant consent was obtained prior to interview. Institutional Review Boards at the Division of the Social Sciences and NORC at the University of Chicago approved data collection procedures . Reanalysis of NSHAP secondary data was approved by a McGill University Research Ethics Board. Table 1 shows the summary statistics for all variables used in the analyses. For all self-reports, question wording was identical across waves. --- Measures: Social Ties Three wave-specific indicators were included in this group. First, kin proportion in network was derived from NSHAP's egocentric social network data, and ranged continuously from 0 to 1 . Respondents were asked to enumerate individuals with whom they discussed important matters-a standard name generator in network studies . This "network roster" allowed up to five people to be named. They were then probed to characterize their relationship with each nominated network member, as one of eighteen distinct types. The kin proportion variable was simply the ratio of family relationships to all ties. Second, perceived support from friends and family combined four Likert scales-of being able to open up to and rely on friends and on family. The questions were included in the main part of the interview, and were drawn from the 2002 Health and Retirement Study . Since these items only contained three categories each-ranging from 0 to 2 -summary indexes based on Cronbach's α were considered suboptimal. Instead, principal component analysis based on a polychoric correlation matrix was used . The first principal component had a Wave 1 eigenvalue of 2.28 and explained 57% of the total variance in the items, more than twice as much as the next component. The corresponding Wave 2 figures were 2.22% and 56%, respectively. Accordingly, this component was adopted as the measure of perceived support. Finally, the network roster data yielded another measure of tie strength: closeness to network members. Participants rated each such social alter on a scale of 1 to 4 . The summary measure was an average of these alter-specific scores. --- Measures: Salivary Testosterone Testosterone was derived from saliva samples taken during the biomeasure collection portion of the in-home interview . Participants were encouraged not to eat during the interview, even though eating and dental care are reported to have no effect on the replicability of steroid levels in saliva . Following previously validated protocols , passive drool was used to collect whole unstimulated saliva, which was then frozen until assay. Salivary enzyme immunoassays were conducted using commercially available kits. Wave 1 assays were by Salimetrics Laboratories ; in Wave 2, specimens were sent to Dresden LabService GmbH for duplicate assays using identical assay kits from Wave 1. Due to extreme right skew, testosterone values-originally in pg/ mL-were log transformed for analysis. f __ f __ f __ f Ethnicity White b 0.81 1,169 0-1 __ f __ f __ f __ f Black b 0.10 1,169 0-1 __ f __ f __ f __ f Hispanic/other b 0.08 1,169 0-1 __ f __ f __ f __ f --- Measures: Control Variables This block of self-reports was comprised of both time varying and time invariant covariates, and was controlled in all models. A first such measure was a participant's age , entered linearly as a continuous variable. This variable was conceptualized as time invariant since it was perfectly correlated with time, with Wave 2 age a perfect linear function of the preceding value. Ethnicity was indexed through a set of dummy variables for Black, Hispanic, and Other, with non-Hispanic White as the reference. Time-varying covariates included, first, a dichotomous indicator of marital status. In addition, network size was included to avert confounding of testosterone's linkages with tie strength or kin composition by the sheer size of one's egocentric network. A next time varying covariate was a standardized summary index for a participant's socioeconomic status-comprised of a participant's wavespecific self-reported household wealth, household income, educational attainment, perceived household income relative to acquaintances and to American families in general. Cronbach's alpha at Wave 1 was 0.75 and at Wave 2 was 0.76. A dichotomous measure indicated current consumption of any sex hormone supplements-included to net out any pharmacological influences on endogenous testosterone. NSHAP collected a complete log of currently used medications during the in-home interview, by direct observation using a computer-based log. The Multum® drug database, based on the hierarchical classifications of the American Hospital Formulary Service, was used for coding drug names . A continuous indicator for saliva collection time was also controlled, given long-established circadian rhythms in older women's testosterone . Similarly, waist size was included to net out potential linkages of this sex steroid with visceral adiposity . Physical health indicators included one's total number of diagnosed conditions. Participants were asked about any lifetime diagnosis of a range of medical conditions, of which nine-heart attack, arthritis, ulcers, asthma, stroke, hypertension, diabetes, cancer, and enlarged prostate-were combined into a single score . Poor functional health was indexed by a continuous additive score for impaired Activities of Daily Living . Specifically, difficulties with routine everyday activities such as dressing, bathing, eating, getting in or out of bed, and using the toilet were queried through Likert scales ranging from 0 to 3 . These were then summed up to create the additive score. --- Statistical Analysis Three models were run, respectively examining linkages of women's testosterone with their network kin proportion , with perceived support from family and friends , and with closeness to network members . Analyses used an ARCL approach . Thus, cross-lagged paths were specified to estimate reciprocal influences for all time varying factors-the four substantively important variables, as well as all time varying covariates. In addition, for each such variable, autoregressive paths examined dependency of Wave 2 on Wave 1 values. Finally, all Wave 2 measures were regressed on time invariant covariates. Supplementary Figure 1 illustrates the model. It is noted that ARCL models do not disaggregate between-and within-subjects effects. A newer autoregressive latent trajectory specification with structured residuals allows extraction of within-person cross lagged effects . Per reviewer recommendation, the latter was tried. Convergence could not be achieved-arguably due to the number and diversity of time varying covariates. Hence, inferences were based on the more conventional and widely used ARCL method. Another analytic issue was selective attrition-that is, nonreinterview of the Wave 1 participant, whether through mortality or nonresponse, due to factors also influencing covariates. To take this selection process into account, pooled logistic regression was used to fit a predictive model for attrition across waves. Covariates included a participant's demographic and health attributes . Based on predicted probabilities from this model, stabilized inverse-probability-of-attrition weights were created ). Thus, participants with characteristics associated with a lower probability of continuation were assigned larger weights, "compensating" for their underrepresentation in the second wave. Finally, all analyses were weighted by the product of these IPA weights with Wave 1 population weights that adjusted for the intentional oversampling of Blacks and Hispanics and incorporated a non-response adjustment based on age and urbanicity . IPA weights were generated with the Stata 14.1 statistical package . All other analyses were conducted in Mplus Version 7.1 . Standard errors were adjusted for sample stratification and clustering . Estimation was through a robust weighted least squares estimator using a diagonal weight matrix. --- Results Tables 2-4 respectively show results from cross-lagged analyses for linkages of testosterone with the kin proportion in one's close personal network, with perceived support from friends and family, and with closeness to network members. Given the range of estimates, the focus below is on those conceptually important for pattern inference. Since each model had a mix of Both autoregressive effects in this model were significantthat of Wave 1 on Wave 2 kin proportion , and that of testosterone across waves . In other words, there seems to be considerable temporal constancy in both of these factors. However, even net of this apparent stability, and consistent with social modulation of testosterone, the cross-lagged effect of Wave 1 kin proportion on Wave 2 testosterone also reached significance . Contrary to hormonal causation arguments, however, the same was not true of the inverse effect, of Wave 1 testosterone on Wave 2 kin proportion. As with other biological processes, then, testosterone may have stochastic as well as stable componentswith at least the former open to social influence . From a longer temporal perspective, the stable component may also be subject to such influence. Early life factors may imprint behavioral patterns that produce and maintain differential testosterone levels -a conjecture that could not be tested with the NSHAP sample of older adults. --- Table 3: Testosterone and Perceived Support from Friends and Family In contrast to objective kin proportion, subjective perception of support from friends and family at Wave 1 did not have a cross-lagged effect on women's Wave 2 testosterone. Rather, consistent with hormonal causation, it was Wave 1 testosterone that negatively affected Wave 2 perceived support . Older women with higher levels of this sex steroid, in other words, do seem to experience more subjective isolation even in their most proximal social ties. As with testosterone and kin proportion, Wave 1 perception of support also had a positive autoregressive effect on Wave 2 values . --- Table 4: Testosterone and Closeness to Network Members As with all of the other substantively important variables, the autoregressive effect of Wave 1 on Wave 2 closeness to one's social network members was positive . Cross lagged effects supported a hormonal causation inference, consistent with Table 3 but contrary to Table 2 patterns. Specifically, Wave 1 testosterone had a negative effect on Wave 2 closeness to network , while the inverse linkage failed to reach significance. --- Discussion The inclusion of biological indicators in population-representative and longitudinal social surveys offers an unprecedented opportunity to explore proximal connections of life course patterns with hormonal or other biological processes. The present study, the first to use a national probability sample to examine potential causal direction in linkages of testosterone with social networks, extended this growing literature. To recall, theory deriving from the challenge hypothesis indicates that testosterone may be negatively associated with having strong, nurturant and kin-centered social ties. While men's linkages have been explored, women's have not-a gender discrepancy that holds across the human literature . Causal direction also remains unclear, with rival conceptual models suggesting inverse effects. Moreover, patterns may vary across network dimensions. While a high kin proportion, as a stable compositional feature, would more likely influence women's testosterone than vice versa , the latter's associations with tie strength could take either a similar social modulation or a hormonal causation form. Per conjecture, cross-lagged effects for kin connections indicated a sociality-to-hormones direction: while high Wave 1 proportions of relatives in one's egocentric network had a negative effect on Wave 2 testosterone, the inverse was not true. In contrast to this clear social modulation finding, those for tie strength were fully consistent with hormonal causation . For both perceived support from friends and family, and closeness to one's network members, it was Wave 1 testosterone that negatively influenced Wave 2 relational outcomes rather than vice versa. Findings add to the emerging evidence that far from being linked solely to men's competitive propensities and aggression-the predominant focus in the first generation of studies based on the challenge hypothesis-testosterone has distinct and nuanced implications for women's sociality. In turn, these social factors may be critical for healthy aging. If testosterone negatively influences women's tie strength, for instance, it also arguably lowers availability of resources channeled through such relationships. Network theorists have long argued that deep social connections rich in mutual trust can enhance a person's perceived agency, lower discomfort with uncertainty, and reduce resistance to change . Late life can be a time of high uncertainty, when individuals experience fundamental changes in the structure of both their families and their broader social network. Children leave home; retirement uproots individuals from their social networks at work; parents and elders pass away; and health problems begin impeding interaction . At such times, persisting strong ties can play a critical role in successful adaptation to changing circumstances. Conversely, if the structure of women's egocentric network influences their testosterone levels, as the results above suggest, it may also confound testosterone's linkages with sexual health. Consistent with this argument, for instance, previous research indicates that having a kincentered network also inhibits older women's partnering patterns . This as-yet-unexplored social confounding possibility implies that at least some of the previously published findings of testosterone's effects on sexuality might be spurious-such that both the purported cause and effect are instead driven by social context . It also adds a new dimension to the ongoing debate over testosterone therapy and the medicalization of women's sexual issues . Current work is examining, for instance, whether endogenous testosterone is more a mediator than a cause of women's sexual desire and capacity, such that the ultimate roots of the latter lie more in a competitive and/or sexualized social context. In other words, this sex steroid might be a biological mechanism through which interpersonal situations marked by heightened sexual signaling elevate arousal. If so, psychosocial interventions may arguably have effectiveness comparable to testosterone therapy, while avoiding potential iatrogenic harm. More generally, the proximal behavioral and psychological traits the neuroendocrine literature has thus far tied to hormones have second-order linkages with a range of factors potentially important for late-life well being. Thus, more research is needed on the role of hormones in the structure of the life course, whether through actions and attitudes that induce negative health transitions and other "turning points" , or social resources that buffer against ill health . The argument here is not to reduce such patterns solely to baseline hormonal differences. At a given stage of the life trajectory, as the social modulation results above indicate, these levels are themselves products of relational patterns. Rather, findings suggest a need for conceptual models that can accommodate the complex interplay of social and neuroendocrine factors in shaping the life cycle. There were several limitations to this study. As noted, although cross-lagged analysis is widely used to explore direction of association in longitudinal data, the approach does not disaggregate between-and within-subjects effects . The more rigorous ALT-SR specification could not be used due to model nonconvergence. Experimental evidence would lend confidence to the causal role of testosterone in the formation and maintenance of social ties. Participants were aged 62-90 years at Wave 2, ages at which not simply testosterone levels but also their linkages with social behaviors may be very different than among younger populations. Generalizability may accordingly be limited. However, hormone-sociality patterns in late life remain understudied, despite having major implications for healthy aging, as argued above. Models adjusted only for a small range of clearly exogenous factors. Variables like negative behaviors and mental health were not controlled because they were conceptualized as mediators of testosterone-sociality connections, such that their inclusion would have amounted to overadjustment and inappropriate attenuation of estimates. However, potential omitted-variable bias remains a concern. Moreover, linkages may well vary across categories of indicators that were controlled -patterns that could not be examined in the current study due to sample-size limitations. IPA weights were designed to adjust for between-wave attrition . However, they could not take into account measure-specific missingness patterns. Given the newness of the topic, values were not imputed. Similarly, the five-year lag between waves, while well suited to detecting stable linkages, may have blinded the analyses to important temporal inflections in effects as well as intervening processes. Finally, given only two waves of data, psychobehavioral mediation of testosterone-sociality links, implicit in the conceptual model, could not be examined. Only baseline connections could be established. More research is therefore needed on precisely why testosterone lowers women's tie strength, and is in turn lowered by their kin-rich networks. --- Conclusion Longitudinal data from a nationally representative U.S. sample suggested that rather than following a uniform pattern, women's endogenous testosterone has distinct associations with specific dimensions of their social networks. Consistent with social modulation of hormones, a higher kin proportion in one's egocentric network, arguably a stable compositional feature, negatively predicted women's testosterone levels. No inverse effect was found. In contrast, results for tie strength were consistent with hormonal regulation of women's sociality. Both perceived support from one's friends and family, and closeness to network members, were negatively influenced by testosterone, but not vice versa. Findings have implications for social confounding of testosterone-sexuality linkages, for medicalization of women's sexuality, as well as for potential hormonal roots of women's late-life social resources. Conceptual models that can accommodate the complex interplay of social and neuroendocrine factors in shaping the life course are needed. --- Conflict of Interest None reported. ---

Objectives: This study examined potentially bidirectional connections of older U.S. women's salivary testosterone with their social network connections. Methods: Data were from the 2005-2006 and 2010-2011 waves of the National Social Life, Health and Aging Project (NSHAP), a national probability sample of older U.S. adults. Autoregressive cross-lagged panel models tested linkages of women's testosterone with their social networks. Results: Consistent with recent biological theory suggesting social modulation of hormones, a higher kin proportion in one's egocentric (person-centered) network, arguably a stable compositional feature, negatively predicted women's testosterone levels. In contrast, findings for tie strength were consistent with hormonal regulation of women's sociality-with both perceived support from friends and family, and closeness to network members, negatively influenced by testosterone. Discussion: Rather than being a static and exogenous biological factor, older women's testosterone levels seem partly an outcome of their social context. Implications for sexual health and hormone therapy are discussed. However, this androgen also influences dimensions of their intimate networks critical to successful aging. Findings suggest the need for social scientists to engage with the neuroendocrine literature, which offers suggestions on linkages of hormones with specific network patterns.

a range of studies links higher testosterone to specialized lifehistory strategies centered around prolific shortterm and nonmonogamous partnering traits facilitating these effects include risk taking and impulsivity and are accompanied by a range of antisocial behaviors reactive aggression as well as lower empathy consistent with this diminished prosocial capacity recent crosssectional evidence from the nationally representative nhanes indicates negative linkages of mens testosterone with cooperative supportive relationships beyond the intimate partnership in other words the welldocumented underinvestment in monogamous partners or in parenting care among men with elevated testosterone may be paralleled by a lack of investment in strong social relationships in general while theory predicts similar patterns among women their testosteronesociality linkages remain unexplored moreover causal direction in associations of testosterone with social relationships remains unclear both clinical and an older sociological literature appear to assume hormones are exogenous to social processessuch that any connection between the two is in the form of hormonal causation in contrast recent studies indicate behavioral and relational modulation of testosterone levels suggesting that close ties may prospectively lower testosterone in turn a large and growing literature indicates womens network ties have consistent associations with a range of better outcomes in late life including physical and mental health thus predictors of these crucial social resources become important to explore while studies have yielded a large number of risk factors none have examined hormones moreover testosterone also has deep physiological linkages with multiple health dimensions in late life if this sex steroid does indeed influence network outcomes therefore it may also confound previously published associations of social ties with behaviors and health conditions conversely as discussed below any influence of a womans egocentric web of relationships on her testosterone levels would have serious implications for the vast literature on testosterones apparent effects on sexual health the current study filled these gaps by examining linkages of older womens salivary testosterone with their social ties as well as potential causal direction in such associations specifically it used data from the first two waves of the national social life health and aging project a national probability sample of older us adultsalong with autoregressive crosslagged panel models to simultaneously address reciprocal influences of womens testosterone on their social relationships and vice versa the latter included one structural indicator of a nurturant relational contextthe proportion of kin in ones egocentric networkas well as two indicators of tie strength perceived support from friends and family and closeness to network members it was conjectured that kin proportion as a stable compositional feature would be driven by a range of factors other than hormones thus any linkage with testosterone would more likely follow a social modulation than hormonal causation pattern in contrast closeness to and perceived support from ones social alters could take either form two research questions were examined do older womens elevated testosterone levels predict their network kin proportion and tie strength and are these effects bidirectional testosterone and social relationships explanatory models of testosteroneprosociality linkages derive from the challenge hypothesis the original version of this conceptual framework concentrated on species differences in mating and social propensities among monogamous species it also addressed temporal changes in them catalyzed by testosterone briefly the model proposes that this sex hormone may facilitate a tradeoff between mating and parenting effort thus rather than stable relationships and parental care those with higher testosterone may invest in shortterm and promiscuous mating strategies these patterns may begin early in life such that an individual is gradually channeled into a sexual career marked by more risky and frequent partnering behaviors associated with such an orientation may include a range of antisocial activities all of which can be viewed as putting shorterterm goals before longerterm onesas also aggression dominance status striving and a general lowering of social empathy rather than having a localized association with sexuality in other words high testosterone might be linked more generally to life trajectories marked by less norm conformity and higher interpersonal conflict as noted clinical as well as an older sociological literature appears to assume hormonal causation with these associations such that testosterone lowers prosocial propensities and heightens promiscuity in contrast a newer social modulation model suggests the inversethat is that exposure to a stable and highquality partnership and constrained sexual opportunities may prospectively lower testosterone similarly behaviors such as wielding power may also raise testosterone while participating in emotionally supportive relationships may lower it per evolutionary logic continuously high testosterone levels and their associated behaviors are suboptimal since they elevate survival costs as well as reproductive ones in monogamous species such costs are controlled by maintaining testosterone at lower baseline levels and making this hormone responsive to environmental cues far from being a static and exogenous biological factor in other words testosterone levels are in large part a dynamic outcome of a changing social context thus for instance testosterone rises when competition or interaction with sexually desirable partners is imminent human mating systems have been described as involving mild polygamy together with high parental care such that testosterone shows substantial ecological responsiveness more constrained exposure to arousalinducing social signals therefore may prospectively lower testosterone in other words while testosterones linkages with sexualized life trajectories and associated behaviors seem clear causal direction at a given stage of the life course does not human literature on the challenge hypothesis has largely focused on men with far fewer studies examining womens patterns a new generation of scholarship rooted in feminist biological theory is beginning to fill these gaps importantly it finds that while there is similarity across genders in linkages of testosterone to behaviors there is also considerable variation these differences may apply not simply to the relative strength of associations but also to the specific behaviors or ecological factors tied to this sex steroid among women or men evolved functions social roles andor sociocultural experiences related to femininity and masculinity are all speculated to play a role for instance certain activities may be testosteroneenhancing for men but not women because only the former have been taught to value them as competitive beyond the challenge hypothesis a new steroidpeptide theory of social bonds addresses these same testosteroneprosocialitypartnership interconnectionsuniting testosterone and oxytocin in a single model and explicitly focusing on womens patterns the framework divides intimacy into sexual and nurturant subtypes both types increase oxytocin however only sexual intimacy is linked to elevated testosterone nurturant intimacy in contrast may have negative associations with it importantly such an orientation of testosterone along a nurturancecompetition gradient in this theoretical model applies to social relationships in general beyond the pair bond current biological literature also assumes any social or relational modulation is due to spontaneous psychobiological downregulation of testosterone in nurturant noncompetitive contexts where empathy and dampening of aggression are more needed in turn evolutionary kin selection theory strongly indicates networks rich in relatives are more likely than any other to provide precisely such an environment the model one of the main evolutionary explanations for altruism predicts behavior to maximize the fitness of ones relatives even at a cost to ones own survival and reproduction however a longstanding network literature indicates a second potential mechanism through which such kincentered contexts can influence testosteronesocial control of antisocial behaviors embeddedness in a dense network of stakeholders such as concerned family members can serve as a crucial source of control over ones counternormative activities indeed such relational inhibition may be genderspecificsuch as enforcement of norms that proscribe older womens but not mens sexuality if so such network composition may also dampen the formers testosteronealthough as a structural feature of ones web of relationships it is less likely than tie strength to be influenced by testosterone levels overall then rather than a genderneutral framework building theory on hormonesociality linkages requires careful attention to factors that may be specifically important to one gender or the other despite these clear and potentially conflicting theoretical predictions no empirical analyses yet exist on linkages of womens testosterone with their social ties accordingly the current study examined three conjectures to test social modulation it was hypothesized that hypothesis 1 womens higher network kin proportions will predict their lower testosterone hypothesis 2 womens stronger social ties will predict their lower testosterone similarly the inverse hormonal causation conjecture led to the following hypothesis hypothesis 3 womens elevated testosterone will predict their weaker social ties in the second wave 2261 of these individuals were reinterviewed the total analytic sample for the current study was comprised of 1162 of these women as described below ipa weights were used to adjust for acrosswave attrition method procedure an inperson questionnaire was administered in either english or spanish by a field interviewer in the participants home most interviewers were experienced personnel given further training by norc at the university of chicago and remained with the project throughout the survey period in addition to selfreport data included assessments of physical and sensory function height and weight and salivary blood and vaginal mucosal samplesall collected at the time of interview by nonmedically trained interviewers participant consent was obtained prior to interview institutional review boards at the division of the social sciences and norc at the university of chicago approved data collection procedures reanalysis of nshap secondary data was approved by a mcgill university research ethics board table 1 shows the summary statistics for all variables used in the analyses for all selfreports question wording was identical across waves measures social ties three wavespecific indicators were included in this group first kin proportion in network was derived from nshaps egocentric social network data and ranged continuously from 0 to 1 respondents were asked to enumerate individuals with whom they discussed important mattersa standard name generator in network studies this network roster allowed up to five people to be named they were then probed to characterize their relationship with each nominated network member as one of eighteen distinct types the kin proportion variable was simply the ratio of family relationships to all ties second perceived support from friends and family combined four likert scalesof being able to open up to and rely on friends and on family the questions were included in the main part of the interview and were drawn from the 2002 health and retirement study since these items only contained three categories eachranging from 0 to 2 summary indexes based on cronbachs α were considered suboptimal instead principal component analysis based on a polychoric correlation matrix was used the first principal component had a wave 1 eigenvalue of 228 and explained 57 of the total variance in the items more than twice as much as the next component the corresponding wave 2 figures were 222 and 56 respectively accordingly this component was adopted as the measure of perceived support finally the network roster data yielded another measure of tie strength closeness to network members participants rated each such social alter on a scale of 1 to 4 the summary measure was an average of these alterspecific scores measures salivary testosterone testosterone was derived from saliva samples taken during the biomeasure collection portion of the inhome interview participants were encouraged not to eat during the interview even though eating and dental care are reported to have no effect on the replicability of steroid levels in saliva following previously validated protocols passive drool was used to collect whole unstimulated saliva which was then frozen until assay salivary enzyme immunoassays were conducted using commercially available kits wave 1 assays were by salimetrics laboratories in wave 2 specimens were sent to dresden labservice gmbh for duplicate assays using identical assay kits from wave 1 due to extreme right skew testosterone valuesoriginally in pg mlwere log transformed for analysis f f f f ethnicity white b 081 1169 01 f f f f black b 010 1169 01 f f f f hispanicother b 008 1169 01 f f f f measures control variables this block of selfreports was comprised of both time varying and time invariant covariates and was controlled in all models a first such measure was a participants age entered linearly as a continuous variable this variable was conceptualized as time invariant since it was perfectly correlated with time with wave 2 age a perfect linear function of the preceding value ethnicity was indexed through a set of dummy variables for black hispanic and other with nonhispanic white as the reference timevarying covariates included first a dichotomous indicator of marital status in addition network size was included to avert confounding of testosterones linkages with tie strength or kin composition by the sheer size of ones egocentric network a next time varying covariate was a standardized summary index for a participants socioeconomic statuscomprised of a participants wavespecific selfreported household wealth household income educational attainment perceived household income relative to acquaintances and to american families in general cronbachs alpha at wave 1 was 075 and at wave 2 was 076 a dichotomous measure indicated current consumption of any sex hormone supplementsincluded to net out any pharmacological influences on endogenous testosterone nshap collected a complete log of currently used medications during the inhome interview by direct observation using a computerbased log the multum® drug database based on the hierarchical classifications of the american hospital formulary service was used for coding drug names a continuous indicator for saliva collection time was also controlled given longestablished circadian rhythms in older womens testosterone similarly waist size was included to net out potential linkages of this sex steroid with visceral adiposity physical health indicators included ones total number of diagnosed conditions participants were asked about any lifetime diagnosis of a range of medical conditions of which nineheart attack arthritis ulcers asthma stroke hypertension diabetes cancer and enlarged prostatewere combined into a single score poor functional health was indexed by a continuous additive score for impaired activities of daily living specifically difficulties with routine everyday activities such as dressing bathing eating getting in or out of bed and using the toilet were queried through likert scales ranging from 0 to 3 these were then summed up to create the additive score statistical analysis three models were run respectively examining linkages of womens testosterone with their network kin proportion with perceived support from family and friends and with closeness to network members analyses used an arcl approach thus crosslagged paths were specified to estimate reciprocal influences for all time varying factorsthe four substantively important variables as well as all time varying covariates in addition for each such variable autoregressive paths examined dependency of wave 2 on wave 1 values finally all wave 2 measures were regressed on time invariant covariates supplementary figure 1 illustrates the model it is noted that arcl models do not disaggregate betweenand withinsubjects effects a newer autoregressive latent trajectory specification with structured residuals allows extraction of withinperson cross lagged effects per reviewer recommendation the latter was tried convergence could not be achievedarguably due to the number and diversity of time varying covariates hence inferences were based on the more conventional and widely used arcl method another analytic issue was selective attritionthat is nonreinterview of the wave 1 participant whether through mortality or nonresponse due to factors also influencing covariates to take this selection process into account pooled logistic regression was used to fit a predictive model for attrition across waves covariates included a participants demographic and health attributes based on predicted probabilities from this model stabilized inverseprobabilityofattrition weights were created thus participants with characteristics associated with a lower probability of continuation were assigned larger weights compensating for their underrepresentation in the second wave finally all analyses were weighted by the product of these ipa weights with wave 1 population weights that adjusted for the intentional oversampling of blacks and hispanics and incorporated a nonresponse adjustment based on age and urbanicity ipa weights were generated with the stata 141 statistical package all other analyses were conducted in mplus version 71 standard errors were adjusted for sample stratification and clustering estimation was through a robust weighted least squares estimator using a diagonal weight matrix results tables 24 respectively show results from crosslagged analyses for linkages of testosterone with the kin proportion in ones close personal network with perceived support from friends and family and with closeness to network members given the range of estimates the focus below is on those conceptually important for pattern inference since each model had a mix of both autoregressive effects in this model were significantthat of wave 1 on wave 2 kin proportion and that of testosterone across waves in other words there seems to be considerable temporal constancy in both of these factors however even net of this apparent stability and consistent with social modulation of testosterone the crosslagged effect of wave 1 kin proportion on wave 2 testosterone also reached significance contrary to hormonal causation arguments however the same was not true of the inverse effect of wave 1 testosterone on wave 2 kin proportion as with other biological processes then testosterone may have stochastic as well as stable componentswith at least the former open to social influence from a longer temporal perspective the stable component may also be subject to such influence early life factors may imprint behavioral patterns that produce and maintain differential testosterone levels a conjecture that could not be tested with the nshap sample of older adults table 3 testosterone and perceived support from friends and family in contrast to objective kin proportion subjective perception of support from friends and family at wave 1 did not have a crosslagged effect on womens wave 2 testosterone rather consistent with hormonal causation it was wave 1 testosterone that negatively affected wave 2 perceived support older women with higher levels of this sex steroid in other words do seem to experience more subjective isolation even in their most proximal social ties as with testosterone and kin proportion wave 1 perception of support also had a positive autoregressive effect on wave 2 values table 4 testosterone and closeness to network members as with all of the other substantively important variables the autoregressive effect of wave 1 on wave 2 closeness to ones social network members was positive cross lagged effects supported a hormonal causation inference consistent with table 3 but contrary to table 2 patterns specifically wave 1 testosterone had a negative effect on wave 2 closeness to network while the inverse linkage failed to reach significance discussion the inclusion of biological indicators in populationrepresentative and longitudinal social surveys offers an unprecedented opportunity to explore proximal connections of life course patterns with hormonal or other biological processes the present study the first to use a national probability sample to examine potential causal direction in linkages of testosterone with social networks extended this growing literature to recall theory deriving from the challenge hypothesis indicates that testosterone may be negatively associated with having strong nurturant and kincentered social ties while mens linkages have been explored womens have nota gender discrepancy that holds across the human literature causal direction also remains unclear with rival conceptual models suggesting inverse effects moreover patterns may vary across network dimensions while a high kin proportion as a stable compositional feature would more likely influence womens testosterone than vice versa the latters associations with tie strength could take either a similar social modulation or a hormonal causation form per conjecture crosslagged effects for kin connections indicated a socialitytohormones direction while high wave 1 proportions of relatives in ones egocentric network had a negative effect on wave 2 testosterone the inverse was not true in contrast to this clear social modulation finding those for tie strength were fully consistent with hormonal causation for both perceived support from friends and family and closeness to ones network members it was wave 1 testosterone that negatively influenced wave 2 relational outcomes rather than vice versa findings add to the emerging evidence that far from being linked solely to mens competitive propensities and aggressionthe predominant focus in the first generation of studies based on the challenge hypothesistestosterone has distinct and nuanced implications for womens sociality in turn these social factors may be critical for healthy aging if testosterone negatively influences womens tie strength for instance it also arguably lowers availability of resources channeled through such relationships network theorists have long argued that deep social connections rich in mutual trust can enhance a persons perceived agency lower discomfort with uncertainty and reduce resistance to change late life can be a time of high uncertainty when individuals experience fundamental changes in the structure of both their families and their broader social network children leave home retirement uproots individuals from their social networks at work parents and elders pass away and health problems begin impeding interaction at such times persisting strong ties can play a critical role in successful adaptation to changing circumstances conversely if the structure of womens egocentric network influences their testosterone levels as the results above suggest it may also confound testosterones linkages with sexual health consistent with this argument for instance previous research indicates that having a kincentered network also inhibits older womens partnering patterns this asyetunexplored social confounding possibility implies that at least some of the previously published findings of testosterones effects on sexuality might be spurioussuch that both the purported cause and effect are instead driven by social context it also adds a new dimension to the ongoing debate over testosterone therapy and the medicalization of womens sexual issues current work is examining for instance whether endogenous testosterone is more a mediator than a cause of womens sexual desire and capacity such that the ultimate roots of the latter lie more in a competitive andor sexualized social context in other words this sex steroid might be a biological mechanism through which interpersonal situations marked by heightened sexual signaling elevate arousal if so psychosocial interventions may arguably have effectiveness comparable to testosterone therapy while avoiding potential iatrogenic harm more generally the proximal behavioral and psychological traits the neuroendocrine literature has thus far tied to hormones have secondorder linkages with a range of factors potentially important for latelife well being thus more research is needed on the role of hormones in the structure of the life course whether through actions and attitudes that induce negative health transitions and other turning points or social resources that buffer against ill health the argument here is not to reduce such patterns solely to baseline hormonal differences at a given stage of the life trajectory as the social modulation results above indicate these levels are themselves products of relational patterns rather findings suggest a need for conceptual models that can accommodate the complex interplay of social and neuroendocrine factors in shaping the life cycle there were several limitations to this study as noted although crosslagged analysis is widely used to explore direction of association in longitudinal data the approach does not disaggregate betweenand withinsubjects effects the more rigorous altsr specification could not be used due to model nonconvergence experimental evidence would lend confidence to the causal role of testosterone in the formation and maintenance of social ties participants were aged 6290 years at wave 2 ages at which not simply testosterone levels but also their linkages with social behaviors may be very different than among younger populations generalizability may accordingly be limited however hormonesociality patterns in late life remain understudied despite having major implications for healthy aging as argued above models adjusted only for a small range of clearly exogenous factors variables like negative behaviors and mental health were not controlled because they were conceptualized as mediators of testosteronesociality connections such that their inclusion would have amounted to overadjustment and inappropriate attenuation of estimates however potential omittedvariable bias remains a concern moreover linkages may well vary across categories of indicators that were controlled patterns that could not be examined in the current study due to samplesize limitations ipa weights were designed to adjust for betweenwave attrition however they could not take into account measurespecific missingness patterns given the newness of the topic values were not imputed similarly the fiveyear lag between waves while well suited to detecting stable linkages may have blinded the analyses to important temporal inflections in effects as well as intervening processes finally given only two waves of data psychobehavioral mediation of testosteronesociality links implicit in the conceptual model could not be examined only baseline connections could be established more research is therefore needed on precisely why testosterone lowers womens tie strength and is in turn lowered by their kinrich networks conclusion longitudinal data from a nationally representative us sample suggested that rather than following a uniform pattern womens endogenous testosterone has distinct associations with specific dimensions of their social networks consistent with social modulation of hormones a higher kin proportion in ones egocentric network arguably a stable compositional feature negatively predicted womens testosterone levels no inverse effect was found in contrast results for tie strength were consistent with hormonal regulation of womens sociality both perceived support from ones friends and family and closeness to network members were negatively influenced by testosterone but not vice versa findings have implications for social confounding of testosteronesexuality linkages for medicalization of womens sexuality as well as for potential hormonal roots of womens latelife social resources conceptual models that can accommodate the complex interplay of social and neuroendocrine factors in shaping the life course are needed conflict of interest none reported

objectives this study examined potentially bidirectional connections of older us womens salivary testosterone with their social network connections methods data were from the 20052006 and 20102011 waves of the national social life health and aging project nshap a national probability sample of older us adults autoregressive crosslagged panel models tested linkages of womens testosterone with their social networks results consistent with recent biological theory suggesting social modulation of hormones a higher kin proportion in ones egocentric personcentered network arguably a stable compositional feature negatively predicted womens testosterone levels in contrast findings for tie strength were consistent with hormonal regulation of womens socialitywith both perceived support from friends and family and closeness to network members negatively influenced by testosterone discussion rather than being a static and exogenous biological factor older womens testosterone levels seem partly an outcome of their social context implications for sexual health and hormone therapy are discussed however this androgen also influences dimensions of their intimate networks critical to successful aging findings suggest the need for social scientists to engage with the neuroendocrine literature which offers suggestions on linkages of hormones with specific network patterns

Plain English summary In India, traditional contraceptive methods are employed by a large population, and most of the time decisions related to family planning are taken by the men of the household. Therefore, it is really necessary for men to have the correct idea of when a woman is most susceptible to pregnancy during the menstrual cycle. The study tries to assess the prevalence of such knowledge among urban men in Uttar Pradesh, India. Also, it attempts to investigate the rationals behind the misconceptions among men of the region under study. We have found that only one-fifth of the men have the correct knowledge about the concept. Further, education, societal perception, caste, and spousal discussion about the reproductive issues are found to be the most important components that affect the knowledge among men about the conception risk during the menstrual cycle. The study suggests promoting the sex education in urban Uttar Pradesh, especially in slum areas to educate the men regarding the reproductive functions of women. Also, the article promotes higher education and motivates couples to discuss the reproductive hurdles among them. These interventions can provide a better reproductive health to the women of urban Uttar Pradesh, India. --- Background The effective contraceptive practice is usually measured by knowledge about the reproductive process and related issues. In India, where men take most family decisions, it is important that they have the adequate knowledge about the pregnancy risk during women's menstrual cycle. In an American study, it is observed that only one-third of urban mothers interviewed twice, a year apart, answered correctly both times about when during the menstrual cycle a woman is most likely to become pregnant [1]. Recently, a research found that about 85% women do not have the correct knowledge of the fertile window of a menstrual cycle [2]. Menstruation is an important reproductive health function, yet it has been dealt with secrecy in India, [3]. Due to some cultural barriers, most couples rarely have a conversation regarding the menstruation and pregnancy risks during menstruation. A number of taboos and social and cultural restrictions still exists concerning menstruation, [4], [5], [6], and [7]. Researchers and policy makers often talk about woman's knowledge regarding the procreative process [8], and [9], although men's knowledge about the reproductive process is as indispensable as their decision making in the family. As it is argued, erroneous information about the risk of conception during the menstrual cycle may lead to increased fertility [10]. It is realized that only 18.4% of the men in rural eastern part of Uttar Pradesh had the correct information about the time of maximum conception risk during the menstrual cycle, while 43.2% did not have any idea about this concept [11]. Usually, the sperm can survive for three to five days in the fallopian tube and after ovulation; the released egg takes approx 12 to 24 hours to make its way through the fallopian tube. Thus, chances of pregnancy to occur are highest when a couple has intercourse without contraceptives one to two days before ovulation. A female usually ovulates 12-14 days after her periods. If a woman has a regular menstrual cycle length of 28 days, she will ovulate in the middle of the cycle, nearly 14 days after day one of her periods. In this connection, the 14th day of the cycle is the most susceptible day for fertilization of the egg [12]. If a woman has her menstrual cycle little longer, say 34 days, she will ovulate around 20 days after day one of her periods. In some cases, women know when they are ovulating by observing the changes in their body and the way they feel. Some quintessential measures are breast tenderness, hefty and denser vaginal discharge, tightness in the abdomen; however, these body changes are difficult to be understood by couples. Many others do not have any noticeable symptoms. In India, the traditional contraceptive methods are still employed by a large population; therefore, the misinformation about the fertile window during MC may lead to the failure of the traditional contraception methods. The knowledge about the conception risk during the menstrual cycle is essential to ward off the unwanted births and abortions due to unwanted pregnancies. Against this background, this study estimates the prevalence of knowledge about the conception risk during menstrual cycle among urban men of Uttar Pradesh, India. In this connection, men have been asked when during the menstrual cycle they think women are most susceptible to the risk of conception and we attempt to discover the rationales behind the misconceptions among urban men about the concept. --- Methods For this study, we use the baseline data of the Measurement, Learning, and Evaluation Project for the Urban Reproductive Health Initiative in Uttar Pradesh, India. URHI is a multi-national study involving, Kenya, Nigeria, and Senegal that assess contraceptive behavior, awareness, and quality among poor belonging to urban areas. The Carolina Population Centre at the University of North Carolina at Chapel Hill commenced the Project, in cooperation with the International Centre for Research on Women sponsored by the Bill & Melinda Gates Foundation to undertake an evaluation of the URHI programs in Uttar Pradesh. The baseline data were collected in four cities, Agra, Aligarh, Allahabad and Gorakhpur. A total of 6431 currently married men aged 18-54 were interviewed in these towns. The comprehensive survey response rate was 88%. A two-stage sampling approach was employed to collect the sample for each city. Cities were split into slum and non-slum as primary sampling units based on ground truthing and satellite imagery. Questions about awareness of contraceptive methods, fertility desires, attitudes toward reproductive health, contraceptive use by themselves or their wives, the pregnancy risk during the menstrual cycle, were asked to the men belonging to urban Uttar Pradesh, India. As Table 2 shows, the dependent variable in this study refers to the response of men regarding the time of highest risk of conception during the menstrual cycle of women. There are five choices of outcome: "just before the menstrual cycle begins", "during the cycle", "right after the period ends", "halfway between the two periods" and "do not know". For the purpose of analysis, the dependent variable was re-coded into a new variable which has only two categories: men who have the false information or do not know about the concept of pregnancy risk during menstrual cycle, and men who have the correct information about the time at which the conception risk is highest i.e. approximately on 14th day of usual menstrual cycle of 28 days. --- Discriminant analysis "Discriminant analysis is a statistical technique which allows us to study the differences between two or more groups of objects concerning several variables simultaneously." [13]. Discriminant analysis does the same analysis as linear regressions, by predicting an outcome; however, in multiple linear regression, the dependent variable is an interval variable so that the combination of explanatory variables will provide estimated mean population Y values for given values of the weighted sum of X values through the regression function. Discriminant analysis is used when the dependent is a categorical variable with the predictors of interval level, such as years of education, income, and age; although one can use dummy variables as predictors similar to multiple regression. --- Discriminant analysis, linear equation The form of the discriminant analysis equation or function is: D¼V 1 X 1 þV 2 X 2 þV 3 X 3 þ………:þV i X i þa where; D = Discriminant function or discriminant score V = The discriminant function coefficient or weight for that variable X = Respondent's score for the particular predictor variable a = A constant i = the number of predictor variables This equation is similar to a regression equation. The V i 's are the discriminant coefficients analogous to the b i 's in the regression equation. Good predictors contain larger weights in discriminant function. The equation should hold strong discriminatory power between groups since the discriminant function is supposed to maximize the distance between the categories of study variable. Thus, the D.A. also explores differences between groups on the basis of different characteristics of the cases, indicating which components contribute most to the group separation. The number of discriminant functions is one less than the number of groups or category. There is only one function for the D.A. of this problem since our dependent variable has only two classes. In our problem the dependent variable, knowledge about the pregnancy risk during menstrual cycle has been classified into two categories; one has the accurate knowledge about the fertile window during the menstrual cycle, and the other category does not have the actual idea of the concept. Since the predictors, involved in our D.A, are not at interval level, we have created dummy variables for each category of predictor variables. In this study, the D.A has been performed for slum area and non-slum area separately. The paramount assumptions required to be tested to check the compatibility of data with D.A are normality and homoscedasticity. We have used Levene's test of equality of error variances to verify the homogeneity of variance . As a result of the Levene's test, the null hypothesis that the error variance of the dependent variable is equal across groups has been accepted . Therefore, it can be concluded that the data hold the homoscedasticity assumption. Further, the normal Q-Q curve for the standardized residuals has been plotted to check the normality assumption. After having a glance at Fig. 1, it is observed that the residuals are normal in nature. Since the data fulfill the assumptions of homoscedasticity and normality, the discriminant analysis has been applied for analysis. SPSS software has been used for the above analysis. --- Results Table 1 reveals the percentage distribution of the variables included in the analysis. We find that about 80% of the men had a discussion about family planning with their wives at least once, while slightly less than onefifth never had any discussion. It is essential to note that only one-fifth of the men have the correct information about pregnancy risk during the menstrual cycle, while the remaining four-fifth of them do not have the accurate information about this concept. Table 2 gives the percentage distribution of men regarding their perception or knowledge regarding the time duration, which has the highest pregnancy risk during the menstrual cycle. We find that in the non-slum areas about 21% of the men respond that the maximum risk of gestation occurs halfway between two periods that is the accurate information regarding the concept, while in slum areas about 19% men have the actual information. Table exhibits that about 13% among uneducated men, about 18% among primarily educated men, about 19% among secondary educated men and 24% among highly educated men have the accurate information about the concept. It is observed that 24% among the men who discussed family planning with their wives and only about 5% among the men who did not discuss family planning with their wives possess the correct idea about the pregnancy risk during MC. After having a glance at the table, it can be concluded that the highest percentage men have given the response that the maximum risk of conception occurs right after the menstruation period ends, and its percentage is more than 50 for each category of variables under consideration. Further, it can also be seen from the table that almost one-fifth respondents, do not have any idea about the concept among the illiterate men and men who have never discussed family planning with their wives. Table 3 presents the test of equality of group means for the different variables taken into consideration for the slum area. In the table, group 1 includes the respondents who do not have the correct idea about the concept and group 2 includes the respondents who have the accurate information about the notion of pregnancy risk during MC. Since all the exogenous variables are made binary , the mean provides the proportion of respondents in a particular category of the variable. The table depicts that the men belonging to Hindu religion have a higher proportion in group 1, and the men belonging to the non-Hindu religion have a greater proportion in group 2 . It shows that men belonging to other religions have better information compared to the men belonging to the Hindu religion. Further, it is found that uneducated men have a higher proportion in group 1 compared to group 2 and the men having higher education have a greater share in group 2 . The above finding indicates that men, having higher education keep better information about the concept compared to the men with no education. The table shows that the media exposure is not a significant factor for the group separation regarding the knowledge about the conception risk during the MC; this might be due to a high correlation between the media exposure and the educational attainment of men in urban Uttar Pradesh. The finding says that the men who dwell in a society that supports MFPM have more actual information compared to the men living in a society that does not support MFPM and the men who do not know about the view of society regarding the MFPM. Further, it is found that the men who discuss family planning with their wives have a higher proportion in group 2 and the men who do not discuss the family planning have a higher percentage in group 1. This finding leads to the statement that the men who discuss family planning with their wives have more actual information regarding the concept of highest pregnancy time during MC compared to the men who do not talk about the family planning with their partner. Table 4 presents the test of equality of group means for the different variables taken into consideration for the non-slum area. It can be regarded from the table that the variables like the perception of society about MFPM, religion, and discussion of the respondent with the wife about family planning reflects the same results as we have found in the analysis for slum area. Further for non-slum population, caste has not been noticed as a significant factor for group separation. The table reflects that for non-slum population, wealth status of men is not an important variable; this may be due to that other social and cultural factors are more dominant; also wealth status is highly associated with educational attainment. Tables 5, and 6 provide the significance testing of the Discriminant functions for slum and non slum data respectively. Tables provide information on each of the discriminant functions produced. The maximum number of discriminant functions produced is the number of groups minus 1. In this study only two groups are considered, thus only one function is displayed. The canonical correlation is the multiple correlation between the predictors and the discriminant function. With only one function, it provides an index of overall model fit which is interpreted as being the proportion of variance explained . In Table 5 a canonical correlation of 0.926 suggests that the model explains 85.75% of the variation in the grouping variable for slum data; while as per the Table 6, a canonical correlation of 0.901 exhibits that the model explains 81.18% of the variation for non slum data. Wilks' Lambda is the ratio of within-groups sums of squares to the total sums of squares. This is the proportion of the total variance in the discriminant scores not explained by differences among groups. This is a measure of how well each function separates cases into groups. Smaller values of Wilks' lambda indicate the greater discriminatory ability of the --- Discussion This study shows that relatively small proportion of urban men has correct information about the fertile window of women's menstrual cycle. Considering that almost four-fifth of married men in both slum and nonslum areas of urban Uttar Pradesh do not have the correct knowledge of the concept, there is an urgent need for sex education. Classical contraceptive methods are also used by a huge number of couples in the region. Therefore, the scientific knowledge of women's reproductive system will help reduce the number of abortions resulting from unwanted pregnancies and unwanted births, which may be a cause of high fertility in Uttar Pradesh, India. The study depicts that the higher education results into a better knowledge about the conception risk during the menstrual cycle. Literacy and employment can bring the wealth condition up; therefore literacy is the only way to get rid of such misinformations regarding the reproductive biology of women, which is why study suggests promoting the higher education. Our perception about something is built according to the society; in which we are living. Due to this, it is found that men living in a society, that encourages the MFPM, have better information about the fertile window than who are residing in a society that does not support MFPM. Thus, to educate people, it is necessary to educate the society as a whole. Also, this study suggests urban men, to have interaction with the society and discuss the reproductive health and other related issues like family planning, etc. The effective inter-spouse communication on matters, related to family planning is very crucial for the success of family planning programs [14], and [15]. In India due to various cultural barriers and customs, even husband and wife feel shy to discuss the sensitive issues like family planning and reproductive process. Sharing the accurate knowledge with the spouse regarding the fertile window during MC will reduce the misconceptions among the urban men in the region. The study recommends couples to talk about the sexual health and other relative issues with their spouses so that they can be aware of the different technicalities related to reproductive health and family planning. The main limitation of the study is that it considers only one state of India, though there are several states which are bearing the same challenges. There exists a huge diversity among the Indian states in terms of education, socio-economic conditions, culture, and norms. Thus, one can not generalize the findings for other states of India. Also, the study involves men only from the urban residence, though the men dwelling in rural settings are less educated and might have less knowledge regarding the fertile window of MC. --- Conclusions The study has its huge significance for reducing the unwanted pregnancies and unwanted births due to the misinformation among men regarding the fertile window of the menstrual cycle. Unwanted conceptions may cause excess abortions, which is harmful to the reproductive health of the women and at the other side unwanted births also cause the high fertility. Thus, the accurate information about the fertile window is essential to eliminate the above two factors. Educating the urban men about the fertile window and other reproductive functions is the ultimate solution to remove the misconceptions regarding the concept among them. The discussion between couples regarding the reproductive biology of women will help to increase the knowledge among the men of urban Uttar Pradesh about the fertile window of the menstrual cycle. --- --- Abbreviations DA: Discriminant analysis; MC: Menstrual cycle; MFPM: Modern family planning methods; MLE: Measurement, learning, and evaluation; OBC: Other backward castes; SC/ST: Scheduled caste/scheduled tribes Authors' contributions PV proposed the problem, analyzed the data, and did literature writing. Prof. KKS designed the study, revised the manuscript critically for important intellectual content, and gave final approval of the version to be published. AS reviewed the literature and conceptualize the problem. All authors read and approved the final manuscript. --- Competing interests The authors declare that they have no competing interests. --- --- ---

Background: In India, where men take most decisions in the family, it is useful that they have adequate knowledge about pregnancy risks during women's menstrual cycles. Since traditional contraceptive methods are still employed by a large population in India, the knowledge regarding the pregnancy risk during the menstrual cycle is indispensable. This research paper attempts to assess the knowledge among urban men in Uttar Pradesh, India about the fertile window of the menstrual cycle; it also attempts to discover the rationales behind the misconceptions about the concept. Methods: This study utilizes the baseline data of the Measurement, Learning, and Evaluation project for the Urban Reproductive Health Initiative in Uttar Pradesh. Descriptive Statistics has been used to assess the prevalence of knowledge among urban men regarding the concept. Using the Discriminant Analysis, we also investigate the rationales behind the misconceptions among urban men about the concept. Results: Only one-fifth of the men have the correct knowledge about the concept. Further, we find that education, societal perception, caste, and spousal discussion about the reproductive issues are the primary factors affecting the knowledge about the pregnancy risk during the menstrual cycle. Conclusions: There is an urgent need for sex education in the region to make the urban men more educated about the reproductive process of women; this may reduce unwanted births and abortion due to an unwanted pregnancy as well. The study promotes the higher education and motivates couples to discuss the reproductive health issues among them. In this manner, we can provide better reproductive health to the women of urban India.

plain english summary in india traditional contraceptive methods are employed by a large population and most of the time decisions related to family planning are taken by the men of the household therefore it is really necessary for men to have the correct idea of when a woman is most susceptible to pregnancy during the menstrual cycle the study tries to assess the prevalence of such knowledge among urban men in uttar pradesh india also it attempts to investigate the rationals behind the misconceptions among men of the region under study we have found that only onefifth of the men have the correct knowledge about the concept further education societal perception caste and spousal discussion about the reproductive issues are found to be the most important components that affect the knowledge among men about the conception risk during the menstrual cycle the study suggests promoting the sex education in urban uttar pradesh especially in slum areas to educate the men regarding the reproductive functions of women also the article promotes higher education and motivates couples to discuss the reproductive hurdles among them these interventions can provide a better reproductive health to the women of urban uttar pradesh india background the effective contraceptive practice is usually measured by knowledge about the reproductive process and related issues in india where men take most family decisions it is important that they have the adequate knowledge about the pregnancy risk during womens menstrual cycle in an american study it is observed that only onethird of urban mothers interviewed twice a year apart answered correctly both times about when during the menstrual cycle a woman is most likely to become pregnant 1 recently a research found that about 85 women do not have the correct knowledge of the fertile window of a menstrual cycle 2 menstruation is an important reproductive health function yet it has been dealt with secrecy in india 3 due to some cultural barriers most couples rarely have a conversation regarding the menstruation and pregnancy risks during menstruation a number of taboos and social and cultural restrictions still exists concerning menstruation 4 5 6 and 7 researchers and policy makers often talk about womans knowledge regarding the procreative process 8 and 9 although mens knowledge about the reproductive process is as indispensable as their decision making in the family as it is argued erroneous information about the risk of conception during the menstrual cycle may lead to increased fertility 10 it is realized that only 184 of the men in rural eastern part of uttar pradesh had the correct information about the time of maximum conception risk during the menstrual cycle while 432 did not have any idea about this concept 11 usually the sperm can survive for three to five days in the fallopian tube and after ovulation the released egg takes approx 12 to 24 hours to make its way through the fallopian tube thus chances of pregnancy to occur are highest when a couple has intercourse without contraceptives one to two days before ovulation a female usually ovulates 1214 days after her periods if a woman has a regular menstrual cycle length of 28 days she will ovulate in the middle of the cycle nearly 14 days after day one of her periods in this connection the 14th day of the cycle is the most susceptible day for fertilization of the egg 12 if a woman has her menstrual cycle little longer say 34 days she will ovulate around 20 days after day one of her periods in some cases women know when they are ovulating by observing the changes in their body and the way they feel some quintessential measures are breast tenderness hefty and denser vaginal discharge tightness in the abdomen however these body changes are difficult to be understood by couples many others do not have any noticeable symptoms in india the traditional contraceptive methods are still employed by a large population therefore the misinformation about the fertile window during mc may lead to the failure of the traditional contraception methods the knowledge about the conception risk during the menstrual cycle is essential to ward off the unwanted births and abortions due to unwanted pregnancies against this background this study estimates the prevalence of knowledge about the conception risk during menstrual cycle among urban men of uttar pradesh india in this connection men have been asked when during the menstrual cycle they think women are most susceptible to the risk of conception and we attempt to discover the rationales behind the misconceptions among urban men about the concept methods for this study we use the baseline data of the measurement learning and evaluation project for the urban reproductive health initiative in uttar pradesh india urhi is a multinational study involving kenya nigeria and senegal that assess contraceptive behavior awareness and quality among poor belonging to urban areas the carolina population centre at the university of north carolina at chapel hill commenced the project in cooperation with the international centre for research on women sponsored by the bill melinda gates foundation to undertake an evaluation of the urhi programs in uttar pradesh the baseline data were collected in four cities agra aligarh allahabad and gorakhpur a total of 6431 currently married men aged 1854 were interviewed in these towns the comprehensive survey response rate was 88 a twostage sampling approach was employed to collect the sample for each city cities were split into slum and nonslum as primary sampling units based on ground truthing and satellite imagery questions about awareness of contraceptive methods fertility desires attitudes toward reproductive health contraceptive use by themselves or their wives the pregnancy risk during the menstrual cycle were asked to the men belonging to urban uttar pradesh india as table 2 shows the dependent variable in this study refers to the response of men regarding the time of highest risk of conception during the menstrual cycle of women there are five choices of outcome just before the menstrual cycle begins during the cycle right after the period ends halfway between the two periods and do not know for the purpose of analysis the dependent variable was recoded into a new variable which has only two categories men who have the false information or do not know about the concept of pregnancy risk during menstrual cycle and men who have the correct information about the time at which the conception risk is highest ie approximately on 14th day of usual menstrual cycle of 28 days discriminant analysis discriminant analysis is a statistical technique which allows us to study the differences between two or more groups of objects concerning several variables simultaneously 13 discriminant analysis does the same analysis as linear regressions by predicting an outcome however in multiple linear regression the dependent variable is an interval variable so that the combination of explanatory variables will provide estimated mean population y values for given values of the weighted sum of x values through the regression function discriminant analysis is used when the dependent is a categorical variable with the predictors of interval level such as years of education income and age although one can use dummy variables as predictors similar to multiple regression discriminant analysis linear equation the form of the discriminant analysis equation or function is d¼v 1 x 1 þv 2 x 2 þv 3 x 3 þ………þv i x i þa where d discriminant function or discriminant score v the discriminant function coefficient or weight for that variable x respondents score for the particular predictor variable a a constant i the number of predictor variables this equation is similar to a regression equation the v i s are the discriminant coefficients analogous to the b i s in the regression equation good predictors contain larger weights in discriminant function the equation should hold strong discriminatory power between groups since the discriminant function is supposed to maximize the distance between the categories of study variable thus the da also explores differences between groups on the basis of different characteristics of the cases indicating which components contribute most to the group separation the number of discriminant functions is one less than the number of groups or category there is only one function for the da of this problem since our dependent variable has only two classes in our problem the dependent variable knowledge about the pregnancy risk during menstrual cycle has been classified into two categories one has the accurate knowledge about the fertile window during the menstrual cycle and the other category does not have the actual idea of the concept since the predictors involved in our da are not at interval level we have created dummy variables for each category of predictor variables in this study the da has been performed for slum area and nonslum area separately the paramount assumptions required to be tested to check the compatibility of data with da are normality and homoscedasticity we have used levenes test of equality of error variances to verify the homogeneity of variance as a result of the levenes test the null hypothesis that the error variance of the dependent variable is equal across groups has been accepted therefore it can be concluded that the data hold the homoscedasticity assumption further the normal qq curve for the standardized residuals has been plotted to check the normality assumption after having a glance at fig 1 it is observed that the residuals are normal in nature since the data fulfill the assumptions of homoscedasticity and normality the discriminant analysis has been applied for analysis spss software has been used for the above analysis results table 1 reveals the percentage distribution of the variables included in the analysis we find that about 80 of the men had a discussion about family planning with their wives at least once while slightly less than onefifth never had any discussion it is essential to note that only onefifth of the men have the correct information about pregnancy risk during the menstrual cycle while the remaining fourfifth of them do not have the accurate information about this concept table 2 gives the percentage distribution of men regarding their perception or knowledge regarding the time duration which has the highest pregnancy risk during the menstrual cycle we find that in the nonslum areas about 21 of the men respond that the maximum risk of gestation occurs halfway between two periods that is the accurate information regarding the concept while in slum areas about 19 men have the actual information table exhibits that about 13 among uneducated men about 18 among primarily educated men about 19 among secondary educated men and 24 among highly educated men have the accurate information about the concept it is observed that 24 among the men who discussed family planning with their wives and only about 5 among the men who did not discuss family planning with their wives possess the correct idea about the pregnancy risk during mc after having a glance at the table it can be concluded that the highest percentage men have given the response that the maximum risk of conception occurs right after the menstruation period ends and its percentage is more than 50 for each category of variables under consideration further it can also be seen from the table that almost onefifth respondents do not have any idea about the concept among the illiterate men and men who have never discussed family planning with their wives table 3 presents the test of equality of group means for the different variables taken into consideration for the slum area in the table group 1 includes the respondents who do not have the correct idea about the concept and group 2 includes the respondents who have the accurate information about the notion of pregnancy risk during mc since all the exogenous variables are made binary the mean provides the proportion of respondents in a particular category of the variable the table depicts that the men belonging to hindu religion have a higher proportion in group 1 and the men belonging to the nonhindu religion have a greater proportion in group 2 it shows that men belonging to other religions have better information compared to the men belonging to the hindu religion further it is found that uneducated men have a higher proportion in group 1 compared to group 2 and the men having higher education have a greater share in group 2 the above finding indicates that men having higher education keep better information about the concept compared to the men with no education the table shows that the media exposure is not a significant factor for the group separation regarding the knowledge about the conception risk during the mc this might be due to a high correlation between the media exposure and the educational attainment of men in urban uttar pradesh the finding says that the men who dwell in a society that supports mfpm have more actual information compared to the men living in a society that does not support mfpm and the men who do not know about the view of society regarding the mfpm further it is found that the men who discuss family planning with their wives have a higher proportion in group 2 and the men who do not discuss the family planning have a higher percentage in group 1 this finding leads to the statement that the men who discuss family planning with their wives have more actual information regarding the concept of highest pregnancy time during mc compared to the men who do not talk about the family planning with their partner table 4 presents the test of equality of group means for the different variables taken into consideration for the nonslum area it can be regarded from the table that the variables like the perception of society about mfpm religion and discussion of the respondent with the wife about family planning reflects the same results as we have found in the analysis for slum area further for nonslum population caste has not been noticed as a significant factor for group separation the table reflects that for nonslum population wealth status of men is not an important variable this may be due to that other social and cultural factors are more dominant also wealth status is highly associated with educational attainment tables 5 and 6 provide the significance testing of the discriminant functions for slum and non slum data respectively tables provide information on each of the discriminant functions produced the maximum number of discriminant functions produced is the number of groups minus 1 in this study only two groups are considered thus only one function is displayed the canonical correlation is the multiple correlation between the predictors and the discriminant function with only one function it provides an index of overall model fit which is interpreted as being the proportion of variance explained in table 5 a canonical correlation of 0926 suggests that the model explains 8575 of the variation in the grouping variable for slum data while as per the table 6 a canonical correlation of 0901 exhibits that the model explains 8118 of the variation for non slum data wilks lambda is the ratio of withingroups sums of squares to the total sums of squares this is the proportion of the total variance in the discriminant scores not explained by differences among groups this is a measure of how well each function separates cases into groups smaller values of wilks lambda indicate the greater discriminatory ability of the discussion this study shows that relatively small proportion of urban men has correct information about the fertile window of womens menstrual cycle considering that almost fourfifth of married men in both slum and nonslum areas of urban uttar pradesh do not have the correct knowledge of the concept there is an urgent need for sex education classical contraceptive methods are also used by a huge number of couples in the region therefore the scientific knowledge of womens reproductive system will help reduce the number of abortions resulting from unwanted pregnancies and unwanted births which may be a cause of high fertility in uttar pradesh india the study depicts that the higher education results into a better knowledge about the conception risk during the menstrual cycle literacy and employment can bring the wealth condition up therefore literacy is the only way to get rid of such misinformations regarding the reproductive biology of women which is why study suggests promoting the higher education our perception about something is built according to the society in which we are living due to this it is found that men living in a society that encourages the mfpm have better information about the fertile window than who are residing in a society that does not support mfpm thus to educate people it is necessary to educate the society as a whole also this study suggests urban men to have interaction with the society and discuss the reproductive health and other related issues like family planning etc the effective interspouse communication on matters related to family planning is very crucial for the success of family planning programs 14 and 15 in india due to various cultural barriers and customs even husband and wife feel shy to discuss the sensitive issues like family planning and reproductive process sharing the accurate knowledge with the spouse regarding the fertile window during mc will reduce the misconceptions among the urban men in the region the study recommends couples to talk about the sexual health and other relative issues with their spouses so that they can be aware of the different technicalities related to reproductive health and family planning the main limitation of the study is that it considers only one state of india though there are several states which are bearing the same challenges there exists a huge diversity among the indian states in terms of education socioeconomic conditions culture and norms thus one can not generalize the findings for other states of india also the study involves men only from the urban residence though the men dwelling in rural settings are less educated and might have less knowledge regarding the fertile window of mc conclusions the study has its huge significance for reducing the unwanted pregnancies and unwanted births due to the misinformation among men regarding the fertile window of the menstrual cycle unwanted conceptions may cause excess abortions which is harmful to the reproductive health of the women and at the other side unwanted births also cause the high fertility thus the accurate information about the fertile window is essential to eliminate the above two factors educating the urban men about the fertile window and other reproductive functions is the ultimate solution to remove the misconceptions regarding the concept among them the discussion between couples regarding the reproductive biology of women will help to increase the knowledge among the men of urban uttar pradesh about the fertile window of the menstrual cycle abbreviations da discriminant analysis mc menstrual cycle mfpm modern family planning methods mle measurement learning and evaluation obc other backward castes scst scheduled castescheduled tribes authors contributions pv proposed the problem analyzed the data and did literature writing prof kks designed the study revised the manuscript critically for important intellectual content and gave final approval of the version to be published as reviewed the literature and conceptualize the problem all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background in india where men take most decisions in the family it is useful that they have adequate knowledge about pregnancy risks during womens menstrual cycles since traditional contraceptive methods are still employed by a large population in india the knowledge regarding the pregnancy risk during the menstrual cycle is indispensable this research paper attempts to assess the knowledge among urban men in uttar pradesh india about the fertile window of the menstrual cycle it also attempts to discover the rationales behind the misconceptions about the concept methods this study utilizes the baseline data of the measurement learning and evaluation project for the urban reproductive health initiative in uttar pradesh descriptive statistics has been used to assess the prevalence of knowledge among urban men regarding the concept using the discriminant analysis we also investigate the rationales behind the misconceptions among urban men about the concept results only onefifth of the men have the correct knowledge about the concept further we find that education societal perception caste and spousal discussion about the reproductive issues are the primary factors affecting the knowledge about the pregnancy risk during the menstrual cycle conclusions there is an urgent need for sex education in the region to make the urban men more educated about the reproductive process of women this may reduce unwanted births and abortion due to an unwanted pregnancy as well the study promotes the higher education and motivates couples to discuss the reproductive health issues among them in this manner we can provide better reproductive health to the women of urban india

BACKGROUND The rise in the median age at first marriage is well documented, but little is known about whether there has been an accompanying change in the median ages at first cohabitation and first union formation. Are Americans waiting longer to form any union, or are they just waiting longer to form marital unions? One reason the median ages at cohabitation or union formation have received little attention is that there are few data sources available to document these shifts. The median age at first marriage is often calculated using indirect methods as specified by Shryock, Siegel, and Larmon . These methods require knowledge about the proportion of the population that has been married at specific age ranges. This information has been available for some time from U.S. census data as well as Current Population Survey data. These indirect methods cannot be used to assess median age at cohabitation because the Census and CPS do not include indicators of the proportion of the population that has cohabited at specific age groups. Starting in 2000, the Census included "unmarried partner" as a household membership category but did not obtain a critical piece of information: the proportion of the population that has ever cohabited. Furthermore, directly assessing changes in the median age at first cohabitation requires survey data that directly ascertain the age at first cohabitation. In response to the growth in cohabitation, starting in the late 1980s a few nationally representative surveys, such as the NSFH and NSFG, expanded the roster of household relationships to include cohabitation. These and now many additional surveys have included direct questions about the start and end dates of cohabitation, akin to measures of marriage. Thus, using nationally representative survey data, we were able to assess changes in direct reports of ages at marriage as well as cohabitation. On the basis of data collected 25 years ago in the 1987-1988 NSFH, the median age at first cohabitation was 21 for women , but little is known about the median age at first cohabitation today. We expect there may have been some changes in the median age at first cohabitation in part because over a 23-year period there has been an 82% increase in the proportion of women who ever cohabited . In 1987, one third of women ages 19-44 ever cohabited and, recently, over half of 19-to 44-year-old women had spent some time in a cohabiting union . The median age at first cohabitation may not be increasing as rapidly as the median age at first marriage because the barriers to cohabitation are not as high as those to marriage. Motivations to cohabit have tended to be based on relational prospects and have not carried the same prerequisites, such as stable economic prospects, as marriage . To date, researchers have not investigated whether there has been an increase in the median age at first cohabitation or first union formation even though the proportion of women who have ever cohabited has increased dramatically. Evidence supporting the theme of diverging destinies, defined as growing racial/ethnic and social class differentials in family behavior, often has focused on the disproportionate rise in nonmarital fertility among the most disadvantaged individuals versus the quite stable, low levels of unwed childbearing among college graduates . Similarly, there appears to be a divergence in marriage trends as growth in nonmarriage has been greatest among the most disadvantaged . We investigated whether the delay in marriage entry characterizing advantaged groups extends to cohabitation formation as well; that is, has the rising age at marriage coincided with a shift in the timing of first cohabitation, or has the median age at first cohabitation remained stable? Bumpass, Sweet, and Cherlin suggested that the delay in marriage entry evident in the 1970s and 1980s was offset by corresponding increases in cohabitation formation, meaning that first union formation was relatively unchanged over time. Instead, the type of first union formed had shifted from marriage to cohabitation. Racial and ethnic differentials in the median age at first marriage are well known. Some of the differentials are due to lower levels of ever marrying among certain subgroups of the population. The proportion of married individuals in the population has declined faster among Black women than White women . For example, Black women have first-marriage rates that are about half the levels experienced by White or Hispanic women. In 2010, the first-marriage rates per 1,000 never-married women were 22.1 among Black women, 52.4 among White women, and 42.6 among native-born Hispanic women . Indeed, the racial and ethnic gap in the age at first marriage persists and actually has widened . Starting in 1980, the racial gap in age at first marriage reached 2 years. In 2010, Black women had a median age at first marriage that was about 4 years greater than the age at first marriage experienced by White and Hispanic women . For these reasons, we anticipated that the median age at first marriage is highest among Blacks and that the rise has been steepest for Blacks compared to Whites and Hispanics. The timing of marriage follows an education gradient. In 2010, the first-marriage rate was notably highest among college-educated women and ranged between 30.4 and 39.4 among women with less than high school and only some college education . The financial resources provided by men have weakened, and women have been increasingly valued for their economic prospects . In 2010, the median age at first marriage was 24 among women with less than a high school degree and 28 among college-educated women . Furthermore, half of women without a high school degree were married by age 25, in contrast to only 37% of women with a college degree, but by age 35 the pattern reversed such that 72% of women without a high school degree had married and 84% with a college degree had married . Although more educated women tend to marry at later ages compared with less educated women, more educated women are ultimately the most likely to ever marry. This education gap in age at first marriage has persisted over time , but it could be narrowing as more disadvantaged Americans delay marrying to meet the economic prerequisites for marriage . Over the past 20 years, the proportions of individuals who have ever cohabited rose somewhat more quickly among Whites and Hispanics than among Blacks . In 1987, the average age at first cohabitation was 21 for Whites, Blacks, and Hispanics . The current differential in the proportion of women who have ever cohabited according to race and ethnicity continues to be relatively small, ranging from 59% among Hispanics to 62% among Whites. We did not expect a divergingdestinies perspective to be operating as strongly for cohabitation as marriage because, unlike marriage, there are few economic barriers to cohabitation. Thus, we expected a continuation of little variation in the median age at first cohabitation according to race and ethnicity. In contrast, the education divide in cohabitation experience has been increasing. In 2009-2010, nearly three quarters of women without a high school degree had ever cohabited, versus half of women with a college degree . The education group that saw the greatest increase in cohabitation was women with a high school degree, who experienced over a 100% increase in cohabitation experience over the past 23 years . Two decades ago, the average age of first cohabitation among college graduates was 24 versus 19 for persons with less than a high school degree . Because the economic barriers to marriage are greater than those for cohabitation, we expected a less steep education gradient for cohabitation than marriage. Given the changes in marriage and cohabitation, we thought it was important to assess union formation and not specifically just cohabitation or marriage. Few studies have jointly considered variation in the timing of marriage and cohabitation. Raley reported that the race gap in the timing of union formation was about half the difference in the timing of first marriage. Thus, there are racial differences in first union formation, but they are considerably smaller than racial differences in the timing of marriage. We examined trends in the levels and timing of union formation, paying attention to variation by race and ethnicity and education. Moreover, we were able to examine these patterns separately for women and men. All data for women came from the NSFG, whereas for men we combined data from the first wave of the NSFH with data from the NSFG . There has been a consistent gender gap in median age at first marriage of roughly 2 years , but whether the median ages at first cohabitation or first union formation differ by gender are unknown. In this study, we asked a fundamental question: During a period when the median age at first marriage has increased and the prevalence of cohabitation has grown, has the median age at first cohabitation increased? Americans may be delaying all union formations, or they may simply be delaying marriage. We showcase change over time in whether the first coresidential union was cohabitation or marriage and the proportion of each age group who were married, cohabiting, or in a union at each interview. We also investigated whether these changes are consistent with the diverging-destinies perspective; we anticipated a stronger divide in marriage than cohabitation. Given that the economic bar to marriage has been rising, we expected to observe widening racial and education gaps in the proportions of married individuals and an increasing median age at first marriage for members of racial/ ethnic minority groups and individuals with less education. The economic prerequisites for cohabitation are lower than those for marriage, and thus cohabitation trends should be less differentiated by race/ethnicity and education. In fact, there is evidence of consistency in the levels of cohabitation across racial and ethnic subgroups and we expected similar ages at first cohabitation among Whites, Blacks, and Hispanics. We expected that the established education gradient in levels and age at entry into cohabitation will continue as more highly educated men and women will continue to adhere to more traditional family behavior and wait until their education is complete prior to forming a union. The goal of the NSFH was to provide a broad range of information on the American family. Central to the NSFG's mission is the production of reliable national statistics and comparable trend data on factors related to pregnancy and birth rates-and in more recent cycles-marriage, divorce, and cohabitation. --- METHOD The 1987-1988 NSFH data were drawn from a household based survey of 5,226 men that included oversamples of members of racial/ethnic minority groups, one-parent families, families with stepchildren, cohabiting families, and recently married persons, with a response rate of 74.3%. Cycle 4 of the NSFG, conducted in 1988, included interviews with 8,450 civilian noninstitutionalized women age 15-44 with oversamples of Black women and a response rate of 79%. Cycle 5 of the NSFG, conducted in 1995, included interviews with 10,847 civilian noninstitutionalized women age 15-44 with oversamples of Hispanic and non-Hispanic Black women and a response rate of 79%. Cycle 6 of the NSFG, conducted from March 2002 through February 2003, included interviews with a total of 12,571 civilian noninstitutionalized men and women age 15-44 with oversamples of Blacks, Hispanics, and teenagers of all races and a combined response rate of 79%. The most recent cycle, 2006-2010 NSFG, was conducted July 1, 2006, through June 2010. It included interviews with a total of 22,682 civilian noninstitutionalized men and women age 15-44 with oversamples of Blacks, Hispanics, teenagers , and female respondents and had a combined response rate of 77%. --- Measures Proportion of respondents married, cohabiting, or in a union-To provide illustrations of the proportion respondents who had ever married, cohabited, or lived in a union, we computed estimates according to 5-year age intervals across interview dates. These findings present birth cohort shifts over time in union formation patterns. We also calculated the proportion of women age 35-44 who had ever married, cohabited or lived in a union according to race/ethnicity and education level. These estimates focused on women who are past the typical first union formation age. For the sake of parsimony we limit the figures we present to women. We computed median ages at first marriage, first cohabitation, and first union for women and men by race/ethnicity and educational attainment, where applicable. Questions specific to cohabitation were explicitly collected starting with Cycle 4 . Because the NSFH and NSFG obtained the exact age at first union formation and the exact date at which a first cohabitation or marriage was experienced , we were able to estimate a direct measure of the median age at first cohabitation, marriage, and union formation by enumerating unions that occurred in a specified range of years for each time point /1984-1988 , 1991-1995 , 1998-2002 , and 2006-2010 by age at union as outlined in Shryock, Siegel, and Larmon , using the following formula: where L = lower limit of median class, n 1 = number of frequencies to be covered in median class to reach middle item, n 2 = number of frequencies in median class, and i = width of median class. The term median class refers to the age in whole years by which half the sample has married. For example, 3,764,946 women in the NSFG 2006-2010 wave first married between the years 2006 and 2010. The age at which half of these women first married was 25 years . To determine the number of frequencies to be covered in the median class to reach the middle item , we subtracted the cumulative number of first marriages at age 24 from half the cumulative number of all first marriages . We then divided the result by the number of first marriages to women age 25 = 387,071.5 and added the result to the lower limit of the median class for a resulting median age at first marriage of 25.9 years. The annual estimates of the median age at first marriage provided by the U.S. Census Bureau used an indirect method that was based on the proportion of people who had ever married for 5-year age groups ranging from 15 to 54 and allowed for the estimation in data sets that did not provide age at a specific event . As discussed above, this method cannot be used to study cohabitation because of data limitations. The direct method is more dependent on the age composition of the population than the indirect method. Furthermore, the direct method does not account for the proportion of women marrying by a given age. To mitigate this issue, we present the proportions marrying and cohabiting by age group. To maximize sample sizes, we chose to compute the median ages at first cohabitation, marriage, and union formation for 5-year intervals as opposed to single-year intervals . Analyses produced a range of cell sizes for women , all adequate for producing reliable estimates. Cycle 4 of the NSFG did not oversample Hispanic women, and thus the cell sizes to produce the median ages of these women was slightly smaller than those of Blacks and Whites in Cycle 4, as well as estimates in subsequent cycles. Among men, the sample sizes ranged from 60 to 678. We do not provide time trends for Hispanic men because of small sample sizes in the NSFH among men who formed a union between 1983 and 1988. The small Hispanic sample sizes also inhibited the disaggregation of foreign-born and native-born respondents. Our results were direct indicators of median ages of first marriage, cohabitation, and union formation derived from the ages of all first unions that occurred in years 1984-1988 for women derived from Cycle 4 and 1983-1988 for men derived from NSFH, 1991-1995 for women derived from Cycle 5 , 1998-2002 for women and men derived from Cycle 6 , and 2006-2010 for women and men derived from the 2006-2010 continuous NSFG. Each respondent's century-month age at first marriage, cohabitation, and union were converted to age in years. Typically, the age at first cohabitation was less than the age at first marriage because most first cohabitations occurred prior to first marriage, but some first cohabiting unions occurred after a first marriage ended, and for this reason some of the estimates of median age at first union are actually lower than either the median ages at first marriage or cohabitation. Estimates were computed separately by race and ethnicity and educational attainment. We categorized race/ethnicity into three groups: Hispanic, non-Hispanic White, and non-Hispanic Black. The ethnicity of respondents was ascertained differently across cycles of the NSFG and NSFH. In NSFG Cycle 4, all respondents were asked to identify their race and then asked to specify their national origin. Respondents who self-identified their national origin as Puerto Rican, Cuban, Mexican American, Central or South American, or Spanish were coded as Hispanic. In the NSFH, respondents were asked to select the group that best described them: Black White-not of Hispanic origin; Mexican American, Chicano, Mexicano; Puerto Rican; Cuban; other Hispanic; American Indian; Asian; or "other." Those who described themselves as Mexican American, Chicano, Mexicano, Puerto Rican, Cuban, or other Hispanic were coded as Hispanic. In NSFG Cycles 5 and 6, as well as the NSFG 2006-2010 cycle, respondents were asked to identify their race. In NSFG Cycle 5, respondents were directly asked if they were of Hispanic or Spanish origin. Cycle 6 and questions for 2006-2010 asked respondents directly if they were Hispanic, Latina, or of Spanish origin. If a respondent reported being of Hispanic descent they were coded as 1, Hispanic. Of the remaining respondents, those who self-identified their race as White or Black were coded as such, meaning those coded as White were non-Hispanic White and those coded as Black were non-Hispanic Black. Unfortunately, we were not able to account for nativity status across the cycles of the NSFG. Respondents who identified their race as "other" were excluded from the analyses because of small sample sizes. Education was coded into four categories: no high school diploma or GED, high school diploma or GED, some college with no degree or associate's degree, and bachelor's degree or higher. This categorization allowed sufficient detail and was available across the cycles of the NSFG as well as the NSFH. Cycle 4 had two questions specific to respondents' completed level of education: "What is the highest grade or year of regular school or college you have ever attended?" and "Did you complete that grade or year?" Beginning with Cycle 5 , more detailed information on the timing of respondents' educational experiences was gathered. In the NSFH, completed education is a constructed variable that provides a summary of the respondents' educational experience, integrating information on both highest grade completed and degrees earned. --- Analytic Sample The analytic sample was limited to women and men age 15 through 44. Among women, the trend covers a 20-year span, 1984-1988 to 2006-2010, with four data points. The time trend for men covers a 21-year span with three data points: 1983-1988, 1998-2002, and 2006-2010. Women and men who experienced a first marriage, cohabitation, or union prior to age 15 were excluded to provide results that are more comparable to other national estimates of the median age at first marriage generated from the Decennial Census, CPS, and American Community Survey data. The upper age limit of 44 was an artifact of the NSFG's sampling frame of women and men age 15-44. Given that most women and men who marry or cohabit have first formed their union prior to age 44, this age limit should have had a very minimal or no impact on our estimates of median age at first union formation. --- RESULTS The median ages at first marriage, cohabitation, and union, and the percentages of first unions that started as cohabitations for each time period for women and men are presented in Table 1 andTable 2, respectively. Consistent with prior research, the median age at first marriage increased over time for women, from age 22.9 in the late 1980s to 25.9 in the late 2000s, and for men, from 24.7 in the late 1980s to 27.6 in the late 2000s. These changes are also reflected in online Figure A on the Journal of Marriage and Family website 1741-3737), which depicts declines in the percentage of women ever married at 5-year age intervals. By ages 40-44, the percentage of women who have ever married declined slightly, from 93% in the late 1980s to 88% in the late 2000s. In contrast, the median age at first cohabitation did not shift much over the past 30 years. Women's median age at first cohabitation in the late 1980s was 22.8, and in the late 2000s it was just 1 year younger, at 21.8. We observed a similar trend among men, whose median age at first cohabitation was 23.9 in the late 1980s and 23.5 in the late 2000s. Online Figure B shows growth in the proportion of each age group who had ever experienced cohabitation, with the greatest increases in the proportion of women who had ever cohabited among women age 25 and older. It appears the delay in marriage formation was offset by younger entry into cohabitation because the rise in the median age at marriage was nearly 3 years versus no change or a decline for median age at cohabitation. Taken together, the age at union formation remained stable and paralleled the trend in the median age at first cohabitation. Online Figure C shows the proportion of women who had ever formed a union has not shifted over time, providing further evidence that cohabitation has offset the decline in marriage. The median ages at union formation in the late 1980s were 21.9 for women and 23.4 for men and, in the late 2000s, 22.2 for women and 23.7 for men. Thus, the gender gap in age at first marriage and cohabitation persisted. Women and men increasingly favored cohabitation as their first coresidential union type, rising from 59% of women in the mid-1980s to nearly three-fourths in the late 2000s. Similarly, the share of men whose first union was cohabitation rose from 60.3% in the 1980s to 82.2% in the late 2000s. It is notable that a small share of first cohabitations occurred after a marriage ended. The race and ethnic divergence in marriage is illustrated in Figure 1. The proportion of 35to 44-year-old women who had ever married, according to race and ethnicity, declined most sharply for Black women. In the late 1980s, 73% of Black women age 35-44 had ever married, but by the later 2000s only 66% had ever married. Patterns of union formation for Hispanic, White, and Black women and men are shown in Tables 3 and4, respectively. Median age at first marriage increased for each race and ethnic group in a similar manner, with about a 3-year increase for each group. During the late 2000s, the median ages at first marriage were 25.6 for Hispanic women, 25.7 for White women, and 27.0 for Black women. Among men, the corresponding figures were 29.9 for Hispanics, 27.1 for Whites, and 28.4 for Blacks. The retreat from marriage was most evident among Blacks, with high ages at first marriage among those who married and nearly one third not marrying. The proportion of 35-to 44-year-old women who had ever cohabited similarly increased for all race and ethnic groups, as shown in Figure 2. In the late 2000s, the percentage of 35-to 44-year-old women who had ever cohabited ranged from 58% of Hispanic women to 67% of Black women. The median age at first cohabitation was stable and strikingly similar for each race and ethnic group among both women and men. Among Hispanic women, median age at first cohabitation ranged from 22.3 in the mid-1980s to 20.9 in the late 2000s. The ranges for White and Black women were 22.9 to 21.8 and 22.9 to 22.6, respectively. Men in each race and ethnic group had a slightly higher age at first cohabitation than women. In the late 2000s, men in all three race and ethnic groups experienced a median age at first cohabitation of roughly 23 years. For men and women alike, the gap between Blacks versus Hispanics and Whites was also smaller for median age at first cohabitation than marriage. The median age at first union formation remained about the same over the last 20 years. There was little variation according to race and ethnicity in the timing of first union formation, which ranged among women from 21.3 for Hispanics to 22.0 for Blacks in the 1980s to 21.2 for Hispanics and 22.6 for Blacks in the late 2000s. The age range was also quite narrow among men, hovering around 23 years for age at first union formation over the past 20 years, regardless of race and ethnicity. Similar proportions of respondents had ever formed a union, and there was almost no change in the proportion of women age 35 and older who had ever formed a union, regardless of race and ethnicity, as depicted in Figure 3. As shown in the bottom row of Tables 3 and4 the proportion of first unions that were cohabitations rose among all three racial and ethnic groups, with the greatest increases among Hispanic women, White men, and Black men. For Hispanic women, the proportion climbed from 56.5% to 78.9%. The pattern for White women was similar, with the proportion rising from 58.0% to 71.0%. Among Black women, the proportion increased from 65.5% to 81.6%. Among men, the proportions of first unions that were cohabitations rose from 68.4% to 80.1% among Hispanics over the past decade or so. Since the mid-1980s, the proportions grew from 60.6% to 82.4% among Whites and 66.3% to 86.7% among Blacks. Overall, the racial and ethnic variation was more modest than we had anticipated. Patterns of change in the timing of cohabitation and union formation, as well as the trend in the proportion of first unions that were cohabitations, were largely comparable across racial and ethnic groups. Figures 4 and5 show the proportions of women by age group who ever married or cohabited, and Tables 5 and6 presents the median ages at first marriage, cohabitation, and union for the four education groups . Data in Figure 4 indicated that college-educated respondents experienced almost no change in the proportion who ever married, whereas declines occurred for every other education group. Findings for women are presented in the Table 5, and Table 6 contains findings for men. The median age at first marriage increased for all education groups, but the greatest change occurred among the least educated respondents, which was consistent with our expectations. In the 1980s, there was nearly a 6-year age gap in the median age at first marriage for the most and least educated women, and this gap narrowed to about a 1-year difference in the late 2000s. The median age at first marriage was 25.7 for women with less than a high school degree versus 26.7 for women with a college degree in the late 2000s. A similar pattern was observed among men, with a narrowing of the education gap in the median age at first marriage from about 5 to roughly 2 years. In the late 2000s, the median age at first marriage for men was 25.9 for those with less than a high school degree and 28.4 for those with a college degree. In terms of cohabitation, Figure 5 shows the greatest increase among women with the lowest education levels and the most modest rise among college graduates, resulting in a widening of the gap in cohabitation experience. The median age at first cohabitation differed according to educational attainment, with the most educated respondents experiencing the latest median ages at first cohabitation, as shown in Tables 5 and6. The age gap between the most and the least educated individuals remained stable. For example, among women in the mid-1980s the difference between the college educated and those who dropped out of high school was 7 years, and by the late 2000s a 6-year gap existed . Among men, a 5-year age gap according to education persisted over the 20-year time span . The group that changed the most in terms of median age at first cohabitation was women who were high school graduates. Women who earned a high school degree experienced a decline in their age at cohabitation and appeared more like women who had not completed high school during the most recent time period compared with 20 years ago. Turning to union formation, there was almost no change in the proportion of each education group ever forming of union . Table 5 shows that in the late 2000s the least educated women were marrying in their mid-20s but started their first coresidential union in their late teens. Twenty years ago, half had married by age 20 and cohabited by age 19. The gap between the age at cohabitation and marriage increased greatly for the least educated respondents, shifting from 1 year to 7 years among women and from less than a year to 5 years among men. The most educated did not change much in the median age at first cohabitation or median age at first marriage, and thus the median age at first union formation was steady, at 24.9, for women with a college degree. In the recent period, among college-educated women the difference between the age at marriage and cohabitation was 2 years . Similarly, Table 6 shows that the median age at first union formation was quite stable among men, fluctuating by less than 1 year regardless of education level. A key factor driving the changing patterns of cohabitation and marriage formation by education was the increase in cohabitation as a first union among individuals with modest levels of education. The least educated women shifted from a rate of 82% experiencing cohabitation as their first union in the mid-1980s to nearly 90% in the late 2000s. There was no change among women with a college degree; 55% in the mid-1980s, and 56% in the late 2000s, experienced cohabitation as their first coresidential union. In contrast, among college-educated men there was a sharp increase in the percentage whose first union was cohabitation, from 44% in the mid-1980s to 70% in the late 2000s. Thus, there has been a persistent education gap in regard to people first entering cohabitation rather than marriage. The growth in cohabitation experience was most evident among women with a high school degree, who shifted from about half cohabiting as their first coresidential union in the mid-1980s to the vast majority, 89%, in the late 2000s. The increase in unions initiated by cohabitation rather than marriage also occurred among working-class men . --- DISCUSSION The decline of marriage and rise of cohabitation are two of the most dramatic family changes in the past two decades. With the growing emphasis on the necessity of secure financial prospects for marriage during an era of economic volubility, it is not surprising that the age at marriage continues its steady ascent. Our analyses detailed well-known shifts in the median age at first marriage and documented that delays in marriage entry have occurred for all racial and ethnic as well as education groups. The especially pronounced delay in marriage among American women and men with low educational attainment resulted in a near-convergence in the age at first marriage according to education. College graduates in the early 1980s waited until their mid-20s to marry and continue to do so today. The question remains whether these delays in marriage may eventually lead to foregone marriages among younger cohorts, and we expect this may be a possibility among those who are the most disadvantaged economically. The trends toward delayed marriage entry do not extend to cohabitation. We found no parallel changes in the median ages at first cohabitation or first union formation. Instead, over a 20-year span women and men were still forming first unions at roughly the same ages. There were few differences in age at cohabitation according to race/ethnicity, but there was large variation by education, with a gap of roughly 6 years between the least and most educated persisting over the past two decades. Men and women with the highest educations were waiting to cohabit and marry, whereas those with the lowest education levels were waiting to marry but not cohabit. Considerable change in the type of first union occurred, shifting from marriage to cohabitation. Among women, about three quarters of first unions formed in the late 2000s were cohabiting, in contrast to just over half 20 years earlier. The greatest increases in cohabitation as a first union appeared among working-class women and men . Among women in the mid-1980s, 56% of first unions were cohabiting unions versus in the late 2000s, when 89% were cohabiting unions. Similarly, age at first union was stable within racial/ethnic group and by education level, and there was a clear education gradient, with age at first union more than 4 years younger for the least educated than the most educated respondents. Thus, it appears that although the education gap in median age at first marriage closed, the education gap in the median age at first union did not. Overall, cohabitation offset changes in the proportion ever marrying and the median age at first marriage. A key advantage of our study was its attention to the union-formation patterns of women and men. The gender gap in the age at first marriage has persisted, remaining at a 2-year differential. Although we had fewer data points for men than women, the findings appeared consistent and tended to hold within racial and ethnic and education groups. In terms of age at first cohabitation, the gender gap was narrower, about 1 year, than the gender gap in age at first marriage. For the most part, the trends among women according to race/ethnicity and education were mirrored among men, although the rise in the proportion of first unions that were cohabitations was negligible for college-educated women but was large for men regardless of education level. This study contains a few limitations. First, because of small sample sizes these analyses were restricted to just three racial and ethnic categories. Among men in the earliest time period the sample was too small to include Hispanic men. Also, the sample sizes were not sufficiently large to distinguish nativity status of respondents. Second, the analyses did not account for shifts in the composition of the population in terms of education and race/ ethnicity. Also, very young people in the sample may not have completed their education yet. Third, we focused solely on the median ages at first marriage and cohabitation. The full range of the distribution of age at union formation may be important to consider in assessing changes in the patterns of union formation over time. We did not statistically test for differences among subgroups of men and women. Another shortcoming is that our indicators of median ages at marriage and cohabitation did not account for the proportions of respondents who married or cohabited by a given age. We provided estimates of the proportions who married and cohabited by age to illustrate changes in the proportions of subgroups experiencing cohabitation and marriage. Our focus was on period change in union formation, but additional work that examines timing of union formation across birth cohorts is warranted. Finally, the NSFG has an upper age limit of 44, so we may have missed a few first marriages and cohabitations among older women and men, but considering the analyses focused on first unions this should not be a serious shortcoming. This study moves beyond prior work by providing trend data on the median age at first cohabitation. Most prior work has focused on change in marriage in the United States, invoking the shift in the median age at marriage without attention to how cohabitation fits into broader change in union formation. Our findings demonstrate that patterns of cohabitation entry are distinct from those of marriage. Although Americans increasingly delay first-marriage entry, the median age at which they form a first cohabiting union has changed little over the past two decades. The education gradient was striking in that the highly educated respondents, on average, delayed both cohabitation and marriage and the more modestly educated delayed marriage but not cohabitation. The delays in marriage have provided more opportunities for cohabitation in young adulthood, especially among Americans with only modest educational attainment. Given the greater instability of cohabiting unions and the fact that fewer cohabiting unions eventuate in marriage , we believe these patterns suggest greater opportunities for serial cohabitation . As a consequence, young adults today will have more complex relationship biographies that may have implications for their own well-being as well as that of their offspring.

The landscape of union formation has been shifting; Americans are now marrying at the highest ages on record and the majority of young adults have cohabited. Yet little attention has been paid to the timing of cohabitation relative to marriage. Using the National Survey of Families and Households and 4 cycles of the National Survey of Family Growth, the authors examined the timing of marriage, cohabitation, and unions over 20 years. As the median age at first marriage has climbed, the age at cohabitation has remained stable for men and women. The changes in the timing of union formation have been similar according to race/ethnicity. The marked delay in marriage among women and men with low educational attainment has resulted in a nearconvergence in the age at first marriage according to education. The authors conclude that the rise in cohabitation has offset changes in the levels and timing of marriage.

background the rise in the median age at first marriage is well documented but little is known about whether there has been an accompanying change in the median ages at first cohabitation and first union formation are americans waiting longer to form any union or are they just waiting longer to form marital unions one reason the median ages at cohabitation or union formation have received little attention is that there are few data sources available to document these shifts the median age at first marriage is often calculated using indirect methods as specified by shryock siegel and larmon these methods require knowledge about the proportion of the population that has been married at specific age ranges this information has been available for some time from us census data as well as current population survey data these indirect methods cannot be used to assess median age at cohabitation because the census and cps do not include indicators of the proportion of the population that has cohabited at specific age groups starting in 2000 the census included unmarried partner as a household membership category but did not obtain a critical piece of information the proportion of the population that has ever cohabited furthermore directly assessing changes in the median age at first cohabitation requires survey data that directly ascertain the age at first cohabitation in response to the growth in cohabitation starting in the late 1980s a few nationally representative surveys such as the nsfh and nsfg expanded the roster of household relationships to include cohabitation these and now many additional surveys have included direct questions about the start and end dates of cohabitation akin to measures of marriage thus using nationally representative survey data we were able to assess changes in direct reports of ages at marriage as well as cohabitation on the basis of data collected 25 years ago in the 19871988 nsfh the median age at first cohabitation was 21 for women but little is known about the median age at first cohabitation today we expect there may have been some changes in the median age at first cohabitation in part because over a 23year period there has been an 82 increase in the proportion of women who ever cohabited in 1987 one third of women ages 1944 ever cohabited and recently over half of 19to 44yearold women had spent some time in a cohabiting union the median age at first cohabitation may not be increasing as rapidly as the median age at first marriage because the barriers to cohabitation are not as high as those to marriage motivations to cohabit have tended to be based on relational prospects and have not carried the same prerequisites such as stable economic prospects as marriage to date researchers have not investigated whether there has been an increase in the median age at first cohabitation or first union formation even though the proportion of women who have ever cohabited has increased dramatically evidence supporting the theme of diverging destinies defined as growing racialethnic and social class differentials in family behavior often has focused on the disproportionate rise in nonmarital fertility among the most disadvantaged individuals versus the quite stable low levels of unwed childbearing among college graduates similarly there appears to be a divergence in marriage trends as growth in nonmarriage has been greatest among the most disadvantaged we investigated whether the delay in marriage entry characterizing advantaged groups extends to cohabitation formation as well that is has the rising age at marriage coincided with a shift in the timing of first cohabitation or has the median age at first cohabitation remained stable bumpass sweet and cherlin suggested that the delay in marriage entry evident in the 1970s and 1980s was offset by corresponding increases in cohabitation formation meaning that first union formation was relatively unchanged over time instead the type of first union formed had shifted from marriage to cohabitation racial and ethnic differentials in the median age at first marriage are well known some of the differentials are due to lower levels of ever marrying among certain subgroups of the population the proportion of married individuals in the population has declined faster among black women than white women for example black women have firstmarriage rates that are about half the levels experienced by white or hispanic women in 2010 the firstmarriage rates per 1000 nevermarried women were 221 among black women 524 among white women and 426 among nativeborn hispanic women indeed the racial and ethnic gap in the age at first marriage persists and actually has widened starting in 1980 the racial gap in age at first marriage reached 2 years in 2010 black women had a median age at first marriage that was about 4 years greater than the age at first marriage experienced by white and hispanic women for these reasons we anticipated that the median age at first marriage is highest among blacks and that the rise has been steepest for blacks compared to whites and hispanics the timing of marriage follows an education gradient in 2010 the firstmarriage rate was notably highest among collegeeducated women and ranged between 304 and 394 among women with less than high school and only some college education the financial resources provided by men have weakened and women have been increasingly valued for their economic prospects in 2010 the median age at first marriage was 24 among women with less than a high school degree and 28 among collegeeducated women furthermore half of women without a high school degree were married by age 25 in contrast to only 37 of women with a college degree but by age 35 the pattern reversed such that 72 of women without a high school degree had married and 84 with a college degree had married although more educated women tend to marry at later ages compared with less educated women more educated women are ultimately the most likely to ever marry this education gap in age at first marriage has persisted over time but it could be narrowing as more disadvantaged americans delay marrying to meet the economic prerequisites for marriage over the past 20 years the proportions of individuals who have ever cohabited rose somewhat more quickly among whites and hispanics than among blacks in 1987 the average age at first cohabitation was 21 for whites blacks and hispanics the current differential in the proportion of women who have ever cohabited according to race and ethnicity continues to be relatively small ranging from 59 among hispanics to 62 among whites we did not expect a divergingdestinies perspective to be operating as strongly for cohabitation as marriage because unlike marriage there are few economic barriers to cohabitation thus we expected a continuation of little variation in the median age at first cohabitation according to race and ethnicity in contrast the education divide in cohabitation experience has been increasing in 20092010 nearly three quarters of women without a high school degree had ever cohabited versus half of women with a college degree the education group that saw the greatest increase in cohabitation was women with a high school degree who experienced over a 100 increase in cohabitation experience over the past 23 years two decades ago the average age of first cohabitation among college graduates was 24 versus 19 for persons with less than a high school degree because the economic barriers to marriage are greater than those for cohabitation we expected a less steep education gradient for cohabitation than marriage given the changes in marriage and cohabitation we thought it was important to assess union formation and not specifically just cohabitation or marriage few studies have jointly considered variation in the timing of marriage and cohabitation raley reported that the race gap in the timing of union formation was about half the difference in the timing of first marriage thus there are racial differences in first union formation but they are considerably smaller than racial differences in the timing of marriage we examined trends in the levels and timing of union formation paying attention to variation by race and ethnicity and education moreover we were able to examine these patterns separately for women and men all data for women came from the nsfg whereas for men we combined data from the first wave of the nsfh with data from the nsfg there has been a consistent gender gap in median age at first marriage of roughly 2 years but whether the median ages at first cohabitation or first union formation differ by gender are unknown in this study we asked a fundamental question during a period when the median age at first marriage has increased and the prevalence of cohabitation has grown has the median age at first cohabitation increased americans may be delaying all union formations or they may simply be delaying marriage we showcase change over time in whether the first coresidential union was cohabitation or marriage and the proportion of each age group who were married cohabiting or in a union at each interview we also investigated whether these changes are consistent with the divergingdestinies perspective we anticipated a stronger divide in marriage than cohabitation given that the economic bar to marriage has been rising we expected to observe widening racial and education gaps in the proportions of married individuals and an increasing median age at first marriage for members of racial ethnic minority groups and individuals with less education the economic prerequisites for cohabitation are lower than those for marriage and thus cohabitation trends should be less differentiated by raceethnicity and education in fact there is evidence of consistency in the levels of cohabitation across racial and ethnic subgroups and we expected similar ages at first cohabitation among whites blacks and hispanics we expected that the established education gradient in levels and age at entry into cohabitation will continue as more highly educated men and women will continue to adhere to more traditional family behavior and wait until their education is complete prior to forming a union the goal of the nsfh was to provide a broad range of information on the american family central to the nsfgs mission is the production of reliable national statistics and comparable trend data on factors related to pregnancy and birth ratesand in more recent cyclesmarriage divorce and cohabitation method the 19871988 nsfh data were drawn from a household based survey of 5226 men that included oversamples of members of racialethnic minority groups oneparent families families with stepchildren cohabiting families and recently married persons with a response rate of 743 cycle 4 of the nsfg conducted in 1988 included interviews with 8450 civilian noninstitutionalized women age 1544 with oversamples of black women and a response rate of 79 cycle 5 of the nsfg conducted in 1995 included interviews with 10847 civilian noninstitutionalized women age 1544 with oversamples of hispanic and nonhispanic black women and a response rate of 79 cycle 6 of the nsfg conducted from march 2002 through february 2003 included interviews with a total of 12571 civilian noninstitutionalized men and women age 1544 with oversamples of blacks hispanics and teenagers of all races and a combined response rate of 79 the most recent cycle 20062010 nsfg was conducted july 1 2006 through june 2010 it included interviews with a total of 22682 civilian noninstitutionalized men and women age 1544 with oversamples of blacks hispanics teenagers and female respondents and had a combined response rate of 77 measures proportion of respondents married cohabiting or in a unionto provide illustrations of the proportion respondents who had ever married cohabited or lived in a union we computed estimates according to 5year age intervals across interview dates these findings present birth cohort shifts over time in union formation patterns we also calculated the proportion of women age 3544 who had ever married cohabited or lived in a union according to raceethnicity and education level these estimates focused on women who are past the typical first union formation age for the sake of parsimony we limit the figures we present to women we computed median ages at first marriage first cohabitation and first union for women and men by raceethnicity and educational attainment where applicable questions specific to cohabitation were explicitly collected starting with cycle 4 because the nsfh and nsfg obtained the exact age at first union formation and the exact date at which a first cohabitation or marriage was experienced we were able to estimate a direct measure of the median age at first cohabitation marriage and union formation by enumerating unions that occurred in a specified range of years for each time point 19841988 19911995 19982002 and 20062010 by age at union as outlined in shryock siegel and larmon using the following formula where l lower limit of median class n 1 number of frequencies to be covered in median class to reach middle item n 2 number of frequencies in median class and i width of median class the term median class refers to the age in whole years by which half the sample has married for example 3764946 women in the nsfg 20062010 wave first married between the years 2006 and 2010 the age at which half of these women first married was 25 years to determine the number of frequencies to be covered in the median class to reach the middle item we subtracted the cumulative number of first marriages at age 24 from half the cumulative number of all first marriages we then divided the result by the number of first marriages to women age 25 3870715 and added the result to the lower limit of the median class for a resulting median age at first marriage of 259 years the annual estimates of the median age at first marriage provided by the us census bureau used an indirect method that was based on the proportion of people who had ever married for 5year age groups ranging from 15 to 54 and allowed for the estimation in data sets that did not provide age at a specific event as discussed above this method cannot be used to study cohabitation because of data limitations the direct method is more dependent on the age composition of the population than the indirect method furthermore the direct method does not account for the proportion of women marrying by a given age to mitigate this issue we present the proportions marrying and cohabiting by age group to maximize sample sizes we chose to compute the median ages at first cohabitation marriage and union formation for 5year intervals as opposed to singleyear intervals analyses produced a range of cell sizes for women all adequate for producing reliable estimates cycle 4 of the nsfg did not oversample hispanic women and thus the cell sizes to produce the median ages of these women was slightly smaller than those of blacks and whites in cycle 4 as well as estimates in subsequent cycles among men the sample sizes ranged from 60 to 678 we do not provide time trends for hispanic men because of small sample sizes in the nsfh among men who formed a union between 1983 and 1988 the small hispanic sample sizes also inhibited the disaggregation of foreignborn and nativeborn respondents our results were direct indicators of median ages of first marriage cohabitation and union formation derived from the ages of all first unions that occurred in years 19841988 for women derived from cycle 4 and 19831988 for men derived from nsfh 19911995 for women derived from cycle 5 19982002 for women and men derived from cycle 6 and 20062010 for women and men derived from the 20062010 continuous nsfg each respondents centurymonth age at first marriage cohabitation and union were converted to age in years typically the age at first cohabitation was less than the age at first marriage because most first cohabitations occurred prior to first marriage but some first cohabiting unions occurred after a first marriage ended and for this reason some of the estimates of median age at first union are actually lower than either the median ages at first marriage or cohabitation estimates were computed separately by race and ethnicity and educational attainment we categorized raceethnicity into three groups hispanic nonhispanic white and nonhispanic black the ethnicity of respondents was ascertained differently across cycles of the nsfg and nsfh in nsfg cycle 4 all respondents were asked to identify their race and then asked to specify their national origin respondents who selfidentified their national origin as puerto rican cuban mexican american central or south american or spanish were coded as hispanic in the nsfh respondents were asked to select the group that best described them black whitenot of hispanic origin mexican american chicano mexicano puerto rican cuban other hispanic american indian asian or other those who described themselves as mexican american chicano mexicano puerto rican cuban or other hispanic were coded as hispanic in nsfg cycles 5 and 6 as well as the nsfg 20062010 cycle respondents were asked to identify their race in nsfg cycle 5 respondents were directly asked if they were of hispanic or spanish origin cycle 6 and questions for 20062010 asked respondents directly if they were hispanic latina or of spanish origin if a respondent reported being of hispanic descent they were coded as 1 hispanic of the remaining respondents those who selfidentified their race as white or black were coded as such meaning those coded as white were nonhispanic white and those coded as black were nonhispanic black unfortunately we were not able to account for nativity status across the cycles of the nsfg respondents who identified their race as other were excluded from the analyses because of small sample sizes education was coded into four categories no high school diploma or ged high school diploma or ged some college with no degree or associates degree and bachelors degree or higher this categorization allowed sufficient detail and was available across the cycles of the nsfg as well as the nsfh cycle 4 had two questions specific to respondents completed level of education what is the highest grade or year of regular school or college you have ever attended and did you complete that grade or year beginning with cycle 5 more detailed information on the timing of respondents educational experiences was gathered in the nsfh completed education is a constructed variable that provides a summary of the respondents educational experience integrating information on both highest grade completed and degrees earned analytic sample the analytic sample was limited to women and men age 15 through 44 among women the trend covers a 20year span 19841988 to 20062010 with four data points the time trend for men covers a 21year span with three data points 19831988 19982002 and 20062010 women and men who experienced a first marriage cohabitation or union prior to age 15 were excluded to provide results that are more comparable to other national estimates of the median age at first marriage generated from the decennial census cps and american community survey data the upper age limit of 44 was an artifact of the nsfgs sampling frame of women and men age 1544 given that most women and men who marry or cohabit have first formed their union prior to age 44 this age limit should have had a very minimal or no impact on our estimates of median age at first union formation results the median ages at first marriage cohabitation and union and the percentages of first unions that started as cohabitations for each time period for women and men are presented in table 1 andtable 2 respectively consistent with prior research the median age at first marriage increased over time for women from age 229 in the late 1980s to 259 in the late 2000s and for men from 247 in the late 1980s to 276 in the late 2000s these changes are also reflected in online figure a on the journal of marriage and family website 17413737 which depicts declines in the percentage of women ever married at 5year age intervals by ages 4044 the percentage of women who have ever married declined slightly from 93 in the late 1980s to 88 in the late 2000s in contrast the median age at first cohabitation did not shift much over the past 30 years womens median age at first cohabitation in the late 1980s was 228 and in the late 2000s it was just 1 year younger at 218 we observed a similar trend among men whose median age at first cohabitation was 239 in the late 1980s and 235 in the late 2000s online figure b shows growth in the proportion of each age group who had ever experienced cohabitation with the greatest increases in the proportion of women who had ever cohabited among women age 25 and older it appears the delay in marriage formation was offset by younger entry into cohabitation because the rise in the median age at marriage was nearly 3 years versus no change or a decline for median age at cohabitation taken together the age at union formation remained stable and paralleled the trend in the median age at first cohabitation online figure c shows the proportion of women who had ever formed a union has not shifted over time providing further evidence that cohabitation has offset the decline in marriage the median ages at union formation in the late 1980s were 219 for women and 234 for men and in the late 2000s 222 for women and 237 for men thus the gender gap in age at first marriage and cohabitation persisted women and men increasingly favored cohabitation as their first coresidential union type rising from 59 of women in the mid1980s to nearly threefourths in the late 2000s similarly the share of men whose first union was cohabitation rose from 603 in the 1980s to 822 in the late 2000s it is notable that a small share of first cohabitations occurred after a marriage ended the race and ethnic divergence in marriage is illustrated in figure 1 the proportion of 35to 44yearold women who had ever married according to race and ethnicity declined most sharply for black women in the late 1980s 73 of black women age 3544 had ever married but by the later 2000s only 66 had ever married patterns of union formation for hispanic white and black women and men are shown in tables 3 and4 respectively median age at first marriage increased for each race and ethnic group in a similar manner with about a 3year increase for each group during the late 2000s the median ages at first marriage were 256 for hispanic women 257 for white women and 270 for black women among men the corresponding figures were 299 for hispanics 271 for whites and 284 for blacks the retreat from marriage was most evident among blacks with high ages at first marriage among those who married and nearly one third not marrying the proportion of 35to 44yearold women who had ever cohabited similarly increased for all race and ethnic groups as shown in figure 2 in the late 2000s the percentage of 35to 44yearold women who had ever cohabited ranged from 58 of hispanic women to 67 of black women the median age at first cohabitation was stable and strikingly similar for each race and ethnic group among both women and men among hispanic women median age at first cohabitation ranged from 223 in the mid1980s to 209 in the late 2000s the ranges for white and black women were 229 to 218 and 229 to 226 respectively men in each race and ethnic group had a slightly higher age at first cohabitation than women in the late 2000s men in all three race and ethnic groups experienced a median age at first cohabitation of roughly 23 years for men and women alike the gap between blacks versus hispanics and whites was also smaller for median age at first cohabitation than marriage the median age at first union formation remained about the same over the last 20 years there was little variation according to race and ethnicity in the timing of first union formation which ranged among women from 213 for hispanics to 220 for blacks in the 1980s to 212 for hispanics and 226 for blacks in the late 2000s the age range was also quite narrow among men hovering around 23 years for age at first union formation over the past 20 years regardless of race and ethnicity similar proportions of respondents had ever formed a union and there was almost no change in the proportion of women age 35 and older who had ever formed a union regardless of race and ethnicity as depicted in figure 3 as shown in the bottom row of tables 3 and4 the proportion of first unions that were cohabitations rose among all three racial and ethnic groups with the greatest increases among hispanic women white men and black men for hispanic women the proportion climbed from 565 to 789 the pattern for white women was similar with the proportion rising from 580 to 710 among black women the proportion increased from 655 to 816 among men the proportions of first unions that were cohabitations rose from 684 to 801 among hispanics over the past decade or so since the mid1980s the proportions grew from 606 to 824 among whites and 663 to 867 among blacks overall the racial and ethnic variation was more modest than we had anticipated patterns of change in the timing of cohabitation and union formation as well as the trend in the proportion of first unions that were cohabitations were largely comparable across racial and ethnic groups figures 4 and5 show the proportions of women by age group who ever married or cohabited and tables 5 and6 presents the median ages at first marriage cohabitation and union for the four education groups data in figure 4 indicated that collegeeducated respondents experienced almost no change in the proportion who ever married whereas declines occurred for every other education group findings for women are presented in the table 5 and table 6 contains findings for men the median age at first marriage increased for all education groups but the greatest change occurred among the least educated respondents which was consistent with our expectations in the 1980s there was nearly a 6year age gap in the median age at first marriage for the most and least educated women and this gap narrowed to about a 1year difference in the late 2000s the median age at first marriage was 257 for women with less than a high school degree versus 267 for women with a college degree in the late 2000s a similar pattern was observed among men with a narrowing of the education gap in the median age at first marriage from about 5 to roughly 2 years in the late 2000s the median age at first marriage for men was 259 for those with less than a high school degree and 284 for those with a college degree in terms of cohabitation figure 5 shows the greatest increase among women with the lowest education levels and the most modest rise among college graduates resulting in a widening of the gap in cohabitation experience the median age at first cohabitation differed according to educational attainment with the most educated respondents experiencing the latest median ages at first cohabitation as shown in tables 5 and6 the age gap between the most and the least educated individuals remained stable for example among women in the mid1980s the difference between the college educated and those who dropped out of high school was 7 years and by the late 2000s a 6year gap existed among men a 5year age gap according to education persisted over the 20year time span the group that changed the most in terms of median age at first cohabitation was women who were high school graduates women who earned a high school degree experienced a decline in their age at cohabitation and appeared more like women who had not completed high school during the most recent time period compared with 20 years ago turning to union formation there was almost no change in the proportion of each education group ever forming of union table 5 shows that in the late 2000s the least educated women were marrying in their mid20s but started their first coresidential union in their late teens twenty years ago half had married by age 20 and cohabited by age 19 the gap between the age at cohabitation and marriage increased greatly for the least educated respondents shifting from 1 year to 7 years among women and from less than a year to 5 years among men the most educated did not change much in the median age at first cohabitation or median age at first marriage and thus the median age at first union formation was steady at 249 for women with a college degree in the recent period among collegeeducated women the difference between the age at marriage and cohabitation was 2 years similarly table 6 shows that the median age at first union formation was quite stable among men fluctuating by less than 1 year regardless of education level a key factor driving the changing patterns of cohabitation and marriage formation by education was the increase in cohabitation as a first union among individuals with modest levels of education the least educated women shifted from a rate of 82 experiencing cohabitation as their first union in the mid1980s to nearly 90 in the late 2000s there was no change among women with a college degree 55 in the mid1980s and 56 in the late 2000s experienced cohabitation as their first coresidential union in contrast among collegeeducated men there was a sharp increase in the percentage whose first union was cohabitation from 44 in the mid1980s to 70 in the late 2000s thus there has been a persistent education gap in regard to people first entering cohabitation rather than marriage the growth in cohabitation experience was most evident among women with a high school degree who shifted from about half cohabiting as their first coresidential union in the mid1980s to the vast majority 89 in the late 2000s the increase in unions initiated by cohabitation rather than marriage also occurred among workingclass men discussion the decline of marriage and rise of cohabitation are two of the most dramatic family changes in the past two decades with the growing emphasis on the necessity of secure financial prospects for marriage during an era of economic volubility it is not surprising that the age at marriage continues its steady ascent our analyses detailed wellknown shifts in the median age at first marriage and documented that delays in marriage entry have occurred for all racial and ethnic as well as education groups the especially pronounced delay in marriage among american women and men with low educational attainment resulted in a nearconvergence in the age at first marriage according to education college graduates in the early 1980s waited until their mid20s to marry and continue to do so today the question remains whether these delays in marriage may eventually lead to foregone marriages among younger cohorts and we expect this may be a possibility among those who are the most disadvantaged economically the trends toward delayed marriage entry do not extend to cohabitation we found no parallel changes in the median ages at first cohabitation or first union formation instead over a 20year span women and men were still forming first unions at roughly the same ages there were few differences in age at cohabitation according to raceethnicity but there was large variation by education with a gap of roughly 6 years between the least and most educated persisting over the past two decades men and women with the highest educations were waiting to cohabit and marry whereas those with the lowest education levels were waiting to marry but not cohabit considerable change in the type of first union occurred shifting from marriage to cohabitation among women about three quarters of first unions formed in the late 2000s were cohabiting in contrast to just over half 20 years earlier the greatest increases in cohabitation as a first union appeared among workingclass women and men among women in the mid1980s 56 of first unions were cohabiting unions versus in the late 2000s when 89 were cohabiting unions similarly age at first union was stable within racialethnic group and by education level and there was a clear education gradient with age at first union more than 4 years younger for the least educated than the most educated respondents thus it appears that although the education gap in median age at first marriage closed the education gap in the median age at first union did not overall cohabitation offset changes in the proportion ever marrying and the median age at first marriage a key advantage of our study was its attention to the unionformation patterns of women and men the gender gap in the age at first marriage has persisted remaining at a 2year differential although we had fewer data points for men than women the findings appeared consistent and tended to hold within racial and ethnic and education groups in terms of age at first cohabitation the gender gap was narrower about 1 year than the gender gap in age at first marriage for the most part the trends among women according to raceethnicity and education were mirrored among men although the rise in the proportion of first unions that were cohabitations was negligible for collegeeducated women but was large for men regardless of education level this study contains a few limitations first because of small sample sizes these analyses were restricted to just three racial and ethnic categories among men in the earliest time period the sample was too small to include hispanic men also the sample sizes were not sufficiently large to distinguish nativity status of respondents second the analyses did not account for shifts in the composition of the population in terms of education and race ethnicity also very young people in the sample may not have completed their education yet third we focused solely on the median ages at first marriage and cohabitation the full range of the distribution of age at union formation may be important to consider in assessing changes in the patterns of union formation over time we did not statistically test for differences among subgroups of men and women another shortcoming is that our indicators of median ages at marriage and cohabitation did not account for the proportions of respondents who married or cohabited by a given age we provided estimates of the proportions who married and cohabited by age to illustrate changes in the proportions of subgroups experiencing cohabitation and marriage our focus was on period change in union formation but additional work that examines timing of union formation across birth cohorts is warranted finally the nsfg has an upper age limit of 44 so we may have missed a few first marriages and cohabitations among older women and men but considering the analyses focused on first unions this should not be a serious shortcoming this study moves beyond prior work by providing trend data on the median age at first cohabitation most prior work has focused on change in marriage in the united states invoking the shift in the median age at marriage without attention to how cohabitation fits into broader change in union formation our findings demonstrate that patterns of cohabitation entry are distinct from those of marriage although americans increasingly delay firstmarriage entry the median age at which they form a first cohabiting union has changed little over the past two decades the education gradient was striking in that the highly educated respondents on average delayed both cohabitation and marriage and the more modestly educated delayed marriage but not cohabitation the delays in marriage have provided more opportunities for cohabitation in young adulthood especially among americans with only modest educational attainment given the greater instability of cohabiting unions and the fact that fewer cohabiting unions eventuate in marriage we believe these patterns suggest greater opportunities for serial cohabitation as a consequence young adults today will have more complex relationship biographies that may have implications for their own wellbeing as well as that of their offspring

the landscape of union formation has been shifting americans are now marrying at the highest ages on record and the majority of young adults have cohabited yet little attention has been paid to the timing of cohabitation relative to marriage using the national survey of families and households and 4 cycles of the national survey of family growth the authors examined the timing of marriage cohabitation and unions over 20 years as the median age at first marriage has climbed the age at cohabitation has remained stable for men and women the changes in the timing of union formation have been similar according to raceethnicity the marked delay in marriage among women and men with low educational attainment has resulted in a nearconvergence in the age at first marriage according to education the authors conclude that the rise in cohabitation has offset changes in the levels and timing of marriage

Introduction Despite reductions in HIV incidence globally, HIV transmission among men who have sex with men continues to increase markedly , especially where sex between men remains highly stigmatized or illegal . Malaysia, a middle-income country with low overall HIV prevalence, has an evolving epidemic in MSM with new HIV cases increasing from 10% in 2008 to 54% in 2016 . Biobehavioral surveys now suggest that HIV prevalence among MSM is now at an all-time high of 21.6%, and is concentrated in the country's capital, Kuala Lumpur, where HIV prevalence among MSM was 43% in 2018, up from 22% just four years before . This growing epidemic among MSM has been associated with condomless sex and concomitant use of drugs and alcohol . In Malaysia, homosexuality is illegal in both secular and Sharia law. Even when criminal sanctions are not enforced, MSM are highly stigmatized and often discriminated against. Consequently, reaching MSM in general, and certainly, those not identifying as "gay", has been especially challenging with HIV prevention services . Traditional outreach at venues where MSM congregate has been challenging. For example, gay clubs are unviable option because of highly publicized police raids of such establishments with the press airing footage of MSM being forced to submit to urine drug testing or even pronouncements against lesbian, gay, bisexual, and transgender persons by leading governmental authorities, including to smear leading public figures seeking election. Consequently, innovative strategies to prevent HIV in MSM must not only be tailored to the context but must be adequately scaled-to-need . The unprecedented expansion of mobile technologies, especially in emerging economies, as well as their potential application to reach groups who are not accessible using venue-based strategies, has opened new frontiers, including mHealth strategies, to promote personal healthcare engagement, including optimized prevention and treatment . The extent to which MSM, especially high-risk MSM in Malaysia use smartphones and the internet, however, is unknown and assessment of their use and interest in using smartphones to access prevention information might provide new insights into reaching this hidden population in Malaysia. Specifically, there has not been an empirical study on the use of mHealth technology to seek sexual health information among Malaysia MSM. Understanding the characteristics of technology users will help us develop appropriate interventions for MSM who use smartphone technology to seek online HIV/sexually transmitted infection information. Therefore, we analyzed data from an online study among Malaysian MSM assessing HIV testing to investigate the characteristics of smartphone users and the use of a smartphone to seek online sexual health information, including HIV/STI. --- Methods --- Study Design and Participants A cross-sectional study assessing HIV testing practices among MSM in Malaysia was conducted from July to November 2017. Inclusion criteria were: i) 18 years or older; ii) identifies as male; iii) Malaysian citizen; iv) reporting recent condomless anal sex with another man; and v)) able to read and understand English or Bahasa Malaysia. --- Study Procedures A convenience sample of MSM was recruited via advertisements on Grindr, the most commonly used social networking apps that MSM use, by providing banner promoting the survey. Interested app users who clicked on advertisements were directed to an eligibility screener hosted by RedCap . Each eligible participants voluntarily completed an online consent form by acknowledging that they understood the purpose, risks, and benefits of the study prior to completing the survey. On average, participants took 15-20 minutes to complete the anonymous online survey. The questionnaire was available in both English and Malay languages and was translated and back-translated to ensure culture meaning . No payments were made for completing the surveys. The primary study was approved by the Medical Ethics Committee of the University of Malaya. --- Measures Participant characteristics included age, ethnicity, educational status , household status, employment status, disclosure of sexual orientation to family or friends, and self-reported history of HIV testing practices and current HIV status. Sexual risk behaviors included the age of sexual debut, sex with regular and casual sex partners, serostatus of sex partners, consistent condom use, engagement in group sex, commercial sex and 'chemsex', and the use of alcohol before or during sex in a lifetime. Chemsex was defined as the use of a psychoactive substance before or during anal intercourse . Perceived social support was measured by a 12-item short version of the original 24-items Social Provisions Scale, which assesses the perceived availability of tangible, informational, emotional, and esteem support . The overall score was obtained by summing responses to all items with higher scores indicating higher perceived social support . Depressive symptoms over the previous week were assessed using the 20-item Center for Epidemiological Studies Depression scale . The total sum score ranges from 0-60, with standard cut-offs of >16 associated with moderate to severe depression . Interpersonal violence was assessed by asking the participants whether have been the victim of IPV in lifetime, including if they had been 'hurt, hit, or slapped by a steady or casual partner', 'being forced by a steady or casual partner to have sex', 'being forced by a person who is not a steady or casual partner to have sex', or 'being fondled or forced into unwanted sexual touching '. Lifetime IPV was indicated by a positive answer to any of the above items. --- Smartphone access or use: Participants were asked about their access to a smartphone and the utilization of the internet on a smartphone for various activities . Participants were further asked about their use of various social networking apps as well as geosocial networking apps commonly used by MSM on their phone. They were also asked if they used a smartphone to seek sexual health information online, including HIV and STIs. --- Data Analysis Analyses were performed using SPSS 23.0. The primary outcome was smartphone use to seek sexual health information. Estimates were evaluated for statistical significance based on 95% confidence intervals using p<0.05. We computed descriptive statistics, including frequencies and percentages for categorical variables and means, standard deviations, and ranges for continuous variables. After conducting bivariate logistic analyses for significant associations with the primary outcome , we conducted parsimonious multivariate logistic regression analyses by including variables on bivariate associations significant at p<0.10. Collinearity between variables was assessed using the variance inflation factor . --- Results --- Participant Characteristics Table 1 provides summary data for the 622 MSM who provided complete data, most of whom were Malay , university graduates , currently employed , and reported to have disclosed their sexual orientation to family or friends. Overall, 239 participants had never tested for HIV, and 44.5% reported to have tested for HIV in the past 12 months. Of the total participants, 24.3% reported being HIV positive, and 60.8% met screening criteria for having moderate to severe depression. In terms of sexual behaviors, 43.2% of participants reported having a regular sex partner in the past three months, with 7.4% of them being in an HIV serodiscordant relationship. Over two-thirds had casual sex partners, and over 45% have engaged in inconsistent condom use in the past three months. A minority reported having ever engaged in Chemsex, and 41% reported to have engaged in group sex. Interestingly, nearly all of the participants reported having ever used a GSN app to find sexual partners . --- Ownership of and utilization of Smartphone Figure 1 describes smartphone use characteristics. Nearly all participants reported owning a smartphone. Social networking apps , followed by general information searches and communication with friends and family were the most common reasons for using the internet on a smartphone. Almost two-thirds of participants reported smartphone use to search for information on sexual health, including HIV/STIs, and 28.8% for information search on finding clinic or healthcare providers. In terms of the use of social networking apps, the majority of the participants reported the current use of Facebook and Instagram . Similarly, the majority of participants used at least one GSN app to talk with or meet other men. Figure 2 shows GSN app use among participants who reported having ever used a GSN app. Grindr was the most commonly used app, followed by Blued , PlanetRomeo , and Jack'd ; increased use of Grindr may be related to recruitment. --- Correlates of smartphone use to find sexual health information online Table 1 shows the bivariate correlates and odds ratio of sexual health information seeking through a smartphone. Of note, factors associated with using a smartphone to find sexual health information were being younger , a university graduate , having ever tested for HIV , having engaged in chemsex , and having sought sexual partners via an online app . In the multivariate logistic regression model, being a university graduate , having tested for HIV , and having met sexual partner via online GSN app were more likely to use a smartphone to seek sexual health information online. Meanwhile, older age were associated with lower use of a smartphone to search for sexual health information . --- Discussion To our knowledge, this is the first study to assess smartphone use in Malaysian MSM, a setting where MSM are stigmatized and discriminated against and consequently difficult to reach with effective HIV prevention. This study provides important insights into the use of smartphone technology by MSM in Malaysia, specifically to seek sexual health information online about HIV and STIs. Specifically, the use of a smartphone to find online sexual health information, including information on HIV and STIs, was a common practice among this sample. This finding is similar to that observed among MSM in Hanoi, Vietnam . Our results further suggest the prevalent use of social networking apps to socialize and find sex partners among our sample -not surprising since MSM were recruited in part from GSN apps. This is much higher than those reported with MSM elsewhere . This finding is particularly important in the Malaysian context where there are limited physical venues for MSM to meet face-to-face, socialize and even to seek healthcare since homosexuality is illegal -a consequence of the increasingly hostile socio-political environment facing LGBT people in Malaysia. With a large proportion of Malaysian MSM utilizing smartphones to seek sexual partners and sexual health information, prevention programs need to be tailored to these contexts that increase the use of anonymous interfaces and reduce "in person" interventions. Though reported previously , MSM in our sample also faced several vulnerabilities to HIV, including inconsistent condom use during sex and engagement in commercial sex, chemsex, and group sex, but at higher levels than previously reported, supporting the evolving HIV epidemic in MSM. The large proportion of MSM at substantial risk for acquiring HIV infection and underutilization of available HIV prevention services, as evident in our sample, partly explain an increasing HIV incidence among MSM in Malaysia. These findings, thus, underscore the urgent need for enhanced primary prevention approaches aimed at more effectively and efficiently preventing HIV in this high-risk population. The findings that younger and more educated MSM were using a smartphone to search for sexual health information online may be reflective of the population subgroups who have better access to smartphones in general and as described in previous research. Prior research has indicated that adolescents and young adults represent the 'digital generation' and utilize the internet as a primary source of information gathering, communication, and social networking . With such widespread access, younger MSM have been found to heavily utilize smartphones to gain information on sex behavior, sexuality, and sexual health . Furthermore, it may be that men with higher education are more likely to have higher income, and that more affluent MSM are able to afford a smartphone as compared to their counterparts. These findings, along with the estimate that 35% of new infections in Malaysia occur among people 13-29 years of age , further emphasize the potential for smartphone-based interventions to reach the most vulnerable individuals. Our findings reveal that a high proportion of Malaysian MSM in the study had never been tested for HIV prior to the study representing a gap in scale-up of HIV testing services among this vulnerable group. This finding suggests the need for interventions to scale-up routine HIV testing among MSM, including the expansion of community-based testing services and at-home HIV testing kits, and innovative online testing programs . As for MSM who had been tested for HIV, testing services could have enhanced their awareness about HIV and motivation to search for online information on prevention and care. Since specific temporal information was not collected; however, it is also plausible that having been HIV tested resulted in online health information-seeking behavior. Nonetheless, the fact that MSM who had never been tested for HIV were less likely to seek sexual health information related to HIV/STI online indicates the need for research on integrating health information, especially information related to HIV/AIDS, into the GSN apps, which are frequently used by MSM in Malaysia. Our findings further revealed that the smartphone GSN apps are popular as a means for meeting sex partners among Malaysian MSM. This finding is consistent with previous studies, which investigated the role of GSN apps for meeting potential sex partners . Also, those who met a sexual partner via GSN apps were more likely to use a smartphone to search for HIV/STI information online. It is possible that individuals who seek sex partners online are making a rational judgment about their risk levels when considering whether to look for information on HIV/STI prevention and care online. Other possible reasons included their preference for online platforms via smartphone, instead of traditional venue-based approach, due to issues related to stigma and discrimination as discussed above. Regardless, our findings indicate the potential for the use of smartphone-based platforms to scale-up HIV prevention efforts among MSM in Malaysian settings. --- Future Implications While tremendous advances in HIV prevention and treatment have been achieved, these advances are still not reaching some of the most vulnerable populations. In Malaysia, the longstanding cultural and legal prohibitions of sex between men have further marginalized MSM and prevented them from accessing HIV prevention services [e.g., HIV testing, preexposure prophylaxis , HIV treatment as prevention ] due to issues related to stigma and discrimination. Our findings support the potential use of mHealth-based approaches, particularly smartphone-based apps, to promote HIV testing and deliver HIV interventions or to facilitate linkage to HIV prevention services among MSM in Malaysia. The existence of inadequate access to HIV prevention services , significant wait-time at existing clinics, stigma, and discrimination are more likely to dissuade MSM from seeking traditional venue-based HIV prevention services, especially if they have to discuss their sexual practices. Given the difficulties faced in targeting MSM to engage in traditional HIV prevention efforts, there may be opportunities via smartphonebased apps or via web-based approaches to facilitate HIV prevention efforts. For example, there are several smartphone app-based HIV prevention interventions in the United States aimed at improving both the HIV treatment cascade and PrEP clinical care among diverse patient populations. Future research should, therefore, focus on adapting/developing similar app-based approaches and conducting feasibility and acceptability trials among MSM in Malaysian contexts. --- Limitations Several limitations of this study need to be acknowledged. First, we used a convenience sample of MSM recruited via gay social media rather than a representative sample of all MSM in Malaysia. The online methodology used in our study may have excluded MSM without access to the Internet on which the study was advertised. Second, the use of self-reported measures in the current study may have resulted in participants inaccurate reporting of socially undesirable behaviors . Third, the use of cross-sectional study design limited our ability to make causal inferences. --- Conclusion Our study suggests high smartphone use by high-risk MSM to seek sexual health information. Smartphone use for seeking sexual health information is likely to increase in prevalence in the coming years among MSM in Malaysia, as it is currently common among younger age groups. These trends reinforce the potential value of engaging MSM in this setting through online smartphone-based interventions. The findings here suggest the need for further research to assess the feasibility and acceptability of smartphone-based interventions as part of overall HIV prevention efforts to address the HIV epidemic among this high-risk, underserved group. Use of different geosocial networking apps by the study participants Note: GSN: Geosocial networking ---

In settings where stigma and discrimination toward men who have sex with men (MSM) are high or illegal, like in Malaysia, innovative methods to anonymously reach them are urgently needed. The near ubiquitous availability of mobile technology, including smartphones, has the potential to open new frontiers (such as mHealth) to prevent HIV and other sexually transmitted infections (STIs). The extent to which MSM use mHealth tools for HIV and STI prevention in the Malaysia context, however, is unknown.A cross-sectional online survey in 622 Malaysian MSM was conducted between July and November 2017. Participants were recruited via advertisements on mobile apps frequently used by MSM. In addition to demographic, smartphone access and utilization, and other information were assessed using logistic regression to determine factors associated with the use of a smartphone to search for online sexual health information. Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. https://www.springer.com/aamterms-v1

introduction despite reductions in hiv incidence globally hiv transmission among men who have sex with men continues to increase markedly especially where sex between men remains highly stigmatized or illegal malaysia a middleincome country with low overall hiv prevalence has an evolving epidemic in msm with new hiv cases increasing from 10 in 2008 to 54 in 2016 biobehavioral surveys now suggest that hiv prevalence among msm is now at an alltime high of 216 and is concentrated in the countrys capital kuala lumpur where hiv prevalence among msm was 43 in 2018 up from 22 just four years before this growing epidemic among msm has been associated with condomless sex and concomitant use of drugs and alcohol in malaysia homosexuality is illegal in both secular and sharia law even when criminal sanctions are not enforced msm are highly stigmatized and often discriminated against consequently reaching msm in general and certainly those not identifying as gay has been especially challenging with hiv prevention services traditional outreach at venues where msm congregate has been challenging for example gay clubs are unviable option because of highly publicized police raids of such establishments with the press airing footage of msm being forced to submit to urine drug testing or even pronouncements against lesbian gay bisexual and transgender persons by leading governmental authorities including to smear leading public figures seeking election consequently innovative strategies to prevent hiv in msm must not only be tailored to the context but must be adequately scaledtoneed the unprecedented expansion of mobile technologies especially in emerging economies as well as their potential application to reach groups who are not accessible using venuebased strategies has opened new frontiers including mhealth strategies to promote personal healthcare engagement including optimized prevention and treatment the extent to which msm especially highrisk msm in malaysia use smartphones and the internet however is unknown and assessment of their use and interest in using smartphones to access prevention information might provide new insights into reaching this hidden population in malaysia specifically there has not been an empirical study on the use of mhealth technology to seek sexual health information among malaysia msm understanding the characteristics of technology users will help us develop appropriate interventions for msm who use smartphone technology to seek online hivsexually transmitted infection information therefore we analyzed data from an online study among malaysian msm assessing hiv testing to investigate the characteristics of smartphone users and the use of a smartphone to seek online sexual health information including hivsti methods study design and participants a crosssectional study assessing hiv testing practices among msm in malaysia was conducted from july to november 2017 inclusion criteria were i 18 years or older ii identifies as male iii malaysian citizen iv reporting recent condomless anal sex with another man and v able to read and understand english or bahasa malaysia study procedures a convenience sample of msm was recruited via advertisements on grindr the most commonly used social networking apps that msm use by providing banner promoting the survey interested app users who clicked on advertisements were directed to an eligibility screener hosted by redcap each eligible participants voluntarily completed an online consent form by acknowledging that they understood the purpose risks and benefits of the study prior to completing the survey on average participants took 1520 minutes to complete the anonymous online survey the questionnaire was available in both english and malay languages and was translated and backtranslated to ensure culture meaning no payments were made for completing the surveys the primary study was approved by the medical ethics committee of the university of malaya measures participant characteristics included age ethnicity educational status household status employment status disclosure of sexual orientation to family or friends and selfreported history of hiv testing practices and current hiv status sexual risk behaviors included the age of sexual debut sex with regular and casual sex partners serostatus of sex partners consistent condom use engagement in group sex commercial sex and chemsex and the use of alcohol before or during sex in a lifetime chemsex was defined as the use of a psychoactive substance before or during anal intercourse perceived social support was measured by a 12item short version of the original 24items social provisions scale which assesses the perceived availability of tangible informational emotional and esteem support the overall score was obtained by summing responses to all items with higher scores indicating higher perceived social support depressive symptoms over the previous week were assessed using the 20item center for epidemiological studies depression scale the total sum score ranges from 060 with standard cutoffs of 16 associated with moderate to severe depression interpersonal violence was assessed by asking the participants whether have been the victim of ipv in lifetime including if they had been hurt hit or slapped by a steady or casual partner being forced by a steady or casual partner to have sex being forced by a person who is not a steady or casual partner to have sex or being fondled or forced into unwanted sexual touching lifetime ipv was indicated by a positive answer to any of the above items smartphone access or use participants were asked about their access to a smartphone and the utilization of the internet on a smartphone for various activities participants were further asked about their use of various social networking apps as well as geosocial networking apps commonly used by msm on their phone they were also asked if they used a smartphone to seek sexual health information online including hiv and stis data analysis analyses were performed using spss 230 the primary outcome was smartphone use to seek sexual health information estimates were evaluated for statistical significance based on 95 confidence intervals using p 005 we computed descriptive statistics including frequencies and percentages for categorical variables and means standard deviations and ranges for continuous variables after conducting bivariate logistic analyses for significant associations with the primary outcome we conducted parsimonious multivariate logistic regression analyses by including variables on bivariate associations significant at p 010 collinearity between variables was assessed using the variance inflation factor results participant characteristics table 1 provides summary data for the 622 msm who provided complete data most of whom were malay university graduates currently employed and reported to have disclosed their sexual orientation to family or friends overall 239 participants had never tested for hiv and 445 reported to have tested for hiv in the past 12 months of the total participants 243 reported being hiv positive and 608 met screening criteria for having moderate to severe depression in terms of sexual behaviors 432 of participants reported having a regular sex partner in the past three months with 74 of them being in an hiv serodiscordant relationship over twothirds had casual sex partners and over 45 have engaged in inconsistent condom use in the past three months a minority reported having ever engaged in chemsex and 41 reported to have engaged in group sex interestingly nearly all of the participants reported having ever used a gsn app to find sexual partners ownership of and utilization of smartphone figure 1 describes smartphone use characteristics nearly all participants reported owning a smartphone social networking apps followed by general information searches and communication with friends and family were the most common reasons for using the internet on a smartphone almost twothirds of participants reported smartphone use to search for information on sexual health including hivstis and 288 for information search on finding clinic or healthcare providers in terms of the use of social networking apps the majority of the participants reported the current use of facebook and instagram similarly the majority of participants used at least one gsn app to talk with or meet other men figure 2 shows gsn app use among participants who reported having ever used a gsn app grindr was the most commonly used app followed by blued planetromeo and jackd increased use of grindr may be related to recruitment correlates of smartphone use to find sexual health information online table 1 shows the bivariate correlates and odds ratio of sexual health information seeking through a smartphone of note factors associated with using a smartphone to find sexual health information were being younger a university graduate having ever tested for hiv having engaged in chemsex and having sought sexual partners via an online app in the multivariate logistic regression model being a university graduate having tested for hiv and having met sexual partner via online gsn app were more likely to use a smartphone to seek sexual health information online meanwhile older age were associated with lower use of a smartphone to search for sexual health information discussion to our knowledge this is the first study to assess smartphone use in malaysian msm a setting where msm are stigmatized and discriminated against and consequently difficult to reach with effective hiv prevention this study provides important insights into the use of smartphone technology by msm in malaysia specifically to seek sexual health information online about hiv and stis specifically the use of a smartphone to find online sexual health information including information on hiv and stis was a common practice among this sample this finding is similar to that observed among msm in hanoi vietnam our results further suggest the prevalent use of social networking apps to socialize and find sex partners among our sample not surprising since msm were recruited in part from gsn apps this is much higher than those reported with msm elsewhere this finding is particularly important in the malaysian context where there are limited physical venues for msm to meet facetoface socialize and even to seek healthcare since homosexuality is illegal a consequence of the increasingly hostile sociopolitical environment facing lgbt people in malaysia with a large proportion of malaysian msm utilizing smartphones to seek sexual partners and sexual health information prevention programs need to be tailored to these contexts that increase the use of anonymous interfaces and reduce in person interventions though reported previously msm in our sample also faced several vulnerabilities to hiv including inconsistent condom use during sex and engagement in commercial sex chemsex and group sex but at higher levels than previously reported supporting the evolving hiv epidemic in msm the large proportion of msm at substantial risk for acquiring hiv infection and underutilization of available hiv prevention services as evident in our sample partly explain an increasing hiv incidence among msm in malaysia these findings thus underscore the urgent need for enhanced primary prevention approaches aimed at more effectively and efficiently preventing hiv in this highrisk population the findings that younger and more educated msm were using a smartphone to search for sexual health information online may be reflective of the population subgroups who have better access to smartphones in general and as described in previous research prior research has indicated that adolescents and young adults represent the digital generation and utilize the internet as a primary source of information gathering communication and social networking with such widespread access younger msm have been found to heavily utilize smartphones to gain information on sex behavior sexuality and sexual health furthermore it may be that men with higher education are more likely to have higher income and that more affluent msm are able to afford a smartphone as compared to their counterparts these findings along with the estimate that 35 of new infections in malaysia occur among people 1329 years of age further emphasize the potential for smartphonebased interventions to reach the most vulnerable individuals our findings reveal that a high proportion of malaysian msm in the study had never been tested for hiv prior to the study representing a gap in scaleup of hiv testing services among this vulnerable group this finding suggests the need for interventions to scaleup routine hiv testing among msm including the expansion of communitybased testing services and athome hiv testing kits and innovative online testing programs as for msm who had been tested for hiv testing services could have enhanced their awareness about hiv and motivation to search for online information on prevention and care since specific temporal information was not collected however it is also plausible that having been hiv tested resulted in online health informationseeking behavior nonetheless the fact that msm who had never been tested for hiv were less likely to seek sexual health information related to hivsti online indicates the need for research on integrating health information especially information related to hivaids into the gsn apps which are frequently used by msm in malaysia our findings further revealed that the smartphone gsn apps are popular as a means for meeting sex partners among malaysian msm this finding is consistent with previous studies which investigated the role of gsn apps for meeting potential sex partners also those who met a sexual partner via gsn apps were more likely to use a smartphone to search for hivsti information online it is possible that individuals who seek sex partners online are making a rational judgment about their risk levels when considering whether to look for information on hivsti prevention and care online other possible reasons included their preference for online platforms via smartphone instead of traditional venuebased approach due to issues related to stigma and discrimination as discussed above regardless our findings indicate the potential for the use of smartphonebased platforms to scaleup hiv prevention efforts among msm in malaysian settings future implications while tremendous advances in hiv prevention and treatment have been achieved these advances are still not reaching some of the most vulnerable populations in malaysia the longstanding cultural and legal prohibitions of sex between men have further marginalized msm and prevented them from accessing hiv prevention services eg hiv testing preexposure prophylaxis hiv treatment as prevention due to issues related to stigma and discrimination our findings support the potential use of mhealthbased approaches particularly smartphonebased apps to promote hiv testing and deliver hiv interventions or to facilitate linkage to hiv prevention services among msm in malaysia the existence of inadequate access to hiv prevention services significant waittime at existing clinics stigma and discrimination are more likely to dissuade msm from seeking traditional venuebased hiv prevention services especially if they have to discuss their sexual practices given the difficulties faced in targeting msm to engage in traditional hiv prevention efforts there may be opportunities via smartphonebased apps or via webbased approaches to facilitate hiv prevention efforts for example there are several smartphone appbased hiv prevention interventions in the united states aimed at improving both the hiv treatment cascade and prep clinical care among diverse patient populations future research should therefore focus on adaptingdeveloping similar appbased approaches and conducting feasibility and acceptability trials among msm in malaysian contexts limitations several limitations of this study need to be acknowledged first we used a convenience sample of msm recruited via gay social media rather than a representative sample of all msm in malaysia the online methodology used in our study may have excluded msm without access to the internet on which the study was advertised second the use of selfreported measures in the current study may have resulted in participants inaccurate reporting of socially undesirable behaviors third the use of crosssectional study design limited our ability to make causal inferences conclusion our study suggests high smartphone use by highrisk msm to seek sexual health information smartphone use for seeking sexual health information is likely to increase in prevalence in the coming years among msm in malaysia as it is currently common among younger age groups these trends reinforce the potential value of engaging msm in this setting through online smartphonebased interventions the findings here suggest the need for further research to assess the feasibility and acceptability of smartphonebased interventions as part of overall hiv prevention efforts to address the hiv epidemic among this highrisk underserved group use of different geosocial networking apps by the study participants note gsn geosocial networking

in settings where stigma and discrimination toward men who have sex with men msm are high or illegal like in malaysia innovative methods to anonymously reach them are urgently needed the near ubiquitous availability of mobile technology including smartphones has the potential to open new frontiers such as mhealth to prevent hiv and other sexually transmitted infections stis the extent to which msm use mhealth tools for hiv and sti prevention in the malaysia context however is unknowna crosssectional online survey in 622 malaysian msm was conducted between july and november 2017 participants were recruited via advertisements on mobile apps frequently used by msm in addition to demographic smartphone access and utilization and other information were assessed using logistic regression to determine factors associated with the use of a smartphone to search for online sexual health information terms of use and reuse academic research for noncommercial purposes see here for full terms

Introduction Many urban residents have few opportunities to interact with ecosystems and organisms, leading them to have little or no experience with nature [1]. Increasing evidence shows positive associations between nature contact and connectedness and a range of indicators, including psychological [2,3,4,5] and physical health indicators [6], environmentally-conscious behaviour, and support for nature conservation [7,8]. The engagement of urban residents with nature is therefore important in impacting urban liveability, and has implications for the conservation of biodiversity at a global scale [9,8]. Urban residents spend most of their time within built-up areas, which are mainly dominated by built infrastructure. Outdoor natural and semi-natural spaces in cities-including parks, gardens, and remnant patches of forest or other natural ecosystems-are therefore important in providing spaces for human-nature interactions [10,11]. By providing spaces for recreation, education, gardening, and nature conservation, these urban outdoor spaces provide much-needed opportunities for urban dwellers to engage with nature [12,13]. Such engagement is largely beneficial, with benefits for health [14,15] and social cohesion [16,17]. In addition, people who spend more time in nature are likely to feel more closely related and connected to nature [18,8], hold positive attitudes towards the environment, and engage in environmentally-friendly behaviours [19,20]. While most research has focused on engagement with nature in public outdoor spaces, engagement with nature can also occur at home. For example, gardening at home is a source of pleasure and valuable connection to nature, especially for older residents [21]. Although urban living offers opportunities for various forms of contact with nature, not all urban residents have equal access to these opportunities [22,23,24,25]. Different demographic groups have different preferences for outdoor spaces, and can be more or less likely to engage in different types of activities [26,27,28]. Several studies have revealed disparities in access to urban outdoor space in relation to socio-economic status, education, ethnic background or age [29,30,31,32,33]. Furthermore, the location where people live can impact their ability to access outdoor spaces, with people having longer travel time to reach parks being less likely to visit them frequently [34,35]. At a cross-city scale, green cover shows a positive relationship with health outcomes in wealthier cities, but a negative relationship in less wealthy cities [36]. Unequal engagement with urban ecosystems has been highlighted as a global problem in the United Nations Sustainable Development Goals, which aim to secure universal access for urban residents to green space by 2030 [37]. Most of our knowledge about public engagement with urban ecosystems comes from cities in temperate climates [29,9], and much less is known about tropical Asia, where cultural attitudes and climatic factors are very different. There is some evidence that river corridors are popular for recreation amongst poorer communities in Indonesia [38], and urban parks are important spaces for recreation in Malaysia [39]. Conversely, students in Singapore have relatively limited contact with natural spaces, and it has been shown that the positive impact of outdoor space use on happiness does not hold among this group of respondents [40]. Singapore provides an interesting case study in which to investigate relationships between people and nature, due to its context as a highly-developed and high-density tropical Asian city. We conducted a survey of 1000 Singapore residents to analyse relationships between demographic factors and the frequency of visitation to different ecosystem types, and the frequency of engagement with different nature-related activities. --- Methods --- Study location and context Singapore is a highly urbanised island nation with a population of approximately 5.6 million residents [41] on a small land area of 714 km 2 . Despite its small land area and rapid urbanisation over the past 60 years [42], Singapore has pursued an ambitious greening strategy where about 50% of the land area is vegetated [43]. There are four nature reserves and over 350 parks [44], in addition to several hundred kilometres of linear open spaces or "park connectors", which connect major residential areas to various parks and nature areas [45]. --- Survey development and delivery The survey was conducted online from 4 to 15 September 2018 through the engagement of an online survey company . The approximate time to complete the survey was 20 minutes. Participants from across Singapore were randomly invited to participate in the survey. Only complete responses were counted and the survey remained open until a total of 1000 responses were collected. The survey company contacted members of the public who had previously agreed to join a general pool of participants. The survey fixed quotas for sex and age classes, targeting an equal number of respondents in each class . The quota for sex was met, giving equal representation of male and female respondents. However, it was not possible to obtain sufficient respondents for all age classes, with the older age classes under-represented . The survey methodology was reviewed and approved by the Ethics Committee of ETH Zu ¨rich , and all participants gave informed consent to participate in the study. The majority of the survey focused on understanding the respondents' engagement with nature-related activities and use of outdoor spaces. The frequency of visitation to outdoor spaces was quantified across a typology of eight outdoor space types, based on the common types of protected nature areas, public parks, and outdoor spaces built into housing developments [46,43] . The frequency of engagement with outdoor activities was queried for a typology of twelve outdoor activities . The list of outdoor activities was developed after collating lists used in previous studies [47,48] and editing for cultural and climatic relevance to Singapore. The lists of outdoor space types and activities were screened through a pilot study to establish a complete list of common activities. A six-point ordinal scale was used to describe the frequency of visitation and engagement . In addition, the survey collected demographic information from the respondents including the ethnicity, sex, age class, and personal income class, according to the format used by the Singapore Department of Statistics [41]. The postal code was also recorded. In Singapore, postal codes typically refer to apartment buildings, thus representing a spatial precision of finer than 500 m. --- Distance from outdoor space calculation The minimum Euclidean distance from the respondent's home location to each outdoor space type was calculated as an indicator of accessibility. Accessibility can be indicated by various metrics, such as self-reported travel time or distance, or path distance along the transport network [49,35]. However, such metrics are complicated by variable modes of transport, and Singapore is highly heterogeneous in this regard, with an efficient mass rail transport system and bus services supplemented by personal car ownership, walking and cycling, taxis and increasing uptake of electric personal mobility devices [50,51]. Euclidean distance is typically correlated with more complex spatial metrics such as road network distance [49]. This index represents a simple yet readily understandable measure of relative accessibility, in which people who live further from an outdoor space type are indicated as having less spatial access to it [49]. Data on the spatial extent of each outdoor space type were collected from a combination of government datasets and remote sensing of vegetation cover; the data used are mapped in Fig 1 . The spatial extent of publicly accessible park connectors, parks and nature reserves was extracted from the corresponding publicly-available spatial datasets , downloaded on the 2nd of February 2019 . Amongst the parks, neighbourhood parks were defined as those with "Playground" or "Outdoor space" in their name, and regional parks were defined as all other parks. The spatial extent of beaches was digitised by hand using high-resolution reference satellite imagery and ground-truthing. The spatial extent of natural areas other than nature reserves was defined by extracting all patches of unmanaged vegetation greater than 2 hectares in size from a national vegetation map [43]. The spatial extent of vacant turf plots was defined by extracting all patches of human-managed vegetation with no tree cover that were larger than 2 hectares, from the national vegetation map [43]. --- Statistical analysis Self-reported frequency of visitation to outdoor spaces and frequency of involvement in nature-related activities were recorded as ordinal data, and were modelled using cumulative link models as implemented in the "ordinal" package for R [52,53]. CLMs model ordinal data explicitly by estimating the probability of each class in relation to the preceding class on the ordinal scale, while simultaneously modelling the influence of explanatory variables in driving responses that are higher or lower on the ordinal scale [53]. Separate CLMs were made for each type of outdoor space and nature-related activity. The same candidate explanatory variables were used for each model-age class, sex, whether the individual had a bachelor's degree or higher, whether the respondent was currently in full-time employment, and personal income level. Age and income class were modelled as if continuous variables, by using the lowest value in the class bracket . The maximal models were simplified using a backwards stepwise procedure, using AIC as the simplification criterion [54]. --- Results --- Demographics The pool of respondents approximately represented the ethnic diversity of Singapore's population, with 73% stating they were Chinese, 11% Malay, 7% Indian, and 9% other races. The distribution of ethnicity of respondents was not significantly different from the 2010 census values . The survey was not significantly different from the 2010 census in terms of sex, with 50% of respondents responding as male and 50% as female . The age distribution of the respondents was significantly different from the census . Older participants were under-represented, with only 9% of respondents being above the age of 50 . However, approximately Locations of outdoor space types, and respondents' home locations, in Singapore. The spatial extent of publicly accessible park connectors, parks and nature reserves was extracted from publicly-available spatial datasets . The location of beaches was digitised by hand using high-resolution reference satellite imagery and ground-truthing. The spatial extent of natural areas and turf areas was extracted from a national vegetation map [43]. Inset shows Singapore in Southeast Asia. https://doi.org/10.1371/journal.pone.0231576.g001 equal numbers of respondents were found for the categories below 45, and at least 50 respondents were reached in each category below 65 . Of the 1000 participants, 121 chose not to reveal their personal income level, leaving 879 participants with all data available for statistical modelling. The income distribution of the respondents was significantly different from the 2010 census , although incomes may have changed substantially between 2010 and 2019. In interpreting the results, it is worth noting a significant association between income and higher education, with degree holders generally having higher personal incomes . --- Visitation to outdoor spaces in Singapore In general, visitation rates to natural and semi-natural outdoor spaces were relatively low, with more than half of respondents visiting a nature reserve or other natural space only once a year at most . Rates were slightly higher in more heavily managed natural spaces, and around half of respondents stated that they visited neighbourhood parks and park connectors at least once a month . The relationships between visitation frequency and personal characteristics were similar across all ecosystem types . People with higher personal incomes were significantly more frequent visitors to all types of outdoor spaces , while degree holders were significantly more frequent visitors to all types of outdoor spaces except beaches . Male respondents were significantly more frequent visitors to vacant turf plots and non-nature reserve natural areas . Age had a significant negative impact on frequency of visitation to all types of outdoor spaces except park connectors, and those in full-time employment were significantly less frequent visitors to park connectors, vacant turf plots, and non-reserve natural areas . Distance from the closest outdoor space was not a significant predictor of frequency of visitation to most types of outdoor space, with the exception of nature reserves . The frequency of visitation to nature reserves declined significantly for people who lived further from them . --- Engagement in nature-related activities in Singapore There was substantial variation in the frequency of engagement with different nature-related activities . Some activities were relatively common; more than 50% of people said that they sit outdoors and go running more than once every month . Other relatively frequent activities were field sports and art or photography . Activities that typically take place in more natural ecosystems, such as nature recreation, nature conservation, and hiking, The relationships between engagement frequency and personal characteristics were similar across all types of nature-related activity . People with higher personal incomes partook more frequently than average in all forms of nature-related activity other group , while degree holders were significantly more likely to engage in running and hiking . Male respondents took part significantly more frequently in field sports, running, hiking, water sports, cycling, and nature conservation . Older people were less likely than average to pursue all activities apart from gardening . People in full-time employment were significantly less likely to engage in field sports . --- Discussion --- Relative visitation to different outdoor spaces and engagement with nature-related activities Nature reserves and other natural areas were visited less frequently than local neighbourhood parks, open spaces and park connectors. A difference in the frequency of visits to outdoor spaces may be due to the perceived attractiveness and ease of access to these outdoor spaces [56]. The attractiveness of an outdoor space is increased if the environment is comfortable and the visitor feels safe [56], and less comfortable thermal conditions have been previously reported as a factor in reducing outdoor space use in other tropical cities [57,39]. While the high air temperature and humidity present across Singapore may discourage people using all open spaces [58], the differences between types of urban green space may not be substantial Estimated coefficients and significance are first indicated, followed by the standard error of the coefficient estimate in parentheses. Increasing numbers of asterix indicate significance at the p < 0.05, p < 0.01, and p< 0.001 levels respectively. https://doi.org/10.1371/journal.pone.0231576.t004 enough to cause major variation in attractiveness [59]. Moreover, there is evidence that people can adapt to Singapore's challenging thermal conditions [60]. Factors other than thermal comfort may thus be more important in determining site attractiveness. The feeling of personal safety is important in determining the attractiveness of a location [61,62], with fears of wildlife and crime listed as reasons for not visiting outdoor spaces in Singapore in an earlier study [63]. Wildlife is more likely to be encountered in the less manicured nature reserves and natural areas [64], and fears of criminal activity associated with forest [61,65]. Therefore, perceptions of danger may partially explain the reduced visitation of the more natural areas included in this study. Finally, the attractiveness of an outdoor space depends partly on the activities which are available to be conducted there. Popular activities such as running and cycling can be conducted in both natural and managed outdoor spaces, while sitting may be more comfortable in suitably managed outdoor spaces that have seating or turf grass available. On the other hand, as nature reserves are ecologically sensitive areas protected by legislation in Singapore, possible activities are limited to mainly hiking, nature recreation, art, and photography. Selection for outdoor spaces that allow particular activities may therefore also contribute to the higher visitation frequency of local neighbourhood parks, open spaces and park connectors. The frequency of visitation to outdoor spaces is also affected by the effort required to travel to them, with shorter travel distances encouraging more frequent use [66,34,67]. Our results suggested that ease of access to neighbourhood parks, park connectors and open spaces may explain why these types of outdoor spaces were used more frequently . Conversely, the lower frequency of visitation to nature reserves may be due to further distances from home. Singapore is a small island city-state with a dense population and well-developed public transport network, making travel to all outdoor spaces relatively rapid and affordable [68]. Nonetheless, some of the more natural spaces are further from the main urban centres [69], while smaller parks and park connectors are tightly integrated within the planning of urban neighbourhoods [45,70,23]. Popular outdoor-related activities documented in this study included sitting, running, cycling, and art or photography. The choice of an individual to engage with a particular activity is highly personal, but people may be influenced by broader trends in society, and the relative opportunity to engage [56]. The benefits of exercise, including running and cycling, are publicised as part of government initiatives to improve public health in Singapore [71]. Photography is a popular pastime, particularly for the purpose of sharing on social media [72]. Similarly, sitting outside while chatting or sharing food is a common social activity for many people, particularly in areas of public housing with extensive outdoor space [73]. --- Variation in visitation and activities between people Younger people were more likely to visit most types of outdoor space, and more likely to engage in most types of nature-related activities . Wealthier and more educated people were more likely to visit several types of outdoor space and engage in many types of nature-related activities . Taken altogether, these results highlight that nature engagement is not uniformly distributed across Singapore's population, but that younger, wealthier, and more educated people are more likely to engage with nature. The findings of the present study are in partial agreement with work in other cities. For example, urban outdoor space use is commonly reported to be lower amongst older members of society [11,35], although outdoor spaces are important for recreation amongst the elderly in many cities [74,75,21]. Park use was reported to be higher amongst more educated residents in Brisbane, Australia [11], but lower amongst more educated residents in Beijing, China [35]. Perhaps more important than the patterns between individual aspects of nature engagement is the overall trend: previous studies have shown that different demographics groups have different preferences for outdoor spaces, and engage with nature in different ways [27,28]. In contrast, we found that the same groups were less likely to visit most types of outdoor space and engage in most types of nature-related activities. Age did not have a significant positive effect on any of the response variables recorded in this study, just as education and income did not have any negative effects. These findings suggest a general lack of engagement with nature among the elderly, the less wealthy, and the less educated. The age range of most respondents in this study was between 18 and 50, meaning that most respondents were of working age. Over this range, it is possible that older respondents had less time available for visits to outdoor space or engagement in nature-related activities, due to considerable work and family commitments. A study from the UK found that 35-64 year olds were more likely than 16-34 year olds to cite being "too busy at work" as their reason for reduced visitation [76]. Income and degree levels were confounded in the dataset, meaning that we may consider these two variables as interchangeable when discussing the results. Greater wealth can increase the time that a person has to spend on outdoor activities, and fund travel or equipment [35]. Education can increase awareness of the benefits of outdoor activities, and support an interest in scientific learning that could be achieved by visiting outdoor spaces [77,78]. People with lower income and education levels may therefore have a lower experience of nature because it costs too much time or money, or because they are less aware of the possibilities and benefits of outdoor activities. --- Societal implications of low nature engagement and opportunities for improvement A growing body of research suggests that engagement with nature brings benefits to urban residents in terms of health and well-being [79,80,15], although the exact nature of these benefits varies according to the health risks that the population faces [81,82]. The use of urban green spaces may strengthen social connectedness and community bonds [16,39,83], and increase people's likelihood of engaging in environmentally-conscious behaviour [78,8]. Given the many benefits of outdoor space use for people, the limited engagement with nature in some sections of Singapore's population-notably older people, the less wealthy and the less educated-should be a matter for concern. There are two key approaches through which we can increase visitation to outdoor spaces and engagement in outdoor-related activities; by increasing motivations through education and public engagement programmes, and by making nature more accessible through urban design [84]. Educating people about the benefits of visiting outdoor spaces can help encourage increased visitation [85,86]. Such education can be done through school, university, and professional programmes [87,88], and also through advertising and public engagement campaigns [89,90]. Urban planning can increase accessibility to outdoor spaces in order to facilitate visits [91]. Accessibility can be enhanced either through creation of local outdoor spaces that are equitably located in different neighbourhoods [33], by creating new entrance points or tackling barriers in the surrounding area, or by improving transport links to ensure that the financial and time costs of visitation are reduced [30,11]. Singapore already aims to provide comprehensive access to outdoor spaces such as neighbourhood parks and park connector pathways across the city [45,23]. However these types of outdoor spaces are typically more manicured and provide few opportunities to interact with biodiversity or engage in pursuits such as hiking or nature recreation [46]. While Singapore's public transport network makes most areas highly accessible [68], some of the nature reserves are more difficult to access at certain times without the use of taxis or private transport. To build engagement with these more remote and natural outdoor spaces, transportation links could be enhanced to make it easier and cheaper to visit these types of outdoor space, for example through setting up shuttle bus services from the urban core. While public visitation to outdoor spaces is widely beneficial for people, it is not without associated impacts for wildlife and environmental quality [92,93]. High visitor pressure has resulted in temporary nature reserve closures in Singapore in recent years [94], so the low current visitation rates reported in this study may be desirable to reduce further harm. In landconstrained urban nations like Singapore, it is critical to successfully balance space for people and nature. Future research could analyse the visitor carrying capacity of Singapore's nature reserves, to establish a sustainable level of visitation that would maximise opportunities for people to experience nature while minimising environmental damage. This study has shown unequal visitation to outdoor spaces and engagement with naturerelated activities across demographic groups, giving rise to a potential inequity in experiences of nature. This inequity may translate to inequities in health and well-being, although the mechanisms through which outdoor space use, of varying time spent in nature and quality, impacts health outcomes are still unclear, and require further research [95,96,97,98]. --- Conclusions Older, less educated, and less wealthy people living in Singapore are less actively engaged with urban nature. This inequity in nature engagement is not restricted to certain types of outdoor space or activities, but appears to be universal. Low levels of engagement with nature correspond to an 'extinction' of nature-based experiences [1], with potential negative impacts for health, well-being, and environmental awareness [8]. To increase engagement with nature amongst older, less educated, and less wealthy people, Singapore and other tropical cities could first seek to make it more convenient and accessible for people to visit outdoor spaces and enjoy nature-related activities through planning and design [84]. Second, public outreach and education programmes could help to make the many benefits of nature engagement more apparent to urban residents [85,86]. --- Data are available on Figshare, DOI: 10.6084/m9.figshare.11889405. --- Supporting information --- S1 Appendix. ---

Urban residents can benefit from spending time in outdoor spaces and engaging with nature-related activities. Such engagement can improve health and well-being, support community cohesion, and improve environmentally-friendly behaviours. However, engagement with nature may not be equal amongst different members of society. We investigated individual variation in engagement with nature in Singapore, a high-density city in tropical Southeast Asia. Through a survey of 1000 residents, we analysed relationships between demographic factors such as age, income, and sex, and the frequency of visitation to different ecosystem types, and the frequency of engagement with different nature-related activities. Parks and neighbourhood open spaces were among the most commonly-visited outdoor spaces, with nature reserves and other natural areas being visited less frequently. Common activities included sitting outdoors, art and photography, and running, while hiking and nature recreation were less frequent. In contrast with previous studies, we found relatively small differences among different groups of the population in their preferred types of outdoor activities. Older people, those with lower incomes, and without degrees were less likely to visit most types of outdoor space and engage with most types of nature-related activities. In the case of nature reserves, the distance from the visitor's home had a significantly negative influence on the frequency of visitation. These findings demonstrate that the benefits of engagement with nature are not equally enjoyed by all demographic groups, and that some groups lack engagement across the board. Strategies to increase nature engagement in tropical cities could include increasing the local availability and accessibility of different types of outdoor space, and education and public outreach programmes to encourage participation.

introduction many urban residents have few opportunities to interact with ecosystems and organisms leading them to have little or no experience with nature 1 increasing evidence shows positive associations between nature contact and connectedness and a range of indicators including psychological 2345 and physical health indicators 6 environmentallyconscious behaviour and support for nature conservation 78 the engagement of urban residents with nature is therefore important in impacting urban liveability and has implications for the conservation of biodiversity at a global scale 98 urban residents spend most of their time within builtup areas which are mainly dominated by built infrastructure outdoor natural and seminatural spaces in citiesincluding parks gardens and remnant patches of forest or other natural ecosystemsare therefore important in providing spaces for humannature interactions 1011 by providing spaces for recreation education gardening and nature conservation these urban outdoor spaces provide muchneeded opportunities for urban dwellers to engage with nature 1213 such engagement is largely beneficial with benefits for health 1415 and social cohesion 1617 in addition people who spend more time in nature are likely to feel more closely related and connected to nature 188 hold positive attitudes towards the environment and engage in environmentallyfriendly behaviours 1920 while most research has focused on engagement with nature in public outdoor spaces engagement with nature can also occur at home for example gardening at home is a source of pleasure and valuable connection to nature especially for older residents 21 although urban living offers opportunities for various forms of contact with nature not all urban residents have equal access to these opportunities 22232425 different demographic groups have different preferences for outdoor spaces and can be more or less likely to engage in different types of activities 262728 several studies have revealed disparities in access to urban outdoor space in relation to socioeconomic status education ethnic background or age 2930313233 furthermore the location where people live can impact their ability to access outdoor spaces with people having longer travel time to reach parks being less likely to visit them frequently 3435 at a crosscity scale green cover shows a positive relationship with health outcomes in wealthier cities but a negative relationship in less wealthy cities 36 unequal engagement with urban ecosystems has been highlighted as a global problem in the united nations sustainable development goals which aim to secure universal access for urban residents to green space by 2030 37 most of our knowledge about public engagement with urban ecosystems comes from cities in temperate climates 299 and much less is known about tropical asia where cultural attitudes and climatic factors are very different there is some evidence that river corridors are popular for recreation amongst poorer communities in indonesia 38 and urban parks are important spaces for recreation in malaysia 39 conversely students in singapore have relatively limited contact with natural spaces and it has been shown that the positive impact of outdoor space use on happiness does not hold among this group of respondents 40 singapore provides an interesting case study in which to investigate relationships between people and nature due to its context as a highlydeveloped and highdensity tropical asian city we conducted a survey of 1000 singapore residents to analyse relationships between demographic factors and the frequency of visitation to different ecosystem types and the frequency of engagement with different naturerelated activities methods study location and context singapore is a highly urbanised island nation with a population of approximately 56 million residents 41 on a small land area of 714 km 2 despite its small land area and rapid urbanisation over the past 60 years 42 singapore has pursued an ambitious greening strategy where about 50 of the land area is vegetated 43 there are four nature reserves and over 350 parks 44 in addition to several hundred kilometres of linear open spaces or park connectors which connect major residential areas to various parks and nature areas 45 survey development and delivery the survey was conducted online from 4 to 15 september 2018 through the engagement of an online survey company the approximate time to complete the survey was 20 minutes participants from across singapore were randomly invited to participate in the survey only complete responses were counted and the survey remained open until a total of 1000 responses were collected the survey company contacted members of the public who had previously agreed to join a general pool of participants the survey fixed quotas for sex and age classes targeting an equal number of respondents in each class the quota for sex was met giving equal representation of male and female respondents however it was not possible to obtain sufficient respondents for all age classes with the older age classes underrepresented the survey methodology was reviewed and approved by the ethics committee of eth zu ¨rich and all participants gave informed consent to participate in the study the majority of the survey focused on understanding the respondents engagement with naturerelated activities and use of outdoor spaces the frequency of visitation to outdoor spaces was quantified across a typology of eight outdoor space types based on the common types of protected nature areas public parks and outdoor spaces built into housing developments 4643 the frequency of engagement with outdoor activities was queried for a typology of twelve outdoor activities the list of outdoor activities was developed after collating lists used in previous studies 4748 and editing for cultural and climatic relevance to singapore the lists of outdoor space types and activities were screened through a pilot study to establish a complete list of common activities a sixpoint ordinal scale was used to describe the frequency of visitation and engagement in addition the survey collected demographic information from the respondents including the ethnicity sex age class and personal income class according to the format used by the singapore department of statistics 41 the postal code was also recorded in singapore postal codes typically refer to apartment buildings thus representing a spatial precision of finer than 500 m distance from outdoor space calculation the minimum euclidean distance from the respondents home location to each outdoor space type was calculated as an indicator of accessibility accessibility can be indicated by various metrics such as selfreported travel time or distance or path distance along the transport network 4935 however such metrics are complicated by variable modes of transport and singapore is highly heterogeneous in this regard with an efficient mass rail transport system and bus services supplemented by personal car ownership walking and cycling taxis and increasing uptake of electric personal mobility devices 5051 euclidean distance is typically correlated with more complex spatial metrics such as road network distance 49 this index represents a simple yet readily understandable measure of relative accessibility in which people who live further from an outdoor space type are indicated as having less spatial access to it 49 data on the spatial extent of each outdoor space type were collected from a combination of government datasets and remote sensing of vegetation cover the data used are mapped in fig 1 the spatial extent of publicly accessible park connectors parks and nature reserves was extracted from the corresponding publiclyavailable spatial datasets downloaded on the 2nd of february 2019 amongst the parks neighbourhood parks were defined as those with playground or outdoor space in their name and regional parks were defined as all other parks the spatial extent of beaches was digitised by hand using highresolution reference satellite imagery and groundtruthing the spatial extent of natural areas other than nature reserves was defined by extracting all patches of unmanaged vegetation greater than 2 hectares in size from a national vegetation map 43 the spatial extent of vacant turf plots was defined by extracting all patches of humanmanaged vegetation with no tree cover that were larger than 2 hectares from the national vegetation map 43 statistical analysis selfreported frequency of visitation to outdoor spaces and frequency of involvement in naturerelated activities were recorded as ordinal data and were modelled using cumulative link models as implemented in the ordinal package for r 5253 clms model ordinal data explicitly by estimating the probability of each class in relation to the preceding class on the ordinal scale while simultaneously modelling the influence of explanatory variables in driving responses that are higher or lower on the ordinal scale 53 separate clms were made for each type of outdoor space and naturerelated activity the same candidate explanatory variables were used for each modelage class sex whether the individual had a bachelors degree or higher whether the respondent was currently in fulltime employment and personal income level age and income class were modelled as if continuous variables by using the lowest value in the class bracket the maximal models were simplified using a backwards stepwise procedure using aic as the simplification criterion 54 results demographics the pool of respondents approximately represented the ethnic diversity of singapores population with 73 stating they were chinese 11 malay 7 indian and 9 other races the distribution of ethnicity of respondents was not significantly different from the 2010 census values the survey was not significantly different from the 2010 census in terms of sex with 50 of respondents responding as male and 50 as female the age distribution of the respondents was significantly different from the census older participants were underrepresented with only 9 of respondents being above the age of 50 however approximately locations of outdoor space types and respondents home locations in singapore the spatial extent of publicly accessible park connectors parks and nature reserves was extracted from publiclyavailable spatial datasets the location of beaches was digitised by hand using highresolution reference satellite imagery and groundtruthing the spatial extent of natural areas and turf areas was extracted from a national vegetation map 43 inset shows singapore in southeast asia equal numbers of respondents were found for the categories below 45 and at least 50 respondents were reached in each category below 65 of the 1000 participants 121 chose not to reveal their personal income level leaving 879 participants with all data available for statistical modelling the income distribution of the respondents was significantly different from the 2010 census although incomes may have changed substantially between 2010 and 2019 in interpreting the results it is worth noting a significant association between income and higher education with degree holders generally having higher personal incomes visitation to outdoor spaces in singapore in general visitation rates to natural and seminatural outdoor spaces were relatively low with more than half of respondents visiting a nature reserve or other natural space only once a year at most rates were slightly higher in more heavily managed natural spaces and around half of respondents stated that they visited neighbourhood parks and park connectors at least once a month the relationships between visitation frequency and personal characteristics were similar across all ecosystem types people with higher personal incomes were significantly more frequent visitors to all types of outdoor spaces while degree holders were significantly more frequent visitors to all types of outdoor spaces except beaches male respondents were significantly more frequent visitors to vacant turf plots and nonnature reserve natural areas age had a significant negative impact on frequency of visitation to all types of outdoor spaces except park connectors and those in fulltime employment were significantly less frequent visitors to park connectors vacant turf plots and nonreserve natural areas distance from the closest outdoor space was not a significant predictor of frequency of visitation to most types of outdoor space with the exception of nature reserves the frequency of visitation to nature reserves declined significantly for people who lived further from them engagement in naturerelated activities in singapore there was substantial variation in the frequency of engagement with different naturerelated activities some activities were relatively common more than 50 of people said that they sit outdoors and go running more than once every month other relatively frequent activities were field sports and art or photography activities that typically take place in more natural ecosystems such as nature recreation nature conservation and hiking the relationships between engagement frequency and personal characteristics were similar across all types of naturerelated activity people with higher personal incomes partook more frequently than average in all forms of naturerelated activity other group while degree holders were significantly more likely to engage in running and hiking male respondents took part significantly more frequently in field sports running hiking water sports cycling and nature conservation older people were less likely than average to pursue all activities apart from gardening people in fulltime employment were significantly less likely to engage in field sports discussion relative visitation to different outdoor spaces and engagement with naturerelated activities nature reserves and other natural areas were visited less frequently than local neighbourhood parks open spaces and park connectors a difference in the frequency of visits to outdoor spaces may be due to the perceived attractiveness and ease of access to these outdoor spaces 56 the attractiveness of an outdoor space is increased if the environment is comfortable and the visitor feels safe 56 and less comfortable thermal conditions have been previously reported as a factor in reducing outdoor space use in other tropical cities 5739 while the high air temperature and humidity present across singapore may discourage people using all open spaces 58 the differences between types of urban green space may not be substantial estimated coefficients and significance are first indicated followed by the standard error of the coefficient estimate in parentheses increasing numbers of asterix indicate significance at the p 005 p 001 and p 0001 levels respectively enough to cause major variation in attractiveness 59 moreover there is evidence that people can adapt to singapores challenging thermal conditions 60 factors other than thermal comfort may thus be more important in determining site attractiveness the feeling of personal safety is important in determining the attractiveness of a location 6162 with fears of wildlife and crime listed as reasons for not visiting outdoor spaces in singapore in an earlier study 63 wildlife is more likely to be encountered in the less manicured nature reserves and natural areas 64 and fears of criminal activity associated with forest 6165 therefore perceptions of danger may partially explain the reduced visitation of the more natural areas included in this study finally the attractiveness of an outdoor space depends partly on the activities which are available to be conducted there popular activities such as running and cycling can be conducted in both natural and managed outdoor spaces while sitting may be more comfortable in suitably managed outdoor spaces that have seating or turf grass available on the other hand as nature reserves are ecologically sensitive areas protected by legislation in singapore possible activities are limited to mainly hiking nature recreation art and photography selection for outdoor spaces that allow particular activities may therefore also contribute to the higher visitation frequency of local neighbourhood parks open spaces and park connectors the frequency of visitation to outdoor spaces is also affected by the effort required to travel to them with shorter travel distances encouraging more frequent use 663467 our results suggested that ease of access to neighbourhood parks park connectors and open spaces may explain why these types of outdoor spaces were used more frequently conversely the lower frequency of visitation to nature reserves may be due to further distances from home singapore is a small island citystate with a dense population and welldeveloped public transport network making travel to all outdoor spaces relatively rapid and affordable 68 nonetheless some of the more natural spaces are further from the main urban centres 69 while smaller parks and park connectors are tightly integrated within the planning of urban neighbourhoods 457023 popular outdoorrelated activities documented in this study included sitting running cycling and art or photography the choice of an individual to engage with a particular activity is highly personal but people may be influenced by broader trends in society and the relative opportunity to engage 56 the benefits of exercise including running and cycling are publicised as part of government initiatives to improve public health in singapore 71 photography is a popular pastime particularly for the purpose of sharing on social media 72 similarly sitting outside while chatting or sharing food is a common social activity for many people particularly in areas of public housing with extensive outdoor space 73 variation in visitation and activities between people younger people were more likely to visit most types of outdoor space and more likely to engage in most types of naturerelated activities wealthier and more educated people were more likely to visit several types of outdoor space and engage in many types of naturerelated activities taken altogether these results highlight that nature engagement is not uniformly distributed across singapores population but that younger wealthier and more educated people are more likely to engage with nature the findings of the present study are in partial agreement with work in other cities for example urban outdoor space use is commonly reported to be lower amongst older members of society 1135 although outdoor spaces are important for recreation amongst the elderly in many cities 747521 park use was reported to be higher amongst more educated residents in brisbane australia 11 but lower amongst more educated residents in beijing china 35 perhaps more important than the patterns between individual aspects of nature engagement is the overall trend previous studies have shown that different demographics groups have different preferences for outdoor spaces and engage with nature in different ways 2728 in contrast we found that the same groups were less likely to visit most types of outdoor space and engage in most types of naturerelated activities age did not have a significant positive effect on any of the response variables recorded in this study just as education and income did not have any negative effects these findings suggest a general lack of engagement with nature among the elderly the less wealthy and the less educated the age range of most respondents in this study was between 18 and 50 meaning that most respondents were of working age over this range it is possible that older respondents had less time available for visits to outdoor space or engagement in naturerelated activities due to considerable work and family commitments a study from the uk found that 3564 year olds were more likely than 1634 year olds to cite being too busy at work as their reason for reduced visitation 76 income and degree levels were confounded in the dataset meaning that we may consider these two variables as interchangeable when discussing the results greater wealth can increase the time that a person has to spend on outdoor activities and fund travel or equipment 35 education can increase awareness of the benefits of outdoor activities and support an interest in scientific learning that could be achieved by visiting outdoor spaces 7778 people with lower income and education levels may therefore have a lower experience of nature because it costs too much time or money or because they are less aware of the possibilities and benefits of outdoor activities societal implications of low nature engagement and opportunities for improvement a growing body of research suggests that engagement with nature brings benefits to urban residents in terms of health and wellbeing 798015 although the exact nature of these benefits varies according to the health risks that the population faces 8182 the use of urban green spaces may strengthen social connectedness and community bonds 163983 and increase peoples likelihood of engaging in environmentallyconscious behaviour 788 given the many benefits of outdoor space use for people the limited engagement with nature in some sections of singapores populationnotably older people the less wealthy and the less educatedshould be a matter for concern there are two key approaches through which we can increase visitation to outdoor spaces and engagement in outdoorrelated activities by increasing motivations through education and public engagement programmes and by making nature more accessible through urban design 84 educating people about the benefits of visiting outdoor spaces can help encourage increased visitation 8586 such education can be done through school university and professional programmes 8788 and also through advertising and public engagement campaigns 8990 urban planning can increase accessibility to outdoor spaces in order to facilitate visits 91 accessibility can be enhanced either through creation of local outdoor spaces that are equitably located in different neighbourhoods 33 by creating new entrance points or tackling barriers in the surrounding area or by improving transport links to ensure that the financial and time costs of visitation are reduced 3011 singapore already aims to provide comprehensive access to outdoor spaces such as neighbourhood parks and park connector pathways across the city 4523 however these types of outdoor spaces are typically more manicured and provide few opportunities to interact with biodiversity or engage in pursuits such as hiking or nature recreation 46 while singapores public transport network makes most areas highly accessible 68 some of the nature reserves are more difficult to access at certain times without the use of taxis or private transport to build engagement with these more remote and natural outdoor spaces transportation links could be enhanced to make it easier and cheaper to visit these types of outdoor space for example through setting up shuttle bus services from the urban core while public visitation to outdoor spaces is widely beneficial for people it is not without associated impacts for wildlife and environmental quality 9293 high visitor pressure has resulted in temporary nature reserve closures in singapore in recent years 94 so the low current visitation rates reported in this study may be desirable to reduce further harm in landconstrained urban nations like singapore it is critical to successfully balance space for people and nature future research could analyse the visitor carrying capacity of singapores nature reserves to establish a sustainable level of visitation that would maximise opportunities for people to experience nature while minimising environmental damage this study has shown unequal visitation to outdoor spaces and engagement with naturerelated activities across demographic groups giving rise to a potential inequity in experiences of nature this inequity may translate to inequities in health and wellbeing although the mechanisms through which outdoor space use of varying time spent in nature and quality impacts health outcomes are still unclear and require further research 95969798 conclusions older less educated and less wealthy people living in singapore are less actively engaged with urban nature this inequity in nature engagement is not restricted to certain types of outdoor space or activities but appears to be universal low levels of engagement with nature correspond to an extinction of naturebased experiences 1 with potential negative impacts for health wellbeing and environmental awareness 8 to increase engagement with nature amongst older less educated and less wealthy people singapore and other tropical cities could first seek to make it more convenient and accessible for people to visit outdoor spaces and enjoy naturerelated activities through planning and design 84 second public outreach and education programmes could help to make the many benefits of nature engagement more apparent to urban residents 8586 data are available on figshare doi 106084m9figshare11889405 supporting information s1 appendix

urban residents can benefit from spending time in outdoor spaces and engaging with naturerelated activities such engagement can improve health and wellbeing support community cohesion and improve environmentallyfriendly behaviours however engagement with nature may not be equal amongst different members of society we investigated individual variation in engagement with nature in singapore a highdensity city in tropical southeast asia through a survey of 1000 residents we analysed relationships between demographic factors such as age income and sex and the frequency of visitation to different ecosystem types and the frequency of engagement with different naturerelated activities parks and neighbourhood open spaces were among the most commonlyvisited outdoor spaces with nature reserves and other natural areas being visited less frequently common activities included sitting outdoors art and photography and running while hiking and nature recreation were less frequent in contrast with previous studies we found relatively small differences among different groups of the population in their preferred types of outdoor activities older people those with lower incomes and without degrees were less likely to visit most types of outdoor space and engage with most types of naturerelated activities in the case of nature reserves the distance from the visitors home had a significantly negative influence on the frequency of visitation these findings demonstrate that the benefits of engagement with nature are not equally enjoyed by all demographic groups and that some groups lack engagement across the board strategies to increase nature engagement in tropical cities could include increasing the local availability and accessibility of different types of outdoor space and education and public outreach programmes to encourage participation

Background Domestic violence against women is a global burden occurring in endemic proportions and requires urgent action [1][2][3]. Domestic violence is also known as Intimate Partner Violence , or Family and Domestic Violence. While there is no one universal definition there are commonalities within each definition. These include physical, sexual, emotional and psychological abuse, and controlling behaviours [2,4]. For the purpose of this paper, the term 'domestic violence' or 'DV' will be used and is defined by the authors as an ongoing pattern of behaviour used to exert power and control to create fear of a current or previous intimate partner through physical, sexual, emotional or psychological abuse, controlling behaviours or a combination of two or more of these behaviours. A World Health Organisation report on studies across 10 countries revealed 13-61% of women had experienced physical violence by a partner; 6-59% reported sexual violence by a partner; and 20-75% reported experiencing one emotionally abusive act, or more, from a partner in their lifetime [2]. Similar statistics have emerged from Australian studies. According to the Australian Bureau of Statistics 16.9% of Australian women have experienced partner violence, specifically physical and sexual violence, since the age of 15 [4]. Furthermore, one in four Australian women have experienced emotional abuse by a partner since the age of 15 [5,6]. Pregnancy has been identified as both a potential protective factor and a risk factor for DV, and may be a trigger for violence beginning [7][8][9]. Australian studies have reported that 5-17% of Australian women experienced DV from an intimate partner for the first time when pregnant and the risk of DV is higher in both pregnancy and the period following birth [9,10]. Additionally, the World Health Organisation [2] reported that for 8-34% of women in abusive relationships, the violence became worse during pregnancy. There have been further reports that pregnancy is a period of high risk for DV occurring for the first time or escalating during this period [11][12][13]. As DV is rarely a one off episode, the violence against women may then continue through to the postnatal period [7][8][9]. Conversely, a cross-sectional study of 768 English-speaking women aged 18-64 years who presented to 2 emergency departments in Ontario, Canada, reported that pregnancy was not a significant risk factor for DV but that prenatal abuse was a predictor of periand post-natal abuse [14]. What is consistent in the literature is that the risk of negative consequences for women, the unborn foetus, and infants and children are high when DV occurs during pregnancy or the post-natal period [3,8,14,15]. Whether or not pregnancy and the post-natal period are considered risk factors for DV, these are the times in a woman's life when she will generally access a health care provider more frequently. Therefore, it is an opportune time for HCPs to undertake DV screening [15][16][17][18]. Screening for DV is described by the Australian Institute of Health and Welfare [9] as "a process to identify victims of violence or abuse in order to offer interventions that can lead to beneficial outcome" . The best method of screening for DV, and the benefits of universal screening, is debated. A number of formalised screening tools exist that can be used for DV screening, such as NSW Health Screening for DV tool, Abuse Assessment Screen , Violence against Women Screen, Index of Spouse Abuse, Danger Assessment Scale, and Conflicts Tactics Scale [17,19]. Support for formalised tools for DV screening exist with claims that such screening instruments can accurately identify women experiencing DV [20,21]. However, there is literature that has raised questions of the validity of some formal DV screening tools due to inadequate testing of such tools [17,22,23]. While the increase in identification of DV towards women from screening is not denied, there are questions as to the health benefits to women from such identification [3,14,24]. The World Health Organisation have recommended that, rather than implementing universal screening for DV, screening women who present with conditions that may be caused or complicated by DV is preferable, but only if such screening is also offered alongside appropriate post-screening action [18]. Other research also supports that DV screening is only beneficial if accompanied by interventions that can support the victim/s of the abuse [25,26]. Research to date indicates that women are not being routinely screened for DV by all HCPs [27,28]. The reluctance of HCPs to screen for DV is purported to be due to inadequate knowledge and training with DV screening tools and the belief that resources to support identified victims are inadequate [27,28]. Furthermore, HCPs' lack of DV screening has been identified as due to fear of offending patients, a lack of time and forgetting to routinely screen, a lack of patient privacy, workload issues, reluctance to see DV as a health issue, and HCPs' personal discomfort with DV [27][28][29]. GPs have also reported reluctance in initiating DV screening due to a lack of formal training and appropriate referral pathways in the event of a positive screen [28,29]. Midwives have a central role in the provision of maternity care to women which place them in a prime positon to screen for DV [30]. In addition to barriers described by other health professionals, midwives have reported barriers to screening to be the personal nature of the topic, negative ideas about victims of abuse, language barriers, and the woman's partner being present during care [30][31][32]. Consequently, international studies have highlighted that midwives feel inadequately prepared to support women who disclose DV [29,33]. Despite the reluctance of HCPs to screen for DV, research has found that women readily accept being asked about DV by HCPs [18,31,34]. Additionally, routine screening for DV has been recognised as an important identification and preventive method that allows the implementation of early intervention strategies for women exposed to DV [17,35,36]. In 2003, NSW Health released a DV policy that enforced mandatory routine DV screening of all women that attend public antenatal and early childhood services in NSW, Australia. This was followed by a directive that all public antenatal, early childhood health, drug and alcohol and mental health services introduce the NSW Health Domestic Violence Routine Screening Program [37]. The same policy highly recommended private and not-for profit community based health care services introduce routine DV screening into their practices [36]. Despite this, there are no universally accepted guidelines for, or consistent approaches to, health care provider practices in DV screening across NSW or Australia. The lack of consistency in the approach to DV screening practices across Australia may be attributed to each Australian State and Territory having their own Government structures. However, there have been numerous Australian government strategies developed to address DV against women; for example, 'Time for Action: The National Council's Plan for Australia to reduce Violence against Women and their Children, 2009-2021'; the Third Action Plan 2016-2019 of the National Plan to Reduce Violence against Women and their Children 2010-2022; and 'Stop the Violence, End the Silence' [38,39]. In an effort to seek consistency, significant policy, structures and investments by all stakeholders in DV prevention and intervention across Australian State and Territory Government bodies are coordinated by the Council of Australian Governments . Despite multiple strategies being implemented, under-reporting of DV persists and there is little known about the screening practices of community HCPs in NSW, Australia. The aim of this research was to explore DV screening practices of community based HCPs. --- Methods This paper presents the survey data from a mixed methods study and provides insights into the DV screening practices of community HCPs in one area of NSW, Australia. Prior to recruitment and data collection, the study was approved by Western Sydney University Human Research Ethics Committee . --- Sampling & Recruitment A convenience sample of community HCPs was recruited for this study. Inclusion criteria were that participants needed to be employed as a community HCP who provided care to pregnant or post-natal women in Western Sydney Local Health District. Specifically, participants were General Practitioners , private practice Midwives , and Registered Nurses either from Women's Health Care centres or General Practice Surgeries. This Local Health District was chosen due to the high prevalence of low income families, unemployment, low educational attainment, Aboriginal origin, women with disabilities and women from culturally and linguistically diverse backgrounds [40] which are all known DV related risk factors [41]. Initially, an introductory letter and an electronic link to the survey were distributed via an email list from a medical publishing company. Hard copies of surveys were also personally distributed by the research team to individual general practice clinics due to a poor response to the electronic survey. --- The survey The survey was developed by consulting published DV screening literature and experts. Face and content validity was gained by distributing the initial survey to a panel of 10 academics whom have expertise in survey development or who were still practicing clinically as RNs or midwives. Feedback was considered by the 2 authors and modifications were made prior to implementation in the study. The final survey was comprised of 20 fixed-choice questions. There were 11 questions that asked about DV screening practices and 9 demographic questions. Of the 11 questions that asked about screening practices, 5 of these questions asked for additional open-ended responses. Survey questions are shown in more detail in Additional file 1. --- Study design and data collection The larger study that the survey sits within was a sequential mixed methods study. Underpinning this sequential mixed method study was a pragmatic approach as the researchers used the methods of data collection and analysis that would best answer the research question [42,43]. Pragmatism as a research method aligns with empirical enquiry that allows for solving practical problems in the "real world" while being guided primarily by the researcher's desire to produce socially useful knowledge [44]. As such, it is well suited to understanding the social health issue of primary health care practitioners DV screening practices. The research question was "What are the practices of community based health care providers in screening peri-natal women for domestic violence?" The survey employed a descriptive design and integrated data from both fixed-choice and open response questions to provide greater context and insights into the DV screening practices of community HCPs. --- Data analysis Quantitative survey data were entered into the Statistical Package for Social Science and analysed using descriptive statistics. Frequencies and percentages of data obtained from the survey were determined. The open ended responses were grouped according to respective questions on the survey and were integrated with the descriptive quantitative results [45,46]. --- Results The survey was completed by 48 community based, non-government health care providers. Of the 48 respondents, 33 were GPs, two were PPMs, ten were RNs, and three did not indicate their specific profession. Fifteen of the respondents were men and 26 were women. Seven respondents did not answer the question on gender. Qualifications of respondents included PhD , Postgraduate degree , Royal Australian College of General Practitioners fellowship ; Bachelor's degree , Hospital certificate , Graduate certificate and Graduate diploma . Six respondents did not provide highest qualifications. Respondents had been qualified for between 1 and 52 years and most were employed on a full-time basis. As well as providing insights into their DV screening practices, respondents highlighted barriers to screening. --- Workplace policy and reminder systems When asked about the existence of workplace policies and reminder systems related to DV screening, 23 respondents indicated they were unsure whether policies existed, and 17 stated there were no policies. Only 7 reported that their workplace had a policy for DV screening and one respondent did not answer. Of the 48 respondents, only 3 reported having a reminder system for DV screening in their workplace, 27 reported no reminder system and 16 indicated they were unsure if reminder systems were in place. Two respondents did not answer this question. --- Screening practices Do you screen? Eighteen of the 48 respondents reported not screening for DV in the 6 months prior to completing the survey. While 28 reported screening for DV, 17 indicated they used general questioning rather than formalised DV screening tools. Nineteen reported having screened between 1 and 5 women, and only 9 participants had screened more than 5 women in the prior 6 months. See Table 1 for a breakdown of screening practices according to employment status of respondents. --- When do you screen? There were 23 open-ended responses related to when screening for DV was undertaken. Nine respondents reported they screened perinatal women for DV routinely. One participant screened all women on their first appointment and one reported "I screen everyone I see". The remaining respondents reported screening during the initial antenatal visit only, or both the antenatal and postnatal visits. Twelve respondents identified that they screened for DV when women presented with signs they considered to be 'red flags'. These 'red flags' included reports or observation of anxiety, depression or stress, signs of physical injury and information gained from the woman's medical history or personal account. One respondent reported they did not screen and another indicated they screened 'Opportunistically at check ups'. --- Barriers to screening Twenty-five participants provided a range of reasons for not screening for DV in the open responses. Among their reasons 4 respondents reported DV screening did not fall within their usual care practice stating "I don't routinely screen -only if there are questions around social support or mental health"; "Not part of usual practice but not against the idea" and "Not part of my routine screening". Six respondents indicated they believed someone else would screen with statements such as "I assumed they [women] were screened at booking in visit at hospital", "Most antenatal clinic screen for it and I refer all my patients to antenatal clinic" and "The doctors do it." Another reason identified by a number of respondents was that they felt the resources available to facilitate the DV screening process were inadequate. Resources required to support the HCP were identified as education on how to screen for DV and the availability of screening tools. This was evident in statements such as: "Not enough education"; "Insufficient screening tools" and "No preset screening tool. No education on how to". Relying on women to reveal they were experiencing DV was reported by 4 respondents. Statements that represented this reliance on women to divulge DV included: "High levels of violence in the community in which I work but generally women come forward when they want to change their situation"; "I would hope the patient would open up to me"; and "No patient has complained about Domestic Violence". Other respondents identified time constraints as a barrier to DV screening citing "Too much to get through in the screening", and "Time restrictionsbut always screen for depression". A further 3 responses indicated that DV screening was never considered during consultations. These respondents provided the following explanations: "Never thought about screening them", "Forgetfulness" and "I don't do it because I just don't think of it". Two respondents indicated they did not find training for DV screening useful because it was "Too brief", "Not detailed enough", and they "Can't specifically recall it". Two of the open responses indicated that respondents had not undertaken training as "Domestic violence is not prevalent in our practice", and DV was "Not really my area". --- Confidence The survey used a likert scale to measure respondents' confidence in undertaking DV screening. Response selections ranged from 'not at all confident' to 'very confident'. Only 12% of respondents who had not undergone training for DV screening were 'very confident' compared to 28% of respondents who reported having had training. Similarly 35% of respondents who had not undergone training for DV screening reported being 'not very confident' compared to 11% of respondents who had training in DV screening. There were 15 open responses that related to how confident the HCP's were in undertaking aspects of DV screening. One third of these responses alluded to them feeling concerned about what to do with a positive DV screen. For example, as some respondents explained "I am confident in asking [about DV] and assessing however unsure of what to do if the situation occurs"; "Unsure who to report to" and "Once DV is discovered, directing women to the appropriate services". A further 5 respondents expressed they were least confident in encouraging the women to divulge DV. Examples of quotes that represent this are: not confident in "Breaking the ice" and that it was a "Difficult subject for some patients to communicate about". Several respondents conveyed their lack of confidence in DV screening was due to not having adequate training and access to standardised procedures and screening tools. These concerns are represented in the following quotes where respondents indicated there was "No obvious protocol" and they required "A standardised screening scale" and "more training and skills not to miss any important information". The remaining respondent revealed a lack of confidence in screening for DV due to concern about the "Severity of stories heard". --- Finding evidence of DV and referral Additional to enquiring about screening practices, the survey also asked whether participants who had screened had found evidence of DV. Twenty-nine confirmed that they had and referred women to DV specific services. Although 18 respondents stated they had not found evidence of DV after screening, 8 of these reported they had referred a DV victim to DV specific services. A variety of options were provided on the survey for respondents to indicate which services they referred women to when DV was identified. Respondents could select more than one service. The most popular DV referral services reported by respondents were psychologists and counsellors , closely followed by women's refuges . Services less commonly referred to were police , community services , legal services and social workers . There were 16 open responses completed regarding the responses of the HCPs to a positive screen for DV. Most of these responses indicated the HCPs used multiple strategies to assist the women. These strategies included counselling the women , and referred them to specialist health care practitioners and women's refuges . Three respondents noted that they encouraged the women to contact police and 4 specifically mentioned that they ensured the women were safe. Two respondents mentioned follow up for the women. Other strategies included listening to the women and allowing them to vent and providing educative brochures. One respondent reported providing DV helpline information for a woman who stated she did not want assistance. --- Discussion This survey examined DV screening practices of community based HCPs, specifically GPs, PPMs and RNs, for pregnant and postnatal women. As well as highlighting practices of DV screening, findings from this study provided insights into barriers to such screening and the needs of HCPs in order to encourage DV screening and referral. While some responses from the survey add to existing knowledge of DV screening practices, barriers, and referral, there were some results that are not prominent in existing literature. Results from this study showed that just over half of respondents screened perinatal women for DV. This meant that 42% did not screen, which is consistent with literature that reports a large number of HCPs do not screen for DV [27][28][29]. Of particular note in this current study were those respondents who did screen for DV favoured a more generalised approach to DV screening rather than using formalised tools. This may be in part due to the fact that the validity of formalised screening tools is rarely tested [17,22,23]. Further testing of the reliability and validity of DV screening tools is necessary before HCPs can be expected to use such tools in their daily practices. Further investigation into the DV screening practices community HCPs choose is warranted and this will be explored in the interviews in the second phase of this study. Additional to the lack of validation of DV screening tools, there is some debate regarding the effectiveness of DV screening and its place in HCPs daily practices. However, there is consensus that perinatal women should be screened for DV as long as this is supported by appropriate interventions and resources for victims [22][23][24]34]. Further, research has highlighted the importance of training that assists HCPs with identifying signs and symptoms of DV and informs the referral of victims to effective services [22]. Results from the current study identified that many HCPs had not undertaken formalised training for DV screening and that they lacked confidence and knowledge in intervention and referral processes. Specifically, inadequate knowledge of supportive resources available for victims of DV, or the lack of such resources, was a barrier to respondents undertaking screening. This is an important finding and adds support to a growing body of evidence that DV screening should be accompanied by adequate referral resources [28,29,[47][48][49][50][51][52]. Results from this study identified additional barriers that are not widely reported in the literature. In particular, some HCPs did not perceive DV screening to be a part of routine care, while others presumed screening would be undertaken by someone else. There was also the assumption by some HCPs that women who were experiencing DV would self-disclose. Each of these barriers to screening warrants deeper exploration. Education is required to highlight how all HCPs can contribute to supporting and ensuring the safety of women and children experiencing DV. Further, the belief that women will self-disclose without being asked must be dispelled. As shown in previous research, women are unlikely to self-disclose DV unless asked directly and do find it acceptable for their HCP to ask about DV [18,31,34]. An important and under reported barrier to DV screening identified in this study was a lack of DV screening policy and reminder systems within the respondents' work places. This finding is disheartening given the multiple Australian Government strategies in place to support DV identification and intervention policies [38], and in particular the NSW Health DV policy [37]. Additionally, the WHO has issued guidelines to support policy-makers and those responsible for planning, funding and implementing health services and professional training in the areas of medicine, nursing and public health [18]. It is clear that policy implementation for DV screening and referral across all health care sectors needs to be reviewed. A number of the HCPs who participated in this study reported having experienced positive DV screening results. In these instances, referral was made predominantly to psychologists. Referral to any services is a better option than no referral at all; however, this as a common option raises the question of attitudes towards victims of DV needing mental health care as a priority over protection from the perpetrator. While counselling is identified as an appropriate intervention for victims of DV, HCPs must ensure the intervention and referral processes are immediate, holistic and individualized to the victim's needs [18,22,23,53]. Existing literature identifies that DV referral and intervention is multi-layered and must begin with immediate, first-line support that assesses further resources required for appropriate referral [18,22,23,53]. Obvious in the findings from this study is the need for education for HCPs that addresses individualised, holistic approaches to appropriate and timely intervention for the victim. --- Limitations Due to the small sample size, results from this study need to be interpreted with some caution. However, the study provided some new insights into the DV screening practices of community HCPs and some of the results are strongly supported by previous research. While this study has reported on overall screening practices and barriers to screening, it has not identified what facilitates community HCPs to conduct DV screening. A further limitation of the study may be the skew in favour of a higher number of GP respondents compared to RNs and PPMs. However, the ratios of the various disciplines were representative of the overall study population. --- Recommendations The pragmatic methodology resulted in findings that allow for the development and implementation of practical interventions to enhance DV screening practices. Previous research supports the need for all HCPs who provide care to pregnant and postnatal women to be well educated and trained in DV screening and appropriate referral [28,30,31,52]. The current study, like others, indicates this is not occurring despite recommendation by Government bodies and the WHO [18,37,38]. A recommendation from this study goes beyond stating there is a need for education and training for all HCPs who provide health care to women. The authors recommend that further research be undertaken to determine the best means of developing and delivering DV screening education and training to ensure it meets the needs of all multi-disciplinary HCPs. This is integral to ensure HCPs identify and provide appropriate support and referral for women and children experiencing DV. In NSW there are limited resources for training which means that existing services are stretched beyond their limits. This calls into question the level of commitment underpinning the Australian Government rhetoric in addressing integral aspects of DV including the educational requirements of the front line HCPs. Implementation of compulsory DV education into undergraduate curricula of health care disciplines is recommended. Further, to ensure contemporary, evidence based practices are adopted, mandatory education for DV screening for all practicing HCPs could be undertaken as a requirement of registration renewal. Such strategies however, require the support of both regulatory and Government bodies. Non-government organisations that provide health care to pregnant and postnatal women should have a mandatory DV screening policy in place that encompasses the best method for implementing DV screening. In NSW, Australia, mandatory screening by Government funded Area Health Services and a standardized screening tool already exists [19,36]; however, the uptake of such tools in community health care settings is limited. This may be due to a lack of awareness or disagreement with the approach of screening. It is recommended that current screening tools be adapted to the primary health care setting. Furthermore, a guide for referral practices for women who have a positive screening result is required to increase screening rates as well as provide appropriate support for women and children affected by DV. --- Conclusions Health care providers often face significant challenges in screening women who are pregnant or post-partum for DV. These challenges can stem from both internal and external sources. Regardless of the source of challenges, health care workers need to be supported and encouraged to undertake regular and suitable education and training for DV screening and referral when indicated, to ensure they are providing holistic and responsible care to their patients. Overcoming barriers to screening pregnant and postpartum women is crucial as the responsibility of care extends to unborn and living children. --- --- Additional file Additional file 1: Study survey of all fixed response and open ended questions. Abbreviations DV: Domestic violence; GP: General Practitioner; HCP: Health Care Provider; PPM: Privately Practicing Midwife; RN: Registered Nurse Authors' contributions Both authors of this manuscript, RO and KP, have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; been involved in drafting the manuscript or revising it critically for important intellectual content; given final approval of the version to be published; and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Domestic violence against women is a global endemic that can commence or escalate during pregnancy and continue postpartum. Pregnant and postpartum women generally access health care providers more at this time than at any other time in their lives. Despite this, little is known about primary health care providers' screening practices for domestic violence. The purpose of this paper is to present survey findings that identified domestic violence screening practices of community based health care providers in pregnant and postpartum women. Methods: This paper reports on the survey results of a larger sequential mixed methods study that involved a survey and semi-structured interviews, and used a pragmatic approach to the data collection and analysis. The survey sought information via both fixed choice and open responses. Quantitative data from the surveys were entered into the Statistical Package for Social Science (SPSS™ Version 22) and analysed using descriptive statistics. Open responses were collated and then integrated and presented with the quantitative data. Results: Results revealed that some health care providers did not screen for domestic violence. Factors contributing to this lack of screening included: a lack of recognition that this was part of their role; and a lack of domestic violence screening policies and/or reminder systems. Further barriers to domestic violence screening were identified as a lack of time, resources and confidence in undertaking the screening and referral of women when domestic violence was detected. Conclusions: The findings reported in this paper confirm that further insights into the domestic violence screening practices of community based health care providers is required. Findings also have the potential to inform interventions that can be implemented to increase domestic violence screening and promote appropriate referral practices.

background domestic violence against women is a global burden occurring in endemic proportions and requires urgent action 1 2 3 domestic violence is also known as intimate partner violence or family and domestic violence while there is no one universal definition there are commonalities within each definition these include physical sexual emotional and psychological abuse and controlling behaviours 24 for the purpose of this paper the term domestic violence or dv will be used and is defined by the authors as an ongoing pattern of behaviour used to exert power and control to create fear of a current or previous intimate partner through physical sexual emotional or psychological abuse controlling behaviours or a combination of two or more of these behaviours a world health organisation report on studies across 10 countries revealed 1361 of women had experienced physical violence by a partner 659 reported sexual violence by a partner and 2075 reported experiencing one emotionally abusive act or more from a partner in their lifetime 2 similar statistics have emerged from australian studies according to the australian bureau of statistics 169 of australian women have experienced partner violence specifically physical and sexual violence since the age of 15 4 furthermore one in four australian women have experienced emotional abuse by a partner since the age of 15 56 pregnancy has been identified as both a potential protective factor and a risk factor for dv and may be a trigger for violence beginning 7 8 9 australian studies have reported that 517 of australian women experienced dv from an intimate partner for the first time when pregnant and the risk of dv is higher in both pregnancy and the period following birth 910 additionally the world health organisation 2 reported that for 834 of women in abusive relationships the violence became worse during pregnancy there have been further reports that pregnancy is a period of high risk for dv occurring for the first time or escalating during this period 11 12 13 as dv is rarely a one off episode the violence against women may then continue through to the postnatal period 7 8 9 conversely a crosssectional study of 768 englishspeaking women aged 1864 years who presented to 2 emergency departments in ontario canada reported that pregnancy was not a significant risk factor for dv but that prenatal abuse was a predictor of periand postnatal abuse 14 what is consistent in the literature is that the risk of negative consequences for women the unborn foetus and infants and children are high when dv occurs during pregnancy or the postnatal period 381415 whether or not pregnancy and the postnatal period are considered risk factors for dv these are the times in a womans life when she will generally access a health care provider more frequently therefore it is an opportune time for hcps to undertake dv screening 15 16 17 18 screening for dv is described by the australian institute of health and welfare 9 as a process to identify victims of violence or abuse in order to offer interventions that can lead to beneficial outcome the best method of screening for dv and the benefits of universal screening is debated a number of formalised screening tools exist that can be used for dv screening such as nsw health screening for dv tool abuse assessment screen violence against women screen index of spouse abuse danger assessment scale and conflicts tactics scale 1719 support for formalised tools for dv screening exist with claims that such screening instruments can accurately identify women experiencing dv 2021 however there is literature that has raised questions of the validity of some formal dv screening tools due to inadequate testing of such tools 172223 while the increase in identification of dv towards women from screening is not denied there are questions as to the health benefits to women from such identification 31424 the world health organisation have recommended that rather than implementing universal screening for dv screening women who present with conditions that may be caused or complicated by dv is preferable but only if such screening is also offered alongside appropriate postscreening action 18 other research also supports that dv screening is only beneficial if accompanied by interventions that can support the victims of the abuse 2526 research to date indicates that women are not being routinely screened for dv by all hcps 2728 the reluctance of hcps to screen for dv is purported to be due to inadequate knowledge and training with dv screening tools and the belief that resources to support identified victims are inadequate 2728 furthermore hcps lack of dv screening has been identified as due to fear of offending patients a lack of time and forgetting to routinely screen a lack of patient privacy workload issues reluctance to see dv as a health issue and hcps personal discomfort with dv 27 28 29 gps have also reported reluctance in initiating dv screening due to a lack of formal training and appropriate referral pathways in the event of a positive screen 2829 midwives have a central role in the provision of maternity care to women which place them in a prime positon to screen for dv 30 in addition to barriers described by other health professionals midwives have reported barriers to screening to be the personal nature of the topic negative ideas about victims of abuse language barriers and the womans partner being present during care 30 31 32 consequently international studies have highlighted that midwives feel inadequately prepared to support women who disclose dv 2933 despite the reluctance of hcps to screen for dv research has found that women readily accept being asked about dv by hcps 183134 additionally routine screening for dv has been recognised as an important identification and preventive method that allows the implementation of early intervention strategies for women exposed to dv 173536 in 2003 nsw health released a dv policy that enforced mandatory routine dv screening of all women that attend public antenatal and early childhood services in nsw australia this was followed by a directive that all public antenatal early childhood health drug and alcohol and mental health services introduce the nsw health domestic violence routine screening program 37 the same policy highly recommended private and notfor profit community based health care services introduce routine dv screening into their practices 36 despite this there are no universally accepted guidelines for or consistent approaches to health care provider practices in dv screening across nsw or australia the lack of consistency in the approach to dv screening practices across australia may be attributed to each australian state and territory having their own government structures however there have been numerous australian government strategies developed to address dv against women for example time for action the national councils plan for australia to reduce violence against women and their children 20092021 the third action plan 20162019 of the national plan to reduce violence against women and their children 20102022 and stop the violence end the silence 3839 in an effort to seek consistency significant policy structures and investments by all stakeholders in dv prevention and intervention across australian state and territory government bodies are coordinated by the council of australian governments despite multiple strategies being implemented underreporting of dv persists and there is little known about the screening practices of community hcps in nsw australia the aim of this research was to explore dv screening practices of community based hcps methods this paper presents the survey data from a mixed methods study and provides insights into the dv screening practices of community hcps in one area of nsw australia prior to recruitment and data collection the study was approved by western sydney university human research ethics committee sampling recruitment a convenience sample of community hcps was recruited for this study inclusion criteria were that participants needed to be employed as a community hcp who provided care to pregnant or postnatal women in western sydney local health district specifically participants were general practitioners private practice midwives and registered nurses either from womens health care centres or general practice surgeries this local health district was chosen due to the high prevalence of low income families unemployment low educational attainment aboriginal origin women with disabilities and women from culturally and linguistically diverse backgrounds 40 which are all known dv related risk factors 41 initially an introductory letter and an electronic link to the survey were distributed via an email list from a medical publishing company hard copies of surveys were also personally distributed by the research team to individual general practice clinics due to a poor response to the electronic survey the survey the survey was developed by consulting published dv screening literature and experts face and content validity was gained by distributing the initial survey to a panel of 10 academics whom have expertise in survey development or who were still practicing clinically as rns or midwives feedback was considered by the 2 authors and modifications were made prior to implementation in the study the final survey was comprised of 20 fixedchoice questions there were 11 questions that asked about dv screening practices and 9 demographic questions of the 11 questions that asked about screening practices 5 of these questions asked for additional openended responses survey questions are shown in more detail in additional file 1 study design and data collection the larger study that the survey sits within was a sequential mixed methods study underpinning this sequential mixed method study was a pragmatic approach as the researchers used the methods of data collection and analysis that would best answer the research question 4243 pragmatism as a research method aligns with empirical enquiry that allows for solving practical problems in the real world while being guided primarily by the researchers desire to produce socially useful knowledge 44 as such it is well suited to understanding the social health issue of primary health care practitioners dv screening practices the research question was what are the practices of community based health care providers in screening perinatal women for domestic violence the survey employed a descriptive design and integrated data from both fixedchoice and open response questions to provide greater context and insights into the dv screening practices of community hcps data analysis quantitative survey data were entered into the statistical package for social science and analysed using descriptive statistics frequencies and percentages of data obtained from the survey were determined the open ended responses were grouped according to respective questions on the survey and were integrated with the descriptive quantitative results 4546 results the survey was completed by 48 community based nongovernment health care providers of the 48 respondents 33 were gps two were ppms ten were rns and three did not indicate their specific profession fifteen of the respondents were men and 26 were women seven respondents did not answer the question on gender qualifications of respondents included phd postgraduate degree royal australian college of general practitioners fellowship bachelors degree hospital certificate graduate certificate and graduate diploma six respondents did not provide highest qualifications respondents had been qualified for between 1 and 52 years and most were employed on a fulltime basis as well as providing insights into their dv screening practices respondents highlighted barriers to screening workplace policy and reminder systems when asked about the existence of workplace policies and reminder systems related to dv screening 23 respondents indicated they were unsure whether policies existed and 17 stated there were no policies only 7 reported that their workplace had a policy for dv screening and one respondent did not answer of the 48 respondents only 3 reported having a reminder system for dv screening in their workplace 27 reported no reminder system and 16 indicated they were unsure if reminder systems were in place two respondents did not answer this question screening practices do you screen eighteen of the 48 respondents reported not screening for dv in the 6 months prior to completing the survey while 28 reported screening for dv 17 indicated they used general questioning rather than formalised dv screening tools nineteen reported having screened between 1 and 5 women and only 9 participants had screened more than 5 women in the prior 6 months see table 1 for a breakdown of screening practices according to employment status of respondents when do you screen there were 23 openended responses related to when screening for dv was undertaken nine respondents reported they screened perinatal women for dv routinely one participant screened all women on their first appointment and one reported i screen everyone i see the remaining respondents reported screening during the initial antenatal visit only or both the antenatal and postnatal visits twelve respondents identified that they screened for dv when women presented with signs they considered to be red flags these red flags included reports or observation of anxiety depression or stress signs of physical injury and information gained from the womans medical history or personal account one respondent reported they did not screen and another indicated they screened opportunistically at check ups barriers to screening twentyfive participants provided a range of reasons for not screening for dv in the open responses among their reasons 4 respondents reported dv screening did not fall within their usual care practice stating i dont routinely screen only if there are questions around social support or mental health not part of usual practice but not against the idea and not part of my routine screening six respondents indicated they believed someone else would screen with statements such as i assumed they women were screened at booking in visit at hospital most antenatal clinic screen for it and i refer all my patients to antenatal clinic and the doctors do it another reason identified by a number of respondents was that they felt the resources available to facilitate the dv screening process were inadequate resources required to support the hcp were identified as education on how to screen for dv and the availability of screening tools this was evident in statements such as not enough education insufficient screening tools and no preset screening tool no education on how to relying on women to reveal they were experiencing dv was reported by 4 respondents statements that represented this reliance on women to divulge dv included high levels of violence in the community in which i work but generally women come forward when they want to change their situation i would hope the patient would open up to me and no patient has complained about domestic violence other respondents identified time constraints as a barrier to dv screening citing too much to get through in the screening and time restrictionsbut always screen for depression a further 3 responses indicated that dv screening was never considered during consultations these respondents provided the following explanations never thought about screening them forgetfulness and i dont do it because i just dont think of it two respondents indicated they did not find training for dv screening useful because it was too brief not detailed enough and they cant specifically recall it two of the open responses indicated that respondents had not undertaken training as domestic violence is not prevalent in our practice and dv was not really my area confidence the survey used a likert scale to measure respondents confidence in undertaking dv screening response selections ranged from not at all confident to very confident only 12 of respondents who had not undergone training for dv screening were very confident compared to 28 of respondents who reported having had training similarly 35 of respondents who had not undergone training for dv screening reported being not very confident compared to 11 of respondents who had training in dv screening there were 15 open responses that related to how confident the hcps were in undertaking aspects of dv screening one third of these responses alluded to them feeling concerned about what to do with a positive dv screen for example as some respondents explained i am confident in asking about dv and assessing however unsure of what to do if the situation occurs unsure who to report to and once dv is discovered directing women to the appropriate services a further 5 respondents expressed they were least confident in encouraging the women to divulge dv examples of quotes that represent this are not confident in breaking the ice and that it was a difficult subject for some patients to communicate about several respondents conveyed their lack of confidence in dv screening was due to not having adequate training and access to standardised procedures and screening tools these concerns are represented in the following quotes where respondents indicated there was no obvious protocol and they required a standardised screening scale and more training and skills not to miss any important information the remaining respondent revealed a lack of confidence in screening for dv due to concern about the severity of stories heard finding evidence of dv and referral additional to enquiring about screening practices the survey also asked whether participants who had screened had found evidence of dv twentynine confirmed that they had and referred women to dv specific services although 18 respondents stated they had not found evidence of dv after screening 8 of these reported they had referred a dv victim to dv specific services a variety of options were provided on the survey for respondents to indicate which services they referred women to when dv was identified respondents could select more than one service the most popular dv referral services reported by respondents were psychologists and counsellors closely followed by womens refuges services less commonly referred to were police community services legal services and social workers there were 16 open responses completed regarding the responses of the hcps to a positive screen for dv most of these responses indicated the hcps used multiple strategies to assist the women these strategies included counselling the women and referred them to specialist health care practitioners and womens refuges three respondents noted that they encouraged the women to contact police and 4 specifically mentioned that they ensured the women were safe two respondents mentioned follow up for the women other strategies included listening to the women and allowing them to vent and providing educative brochures one respondent reported providing dv helpline information for a woman who stated she did not want assistance discussion this survey examined dv screening practices of community based hcps specifically gps ppms and rns for pregnant and postnatal women as well as highlighting practices of dv screening findings from this study provided insights into barriers to such screening and the needs of hcps in order to encourage dv screening and referral while some responses from the survey add to existing knowledge of dv screening practices barriers and referral there were some results that are not prominent in existing literature results from this study showed that just over half of respondents screened perinatal women for dv this meant that 42 did not screen which is consistent with literature that reports a large number of hcps do not screen for dv 27 28 29 of particular note in this current study were those respondents who did screen for dv favoured a more generalised approach to dv screening rather than using formalised tools this may be in part due to the fact that the validity of formalised screening tools is rarely tested 172223 further testing of the reliability and validity of dv screening tools is necessary before hcps can be expected to use such tools in their daily practices further investigation into the dv screening practices community hcps choose is warranted and this will be explored in the interviews in the second phase of this study additional to the lack of validation of dv screening tools there is some debate regarding the effectiveness of dv screening and its place in hcps daily practices however there is consensus that perinatal women should be screened for dv as long as this is supported by appropriate interventions and resources for victims 22 23 24 34 further research has highlighted the importance of training that assists hcps with identifying signs and symptoms of dv and informs the referral of victims to effective services 22 results from the current study identified that many hcps had not undertaken formalised training for dv screening and that they lacked confidence and knowledge in intervention and referral processes specifically inadequate knowledge of supportive resources available for victims of dv or the lack of such resources was a barrier to respondents undertaking screening this is an important finding and adds support to a growing body of evidence that dv screening should be accompanied by adequate referral resources 2829 47 48 49 50 51 52 results from this study identified additional barriers that are not widely reported in the literature in particular some hcps did not perceive dv screening to be a part of routine care while others presumed screening would be undertaken by someone else there was also the assumption by some hcps that women who were experiencing dv would selfdisclose each of these barriers to screening warrants deeper exploration education is required to highlight how all hcps can contribute to supporting and ensuring the safety of women and children experiencing dv further the belief that women will selfdisclose without being asked must be dispelled as shown in previous research women are unlikely to selfdisclose dv unless asked directly and do find it acceptable for their hcp to ask about dv 183134 an important and under reported barrier to dv screening identified in this study was a lack of dv screening policy and reminder systems within the respondents work places this finding is disheartening given the multiple australian government strategies in place to support dv identification and intervention policies 38 and in particular the nsw health dv policy 37 additionally the who has issued guidelines to support policymakers and those responsible for planning funding and implementing health services and professional training in the areas of medicine nursing and public health 18 it is clear that policy implementation for dv screening and referral across all health care sectors needs to be reviewed a number of the hcps who participated in this study reported having experienced positive dv screening results in these instances referral was made predominantly to psychologists referral to any services is a better option than no referral at all however this as a common option raises the question of attitudes towards victims of dv needing mental health care as a priority over protection from the perpetrator while counselling is identified as an appropriate intervention for victims of dv hcps must ensure the intervention and referral processes are immediate holistic and individualized to the victims needs 18222353 existing literature identifies that dv referral and intervention is multilayered and must begin with immediate firstline support that assesses further resources required for appropriate referral 18222353 obvious in the findings from this study is the need for education for hcps that addresses individualised holistic approaches to appropriate and timely intervention for the victim limitations due to the small sample size results from this study need to be interpreted with some caution however the study provided some new insights into the dv screening practices of community hcps and some of the results are strongly supported by previous research while this study has reported on overall screening practices and barriers to screening it has not identified what facilitates community hcps to conduct dv screening a further limitation of the study may be the skew in favour of a higher number of gp respondents compared to rns and ppms however the ratios of the various disciplines were representative of the overall study population recommendations the pragmatic methodology resulted in findings that allow for the development and implementation of practical interventions to enhance dv screening practices previous research supports the need for all hcps who provide care to pregnant and postnatal women to be well educated and trained in dv screening and appropriate referral 28303152 the current study like others indicates this is not occurring despite recommendation by government bodies and the who 183738 a recommendation from this study goes beyond stating there is a need for education and training for all hcps who provide health care to women the authors recommend that further research be undertaken to determine the best means of developing and delivering dv screening education and training to ensure it meets the needs of all multidisciplinary hcps this is integral to ensure hcps identify and provide appropriate support and referral for women and children experiencing dv in nsw there are limited resources for training which means that existing services are stretched beyond their limits this calls into question the level of commitment underpinning the australian government rhetoric in addressing integral aspects of dv including the educational requirements of the front line hcps implementation of compulsory dv education into undergraduate curricula of health care disciplines is recommended further to ensure contemporary evidence based practices are adopted mandatory education for dv screening for all practicing hcps could be undertaken as a requirement of registration renewal such strategies however require the support of both regulatory and government bodies nongovernment organisations that provide health care to pregnant and postnatal women should have a mandatory dv screening policy in place that encompasses the best method for implementing dv screening in nsw australia mandatory screening by government funded area health services and a standardized screening tool already exists 1936 however the uptake of such tools in community health care settings is limited this may be due to a lack of awareness or disagreement with the approach of screening it is recommended that current screening tools be adapted to the primary health care setting furthermore a guide for referral practices for women who have a positive screening result is required to increase screening rates as well as provide appropriate support for women and children affected by dv conclusions health care providers often face significant challenges in screening women who are pregnant or postpartum for dv these challenges can stem from both internal and external sources regardless of the source of challenges health care workers need to be supported and encouraged to undertake regular and suitable education and training for dv screening and referral when indicated to ensure they are providing holistic and responsible care to their patients overcoming barriers to screening pregnant and postpartum women is crucial as the responsibility of care extends to unborn and living children additional file additional file 1 study survey of all fixed response and open ended questions abbreviations dv domestic violence gp general practitioner hcp health care provider ppm privately practicing midwife rn registered nurse authors contributions both authors of this manuscript ro and kp have made substantial contributions to conception and design acquisition of data analysis and interpretation of data been involved in drafting the manuscript or revising it critically for important intellectual content given final approval of the version to be published and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved competing interests the authors declare that they have no competing interests

background domestic violence against women is a global endemic that can commence or escalate during pregnancy and continue postpartum pregnant and postpartum women generally access health care providers more at this time than at any other time in their lives despite this little is known about primary health care providers screening practices for domestic violence the purpose of this paper is to present survey findings that identified domestic violence screening practices of community based health care providers in pregnant and postpartum women methods this paper reports on the survey results of a larger sequential mixed methods study that involved a survey and semistructured interviews and used a pragmatic approach to the data collection and analysis the survey sought information via both fixed choice and open responses quantitative data from the surveys were entered into the statistical package for social science spss™ version 22 and analysed using descriptive statistics open responses were collated and then integrated and presented with the quantitative data results results revealed that some health care providers did not screen for domestic violence factors contributing to this lack of screening included a lack of recognition that this was part of their role and a lack of domestic violence screening policies andor reminder systems further barriers to domestic violence screening were identified as a lack of time resources and confidence in undertaking the screening and referral of women when domestic violence was detected conclusions the findings reported in this paper confirm that further insights into the domestic violence screening practices of community based health care providers is required findings also have the potential to inform interventions that can be implemented to increase domestic violence screening and promote appropriate referral practices

A LCOHOL CONSUMPTION IN AFRICA is respon- sible for approximately 6.4% of deaths and 4.7% of disability-adjusted life years lost . It is a major risk factor for chronic disease, injury, HIV/AIDS, adverse women's health outcomes, and interpersonal violence . In the rural We stern Cape of South Africa, alcohol use among women is often symptomatic of domestic and sexual violence, poverty, and a complex history of alcohol as a tool of colonization . Prenatal alcohol use is associated with adverse consequences for the child, including childhood behavioral and developmental disorders and fetal alcohol spectrum disorders . Effects of FA SD include irreversible birth defects that hinder children's neurological, physical, and social development . Fetal alcohol syndrome is the most severe form of FA SD and is common in the Western Cape . In one Western Cape town in the rural We st Coast District, a research site in this study, FA S prevalence rate was reported at 17% -the highest rate globally. South Africa's elevated FA S rates are partly the result of historical practices under colonial agriculture of paying farm workers with alcohol , a practice that, despite its nominal illegality, persisted in some Western Cape farms well into the post-apartheid period . The historical legacy of the Dop system-along with poverty, easy access to alcohol and advertisements, and other intersecting social and health factors-has contributed to high levels of alcohol consumption and dependence in the Western Cape . Throughout Africa, the alcohol industry has used marketing campaigns and lobbied intensely to halt public health measures aiming to limit alcohol availability . National legislation to ban alcohol advertising and sports sponsorship has been stalled, and equivalent Western Cape provincial legislation restrict-ing access was substantially weakened following aggressive opposition by the liquor, sporting, and advertising industries . In addition, self-regulation by alcohol companies has left adolescents vulnerable to the harmful effects of alcohol advertisements . The alcohol industry claims that it plays an indispensable role in South Africa's formal and informal economies . However, the consequences of alcohol consumption cost the economy approximately 10%-12% of South Africa's 2009 gross domestic product . Research has shown that greater exposure to alcohol outlets and advertisements correlates with greater alcohol consumption at the community level . Alcohol accessibility is an important risk factor in problem drinking , particularly among adolescents . Alcohol advertisements have been shown to influence young people's attitudes toward drinking and risk of alcohol consumption , as well as earlier initiation and heavier drinking globally . In southern Africa, alcohol companies have targeted adolescents and women through heavy marketing and availability , potentially contributing to problem drinking among teenage students in Zambia and South Africa . Similarly, much alcohol advertising targets young African women . Given the adverse health, social, and economic consequences of alcohol use, the targeting of women by alcohol companies in Africa, and the significant associations of alcohol accessibility and advertising with early and problem drinking, this study aimed to test the hypotheses that alcohol accessibility and exposure to alcohol advertisements are associated with women's problem drinking, reproductive complications, and a range of adverse health and social outcomes in urban and rural sites of South Africa. This study addresses a gap in the literature on the effects of alcohol accessibility and advertising among women of childbearing age, thereby helping to inform policy debates . --- Method --- Research design and sampling This article analyzes data from a 2006 FA S prevention intervention study in South Africa that surveyed 1,018 women ages 18-44 years living in the Moot, Mamelodi, and Eesterus areas of the City of Tshwane in Gauteng province and in the rural Cederberg, Bergrivier, and Swartland municipalities in the Western Cape province . In Tshwane, cluster random sampling was used to recruit 606 women, one from each of 10 households in 82 randomly selected census enumeration areas. In the rural Western Cape, stratified cluster random sampling was used to recruit 412 female participants from 150 randomly selected farms within the boundaries of the three municipalities. Trained fi eldworkers administered 15-to 90-minute face-to-face interviews with consenting participants in their preferred language. The Faculty of Health Sciences Research Ethics Committees of the Universities of Pretoria and Cape Town approved the study protocol. --- Exposure variables Two exposure variables-alcohol accessibility and exposure to advertisements-were measured by women's extent of agreement or disagreement with the prompts "it is easy to buy alcohol in your community if you want to" and "there are many advertisements in your community," respectively. Both variables were measured on a 5-point Likert scale, which was recoded into a binary scale . --- Outcome variables The structured questionnaire included fi ve individuallevel and fi ve household-level outcomes related to alcohol use, social impact, and reproductive health. The individuallevel outcomes included any history of general and last-pregnancy-related adverse reproductive outcomes and problem drinking. General adverse reproductive impacts, using a history of miscarriage and having children with FA S, generated three categories: no miscarriages and no children with FA S; either at least one miscarriage or a child with FA S; or at least one miscarriage and at least one child with FA S. Adverse reproductive outcomes in the last pregnancy were categorized using a composite variable of complications during last birth, developmental issues of the last child, and adverse outcomes of the last pregnancy as follows: no complications in any category versus a complication in at least one of these categories. Problem drinking variables included self-reported binge drinking ; the 10-item Alcohol Use Disorders Identifi cation Test categorized into a score of less than 8 versus a score of 8 or more; and the CAGE questionnaire categorized into a score of less than 2 versus 2 or more. Household-level alcohol-related outcome variables included partner binge drinking and community drinking . Social impact variables included household hunger and food insecurity combined , money for health care , and interpartner violence . --- Control variables Demographic factors included age in three categories , education , socioeconomic status , and time lived in the community in three categories . --- Statistical analysis Univariate logistic regression analyses were conducted to examine the relationships between the outcome variables and six demographic factors to determine outcome variables for inclusion in the multivariate regressions . Forced entry multivariate logistic regression analyses were then run to explore the association of easy access to alcohol and exposure to alcohol advertising to each of the fi ve individual-level adverse outcomes and the fi ve household-level adverse outcomes, controlling for age, education, socioeconomic status, and time lived in the community . Individual-level outcome variables were analyzed among women who had at least one drink in the past month, and household-level outcome variables were examined among both drinking and nondrinking women. Analyses were stratified by location because the urban and rural samples were notably different in terms of languages, historical practices, and sociocultural contexts. A third set of forced entry multiple regressions were conducted to assess whether there is a dose-response relationship between the exposure variables-easy access to alcohol and exposure to advertisements-and the signifi cantly related outcome variables . Analyses were conducted using IBM SPSS Statistics for Windows, Ve rsion 23.0 . All statistical tests were two-tailed, using an α of .15 for uni-variate regression analyses and an α of .05 for multivariate regression analyses. --- Results Participants in the urban and rural sites had similar age distributions but differed in education ; duration lived in the community ; and SES . Urban-dwelling women identified predominantly as Black/African and spoke an African language , whereas rural-dwelling women identified mostly as Coloured and spoke Afrikaans ; these were highly significant differences .1 In the rural compared with urban sites, a greater percentage reported interpartner violence and problem drinking at the individual level . In the urban and rural sites, the individual-level outcome variable on general adverse reproductive outcomes and, in the urban site, the household-level outcome "money for health care" were not significantly associated with the exposure variables in the univariate analyses and were therefore excluded as outcomes for the respective multivariate regression analyses. In addition, univariate regression analyses were conducted confirming that the exposure variables were not themselves related. In the multivariate regression analyses controlling for demographic factors , women in the urban site with easy access to alcohol were 7.8 times more likely to have experienced complications in the last pregnancy , 6.5 times more likely to have a partner who binge drinks , and 7.9 times more likely to report heavy community drinking . Women who reported high exposure to alcohol advertisements were 4.2 times more likely to experience interpartner violence and 3.4 times more likely to report heavy community drinking . Rural-dwelling women with easy access to alcohol were 10.3 times more likely to report heavy community drinking and less likely to report household hunger/food insecurity . Rural-dwelling women who reported high exposure to alcohol advertisements were 2.3 times more likely to report hazardous drinking according to AUDIT , 4.5 times more likely to report problem drinking according to CAGE , 1.7 times more likely to report interpartner violence , and 3.4 times more likely to report heavy community drinking . Analyses of dose responses in the urban site suggested that there was a positive dose-response relationship for easy access to alcohol with reported community drinking. Compared with the category strongly disagree, ORs for high levels of community drinking increased from 0.9 for the category less than moderate agreement to 4.5 for the category moderate agreement to 6.3 for the category of strong agreement regarding easy access. There was also a positive dose-response relationship for exposure to alcohol advertisements with adverse outcomes. Compared with the category strongly disagree, ORs for problem drinking according to CAGE increased from 2.9 for the category less than moderate agreement and 2.6 for the category moderate agreement to 6.4 for the category of strong agreement regarding the presence of many advertisements in the com-munity. Interpartner violence also showed a suggestive trend of association with advertising. Compared with the category strongly disagree, ORs for interpartner violence increased from 0.8 for the category less than moderate agreement to 2.7 for the category moderate agreement to 4.5 for the category of strong agreement regarding the presence of many advertisements in the community. Last, a similar pattern emerged with community drinking. Compared with the category strongly disagree, ORs for community drinking increased from 1.0 for the category less than moderate agreement to 3.1 for the category moderate agreement to 3.7 for the category of strong agreement regarding the presence of many advertisements in the community. In the rural site, there was a negative dose-response relationship between easy access to alcohol and ability to pay for health care . There was a nonlinear increasing dose-response relationship between easy access and community drinking. Compared with the category strongly disagree, the categories reporting less than moderate agreement, [0.781, [0.419, [1.766, [0.478, [0.541, [3.854, [4.593, 11.128 moderate agreement, and strong agreement regarding easy access to alcohol were 1.4, 20.7 and 6.2 times more likely to report a lot of community drinking, respectively. Exposure to advertisements also demonstrated a positive dose-response relationship for three outcomes. Compared with the category strongly disagree, the categories reporting less than moderate agreement, moderate agreement, and strong agreement regarding advertising exposure were 0.9, 1.9, and 2.4 times more likely to report high AUDIT; were 1.1, 3.5, and 1.3 times more likely to report interpartner violence and 2.2, 6.2, and 2.1 times more likely to report a lot of community drinking, respectively. --- Discussion In both urban and rural sites, reported easy access to alcohol and exposure to alcohol advertisements were associated with adverse social and health outcomes. In urban Tshwane, easy access to alcohol was related to partner binge drinking, problem drinking in the community, and complications during pregnancy. Exposure to alcohol advertisements was related to hazardous drinking in the community and interpartner violence. In rural We stern Cape, easy access to alcohol was related to community drinking and inversely related to the family's ability to pay for health care. Exposure to alcohol advertisements was related to hazardous drinking among women, community drinking, and interpartner violence. These fi ndings were generally supported by demonstration of dose-response effects for both advertising and access. Differences in the fi ndings between the urban and rural sites likely lie in the varied cultural, educational, and socioeconomic contexts of the different communities included in the study. Also, given the history of the Dop system in the We stern Cape and its more recent manifestation as alcohol sold to workers but directly deducted from farm workers' salaries , farm workers may have understated responses to "it is easy for you to buy alcohol in your community if you want to." Limited disposable income in rural farm worker populations would also mean that the ease of accessing alcohol may not be best captured by a question linking easy access to an exchange of money . --- Limitations First, although research in comparable South African communities has found that women are unlikely to underreport alcohol use , there may still have been some social desirability and recall biases regarding alcohol use and other behaviors, despite assurances of confidentiality. Second, the exposure variables-alcohol accessibility and exposure to advertisements-are based on participants' reports rather than objective measurements and should, ideally, be validated in future studies. Third, the sample did not include females below 18 or over 44 years and the data were collected in 2006, meaning that they may have become dated. Last, with a cross-sectional design, one cannot make fi rm conclusions on causality and further studies of more rigorous design would be needed to do so. However, although the results from select urban and rural sites cannot represent the whole country, this is the fi rst study in South Africa to identify potential associations involving easy access to alcohol and exposure to alcohol advertisements with adverse health and social outcomes. The study fi ndings are generally consistent with literature on the relationships between alcohol accessibility, alcohol use, and a range of factors including sexual risks and food insecurity among women in southern Africa . Moreover, in both sites, education and socioeconomic status were negatively correlated with a range of adverse outcomes and positively correlated with ability to pay for health care-intuitive fi ndings supporting the validity of the instruments used in this study and the fi ndings regarding alcohol accessibility and advertisements. --- Implications The fi ndings suggest that easy access to alcohol and exposure to alcohol advertisements are associated with a number of adverse health and social outcomes. In South Africa, despite the World Health Organization's policy recommendations for alcohol reduction strategies , the Department of Health and other government ministries face pressure from the alcohol industry to weaken or stall regulatory policies, often at the expense of the social, economic, and physical well-being of families in urban and rural South Africa. Nevertheless, upstream policy interventions that limit access to alcohol and advertisements by regulating the alcohol and marketing industries appear to be supported by these fi ndings. Moreover, these results lend important insights for other low-and middle-income countries facing significant alcohol-related burdens of disease and injury, as well as economic costs .

The purpose of this study was to analyze the impact of easy access to alcohol and exposure to alcohol advertisements on women's alcohol consumption, reproductive history, and health and social outcomes in an urban and rural site in South Africa. Method: Trained fi eldworkers conducted face-to-face interviews with 1,018 women of childbearing age in the Moot, Mamelodi, and Eesterus areas of the City of Tshwane (Gauteng province) and in the rural Cederberg, Bergrivier, and Swartland municipalities (Western Cape province), recruited through random sampling and stratified cluster random sampling, respectively. Multivariate logistic regression analyses were conducted, stratified according to the urban and rural sites and controlled for four demographic factors. Results: In Tshwane, complications in the last pregnancy (odds ratio [OR] = 7.84, 95% CI [1.77, 34.80]), interpartner binge drinking (OR = 6.50, 95% CI [3.85, 10.94]), and community drinking (OR = 7.92, 95% CI [4.59, 13.65]) were positively associated with alcohol accessibility. Interpartner violence (OR = 4.16, 95% CI [1.99, 8.70]) and community drinking (OR = 3.39, 95% CI [2.07, 5.53]) were positively associated with exposure to alcohol advertisements. In Western Cape, community drinking (OR = 10.26, 95% CI [4.02, 26.20]) was positively associated with alcohol accessibility, whereas ability to pay for health care (OR = 0.48, 95% CI [0.24, 0.96]) was inversely associated. Hazardous drinking on the Alcohol Use Disorders Identification Te st (AUDIT; OR = 2.26, 95% CI [1.03, 4.95]) and CAGE (OR = 4.51, 95% CI [1.30, 15.61]), interpartner violence (OR = 1.69, 95% CI [1.04, 2.76]), and community drinking (OR = 3.39, 95% CI [2.07, 5.53]) were positively associated with exposure to alcohol advertisements. Conclusion: Easy access to alcohol and exposure to alcohol advertisements are positively associated with adverse health and social outcomes. Although further studies are needed, these fi ndings lend support to emphasizing upstream policy interventions to limit access to alcohol and advertisements. (J.

a lcohol consumption in africa is respon sible for approximately 64 of deaths and 47 of disabilityadjusted life years lost it is a major risk factor for chronic disease injury hivaids adverse womens health outcomes and interpersonal violence in the rural we stern cape of south africa alcohol use among women is often symptomatic of domestic and sexual violence poverty and a complex history of alcohol as a tool of colonization prenatal alcohol use is associated with adverse consequences for the child including childhood behavioral and developmental disorders and fetal alcohol spectrum disorders effects of fa sd include irreversible birth defects that hinder childrens neurological physical and social development fetal alcohol syndrome is the most severe form of fa sd and is common in the western cape in one western cape town in the rural we st coast district a research site in this study fa s prevalence rate was reported at 17 the highest rate globally south africas elevated fa s rates are partly the result of historical practices under colonial agriculture of paying farm workers with alcohol a practice that despite its nominal illegality persisted in some western cape farms well into the postapartheid period the historical legacy of the dop systemalong with poverty easy access to alcohol and advertisements and other intersecting social and health factorshas contributed to high levels of alcohol consumption and dependence in the western cape throughout africa the alcohol industry has used marketing campaigns and lobbied intensely to halt public health measures aiming to limit alcohol availability national legislation to ban alcohol advertising and sports sponsorship has been stalled and equivalent western cape provincial legislation restricting access was substantially weakened following aggressive opposition by the liquor sporting and advertising industries in addition selfregulation by alcohol companies has left adolescents vulnerable to the harmful effects of alcohol advertisements the alcohol industry claims that it plays an indispensable role in south africas formal and informal economies however the consequences of alcohol consumption cost the economy approximately 10 12 of south africas 2009 gross domestic product research has shown that greater exposure to alcohol outlets and advertisements correlates with greater alcohol consumption at the community level alcohol accessibility is an important risk factor in problem drinking particularly among adolescents alcohol advertisements have been shown to influence young peoples attitudes toward drinking and risk of alcohol consumption as well as earlier initiation and heavier drinking globally in southern africa alcohol companies have targeted adolescents and women through heavy marketing and availability potentially contributing to problem drinking among teenage students in zambia and south africa similarly much alcohol advertising targets young african women given the adverse health social and economic consequences of alcohol use the targeting of women by alcohol companies in africa and the significant associations of alcohol accessibility and advertising with early and problem drinking this study aimed to test the hypotheses that alcohol accessibility and exposure to alcohol advertisements are associated with womens problem drinking reproductive complications and a range of adverse health and social outcomes in urban and rural sites of south africa this study addresses a gap in the literature on the effects of alcohol accessibility and advertising among women of childbearing age thereby helping to inform policy debates method research design and sampling this article analyzes data from a 2006 fa s prevention intervention study in south africa that surveyed 1018 women ages 1844 years living in the moot mamelodi and eesterus areas of the city of tshwane in gauteng province and in the rural cederberg bergrivier and swartland municipalities in the western cape province in tshwane cluster random sampling was used to recruit 606 women one from each of 10 households in 82 randomly selected census enumeration areas in the rural western cape stratified cluster random sampling was used to recruit 412 female participants from 150 randomly selected farms within the boundaries of the three municipalities trained fi eldworkers administered 15to 90minute facetoface interviews with consenting participants in their preferred language the faculty of health sciences research ethics committees of the universities of pretoria and cape town approved the study protocol exposure variables two exposure variablesalcohol accessibility and exposure to advertisementswere measured by womens extent of agreement or disagreement with the prompts it is easy to buy alcohol in your community if you want to and there are many advertisements in your community respectively both variables were measured on a 5point likert scale which was recoded into a binary scale outcome variables the structured questionnaire included fi ve individuallevel and fi ve householdlevel outcomes related to alcohol use social impact and reproductive health the individuallevel outcomes included any history of general and lastpregnancyrelated adverse reproductive outcomes and problem drinking general adverse reproductive impacts using a history of miscarriage and having children with fa s generated three categories no miscarriages and no children with fa s either at least one miscarriage or a child with fa s or at least one miscarriage and at least one child with fa s adverse reproductive outcomes in the last pregnancy were categorized using a composite variable of complications during last birth developmental issues of the last child and adverse outcomes of the last pregnancy as follows no complications in any category versus a complication in at least one of these categories problem drinking variables included selfreported binge drinking the 10item alcohol use disorders identifi cation test categorized into a score of less than 8 versus a score of 8 or more and the cage questionnaire categorized into a score of less than 2 versus 2 or more householdlevel alcoholrelated outcome variables included partner binge drinking and community drinking social impact variables included household hunger and food insecurity combined money for health care and interpartner violence control variables demographic factors included age in three categories education socioeconomic status and time lived in the community in three categories statistical analysis univariate logistic regression analyses were conducted to examine the relationships between the outcome variables and six demographic factors to determine outcome variables for inclusion in the multivariate regressions forced entry multivariate logistic regression analyses were then run to explore the association of easy access to alcohol and exposure to alcohol advertising to each of the fi ve individuallevel adverse outcomes and the fi ve householdlevel adverse outcomes controlling for age education socioeconomic status and time lived in the community individuallevel outcome variables were analyzed among women who had at least one drink in the past month and householdlevel outcome variables were examined among both drinking and nondrinking women analyses were stratified by location because the urban and rural samples were notably different in terms of languages historical practices and sociocultural contexts a third set of forced entry multiple regressions were conducted to assess whether there is a doseresponse relationship between the exposure variableseasy access to alcohol and exposure to advertisementsand the signifi cantly related outcome variables analyses were conducted using ibm spss statistics for windows ve rsion 230 all statistical tests were twotailed using an α of 15 for univariate regression analyses and an α of 05 for multivariate regression analyses results participants in the urban and rural sites had similar age distributions but differed in education duration lived in the community and ses urbandwelling women identified predominantly as blackafrican and spoke an african language whereas ruraldwelling women identified mostly as coloured and spoke afrikaans these were highly significant differences 1 in the rural compared with urban sites a greater percentage reported interpartner violence and problem drinking at the individual level in the urban and rural sites the individuallevel outcome variable on general adverse reproductive outcomes and in the urban site the householdlevel outcome money for health care were not significantly associated with the exposure variables in the univariate analyses and were therefore excluded as outcomes for the respective multivariate regression analyses in addition univariate regression analyses were conducted confirming that the exposure variables were not themselves related in the multivariate regression analyses controlling for demographic factors women in the urban site with easy access to alcohol were 78 times more likely to have experienced complications in the last pregnancy 65 times more likely to have a partner who binge drinks and 79 times more likely to report heavy community drinking women who reported high exposure to alcohol advertisements were 42 times more likely to experience interpartner violence and 34 times more likely to report heavy community drinking ruraldwelling women with easy access to alcohol were 103 times more likely to report heavy community drinking and less likely to report household hungerfood insecurity ruraldwelling women who reported high exposure to alcohol advertisements were 23 times more likely to report hazardous drinking according to audit 45 times more likely to report problem drinking according to cage 17 times more likely to report interpartner violence and 34 times more likely to report heavy community drinking analyses of dose responses in the urban site suggested that there was a positive doseresponse relationship for easy access to alcohol with reported community drinking compared with the category strongly disagree ors for high levels of community drinking increased from 09 for the category less than moderate agreement to 45 for the category moderate agreement to 63 for the category of strong agreement regarding easy access there was also a positive doseresponse relationship for exposure to alcohol advertisements with adverse outcomes compared with the category strongly disagree ors for problem drinking according to cage increased from 29 for the category less than moderate agreement and 26 for the category moderate agreement to 64 for the category of strong agreement regarding the presence of many advertisements in the community interpartner violence also showed a suggestive trend of association with advertising compared with the category strongly disagree ors for interpartner violence increased from 08 for the category less than moderate agreement to 27 for the category moderate agreement to 45 for the category of strong agreement regarding the presence of many advertisements in the community last a similar pattern emerged with community drinking compared with the category strongly disagree ors for community drinking increased from 10 for the category less than moderate agreement to 31 for the category moderate agreement to 37 for the category of strong agreement regarding the presence of many advertisements in the community in the rural site there was a negative doseresponse relationship between easy access to alcohol and ability to pay for health care there was a nonlinear increasing doseresponse relationship between easy access and community drinking compared with the category strongly disagree the categories reporting less than moderate agreement 0781 0419 1766 0478 0541 3854 4593 11128 moderate agreement and strong agreement regarding easy access to alcohol were 14 207 and 62 times more likely to report a lot of community drinking respectively exposure to advertisements also demonstrated a positive doseresponse relationship for three outcomes compared with the category strongly disagree the categories reporting less than moderate agreement moderate agreement and strong agreement regarding advertising exposure were 09 19 and 24 times more likely to report high audit were 11 35 and 13 times more likely to report interpartner violence and 22 62 and 21 times more likely to report a lot of community drinking respectively discussion in both urban and rural sites reported easy access to alcohol and exposure to alcohol advertisements were associated with adverse social and health outcomes in urban tshwane easy access to alcohol was related to partner binge drinking problem drinking in the community and complications during pregnancy exposure to alcohol advertisements was related to hazardous drinking in the community and interpartner violence in rural we stern cape easy access to alcohol was related to community drinking and inversely related to the familys ability to pay for health care exposure to alcohol advertisements was related to hazardous drinking among women community drinking and interpartner violence these fi ndings were generally supported by demonstration of doseresponse effects for both advertising and access differences in the fi ndings between the urban and rural sites likely lie in the varied cultural educational and socioeconomic contexts of the different communities included in the study also given the history of the dop system in the we stern cape and its more recent manifestation as alcohol sold to workers but directly deducted from farm workers salaries farm workers may have understated responses to it is easy for you to buy alcohol in your community if you want to limited disposable income in rural farm worker populations would also mean that the ease of accessing alcohol may not be best captured by a question linking easy access to an exchange of money limitations first although research in comparable south african communities has found that women are unlikely to underreport alcohol use there may still have been some social desirability and recall biases regarding alcohol use and other behaviors despite assurances of confidentiality second the exposure variablesalcohol accessibility and exposure to advertisementsare based on participants reports rather than objective measurements and should ideally be validated in future studies third the sample did not include females below 18 or over 44 years and the data were collected in 2006 meaning that they may have become dated last with a crosssectional design one cannot make fi rm conclusions on causality and further studies of more rigorous design would be needed to do so however although the results from select urban and rural sites cannot represent the whole country this is the fi rst study in south africa to identify potential associations involving easy access to alcohol and exposure to alcohol advertisements with adverse health and social outcomes the study fi ndings are generally consistent with literature on the relationships between alcohol accessibility alcohol use and a range of factors including sexual risks and food insecurity among women in southern africa moreover in both sites education and socioeconomic status were negatively correlated with a range of adverse outcomes and positively correlated with ability to pay for health careintuitive fi ndings supporting the validity of the instruments used in this study and the fi ndings regarding alcohol accessibility and advertisements implications the fi ndings suggest that easy access to alcohol and exposure to alcohol advertisements are associated with a number of adverse health and social outcomes in south africa despite the world health organizations policy recommendations for alcohol reduction strategies the department of health and other government ministries face pressure from the alcohol industry to weaken or stall regulatory policies often at the expense of the social economic and physical wellbeing of families in urban and rural south africa nevertheless upstream policy interventions that limit access to alcohol and advertisements by regulating the alcohol and marketing industries appear to be supported by these fi ndings moreover these results lend important insights for other lowand middleincome countries facing significant alcoholrelated burdens of disease and injury as well as economic costs

the purpose of this study was to analyze the impact of easy access to alcohol and exposure to alcohol advertisements on womens alcohol consumption reproductive history and health and social outcomes in an urban and rural site in south africa method trained fi eldworkers conducted facetoface interviews with 1018 women of childbearing age in the moot mamelodi and eesterus areas of the city of tshwane gauteng province and in the rural cederberg bergrivier and swartland municipalities western cape province recruited through random sampling and stratified cluster random sampling respectively multivariate logistic regression analyses were conducted stratified according to the urban and rural sites and controlled for four demographic factors results in tshwane complications in the last pregnancy odds ratio or 784 95 ci 177 3480 interpartner binge drinking or 650 95 ci 385 1094 and community drinking or 792 95 ci 459 1365 were positively associated with alcohol accessibility interpartner violence or 416 95 ci 199 870 and community drinking or 339 95 ci 207 553 were positively associated with exposure to alcohol advertisements in western cape community drinking or 1026 95 ci 402 2620 was positively associated with alcohol accessibility whereas ability to pay for health care or 048 95 ci 024 096 was inversely associated hazardous drinking on the alcohol use disorders identification te st audit or 226 95 ci 103 495 and cage or 451 95 ci 130 1561 interpartner violence or 169 95 ci 104 276 and community drinking or 339 95 ci 207 553 were positively associated with exposure to alcohol advertisements conclusion easy access to alcohol and exposure to alcohol advertisements are positively associated with adverse health and social outcomes although further studies are needed these fi ndings lend support to emphasizing upstream policy interventions to limit access to alcohol and advertisements j

INTRODUCTION Responding to social awareness and the movement toward diversity, workforce diversity and inclusion has become a significant topic in human resource management . As part of sustainable development goals, ensuring fairness and embracing diversity in managing employees have become imperative for business. The younger generation is particularly conscious of corporate social responsibilities that include companies' endeavors regarding the fair and equal treatment of employees . Building a corporate D&I brand identity by establishing and implementing D&I practices is becoming more important in terms of attracting talent . Despite the increased focus on D&I and its importance, research on the topic is in the embryonic stage, thus its effective formulas and practical implementation in companies are not clearly disclosed yet. Generally, workforce diversity encompasses demographic aspects including gender, age, race, disability, and sexual orientation. Of these, gender diversity is an immediate issue in Japan . Since the start of the millennium, there has been practical discussion about embracing a female workforce and the potential economic benefits of female participation in Japan. In 2014, the Abe administration adopted the idea of Womenomics 1 and initiated nationwide programs to support women's participation and advancement in Japan. Such attention and initiatives on gender D&I have drawn some progress. The rate of female workers aged 15-64 has gradually increased from 63.63% in 2012 to 72.77% in 2019 . However, this quantitative increase in female participation has not come with qualitative growth in women's advancement. Japanese women continue to suffer from disadvantages in rewards and career development in companies. They are paid 32% less than their male counterparts and face obstacles to promotion to senior positions. Women occupy only 12.6% of corporate board positions in listed companies in 2021, which is far below the average of OECD countries and very low compared with that in other advanced economies, such as Canada , France , and the United Kingdom . Against this background, this study deals with gender D&I in the business sector of Japan. Specifically, the study focuses on female leadership and investigates its effectiveness on gender D&I climate and employees' hope in Japan. Synthesizing ambidextrous leadership theory , social information processing theory , and social identity theory , the study clarifies how female ambidextrous leadership helps shape and strengthen a diversity climate and thus increases employees' hope on their work. Even though studies on female leadership have been gradually increasing, these have been confined to the expected advantages of female leadership , the effectiveness of such leadership , and female leaders in specific sectors and contexts . These explorations have endeavored to illuminate why more women deserve assignment to management positions and provide evidence of the benefits that can be anticipated from the promotion of women in organizations. They have added value to female leadership research, but they have not clearly answered the fundamental question of how female leaders should behave. That is, the 1 The term was first introduced in a Goldman Sachs' research report titled "Womenomics: Buy the Female Economy" . The research shows that female participation could contribute significantly to economic growth in Japan. The research was continued, and the recent "Womenomics 5.0" report argues that resolving the gender gap in employment could increase Japan's GDP by 10% and that if the ratio of female to male working hours rose to the average OECD level, Japan could achieve a 15% increase in GDP. most effective female leadership qualities and their effects have yet to be determined. To cast light on this issue, the current work adopted the concept of ambidextrous leadership in investigating female leadership qualities and the mechanism expected to underlie it. This study also focused on employees' hope, a component of psychological capital , which pertains to a positive psychological status that is important in determining individuals' work attitudes, behaviors and task performance . Hope toward work, as an element constituting psychological capital, is related to work motivation and thus holds particular importance for the achievement of work goals. Hope among employees increases positive energy at work and directs them to engage in productive and creative job activities, thereby elevating the possibility of success . Hopeful employees are also intrinsically motivated and perseverant, so when they face obstacles and problems in the workplace, they endeavor to take a positive stance and find a different pathway, which in turn helps them overcome risks and generate favorable outcomes. Social information processing theory posits that an organization's socio-environmental factors influence the shaping of employees' positive psychological states . Employees' information processing and appraisal of their work environment determines their levels of psychological capital , which is also significantly determined by the leadership of supervisors, among various organizational factors . Notwithstanding the insights provided by previous research, however, the effects of leadership from female supervisors on employees' positive psychology have rarely been studied. This paucity is particularly serious in Japan. Some academic attempts have been made to inquire into female leaders in Japan, but these efforts have been limited to discussions of the necessity or urgency of cultivating female entrepreneurs and female leaders in business . No study has addressed the leadership characteristics required for women to take on this position, the effectiveness of female leadership, and its potential influence on employees in the business sector in Japan. Correspondingly, the present work was intended to identify effective female leadership styles and their influence on employees' perceptions regarding the diversity climate of organizations and hope toward work. Considering the flexible, balanced, and open characteristics of female leadership , this study centered on ambidextrous leadership among women and its effects on employees in Japanese manufacturing companies. The findings can contribute to the development of female leadership studies by shedding light on unanswered questions and doubts related to female leadership's expected effects in Japanese organizations. By providing empirical evidence from the analysis of survey responses, this study offers practical advice and solutions to companies' decision makers who are unconvinced about women's leadership abilities, thereby aiding companies in facilitating the implementation of effective gender D&I management. This research is a timely initiative that is expected to add value to current theoretical studies, businesses, and society. --- LITERATURE REVIEW --- Gender D&I Management in Japan The concept of D&I is no longer new; in fact, it has been advocated globally. D&I in companies has been discussed by critics of serious and prevalent social problems such as unfair treatment, stereotyping, prejudice, social discrimination, and social stratification due to demographic differences among individuals . Individuals' demographic features are not chosen, but naturally given; however, these factors play roles, explicitly or implicitly, in terms of determining the boundaries of individuals' social activities, such as job choice, wage range, chance of promotion, and so forth. Such restrictions on free will and choices discourage individuals, hindering their growth and development, which ultimately leads individuals' counterproductive behaviors, increasing problems and costs. Recently, stakeholders involved in companies' business activities are more concerned about companies' D&I practices . They request fair treatment of employees maintaining diversity and consequently, D&I management has become imperative in the business world . This implies that companies should take a strategic approach in D&I by investing in building a D&I brand image as a part of impressment management to attract their stakeholders. D&I management in Japanese companies is not progressive compared to the one in other advance economies. This stagnancy in gender D&I management is partly because of Japan's distinctive cultural values and societal-contextual characteristics. In pursuing group harmony and not causing noise or conflict, unanimous decision making based on the so-called Ringi system is commonly implemented throughout Japanese society . Moreover, this tendency to maintain harmony in a group is made possible and is strengthened by the ethnic homogeneity of Japanese society. As of 2020, 97.71% of the population was Japanese, with only 2.19% being non-Japanese, mostly from Asian countries whose cultures have something in common with Japan. Current statistics indicate that people of an Asian nationality account for 84.12% of the total foreign population in Japan. The socio-contextual homogeneity of Japanese society strengthens its appreciation of the values of harmony and oneness and the need to avoid conflict situations. These values fundamentally collide with the values of individuality and variety that underlie D&I management in which conflict and discord are inevitable, so conflict situations should be encouraged from the outset to be solved not to be avoided. The contradictions cause a considerable gap between the founding values and the reality faced by Japan, thus delaying the comprehension, adoption, and implementation of D&I management in Japanese companies. In Japan, gender D&I management has been gaining momentum since the start of the millennium due to the internal and external pressures. Japan's population is aging, and the country is faced with a reduced workforce and a limited supply of young talent. This shortage is associated with the high possibility of the diminishing competitiveness of Japanese companies, which will put the Japanese economy at risk. This national demographic imbalance necessitates that companies embrace a more diverse workforce. Also, Japanese global firms are pressured to follow the global standards by assuring gender equality. Led by global Japanese companies, which are under high normative pressure to conform to advanced global standards in managing human resources, awareness of gender D&I management in Japan has increased. Since the enforcement of the act promoting female employment in 2015, large Japanese companies have been obliged to make their gender diversity management plans public. Specifically, companies must report to the Ministry of Health, Labor, and Welfare about whether they provide equal opportunities to women and about the extent to which their organizations' working environment is ready to embrace female workers. The act will be extended to medium-sized companies in April 2022 . Due to this coercive and normative pressures from the world business, government, and the social need for diversity management, Japanese companies have become more engaged in devising and practicing gender D&I management. Thus, women's social participation in Japan has been gradually increasing, showing the quantitative growth in number of female workers. --- Social Information Processing Theory and Female Leadership According to social information processing theory, an individual is an "adaptive" entity . Individuals are influenced by the social environment in which they work, and therefore their attitudes and behaviors are determined by their perceptions and interpretations of the nature of the organizational environment. As Salancik and Pfeffer state, "One can learn most about individual behavior by studying the informational and social environment within which that behavior occurs and to which it adapts." This implies the importance of understanding the social context of organizations to understand and predict employees' attitudes toward works. In particular, affective attitudes toward work are highly related with organizational characteristics . Of the various organizational factors that revolve around employees, leadership has an especially influential impact due to the frequent and proximate interactions between employees and leaders. Leadership behaviors send a signal to employees about the values and direction the organization is pursuing and thus shape employees' attitudes toward work. As a result, certain leadership behaviors can motivate employees and guide them toward achieving the organizational goals. Female leaders are argued to have specific characteristics . Sueda et al. studied female leaders in four different countries and found they have distinctive characteristics; for example, they have long-term views, set higher and broader vision, embrace the different ideas of others, and exhibit flexible behavior. Similarly, Girdauskiene and Eyvazzade found that female leaders are flexible and open minded and that these characteristics are very effective when managing people. Related research argues that female leaders are more transformational, communal, and relational than male leaders and further, researchers discovered that female leadership is as effective as male leadership . Even if there is no specifically named leadership style that describes female leadership, previous studies have consistently argued that female leadership is characterized as being balanced, flexible, and open minded. Building on these findings, the present study focuses on ambidextrous leadership in investigating the effectiveness of female leadership in Japanese organizations. Female Ambidextrous Leadership, Gender D&I Climate, and Employees' Hope Rosing et al. define ambidextrous leadership as "the ability to foster both explorative and exploitative behaviors in followers by increasing or reducing variance in their behaviors and flexibly switching between those behaviors" . The explorative behaviors of allowing and providing autonomy to employees and letting them generate and test new ideas are referred to as opening behaviors. The exploitative behaviors of managing and controlling employees by monitoring and evaluating their progress and achievements are referred to as closing behaviors. These two kinds of behaviors exhibited by ambidextrous leaders are argued to be complementary and to have an integrative effect on enhancing employees' task performance by clarifying their role and increasing self-efficacy . As argued in the literature, ambidextrous leaders allow flexibility and autonomy to employees when they work, such relationship with ambidextrous leaders have employees feel confident and passionate regarding their work . Thus, ambidextrous leaders help employees shape positive psychological state at work and such psychological capital of employees results in the increase of work performances . Given the proven positive effects of ambidextrous leadership on employees' work attitudes, ambidextrous leadership of female leaders is expected to increase employees' hope. As one component of psychological capital , hope on work is defined as "a positive motivational state that is based on an interactively derived sense of successful agency and pathways " . Employees' hope on work is achieved when they are clear about the work goals and at the same time when they have room to think about how to achieve these goals and to test alternative work paths . Employees exert hopeful and positive energy at working when they are confident about what should be achieved and also their ideas and thoughts are appreciated. Female leaders' ambidextrous leadership behaviors are open to individual different ideas and allow flexibility at work with clear guidelines about work goals and providing feedback. Such opening and closing behaviors flexibly exhibited by female leaders influence employees to be confident and positive at their work, which contributes to increasing their hope on work. Therefore, the following hypothesis is proposed: H1. Female ambidextrous leadership positively influences employees' hope on work. However, if the gender of leaders is considered, that is, if ambidextrous leadership behaviors are exhibited by female managers, the underlying mechanisms through which female ambidextrous leadership affects employees' work attitude can differ due to the distinctive information gained from such female leadership. According to social information processing theory , individuals recognize salient information, and their perception and interpretation of the information determines their work attitude. Because leader gender is salient for employees in less diverse organizations , female ambidextrous leadership sends a particular signal about the organization's gender D&I climate; that is, how female workers are treated. Along with the existence of female leaders, their implementation of balanced leadership behaviors and flexibility in practicing exploitative and explorative behaviors signal organizations' progender D&I climate. As such, female ambidextrous leadership shapes employees' perception that their organization treats employees fairly and has a favorable environment in which individuals' different needs and values are supported through the implementation of inclusive policies and practices in progender D&I climate. Such a perception improves employees' organizational identity, thus motivating them to devote more energy to their work. This implies that female ambidextrous leadership helps create a gender D&I climate where fair treatment and valuing different ideas are encouraged and different ways of working are accepted in order to achieve employees' work goals. Consequently, the flexible leadership behaviors of female leaders motivate employees to be positive and proactive in their work through their perception of pro-gender D&I climate. This suggests the potential mediating role of a gender D&I climate in the relationship between female ambidextrous leadership and employees' hope on work. Therefore, the following hypothesis is proposed: H2. Gender D&I climate mediates female ambidextrous leadership and employees' hope on work. The salient organizational information and its relative importance are different depending on individual social groups . According to social identity theory , people tend to seek an environment that is of immediate interest, and if they perceive that environment is supportive, its expected positive effect is relatively greater for them than for those in other social groups. Generally, minority groups are exposed to discrimination and experience unfair treatment in their organizations; therefore, they are more sensitive to D&I climate, and their perceptions in this regard have a greater effect on their attitudes and performance compared to majority groups ; Newman et al. found that diversity climate increases employees' psychological capital, thus elevating organizational commitment and reducing turnover intentions. However, this positive effect of diversity climate is moderated by ethnic identity. In studying sales employees in the US, McKay et al. found that diversity climate has considerable effects on employees belonging to ethnic minorities. Such climate enhances the employees' perceptions of fair and equal treatment of human resources in organizations, thus reducing discrimination and conflicts among ethnically different groups and enhancing sales performance. Companies' gender D&I climate denotes employees' perceptions of companies' structured and implemented practices and policies regarding the treatment of female employees. The organizational information of gender D&I is more salient for female employees who are generally under-represented and less well treated compared to male employees. Therefore, companies' efforts in supporting and embracing female employees will be more important to female employees and will enhance their organizational identity and have a greater positive effect on their motivational and positive state at work. Based on this reasoning, the following hypothesis is proposed: H3. The positive link between gender D&I climate and employees' hope on work depends on employees' gender such that the positive effect of gender D&I climate is greater on female employees than male employees. This develops the following research model. Figure 1 illustrates the hypothesized research framework. --- MATERIALS AND METHODS In this study, quantitative longitudinal survey data was collected from employees working for manufacturing companies in Japan. Initially, the study targeted large manufacturing companies with over 300 employees; however, the criteria should be revised because it was difficult to find participants working in large manufacturing companies in Japan whose direct supervisor is a woman. Therefore, the bar was lowered and participants whose companies employ more than 100 people joined. The data collection was conducted in collaboration with an established survey agency in Japan. Two surveys were conducted, with a two-week gap between them to determine the causal effect of leadership on employees and also to minimize common method bias . Before the first survey, a screening test was conducted to select only participants whose direct supervisor is a woman. Direct supervisor was defined as the leader who the participants contact, report to, and consult with on a regular basis in their organization. This definition was given to the participants in advance. In the first survey, the participants were asked about the ambidextrous leadership behaviors of their female direct supervisor and their perception about the organization's gender D&I climate. The second survey asked about the participants' hope on work. From the two surveys, 311 responses were collected. After removing five survey responses that had the same answers for all questions, 306 responses remained for the analysis. Of the remaining respondents, 156 were men and 150 were women. The average age of the respondents was 43.8 years old. The majority held employee-level positions , followed by assistant manager positions . Most respondents were highly educated; 206 were graduates of a four-year university program. --- MEASURES Ambidextrous leadership was measured using the 14-item scale developed by Rosing et al. . The scale describes leaders' opening and closing behaviors. Sample questions relating to leaders' opening behaviors are "My direct supervisor gives possibilities for independent thinking and acting" and "My direct supervisor allows different ways of accomplishing a task." Sample questions relating to leaders' closing behaviors are "My direct supervisor establishes routines" and "My direct supervisor monitors and controls goal attainment." Survey respondents were asked to answer each question by thinking about the frequencies of behaviors exhibited by their leaders using a five-point Likert scale ranging from 1 to 5 Gender: male = 1, female = 0; Tenure: unit = ln. Total tenure: the total period of working to date; Leader tenure: the period of time working with the current leader. **p < 0.01, *p < 0.05. . The Cronbach's alpha for the ambidextrous leadership is 0.93. Gender D&I climate was measured using questions developed to represent the concept due to the unavailability from prior studies and the concept's contextual dependency. Referring to prior research on diversity climate and interviews with Japanese employees, questions relating to fair and equal treatment of the genders and female career support and advancement in organizations were developed. The five questions are "My company has quite a number of female managers, " "My company has diversity practices to support female employees, " "My company motivates female employees to work better, " "My company treats employees fairly regardless of gender, " and "My company is a good place for women to work." This concept was rated using a five-point Likert scale ranging from 1 to 5 . The Cronbach's alpha for this scale is 0.85, showing the internal consistency of the questions used in the study. Hope on work was measured using the 6-item scale developed by Luthans et al. . This scale was adapted from the questions developed by Snyder et al. . The questions were intended to measure how hopeful respondents feel about achieving their work goals by developing flexible ideas. Sample questions are "At the present time, I am energetically pursuing my work goals" and "If I should find myself in a jam at work, I could think of many ways to get out of it." The items were rated on a six-point Likert scale ranging from 1 to 6 . The Cronbach's alpha for this concept is 0.92. Control variables were added to the analysis; respondents' demographic variables were included in the models. Gender was dummy coded as 1 for the male participants and as 0 for the female participants. Age was a categorical variable coded from 1 to 5 , and education was coded as 1 to 5 . Position was coded as 1 to 5, with a high number indicating a high position. Organizational tenure was measured as the total work period expressed in months. Leader tenure was measured as the period of time working with the current female leader expressed in months. --- RESULTS Confirmatory factor analysis was conducted to ensure distinctiveness among the variables, and the model fit of a three-factor model was compared with that of nested models. The goodness of fit indices of the three-factor model confirmed that it fits the model and that the three variables are distinctive [comparative fit index = 0.891, tuker-lewis index = 0.880, root mean square error of approximation = 0.066, standardized root mean square residual = 0.061]. Table 1 presents the mean values, standard deviations, and correlations of the variables. Significant correlations were found among the main independent, dependent, and mediating variables. Female ambidextrous leadership is significantly correlated with gender D&I climate and employees' hope on work . Gender D&I climate is also significantly associated with hope on work . Table 2 shows the results of the hierarchical regression analysis of the variables. Model 1 included only the demographic variables and the finding shows that the included six demographic variables explain 14.8% of total variance of hope on work . Specifically, it shows that employees' age is related to hope on work . In addition, education and position have significant effects on employees' hope on work . Female ambidextrous leadership was incorporated into Model 2, and the finding showed that it has a significant positive effect on employees' hope , explaining an additional 4.7% of the total variance in hope toward work Preacher and Hayes was employed to reconfirm the significance of the mediation effect. The test results indicate that the mediation effect of gender D&I climate on the link between female ambidextrous leadership and employees' hope on work is significantly valid [0.041, 0.176]). Therefore, hypothesis 2 that assumed the mediating role of gender D&I climate between female ambidextrous leadership and employees' hope on work is supported. Model 5 added the interaction term of gender and gender D&I climate to test the moderating effect of gender on the relationship between gender D&I climate and hope on work. Hypothesis 3 assumed that gender D&I climate is more critical for female employees than male employees; therefore, the positive effect of gender D&I climate on employees' hope would be more considerable among female employees than among their male equivalents. However, Model 5 uncovered a non-significant moderating effect of gender , and the interaction term explains only 0.9% of the total variance in the dependent variable [i.e., hope on work; = 0.009]. The nonsignificance of the value change in model fits also indicated that the moderating term does not determine the dependent variable [change in F = 3.426 , p = 0.065]. This finding means that no support was derived for Hypothesis 3. --- DISCUSSION The study investigates Japanese employees who work with female supervisors and examines the relationships among the ambidextrous leadership of female supervisors, gender D&I climate, and employees' hope on work. Female leadership studies have focused only on examining the perceptions and appraisals of female leadership and the potential organizational benefits of the increases in female leaders . However, the prior studies ignored the specific and qualitative aspects of female leadership, such as its characteristics and the underlying mechanism through which employees are influenced. Addressing this gap, this study focuses on the ambidextrous leadership style of female leaders and its effect on shaping organization's gender D&I climate and ultimately its influence on employees' hope on work. This first empirical findings contribute to enhance understanding of the effectiveness of female leadership style vis-à-vis employees' perception of organizational environment and their psychological state regarding their work in Japan. An interesting and unexpected finding should be addressed. The study assumed that the effect of pro-gender D&I climate on hope would be greater among female employees than male employees . Contrastingly, the results showed a non-significant effect of gender on the relationship between gender D&I climate and employee hope-a phenomenon that contradicts the view advocated in social identity theory . A possible explanation for this result lies in the diversity of individual social identity, which thus means that the extent to which a certain social identity is shaped depends on individuals . In the same vein, the recognition of female identity by women varies per person. Therefore, the extent to which gender D&I climate influences on female employees is contingent on their level of female identity. That is, females who have strong female identity are more remarkably influenced by gender D&I climate than those with low female identity. Such individual differences in female identity among female employees might draw such result. Another reason for the above-mentioned result is that gender D&I climate is an immediate and relevant issue not only to female employees but also to their male counterparts. Pro-gender D&I climate signifies an organization's choice to treat employees fairly by fostering an open and flexible organizational climate, in which differences in ideas and needs among employees are allowed and accepted. Such a climate is therefore meaningful to all employees; that is, it exerts the same effects, with no considerable differences, whether an employee is female or male. --- Theoretical and Practical Contributions The significance of this research should be addressed. First, this study contributes to advancing the prior female leadership studies . In particular, this is the first attempt that disclosed the effectiveness of female ambidextrous leadership in Japan. The study highlights that female ambidextrous leadership sends a positive signal about companies' gender D&I management, helps shape the perception of pro-gender C&I climate among employees, and consequently, increases employees' hopeful and positive energy regarding their works. This finding lends a support of ambidextrous leadership theory and social information processing theory . Considering the paucity in empirical evidence of female leadership effectiveness and its underlying process, particularly in Japan, the findings of showing the positive and procedural effect of female leadership on employees' hope on work have a particular academic value, contributing to the development of female leadership studies. In addition, the study contributes to the understanding D&I management in the HRM studies . As pointed by Farndale et al. , the diversity concept and relevant diversity issue vary across counties. The broad-defined concept of diversity prevalent in the West is not applicable in Japan because of its specific socio-contextual characteristic. Therefore, this study focused on one aspect of diversity, gender D&I that is the most relevant to the Japanese context. Referring to prior studies and interviewees' responses regarding their perceptions on companies' gender D&I climate, the study developed the five-item scale measuring gender D&I climate. This context-contingent approach in D&I management can capture and explain better the effect of diversity management. Also, the context-contingent approach with a focus on gender D&I can be applied to other Eastern contexts such as South Korea in which gender D&I is the most relevant and immediate diversity aspect as similar as Japan. Taking the context-contingency view, this study broadens the perspective understanding D&I management, contributing to developing the current D&I management studies. Related to this, given that human resources are a valuable source of organizational growth and sustainability, the finding regarding the positive effect of gender D&I climate on employees' hope has a significant implication. Organizations' initiatives in terms of gender D&I and shaping gender D&I climate indicate they are making an effort to treat their employees fairly and equally. Such efforts are favored by employees; thus, employees show optimistic and hopeful attitudes at their work. This psychological process implies that organizations' stance about gender D&I management signaled by female ambidextrous leadership shapes pro-gender D&I climate, which thus is linked to the increased work motivation of employees. More importantly, the lack of moderation from gender on the effect of gender D&I climate on employees' hope reflects that such a positive effect of pro-gender D&I climate on shaping employees' positive work attitudes is not confined to a particular gender. In other words, favorable perceptions about D&I practices and management in Japanese companies can benefit and increase all employees' hope, regardless of gender. The finding further signifies that Japanese employees are conscious of and favor D&I management. If they believe the climate in their organizations to be gender inclusive, they are more motivated and engaged in their work. Therefore, companies should actively implement gender D&I management to shape a climate that favors gender D&I. Such efforts not only increase the psychological capital of employees but also enhance their productivity and financially benefit companies . In clarifying the direct influence of gender D&I climate on employees' hope, the study contributes to the development of prior diversity management studies in Japan . Expected practical implications are also worth noting. First, the findings may motivate Japanese companies to embrace and cultivate female leaders and welcome the advantages of implementing gender D&I management. Japan has a strongly stereotyped view of gender roles and a firm belief in role congruity, with leadership seen as equivalent to direction by males . This stereotype and the reluctance to initiate changes have delayed the implementation of gender D&I management in Japanese companies. This delay, in turn, has given rise to explicit and implicit disadvantages for women, discouraging female talents from aspiring for career advancement. The upshot of all these is the loss of company competitiveness. The results of this study can serve as reference for Japanese companies that want to eliminate the long-standing social misunderstanding of gender roles and concerns about female advancement. The finding on the positive effects of female leadership on employees' work motivation and energy can convince Japanese companies that it is advisable to embrace gender diversity and that they can expect potential benefits from this initiative. The acceptance of gender diversity shapes institutional norms regarding gender D&I management in Japan. As the institutional normalization of gender diversity facilitates its direct and indirect financial benefits by assuring stakeholders of the advantages of such management , industryand society-wide social acceptance is expected to bear fruit for Japanese companies who engage in gender D&I actively. The findings can also be useful in the leadership development of Japanese companies. The results indicated that the ambidextrous leadership skills of female leaders enable them to effectively increase perceptions regarding on pro-gender D&I climate and enhance employees' hope on work. This finding can be utilized to companies to identify, educate, and train female employees for leadership positions. Focusing on the ambidextrous nature of leadership, companies can find female employees who are capable of exhibiting such leadership behaviors or they can foster such leadership skills of potential leaders by designing and providing leadership training programs. Such efforts will benefit companies to achieve diversity management effectively and thus draw successful and sustainable outcomes from it. --- Limitations and Future Research Despite the aforementioned implications, the study has some limitations. First, the study only focused on the ambidextrous behaviors associated with female leadership. Even if the findings indicate that female leaders exhibit such ambidextrous leadership behaviors and that such leadership influences employees positively, the study did not consider other female leadership styles. Prior studies revealed that female leaders exert transformational behaviors more than male leaders and also, such female transformational leadership is as effective as male leadership . Therefore, future studies should investigate other female leadership styles together with ambidextrous female leadership. By comparing and contrasting different female leadership styles, future studies can clarify the exact attributes of female leadership and the effects on employees. Second, this study investigated only employees' hope on work as a consequence of female leadership. However, other work-related concepts, such as work commitment, psychological empowerment, organizational citizenship behavior, and innovative behavior, may be associated with female ambidextrous leadership. Considering the potential relationship between female ambidextrous leadership and other positive attitudinal and behavioral concepts, future studies should examine other potential target variables that female ambidextrous leadership may influence. Adding these variables and determining their relationship with female ambidextrous leadership will enhance the understanding of this leadership style and its potential and practical impact on employees. Related to this, the research model may be inapplicable to other research contexts. The study showed that direct ambidextrous leadership by females denotes organizational diversity management and shapes employees' perception of progender D&I climate in organizations. This indicates that female leaders serve as change agents of organizations, not merely cogs in a machine . However, depending on the social cognition of gender in organizations and general viewpoints regarding female leadership, this research model may or may not be supported. Therefore, to generalize the research model, it necessitates investigating female leaders' roles, along with general perceptions and evaluations of female leadership in the future studies. Finally, this study did not control for organizational factors. Given that the attitudes of individuals about their organizations and jobs are influenced by socio-environmental factors, researchers should explore other social and environmental determinants, such as the quality of the relationship between employees and their female supervisors, organizational structure, organizational support, and work design, as these may influence how employees view their organizations and shape their attitudes toward work. Future studies should incorporate and regulate the potential effects of such factors to validate and generalize the research model put forward in the current work. --- CONCLUSION Japan, the homogenous and aging society is facing the shortage in their workforce, which diminishes their business competitiveness. One effective solution that Japanese companies can choose may be to engage in and implement gender D&I management effectively. Focusing on the significant meaning of gender D&I in Japan, this study addresses this issue. Building on social informational processing theory and social identity theory, the study examined female ambidextrous leadership's effect on employees' hope on work and its underlying mechanism. Findings showed that female ambidextrous leadership strengthens employees' perception on pro-gender D&I climate of their organizations. This improved perception of pro-gender D&I climate contributes to increase employees' positive and hopeful energy at work. In addition, the positive effect of pro-gender D&I climate on employees' hope is the same for all employees regardless of gender. The findings highlight the effective female leadership style and its positive effect on shaping employees' positive work attitude. Therefore, the study contributes to the development of female leadership and diversity management studies in Japan. In addition, the study provides empirical evidence of the positive effects of female leadership on employees and highlights the potential benefits of gender D&I by advancing and cultivating female leaders in Japanese companies. --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- ETHICS STATEMENT Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. --- --- Conflict of Interest: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

There are two well-known truths about Japan: one is that Japan is one of the most advanced economies, which takes pride in its highly advanced technology, social infrastructure and system; the other is that Japan ranks lowest at women's social participation among Organization for Economic Co-operation and Development countries. Even though the Japanese government has initiated programs to promote female participation and advancement in society, these initiatives have not yet borne remarkable fruit. This study intends to address this issue by investigating the effectiveness of female leadership in Japan, specifically its effect on organizations' gender diversity and inclusion (D&I) climate and employees' task-related positive attitudes. Synthesizing social information processing theory and social identity theory, the study examines 306 Japanese employees working with their female supervisors in medium-and large-sized manufacturing companies. The findings show that female ambidextrous leadership contributes to shape and strengthen a gender D&I climate and ultimately enhances employees' hope on their work. In addition, the positive effect of a gender D&I climate on employees' hope is the same for all employees regardless of gender. The findings clarify the role of female leadership and the underlying psychological mechanism through which female leadership influences employees' positive work attitudes. This first empirical study in Japan contributes to the research on female leadership and D&I management.

introduction responding to social awareness and the movement toward diversity workforce diversity and inclusion has become a significant topic in human resource management as part of sustainable development goals ensuring fairness and embracing diversity in managing employees have become imperative for business the younger generation is particularly conscious of corporate social responsibilities that include companies endeavors regarding the fair and equal treatment of employees building a corporate d i brand identity by establishing and implementing d i practices is becoming more important in terms of attracting talent despite the increased focus on d i and its importance research on the topic is in the embryonic stage thus its effective formulas and practical implementation in companies are not clearly disclosed yet generally workforce diversity encompasses demographic aspects including gender age race disability and sexual orientation of these gender diversity is an immediate issue in japan since the start of the millennium there has been practical discussion about embracing a female workforce and the potential economic benefits of female participation in japan in 2014 the abe administration adopted the idea of womenomics 1 and initiated nationwide programs to support womens participation and advancement in japan such attention and initiatives on gender d i have drawn some progress the rate of female workers aged 1564 has gradually increased from 6363 in 2012 to 7277 in 2019 however this quantitative increase in female participation has not come with qualitative growth in womens advancement japanese women continue to suffer from disadvantages in rewards and career development in companies they are paid 32 less than their male counterparts and face obstacles to promotion to senior positions women occupy only 126 of corporate board positions in listed companies in 2021 which is far below the average of oecd countries and very low compared with that in other advanced economies such as canada france and the united kingdom against this background this study deals with gender d i in the business sector of japan specifically the study focuses on female leadership and investigates its effectiveness on gender d i climate and employees hope in japan synthesizing ambidextrous leadership theory social information processing theory and social identity theory the study clarifies how female ambidextrous leadership helps shape and strengthen a diversity climate and thus increases employees hope on their work even though studies on female leadership have been gradually increasing these have been confined to the expected advantages of female leadership the effectiveness of such leadership and female leaders in specific sectors and contexts these explorations have endeavored to illuminate why more women deserve assignment to management positions and provide evidence of the benefits that can be anticipated from the promotion of women in organizations they have added value to female leadership research but they have not clearly answered the fundamental question of how female leaders should behave that is the 1 the term was first introduced in a goldman sachs research report titled womenomics buy the female economy the research shows that female participation could contribute significantly to economic growth in japan the research was continued and the recent womenomics 50 report argues that resolving the gender gap in employment could increase japans gdp by 10 and that if the ratio of female to male working hours rose to the average oecd level japan could achieve a 15 increase in gdp most effective female leadership qualities and their effects have yet to be determined to cast light on this issue the current work adopted the concept of ambidextrous leadership in investigating female leadership qualities and the mechanism expected to underlie it this study also focused on employees hope a component of psychological capital which pertains to a positive psychological status that is important in determining individuals work attitudes behaviors and task performance hope toward work as an element constituting psychological capital is related to work motivation and thus holds particular importance for the achievement of work goals hope among employees increases positive energy at work and directs them to engage in productive and creative job activities thereby elevating the possibility of success hopeful employees are also intrinsically motivated and perseverant so when they face obstacles and problems in the workplace they endeavor to take a positive stance and find a different pathway which in turn helps them overcome risks and generate favorable outcomes social information processing theory posits that an organizations socioenvironmental factors influence the shaping of employees positive psychological states employees information processing and appraisal of their work environment determines their levels of psychological capital which is also significantly determined by the leadership of supervisors among various organizational factors notwithstanding the insights provided by previous research however the effects of leadership from female supervisors on employees positive psychology have rarely been studied this paucity is particularly serious in japan some academic attempts have been made to inquire into female leaders in japan but these efforts have been limited to discussions of the necessity or urgency of cultivating female entrepreneurs and female leaders in business no study has addressed the leadership characteristics required for women to take on this position the effectiveness of female leadership and its potential influence on employees in the business sector in japan correspondingly the present work was intended to identify effective female leadership styles and their influence on employees perceptions regarding the diversity climate of organizations and hope toward work considering the flexible balanced and open characteristics of female leadership this study centered on ambidextrous leadership among women and its effects on employees in japanese manufacturing companies the findings can contribute to the development of female leadership studies by shedding light on unanswered questions and doubts related to female leaderships expected effects in japanese organizations by providing empirical evidence from the analysis of survey responses this study offers practical advice and solutions to companies decision makers who are unconvinced about womens leadership abilities thereby aiding companies in facilitating the implementation of effective gender d i management this research is a timely initiative that is expected to add value to current theoretical studies businesses and society literature review gender d i management in japan the concept of d i is no longer new in fact it has been advocated globally d i in companies has been discussed by critics of serious and prevalent social problems such as unfair treatment stereotyping prejudice social discrimination and social stratification due to demographic differences among individuals individuals demographic features are not chosen but naturally given however these factors play roles explicitly or implicitly in terms of determining the boundaries of individuals social activities such as job choice wage range chance of promotion and so forth such restrictions on free will and choices discourage individuals hindering their growth and development which ultimately leads individuals counterproductive behaviors increasing problems and costs recently stakeholders involved in companies business activities are more concerned about companies d i practices they request fair treatment of employees maintaining diversity and consequently d i management has become imperative in the business world this implies that companies should take a strategic approach in d i by investing in building a d i brand image as a part of impressment management to attract their stakeholders d i management in japanese companies is not progressive compared to the one in other advance economies this stagnancy in gender d i management is partly because of japans distinctive cultural values and societalcontextual characteristics in pursuing group harmony and not causing noise or conflict unanimous decision making based on the socalled ringi system is commonly implemented throughout japanese society moreover this tendency to maintain harmony in a group is made possible and is strengthened by the ethnic homogeneity of japanese society as of 2020 9771 of the population was japanese with only 219 being nonjapanese mostly from asian countries whose cultures have something in common with japan current statistics indicate that people of an asian nationality account for 8412 of the total foreign population in japan the sociocontextual homogeneity of japanese society strengthens its appreciation of the values of harmony and oneness and the need to avoid conflict situations these values fundamentally collide with the values of individuality and variety that underlie d i management in which conflict and discord are inevitable so conflict situations should be encouraged from the outset to be solved not to be avoided the contradictions cause a considerable gap between the founding values and the reality faced by japan thus delaying the comprehension adoption and implementation of d i management in japanese companies in japan gender d i management has been gaining momentum since the start of the millennium due to the internal and external pressures japans population is aging and the country is faced with a reduced workforce and a limited supply of young talent this shortage is associated with the high possibility of the diminishing competitiveness of japanese companies which will put the japanese economy at risk this national demographic imbalance necessitates that companies embrace a more diverse workforce also japanese global firms are pressured to follow the global standards by assuring gender equality led by global japanese companies which are under high normative pressure to conform to advanced global standards in managing human resources awareness of gender d i management in japan has increased since the enforcement of the act promoting female employment in 2015 large japanese companies have been obliged to make their gender diversity management plans public specifically companies must report to the ministry of health labor and welfare about whether they provide equal opportunities to women and about the extent to which their organizations working environment is ready to embrace female workers the act will be extended to mediumsized companies in april 2022 due to this coercive and normative pressures from the world business government and the social need for diversity management japanese companies have become more engaged in devising and practicing gender d i management thus womens social participation in japan has been gradually increasing showing the quantitative growth in number of female workers social information processing theory and female leadership according to social information processing theory an individual is an adaptive entity individuals are influenced by the social environment in which they work and therefore their attitudes and behaviors are determined by their perceptions and interpretations of the nature of the organizational environment as salancik and pfeffer state one can learn most about individual behavior by studying the informational and social environment within which that behavior occurs and to which it adapts this implies the importance of understanding the social context of organizations to understand and predict employees attitudes toward works in particular affective attitudes toward work are highly related with organizational characteristics of the various organizational factors that revolve around employees leadership has an especially influential impact due to the frequent and proximate interactions between employees and leaders leadership behaviors send a signal to employees about the values and direction the organization is pursuing and thus shape employees attitudes toward work as a result certain leadership behaviors can motivate employees and guide them toward achieving the organizational goals female leaders are argued to have specific characteristics sueda et al studied female leaders in four different countries and found they have distinctive characteristics for example they have longterm views set higher and broader vision embrace the different ideas of others and exhibit flexible behavior similarly girdauskiene and eyvazzade found that female leaders are flexible and open minded and that these characteristics are very effective when managing people related research argues that female leaders are more transformational communal and relational than male leaders and further researchers discovered that female leadership is as effective as male leadership even if there is no specifically named leadership style that describes female leadership previous studies have consistently argued that female leadership is characterized as being balanced flexible and open minded building on these findings the present study focuses on ambidextrous leadership in investigating the effectiveness of female leadership in japanese organizations female ambidextrous leadership gender d i climate and employees hope rosing et al define ambidextrous leadership as the ability to foster both explorative and exploitative behaviors in followers by increasing or reducing variance in their behaviors and flexibly switching between those behaviors the explorative behaviors of allowing and providing autonomy to employees and letting them generate and test new ideas are referred to as opening behaviors the exploitative behaviors of managing and controlling employees by monitoring and evaluating their progress and achievements are referred to as closing behaviors these two kinds of behaviors exhibited by ambidextrous leaders are argued to be complementary and to have an integrative effect on enhancing employees task performance by clarifying their role and increasing selfefficacy as argued in the literature ambidextrous leaders allow flexibility and autonomy to employees when they work such relationship with ambidextrous leaders have employees feel confident and passionate regarding their work thus ambidextrous leaders help employees shape positive psychological state at work and such psychological capital of employees results in the increase of work performances given the proven positive effects of ambidextrous leadership on employees work attitudes ambidextrous leadership of female leaders is expected to increase employees hope as one component of psychological capital hope on work is defined as a positive motivational state that is based on an interactively derived sense of successful agency and pathways employees hope on work is achieved when they are clear about the work goals and at the same time when they have room to think about how to achieve these goals and to test alternative work paths employees exert hopeful and positive energy at working when they are confident about what should be achieved and also their ideas and thoughts are appreciated female leaders ambidextrous leadership behaviors are open to individual different ideas and allow flexibility at work with clear guidelines about work goals and providing feedback such opening and closing behaviors flexibly exhibited by female leaders influence employees to be confident and positive at their work which contributes to increasing their hope on work therefore the following hypothesis is proposed h1 female ambidextrous leadership positively influences employees hope on work however if the gender of leaders is considered that is if ambidextrous leadership behaviors are exhibited by female managers the underlying mechanisms through which female ambidextrous leadership affects employees work attitude can differ due to the distinctive information gained from such female leadership according to social information processing theory individuals recognize salient information and their perception and interpretation of the information determines their work attitude because leader gender is salient for employees in less diverse organizations female ambidextrous leadership sends a particular signal about the organizations gender d i climate that is how female workers are treated along with the existence of female leaders their implementation of balanced leadership behaviors and flexibility in practicing exploitative and explorative behaviors signal organizations progender d i climate as such female ambidextrous leadership shapes employees perception that their organization treats employees fairly and has a favorable environment in which individuals different needs and values are supported through the implementation of inclusive policies and practices in progender d i climate such a perception improves employees organizational identity thus motivating them to devote more energy to their work this implies that female ambidextrous leadership helps create a gender d i climate where fair treatment and valuing different ideas are encouraged and different ways of working are accepted in order to achieve employees work goals consequently the flexible leadership behaviors of female leaders motivate employees to be positive and proactive in their work through their perception of progender d i climate this suggests the potential mediating role of a gender d i climate in the relationship between female ambidextrous leadership and employees hope on work therefore the following hypothesis is proposed h2 gender d i climate mediates female ambidextrous leadership and employees hope on work the salient organizational information and its relative importance are different depending on individual social groups according to social identity theory people tend to seek an environment that is of immediate interest and if they perceive that environment is supportive its expected positive effect is relatively greater for them than for those in other social groups generally minority groups are exposed to discrimination and experience unfair treatment in their organizations therefore they are more sensitive to d i climate and their perceptions in this regard have a greater effect on their attitudes and performance compared to majority groups newman et al found that diversity climate increases employees psychological capital thus elevating organizational commitment and reducing turnover intentions however this positive effect of diversity climate is moderated by ethnic identity in studying sales employees in the us mckay et al found that diversity climate has considerable effects on employees belonging to ethnic minorities such climate enhances the employees perceptions of fair and equal treatment of human resources in organizations thus reducing discrimination and conflicts among ethnically different groups and enhancing sales performance companies gender d i climate denotes employees perceptions of companies structured and implemented practices and policies regarding the treatment of female employees the organizational information of gender d i is more salient for female employees who are generally underrepresented and less well treated compared to male employees therefore companies efforts in supporting and embracing female employees will be more important to female employees and will enhance their organizational identity and have a greater positive effect on their motivational and positive state at work based on this reasoning the following hypothesis is proposed h3 the positive link between gender d i climate and employees hope on work depends on employees gender such that the positive effect of gender d i climate is greater on female employees than male employees this develops the following research model figure 1 illustrates the hypothesized research framework materials and methods in this study quantitative longitudinal survey data was collected from employees working for manufacturing companies in japan initially the study targeted large manufacturing companies with over 300 employees however the criteria should be revised because it was difficult to find participants working in large manufacturing companies in japan whose direct supervisor is a woman therefore the bar was lowered and participants whose companies employ more than 100 people joined the data collection was conducted in collaboration with an established survey agency in japan two surveys were conducted with a twoweek gap between them to determine the causal effect of leadership on employees and also to minimize common method bias before the first survey a screening test was conducted to select only participants whose direct supervisor is a woman direct supervisor was defined as the leader who the participants contact report to and consult with on a regular basis in their organization this definition was given to the participants in advance in the first survey the participants were asked about the ambidextrous leadership behaviors of their female direct supervisor and their perception about the organizations gender d i climate the second survey asked about the participants hope on work from the two surveys 311 responses were collected after removing five survey responses that had the same answers for all questions 306 responses remained for the analysis of the remaining respondents 156 were men and 150 were women the average age of the respondents was 438 years old the majority held employeelevel positions followed by assistant manager positions most respondents were highly educated 206 were graduates of a fouryear university program measures ambidextrous leadership was measured using the 14item scale developed by rosing et al the scale describes leaders opening and closing behaviors sample questions relating to leaders opening behaviors are my direct supervisor gives possibilities for independent thinking and acting and my direct supervisor allows different ways of accomplishing a task sample questions relating to leaders closing behaviors are my direct supervisor establishes routines and my direct supervisor monitors and controls goal attainment survey respondents were asked to answer each question by thinking about the frequencies of behaviors exhibited by their leaders using a fivepoint likert scale ranging from 1 to 5 gender male 1 female 0 tenure unit ln total tenure the total period of working to date leader tenure the period of time working with the current leader p 001 p 005 the cronbachs alpha for the ambidextrous leadership is 093 gender d i climate was measured using questions developed to represent the concept due to the unavailability from prior studies and the concepts contextual dependency referring to prior research on diversity climate and interviews with japanese employees questions relating to fair and equal treatment of the genders and female career support and advancement in organizations were developed the five questions are my company has quite a number of female managers my company has diversity practices to support female employees my company motivates female employees to work better my company treats employees fairly regardless of gender and my company is a good place for women to work this concept was rated using a fivepoint likert scale ranging from 1 to 5 the cronbachs alpha for this scale is 085 showing the internal consistency of the questions used in the study hope on work was measured using the 6item scale developed by luthans et al this scale was adapted from the questions developed by snyder et al the questions were intended to measure how hopeful respondents feel about achieving their work goals by developing flexible ideas sample questions are at the present time i am energetically pursuing my work goals and if i should find myself in a jam at work i could think of many ways to get out of it the items were rated on a sixpoint likert scale ranging from 1 to 6 the cronbachs alpha for this concept is 092 control variables were added to the analysis respondents demographic variables were included in the models gender was dummy coded as 1 for the male participants and as 0 for the female participants age was a categorical variable coded from 1 to 5 and education was coded as 1 to 5 position was coded as 1 to 5 with a high number indicating a high position organizational tenure was measured as the total work period expressed in months leader tenure was measured as the period of time working with the current female leader expressed in months results confirmatory factor analysis was conducted to ensure distinctiveness among the variables and the model fit of a threefactor model was compared with that of nested models the goodness of fit indices of the threefactor model confirmed that it fits the model and that the three variables are distinctive comparative fit index 0891 tukerlewis index 0880 root mean square error of approximation 0066 standardized root mean square residual 0061 table 1 presents the mean values standard deviations and correlations of the variables significant correlations were found among the main independent dependent and mediating variables female ambidextrous leadership is significantly correlated with gender d i climate and employees hope on work gender d i climate is also significantly associated with hope on work table 2 shows the results of the hierarchical regression analysis of the variables model 1 included only the demographic variables and the finding shows that the included six demographic variables explain 148 of total variance of hope on work specifically it shows that employees age is related to hope on work in addition education and position have significant effects on employees hope on work female ambidextrous leadership was incorporated into model 2 and the finding showed that it has a significant positive effect on employees hope explaining an additional 47 of the total variance in hope toward work preacher and hayes was employed to reconfirm the significance of the mediation effect the test results indicate that the mediation effect of gender d i climate on the link between female ambidextrous leadership and employees hope on work is significantly valid 0041 0176 therefore hypothesis 2 that assumed the mediating role of gender d i climate between female ambidextrous leadership and employees hope on work is supported model 5 added the interaction term of gender and gender d i climate to test the moderating effect of gender on the relationship between gender d i climate and hope on work hypothesis 3 assumed that gender d i climate is more critical for female employees than male employees therefore the positive effect of gender d i climate on employees hope would be more considerable among female employees than among their male equivalents however model 5 uncovered a nonsignificant moderating effect of gender and the interaction term explains only 09 of the total variance in the dependent variable ie hope on work 0009 the nonsignificance of the value change in model fits also indicated that the moderating term does not determine the dependent variable change in f 3426 p 0065 this finding means that no support was derived for hypothesis 3 discussion the study investigates japanese employees who work with female supervisors and examines the relationships among the ambidextrous leadership of female supervisors gender d i climate and employees hope on work female leadership studies have focused only on examining the perceptions and appraisals of female leadership and the potential organizational benefits of the increases in female leaders however the prior studies ignored the specific and qualitative aspects of female leadership such as its characteristics and the underlying mechanism through which employees are influenced addressing this gap this study focuses on the ambidextrous leadership style of female leaders and its effect on shaping organizations gender d i climate and ultimately its influence on employees hope on work this first empirical findings contribute to enhance understanding of the effectiveness of female leadership style visàvis employees perception of organizational environment and their psychological state regarding their work in japan an interesting and unexpected finding should be addressed the study assumed that the effect of progender d i climate on hope would be greater among female employees than male employees contrastingly the results showed a nonsignificant effect of gender on the relationship between gender d i climate and employee hopea phenomenon that contradicts the view advocated in social identity theory a possible explanation for this result lies in the diversity of individual social identity which thus means that the extent to which a certain social identity is shaped depends on individuals in the same vein the recognition of female identity by women varies per person therefore the extent to which gender d i climate influences on female employees is contingent on their level of female identity that is females who have strong female identity are more remarkably influenced by gender d i climate than those with low female identity such individual differences in female identity among female employees might draw such result another reason for the abovementioned result is that gender d i climate is an immediate and relevant issue not only to female employees but also to their male counterparts progender d i climate signifies an organizations choice to treat employees fairly by fostering an open and flexible organizational climate in which differences in ideas and needs among employees are allowed and accepted such a climate is therefore meaningful to all employees that is it exerts the same effects with no considerable differences whether an employee is female or male theoretical and practical contributions the significance of this research should be addressed first this study contributes to advancing the prior female leadership studies in particular this is the first attempt that disclosed the effectiveness of female ambidextrous leadership in japan the study highlights that female ambidextrous leadership sends a positive signal about companies gender d i management helps shape the perception of progender c i climate among employees and consequently increases employees hopeful and positive energy regarding their works this finding lends a support of ambidextrous leadership theory and social information processing theory considering the paucity in empirical evidence of female leadership effectiveness and its underlying process particularly in japan the findings of showing the positive and procedural effect of female leadership on employees hope on work have a particular academic value contributing to the development of female leadership studies in addition the study contributes to the understanding d i management in the hrm studies as pointed by farndale et al the diversity concept and relevant diversity issue vary across counties the broaddefined concept of diversity prevalent in the west is not applicable in japan because of its specific sociocontextual characteristic therefore this study focused on one aspect of diversity gender d i that is the most relevant to the japanese context referring to prior studies and interviewees responses regarding their perceptions on companies gender d i climate the study developed the fiveitem scale measuring gender d i climate this contextcontingent approach in d i management can capture and explain better the effect of diversity management also the contextcontingent approach with a focus on gender d i can be applied to other eastern contexts such as south korea in which gender d i is the most relevant and immediate diversity aspect as similar as japan taking the contextcontingency view this study broadens the perspective understanding d i management contributing to developing the current d i management studies related to this given that human resources are a valuable source of organizational growth and sustainability the finding regarding the positive effect of gender d i climate on employees hope has a significant implication organizations initiatives in terms of gender d i and shaping gender d i climate indicate they are making an effort to treat their employees fairly and equally such efforts are favored by employees thus employees show optimistic and hopeful attitudes at their work this psychological process implies that organizations stance about gender d i management signaled by female ambidextrous leadership shapes progender d i climate which thus is linked to the increased work motivation of employees more importantly the lack of moderation from gender on the effect of gender d i climate on employees hope reflects that such a positive effect of progender d i climate on shaping employees positive work attitudes is not confined to a particular gender in other words favorable perceptions about d i practices and management in japanese companies can benefit and increase all employees hope regardless of gender the finding further signifies that japanese employees are conscious of and favor d i management if they believe the climate in their organizations to be gender inclusive they are more motivated and engaged in their work therefore companies should actively implement gender d i management to shape a climate that favors gender d i such efforts not only increase the psychological capital of employees but also enhance their productivity and financially benefit companies in clarifying the direct influence of gender d i climate on employees hope the study contributes to the development of prior diversity management studies in japan expected practical implications are also worth noting first the findings may motivate japanese companies to embrace and cultivate female leaders and welcome the advantages of implementing gender d i management japan has a strongly stereotyped view of gender roles and a firm belief in role congruity with leadership seen as equivalent to direction by males this stereotype and the reluctance to initiate changes have delayed the implementation of gender d i management in japanese companies this delay in turn has given rise to explicit and implicit disadvantages for women discouraging female talents from aspiring for career advancement the upshot of all these is the loss of company competitiveness the results of this study can serve as reference for japanese companies that want to eliminate the longstanding social misunderstanding of gender roles and concerns about female advancement the finding on the positive effects of female leadership on employees work motivation and energy can convince japanese companies that it is advisable to embrace gender diversity and that they can expect potential benefits from this initiative the acceptance of gender diversity shapes institutional norms regarding gender d i management in japan as the institutional normalization of gender diversity facilitates its direct and indirect financial benefits by assuring stakeholders of the advantages of such management industryand societywide social acceptance is expected to bear fruit for japanese companies who engage in gender d i actively the findings can also be useful in the leadership development of japanese companies the results indicated that the ambidextrous leadership skills of female leaders enable them to effectively increase perceptions regarding on progender d i climate and enhance employees hope on work this finding can be utilized to companies to identify educate and train female employees for leadership positions focusing on the ambidextrous nature of leadership companies can find female employees who are capable of exhibiting such leadership behaviors or they can foster such leadership skills of potential leaders by designing and providing leadership training programs such efforts will benefit companies to achieve diversity management effectively and thus draw successful and sustainable outcomes from it limitations and future research despite the aforementioned implications the study has some limitations first the study only focused on the ambidextrous behaviors associated with female leadership even if the findings indicate that female leaders exhibit such ambidextrous leadership behaviors and that such leadership influences employees positively the study did not consider other female leadership styles prior studies revealed that female leaders exert transformational behaviors more than male leaders and also such female transformational leadership is as effective as male leadership therefore future studies should investigate other female leadership styles together with ambidextrous female leadership by comparing and contrasting different female leadership styles future studies can clarify the exact attributes of female leadership and the effects on employees second this study investigated only employees hope on work as a consequence of female leadership however other workrelated concepts such as work commitment psychological empowerment organizational citizenship behavior and innovative behavior may be associated with female ambidextrous leadership considering the potential relationship between female ambidextrous leadership and other positive attitudinal and behavioral concepts future studies should examine other potential target variables that female ambidextrous leadership may influence adding these variables and determining their relationship with female ambidextrous leadership will enhance the understanding of this leadership style and its potential and practical impact on employees related to this the research model may be inapplicable to other research contexts the study showed that direct ambidextrous leadership by females denotes organizational diversity management and shapes employees perception of progender d i climate in organizations this indicates that female leaders serve as change agents of organizations not merely cogs in a machine however depending on the social cognition of gender in organizations and general viewpoints regarding female leadership this research model may or may not be supported therefore to generalize the research model it necessitates investigating female leaders roles along with general perceptions and evaluations of female leadership in the future studies finally this study did not control for organizational factors given that the attitudes of individuals about their organizations and jobs are influenced by socioenvironmental factors researchers should explore other social and environmental determinants such as the quality of the relationship between employees and their female supervisors organizational structure organizational support and work design as these may influence how employees view their organizations and shape their attitudes toward work future studies should incorporate and regulate the potential effects of such factors to validate and generalize the research model put forward in the current work conclusion japan the homogenous and aging society is facing the shortage in their workforce which diminishes their business competitiveness one effective solution that japanese companies can choose may be to engage in and implement gender d i management effectively focusing on the significant meaning of gender d i in japan this study addresses this issue building on social informational processing theory and social identity theory the study examined female ambidextrous leaderships effect on employees hope on work and its underlying mechanism findings showed that female ambidextrous leadership strengthens employees perception on progender d i climate of their organizations this improved perception of progender d i climate contributes to increase employees positive and hopeful energy at work in addition the positive effect of progender d i climate on employees hope is the same for all employees regardless of gender the findings highlight the effective female leadership style and its positive effect on shaping employees positive work attitude therefore the study contributes to the development of female leadership and diversity management studies in japan in addition the study provides empirical evidence of the positive effects of female leadership on employees and highlights the potential benefits of gender d i by advancing and cultivating female leaders in japanese companies data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements conflict of interest the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

there are two wellknown truths about japan one is that japan is one of the most advanced economies which takes pride in its highly advanced technology social infrastructure and system the other is that japan ranks lowest at womens social participation among organization for economic cooperation and development countries even though the japanese government has initiated programs to promote female participation and advancement in society these initiatives have not yet borne remarkable fruit this study intends to address this issue by investigating the effectiveness of female leadership in japan specifically its effect on organizations gender diversity and inclusion d i climate and employees taskrelated positive attitudes synthesizing social information processing theory and social identity theory the study examines 306 japanese employees working with their female supervisors in mediumand largesized manufacturing companies the findings show that female ambidextrous leadership contributes to shape and strengthen a gender d i climate and ultimately enhances employees hope on their work in addition the positive effect of a gender d i climate on employees hope is the same for all employees regardless of gender the findings clarify the role of female leadership and the underlying psychological mechanism through which female leadership influences employees positive work attitudes this first empirical study in japan contributes to the research on female leadership and d i management

Introduction The smartphone has become the most frequently used technology worldwide and is seen as a necessity in modern society [1]. Due to the multifunctionality of smartphones, they have become essential information and communication tools of daily life [2]. Smartphone ownership has been growing rapidly worldwide; for example, the rate in the US increased from 35% in 2011 to 64% in 2015 [3], and smartphone ownership among South Koreans in 2016 was 88%, which is the highest in the world [1]. Particularly among adolescents, who are in the forefront of new technology and media use [4], smartphones have become an important part of life. Some 97% of adolescents in Switzerland [5] and 84% of adolescents in Japan [6] have reported having their own smartphone. Adolescents can be more vulnerable to the adverse effects of smartphone use because they are uncritically receptive and easily adapt to new technologies. In addition, they are sensitive to the influence of their environment and peers. A study by Jo et al. found that adolescents are vulnerable to smartphone addiction, which is similar to substance addiction and other types of behavioral addiction [7]. For example, 60% of UK adolescents have admitted that they are highly addicted to their smartphones [6], and according to a government survey in South Korea the smartphone addiction rate among adolescents was 18%, double the 9.1% addiction rate for adults [6,8]. In another study, the percentage of adolescents with addictive smartphone usage was 80%, whereas the rate was 58% among adults [9]. A prior study has indicated that smartphone usage time is closely related to smartphone addiction and provided better indicators for smartphone addiction than any others [5]. Furthermore, some studies suggest that excessive smartphone use by adolescents, who are vulnerable to emotional changes and interpersonal issues, could be associated with various psychopathologies and behavioral problems [10][11][12]. Smartphones are useful for multiple purposes, including general productivity enhancement, information seeking, social interaction, diversion, relaxation, and entertainment [13]. Smartphones also provide enhanced educational productivity [14]. However, numerous studies have indicated that although smartphones can be useful, their overuse can result in a range of problems that are similar to internet overuse. Excessive smartphone use has been related to significant risks to well-being [15], and it also has adverse effects on physical [16,17] and mental health [11]. Excessive use of smartphones is also associated with decreased productivity and is negatively related to students' academic performance [18]. Specifically, excessive smartphone use has been associated with various psychopathologies and behavioral problems in adolescents. In a study on university students, the authors found that certain psychological characteristics, such as depression, anxiety, type A personality, high stress levels, and low mood might predispose students to excessive smartphone use [10]. The results of another study focusing on young adults suggested a positive relationship between excessive smartphone use and stress, a negative relationship between excessive smartphone use and academic performance, and a mediated negative relationship between excessive smartphone use and life satisfaction [18]. Despite the possible associations between excessive smartphone use and mental health outcomes, few studies have specifically examined its relationship to suicidal behaviors, one of the most important and critical factors in adolescent mental health. In our study, we used a school-based, nationally representative data set of the Korean adolescent population to investigate the association between time spent on a smartphone and suicide. The running hypothesis of this study was that spending more time on a smartphone might increase suicide attempts. This study also assumed that conflicts with family, conflicts with friends, and poor academic performance were linked with both smartphone use and suicide because interpersonal issues and academic burden are among the most important of risk factors for adolescent suicide attempt [19][20][21][22]. --- Method --- Study population and data collection Data on the study population were obtained from the 13th Korea Youth Risk Behavior Webbased Survey , which was administered in 2017 by the Korean Ministry of Education, Science and Technology, the Ministry of Health and Welfare, and the Korea Centers for Disease Control and Prevention. The KYRBS is a nationally representative sample of Korean adolescents that originally included over 123 questions in 13 domains of health-risk behaviors [23]. To select a representative sample, a multi-stage clustered probability design based on the administrative district and school grade was adopted. In the 13th KYRBS, a total 62,276 students from 799 schools responded to the survey [24]. Written informed consent was obtained from each participant prior to the survey. All the data used in this study were fully anonymized before access and were analyzed anonymously. This consent procedure was approved by the Institutional Review Board of the Korea Centers for Disease Control and Prevention . --- Measures The exposure variable, the number of hours spent using a smartphone, was assessed by the question "On an average school day, how many hours do you use a smartphone?" Participants were divided into four groups according to the time spent in smartphone use: less than 1 h; 1-2 h; 3-4 h; and 5 h or more a day [5]. We also adopted the concepts proposed in previous studies to identify and categorize the main purpose of using a smartphone [25]. From the question, "In the last 30 days, please select only one service that you used mainly, when using your smartphone," 13 answers were possible, and the answers were classified into two categories: process purposes and videos, and online shopping) and social purposes . From the question, "In the last 30 days, have you ever experience the severe conflicts with family due to your smartphone usage?" and "In the last 30 days, have you ever experience the severe conflicts with friends due to your smartphone usage?", participants were asked whether they had experienced any conflicts with family and conflicts with friends due to smartphone use , which would suggest a tolerance that is one of the important factors of smartphone addiction [26]. They were also asked whether they had experienced poor academic performance due to smartphone use , by the question "In the last 30 days, were there any difficulties in your academic performance due to your smartphone usage?", which would suggest a daily disturbance due to smartphone addiction [26]. The outcome variable, suicide attempt, was assessed by the question "During the past 12 months, did you ever attempt suicide?" Participants responded with one of the following: No, I never attempted suicide; or Yes, I have attempted suicide at least once. For the control variables, the sociodemographic and general characteristics employed included age, sex, residential area, family economic status, hours of sleep, subjective stress, current alcohol consumption, cigarette smoking, and violence, all of which the literature has linked to suicidal behaviors. Respondents who lived in the country or in rural areas were categorized as "rural area"; those who lived in small-to middle-sized areas were categorized as "small city"; and those who lived in large cities were categorized as "large city". Family economic status was assessed by the question, "What is your family's economic status?" The five possible response categories were combined into three subgroups: high ; middle ; and low [27]. Sleep hours were divided into two categories: under 6 h; and 6 or more hours. We also evaluated the subjective stress level of the participants by asking "How much stress do you usually feel?" The five possible response categories were the same as the five noted above. Participants were also asked about their current alcohol consumption and cigarette smoking . To measure violence, we used the question: "Have you had any experience of receiving treatment at a hospital for violence from friends, superiors?" . --- Statistical analysis The participants' characteristics according to each quartile of smartphone use were summarized using either a one-way analysis of variance for continuous variables or a chi-squared test for categorical variables with Bonferroni correction. We also performed a chi-squared test and a binary logistic regression analysis to investigate the proportion of responses to the main purpose of smartphone use for each quartile. To analyze the associations between the adolescents' smartphone use and its adverse consequences, univariate logistic regression tests were performed using "smartphone use" as the principal predictor and each adverse consequence as the main outcome variables. Given that adolescent suicide attempts can be influenced by a number of intertwined emotional problems such as interpersonal problems and academic stress [28,29], we extended the previous analyses to take into account the effects of smartphone use on suicidal behavior. We first analyzed smartphone usage regarding their association with conflicts with family, conflicts with friends, and poor academic performance, all of which can influence attempts at suicide. We then analyzed the association between smartphone use and suicide attempts through multivariable logistic regression, adjusting for conflicts with family, conflicts with friends, and poor academic performance, along with other covariates. Finally, the odds ratios for suicide attempts in terms of conflicts with family, conflicts with friends, and poor academic performance due to smartphone use were calculated using multiple logistic regression analyses with complex sampling, adjusting for age, sex, residential area, family economic status, hours of sleep, subjective stress, current alcohol consumption, cigarette smoking, and violence. Considering the different association between psychosocial risk factors and mental health outcomes with respect to gender in previous study, the analysis were assessed after stratifying the subjects by gender [30,31]. All the ORs were also stratified by the main purpose of smartphone use. Two-tailed analyses were conducted, and P-values lower than 0.05 were considered significant. Adjusted ORs and 95% confidence intervals were calculated. All the statistical analyses were performed using SPSS software . --- Results Table 1 shows the descriptive characteristics according to the quartiles of length of smartphone use. The participants used a smartphone for a mean 180.12 min per day. The results showed the proportion of girls, living in a large city, with middle-to-low family economic status, with less than 6 h of sleep, with high subjective stress levels, with current alcohol consumption, with current cigarette smoking, and having experienced violence, became significantly higher as the quartile of smartphone use time increased . Table 2 shows the smartphone usage rates according to purposes of smartphone. The time spent on social purposes was greater than that spent on process purposes. In particular, the girls were more likely to use the smartphones for social purposes at all usage levels, whereas the boys used the smartphones more for social than process purposes only when their usage was 5 or more hours a day. The ORs for using the smartphone for social purposes were 1.73 and 2.77 in boys and girls, respectively. Because the purpose for using the smartphone was related to the time spent on the device, we performed a sub-analysis including the purpose. Adverse consequences of smartphone use, including conflicts with family, conflicts with friends, and poor academic performance, showed significant associations with the amount of spent time on the smartphone in the logistic regression analyses . In both boys and girls, the associations were more prominent in smartphone use for process purposes. Independent variables, such as conflicts with family due to smartphone use and conflicts with friends due to smartphone use were positively associated with suicide attempts; however, poor academic performance due to smartphone use was not . Therefore, the conflicts with family and conflicts with friends due to smartphone use were adjusted to analyze the association between time spent on a smartphone and suicide attempts. Longer time on a smartphone was significantly associated with suicide attempts in the multivariable logistic regression analyses . Adolescents reporting 3-4 h and 5 h or more of daily smartphone use were significantly more likely to report a suicide attempt over the previous year compared with adolescents reporting less than 1 h of daily use. In adolescents who used a smartphone for process purposes, all levels from 1-2 to 5 h or more of smartphone use were related to suicide attempts compared with less than 1 h. However, in adolescents who used a smartphone for social purposes, 1-2 h of smartphone use was shown to be protective against suicide attempts, with an AOR of 0.83 . The subgroup analyses by sex also showed comparable results in each logistic analysis. --- Discussion This study examined the association of smartphone use and suicide attempts within a relatively large convenience sample of adolescents in Korea. Four key factors associated with smartphone use were assessed. First, the main purposes of smartphone use are as follows: process purposes or social purposes determined the adolescents' levels of use. Among both boys and girls, high smartphone use was associated with more time using the smartphone for social purposes. Second, conflicts with family, conflicts with friends and poor academic performance were significantly related to greater use of a smartphone. Furthermore, both boys and girls were more likely to show adverse effects from using smartphones for process purposes, and girls were found to be more prone to adverse consequences from smartphone overuse compared with boys, regardless of the main purpose for use. Third, smartphone overuse and conflicts with family and conflicts with friends related to smartphone use predicted suicidal behaviors, however, poor academic performance due to smartphone use did not. In particular, both girls having family conflicts due to using a smartphone for social purposes and boys conflicting with friends due to using a smartphone for process purposes showed a higher correlation with suicide attempts. Finally, after adjusting for all the factors listed above, there was a significant association between time spent on a smartphone and suicide attempts among both boys and girls. The relevance was greater when adolescents used smartphones for process purposes. We also found a potential protective effect from moderate use of a smartphone for social purposes with regard to suicide attempts. The results of this study are largely consistent with the findings of previous studies. In terms of the potential problematic role of smartphone use in promoting adolescents' negative affect and psychopathologies, a previous systematic review by Elhai et al. reported on associations between excessive smartphone use and both depression and anxiety severity, and they also found some support for increased stress and reduced self-esteem [11]. A prior longitudinal study has suggested that the rapid adoption of smartphone technology can have a markedly negative impact on adolescents' psychological well-being due to their spending more time on electronic communication and less time on nonscreen activities, such as in-person social interaction [32]. Our study indicated that the major problems of suicidal behavior as well as conflicts with family, conflicts with friends, and poor academic performance should be addressed in adolescents with high smartphone use. In addressing the relationship between smartphone use and suicide attempts, the results of this study should be considered under the prevalent understanding of media screen use, including use of the internet. Most research focusing on similar topics has addressed the associations between internet overuse and psychological distress and suicidal behaviors. A nationally representative study of adolescents in the US found an association between excessive internet use and risks for adolescent suicide [33]. Another study that had been implemented within the framework of the European Union project, with a sample of 11,356 school-based adolescents, indicated a correlation between problematic internet use and suicidal behaviors [34]. Most smartphone use is internet based, and addictive use can show many similarities to internet addiction [35], however, there are also some unique characteristics of smartphone such as ubiquity and immediacy. Due to the nature of the smartphone's easy and direct communication [26], it has been reported that smartphone addiction has a greater association with a desire for interpersonal relationships and is less related to features of social introversion than internet addiction [36]. Indeed, in our study, adolescents had more adverse consequences from the use of smartphones for process purposes compared with social purposes, and the conflicts with family and conflicts with friends related to smartphone use predicted suicidal behavior. The association between the time spent on a smartphone and suicide attempts might be partially influenced by conflicts with family and conflicts with friends due to smartphone use. The effects of high smartphone use on interpersonal relationships could contribute to poor mental health in adolescents. Social deficits and withdrawal are known to be associated with depression, and depressed individuals tend to become preoccupied with the nonsocial aspects of technology use [37]. A prior study on Korean adolescents had indicated a significant association between smartphone addiction and family dysfunction or poor family relationships [12], and a recent study has indicated that adolescent excessive smartphone use was negatively associated with friendship satisfaction [38]. Smartphones can reduce the quality of interpersonal relationships in the real world because it omits many social cues, such as "nonverbal cues," and involves less control of disclosure [39]. There have also been reports of a significant association between smartphone use and poor social skills [40], which leads to poor mental health in adolescents. Consequently, smartphone use was proportionally related to social distress, and its association with suicide attempts might be partially influenced by stress caused by conflicts with others, as demonstrated in the present study. Our results from the stratification analysis of the main purposes for using a smartphone confirmed that there is a greater association between suicide attempts and using a smartphone for process purposes compared with using it for social purposes. These findings are similar to a recent smartphone study that found a closer relationship between smartphones used for process purposes and anxiety severity compared with those used for social purposes [25]. Some researchers have also suggested that pleasurable experiences that potentially result from process purposes-oriented smartphone use might result in losing behavioral control [13]. The results indicated that further research is needed to assess the different aspects on the purpose of smartphone usage and to expand them as a preventive or a treatment tool for adolescent suicidal behavior. A number of studies have suggested that behavioral addictions, such as gambling, internet usage, and gaming, might share neurobiological mechanisms with substance addiction and that they have similarities including urges and cravings [41,42]. Moreover, studies have shown that addictive smartphone use including excessive usage time, is related to impulsivity, and high impulsivity is a psychological risk factor for developing addiction to social networking sites among smartphone users [7,[43][44][45]. Adolescence is an important period for brain development, and overuse of a smartphone during adolescence has been shown to decrease functional connectivity in the anterior insula and the primary motor cortex [46], altering higher executive functions that promote continued risk for developing substance and behavioral addiction, mood dysregulations, and impulsive behavior [47]. These negative neurological and psychological traits might contribute to aggravating risk behaviors in adolescents with high smartphone use, including suicide attempts. Future studies on excessive use of smartphone, psychopathologies, and addictive personality characteristics might provide important insights into addiction-related risk behaviors, including suicide attempts. Considering the increasing rate of smartphone use among adolescents in recent years, effective strategies are needed to prevent high smartphone use-related adverse mental health outcomes. --- Limitations and strengths The present study has several limitations. First, due to the cross-sectional nature of national surveys, causal inferences based on the findings from this present study might not be valid. Longitudinal studies are necessary to further investigate the risk and protective factors of smartphone use for suicidal behavior. Second, the level of smartphone use was calculated by self-reported answers, and participants were grouped into quartiles by time on a smartphone rather than smartphone addiction scales. However, excessive smartphone use was validated as the most powerful independent predictor of smartphone addiction in the previous study [10]. In addition, longer smartphone use was found to be a significant predictor of smartphone addiction, which was diagnosed by the validated smartphone addiction scale [5]. Third and last, most variables in the study, including conflicts with family/friends and poor academic performance due to smartphone use, and suicide attempts, were surveyed on the basis of a self-reported questionnaire, which has inherent limitations regarding the validity of the data and the recall bias. Therefore, further studies not only with self-reported psychiatric pathologies but also with more precise evaluation and diagnosis are needed to provide stronger evidence of an association between smartphone use and suicidal behavior in adolescents. However, the strength of the present study included the use of a multilevel multinomial logistic modeling approach based on a nationally representative sample of Korean adolescents, who have the highest smartphone ownership rate in the world [1]. Considering the possibility of increased use of smartphones worldwide in the future, the results of the present study could be a cornerstone for future research on issues related to their use among adolescents. Additionally, to our knowledge, this is the first study to investigate the association between adverse consequences of smartphone overuse and suicide attempts. --- Conclusion It is noteworthy that we confirmed a significant and specific relationship between time spent on a smartphone and the prevalence of attempted suicide, independent of other problems associated with smartphone use, in a nationally representative sample of adolescents in Korea, even when controlling for conflicts with family, conflicts with friends, and poor academic performance. In addition, our findings indicate that high smartphone use for process purposes ultimately turned out to have stronger associations with negative outcomes, whereas moderate smartphone use for social purposes showed some protection against attempted suicide. The results of this study suggest that consideration should be given to improving screening and prevention for mental health problems in adolescents with excessive use of smartphones. Further research is needed to understand the impact of specific length of time using a smartphone on the mental health of adolescents to develop preventive approaches and to help strengthen current smartphone use guidelines. --- All data files are available from the 'Korea Youth Risk Behavior Web-based Survey ' database, http:// www.cdc.go.kr/yhs/. --- --- Data curation: Seongho Min, Joung-Sook Ahn, Jinhee Lee. Formal analysis: Seongho Min, Joung-Sook Ahn, Jinhee Lee. --- Methodology: Jinhee Lee. Validation: Min-Hyuk Kim, Seongho Min, Joung-Sook Ahn, Chisoo An, Jinhee Lee. Writing -original draft: Jinhee Lee. Writing -review & editing: Jinhee Lee.

This study aims to evaluate the association between smartphone use and suicide attempts, independent of possible confounders, including conflicts with family/friends and poor academic performance due to smartphone use. Data were obtained from the 2017 Korea Youth Risk Behavior Web-based Survey, a nationally representative survey of middle-and highschool students (N = 62,276). Time spent using a smartphone was divided into four categories: less than 1 h, 1-2 h, 3-4 h, and 5 h or more a day. The association of conflicts with family due to smartphone use, conflicts with friends due to smartphone use, and poor academic performance due to smartphone use with suicide attempts and time spent using a smartphone were analyzed using multiple and binary logistic regression analyses, respectively. The relationship between time spent on a smartphone and suicide attempts was analyzed using a multiple logistic regression analysis. All analyses were also stratified according to the main purpose of smartphone use (process purposes/social purposes). Conflicts with family/friends due to smartphone use was significantly associated with suicide attempts (P <0.001). The variables of conflicts with family, conflicts with friends and poor academic performance were also proportionally related to higher smartphone use (P <0.001). The use of a smartphone was significantly associated with suicide attempts in a multiple logistic regression analysis (adjusted odds ratio for smartphone use 5 h or more a day 2.16; 95% CI 2.07-2.26; P <0.001), and the association was more prominent with smartphone use for process purposes. Conflicts with family, conflicts with friends, poor academic performance, and suicide attempts were related to higher smartphone use in Korean adolescents. Time spent on a smartphone was positively related to suicide attempts, even after adjusting for conflicts with family members or friends and poor academic performance due to smartphone use.

introduction the smartphone has become the most frequently used technology worldwide and is seen as a necessity in modern society 1 due to the multifunctionality of smartphones they have become essential information and communication tools of daily life 2 smartphone ownership has been growing rapidly worldwide for example the rate in the us increased from 35 in 2011 to 64 in 2015 3 and smartphone ownership among south koreans in 2016 was 88 which is the highest in the world 1 particularly among adolescents who are in the forefront of new technology and media use 4 smartphones have become an important part of life some 97 of adolescents in switzerland 5 and 84 of adolescents in japan 6 have reported having their own smartphone adolescents can be more vulnerable to the adverse effects of smartphone use because they are uncritically receptive and easily adapt to new technologies in addition they are sensitive to the influence of their environment and peers a study by jo et al found that adolescents are vulnerable to smartphone addiction which is similar to substance addiction and other types of behavioral addiction 7 for example 60 of uk adolescents have admitted that they are highly addicted to their smartphones 6 and according to a government survey in south korea the smartphone addiction rate among adolescents was 18 double the 91 addiction rate for adults 68 in another study the percentage of adolescents with addictive smartphone usage was 80 whereas the rate was 58 among adults 9 a prior study has indicated that smartphone usage time is closely related to smartphone addiction and provided better indicators for smartphone addiction than any others 5 furthermore some studies suggest that excessive smartphone use by adolescents who are vulnerable to emotional changes and interpersonal issues could be associated with various psychopathologies and behavioral problems 10 11 12 smartphones are useful for multiple purposes including general productivity enhancement information seeking social interaction diversion relaxation and entertainment 13 smartphones also provide enhanced educational productivity 14 however numerous studies have indicated that although smartphones can be useful their overuse can result in a range of problems that are similar to internet overuse excessive smartphone use has been related to significant risks to wellbeing 15 and it also has adverse effects on physical 1617 and mental health 11 excessive use of smartphones is also associated with decreased productivity and is negatively related to students academic performance 18 specifically excessive smartphone use has been associated with various psychopathologies and behavioral problems in adolescents in a study on university students the authors found that certain psychological characteristics such as depression anxiety type a personality high stress levels and low mood might predispose students to excessive smartphone use 10 the results of another study focusing on young adults suggested a positive relationship between excessive smartphone use and stress a negative relationship between excessive smartphone use and academic performance and a mediated negative relationship between excessive smartphone use and life satisfaction 18 despite the possible associations between excessive smartphone use and mental health outcomes few studies have specifically examined its relationship to suicidal behaviors one of the most important and critical factors in adolescent mental health in our study we used a schoolbased nationally representative data set of the korean adolescent population to investigate the association between time spent on a smartphone and suicide the running hypothesis of this study was that spending more time on a smartphone might increase suicide attempts this study also assumed that conflicts with family conflicts with friends and poor academic performance were linked with both smartphone use and suicide because interpersonal issues and academic burden are among the most important of risk factors for adolescent suicide attempt 19 20 21 22 method study population and data collection data on the study population were obtained from the 13th korea youth risk behavior webbased survey which was administered in 2017 by the korean ministry of education science and technology the ministry of health and welfare and the korea centers for disease control and prevention the kyrbs is a nationally representative sample of korean adolescents that originally included over 123 questions in 13 domains of healthrisk behaviors 23 to select a representative sample a multistage clustered probability design based on the administrative district and school grade was adopted in the 13th kyrbs a total 62276 students from 799 schools responded to the survey 24 written informed consent was obtained from each participant prior to the survey all the data used in this study were fully anonymized before access and were analyzed anonymously this consent procedure was approved by the institutional review board of the korea centers for disease control and prevention measures the exposure variable the number of hours spent using a smartphone was assessed by the question on an average school day how many hours do you use a smartphone participants were divided into four groups according to the time spent in smartphone use less than 1 h 12 h 34 h and 5 h or more a day 5 we also adopted the concepts proposed in previous studies to identify and categorize the main purpose of using a smartphone 25 from the question in the last 30 days please select only one service that you used mainly when using your smartphone 13 answers were possible and the answers were classified into two categories process purposes and videos and online shopping and social purposes from the question in the last 30 days have you ever experience the severe conflicts with family due to your smartphone usage and in the last 30 days have you ever experience the severe conflicts with friends due to your smartphone usage participants were asked whether they had experienced any conflicts with family and conflicts with friends due to smartphone use which would suggest a tolerance that is one of the important factors of smartphone addiction 26 they were also asked whether they had experienced poor academic performance due to smartphone use by the question in the last 30 days were there any difficulties in your academic performance due to your smartphone usage which would suggest a daily disturbance due to smartphone addiction 26 the outcome variable suicide attempt was assessed by the question during the past 12 months did you ever attempt suicide participants responded with one of the following no i never attempted suicide or yes i have attempted suicide at least once for the control variables the sociodemographic and general characteristics employed included age sex residential area family economic status hours of sleep subjective stress current alcohol consumption cigarette smoking and violence all of which the literature has linked to suicidal behaviors respondents who lived in the country or in rural areas were categorized as rural area those who lived in smallto middlesized areas were categorized as small city and those who lived in large cities were categorized as large city family economic status was assessed by the question what is your familys economic status the five possible response categories were combined into three subgroups high middle and low 27 sleep hours were divided into two categories under 6 h and 6 or more hours we also evaluated the subjective stress level of the participants by asking how much stress do you usually feel the five possible response categories were the same as the five noted above participants were also asked about their current alcohol consumption and cigarette smoking to measure violence we used the question have you had any experience of receiving treatment at a hospital for violence from friends superiors statistical analysis the participants characteristics according to each quartile of smartphone use were summarized using either a oneway analysis of variance for continuous variables or a chisquared test for categorical variables with bonferroni correction we also performed a chisquared test and a binary logistic regression analysis to investigate the proportion of responses to the main purpose of smartphone use for each quartile to analyze the associations between the adolescents smartphone use and its adverse consequences univariate logistic regression tests were performed using smartphone use as the principal predictor and each adverse consequence as the main outcome variables given that adolescent suicide attempts can be influenced by a number of intertwined emotional problems such as interpersonal problems and academic stress 2829 we extended the previous analyses to take into account the effects of smartphone use on suicidal behavior we first analyzed smartphone usage regarding their association with conflicts with family conflicts with friends and poor academic performance all of which can influence attempts at suicide we then analyzed the association between smartphone use and suicide attempts through multivariable logistic regression adjusting for conflicts with family conflicts with friends and poor academic performance along with other covariates finally the odds ratios for suicide attempts in terms of conflicts with family conflicts with friends and poor academic performance due to smartphone use were calculated using multiple logistic regression analyses with complex sampling adjusting for age sex residential area family economic status hours of sleep subjective stress current alcohol consumption cigarette smoking and violence considering the different association between psychosocial risk factors and mental health outcomes with respect to gender in previous study the analysis were assessed after stratifying the subjects by gender 3031 all the ors were also stratified by the main purpose of smartphone use twotailed analyses were conducted and pvalues lower than 005 were considered significant adjusted ors and 95 confidence intervals were calculated all the statistical analyses were performed using spss software results table 1 shows the descriptive characteristics according to the quartiles of length of smartphone use the participants used a smartphone for a mean 18012 min per day the results showed the proportion of girls living in a large city with middletolow family economic status with less than 6 h of sleep with high subjective stress levels with current alcohol consumption with current cigarette smoking and having experienced violence became significantly higher as the quartile of smartphone use time increased table 2 shows the smartphone usage rates according to purposes of smartphone the time spent on social purposes was greater than that spent on process purposes in particular the girls were more likely to use the smartphones for social purposes at all usage levels whereas the boys used the smartphones more for social than process purposes only when their usage was 5 or more hours a day the ors for using the smartphone for social purposes were 173 and 277 in boys and girls respectively because the purpose for using the smartphone was related to the time spent on the device we performed a subanalysis including the purpose adverse consequences of smartphone use including conflicts with family conflicts with friends and poor academic performance showed significant associations with the amount of spent time on the smartphone in the logistic regression analyses in both boys and girls the associations were more prominent in smartphone use for process purposes independent variables such as conflicts with family due to smartphone use and conflicts with friends due to smartphone use were positively associated with suicide attempts however poor academic performance due to smartphone use was not therefore the conflicts with family and conflicts with friends due to smartphone use were adjusted to analyze the association between time spent on a smartphone and suicide attempts longer time on a smartphone was significantly associated with suicide attempts in the multivariable logistic regression analyses adolescents reporting 34 h and 5 h or more of daily smartphone use were significantly more likely to report a suicide attempt over the previous year compared with adolescents reporting less than 1 h of daily use in adolescents who used a smartphone for process purposes all levels from 12 to 5 h or more of smartphone use were related to suicide attempts compared with less than 1 h however in adolescents who used a smartphone for social purposes 12 h of smartphone use was shown to be protective against suicide attempts with an aor of 083 the subgroup analyses by sex also showed comparable results in each logistic analysis discussion this study examined the association of smartphone use and suicide attempts within a relatively large convenience sample of adolescents in korea four key factors associated with smartphone use were assessed first the main purposes of smartphone use are as follows process purposes or social purposes determined the adolescents levels of use among both boys and girls high smartphone use was associated with more time using the smartphone for social purposes second conflicts with family conflicts with friends and poor academic performance were significantly related to greater use of a smartphone furthermore both boys and girls were more likely to show adverse effects from using smartphones for process purposes and girls were found to be more prone to adverse consequences from smartphone overuse compared with boys regardless of the main purpose for use third smartphone overuse and conflicts with family and conflicts with friends related to smartphone use predicted suicidal behaviors however poor academic performance due to smartphone use did not in particular both girls having family conflicts due to using a smartphone for social purposes and boys conflicting with friends due to using a smartphone for process purposes showed a higher correlation with suicide attempts finally after adjusting for all the factors listed above there was a significant association between time spent on a smartphone and suicide attempts among both boys and girls the relevance was greater when adolescents used smartphones for process purposes we also found a potential protective effect from moderate use of a smartphone for social purposes with regard to suicide attempts the results of this study are largely consistent with the findings of previous studies in terms of the potential problematic role of smartphone use in promoting adolescents negative affect and psychopathologies a previous systematic review by elhai et al reported on associations between excessive smartphone use and both depression and anxiety severity and they also found some support for increased stress and reduced selfesteem 11 a prior longitudinal study has suggested that the rapid adoption of smartphone technology can have a markedly negative impact on adolescents psychological wellbeing due to their spending more time on electronic communication and less time on nonscreen activities such as inperson social interaction 32 our study indicated that the major problems of suicidal behavior as well as conflicts with family conflicts with friends and poor academic performance should be addressed in adolescents with high smartphone use in addressing the relationship between smartphone use and suicide attempts the results of this study should be considered under the prevalent understanding of media screen use including use of the internet most research focusing on similar topics has addressed the associations between internet overuse and psychological distress and suicidal behaviors a nationally representative study of adolescents in the us found an association between excessive internet use and risks for adolescent suicide 33 another study that had been implemented within the framework of the european union project with a sample of 11356 schoolbased adolescents indicated a correlation between problematic internet use and suicidal behaviors 34 most smartphone use is internet based and addictive use can show many similarities to internet addiction 35 however there are also some unique characteristics of smartphone such as ubiquity and immediacy due to the nature of the smartphones easy and direct communication 26 it has been reported that smartphone addiction has a greater association with a desire for interpersonal relationships and is less related to features of social introversion than internet addiction 36 indeed in our study adolescents had more adverse consequences from the use of smartphones for process purposes compared with social purposes and the conflicts with family and conflicts with friends related to smartphone use predicted suicidal behavior the association between the time spent on a smartphone and suicide attempts might be partially influenced by conflicts with family and conflicts with friends due to smartphone use the effects of high smartphone use on interpersonal relationships could contribute to poor mental health in adolescents social deficits and withdrawal are known to be associated with depression and depressed individuals tend to become preoccupied with the nonsocial aspects of technology use 37 a prior study on korean adolescents had indicated a significant association between smartphone addiction and family dysfunction or poor family relationships 12 and a recent study has indicated that adolescent excessive smartphone use was negatively associated with friendship satisfaction 38 smartphones can reduce the quality of interpersonal relationships in the real world because it omits many social cues such as nonverbal cues and involves less control of disclosure 39 there have also been reports of a significant association between smartphone use and poor social skills 40 which leads to poor mental health in adolescents consequently smartphone use was proportionally related to social distress and its association with suicide attempts might be partially influenced by stress caused by conflicts with others as demonstrated in the present study our results from the stratification analysis of the main purposes for using a smartphone confirmed that there is a greater association between suicide attempts and using a smartphone for process purposes compared with using it for social purposes these findings are similar to a recent smartphone study that found a closer relationship between smartphones used for process purposes and anxiety severity compared with those used for social purposes 25 some researchers have also suggested that pleasurable experiences that potentially result from process purposesoriented smartphone use might result in losing behavioral control 13 the results indicated that further research is needed to assess the different aspects on the purpose of smartphone usage and to expand them as a preventive or a treatment tool for adolescent suicidal behavior a number of studies have suggested that behavioral addictions such as gambling internet usage and gaming might share neurobiological mechanisms with substance addiction and that they have similarities including urges and cravings 4142 moreover studies have shown that addictive smartphone use including excessive usage time is related to impulsivity and high impulsivity is a psychological risk factor for developing addiction to social networking sites among smartphone users 7 43 44 45 adolescence is an important period for brain development and overuse of a smartphone during adolescence has been shown to decrease functional connectivity in the anterior insula and the primary motor cortex 46 altering higher executive functions that promote continued risk for developing substance and behavioral addiction mood dysregulations and impulsive behavior 47 these negative neurological and psychological traits might contribute to aggravating risk behaviors in adolescents with high smartphone use including suicide attempts future studies on excessive use of smartphone psychopathologies and addictive personality characteristics might provide important insights into addictionrelated risk behaviors including suicide attempts considering the increasing rate of smartphone use among adolescents in recent years effective strategies are needed to prevent high smartphone userelated adverse mental health outcomes limitations and strengths the present study has several limitations first due to the crosssectional nature of national surveys causal inferences based on the findings from this present study might not be valid longitudinal studies are necessary to further investigate the risk and protective factors of smartphone use for suicidal behavior second the level of smartphone use was calculated by selfreported answers and participants were grouped into quartiles by time on a smartphone rather than smartphone addiction scales however excessive smartphone use was validated as the most powerful independent predictor of smartphone addiction in the previous study 10 in addition longer smartphone use was found to be a significant predictor of smartphone addiction which was diagnosed by the validated smartphone addiction scale 5 third and last most variables in the study including conflicts with familyfriends and poor academic performance due to smartphone use and suicide attempts were surveyed on the basis of a selfreported questionnaire which has inherent limitations regarding the validity of the data and the recall bias therefore further studies not only with selfreported psychiatric pathologies but also with more precise evaluation and diagnosis are needed to provide stronger evidence of an association between smartphone use and suicidal behavior in adolescents however the strength of the present study included the use of a multilevel multinomial logistic modeling approach based on a nationally representative sample of korean adolescents who have the highest smartphone ownership rate in the world 1 considering the possibility of increased use of smartphones worldwide in the future the results of the present study could be a cornerstone for future research on issues related to their use among adolescents additionally to our knowledge this is the first study to investigate the association between adverse consequences of smartphone overuse and suicide attempts conclusion it is noteworthy that we confirmed a significant and specific relationship between time spent on a smartphone and the prevalence of attempted suicide independent of other problems associated with smartphone use in a nationally representative sample of adolescents in korea even when controlling for conflicts with family conflicts with friends and poor academic performance in addition our findings indicate that high smartphone use for process purposes ultimately turned out to have stronger associations with negative outcomes whereas moderate smartphone use for social purposes showed some protection against attempted suicide the results of this study suggest that consideration should be given to improving screening and prevention for mental health problems in adolescents with excessive use of smartphones further research is needed to understand the impact of specific length of time using a smartphone on the mental health of adolescents to develop preventive approaches and to help strengthen current smartphone use guidelines all data files are available from the korea youth risk behavior webbased survey database data curation seongho min joungsook ahn jinhee lee formal analysis seongho min joungsook ahn jinhee lee methodology jinhee lee validation minhyuk kim seongho min joungsook ahn chisoo an jinhee lee writing original draft jinhee lee writing review editing jinhee lee

this study aims to evaluate the association between smartphone use and suicide attempts independent of possible confounders including conflicts with familyfriends and poor academic performance due to smartphone use data were obtained from the 2017 korea youth risk behavior webbased survey a nationally representative survey of middleand highschool students n 62276 time spent using a smartphone was divided into four categories less than 1 h 12 h 34 h and 5 h or more a day the association of conflicts with family due to smartphone use conflicts with friends due to smartphone use and poor academic performance due to smartphone use with suicide attempts and time spent using a smartphone were analyzed using multiple and binary logistic regression analyses respectively the relationship between time spent on a smartphone and suicide attempts was analyzed using a multiple logistic regression analysis all analyses were also stratified according to the main purpose of smartphone use process purposessocial purposes conflicts with familyfriends due to smartphone use was significantly associated with suicide attempts p 0001 the variables of conflicts with family conflicts with friends and poor academic performance were also proportionally related to higher smartphone use p 0001 the use of a smartphone was significantly associated with suicide attempts in a multiple logistic regression analysis adjusted odds ratio for smartphone use 5 h or more a day 216 95 ci 207226 p 0001 and the association was more prominent with smartphone use for process purposes conflicts with family conflicts with friends poor academic performance and suicide attempts were related to higher smartphone use in korean adolescents time spent on a smartphone was positively related to suicide attempts even after adjusting for conflicts with family members or friends and poor academic performance due to smartphone use

Background Urban settings include a diversity of characteristics that, on the one hand, can be hazardous to human health , while on the other hand, can provide health-supportive functions [1,2]. In particular, urban parks are important for population health because they can impact human health via multiple pathways [3][4][5] and they can serve as a publically-available recreational facility for many people over multiple generations. Urban parks provide opportunities for socializing, contemplation, and physical activity. Moreover, urban parks can be designed and managed to link people with each other and with nature across a range of different demographic, socioeconomic, and cultural backgrounds [6]. The importance of parks for enhancing the quality of human life has long been recognized. Indeed, urban planning practices since the late 1800s have included provision for park space so as to separate industrial and residential land use, and to serve as central gathering places for civic activities [6]. More recently, local or municipal governments have devoted much of their services and significant proportion of financial resources in the creation, renewal, and upkeep of parks within urban settings. These investments, furthermore, often depend on transfers of resources from higher levels of government and engagement of citizens as tax-payers and volunteers. The provision of functional, attractive, and safe park space is considered to be an important characteristic of healthy communities and cities [7,8]. Despite their recognized importance, evidence regarding which characteristics of urban parks influence behaviour, in particular physical activity, is only just beginning to be systematically collated and analyzed from the perspective of promoting population health [9][10][11]. Regular participation in physical activity, especially at recommended levels, can reduce the risk of cardiovascular disease, diabetes, depression, obesity, and some cancers [12,13]. Moreover, physical activity in urban parks and neighbourhoods can promote social connectedness and interaction, which are also positively linked with physical and mental health outcomes [14,15]. Existing quantitative and qualitative evidence suggests that parks support physical activity, but not uniformly across the life course [9][10][11]. Youth activities in parks often involve participating in unstructured activities such as play [16,17] while for adults of different ages, walking is a common park-based physical activity [18]. Sedentary behaviour is also a common parkbased activity [19], which may entail walking to, within, and from the park [20]. Variation in the patterns and levels of park-based activity are likely influenced by the interaction between the characteristics of park users and characteristics of the park environment, as well as by the built and social characteristics of the surrounding neighbourhood [21][22][23]. Bedimo-Rung et al. [24] offer a conceptual framework for understanding how park characteristics influence physical activity, and this framework points to a need for synthesizing data derived from multiple methods. Yet most studies do not explore reasons why such relationships exist or integrate any qualitative data; rather, they focus on the influence of built environmental features on physical activity by adjusting statistically for the influence of other contextual and visitor characteristics [10,11]. An approach that incorporates both quantitative and qualitative approaches to investigate the determinants of park-based physical activity may provide greater insight into nuanced interactions between park visits, physical features, and socio-demographic characteristics. In addition, whereas qualitative as well as quantitative data about park use can be generated in situ [6], qualitative studies of physical activity in urban parks have been dominated by face-to-face and focus group interviews conducted off-site [9]. Thus, for this multiple case study of four urban parks in a Canadian city, we apply quantitative and qualitative methods of direct observation to study patterns of park-based physical activity. The objective of this study was to document and account for patterns of park-based physical activity in ways that could meaningfully inform urban planning and policies to promote health. The University of Calgary Conjoint Human Research Ethics Board granted ethics approval for this study. --- Methods --- Study background and design Case studies seek to account for the existence of phenomena and the impact of events within specified contexts. Thus, case study designs tend to involve non-probability samples. Each selected case has the potential to yield a great deal of information on its own and in comparison with other cases. This multiple case study emphasized description, using qualitative and quantitative methodological approaches to exploit different data sources in order to generate insights through multiple disciplinary perspectives. --- Sampling strategy Purposive sampling was used for selecting parks [25]. The sampling strategy was informed by: 1) the recent implementation of a new municipal policy framework for off-leash dog areas, which included designating additional off-leash areas in existing parks [26], and; 2) the larger project, the aim of which was to investigate longitudinal changes in park use, and park-based physical activity and social interaction before and after off-leash designation. We selected the first three existing parks to be publicly-announced as candidate sites for new off-leash areas [26] as well as an approved off-leash park area already in development on the city's urban fringe [27]. This paper presents the findings regarding the physical and social environmental characteristics and usage patterns of the four neighbourhood parks two months before final decisions was announced about whether they would become officially designated as sites for off-leash areas. --- Data collection Direct observation: quantitative data During an initial visit to the four parks , observation points were identified and decided upon through consensus by three of the authors . The chosen observation points were centrally located and provided the most comprehensive view of the park area as well as clear sight lines to park entrances and activity settings . Only one observation point was necessary for West Hillhurst, Taradale, and Martindale, while two observation points were necessary for Meadowlark because of an elevated section of open space that could not be adequately observed from the other observation point. From May to July 2011, trained observers stood at the pre-determined observation points within each park and collected data. Data were collected in each park from 830-1230 hrs and 1430-1830 hrs on one weekday and one weekend only. Time periods were intended to capture early morning and late afternoon activities; the period from 1230-1430 hrs was not captured because of limited resources. Three observers were rotated between the four parks. Captured user characteristics included gender, age group , group membership , number of dogs, dog size , whether or not dog litter was cleaned up, and activities . Each park user was observed for a maximum of two minutes to capture the scope of activities being undertaken and to maximize the number of users that could be observed. Observers selected users by systematically scanning the observation area in an anti-clockwise direction and selecting the next user in the field of vision who had not already been observed. Inter-rater reliability of the structured direct observation was tested at a heavily used park site, not included in the current study, and involved the observation of 72 park users by five observersthree observers of which collected data in the four study parks. The three observers were undergraduate students in the health science or wildlife ecology disciplines; all three received training for this project and had prior experience collecting field data. Variables that had moderate-to-high interrater reliability only were collected in the four study parks . --- Direct observation: qualitative data Throughout the research process, qualitative data collection was integrated into fieldwork. Two field assistants , who both had prior training in social research on physical activity, compiled a comprehensive photographic record of the parks. The photographs were taken to illustrate attributes of the parks that had the potential to influence patterns of park usage and physical activity. Previous research [9,24] relevant to the study, and firsthand experience of the field researchers, informed their decisions about which attributes to photograph. The photographs were all taken using a Panasonic DMC-TS3 digital camera, which time-stamps, date-stamps, and assigns global positioning coordinates to each photograph. The photographs were not taken in conjunction with the quantitative direct observations, so as to minimize the potential for distraction and influencing the behaviours of park visitors. KS and LB also provided oral and written reports to MR and GM throughout the fieldwork period, including timely descriptions of critical incidents. For our purposes, critical incidents comprised events and circumstances that interfered with the task of fieldwork and that could, through description and discussion, generate insights relevant to our research objectives. The photographs, and written and oral reports were included in the qualitative dataset maintained using NVivo 10 . --- Additional data sources To supplement the qualitative and quantitative data derived from direct observation, we inventoried park attributes, consulted published maps, and drew on sociodemographic profiles of the surrounding neighbourhoods and the city as a whole [29]. Neighbourhood sociodemographic characteristic profiles were extracted from the most up-to-date information at the time of analysis . In addition, team members with previous training and professional experience in qualitative research attended public consultations on the potential off-leash designations which took place during the fieldwork period. Participant observation at the public consultations provided the basis for extended fieldnotes and allowed us to collect City-sponsored brochures and reports that were distributed during these events . Reports on the results of the consultation sessions posted online, provided information on local people's perceptions of the parks [26]. These documents were added to the NVivo qualitative dataset. --- Data analysis This study employed three main analytic strategies; relying on theoretical propositions, developing case descriptions, and examining rival explanations [29]. Analytic strategies in case study research include detailed descriptions that integrate multiple sources of information, pattern-matching across data sources, time-series, and comparisons within a single case and across multiple cases. These analytic strategies tend to be guided by theoretical propositions distilled from the existing literature, and throughout a given project, the research team seeks to substantiate, refine or refute their theoretical propositions [29]. --- Theoretical propositions For this study, Bedimo-Rung et al.'s [24] conceptual framework was used as a guide. This framework outlines how characteristics of urban parks and surrounding neighbourhoods influence visits and physical activity within parks, to the extent of plausibly influencing health outcomes in populations. Whereas Bedimo-Rung et al. [24] derived this framework by synthesizing quantitative research, this framework is also applicable to qualitative research [9]. According to the framework, important park characteristics include physical features, the condition of these features, accessibility, aesthetics, objective and subjective aspects of safety, and policies. However, our analytic approach treated the other park attributes identified by Bedimo-Rung et al. [24] as manifestations of policy , rather than treating policy as a discrete category. Our approach also recognized the potential for overlap across these characteristics, and treated instances of overlap as points of entry into complex relationships rather than trying to isolate characteristics as though they were discrete variables. --- Developing case descriptions The purpose of developing case descriptions was to specify the activities observed in each of the parks, and to put these observations into context [29]. The techniques of pattern-matching and time-series [29] were employed using the quantitative direct observation data, which involved comparing frequencies of activity, types of visitors, and site characteristics in the four parks. Pearson's chi-square was used to detect significant differences in observed activities , gender, age, group association, presence of a dog, time of day, and day of week by park site. Where statistically significant park differences were found based on the Pearson's chi-square tests , Bonferroni adjusted z-tests of proportions was then used to identify significant pairwise differences between parks. Statistical analysis was undertaken using SPSS 19 . As for qualitative data analysis, the techniques of pattern-matching, time-series, and explanation-building were deployed [29]. Following the completion of fieldwork, KS and LB verified geo-codes for each photograph, correcting the global positioning coordinates manually as required on a map of each park. Next, the photographs were imported into NVivo 10, and then sorted by park and by date. Photographs were then captioned in a three-step process. First, the photographs were titled to reflect the focal element of the photograph. Second, keeping in mind the research objectives and based on recollections of the fieldwork from KS, LB or both, the photographs were described in as little as one sentence or as much as paragraph. This phase of captioning also allowed for a time-series approach to analysis, in that photographs could be tagged as being part of a series from a single day or across multiple days . Third, each description was classified and elaborated upon in relation to park attributes outlined by Bedimo-Rung et al. [24]: features, condition, access, aesthetics, and safety. Here, the emphasis was on explanation-building [29]. Recognizing that citizens view parks in different ways, the captions included different viewpoints that were generated through discussion within the research team. Qualitative and quantitative data were synthesized, first in the course of developing a descriptive profile for each park and then by comparing across qualitative and quantitative data for all four parks in the study. Analysis took place iteratively; rival explanations were generated and discussed with stakeholder organizations and within the team [29]. In particular, the extent to which observable within-park attributes can account for patterns of activity in a park was continually questioned. Therefore, we actively considered whether the surroundings were just as or even more important than what is or is not found within a specific park . City documents, fieldwork reports, and debriefing notes were used as supplemental resources to assist with synthesizing the quantitative and qualitative data based on first-hand observation. --- Results --- Descriptions of park and neighbourhood characteristics in relation to patterns of use Taradale park The neighbourhood of Taradale was established in 1984, has a curvilinear street pattern , and is located in the north east quadrant of the city. In 2011, the neighbourhood consisted of 16,110 residents . It has a median annual household income of $71,401 with 15.9% of residents living in low-income households and 9.1% renting. Of those ≥25 years of age, 3.9% are unemployed and 54.8% have less than or equivalent to a high school level education. Over one-third of neighbourhood residents are infants or youth and 60.6% are adults. Fewer than 5% of neighbourhood residents are seniors. Almost half of the Taradale population are immigrants , of which two thirds were born in India or Pakistan and one-tenth born in the Philippines . Taradale Park was new, and an offleash area had already been planned and approved at the time of the study. At the public consultation on the potential designation of an off-leash area within the nearby park in Martindale, a couple of participants indicated that they looked forward to using the new off-leash area in the Taradale park [30]. Taradale Park is located on the edge of the neighbourhood and borders a major road on one side. The park is large , un-maintained, 'natural' field landscape without trees. A baseball diamond was adjacent to the park but separated by a fence. The open green spaces dissected by the dual-use path were undeveloped and overgrown with tall weeds and grass and provided an ideal location for off-leash dogs to run and explore . The park included a multi-use path that ran through the park and connected to a path running along the park's perimeterlinking the surrounding neighbourhoods. An informal path ran parallel to the formal path along a wooden fence separating the park from a residential area. This pathway system was frequently used by both pedestrians and cyclists. The formal and informal paths ran past a pond located in one corner of the park. The un-landscaped pond area was populated by a variety of wildlife , and it provided a storm water drainage for the area. This pond was also an attractive feature for larger off-leash dogs, and thus, for the people accompanying them . Hawks were frequently sighted in the vicinity of this park. A lack of maintenance made visibility problematic and served as an ideal breeding ground for mosquitos. Household garbage and debris 'dumped' in the park posed a safety concern for wildlife and visitors such as dogs and children, who might have come into direct contact with the material . A bench and garbage can surrounded by a small landscaped area was located at one entrance to the park. There were signs at the main entrance to the park and at the seating area to indicate that the park contained an off-leash dog area. Graffiti was evident on the wooden fence at the end of the park at the main entrance adjacent to the residential area. A designated 'rest stop' , located alongside the main pathways, provided a bench for seating; receptacles for garbage and recycling; and signage . Older adults of South Asian ancestry, sometimes accompanied by children, would often walk through the park with the 'rest stop' as their destination. --- Martindale park Martindale 2). Martindale Park is a large open green space which includes a natural wooded area in one corner and trees along the park perimeter. A paved pathway ran through the park and exited onto the streets of the surrounding neighbourhood on either side. Dual-use paths ran through the park and an informal path ran through the natural wooded area . An open grassy area containing a storm water drainage basin provided an open space for dogs to run and play off-leash, however; it was often flooded and maintenance was often incomplete, contributing to a 'mosquito problem.' The park had no benches or seating nor did it have any dedicated lighting . A garbage can was located beside a formal path which was adjacent to street parking allocated for park visitors. An unkempt wooded area existed alongside the paved path at the rear of the park . The interior of this wooded area was not visible unless one walked directly inside ; it was overgrown with weeds, covered with litter, and frequently visited by youth . The dogwalkers who regularly visited this park tended to be white males. South Asian and Southeast Asian visitors tended to be adults who walked briskly through the park. On occasion, adults brought school-aged or preschool-aged children to the park, but they did not tend to stay for long or return on a regular basis. Whereas a public art installation located at the front of the park is suggestive of a playground, the park does not contain a playground. The public art installation consists of three brass figures; a Caucasian-looking woman pushing a girl on a swing-set and an off-leash Cocker Spaniel jumping in the grass nearby. In public consultations regarding the potential designation of an off-leash area within this park, local residents indicated that this park is a much-needed amenity but they also cited concerns about litter and safety [30]. --- West Hillhurst park West Hillhurst was established in 1945, has a grid street pattern with streets that are lined with mature landscaping and sidewalks on both sides, and is located in the northwest quadrant of the city. In 2011, West Hillhurst's population was 5,757 . The majority of West Hillhurst residents were born in Canada, however; the socio-economic status is mixed, and a process of gentrification was apparent from the housing, gardens, and yard maintenance. The community has a median annual household income of $61,401, with 15.9% of the neighbourhood residents living in low-income households, 31.5% having less than or equivalent to a high level education, and 1.4% unemployment. The proportion of West Hillhurst residents dwelling in rental properties is high compared with the Calgary overall . Almost two-thirds of the West Hillhurst population are adults followed by youth and seniors . In West Hillhurst, 13% of people are first-generation immigrants, and of those recently immigrating, 26.3% were born in the United States. West Hillhurst park is an open green space that includes tall, well-established trees scattered throughout the park. Although not visible from within the park due to the presence of a utility building, a bridge at one end of the park provided a route for pedestrians and cyclists to cross over major arterial road and joined with a pathway that runs along the Bow River. Within the park, an informal trail ran parallel to the chain-link fence separating the park from Memorial Drive . This informal trail was frequently used by joggers headed toward the bridge intended for pedestrian and cyclist use, as well as by dog-walkers. The large, open grassy area that was well-maintained provided a suitable place for a range of recreational activities . Dogs were frequently unleashed to roam and play fetch. This park had a playground in the northeast corner with benches and a garbage receptacle near the perimeter. The playground included three benches, a picnic table, two swing sets , two animal figurines mounted on springs, a seesaw, a climbing apparatus, and a slide. At the top of one swing set was a sign that stated no dogs allowed within 20-meters of the playground. Graffiti was evident on the garbage can by the playground and on a box where the chain-link fence met a solid fence. In public consultations regarding the potential of formally designating an off-leash area within this park, local residents' views were divided. Many participants appreciated bringing their dogs to the park, while other participants appreciated bringing their children to the playground and the park itself. Some but by no means all participants felt that dog-walking and childcare were compatible uses for this park [31]. --- Meadowlark park Meadowlark was established in 1955, has a warped-grid street pattern, and is located in the southwest quadrant of the city. Meadowlark is a small community, with a population of 605 in 2011 . In Meadowlark, 17.3% of people reside in rented dwellings. The neighbourhood has a median annual household income of $74,380 with 6.6% of persons living in low-income householdshalf of the percentage found for Calgary overall . Among resident's ≥25 years of age, 2.9% are unemployed and 36.9% have a high school diploma or less. Less than on quarter of residents are first-generation immigrants , and among recent immigrants, two-thirds were born in the Philippines . Meadowlark park consists of multiple open green spaces separated by trees, shrubbery, and fences. Prior to the construction of this park in 2004, a school stood at this location. The school was removed and the park was created to allow for expansion and redevelopment of a major roadway immediately adjacent to the park. In the park, multiple connecting paved pathways designated for use by pedestrians and cyclists ran from the surrounding neighbourhood through the centre of the park and alongside the stone wall separating the park and neighbourhood from a major arterial road . A dual-use path cut through the middle of the park, connecting the neighbourhood with an adjacent community and a major shopping mall. The adjacent community and major arterial road were separated from the park by a 10-foot high concrete fence which ran along the entire south side border of the park. Sidewalks were located on the northern perimeter of the park running adjacent to a local road. A chain-link fence enclosed an area up to the sidewalk on the northwest end. The park had landscaped features and a monument in the center of the park with surrounding benches . Most grassed areas of the park were maintained, but were overgrown near a fenced area at the northwest corner of the park . A public art installation had been constructed near the entrance from the surrounding neighbourhood to the park. It consisted of a brick and stone 'tower' topped by painted larks with plaques that told the history of the park and surrounding neighbourhood. This public art installation was framed by attractive landscaping . Surrounding the public art installation were two benches, wrought-iron receptacles for garbage and litter, and street lamps. Graffiti was evident on multiple utility distribution poles along the park perimeter. Near the public art installation, there was a partially-fenced un-landscaped section , littered with construction debris. Chinook Shopping Centre could be seen from within the park, and this destination is readily accessible via designated pathways and the green space itself. The majority of residents in the neighbourhood of Meadowlark are Canadian-born and older in age than the City of Calgary average, yet older adults were rarely observed in the park. In public consultations regarding the potential designation of an off-leash area within this park, local residents indicated that they appreciated the park, and they complained about traffic and parking as issues that already compromised their use of this park and that off-leash designation could exacerbate [32]. --- Descriptions of park use and physical activity between parks Park use Differences in time use patterns between the four parks were found . For Taradale , Martindale , and Meadowlark parks, the majority of visitors were observed in the afternoon from 14:30-18:30 hrs, whereas for West Hillhurst, similar proportions of visitors were observed in the morning and afternoon . The proportion of visitors to Taradale park was higher on Sundays compared with other days of the week and was significantly higher on Sundays than the other park sites . The highest proportion of Meadowlark visitors was observed on Saturdays , which was also significantly higher on Saturdays compared with the other parks sites . --- Park visitor characteristics In the four parks, a combined total of 783 visits were observed. Overall, West Hillhurst , followed by Meadowlark , Martindale , and Taradale had the most observations of park use . The majority of those observed in Taradale , Martindale , and West Hillhurst parks were observed for a full two minutes. By contrast, less than half of the observations in Meadowlark took two minutes . Observations lasting fewer than two minutes included visitors who walked or cycled through the parks en route elsewhere. The majority of individuals observed in Meadowlark park were either walking or cycling along pathways crossing the park. Males were more likely to be observed in the parks than females, with no statistically significant differences between the four parks. Compared with the other sites, those observed in Taradale park were more likely to be adults reflecting the lack of facilities for children's activities. For Martindale park, those observed tended to be youth as opposed to adults or children, again reflecting a lack of facilities to support play amongst youngsters . For West Hillhurst and Meadowlark, similar proportions of adults and youth were observed. Compared with the Taradale, Martindale, and Meadowlark parks, the proportion of those visiting alone was significantly lower in West Hillhurst . Children and adult caregivers were frequently observed using the West Hillhurst park facilities . --- Park activity types The majority of park visitors participated in only one activity whilst being observed, with fewer undertaking multiple activities . The two most popular activities across all parks included walking and dog-related physical activity . Walking was the most popular activity in Meadowlark compared with the other three sites, while walking was less common in West Hillhurst compared with the other sites. Compared with Martindale and Meadowlark, a higher proportion of dog-related activitythe majority of which included dog-walking - The pathway which was adjacent to one end of the park space and the park space itself was not generally used as a corridor linking between destinations. Play activity was significantly higher in West Hillhurst compared with the other parks , which could reflect the low levels of pedestrian and cyclist traffic through the park. In addition, West Hillhurst park included the highest proportion of sedentary activity followed by Meadowlark , Taradale , and Martindale parks. --- Discussion Among the four park study sites, we found variations in the patterns of use, characteristics of users, and the types of activities undertaken. In general, the patterns of use in all four parks combined reflected findings regarding the gender and age characteristics of urban park visitors elsewhere [33][34][35][36]. However, contrary to previous evidence [18,19,34,37], we found that sedentary activities were not the most common park activity. Rather, walking and dog-walking were the most common activities for our sample of parks. Our findings also suggest that patterns of park activities are associated with the physical attributes within each of the parks and the surrounding neighbourhoods. Few other studies have integrated multiple quantitative and qualitative approaches to interpret the interrelationships between the characteristic of parks and surrounding neighbourhoods and park use and activity [38]. Despite being unable to collect data for the entire day, we found that patterns of park use were consistent with patterns of use found elsewhere [33,34,39], whereby that the majority of visits take place in the afternoons and evenings. Patterns of weekday and weekend use differed between parks but not in a consistent way. Across the four parks, male visitors were more common than female visitors, while for three of the four parks, users were more likely to be adults than children or youtha pattern that is consistent with evidence collected using systematic observation [33][34][35][36]. While we were unable to quantify the interaction between gender and activity types within the parks due to sample size, elsewhere men have been found to be more physically active within park settings than have women [19,35,36]. This pattern is similar to differences in physical activity found between men and women in population-based studies [40,41]. Creating more opportunities for physical activity within parks could contribute to more park-based physical activity among women, thereby reducing gender disparities in physical activity. To encourage more park visits and more park-based physical activity among women, design and management strategies could include improvements associated with safety as well as greater opportunities for social interaction [9]. Park visitors are often more likely to be adults than children or youth [18,19,34,42]. In one of our parks however, over one-half of all users observed were children or youth. This park did not include physical attributes, such as playgrounds, typically associated with children's use and physical activity within parks [21]. Moreover, within this same park, participation in "play" activity was low compared with other activities which is noteworthy as we expected to see more "play" in settings with high numbers of children. Our qualitative data suggest that the youth who visited this park were unaccompanied by adults and that they visited a central secluded wooded area to 'hang-out' and socialize. Furthermore, monuments within the Martindale park were used for play activity, such as climbing. This finding stands in contrast with the West Hillhurst park, which included a playground, where one-third of visitors were children or teenagers, and where onethird of activity observed was "play". Our findings suggest that playgrounds, while encouraging children to be physically active, are not the only reason why children visit parks. For older children and teenagers, park attributes that provide places for friends to meet and socialize are likely just as important [9]. Introducing age-appropriate playground equipment, creating and maintaining sports fields and courts and open spaces, as well as the provision of areas for socializing that balance privacy with safety, might encourage more children and teenagers to be physically active by visiting parks [9,33]. Sedentary behaviour is commonly observed in parks [18,19,34,37]. Kaczynski et al. [19] found that just over half of observed park users participated in sedentary activity while Floyd et al. [18] and Cohen et al. [37] found that almost two-thirds of park users were sedentary. Contrary to this evidence, our findings suggest that for the four parks included in our study, sedentary activity was less common than other activities. Nevertheless, observed participation in sedentary activity differed between the parks and the reasons for these differences are in part explained by the qualitative data. Located within Taradale and Martindale parks are storm water drains and pools of stagnate water that facilitate mosquito breeding, which is particularly severe during the early months of the Calgary summer. The mosquito populations within these two parks were particularly numerous during the data collection , likely deterring people from spending extended periods of sedentary time within these locations. Furthermore, the parks were relatively small in area and the layout of the open space was not particularly suitable for organized or unorganized sports activities, which often attract spectators [37]. Seating was also entirely absent or in short supply . Nevertheless, even those observed to be sedentary in parks likely derived some health benefit from the physical activity accumulated whilst traveling to and from the park. Active transportation is a common mode of transportation for reaching public recreational opportunities [43]. Creating and redesigning parks to include attributes and amenities that support both passive and active pursuits, therefore, could increase levels of physical activity in urban populations [44,45]. People may visit parks more frequently when accompanied [46,47]. We found that almost two-thirds of park visitors were with another person and that about one-half of children visiting parks were accompanied by parents or guardians. Compared with other parks, West Hillhurst included the highest proportion of group visits. Because of its playground, "playing" was also the most common activity in West Hillhurst park relative to the other parks. Together, these findings might suggest that some parents and caregivers are physically active while accompanying their children to the playground, but are themselves inactive in parks while their children play. The physical attributes within this park including benches and shade close to the playground and the limited amount of pathway might facilitate sedentary activity among these caregivers. Besenyi et al. [21] found that for adults and seniors higher levels of park-based physical activity energy expenditure occurred on paths and courts compared with other areas , while for children, higher levels of park-based physical activity energy expenditure occurred in playgrounds. Floyd et al. [33] found that less shade was associated with a greater likelihood of park users walking and participating in vigorous-intensity activity versus sedentary behaviour. Shores and West [22] also found sedentary activities to be more common in parks with shelter and picnic areas. One suggestion for park planners might be to include attributes that will support physical activity for adults near playgrounds so parents or caregivers can still supervise their children while they are physically active themselves. Dogs, in our study, contributed positively to patterns of physical activity. After walking without a dog, dogwalking and other dog-related pursuits, such as playing fetch, were the most commonly observed activities. These findings extend a growing body of research in health promotion linking dog-walking with physical activity [48]. This line of inquiry is highly relevant to population-level patterns of physical activity because in Canada, dogs reside in one out of every three urban households [49], and similar statistics have been reported in other Western countries [50,51]. Dog-walking is also becoming a common form of physical activity in some non-Western countries, such as China and Japan [52,53]. Nevertheless, high levels of dog-ownership can also impact negatively on physical activity for both dog-owners and non-dog-owners, given that ill-controlled dogs and litter from dog-waste can deter people from visiting parks [51], so policies and management strategies need to take dog and owner behaviour into account. Our method of systematic observation differed from methods used elsewhere . Unlike other approaches, we attempted to record park user information and activities for the entire park and not for separate activity zones within the park. This approach was facilitated because of our focus on neighbourhood parks that were typically smaller than other open spaces . Because we centered our observations on persons, not on multiple activity areas in the same park, double counting of visitors was minimized. When multiple activity areas serve as the basis for observations, any visitors who moved between activity areas during observation periods could be double-counted [39]. Whenever possible, we observed each park user for a full two minutes so as to document multiple activities during the same park visit. The time frame of two minutes was selected to balance the need to capture the range of activities undertaken by a single individual and the need to include as many cases as possible. In the Taradale, Martindale, and West Hillurst parks, most visitor observations lasted for two minutes. In Meadowlark however, less than one-half of all visitors were observed for two minutes. Meadowlark included a short pathway that connected a residential area and large mall both of which were surrounded by major roads with high volume traffic. Many walkers and cyclists observed in the Meadowlark park were passing through en route to other destinations, thus the fact that fewer visitors were observed for the entire two minutes reflects the activity patterns within, and the design of, the park. During times when the volume of visitors was low, observation of visitors may have begun immediately as they entered the parkthus their activity would likely have been recorded as walking or cycling but underestimating other types of activity . Similarly, visitors who were already in the park and were being sedentary, playing, or undertaking dog-related activity likely entered the park via walking or cycling, so our results may underestimate walking and cycling. Whereas our findings are a cross-sectional representation of summer park activities in four parks only, they suggest that the relationships between park policies and physical activity are complex. Despite limitations, our case study approach provided a rich description of the activities and settings and their interaction within the four parks. Indeed, such a detailed description would not have been possible using a single methodological approach or data source. The unique findings from our case study highlight that while policyrelated physical attributes in some parks appear to encourage certain types of behaviour , in other parks, the relationship between context and behaviour was less than straight-forward. Thus, the physical and social characteristics as well as the history of the community in which a park is situated are potentially important influences on park use. The case study approach might provide useful information for park developers and planners in creating or modifying parks, for example, to encourage specific types of activities or to encourage more use among particular types of visitors [6]. Furthermore, this approach is highly relevant to innovations in park planning and management, which often begin with pilot or demonstration projects that require consideration of ambient policy, sociocultural and geographical contexts [6]. --- Conclusions Park attributes and the surrounding neighbourhood social characteristics are important for determining the types of park-based activities visitors undertake and the socio-demographic profile of visitors. The desire to sit outside, surrounded by nature, might be the very reason people visit parks, yet this desire could still contribute to physical activity levels by prompting people to walk or cycle, to and from parks. Planners and mangers of parks should consider the potential impacts that physical and symbolic attributes may have on visits and they should look to maximize attributes that encourage park visitors to be physically active. --- Additional files --- Competing interests The authors declare that they have no competing interest. --- --- Author information

Background: Many characteristics of urban parks and neighbourhoods have been linked to patterns of physical activity, yet untangling these relationships to promote increased levels of physical activity presents methodological challenges. Based on qualitative and quantitative data, this article describes patterns of activity within urban parks and the socio-demographic characteristics of park visitors. It also accounts for these patterns in relation to the attributes of parks and their surrounding neighbourhoods. Methods: A multiple case study was undertaken that incorporated quantitative and qualitative data derived from first-hand observation in a purposive sample of four urban parks. Quantitative data, based on direct observation of visitors' patterns of use and socio-demographic characteristics, were collected using a structured instrument. Differences in frequencies of observed activities and socio-demographic characteristics of visitors were compared between the four parks. Qualitative data, based on direct observation of park characteristics and patterns of use, were generated through digital photography and analyzed through captioning. Quantitative data on patterns in activity and socio-demographic characteristics were synthesized with the qualitative data on park and usage characteristics. Results: A comprehensive portrait of each park in the study was generated. Activity types (sedentary, walking, dog-related, cycling, and play), patterns of park use (time of day, day of week), and socio-demographic characteristics (age group, social group) differed between the four parks. Patterns in park use and activity appeared to be associated with socio-demographic characteristics of the surrounding neighbourhoods as well as the physical and social environmental characteristics specific to each park. Conclusions: Both park and neighbourhood characteristics influence patterns of use and physical activity within parks. The study findings suggest that socio-demographic characteristics of neighbourhoods surrounding parks need be considered in planning, development and management. Engaging local communities could help planners to develop and update urban parks in ways that reflect the needs and characteristics of community residents and, in turn, encourage visits and more physical activity amongst visitors.

background urban settings include a diversity of characteristics that on the one hand can be hazardous to human health while on the other hand can provide healthsupportive functions 12 in particular urban parks are important for population health because they can impact human health via multiple pathways 3 4 5 and they can serve as a publicallyavailable recreational facility for many people over multiple generations urban parks provide opportunities for socializing contemplation and physical activity moreover urban parks can be designed and managed to link people with each other and with nature across a range of different demographic socioeconomic and cultural backgrounds 6 the importance of parks for enhancing the quality of human life has long been recognized indeed urban planning practices since the late 1800s have included provision for park space so as to separate industrial and residential land use and to serve as central gathering places for civic activities 6 more recently local or municipal governments have devoted much of their services and significant proportion of financial resources in the creation renewal and upkeep of parks within urban settings these investments furthermore often depend on transfers of resources from higher levels of government and engagement of citizens as taxpayers and volunteers the provision of functional attractive and safe park space is considered to be an important characteristic of healthy communities and cities 78 despite their recognized importance evidence regarding which characteristics of urban parks influence behaviour in particular physical activity is only just beginning to be systematically collated and analyzed from the perspective of promoting population health 9 10 11 regular participation in physical activity especially at recommended levels can reduce the risk of cardiovascular disease diabetes depression obesity and some cancers 1213 moreover physical activity in urban parks and neighbourhoods can promote social connectedness and interaction which are also positively linked with physical and mental health outcomes 1415 existing quantitative and qualitative evidence suggests that parks support physical activity but not uniformly across the life course 9 10 11 youth activities in parks often involve participating in unstructured activities such as play 1617 while for adults of different ages walking is a common parkbased physical activity 18 sedentary behaviour is also a common parkbased activity 19 which may entail walking to within and from the park 20 variation in the patterns and levels of parkbased activity are likely influenced by the interaction between the characteristics of park users and characteristics of the park environment as well as by the built and social characteristics of the surrounding neighbourhood 21 22 23 bedimorung et al 24 offer a conceptual framework for understanding how park characteristics influence physical activity and this framework points to a need for synthesizing data derived from multiple methods yet most studies do not explore reasons why such relationships exist or integrate any qualitative data rather they focus on the influence of built environmental features on physical activity by adjusting statistically for the influence of other contextual and visitor characteristics 1011 an approach that incorporates both quantitative and qualitative approaches to investigate the determinants of parkbased physical activity may provide greater insight into nuanced interactions between park visits physical features and sociodemographic characteristics in addition whereas qualitative as well as quantitative data about park use can be generated in situ 6 qualitative studies of physical activity in urban parks have been dominated by facetoface and focus group interviews conducted offsite 9 thus for this multiple case study of four urban parks in a canadian city we apply quantitative and qualitative methods of direct observation to study patterns of parkbased physical activity the objective of this study was to document and account for patterns of parkbased physical activity in ways that could meaningfully inform urban planning and policies to promote health the university of calgary conjoint human research ethics board granted ethics approval for this study methods study background and design case studies seek to account for the existence of phenomena and the impact of events within specified contexts thus case study designs tend to involve nonprobability samples each selected case has the potential to yield a great deal of information on its own and in comparison with other cases this multiple case study emphasized description using qualitative and quantitative methodological approaches to exploit different data sources in order to generate insights through multiple disciplinary perspectives sampling strategy purposive sampling was used for selecting parks 25 the sampling strategy was informed by 1 the recent implementation of a new municipal policy framework for offleash dog areas which included designating additional offleash areas in existing parks 26 and 2 the larger project the aim of which was to investigate longitudinal changes in park use and parkbased physical activity and social interaction before and after offleash designation we selected the first three existing parks to be publiclyannounced as candidate sites for new offleash areas 26 as well as an approved offleash park area already in development on the citys urban fringe 27 this paper presents the findings regarding the physical and social environmental characteristics and usage patterns of the four neighbourhood parks two months before final decisions was announced about whether they would become officially designated as sites for offleash areas data collection direct observation quantitative data during an initial visit to the four parks observation points were identified and decided upon through consensus by three of the authors the chosen observation points were centrally located and provided the most comprehensive view of the park area as well as clear sight lines to park entrances and activity settings only one observation point was necessary for west hillhurst taradale and martindale while two observation points were necessary for meadowlark because of an elevated section of open space that could not be adequately observed from the other observation point from may to july 2011 trained observers stood at the predetermined observation points within each park and collected data data were collected in each park from 8301230 hrs and 14301830 hrs on one weekday and one weekend only time periods were intended to capture early morning and late afternoon activities the period from 12301430 hrs was not captured because of limited resources three observers were rotated between the four parks captured user characteristics included gender age group group membership number of dogs dog size whether or not dog litter was cleaned up and activities each park user was observed for a maximum of two minutes to capture the scope of activities being undertaken and to maximize the number of users that could be observed observers selected users by systematically scanning the observation area in an anticlockwise direction and selecting the next user in the field of vision who had not already been observed interrater reliability of the structured direct observation was tested at a heavily used park site not included in the current study and involved the observation of 72 park users by five observersthree observers of which collected data in the four study parks the three observers were undergraduate students in the health science or wildlife ecology disciplines all three received training for this project and had prior experience collecting field data variables that had moderatetohigh interrater reliability only were collected in the four study parks direct observation qualitative data throughout the research process qualitative data collection was integrated into fieldwork two field assistants who both had prior training in social research on physical activity compiled a comprehensive photographic record of the parks the photographs were taken to illustrate attributes of the parks that had the potential to influence patterns of park usage and physical activity previous research 924 relevant to the study and firsthand experience of the field researchers informed their decisions about which attributes to photograph the photographs were all taken using a panasonic dmcts3 digital camera which timestamps datestamps and assigns global positioning coordinates to each photograph the photographs were not taken in conjunction with the quantitative direct observations so as to minimize the potential for distraction and influencing the behaviours of park visitors ks and lb also provided oral and written reports to mr and gm throughout the fieldwork period including timely descriptions of critical incidents for our purposes critical incidents comprised events and circumstances that interfered with the task of fieldwork and that could through description and discussion generate insights relevant to our research objectives the photographs and written and oral reports were included in the qualitative dataset maintained using nvivo 10 additional data sources to supplement the qualitative and quantitative data derived from direct observation we inventoried park attributes consulted published maps and drew on sociodemographic profiles of the surrounding neighbourhoods and the city as a whole 29 neighbourhood sociodemographic characteristic profiles were extracted from the most uptodate information at the time of analysis in addition team members with previous training and professional experience in qualitative research attended public consultations on the potential offleash designations which took place during the fieldwork period participant observation at the public consultations provided the basis for extended fieldnotes and allowed us to collect citysponsored brochures and reports that were distributed during these events reports on the results of the consultation sessions posted online provided information on local peoples perceptions of the parks 26 these documents were added to the nvivo qualitative dataset data analysis this study employed three main analytic strategies relying on theoretical propositions developing case descriptions and examining rival explanations 29 analytic strategies in case study research include detailed descriptions that integrate multiple sources of information patternmatching across data sources timeseries and comparisons within a single case and across multiple cases these analytic strategies tend to be guided by theoretical propositions distilled from the existing literature and throughout a given project the research team seeks to substantiate refine or refute their theoretical propositions 29 theoretical propositions for this study bedimorung et als 24 conceptual framework was used as a guide this framework outlines how characteristics of urban parks and surrounding neighbourhoods influence visits and physical activity within parks to the extent of plausibly influencing health outcomes in populations whereas bedimorung et al 24 derived this framework by synthesizing quantitative research this framework is also applicable to qualitative research 9 according to the framework important park characteristics include physical features the condition of these features accessibility aesthetics objective and subjective aspects of safety and policies however our analytic approach treated the other park attributes identified by bedimorung et al 24 as manifestations of policy rather than treating policy as a discrete category our approach also recognized the potential for overlap across these characteristics and treated instances of overlap as points of entry into complex relationships rather than trying to isolate characteristics as though they were discrete variables developing case descriptions the purpose of developing case descriptions was to specify the activities observed in each of the parks and to put these observations into context 29 the techniques of patternmatching and timeseries 29 were employed using the quantitative direct observation data which involved comparing frequencies of activity types of visitors and site characteristics in the four parks pearsons chisquare was used to detect significant differences in observed activities gender age group association presence of a dog time of day and day of week by park site where statistically significant park differences were found based on the pearsons chisquare tests bonferroni adjusted ztests of proportions was then used to identify significant pairwise differences between parks statistical analysis was undertaken using spss 19 as for qualitative data analysis the techniques of patternmatching timeseries and explanationbuilding were deployed 29 following the completion of fieldwork ks and lb verified geocodes for each photograph correcting the global positioning coordinates manually as required on a map of each park next the photographs were imported into nvivo 10 and then sorted by park and by date photographs were then captioned in a threestep process first the photographs were titled to reflect the focal element of the photograph second keeping in mind the research objectives and based on recollections of the fieldwork from ks lb or both the photographs were described in as little as one sentence or as much as paragraph this phase of captioning also allowed for a timeseries approach to analysis in that photographs could be tagged as being part of a series from a single day or across multiple days third each description was classified and elaborated upon in relation to park attributes outlined by bedimorung et al 24 features condition access aesthetics and safety here the emphasis was on explanationbuilding 29 recognizing that citizens view parks in different ways the captions included different viewpoints that were generated through discussion within the research team qualitative and quantitative data were synthesized first in the course of developing a descriptive profile for each park and then by comparing across qualitative and quantitative data for all four parks in the study analysis took place iteratively rival explanations were generated and discussed with stakeholder organizations and within the team 29 in particular the extent to which observable withinpark attributes can account for patterns of activity in a park was continually questioned therefore we actively considered whether the surroundings were just as or even more important than what is or is not found within a specific park city documents fieldwork reports and debriefing notes were used as supplemental resources to assist with synthesizing the quantitative and qualitative data based on firsthand observation results descriptions of park and neighbourhood characteristics in relation to patterns of use taradale park the neighbourhood of taradale was established in 1984 has a curvilinear street pattern and is located in the north east quadrant of the city in 2011 the neighbourhood consisted of 16110 residents it has a median annual household income of 71401 with 159 of residents living in lowincome households and 91 renting of those ≥25 years of age 39 are unemployed and 548 have less than or equivalent to a high school level education over onethird of neighbourhood residents are infants or youth and 606 are adults fewer than 5 of neighbourhood residents are seniors almost half of the taradale population are immigrants of which two thirds were born in india or pakistan and onetenth born in the philippines taradale park was new and an offleash area had already been planned and approved at the time of the study at the public consultation on the potential designation of an offleash area within the nearby park in martindale a couple of participants indicated that they looked forward to using the new offleash area in the taradale park 30 taradale park is located on the edge of the neighbourhood and borders a major road on one side the park is large unmaintained natural field landscape without trees a baseball diamond was adjacent to the park but separated by a fence the open green spaces dissected by the dualuse path were undeveloped and overgrown with tall weeds and grass and provided an ideal location for offleash dogs to run and explore the park included a multiuse path that ran through the park and connected to a path running along the parks perimeterlinking the surrounding neighbourhoods an informal path ran parallel to the formal path along a wooden fence separating the park from a residential area this pathway system was frequently used by both pedestrians and cyclists the formal and informal paths ran past a pond located in one corner of the park the unlandscaped pond area was populated by a variety of wildlife and it provided a storm water drainage for the area this pond was also an attractive feature for larger offleash dogs and thus for the people accompanying them hawks were frequently sighted in the vicinity of this park a lack of maintenance made visibility problematic and served as an ideal breeding ground for mosquitos household garbage and debris dumped in the park posed a safety concern for wildlife and visitors such as dogs and children who might have come into direct contact with the material a bench and garbage can surrounded by a small landscaped area was located at one entrance to the park there were signs at the main entrance to the park and at the seating area to indicate that the park contained an offleash dog area graffiti was evident on the wooden fence at the end of the park at the main entrance adjacent to the residential area a designated rest stop located alongside the main pathways provided a bench for seating receptacles for garbage and recycling and signage older adults of south asian ancestry sometimes accompanied by children would often walk through the park with the rest stop as their destination martindale park martindale 2 martindale park is a large open green space which includes a natural wooded area in one corner and trees along the park perimeter a paved pathway ran through the park and exited onto the streets of the surrounding neighbourhood on either side dualuse paths ran through the park and an informal path ran through the natural wooded area an open grassy area containing a storm water drainage basin provided an open space for dogs to run and play offleash however it was often flooded and maintenance was often incomplete contributing to a mosquito problem the park had no benches or seating nor did it have any dedicated lighting a garbage can was located beside a formal path which was adjacent to street parking allocated for park visitors an unkempt wooded area existed alongside the paved path at the rear of the park the interior of this wooded area was not visible unless one walked directly inside it was overgrown with weeds covered with litter and frequently visited by youth the dogwalkers who regularly visited this park tended to be white males south asian and southeast asian visitors tended to be adults who walked briskly through the park on occasion adults brought schoolaged or preschoolaged children to the park but they did not tend to stay for long or return on a regular basis whereas a public art installation located at the front of the park is suggestive of a playground the park does not contain a playground the public art installation consists of three brass figures a caucasianlooking woman pushing a girl on a swingset and an offleash cocker spaniel jumping in the grass nearby in public consultations regarding the potential designation of an offleash area within this park local residents indicated that this park is a muchneeded amenity but they also cited concerns about litter and safety 30 west hillhurst park west hillhurst was established in 1945 has a grid street pattern with streets that are lined with mature landscaping and sidewalks on both sides and is located in the northwest quadrant of the city in 2011 west hillhursts population was 5757 the majority of west hillhurst residents were born in canada however the socioeconomic status is mixed and a process of gentrification was apparent from the housing gardens and yard maintenance the community has a median annual household income of 61401 with 159 of the neighbourhood residents living in lowincome households 315 having less than or equivalent to a high level education and 14 unemployment the proportion of west hillhurst residents dwelling in rental properties is high compared with the calgary overall almost twothirds of the west hillhurst population are adults followed by youth and seniors in west hillhurst 13 of people are firstgeneration immigrants and of those recently immigrating 263 were born in the united states west hillhurst park is an open green space that includes tall wellestablished trees scattered throughout the park although not visible from within the park due to the presence of a utility building a bridge at one end of the park provided a route for pedestrians and cyclists to cross over major arterial road and joined with a pathway that runs along the bow river within the park an informal trail ran parallel to the chainlink fence separating the park from memorial drive this informal trail was frequently used by joggers headed toward the bridge intended for pedestrian and cyclist use as well as by dogwalkers the large open grassy area that was wellmaintained provided a suitable place for a range of recreational activities dogs were frequently unleashed to roam and play fetch this park had a playground in the northeast corner with benches and a garbage receptacle near the perimeter the playground included three benches a picnic table two swing sets two animal figurines mounted on springs a seesaw a climbing apparatus and a slide at the top of one swing set was a sign that stated no dogs allowed within 20meters of the playground graffiti was evident on the garbage can by the playground and on a box where the chainlink fence met a solid fence in public consultations regarding the potential of formally designating an offleash area within this park local residents views were divided many participants appreciated bringing their dogs to the park while other participants appreciated bringing their children to the playground and the park itself some but by no means all participants felt that dogwalking and childcare were compatible uses for this park 31 meadowlark park meadowlark was established in 1955 has a warpedgrid street pattern and is located in the southwest quadrant of the city meadowlark is a small community with a population of 605 in 2011 in meadowlark 173 of people reside in rented dwellings the neighbourhood has a median annual household income of 74380 with 66 of persons living in lowincome householdshalf of the percentage found for calgary overall among residents ≥25 years of age 29 are unemployed and 369 have a high school diploma or less less than on quarter of residents are firstgeneration immigrants and among recent immigrants twothirds were born in the philippines meadowlark park consists of multiple open green spaces separated by trees shrubbery and fences prior to the construction of this park in 2004 a school stood at this location the school was removed and the park was created to allow for expansion and redevelopment of a major roadway immediately adjacent to the park in the park multiple connecting paved pathways designated for use by pedestrians and cyclists ran from the surrounding neighbourhood through the centre of the park and alongside the stone wall separating the park and neighbourhood from a major arterial road a dualuse path cut through the middle of the park connecting the neighbourhood with an adjacent community and a major shopping mall the adjacent community and major arterial road were separated from the park by a 10foot high concrete fence which ran along the entire south side border of the park sidewalks were located on the northern perimeter of the park running adjacent to a local road a chainlink fence enclosed an area up to the sidewalk on the northwest end the park had landscaped features and a monument in the center of the park with surrounding benches most grassed areas of the park were maintained but were overgrown near a fenced area at the northwest corner of the park a public art installation had been constructed near the entrance from the surrounding neighbourhood to the park it consisted of a brick and stone tower topped by painted larks with plaques that told the history of the park and surrounding neighbourhood this public art installation was framed by attractive landscaping surrounding the public art installation were two benches wroughtiron receptacles for garbage and litter and street lamps graffiti was evident on multiple utility distribution poles along the park perimeter near the public art installation there was a partiallyfenced unlandscaped section littered with construction debris chinook shopping centre could be seen from within the park and this destination is readily accessible via designated pathways and the green space itself the majority of residents in the neighbourhood of meadowlark are canadianborn and older in age than the city of calgary average yet older adults were rarely observed in the park in public consultations regarding the potential designation of an offleash area within this park local residents indicated that they appreciated the park and they complained about traffic and parking as issues that already compromised their use of this park and that offleash designation could exacerbate 32 descriptions of park use and physical activity between parks park use differences in time use patterns between the four parks were found for taradale martindale and meadowlark parks the majority of visitors were observed in the afternoon from 14301830 hrs whereas for west hillhurst similar proportions of visitors were observed in the morning and afternoon the proportion of visitors to taradale park was higher on sundays compared with other days of the week and was significantly higher on sundays than the other park sites the highest proportion of meadowlark visitors was observed on saturdays which was also significantly higher on saturdays compared with the other parks sites park visitor characteristics in the four parks a combined total of 783 visits were observed overall west hillhurst followed by meadowlark martindale and taradale had the most observations of park use the majority of those observed in taradale martindale and west hillhurst parks were observed for a full two minutes by contrast less than half of the observations in meadowlark took two minutes observations lasting fewer than two minutes included visitors who walked or cycled through the parks en route elsewhere the majority of individuals observed in meadowlark park were either walking or cycling along pathways crossing the park males were more likely to be observed in the parks than females with no statistically significant differences between the four parks compared with the other sites those observed in taradale park were more likely to be adults reflecting the lack of facilities for childrens activities for martindale park those observed tended to be youth as opposed to adults or children again reflecting a lack of facilities to support play amongst youngsters for west hillhurst and meadowlark similar proportions of adults and youth were observed compared with the taradale martindale and meadowlark parks the proportion of those visiting alone was significantly lower in west hillhurst children and adult caregivers were frequently observed using the west hillhurst park facilities park activity types the majority of park visitors participated in only one activity whilst being observed with fewer undertaking multiple activities the two most popular activities across all parks included walking and dogrelated physical activity walking was the most popular activity in meadowlark compared with the other three sites while walking was less common in west hillhurst compared with the other sites compared with martindale and meadowlark a higher proportion of dogrelated activitythe majority of which included dogwalking the pathway which was adjacent to one end of the park space and the park space itself was not generally used as a corridor linking between destinations play activity was significantly higher in west hillhurst compared with the other parks which could reflect the low levels of pedestrian and cyclist traffic through the park in addition west hillhurst park included the highest proportion of sedentary activity followed by meadowlark taradale and martindale parks discussion among the four park study sites we found variations in the patterns of use characteristics of users and the types of activities undertaken in general the patterns of use in all four parks combined reflected findings regarding the gender and age characteristics of urban park visitors elsewhere 33 34 35 36 however contrary to previous evidence 18193437 we found that sedentary activities were not the most common park activity rather walking and dogwalking were the most common activities for our sample of parks our findings also suggest that patterns of park activities are associated with the physical attributes within each of the parks and the surrounding neighbourhoods few other studies have integrated multiple quantitative and qualitative approaches to interpret the interrelationships between the characteristic of parks and surrounding neighbourhoods and park use and activity 38 despite being unable to collect data for the entire day we found that patterns of park use were consistent with patterns of use found elsewhere 333439 whereby that the majority of visits take place in the afternoons and evenings patterns of weekday and weekend use differed between parks but not in a consistent way across the four parks male visitors were more common than female visitors while for three of the four parks users were more likely to be adults than children or youtha pattern that is consistent with evidence collected using systematic observation 33 34 35 36 while we were unable to quantify the interaction between gender and activity types within the parks due to sample size elsewhere men have been found to be more physically active within park settings than have women 193536 this pattern is similar to differences in physical activity found between men and women in populationbased studies 4041 creating more opportunities for physical activity within parks could contribute to more parkbased physical activity among women thereby reducing gender disparities in physical activity to encourage more park visits and more parkbased physical activity among women design and management strategies could include improvements associated with safety as well as greater opportunities for social interaction 9 park visitors are often more likely to be adults than children or youth 18193442 in one of our parks however over onehalf of all users observed were children or youth this park did not include physical attributes such as playgrounds typically associated with childrens use and physical activity within parks 21 moreover within this same park participation in play activity was low compared with other activities which is noteworthy as we expected to see more play in settings with high numbers of children our qualitative data suggest that the youth who visited this park were unaccompanied by adults and that they visited a central secluded wooded area to hangout and socialize furthermore monuments within the martindale park were used for play activity such as climbing this finding stands in contrast with the west hillhurst park which included a playground where onethird of visitors were children or teenagers and where onethird of activity observed was play our findings suggest that playgrounds while encouraging children to be physically active are not the only reason why children visit parks for older children and teenagers park attributes that provide places for friends to meet and socialize are likely just as important 9 introducing ageappropriate playground equipment creating and maintaining sports fields and courts and open spaces as well as the provision of areas for socializing that balance privacy with safety might encourage more children and teenagers to be physically active by visiting parks 933 sedentary behaviour is commonly observed in parks 18193437 kaczynski et al 19 found that just over half of observed park users participated in sedentary activity while floyd et al 18 and cohen et al 37 found that almost twothirds of park users were sedentary contrary to this evidence our findings suggest that for the four parks included in our study sedentary activity was less common than other activities nevertheless observed participation in sedentary activity differed between the parks and the reasons for these differences are in part explained by the qualitative data located within taradale and martindale parks are storm water drains and pools of stagnate water that facilitate mosquito breeding which is particularly severe during the early months of the calgary summer the mosquito populations within these two parks were particularly numerous during the data collection likely deterring people from spending extended periods of sedentary time within these locations furthermore the parks were relatively small in area and the layout of the open space was not particularly suitable for organized or unorganized sports activities which often attract spectators 37 seating was also entirely absent or in short supply nevertheless even those observed to be sedentary in parks likely derived some health benefit from the physical activity accumulated whilst traveling to and from the park active transportation is a common mode of transportation for reaching public recreational opportunities 43 creating and redesigning parks to include attributes and amenities that support both passive and active pursuits therefore could increase levels of physical activity in urban populations 4445 people may visit parks more frequently when accompanied 4647 we found that almost twothirds of park visitors were with another person and that about onehalf of children visiting parks were accompanied by parents or guardians compared with other parks west hillhurst included the highest proportion of group visits because of its playground playing was also the most common activity in west hillhurst park relative to the other parks together these findings might suggest that some parents and caregivers are physically active while accompanying their children to the playground but are themselves inactive in parks while their children play the physical attributes within this park including benches and shade close to the playground and the limited amount of pathway might facilitate sedentary activity among these caregivers besenyi et al 21 found that for adults and seniors higher levels of parkbased physical activity energy expenditure occurred on paths and courts compared with other areas while for children higher levels of parkbased physical activity energy expenditure occurred in playgrounds floyd et al 33 found that less shade was associated with a greater likelihood of park users walking and participating in vigorousintensity activity versus sedentary behaviour shores and west 22 also found sedentary activities to be more common in parks with shelter and picnic areas one suggestion for park planners might be to include attributes that will support physical activity for adults near playgrounds so parents or caregivers can still supervise their children while they are physically active themselves dogs in our study contributed positively to patterns of physical activity after walking without a dog dogwalking and other dogrelated pursuits such as playing fetch were the most commonly observed activities these findings extend a growing body of research in health promotion linking dogwalking with physical activity 48 this line of inquiry is highly relevant to populationlevel patterns of physical activity because in canada dogs reside in one out of every three urban households 49 and similar statistics have been reported in other western countries 5051 dogwalking is also becoming a common form of physical activity in some nonwestern countries such as china and japan 5253 nevertheless high levels of dogownership can also impact negatively on physical activity for both dogowners and nondogowners given that illcontrolled dogs and litter from dogwaste can deter people from visiting parks 51 so policies and management strategies need to take dog and owner behaviour into account our method of systematic observation differed from methods used elsewhere unlike other approaches we attempted to record park user information and activities for the entire park and not for separate activity zones within the park this approach was facilitated because of our focus on neighbourhood parks that were typically smaller than other open spaces because we centered our observations on persons not on multiple activity areas in the same park double counting of visitors was minimized when multiple activity areas serve as the basis for observations any visitors who moved between activity areas during observation periods could be doublecounted 39 whenever possible we observed each park user for a full two minutes so as to document multiple activities during the same park visit the time frame of two minutes was selected to balance the need to capture the range of activities undertaken by a single individual and the need to include as many cases as possible in the taradale martindale and west hillurst parks most visitor observations lasted for two minutes in meadowlark however less than onehalf of all visitors were observed for two minutes meadowlark included a short pathway that connected a residential area and large mall both of which were surrounded by major roads with high volume traffic many walkers and cyclists observed in the meadowlark park were passing through en route to other destinations thus the fact that fewer visitors were observed for the entire two minutes reflects the activity patterns within and the design of the park during times when the volume of visitors was low observation of visitors may have begun immediately as they entered the parkthus their activity would likely have been recorded as walking or cycling but underestimating other types of activity similarly visitors who were already in the park and were being sedentary playing or undertaking dogrelated activity likely entered the park via walking or cycling so our results may underestimate walking and cycling whereas our findings are a crosssectional representation of summer park activities in four parks only they suggest that the relationships between park policies and physical activity are complex despite limitations our case study approach provided a rich description of the activities and settings and their interaction within the four parks indeed such a detailed description would not have been possible using a single methodological approach or data source the unique findings from our case study highlight that while policyrelated physical attributes in some parks appear to encourage certain types of behaviour in other parks the relationship between context and behaviour was less than straightforward thus the physical and social characteristics as well as the history of the community in which a park is situated are potentially important influences on park use the case study approach might provide useful information for park developers and planners in creating or modifying parks for example to encourage specific types of activities or to encourage more use among particular types of visitors 6 furthermore this approach is highly relevant to innovations in park planning and management which often begin with pilot or demonstration projects that require consideration of ambient policy sociocultural and geographical contexts 6 conclusions park attributes and the surrounding neighbourhood social characteristics are important for determining the types of parkbased activities visitors undertake and the sociodemographic profile of visitors the desire to sit outside surrounded by nature might be the very reason people visit parks yet this desire could still contribute to physical activity levels by prompting people to walk or cycle to and from parks planners and mangers of parks should consider the potential impacts that physical and symbolic attributes may have on visits and they should look to maximize attributes that encourage park visitors to be physically active additional files competing interests the authors declare that they have no competing interest author information

background many characteristics of urban parks and neighbourhoods have been linked to patterns of physical activity yet untangling these relationships to promote increased levels of physical activity presents methodological challenges based on qualitative and quantitative data this article describes patterns of activity within urban parks and the sociodemographic characteristics of park visitors it also accounts for these patterns in relation to the attributes of parks and their surrounding neighbourhoods methods a multiple case study was undertaken that incorporated quantitative and qualitative data derived from firsthand observation in a purposive sample of four urban parks quantitative data based on direct observation of visitors patterns of use and sociodemographic characteristics were collected using a structured instrument differences in frequencies of observed activities and sociodemographic characteristics of visitors were compared between the four parks qualitative data based on direct observation of park characteristics and patterns of use were generated through digital photography and analyzed through captioning quantitative data on patterns in activity and sociodemographic characteristics were synthesized with the qualitative data on park and usage characteristics results a comprehensive portrait of each park in the study was generated activity types sedentary walking dogrelated cycling and play patterns of park use time of day day of week and sociodemographic characteristics age group social group differed between the four parks patterns in park use and activity appeared to be associated with sociodemographic characteristics of the surrounding neighbourhoods as well as the physical and social environmental characteristics specific to each park conclusions both park and neighbourhood characteristics influence patterns of use and physical activity within parks the study findings suggest that sociodemographic characteristics of neighbourhoods surrounding parks need be considered in planning development and management engaging local communities could help planners to develop and update urban parks in ways that reflect the needs and characteristics of community residents and in turn encourage visits and more physical activity amongst visitors

Globally, nearly 16 million girls aged between 15 and 19 give birth to their first child each year . In developing countries, approximately one-third of women begin having children at 19 or younger, and nearly half of the first births in adolescence are from girls aged 17 or younger. Half of the girls who give birth between the ages of 15 and 17 have a second birth in adolescence, and 11 percent of girls with two births have the third birth in adolescence . Early pregnancy and motherhood are common in east African countries, ranging from 18% in Kenya and 29% in Malawi . The socioeconomic implications of youth pregnancy and early childbearing are significant in developing nations and are linked with maternal mortality, low birth weight, poor school achievement and productivity, and, subsequently, intergenerational poverty transmission . As the age at first birth decreases, the likelihood of maternal mortality rises. Girls who give birth under 15 and between 15 and 19 years of age are five and two times more at risk of mortality related to pregnancy and childbirth consequences, respectively, than women aged 20-24 at first birth . Additionally, pregnancy-related consequences, such as eclampsia, obstetric fistula, and systemic infection, are linked to early age at first birth . Later in women's lives, early age birth is also linked to an increased risk of diabetes mellitus, hypertension, lung disease, and poor physical performance . In addition to having an adverse effect on the mother's health, it also has negative repercussions on their education, work prospects, and opportunities. Moreover, it is related to societal consequences such as violence, rejection, and shame . Additionally, early age at first birth significantly affects a country's population growth, particularly in countries where modern contraception is underutilized . Under 5 morbidity is also greater among children born to mothers under 20 years of age . Additionally, the risk of newborn mortality is considerably higher for infants whose mothers are under 16 years of age . However, bearing a first child at an advanced age is associated with a higher risk of miscarriage, multiple pregnancies, diabetes, chromosomal abnormities, and maternal mortality . The age at first birth varies across different regions. Among European Union countries the mean age of women at first childbirth ranges from 26.3 in Bulgaria to 31.3 in Italy . The median ages at first birth in East Asia and the Pacific , Bangladesh , Nigeria and Ghana , Sub-Saharan Africa , and Uganda are 20.2, 16.34, 20, 19, and 19.2 years, respectively . In Ethiopia, 13% of women aged 15-19 have begun childbearing and 2% are pregnant with their first child. One in two women aged 25-49 give birth for the first time before age of 20 years . Lower level educational status , rural residency , poor wealth index , unemployment , husband's education and occupation , early age at first sexual intercourse , younger age at first marriage , peer pressure , and smoking status were identified as predictors for early age at first childbirth in several studies. Delaying pregnancy and childbearing in adolescent women may result in higher academic achievement, ensuring women's economic independence and a better life. Even though promising progress has been made so far regarding age at first birth, early childbearing remains a great challenge in Ethiopia. In 2021, Ethiopia launched a new national adolescent and youth health strategy with the aim of reducing early age at first pregnancy from 13% to 7% and increasing the median age at first marriage from 17 to 18, thereby reducing early age at first birth . Understanding the current nationwide status of age at first birth will play an enormous role in achieving the above-stated goal. A few related studies have been undertaken so far in Ethiopia. Most studies focused on only teenage and/or adolescent childbearing . Furthermore, studies were limited to specific districts/areas . Survival analysis of time to first birth among reproductive-age women will have a paramount role in subduing those limitations and further estimating the significant impact of predictor variables at a national level. The age at which childbearing first commences will have a crucial role in estimating the overall fertility level at the country level. Furthermore, this study uses recent Ethiopia Demographic and Health Survey data, which is crucial in providing up-to-date information on national improvements regarding early childbearing. --- Methods Study setting, study period, and data source Based on the latest census figures and projections from trading economics, the total population in Ethiopia was estimated at 115.0 million people in 2020 . The final report of the EDHS 2019 contained detailed information at a national level from the nine regional states and two city administrations of Ethiopia. The administration levels went from regions to zones and through woreda. A survival analysis was conducted among reproductive-age group women in Ethiopia using the EDHS data. The EDHS was implemented by the Ethiopian Public Health Institute in collaboration with the Central Statistical Agency and the Federal Ministry of Health . The target populations were women aged 15-49 and men aged 15-59 in selected households across Ethiopia. The EDHS contains information on the background characteristics of the respondents, maternal health care, fertility, marriage and sexual activity, child feeding practices, nutritional status of women and children, and adult and childhood mortality. Data collection was carried out from March to June 2019 . --- Data extraction and population We received a letter permitting us to acquire the EDHS 2019 data from the DHS program after making a reasonable request. Data extraction was carried out to select reproductive-age women. For this study, a weighted sample of 8,885 reproductiveage women was drawn. The data extraction period was from October 1, 2022 to October 15, 2022. All reproductive-age women in Ethiopia were the source population, whereas all reproductive-age women in Ethiopia in the selected enumeration area were the study population. --- Sampling methods The 2019 EDHS sample was stratified and selected in two stages. Each region was stratified into urban and rural areas, yielding 21 sampling strata. In the first stage, 305 enumeration areas were selected with a probability proportional to EA size. In the second stage, a fixed number of 30 households per cluster were selected with an equal probability systematic selection from the newly created household listing. Sample allocation was carried out to ensure that survey precision was comparable among regions. A total of 25 EAs were selected from eight regions , and 35 EAs were selected from the three largest regions: Amhara, Oromia, and the Southern Nations, Nationalities, and Peoples' Region . The detailed sampling procedure is accessible in the EDHS 2019 report . In this study, a total of 8,885 weighted reproductive-age women were included. The highlighted sampling procedure for this study is indicated in the figure below . --- Inclusion and exclusion criteria All reproductive-age women in the selected enumeration area were included in the study, whereas women declared infecund were excluded. --- Study variables The dependent variable is the time at first childbirth. This study considered different explanatory variables to determine predictors of time to first childbirth . --- Operational definition Event: mothers who first gave birth until the 2019 EDHS data collection end date. Censored: women who did not first give birth until the 2019 EDHS data collection date. Time to first birth: age of the mother in years when she first gave birth . --- Data processing and analysis STATA version 17 software was used to extract data from the EDHS 2019 individual record folder. The data were coded, cleaned, and edited. Listing and sorting were carried out to find any missing values. Descriptive statistics were analyzed and presented in terms of frequency and percentage. Age at first birth is calculated as the age difference between the mother and her --- FIGURE 1 Schematic representation of the sampling procedures in the study of time to first childbirth and its predictors among reproductive age women in Ethiopia . EAs; enumeration areas. . In this study, the maximum VIF was 2.30 with a mean VIF of 1.54 and the minimum tolerance value was 0.43. Thus, there was no multicollinearity between covariates. Variables with a p ≤ 0.25 in the bivariate analysis were fitted and included in the multivariable Weibull accelerated failure time model. In the multivariable analysis, variables with a p ≤ 0.05 were considered statically significant. --- Rationale for using the survival analysis Survival analysis is a statistical method for analyzing data in which the outcome variable of interest is the time until an event occurs. The outcome of interest in this study was the time to first childbirth, which is time to event data and do not merely depend on whether the event occurred or not but also the time at which the event occurred. Thus, it is best suited to use a survival analysis model. Furthermore, the outcome of interest contained both an event and a time. Thus, linear and logistic regressions were not appropriate. Additionally, those regression models are not well enough equipped to handle censoring events. --- Results --- Socio-demographic and reproductive health-related characteristics A total of 8,885 weighted reproductive-age women were included for the examination on the time to first childbirth in Ethiopia; 5,855 of women gave birth to at least one child . Weighted frequency analysis showed that 6,024 of the respondents resided in rural areas. Regarding educational status, 3, 589 of the respondents had no formal education. A total of 3,052 reproductive age women were in the poor household wealth index category. Concerning knowledge of any contraceptive method, 424 of the women did not know of any contraceptive method . --- Survival time of first childbirth The overall median survival time to first childbirth was 18 years. The total follow-up time contributed by all study participants was 107,124 person years. The survival probability of time to first childbirth beyond 14, 16, 18, and 20 years was 87.8%, 72.6%, 53.5%, and 34.4%, respectively . The median survival time differed among the participant characteristics. The median survival time was 19 years for women who resided in an urban area and 17 years for women from a rural area. By educational status, the median survival time was 17 years for women with no formal education and 20 years for those with secondary and above education. Regarding the wealth index, the median survival times for poor, middle, and rich were 17, 18, and 19 years, respectively. --- Comparisons of survival functions of different categorical variables A Kaplan-Meier survival curve and log-rank test were computed to compare and estimate the survivor function among different characteristics of the respondent. In the Kaplan-Meier survival curve, one survivorship function curve located under another implies that the lower curve group has a lower survival status than the upper curve group. Furthermore, the difference is explained statistically by the log-rank test. Generally, the Kaplan-Meier survival curve shows that women who reside in a rural area, have no formal education, and have lower wealth index categories had their first child earlier than the reverse group. Furthermore, the log-rank test p-value showed that there was a significant difference in survival experience among covariates of residence , women's educational level , and wealth index categories . --- Model selection Proportional hazard assumption test by schoenfeld residual The rho statistic p-value of all covariates and the global test p-value in the Schoenfeld residual was below 0.05. Therefore, the proportional hazard assumption was not fulfilled. Thus, the accelerated failure time model was considered. --- Accelerated failure time model test The model with the smallest AIC and BIC values was considered to be the best survival model for the given data. The Weibull accelerated failure time model with no frailty was found to have the smallest AIC and BIC values . Thus, the Weibull accelerated failure time model with no frailty was the best model for the data to describe the status of women towards time to first childbirth and its predictors . --- Predictors of time to first childbirth In the bivariable Weibull AFT model, age, residence, mother education level, wealth index, sex of household head, knowledge of any contraceptive method, media exposure , and media exposure were found to be significant, with a p ≤ 0.25. Additionally, in this model, mother educational level, knowledge of any contraceptive method, and media exposure were predictors of time to first childbirth. The acceleration factor for time to first childbirth among mothers who had secondary and above education level was 1.154 compared with an uneducated mother. Additionally, the acceleration factor for time to first childbirth in mothers with only primary education was 1.036 compared with the reference group . This shows that uneducated women gave birth to their first child earlier than educated mothers. Regarding knowledge towards contraceptive methods, the acceleration factor of time to first birth for women who know of at least one contraceptive method was 1.051 . This implies that women with knowledge of at least one contraceptive method have a delayed age at first birth compared to women without knowledge of contraceptive methods. In another way, women without knowledge of any contraceptive methods had their first child earlier than their counterparts. Women with media exposure have a 1.048 times acceleration factor for time to first childbirth compared with the reverse group. . --- Discussion Time to first childbirth and its predictors were determined by using data from the recent 2019 Ethiopian Demographic Health Survey. Mother education level, knowledge of any contraceptive method, and media exposure were found to be predictors of time to first childbirth. The overall median survival time to first childbirth was 18 years. This finding is in line with a study carried out in Gambia . This result is lower than the that from a study undertaken in several regions, such as the USA , Ghana , Uganda , Nigeria , and Kenya . The awareness of women about the consequence of having babies at an early age and contraceptive access and utilization plays a paramount role in delaying age at first childbirth in developed countries . In developing countries like Ethiopia, women's autonomy regarding reproductive health decisions is low. This might lead to poor reproductive health care seeking behaviors, such as low contraceptive utilization, thereby resulting in early first childbearing . In addition, the variation could be attributed to different factors such as age at first marriage, age at first sexual experience, and contraceptive usage, which were listed as factors that shortened the survival time of onset of first childbirth in different studies . For instance, the median ages at first marriage in Ethiopia and Kenya , whereas as in Ethiopia it is 20.42% . On the contrary, the finding of this study is higher than the study conducted in Bangladesh . This variation could be attributed to differences in religious beliefs. In Bangladesh, most of the population has a Muslim affiliation. A Muslim religious affiliation is closely linked with the early age of the mother at first birth . In addition, in Bangladesh, many people are unaware of the consequences of early marriage and early pregnancy . This study revealed that women's educational level is a predictor of time to first childbirth. Women who attend primary, secondary, and higher education delayed their first childbirth more than those who did not have any education. This finding is consistent with a study carried out in Kenya , which concluded that the probability of giving birth at an earlier age decreases as the educational level increases. Similarly, a study carried out in Ghana revealed that the higher the woman's educational level, the longer the waiting time for her first birth: 73% of postsecondary level women had yet to give birth before the age of 30 . Furthermore, a study conducted in Bangladesh also found pretty consistent findings that women with higher levels of education have a lower risk of having an early first birth . The possible explanation might be that uneducated women might not know the optimal age at which giving childbirth has the minimum risk. Education level and contraceptive utilization is directly proportional. The higher the education level, the higher the use of contraception . Thus, the low contraceptive use of uneducated mothers leads to early first childbirth. Therefore, enrolling women in at least primary education will reduce the incidence of early first childbirth and the related consequences. This finding indicates a positive interaction between women's knowledge of contraceptive methods and delaying the time of first childbirth. This finding is supported by a study carried out in East Asia and the Pacific that found that there is a high incidence of early first childbirth among women without any knowledge of contraceptive methods. Likewise, a study conducted in Tanzania also revealed that contraceptive knowledge is considerably high among women who delay their first childbirth. This might be because the likelihood of contraceptive use was high among women who know about contraceptives . Women might delay early-age maternity as long as she uses contraceptive methods. Thus, policymakers should emphasize improving women's knowledge of different types of contraceptives by providing access to information about contraceptives through healthcare providers, online resources, and community organizations. Furthermore, it is recommended that open dialogue about contraception is encouraged between women and their partners, family members, and healthcare providers. Thus, increasing women's knowledge of contraceptive methods can delay early maternity, preventing unintended adolescent pregnancy and early pregnancy-related mortality and morbidity. Media exposure has also been found to be a predictor of time to first birth. Women who have access to media are less likely to give birth to their first child at an early age than those who did not have access. This result is in agreement with a study carried out in Bangladesh that indicated that women exposed to media on a regular basis were less likely to give birth to their first child at an early age than those who are not exposed . This finding points to the fact that women who do not have access to media might be unaware of the complications associated with early age at first childbirth. In addition, maternal healthcare utilization, including family planning services, is significantly higher among women exposed to mass media, which delays early maternity . Furthermore, those who were not exposed to media were more likely to get married earlier and have earlier sexual experiences, resulting in early first childbirth. Thus, advertisements and educational programs through mass media targeting the consequences of early first childbirth on maternal and child health are highly recommended. The strength of this study is that it uses nationally representative data and can be generalizable to all Ethiopian reproductive-age women. Owing to the self-reported nature of the data, there might be recall bias. As the data source is secondary, it is difficult to quantify other potential predictors of time to first childbirth. A lack of trend analysis is also a limitation of this study. --- Conclusion In this study, the median survival time to first childbirth was 18 years, which is lower than the optimal age for first childbirth, between the late 20 s and 30 s . This is the ideal age for education. In addition to having implications on her social, physical, and mental health, being a mother at this age may prevent the woman from attending school. The timing of first childbirth in Ethiopia is mainly influenced by women's level of educational, knowledge of contraceptive methods, and access to media. Interventions could involve raising women's educational levels by exposing them to educational materials and other awareness-creation efforts regarding the consequences of early first childbirth. In addition, expanding adolescent and youth-friendly services in the country might increase women's knowledge of contraceptive methods. Furthermore, including sexual and reproductive health education programs in the educational curriculum also contributes to reducing early marriage and sexual initiation, thereby decreasing early first childbirth. Furthermore, policymakers and other nongovernmental organizations should continuously invest resources in transmitting messages through mass media , such as advertisements and other programs, regarding the impact of early childbirth. In conclusion, a prospective follow-up study that includes other potential predictors is recommended. Participated equally in design, data management, analyses, interpretation, and manuscript write up. All authors contributed to the article and approved the submitted version. --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. --- Supplementary material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frph.2023. 1165204/full#supplementary-material.

Background: Being a mother for the first time is the most significant event in a woman's life. "Age at first birth" refers to a mother's age in years when she gives birth to her first child. The age of first childbirth has physical, economic, and social implications. However, little is known about this issue in Ethiopia. Thus, this study sought to determine the time to first childbirth and its predictors at a national level. Methods: Data were extracted from the 2019 Ethiopia Demographic and Health Survey using STATA version 17 software. A total of 8,885 weighted reproductiveage women (15-49 years) were included in this study. A Kaplan-Meier survivor curve was generated to estimate the time of first childbirth. A log-rank test was used to compare the difference in survival curves. Akaike information criteria and Bayesian information criteria were calculated to select the appropriate survival model for the data. The Weibull accelerated failure time model with no frailty distribution was used to identify significant predictors. Results: The overall median survival time to first childbirth was 18 years. The significant predictors of time to first childbirth were the educational level of the mother [primary education (ϕ = 1.036, 95% CI: 1.011, 1.063), secondary and above education (ϕ = 1.154, 95% CI: 1.118, 1.191)], knowledge of any contraceptive method [know at least one (ϕ = 1.051, 95% CI: 1.006, 1.101)], and media exposure (ϕ = 1.048, 95% CI: 1.011, 1.086).The median survival time to first childbirth was 18 years, which is lower than the optimal age for first childbirth (late 20 s and early 30 s). The timing of first childbirth in Ethiopia is mainly influenced by the educational level of women, knowledge of contraceptive methods, and exposure to media. Thus, exposing women to educational materials and other awareness-creation campaigns regarding the consequences of early first childbirth and strategies to improve women's knowledge of contraceptive methods is highly recommended. KEYWORDS childbirth, determinants, Ethiopia, reproductive age, survival analysis, time to firstAge at first birth refers to the woman's age in years when she gives birth to her first child (1). Childbirth is the most significant event in a woman's life. It is an intense event that is physically, psychologically, socially, and culturally significant (2). The impact could be positive, both in the short and long term; however, sometimes, it could result in negative and traumatizing events (3).

globally nearly 16 million girls aged between 15 and 19 give birth to their first child each year in developing countries approximately onethird of women begin having children at 19 or younger and nearly half of the first births in adolescence are from girls aged 17 or younger half of the girls who give birth between the ages of 15 and 17 have a second birth in adolescence and 11 percent of girls with two births have the third birth in adolescence early pregnancy and motherhood are common in east african countries ranging from 18 in kenya and 29 in malawi the socioeconomic implications of youth pregnancy and early childbearing are significant in developing nations and are linked with maternal mortality low birth weight poor school achievement and productivity and subsequently intergenerational poverty transmission as the age at first birth decreases the likelihood of maternal mortality rises girls who give birth under 15 and between 15 and 19 years of age are five and two times more at risk of mortality related to pregnancy and childbirth consequences respectively than women aged 2024 at first birth additionally pregnancyrelated consequences such as eclampsia obstetric fistula and systemic infection are linked to early age at first birth later in womens lives early age birth is also linked to an increased risk of diabetes mellitus hypertension lung disease and poor physical performance in addition to having an adverse effect on the mothers health it also has negative repercussions on their education work prospects and opportunities moreover it is related to societal consequences such as violence rejection and shame additionally early age at first birth significantly affects a countrys population growth particularly in countries where modern contraception is underutilized under 5 morbidity is also greater among children born to mothers under 20 years of age additionally the risk of newborn mortality is considerably higher for infants whose mothers are under 16 years of age however bearing a first child at an advanced age is associated with a higher risk of miscarriage multiple pregnancies diabetes chromosomal abnormities and maternal mortality the age at first birth varies across different regions among european union countries the mean age of women at first childbirth ranges from 263 in bulgaria to 313 in italy the median ages at first birth in east asia and the pacific bangladesh nigeria and ghana subsaharan africa and uganda are 202 1634 20 19 and 192 years respectively in ethiopia 13 of women aged 1519 have begun childbearing and 2 are pregnant with their first child one in two women aged 2549 give birth for the first time before age of 20 years lower level educational status rural residency poor wealth index unemployment husbands education and occupation early age at first sexual intercourse younger age at first marriage peer pressure and smoking status were identified as predictors for early age at first childbirth in several studies delaying pregnancy and childbearing in adolescent women may result in higher academic achievement ensuring womens economic independence and a better life even though promising progress has been made so far regarding age at first birth early childbearing remains a great challenge in ethiopia in 2021 ethiopia launched a new national adolescent and youth health strategy with the aim of reducing early age at first pregnancy from 13 to 7 and increasing the median age at first marriage from 17 to 18 thereby reducing early age at first birth understanding the current nationwide status of age at first birth will play an enormous role in achieving the abovestated goal a few related studies have been undertaken so far in ethiopia most studies focused on only teenage andor adolescent childbearing furthermore studies were limited to specific districtsareas survival analysis of time to first birth among reproductiveage women will have a paramount role in subduing those limitations and further estimating the significant impact of predictor variables at a national level the age at which childbearing first commences will have a crucial role in estimating the overall fertility level at the country level furthermore this study uses recent ethiopia demographic and health survey data which is crucial in providing uptodate information on national improvements regarding early childbearing methods study setting study period and data source based on the latest census figures and projections from trading economics the total population in ethiopia was estimated at 1150 million people in 2020 the final report of the edhs 2019 contained detailed information at a national level from the nine regional states and two city administrations of ethiopia the administration levels went from regions to zones and through woreda a survival analysis was conducted among reproductiveage group women in ethiopia using the edhs data the edhs was implemented by the ethiopian public health institute in collaboration with the central statistical agency and the federal ministry of health the target populations were women aged 1549 and men aged 1559 in selected households across ethiopia the edhs contains information on the background characteristics of the respondents maternal health care fertility marriage and sexual activity child feeding practices nutritional status of women and children and adult and childhood mortality data collection was carried out from march to june 2019 data extraction and population we received a letter permitting us to acquire the edhs 2019 data from the dhs program after making a reasonable request data extraction was carried out to select reproductiveage women for this study a weighted sample of 8885 reproductiveage women was drawn the data extraction period was from october 1 2022 to october 15 2022 all reproductiveage women in ethiopia were the source population whereas all reproductiveage women in ethiopia in the selected enumeration area were the study population sampling methods the 2019 edhs sample was stratified and selected in two stages each region was stratified into urban and rural areas yielding 21 sampling strata in the first stage 305 enumeration areas were selected with a probability proportional to ea size in the second stage a fixed number of 30 households per cluster were selected with an equal probability systematic selection from the newly created household listing sample allocation was carried out to ensure that survey precision was comparable among regions a total of 25 eas were selected from eight regions and 35 eas were selected from the three largest regions amhara oromia and the southern nations nationalities and peoples region the detailed sampling procedure is accessible in the edhs 2019 report in this study a total of 8885 weighted reproductiveage women were included the highlighted sampling procedure for this study is indicated in the figure below inclusion and exclusion criteria all reproductiveage women in the selected enumeration area were included in the study whereas women declared infecund were excluded study variables the dependent variable is the time at first childbirth this study considered different explanatory variables to determine predictors of time to first childbirth operational definition event mothers who first gave birth until the 2019 edhs data collection end date censored women who did not first give birth until the 2019 edhs data collection date time to first birth age of the mother in years when she first gave birth data processing and analysis stata version 17 software was used to extract data from the edhs 2019 individual record folder the data were coded cleaned and edited listing and sorting were carried out to find any missing values descriptive statistics were analyzed and presented in terms of frequency and percentage age at first birth is calculated as the age difference between the mother and her figure 1 schematic representation of the sampling procedures in the study of time to first childbirth and its predictors among reproductive age women in ethiopia eas enumeration areas in this study the maximum vif was 230 with a mean vif of 154 and the minimum tolerance value was 043 thus there was no multicollinearity between covariates variables with a p ≤ 025 in the bivariate analysis were fitted and included in the multivariable weibull accelerated failure time model in the multivariable analysis variables with a p ≤ 005 were considered statically significant rationale for using the survival analysis survival analysis is a statistical method for analyzing data in which the outcome variable of interest is the time until an event occurs the outcome of interest in this study was the time to first childbirth which is time to event data and do not merely depend on whether the event occurred or not but also the time at which the event occurred thus it is best suited to use a survival analysis model furthermore the outcome of interest contained both an event and a time thus linear and logistic regressions were not appropriate additionally those regression models are not well enough equipped to handle censoring events results sociodemographic and reproductive healthrelated characteristics a total of 8885 weighted reproductiveage women were included for the examination on the time to first childbirth in ethiopia 5855 of women gave birth to at least one child weighted frequency analysis showed that 6024 of the respondents resided in rural areas regarding educational status 3 589 of the respondents had no formal education a total of 3052 reproductive age women were in the poor household wealth index category concerning knowledge of any contraceptive method 424 of the women did not know of any contraceptive method survival time of first childbirth the overall median survival time to first childbirth was 18 years the total followup time contributed by all study participants was 107124 person years the survival probability of time to first childbirth beyond 14 16 18 and 20 years was 878 726 535 and 344 respectively the median survival time differed among the participant characteristics the median survival time was 19 years for women who resided in an urban area and 17 years for women from a rural area by educational status the median survival time was 17 years for women with no formal education and 20 years for those with secondary and above education regarding the wealth index the median survival times for poor middle and rich were 17 18 and 19 years respectively comparisons of survival functions of different categorical variables a kaplanmeier survival curve and logrank test were computed to compare and estimate the survivor function among different characteristics of the respondent in the kaplanmeier survival curve one survivorship function curve located under another implies that the lower curve group has a lower survival status than the upper curve group furthermore the difference is explained statistically by the logrank test generally the kaplanmeier survival curve shows that women who reside in a rural area have no formal education and have lower wealth index categories had their first child earlier than the reverse group furthermore the logrank test pvalue showed that there was a significant difference in survival experience among covariates of residence womens educational level and wealth index categories model selection proportional hazard assumption test by schoenfeld residual the rho statistic pvalue of all covariates and the global test pvalue in the schoenfeld residual was below 005 therefore the proportional hazard assumption was not fulfilled thus the accelerated failure time model was considered accelerated failure time model test the model with the smallest aic and bic values was considered to be the best survival model for the given data the weibull accelerated failure time model with no frailty was found to have the smallest aic and bic values thus the weibull accelerated failure time model with no frailty was the best model for the data to describe the status of women towards time to first childbirth and its predictors predictors of time to first childbirth in the bivariable weibull aft model age residence mother education level wealth index sex of household head knowledge of any contraceptive method media exposure and media exposure were found to be significant with a p ≤ 025 additionally in this model mother educational level knowledge of any contraceptive method and media exposure were predictors of time to first childbirth the acceleration factor for time to first childbirth among mothers who had secondary and above education level was 1154 compared with an uneducated mother additionally the acceleration factor for time to first childbirth in mothers with only primary education was 1036 compared with the reference group this shows that uneducated women gave birth to their first child earlier than educated mothers regarding knowledge towards contraceptive methods the acceleration factor of time to first birth for women who know of at least one contraceptive method was 1051 this implies that women with knowledge of at least one contraceptive method have a delayed age at first birth compared to women without knowledge of contraceptive methods in another way women without knowledge of any contraceptive methods had their first child earlier than their counterparts women with media exposure have a 1048 times acceleration factor for time to first childbirth compared with the reverse group discussion time to first childbirth and its predictors were determined by using data from the recent 2019 ethiopian demographic health survey mother education level knowledge of any contraceptive method and media exposure were found to be predictors of time to first childbirth the overall median survival time to first childbirth was 18 years this finding is in line with a study carried out in gambia this result is lower than the that from a study undertaken in several regions such as the usa ghana uganda nigeria and kenya the awareness of women about the consequence of having babies at an early age and contraceptive access and utilization plays a paramount role in delaying age at first childbirth in developed countries in developing countries like ethiopia womens autonomy regarding reproductive health decisions is low this might lead to poor reproductive health care seeking behaviors such as low contraceptive utilization thereby resulting in early first childbearing in addition the variation could be attributed to different factors such as age at first marriage age at first sexual experience and contraceptive usage which were listed as factors that shortened the survival time of onset of first childbirth in different studies for instance the median ages at first marriage in ethiopia and kenya whereas as in ethiopia it is 2042 on the contrary the finding of this study is higher than the study conducted in bangladesh this variation could be attributed to differences in religious beliefs in bangladesh most of the population has a muslim affiliation a muslim religious affiliation is closely linked with the early age of the mother at first birth in addition in bangladesh many people are unaware of the consequences of early marriage and early pregnancy this study revealed that womens educational level is a predictor of time to first childbirth women who attend primary secondary and higher education delayed their first childbirth more than those who did not have any education this finding is consistent with a study carried out in kenya which concluded that the probability of giving birth at an earlier age decreases as the educational level increases similarly a study carried out in ghana revealed that the higher the womans educational level the longer the waiting time for her first birth 73 of postsecondary level women had yet to give birth before the age of 30 furthermore a study conducted in bangladesh also found pretty consistent findings that women with higher levels of education have a lower risk of having an early first birth the possible explanation might be that uneducated women might not know the optimal age at which giving childbirth has the minimum risk education level and contraceptive utilization is directly proportional the higher the education level the higher the use of contraception thus the low contraceptive use of uneducated mothers leads to early first childbirth therefore enrolling women in at least primary education will reduce the incidence of early first childbirth and the related consequences this finding indicates a positive interaction between womens knowledge of contraceptive methods and delaying the time of first childbirth this finding is supported by a study carried out in east asia and the pacific that found that there is a high incidence of early first childbirth among women without any knowledge of contraceptive methods likewise a study conducted in tanzania also revealed that contraceptive knowledge is considerably high among women who delay their first childbirth this might be because the likelihood of contraceptive use was high among women who know about contraceptives women might delay earlyage maternity as long as she uses contraceptive methods thus policymakers should emphasize improving womens knowledge of different types of contraceptives by providing access to information about contraceptives through healthcare providers online resources and community organizations furthermore it is recommended that open dialogue about contraception is encouraged between women and their partners family members and healthcare providers thus increasing womens knowledge of contraceptive methods can delay early maternity preventing unintended adolescent pregnancy and early pregnancyrelated mortality and morbidity media exposure has also been found to be a predictor of time to first birth women who have access to media are less likely to give birth to their first child at an early age than those who did not have access this result is in agreement with a study carried out in bangladesh that indicated that women exposed to media on a regular basis were less likely to give birth to their first child at an early age than those who are not exposed this finding points to the fact that women who do not have access to media might be unaware of the complications associated with early age at first childbirth in addition maternal healthcare utilization including family planning services is significantly higher among women exposed to mass media which delays early maternity furthermore those who were not exposed to media were more likely to get married earlier and have earlier sexual experiences resulting in early first childbirth thus advertisements and educational programs through mass media targeting the consequences of early first childbirth on maternal and child health are highly recommended the strength of this study is that it uses nationally representative data and can be generalizable to all ethiopian reproductiveage women owing to the selfreported nature of the data there might be recall bias as the data source is secondary it is difficult to quantify other potential predictors of time to first childbirth a lack of trend analysis is also a limitation of this study conclusion in this study the median survival time to first childbirth was 18 years which is lower than the optimal age for first childbirth between the late 20 s and 30 s this is the ideal age for education in addition to having implications on her social physical and mental health being a mother at this age may prevent the woman from attending school the timing of first childbirth in ethiopia is mainly influenced by womens level of educational knowledge of contraceptive methods and access to media interventions could involve raising womens educational levels by exposing them to educational materials and other awarenesscreation efforts regarding the consequences of early first childbirth in addition expanding adolescent and youthfriendly services in the country might increase womens knowledge of contraceptive methods furthermore including sexual and reproductive health education programs in the educational curriculum also contributes to reducing early marriage and sexual initiation thereby decreasing early first childbirth furthermore policymakers and other nongovernmental organizations should continuously invest resources in transmitting messages through mass media such as advertisements and other programs regarding the impact of early childbirth in conclusion a prospective followup study that includes other potential predictors is recommended participated equally in design data management analyses interpretation and manuscript write up all authors contributed to the article and approved the submitted version data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at 1165204full supplementarymaterial

background being a mother for the first time is the most significant event in a womans life age at first birth refers to a mothers age in years when she gives birth to her first child the age of first childbirth has physical economic and social implications however little is known about this issue in ethiopia thus this study sought to determine the time to first childbirth and its predictors at a national level methods data were extracted from the 2019 ethiopia demographic and health survey using stata version 17 software a total of 8885 weighted reproductiveage women 1549 years were included in this study a kaplanmeier survivor curve was generated to estimate the time of first childbirth a logrank test was used to compare the difference in survival curves akaike information criteria and bayesian information criteria were calculated to select the appropriate survival model for the data the weibull accelerated failure time model with no frailty distribution was used to identify significant predictors results the overall median survival time to first childbirth was 18 years the significant predictors of time to first childbirth were the educational level of the mother primary education ϕ 1036 95 ci 1011 1063 secondary and above education ϕ 1154 95 ci 1118 1191 knowledge of any contraceptive method know at least one ϕ 1051 95 ci 1006 1101 and media exposure ϕ 1048 95 ci 1011 1086 the median survival time to first childbirth was 18 years which is lower than the optimal age for first childbirth late 20 s and early 30 s the timing of first childbirth in ethiopia is mainly influenced by the educational level of women knowledge of contraceptive methods and exposure to media thus exposing women to educational materials and other awarenesscreation campaigns regarding the consequences of early first childbirth and strategies to improve womens knowledge of contraceptive methods is highly recommended keywords childbirth determinants ethiopia reproductive age survival analysis time to firstage at first birth refers to the womans age in years when she gives birth to her first child 1 childbirth is the most significant event in a womans life it is an intense event that is physically psychologically socially and culturally significant 2 the impact could be positive both in the short and long term however sometimes it could result in negative and traumatizing events 3

INTRODUCTION Agroforestry is a land management system that combines trees, shrubs and agricultural plants in one production unit. Agroforestry land has the potential to store more carbon than fallow land, bushland or monoculture agriculture. The carbon storage process in an agroforestry system occurs through two pathways: increasing plant biomass and increasing soil organic matter, while other plants in the agroforestry system help increase soil organic matter. 3 Indigenous communities have their own local wisdom in caring for and managing the land and environment where people live in each region . Agroforestry of the wallacea region, as a means of expanding understanding of the ecological potential of the Wallacea Region. including the agroforestry plant-tree Interaction, the selection of plant types, and the Features, Species, and Advantages of Multipurpose Trees . Local wisdom is often associated with conservation. Therefore, the application of local wisdom in agroforestry systems can contribute to environmental conservation. The wisdom and traditional knowledge of local communities is an important component in efforts to utilize and manage local natural resources. Forms of resource management knowledge can be in the form of farming systems, plantation systems and simple conservation systems carried out traditionally The benefits of agroforestry compared to monoculture farming systems for biodiversity conservation and climate change mitigation prompted this research to investigate how local wisdom is applied in the agroforestry system in Wanga Village. The people of Wanga Village still apply their traditional knowledge in carrying out farming activities. The traditional method they apply is to pay attention to the "New Moon" phase. This "New Moon" phase is the beginning of the lunar cycle which lasts around 29-30 days. The New Moon appears in the sky at sunset, where the moon is almost invisible from the earth because of its bright side or what is usually called a crescent moon. This research aims to determine the local wisdom of the Wanga Village community in managing land using an agroforestry system. --- RESEARCH METHODS --- Location and Time of Research This research was conducted in Wanga Village, East Motoling District, South Minahasa Regency in June 2023. The method used was a survey using interview techniques and field observations. The determination of respondents was carried out using purposive sampling with the criteria for respondents being the indigenous people of Wanga Village who manage agroforestry land. Interviews with respondents using questionnaires. The data obtained from the research results were then analyzed descriptively. --- RESULTS AND DISCUSSION --- Agrisilviculture The types of components available on the respondent's site vary according to the observations made. Agrisilviculture, agrosilvofishery, agrosilvopasture and homestead agroforestry are agroforestry patterns used by the Wanga Village community. This local wisdom includes several of the same farming activities, but each pattern has its own local wisdom Agrisilviculture is a system that combines agricultural and forestry crops on one land, known as agrisilviculture . Based on observations made, the people of Wanga Village use an agrisilviculture system by combining various types of plants based on their benefits, such as spice plants, fruit plants and woody plants. The people of Wanga Village usually use spices such as chili, cloves and vanilla as food ingredients to add flavor and taste. Apart from that, the people of Wanga Village consume various types of fruit for nutrition and well-being, such as durian, avocado, chocolate, langsat, mango, matoa, jackfruit, papaya and banana. Some respondents rely on these fruit plants as a source of side income. Apart from fruit --- Agrisilvofisheries Agrisilvofishery is a land management system that combines fisheries, forestry, and agricultural crops for sustainable and environmentally friendly land use . From the results obtained, various types of plants and fish can be found in the agrisilvofishery land of Wanga village. The types of fish cultivated by the community are tilapia, tilapia and goldfish. The implementation of the agrisilvofishery pattern carried out by the people of Wanga Village really helps their daily economy because it uses different components in one piece of land. This agrisilvofishery approach has the potential to provide multiple benefits for farmers, the environment and society by optimizing available natural resources . Plants and trees planted around ponds help maintain water quality, regulate water flow, and prevent erosion. Table 2 below shows the types of plants found on the agrosilvofishery land in Wanga Village. --- Agrisilvopasture Agrosilvopasture is a land management system that combines livestock, woody plants and annual crops in one area. The people of Wanga Village raise pigs and use ripe papaya and taro as feed. The pigs are kept in pens and fed conga rice and corn every day. The types of plants planted on agrosilvopasture land in Wanga Village are shown in Table 3 below. Table 3 above shows that the agrosilvopasture land in Wanga Village is planted with fruit plants such as langsa, matoa, banana and papaya; spices such as cloves and vanilla; and woody plants such as cempaka, coconut, and palm. The distance and types of plants on agrosilvopasture land are random and irregular . The agrosilvopasture land managed by the Wanga Village community grows various types of plants. However, they argue that the location of the livestock pen must be open and receive lots of sunlight so that air can flow and air circulation is good . The people of Wanga Village understand that if the plants on the land are too dense or dense, plant growth will be hampered due to lack of sunlight. The livestock pens on this land are surrounded by cocoa, cempaka, cloves and taro plants. The livestock on the Silvopastura land in Wanga village are pigs. 6 --- Agroforestry Homestead ecosystems play an important role in the livelihoods of rural communities and provide various ecosystem service functions , effective yard management must pay attention to the socio-cultural, economic and biological aspects of society. Homestead agroforestry is a type of complex agroforestry that has a diverse structure and species composition that meets social and environmental sustainability . Yard agroforestry is a system for managing household yard land with a diversity of yard plants consisting of various types of tubers, vegetables, fruit, spices, wood and ornamental plants. Types of home garden agroforestry plants in Wanga Village are presented in Table 4 below. Based on observations of agroforestry yards in Wanga village, the types of fruit plants found on this land include bananas, mangoes, water apples, durian and rambutan. Ornamental plants such as horse carts or tawaang are generally used by people to beautify gardens and as garden borders. People also grow spices for daily needs . They also planted trees around their yard. Trees are usually planted on the edge of the yard to reduce carbon emissions. --- Local Wisdom In Agroforestry Systems The local wisdom of farmers applied in the agroforestry system in Wanga Village is "Mapalus" or "Maendo, moon observation, and "Toki Bulu". The three local wisdoms are described below. 3.5.1 "Mapalus" or "Maendo" "Mapalus" is a social activity originating from Minahasa culture and is usually called mutual cooperation. "Mapalus" for the Tountemboan people is called "Maendo" which means taking the day or taking advantage of the day to work together with other people. The Wanga Village community still carries out this activity, especially in land preparation. --- Moon Observations The new moon is a science that is still applied by people when carrying out several agricultural management activities by looking at the moon. Where when people see the "New Moon" they do not carry out agricultural activities such as planting, carrying out maintenance processes, and harvesting. By looking at the moon, they are sure that the harvest they will harvest will produce good results. The people of Wanga Village themselves, if they do not implement this, will have a bad impact on the plants, for example if they plant on the "new moon" the plants will wither because according to the knowledge gained, the seeds will wither. planted has new roots. When the maintenance process is carried out in terms of clearing land during the "new moon" ants will appear because ants tend to gather in disturbed areas. When harvesting, which is also carried out during the "new moon" phase, the plants must not be touched because if they are not cared for it can delay the next harvest. The way the people of Wanga Village view the "New Moon" phase which occurs once a month when the moon is in the west, appears at sunset and the moon takes the shape of a crescent. This "new moon" phase lasts for 3 days where it is believed that people should not carry out the planting process, after the new moon is finished it continues with the young quartile moon phase, then after the young quartile moon, wait 6 days. To get the big moon phase where people believe that during this phase they are not allowed to plant fruit plants because they will not produce fruit, except for plants that do not produce fruit such as feather plants where if this plant is planted during the big moon it will be big like the moon, after the moon Just wait 6 days to get the old quartile phase, this phase is the lunar phase that people wait for when planting. The dead moon phase occurs after the old quartile phase, which is believed by the people to be good for logging, after this process is complete it returns to the phase, namely the new moon phase. This local wisdom is what the people of Wanga village really pay attention to when carrying out planting, plant maintenance and harvesting activities. --- "Toki Bulu" "Toki Bulu" is a community activity on agrosilvofishery land in providing fish food. Based on the results of interviews, the community's unique way of feeding fish is by "Toki Bulu" first to call the fish.

The purpose of this study is to ascertain how the Wanga Village community manages land using agroforestry technologies. Based on the observations, different component kinds are found in the sites of the respondents. Agrisilviculture, agrosilvofishery, agrosilvopasture and agroforestry patterns employed by the residents of Wanga village.The approach is a survey that combines field observations and interviewing methods. Purposive sampling was used to select respondents, and the indigenous inhabitants of Wanga Village who oversee agroforestry land met the selection criterion. Interviews with respondents using questionnaires. Following the research results, a descriptive analysis was conducted on the data.The Wanga Village community still uses an agroforestry technique to manage their land with the help of local knowledge. The agroforestry system in Wanga Village is still used to manage land utilizing the traditional knowledge of "mapalus" or "maendo," "toki bulu," and moon observation.The way the residents of Wanga Village observe the "New Moon" phase which comes once a month when the moon is in the west, appears at sunset and the moon adopts the appearance of a crescent. The young quartile moon phase follows the "new moon" phase, which lasts for three days during which people are believed to not plant anything. After the young quartile phase, people wait six days for the big moon phase, during which they believe they cannot plant any fruit plants because they will not bear fruit.

introduction agroforestry is a land management system that combines trees shrubs and agricultural plants in one production unit agroforestry land has the potential to store more carbon than fallow land bushland or monoculture agriculture the carbon storage process in an agroforestry system occurs through two pathways increasing plant biomass and increasing soil organic matter while other plants in the agroforestry system help increase soil organic matter 3 indigenous communities have their own local wisdom in caring for and managing the land and environment where people live in each region agroforestry of the wallacea region as a means of expanding understanding of the ecological potential of the wallacea region including the agroforestry planttree interaction the selection of plant types and the features species and advantages of multipurpose trees local wisdom is often associated with conservation therefore the application of local wisdom in agroforestry systems can contribute to environmental conservation the wisdom and traditional knowledge of local communities is an important component in efforts to utilize and manage local natural resources forms of resource management knowledge can be in the form of farming systems plantation systems and simple conservation systems carried out traditionally the benefits of agroforestry compared to monoculture farming systems for biodiversity conservation and climate change mitigation prompted this research to investigate how local wisdom is applied in the agroforestry system in wanga village the people of wanga village still apply their traditional knowledge in carrying out farming activities the traditional method they apply is to pay attention to the new moon phase this new moon phase is the beginning of the lunar cycle which lasts around 2930 days the new moon appears in the sky at sunset where the moon is almost invisible from the earth because of its bright side or what is usually called a crescent moon this research aims to determine the local wisdom of the wanga village community in managing land using an agroforestry system research methods location and time of research this research was conducted in wanga village east motoling district south minahasa regency in june 2023 the method used was a survey using interview techniques and field observations the determination of respondents was carried out using purposive sampling with the criteria for respondents being the indigenous people of wanga village who manage agroforestry land interviews with respondents using questionnaires the data obtained from the research results were then analyzed descriptively results and discussion agrisilviculture the types of components available on the respondents site vary according to the observations made agrisilviculture agrosilvofishery agrosilvopasture and homestead agroforestry are agroforestry patterns used by the wanga village community this local wisdom includes several of the same farming activities but each pattern has its own local wisdom agrisilviculture is a system that combines agricultural and forestry crops on one land known as agrisilviculture based on observations made the people of wanga village use an agrisilviculture system by combining various types of plants based on their benefits such as spice plants fruit plants and woody plants the people of wanga village usually use spices such as chili cloves and vanilla as food ingredients to add flavor and taste apart from that the people of wanga village consume various types of fruit for nutrition and wellbeing such as durian avocado chocolate langsat mango matoa jackfruit papaya and banana some respondents rely on these fruit plants as a source of side income apart from fruit agrisilvofisheries agrisilvofishery is a land management system that combines fisheries forestry and agricultural crops for sustainable and environmentally friendly land use from the results obtained various types of plants and fish can be found in the agrisilvofishery land of wanga village the types of fish cultivated by the community are tilapia tilapia and goldfish the implementation of the agrisilvofishery pattern carried out by the people of wanga village really helps their daily economy because it uses different components in one piece of land this agrisilvofishery approach has the potential to provide multiple benefits for farmers the environment and society by optimizing available natural resources plants and trees planted around ponds help maintain water quality regulate water flow and prevent erosion table 2 below shows the types of plants found on the agrosilvofishery land in wanga village agrisilvopasture agrosilvopasture is a land management system that combines livestock woody plants and annual crops in one area the people of wanga village raise pigs and use ripe papaya and taro as feed the pigs are kept in pens and fed conga rice and corn every day the types of plants planted on agrosilvopasture land in wanga village are shown in table 3 below table 3 above shows that the agrosilvopasture land in wanga village is planted with fruit plants such as langsa matoa banana and papaya spices such as cloves and vanilla and woody plants such as cempaka coconut and palm the distance and types of plants on agrosilvopasture land are random and irregular the agrosilvopasture land managed by the wanga village community grows various types of plants however they argue that the location of the livestock pen must be open and receive lots of sunlight so that air can flow and air circulation is good the people of wanga village understand that if the plants on the land are too dense or dense plant growth will be hampered due to lack of sunlight the livestock pens on this land are surrounded by cocoa cempaka cloves and taro plants the livestock on the silvopastura land in wanga village are pigs 6 agroforestry homestead ecosystems play an important role in the livelihoods of rural communities and provide various ecosystem service functions effective yard management must pay attention to the sociocultural economic and biological aspects of society homestead agroforestry is a type of complex agroforestry that has a diverse structure and species composition that meets social and environmental sustainability yard agroforestry is a system for managing household yard land with a diversity of yard plants consisting of various types of tubers vegetables fruit spices wood and ornamental plants types of home garden agroforestry plants in wanga village are presented in table 4 below based on observations of agroforestry yards in wanga village the types of fruit plants found on this land include bananas mangoes water apples durian and rambutan ornamental plants such as horse carts or tawaang are generally used by people to beautify gardens and as garden borders people also grow spices for daily needs they also planted trees around their yard trees are usually planted on the edge of the yard to reduce carbon emissions local wisdom in agroforestry systems the local wisdom of farmers applied in the agroforestry system in wanga village is mapalus or maendo moon observation and toki bulu the three local wisdoms are described below 351 mapalus or maendo mapalus is a social activity originating from minahasa culture and is usually called mutual cooperation mapalus for the tountemboan people is called maendo which means taking the day or taking advantage of the day to work together with other people the wanga village community still carries out this activity especially in land preparation moon observations the new moon is a science that is still applied by people when carrying out several agricultural management activities by looking at the moon where when people see the new moon they do not carry out agricultural activities such as planting carrying out maintenance processes and harvesting by looking at the moon they are sure that the harvest they will harvest will produce good results the people of wanga village themselves if they do not implement this will have a bad impact on the plants for example if they plant on the new moon the plants will wither because according to the knowledge gained the seeds will wither planted has new roots when the maintenance process is carried out in terms of clearing land during the new moon ants will appear because ants tend to gather in disturbed areas when harvesting which is also carried out during the new moon phase the plants must not be touched because if they are not cared for it can delay the next harvest the way the people of wanga village view the new moon phase which occurs once a month when the moon is in the west appears at sunset and the moon takes the shape of a crescent this new moon phase lasts for 3 days where it is believed that people should not carry out the planting process after the new moon is finished it continues with the young quartile moon phase then after the young quartile moon wait 6 days to get the big moon phase where people believe that during this phase they are not allowed to plant fruit plants because they will not produce fruit except for plants that do not produce fruit such as feather plants where if this plant is planted during the big moon it will be big like the moon after the moon just wait 6 days to get the old quartile phase this phase is the lunar phase that people wait for when planting the dead moon phase occurs after the old quartile phase which is believed by the people to be good for logging after this process is complete it returns to the phase namely the new moon phase this local wisdom is what the people of wanga village really pay attention to when carrying out planting plant maintenance and harvesting activities toki bulu toki bulu is a community activity on agrosilvofishery land in providing fish food based on the results of interviews the communitys unique way of feeding fish is by toki bulu first to call the fish

the purpose of this study is to ascertain how the wanga village community manages land using agroforestry technologies based on the observations different component kinds are found in the sites of the respondents agrisilviculture agrosilvofishery agrosilvopasture and agroforestry patterns employed by the residents of wanga villagethe approach is a survey that combines field observations and interviewing methods purposive sampling was used to select respondents and the indigenous inhabitants of wanga village who oversee agroforestry land met the selection criterion interviews with respondents using questionnaires following the research results a descriptive analysis was conducted on the datathe wanga village community still uses an agroforestry technique to manage their land with the help of local knowledge the agroforestry system in wanga village is still used to manage land utilizing the traditional knowledge of mapalus or maendo toki bulu and moon observationthe way the residents of wanga village observe the new moon phase which comes once a month when the moon is in the west appears at sunset and the moon adopts the appearance of a crescent the young quartile moon phase follows the new moon phase which lasts for three days during which people are believed to not plant anything after the young quartile phase people wait six days for the big moon phase during which they believe they cannot plant any fruit plants because they will not bear fruit

L ife expectancy has increased over the last 6 decades in many societies around the world. 1 Women generally have longer life expectancy than men, yet have higher levels of disability and morbidity. 2,3 Male:female mortality ratios increased from the beginning of the 19th century and slightly decreased over the last 3 decades. 4,5 It has been suggested that the biological differences between the sexes, including genetics and hormones, provide stronger resilience to disadvantageous situations for women than men. 6 However, biological sex is related to gender, a construct that also incorporates cultural and social differences between men and women. Although some studies suggest that the recent reduction in the male:female mortality ratio is likely a result of improvements in men's health, lifestyle or occupational environ ments, others attribute it to women's changing societal roles and increasing mortality from diseases such as lung cancer, which have traditionally affected mostly men. 3,[7][8][9] Many studies have examined the potential impact of social, behavioural and biological factors on sex differences in mortality, 10,11 but few have been able to investigate potential variation across countries. Different cultural traditions, historical contexts, and economic and societal development may influence gender experiences in different countries, and thus variably affect the health status of men and women. We aimed to identify factors that may explain the difference in mortality risk between men and women at older age and to investigate potential variation across countries, using the harmonized data set of 12 cohort studies from the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies consortium. 12 work, we applied Cox proportional hazards modelling to investigate the association between sex and mortality across different countries. We included socioeconomic , lifestyle , social and health factors as covariates or interaction terms with sex to test whether these factors contributed to the mortality gap between men and women. --- Outcomes and variables We obtained all data from the ATHLOS harmonized data set, which provides comparable measures across cohort studies. The primary outcome was mortality. Information on date of death was collected using death registers or interviews with participants' family or informants . The censoring time was set to be the end of follow-up in each cohort study. The longest follow-up period was 20 years in ALSA and HRS, and the shortest was 2 years in CHARLS. Other variables of interest included socioeconomic , lifestyle , health and social factors at baseline. These variables were selected as most cohorts had available data. We categorized education into low , middle and high levels. Wealth was based on individual or household income and other financial information and was divided into quintiles within specific cohorts. Self-reported smoking status included 3 groups: nonsmoker, ex-smoker and current smoker. Alcohol consumption was based on self-reported frequency and categorized into 3 groups: never, rare and often . Four types of health conditions were recorded as binary variables . We used self-reported diagnosis of cardiovascular disease , diabetes and hypertension to identify patients with these conditions. We determined depression status using the available assessment tools and their established cut-offs in specific cohort studies. We dichotomized 2 social factors, living alone and no spouse or partner, based on self-reported information. The Japanese cohort did not have data on living alone; therefore, analyses related to this variable included only 27 countries. To establish baseline conditions of these factors, we obtained all variables from the first wave if available. If some variables were not available at the baseline, we used information from the second or third follow-up waves to inform possible conditions of participants. More details on data harmonization are available online at https://github.com/athlosproject/athlos-project.github.io. To contextualize the results, we obtained the gender inequality index and the gender development index for each country from the United Nations Human Development Reports 2018. 25 The gender inequality index focuses on the disadvantages that women face in terms of reproductive health, empowerment and labour market. 26 The gender development index was developed to measure disparities of human development achievements between men and women, including health, knowledge and standard of living. 26 --- Statistical analysis A factor might lead to sex differences in mortality in 2 ways. First, if a factor has similar effects on females and males, the variation could be a result of differential prevalence of this factor across the sexes. Higher mortality in males could be attributed to higher prevalence of this factor. Adjusting for this factor as a covariate should attenuate the effect size of sex. Second, if a factor has different effects on females and males, sex differences might not be attenuated by the prevalence of this factor. In this case, the model should include the interaction terms between sex and this factor to account for its effect. To estimate hazard ratios of mortality between men and women, we carried out Cox proportion hazards modelling to include different factors as covariates or their interaction terms with sex . We fitted each factor individually in Model a or Model b to investigate changes in the sex coefficient compared with the original model, which included only sex and age. We included factors that were identified to attenuate age-adjusted hazard ratios between men and women in 1 multivariable model. We estimated the marginal effects of sex on mortality for Model a and b with adjustment for age and calculated the percentage of change in estimates. According to the literature, a 10% change between unadjusted and adjusted estimates is generally used in confounder selection. 27 Given that multiple factors could be related to sex differences in mortality, we used a > 5% attenuation to indicate partial contribution of a factor. We used a 2-stage individual participant-data analytical approach 28 to generate country-specific and overall pooled estimates. Given the large heterogeneity, we used a random-effects meta-analysis model to identify the distribution of sex differences in mortality across countries. We used Spearman rank correlation to estimate the direction and strength of monotonic relationships between adjusted hazard ratios and the gender inequality and gender development indicators individually. Overall I 2 = We examined the proportional hazards assumption using the Schoenfeld residual test and interaction terms between time and covariates. Because the effect sizes were generally small, modelling did not further include variables with time-varying effects . We carried out full models including all socioeconomic, lifestyle, health and social factors as sensitivity analyses . To address time-varying covariates, we performed additional sensitivity analyses to incorporate lifestyle, health and social factors at different waves in modelling . To test the impact of birth cohorts, sensitivity analyses further included birth cohorts and their interaction terms with age in the modelling . We carried out all analyses using Stata 15.0. --- Results We included 179 044 participants in the analysis. The median age of participants was 63 years, with an interquartile range between 55 and 71 years . Nearly 55% were women . The median period of follow-up was 4 years , and 14.7% died at the end of follow-up. Among the participants, 36.3% had primary education or less, 20.7% were current smokers and just more than 40% abstained from alcohol. Among the 4 health conditions, hypertension was the most frequent and the least frequent was diabetes . There were 28.3% participants without a spouse and 17.5% lived alone. More detailed results, stratified by sex, are reported in Appendix 1, Table S6. Based on the pooled estimate, men had a 60% higher mortality risk than women . The heterogeneity across countries was 71.5%, with a range from 1.07 in Mexico to 2.44 in Japan . The strength of association between sex and mortality did not decrease when we adjusted for most socioeconomic, lifestyle, social or health factors . Sex differences in mortality became wider when we accounted for education, wealth, alcohol consumption, depression and no spouse. Only adjustment for smoking and cardiovascular disease slightly attenuated sex differences in mortality. Country-specific estimates are reported in Appendix 1, Table S7. The amount of reduction was similar across Model a and Model b . Only a small number of interaction terms with sex achieved statistical significance. Because most attenuations were found in smoking and cardiovascular disease , we stratified age-adjusted hazard ratios by smoking , and by smoking and cardiovascular disease . The overall sex differences reduced in nonsmokers and ex-smokers . Adjustment for smoking and cardiovascular disease further attenuated the hazard ratio slightly . When stratified by smoking status and cardiovascular disease, the overall sex differences decreased to 1.34 in nonsmokers who did not have cardiovascular disease. We observed no clear patterns in the scatter plots between the adjusted hazard ratios and the 2 UN indicators at the country level . Spearman correlation coefficients were 0.05 for the gender inequality index and 0.12 for the gender development index . The full models including all factors did not attenuate sex differences in mortality . The sensitivity analyses incorporating time-varying covariates across follow-up waves showed results similar to those of the main analysis . Because birth cohorts had limited effects on the results , the main analyses did not include the birth cohort variable. --- Interpretation The analysis of a harmonized data set of 12 population-based cohort studies shows that men had a 60% higher mortality risk than women, but this gap varied across countries. Among a wide range of socioeconomic status, lifestyle, health and social factors, only smoking and cardiovascular disease attenuated sex differences in mortality by up to 22%. The results of this study correspond to the literature on life expectancy and mortality rates 4,5 and highlight sex differences in mortality at older age and substantial heterogeneity across countries. Although the ATHLOS harmonized data set and existing studies mainly used the measure for biological sex, the effects of sex on mortality should include not only physiologic variation between men and women but also the social construct of gender, which differs across societies. In particular, the large variation across countries may imply a greater effect of gender than sex. Although the biology of the sexes is consistent across populations, variation in cultural, societal and historical contexts can lead to different life experiences of men and women and variation in the mortality gap across countries. 6 Among all factors, smoking had the largest contribution to the difference in mortality between men and women, particularly in the countries where men had more than twice the mortality risk of women . International studies and primary research in these regions have reported large sex differences in the prevalence of smoking and related morbidity and mortality, with trends that are stable or decreasing in men but increasing in women. [29][30][31][32][33] Although tobacco control polices have been suggested to reduce smoking-related mortality in some Eastern European countries, 32,34 their effects may differ between men and women. We observed differential impacts of smoking and cardiovascular disease on mortality in men and women across countries. This might indicate that male smokers experienced different risk factors or prognosis of chronic conditions than their female counterparts. 35 The heterogeneity of sex differences in mortality across countries may indicate the substantial impact of gender on healthy aging in addition to biological sex, and the crucial contributions of smoking may also vary across different populations. Public health policies must recognize variation among genders and further incorporate cultural and societal factors within and across countries. 36 For example, given that opposite trends in prevalence of smoking, associated morbidity and mortality have been observed in men and women , 32,33,37 tobacco control policy-makers should consider changes in gender roles over time and the variation in life experiences across different societies so as to reduce the impact of smoking on the whole population. To strengthen evidence and inform populationlevel interventions, advanced epidemiologic methods for causal inference are needed to facilitate subgroup and mediation analyses in future research. --- Limitations Variation in study designs across cohort studies -such as sampling methods, response rates and the length of follow-up periods -might affect representation of older populations in specific countries. In addition, most cohort studies were from high-income countries. This might limit generalizability of the findings. Although all variables were harmonized, methods of data collection -such as mortality data based on family-reported death or national death registry -could still differ across cohort studies, and this may lead to misclassification and variation in measurements. The residual sex differences might be attributed to other factors such as physical activity, but several cohort studies did not have comparable data for harmonization. Data on wealth based on individual or household income could be inaccurate for older participants who were retired. Some cohort studies had more comprehensive data on pension, insurance or other financial information, and we used these to generate the relative wealth quintile where possible. Some lifestyle, health and social factors were likely to change over time, but the results of models incorporating time-varying covariates were similar to the main analysis. Although we obtained the UN gender inequality and development indexes to contextualize the results, these 2 indexes composite several health and socioeconomic indicators and might not sufficiently reflect societal and cultural factors across countries. The change-in-estimate approach might be limited to address potential confounders on different pathways between sex, risk factors and mortality. 38 However, complex modelling frameworks can be difficult to incorporate into the 2-stage individual participant-data analysis. The results did not indicate to what extent sex differences in mortality could be attributed to either biological sex or gender. For better understanding of gender inequality, it is essential to integrate data on biological, ma terial, behavioural and societal factors over the life course in men and women. Data harmonization may be a fruitful approach for bringing together strengths of existing cohort studies and identifying different mechanisms across genders, populations and generations. 6 --- B) --- Gender inequality index ln --- Conclusion This study highlights sex inequality in mortality at older age and the crucial contributions of smoking to excess mortality in men. Future research should investigate variation in life experience between men and women and underlying mechanisms across different societies. --- Ethics approval The project was approved by the research ethics committee at Fundación Sant Joan de Déu, Barcelona, Spain . Competing interests: None declared. This article has been peer reviewed. ) and from various national funding sources is gratefully acknowledged . The funders had no role in study design, data collection, data analysis, data interpretation, writing of the report or decision to submit for publication. --- Affiliations

BACKGROUND: Women generally have longer life expectancy than men but have higher levels of disability and morbidity. Few studies have identified factors that explain higher mortality in men. The aim of this study was to identify potential factors contributing to sex differences in mortality at older age and to investigate variation across countries.This study included participants age ≥ 50 yr from 28 countries in 12 cohort studies of the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) consortium. Using a 2-step individual participant data meta-analysis frame-R E S U L T S : T h e s t u d y i n c l u d e d 179 044 individuals. Men had 60% higher mortality risk than women after adjust-ment for age (pooled hazard ratio [HR] 1.6; 95% confidence interval 1.5-1.7), yet the effect sizes varied across countries (I 2 = 71.5%, HR range 1.1-2.4). Only smoking and cardiovascular diseases substantially attenuated the effect size (by about 22%).Lifestyle and health factors may partially account for excess mortality in men compared with women, but residual variation remains unaccounted for. Variation in the effect sizes across countries may indicate contextual factors contributing to gender inequality in specific settings.

l ife expectancy has increased over the last 6 decades in many societies around the world 1 women generally have longer life expectancy than men yet have higher levels of disability and morbidity 23 malefemale mortality ratios increased from the beginning of the 19th century and slightly decreased over the last 3 decades 45 it has been suggested that the biological differences between the sexes including genetics and hormones provide stronger resilience to disadvantageous situations for women than men 6 however biological sex is related to gender a construct that also incorporates cultural and social differences between men and women although some studies suggest that the recent reduction in the malefemale mortality ratio is likely a result of improvements in mens health lifestyle or occupational environ ments others attribute it to womens changing societal roles and increasing mortality from diseases such as lung cancer which have traditionally affected mostly men 3 7 8 9 many studies have examined the potential impact of social behavioural and biological factors on sex differences in mortality 1011 but few have been able to investigate potential variation across countries different cultural traditions historical contexts and economic and societal development may influence gender experiences in different countries and thus variably affect the health status of men and women we aimed to identify factors that may explain the difference in mortality risk between men and women at older age and to investigate potential variation across countries using the harmonized data set of 12 cohort studies from the ageing trajectories of health longitudinal opportunities and synergies consortium 12 work we applied cox proportional hazards modelling to investigate the association between sex and mortality across different countries we included socioeconomic lifestyle social and health factors as covariates or interaction terms with sex to test whether these factors contributed to the mortality gap between men and women outcomes and variables we obtained all data from the athlos harmonized data set which provides comparable measures across cohort studies the primary outcome was mortality information on date of death was collected using death registers or interviews with participants family or informants the censoring time was set to be the end of followup in each cohort study the longest followup period was 20 years in alsa and hrs and the shortest was 2 years in charls other variables of interest included socioeconomic lifestyle health and social factors at baseline these variables were selected as most cohorts had available data we categorized education into low middle and high levels wealth was based on individual or household income and other financial information and was divided into quintiles within specific cohorts selfreported smoking status included 3 groups nonsmoker exsmoker and current smoker alcohol consumption was based on selfreported frequency and categorized into 3 groups never rare and often four types of health conditions were recorded as binary variables we used selfreported diagnosis of cardiovascular disease diabetes and hypertension to identify patients with these conditions we determined depression status using the available assessment tools and their established cutoffs in specific cohort studies we dichotomized 2 social factors living alone and no spouse or partner based on selfreported information the japanese cohort did not have data on living alone therefore analyses related to this variable included only 27 countries to establish baseline conditions of these factors we obtained all variables from the first wave if available if some variables were not available at the baseline we used information from the second or third followup waves to inform possible conditions of participants more details on data harmonization are available online at to contextualize the results we obtained the gender inequality index and the gender development index for each country from the united nations human development reports 2018 25 the gender inequality index focuses on the disadvantages that women face in terms of reproductive health empowerment and labour market 26 the gender development index was developed to measure disparities of human development achievements between men and women including health knowledge and standard of living 26 statistical analysis a factor might lead to sex differences in mortality in 2 ways first if a factor has similar effects on females and males the variation could be a result of differential prevalence of this factor across the sexes higher mortality in males could be attributed to higher prevalence of this factor adjusting for this factor as a covariate should attenuate the effect size of sex second if a factor has different effects on females and males sex differences might not be attenuated by the prevalence of this factor in this case the model should include the interaction terms between sex and this factor to account for its effect to estimate hazard ratios of mortality between men and women we carried out cox proportion hazards modelling to include different factors as covariates or their interaction terms with sex we fitted each factor individually in model a or model b to investigate changes in the sex coefficient compared with the original model which included only sex and age we included factors that were identified to attenuate ageadjusted hazard ratios between men and women in 1 multivariable model we estimated the marginal effects of sex on mortality for model a and b with adjustment for age and calculated the percentage of change in estimates according to the literature a 10 change between unadjusted and adjusted estimates is generally used in confounder selection 27 given that multiple factors could be related to sex differences in mortality we used a 5 attenuation to indicate partial contribution of a factor we used a 2stage individual participantdata analytical approach 28 to generate countryspecific and overall pooled estimates given the large heterogeneity we used a randomeffects metaanalysis model to identify the distribution of sex differences in mortality across countries we used spearman rank correlation to estimate the direction and strength of monotonic relationships between adjusted hazard ratios and the gender inequality and gender development indicators individually overall i 2 we examined the proportional hazards assumption using the schoenfeld residual test and interaction terms between time and covariates because the effect sizes were generally small modelling did not further include variables with timevarying effects we carried out full models including all socioeconomic lifestyle health and social factors as sensitivity analyses to address timevarying covariates we performed additional sensitivity analyses to incorporate lifestyle health and social factors at different waves in modelling to test the impact of birth cohorts sensitivity analyses further included birth cohorts and their interaction terms with age in the modelling we carried out all analyses using stata 150 results we included 179 044 participants in the analysis the median age of participants was 63 years with an interquartile range between 55 and 71 years nearly 55 were women the median period of followup was 4 years and 147 died at the end of followup among the participants 363 had primary education or less 207 were current smokers and just more than 40 abstained from alcohol among the 4 health conditions hypertension was the most frequent and the least frequent was diabetes there were 283 participants without a spouse and 175 lived alone more detailed results stratified by sex are reported in appendix 1 table s6 based on the pooled estimate men had a 60 higher mortality risk than women the heterogeneity across countries was 715 with a range from 107 in mexico to 244 in japan the strength of association between sex and mortality did not decrease when we adjusted for most socioeconomic lifestyle social or health factors sex differences in mortality became wider when we accounted for education wealth alcohol consumption depression and no spouse only adjustment for smoking and cardiovascular disease slightly attenuated sex differences in mortality countryspecific estimates are reported in appendix 1 table s7 the amount of reduction was similar across model a and model b only a small number of interaction terms with sex achieved statistical significance because most attenuations were found in smoking and cardiovascular disease we stratified ageadjusted hazard ratios by smoking and by smoking and cardiovascular disease the overall sex differences reduced in nonsmokers and exsmokers adjustment for smoking and cardiovascular disease further attenuated the hazard ratio slightly when stratified by smoking status and cardiovascular disease the overall sex differences decreased to 134 in nonsmokers who did not have cardiovascular disease we observed no clear patterns in the scatter plots between the adjusted hazard ratios and the 2 un indicators at the country level spearman correlation coefficients were 005 for the gender inequality index and 012 for the gender development index the full models including all factors did not attenuate sex differences in mortality the sensitivity analyses incorporating timevarying covariates across followup waves showed results similar to those of the main analysis because birth cohorts had limited effects on the results the main analyses did not include the birth cohort variable interpretation the analysis of a harmonized data set of 12 populationbased cohort studies shows that men had a 60 higher mortality risk than women but this gap varied across countries among a wide range of socioeconomic status lifestyle health and social factors only smoking and cardiovascular disease attenuated sex differences in mortality by up to 22 the results of this study correspond to the literature on life expectancy and mortality rates 45 and highlight sex differences in mortality at older age and substantial heterogeneity across countries although the athlos harmonized data set and existing studies mainly used the measure for biological sex the effects of sex on mortality should include not only physiologic variation between men and women but also the social construct of gender which differs across societies in particular the large variation across countries may imply a greater effect of gender than sex although the biology of the sexes is consistent across populations variation in cultural societal and historical contexts can lead to different life experiences of men and women and variation in the mortality gap across countries 6 among all factors smoking had the largest contribution to the difference in mortality between men and women particularly in the countries where men had more than twice the mortality risk of women international studies and primary research in these regions have reported large sex differences in the prevalence of smoking and related morbidity and mortality with trends that are stable or decreasing in men but increasing in women 29 30 31 32 33 although tobacco control polices have been suggested to reduce smokingrelated mortality in some eastern european countries 3234 their effects may differ between men and women we observed differential impacts of smoking and cardiovascular disease on mortality in men and women across countries this might indicate that male smokers experienced different risk factors or prognosis of chronic conditions than their female counterparts 35 the heterogeneity of sex differences in mortality across countries may indicate the substantial impact of gender on healthy aging in addition to biological sex and the crucial contributions of smoking may also vary across different populations public health policies must recognize variation among genders and further incorporate cultural and societal factors within and across countries 36 for example given that opposite trends in prevalence of smoking associated morbidity and mortality have been observed in men and women 323337 tobacco control policymakers should consider changes in gender roles over time and the variation in life experiences across different societies so as to reduce the impact of smoking on the whole population to strengthen evidence and inform populationlevel interventions advanced epidemiologic methods for causal inference are needed to facilitate subgroup and mediation analyses in future research limitations variation in study designs across cohort studies such as sampling methods response rates and the length of followup periods might affect representation of older populations in specific countries in addition most cohort studies were from highincome countries this might limit generalizability of the findings although all variables were harmonized methods of data collection such as mortality data based on familyreported death or national death registry could still differ across cohort studies and this may lead to misclassification and variation in measurements the residual sex differences might be attributed to other factors such as physical activity but several cohort studies did not have comparable data for harmonization data on wealth based on individual or household income could be inaccurate for older participants who were retired some cohort studies had more comprehensive data on pension insurance or other financial information and we used these to generate the relative wealth quintile where possible some lifestyle health and social factors were likely to change over time but the results of models incorporating timevarying covariates were similar to the main analysis although we obtained the un gender inequality and development indexes to contextualize the results these 2 indexes composite several health and socioeconomic indicators and might not sufficiently reflect societal and cultural factors across countries the changeinestimate approach might be limited to address potential confounders on different pathways between sex risk factors and mortality 38 however complex modelling frameworks can be difficult to incorporate into the 2stage individual participantdata analysis the results did not indicate to what extent sex differences in mortality could be attributed to either biological sex or gender for better understanding of gender inequality it is essential to integrate data on biological ma terial behavioural and societal factors over the life course in men and women data harmonization may be a fruitful approach for bringing together strengths of existing cohort studies and identifying different mechanisms across genders populations and generations 6 b gender inequality index ln conclusion this study highlights sex inequality in mortality at older age and the crucial contributions of smoking to excess mortality in men future research should investigate variation in life experience between men and women and underlying mechanisms across different societies ethics approval the project was approved by the research ethics committee at fundación sant joan de déu barcelona spain competing interests none declared this article has been peer reviewed and from various national funding sources is gratefully acknowledged the funders had no role in study design data collection data analysis data interpretation writing of the report or decision to submit for publication affiliations

background women generally have longer life expectancy than men but have higher levels of disability and morbidity few studies have identified factors that explain higher mortality in men the aim of this study was to identify potential factors contributing to sex differences in mortality at older age and to investigate variation across countriesthis study included participants age ≥ 50 yr from 28 countries in 12 cohort studies of the ageing trajectories of health longitudinal opportunities and synergies athlos consortium using a 2step individual participant data metaanalysis framer e s u l t s t h e s t u d y i n c l u d e d 179 044 individuals men had 60 higher mortality risk than women after adjustment for age pooled hazard ratio hr 16 95 confidence interval 1517 yet the effect sizes varied across countries i 2 715 hr range 1124 only smoking and cardiovascular diseases substantially attenuated the effect size by about 22 lifestyle and health factors may partially account for excess mortality in men compared with women but residual variation remains unaccounted for variation in the effect sizes across countries may indicate contextual factors contributing to gender inequality in specific settings

Introduction The Syrian civil war has resulted in Syrians being the largest forcibly displaced population over recent years. More than 13 million people have left their homes with 6.1 million internally displaced people, 6.6 million refugees and 118,445 asylum-seekers by the end of 2019. They are hosted in 127 countries, with 83% having fled to neighbouring countries: Turkey hosts most Syrian refugees with 3.6 million, Lebanon hosts 910,600, and Jordan hosts 654,700 [1]. A vast number of Syrian refugees and asylum seekers also arrived in Europe, including Germany having registered 572,800 [1] SRAs and Switzerland almost 20,000 by the end of 2019 [2]. Forcibly displaced people are frequently exposed to potentially traumatic events and other stressful experiences in their countries of origin, as well as during and after flight, which may impact their mental health and overall functioning [3,4]. Past research has emphasised the importance of a combination of pre-and post-migration stressors, whereby the post-migration environment can play a significant role in modulating recovery from war-related trauma and grief [5,6]. Displacement-related stressors include, but are not limited to poverty, uncertainty of asylum seeking process, unemployment/dependency on aid, family conflict, and loss of social network [6][7][8]. These stressors impact mental health directly or through their adverse impact on the social ecology, which refers to one's relation with the social and family environment [6,9]. It is argued that each host country presents a unique set of post-migration factors, which partly results from local policies. Therefore, the type and severity of post-migration stressors can differ widely between countries [10]. Previous studies in Jordan's camps have reported displacement-related problems such as poor living conditions, insufficient access to services such as medical, sanitation [11], marginalisation from international and regional agencies, socio-economic pressures [12] and work exploitation [13]. Concerning the legal status, in Turkey, Syrians are under "temporary protection" meaning they can stay as "guests" until they reside in a third country [8]. There are also thousands of Syrians without temporary protection status and an unknown number of Syrian irregular migrants [14]. Similarly in Switzerland, from over 20′000 Syrian refugees and asylum seekers by the end of 2019, almost half of them hold only the "N" or "F" permit meaning a tolerated stay, not the recognition as refugees in Switzerland [2,15]. These permits need to be renewed every 6 or 12 months [16]. 'N' permit holders have serious restrictions in accessing the labour market, governmental subsidies, leaving the country and no right to family reunion [17]. It applies to both country that the temporary protection status leads to feelings of uncertainty and fears of being sent home [8,18]. Concerning employment in Turkey, since the "Regulation on Work Permit on Refugees under Temporary Protection" in January 2016, access to formal employment has been established [19]. However, the issue of work permits is limited by specific criteria, and illegal work as well as unfavourable working conditions are widespread. Unsurprisingly, employment problems and poverty are reported as most salient problems among Syrians in Istanbul, Turkey [8]. Work permit challenges based on the legal status were also significant problems for Syrians in Switzerland [18]. In Turkey, Syrians have established their own neighbourhoods and communities in Istanbul and cities along the border due to the vast influx. Despite commonalities between Syria and Turkey such as cultural and geographical proximity, increased discrimination towards Syrians due to their nationality, culture, and language has been reported in Turkey [14]. Discrimination, feelings of marginalisation and language difficulties related to entitlements based on legal status such as language courses have been reported by previous research in Switzerland [18]. Stressors and mental health of SRAs have been predominantly assessed through nomothetic measurements -often developed and validated in western contexts [20]. Studies have shown that standard instruments often fail to encompass all aspects of distress in cross-cultural settings, and that it is a fallacy to assume that symptoms in different cultural contexts carry the same significance across cultures [21][22][23]. Client-generated outcome measurements are person-centred by definition and unlike standardized measures, they seek to encompass the individuals' phenomenological experiences as well as their priorities, local values, perspectives and expectations [22,24,25]. Individuals' social circumstances and culture are at the core of the WHO global strategy on personcentred care, which suggests that care should address physical, socioeconomic, mental and emotional wellbeing [26]. A person-centred approach is appropriate for understanding the stressors and needs of SRAs because they emigrate to diverse cultural, social, political and religious contexts. Furthermore, despite general cultural commonalities among SRAs, there is also great diversity among Syrians and their individual experiences [21,27]. This approach also accords with the UNHCR mental health and psychosocial support programs. These have highlighted the need for a culturally safe environment and respect of diversity when exploring Syrians' perspectives, and hence favour a personcentred approach to psychosocial support and clinical interaction [22]. Moreover, understanding stressors and needs, including non-psychological or social needs, is a crucial first step before the provision of psychosocial support and effective mental health services, or referral to other relevant services [27][28][29]. Inadequate assessment of postmigration stressors could risk overlooking key sources of ongoing stress in the social ecology that could be targeted for change [6]. Regarding SRAs' mental health stressors and needs, many assessments have been conducted in Syria's neighbouring countries, such as Jordan, Lebanon and Turkey [30,31], and generalizability to Western European countries is questionable. Comparative studies between low-and middle-, and high-income countries may shed light on key environmental factors affecting adjustment needs of SRAs in these different settings. However, such comparative studies are scant [8,32] and little is known about the SRAs' salient problems from their own perspective. The overall aim of this study was to use a person-centred approach to investigate self-reported problems of SRAs and to identify key stressors within Jordan, Turkey and Switzerland. A mixed-method study approach was used to gain a detailed understanding of the SRAs' emic perspectives on their problems. Aside from understanding their emic perspectives, we focus on the similarities and differences between the countries and describe local environmental factors, which might account for the variability. --- Methods --- Setting Data were collected as part of three studies conducted in Jordan, Turkey and Switzerland which aimed to assess the feasibility of conducting large controlled trials designed to evaluate the effectiveness and implementation of Problem Management Plus with SRAs [33][34][35]. PM+ is a scalable low-intensity intervention developed by the WHO for people affected by adversity aiming to reduce symptoms of common mental disorders [36,37]. These trials are part of the larger STRENGTHS project "Scaling up psychological intervention for Syrian refugees" [38]. --- --- Recruitment In Jordan, participants were recruited through door-todoor-screening from the Village 2 and the highly restricted, fenced off Village 5 in Al-Azraq Refugee Camp. Unlike refugees in other parts of the camp such as Village 2, those in Village 5 were not allowed to leave the area, visit relatives in other parts of the camp, obtain temporary leave permits or access work outside the camp [41]. In Turkey, participants were recruited from Sultanbeyli, an economically disadvantaged neighbourhood in Istanbul via phone calls using the contact list from the collaborating Refugee and Asylum Seekers Assistance and Solidarity Association , as well as through direct referral from RASASA social workers. In Switzerland, participants were recruited through social media, brochures, word-of-mouth propaganda, and local stakeholders from German speaking cantons. --- PSYCHLOPS measure Data were collected through the brief and idiographic questionnaire Psychological Outcomes Profile based on Ashworth's original version [42]. At the core of the questionnaire are three domains . The participant was asked to give short free-text responses for the following problem items and functioning domain: 1) "Choose the problem that troubles you most"; 2) "Choose another problem that troubles you"; and 3) "Choose one thing that is hard to do because of your problem". PSYCHLOPS has been used within large trials designed to test the effectiveness of PM+ in communities affected by adversity in Kenya [43] and Pakistan [44]. --- Data collection PSYCHLOPS data were collected between the end of January and beginning of February 2019 in Jordan, in September 2018 in Turkey and between January and November 2019 in Switzerland. Research assistants were native Arabic speakers and received a one-day or three-day training in data collection methods and research ethics. After explaining the study by a research assistant to the participant who had previously screened positively, written informed consent was obtained. Gender-matching with participants was achieved in most cases. In order to access illiterate participants, in Jordan and Turkey PSYC HLOPS was conducted as a guided interview measure, whereas in Switzerland this was done only if necessary. Assessments were conducted in confidential rooms to ensure privacy using paper-pencil method in Jordan, in separate rooms in the building of RASASA outside official hours using paper-pencil method in Turkey, and in separate rooms of specialized centres on computer using the Multi Adaptive Psychological Software [45] in Switzerland. PSYCHLOPS responses were recorded by the participants and research assistants in one or two short sentences to encapsulate the participants' problems as closely and concise as possible. --- Data analysis Analysis of SRAs' self-reported problems focused on the first two questions of the PSYCHLOPS tool . Translations of Jordan's and a number of Switzerland's responses were conducted by a mental health professional interpreter. Responses in Turkey were translated by a bilingual research member. For analysis we used a data-driven approach in order to respect the geographical and cultural diversity and employed thematic analysis according to Braun & Clarke [46]. Focusing on the semantic meaning, all problem items were given a code. Codes were each compared and similar themes were condensed per question and country. These themes were integrated into broader categories, again compared, and refined to minimize overlap and maximize coherency and consistency. The research team then reviewed and mutually agreed on the coding framework. Finally, a psychology student and AD coded the data set separately according to the final coding framework. The interrater reliability was k = 0.98 for all three countries. Once the coding was completed, similarities and differences across the three countries were investigated. The coding process and the reliability calculations were performed using NVivo 12 software [47]. The socio-demographic variables were statistically analysed using SPSS Statistics 25 [48]. The variable "Age" was normally distributed. Years since flight from hometown, from Syria and arrival in host country were not normally distributed. Therefore, for these variables median and inter-quartile range will be reported. --- Results --- Demographic characteristics Overall, 164 participants participated across the three trials . Table 1 shows the socio-demographic characteristics across the three study sites. The main differences were that the participants in Switzerland left their hometown 2 years earlier, were considerably more educated, more frequently divorced/separated or unmarried and more students than participants in Jordan and Turkey. Despite the high number of working permits in Switzerland, the unemployment rate was the highest in Switzerland and more participants in Jordan and Turkey pursued gainful employment. --- Overview reported problems Across all countries, over half of participants stated two or three problems. Participants who stated more than one problem per question either described causes and consequences or listed multiple single problems. Between the countries, problem types were similar with identical categories but varied in frequency. As shown in Table 2, the main two categories were a) practical and b) psychological. Further frequent categories encompassed social issues such as interpersonal problems, separation from family members and problems related to family duties, and physical and psychosomatic problems. --- Practical problems For a majority the troubling problems were of a practical nature. A prominent concern among all participants was employment, whereas camp-related issues emerged only in Jordan. Financial concerns were most prevalent in Turkey and government-related issues and housing were of greater concern in Switzerland. A further breakdown of the coding is reported in Table 3. --- Jordan Camp issues were identified by a significant proportion of participants in the Jordan sample . Many participants expressed impairment of freedom, oppression and enforcement of being in the camp , whereby eight directly linked those problems to Village 5, and challenging living conditions , such as long waiting time for supplies, electricity shortage, distances to services or general terms for living conditions. Examples of the salient practical problems are shown in Table 4. There were common concerns about employment . Participants expressed causes such as governmental regulations on working permits, stay in the restricted Village 5 of the camp, lack of job opportunities, or financial stress associated with unemployment. Financial concerns were the third most frequent practical problem . Seven used general terms such as 'financial problems' or 'lack of money', whilst others related to house and childcare expenses, rising prices or were challenged by the role change to primary provider. A slightly less prominent problem was not receiving appropriate medical treatment or worrying about it . Residence permit issues assigned to government regulations, housing, education and climate issues were of minor importance. --- Turkey Many participants stated financial problems in Turkey. Most participants expressed financial issues in a general way . They stated causes for the financial problems such as the lack of financial support by an institution/organization, no work or the associated consequences, such as not receiving appropriate medical treatment or financial instability. Regarding employment problems , four participants related these problems to financial stress. When considering work status, four people pursued paid work, three were homemakers and only one was unemployed. Respondents expressed problems such as not finding a job, followed by work disability due to health reasons, and the lack of social security after leaving a job. One participant expressed problems at work, including discrimination. Challenge of learning a new language was described as a problem , including impact on education and inability to learn Turkish due to family duties. Other less frequently stated problems were medical treatment , unsuitable housing, children's problems at school, and government regulations such as current residence permits preventing receipt of appropriate medical treatment or educational opportunity. --- Switzerland Eighteen participants expressed employment problems, whereby sixteen stated concerns about finding a job/inability to work, some being unable to find a suitable job according to their original profession or expectation. Furthermore, participants expressed difficulties in finding an apprenticeship or pursuing their studies or linked language competence with successful job seeking. One person referred to exploitation at work. Eight out of twelve participants, who stated problems with government regulations, commented on the negative impact of residency status on freedom of movement, family reunion and temporary residency. retired 1 [2] 1 [2] 0 [0] 2 [1] student 1 [2] 1 [2] 7 [12] 9 [6] others 1 [2] 1 [2] 0 [0] 2 [1] No legal work permission 44 [72] 33 [71] 16 [28] [57] Note: N J number of participants in Jordan, N T number of participants in Turkey, N S number of participants in Switzerland Another common problem was housing , such as finding an appropriate apartment, dissatisfaction with living conditions in asylum centres or cost of rent. Educational, financial and language problems were each mentioned by six participants. Beside general terms, specific descriptions ranged from finding an education place or apprenticeship, discrimination at school, cost of housing, financial uncertainty, and inconvenience in daily activities due lacking knowledge of the German language. Medical treatment and other problems were very minor. Taken together, this section shows how strongly practical issues are linked to displacement-related factors, such as employment, government regulations, and language difficulties. --- Psychological problems Various emotional, cognitive and behavioural symptoms of mental disorders such as depression, anxiety, posttraumatic stress disorder , and psychotic symptoms were expressed in all three countries, illustrated in Table 5. Many issues were mentioned only once. In general, participants did not use diagnostic labels with one exception of 'psychosis' . They used various terms of emotional or psychological symptoms , described their feelings by using simple language or used general terms . In Jordan, frequent problems included worries about another person , fear and anxiety and anger as was in Switzerland the feeling of uncertainty/insecurity . The emotional impact of war, such as missing family members, memories of lost family members and past events in Syria, and fear for family members back in Syria, were of similar importance across all countries. In Turkey, the great number and variability of psychological problems endorsed by participants didn't allow to build more particular problem categories. Psychological problems were frequently related to other non-psychological problems, either as causes or as consequences. One's social network seemed to play a crucial role since over half of the psychological problems were of psychosocial nature meaning the interrelation of social environment and psychological wellbeing and hence, showed frequent overlap with social problems, others' health problems, and the wellbeing of family members. Of 65 participants who mentioned psychological problems, 35 indicated also practical problems, with some making a causal link with psychological issues . Overall, the results show the prevalence of psychological problems and the importance of social network and local displacement-related factors on psychological wellbeing, and illustrate psychological problems as the common consequence of a range of stressors. Psychological 27 [44] 15 [33] 23 [40] 65 [40] Interpersonal 15 [25] 14 [30] 15 [26] 44 [27] Physical/psychosomatic health 13 [21] 13 [28] 10 [18] 36 [22] Separation from family members 11 [18] 8 [17] 13 [23] 32 [20] Related to war/home country 7 [11] 6 [14] 7 [12] 20 [12] Related to family duties 10 [16] 5 [13] 2 [4] 17 [10] Personal development/unmet personal needs 0 [0] 3 [7] 7 [12] 10 [6] Note: N J number of participants in Jordan, N T number of participants in Turkey, N S number of participants in Switzerland, n/a not applicable Table 3 Sub-codes of practical problem category of the three study populations --- Sub-codes practical problems Jordan Turkey Switzerland Total n [%N J ] n [%N T ] n [%N S ] n[ % N] Employment 16 [26] 8 [17] 18 [32] 42 [26] Finances 11 [18] 17 [37] 6 [11] 34 [21] Camp related issues 26 [43] n/a n/a 26 [16] Government regulations 3 [5] 4 [9] 12 [21] 19 [12] Housing 2 [3] 5 [11] 11 [19] 18 [11] Medical treatment 6 [10] 6 [13] 3 [5] 15 [9] Education 2 [3] 5 [11] 6 [11] 13 [8] Language n/a 7 [15] 6 [11] 13 [8] Others 1 [2] 0 [0] 2 [4] 3 [2] Note: n/a not applicable --- Social problems Three categories could be assigned to social problems, which encompass issues usually resulting from a personal or societal relationship. First, interpersonal aspects consisted of interpersonal problems within the family such as conflicts or concerns with relationships with family members . Another recurring interpersonal problem across all settings was undignified behaviour such as physical, verbal, or non-verbal violence towards individuals . However, conflicts linked to the host community and displacement-related factors such as discrimination, labour exploitation, oppression were present only in Turkey and Switzerland. Second, separation from family members was commonly described as emotional and geographical separation, whereas the category of family reunion, meaning the inability of reunification of family members in the host country, emerged only in Switzerland . Leaving/divorce from spouse assigned to interpersonal problems, as well as consequences of separation from family members, were expressed by participants in Turkey and Switzerland . Third, family duties , mostly described as household chores and parental responsibilities such as upbringing of, marrying off children and consequences of family dynamics, were more frequent among participants in Jordan and Turkey compared to Switzerland. Exemplar quotes of social problems are shown in Table 6. This category highlights the role of stress within the familial social network, but also through the host society such as conflict, health-related, and displacement-related concerns within the family/community. Furthermore, the results also show a frequent overlap of interpersonal problems, separation from family members and family duties with psychological problems. --- Physical and psychosomatic problems Across the three study sites a broad range of health issues was described and rarely mentioned more than once . Additionally, participants often used general terms or cultural idioms . For participants in Jordan and Turkey, worries due to another person's health problem , as well as connection between health and practical problems, such as lack of appropriate treatment, and in Turkey, inability to work were more common. In Switzerland, possible psychosomatic symptoms such as pain were of relevant concern compared to Jordan and Turkey. Some of the above described results are exemplified in Table 7. These results indicate that not only personal physical integrity, but also health issues in the social milieu critically influence psychological wellbeing. Furthermore, health issues are associated with displacement-related factors. --- Personal development/unmet personal needs There was a sense of impairment in personal development and meeting personal needs, including future job possibilities, having a family, or other aspirations which are illustrated by examples in Table 8. These problems occurred only in Turkey and Switzerland . --- Discussion This study presents the idiographic perspectives of distressed SRAs on their problems after their flight to Jordan, Turkey or Switzerland. To our knowledge, this is the first attempt to compare self-reported problems of a vulnerable group of SRAs between three host countries based on a standardized client-generated outcome measurement. We found similarities and differences between the settings. In summary, the results show that SRAs across the three countries suffer from post-migration problems frequently related to their social ecology: primarily practical, followed by psychological, social, physical and psychosomatic problems. The findings differed somewhat between the settings, with camp-related and employment-related issues more common in Jordan, financial problems in Turkey, and employment, government regulations and housing problems in Switzerland. The finding of post-migration problems as major concerns of refugees and asylum seekers concurs with previous studies demonstrating the importance of postmigration stressors [6,27,49,50]. Demographic characteristics and contextual factors in Jordan, Turkey and Switzerland differed in a number of important ways. It is possible that education affected the migration destination as the Swiss sample showed more highly educated SRAs than Jordan and Turkey. Similar to our results, Carlson & Williams [51] found a positive selection for advanced education in Syrian refugees migrating to Europe compared to Syrian refugees resettling in neighbouring countries, such as Lebanon or Jordan. A study by Brücker and colleagues [52] found a similar pattern in a sample of Syrian refugees in Germany. Previous research suggested that advantaged social positions relate to an earlier flight which could explain the tendency of an earlier flight in the Swiss sample [53]. In Turkey and Switzerland, the study design for recruitment implied a help-seeking behaviour, whereas in Jordan assessors conducted door-to-door screening. Therefore, it can be assumed that in Turkey and Switzerland participants may be more affected and hence, showed more interest in receiving help. This study revealed that SRAs face overarching problems occurring in a similar way in all host settings as well as country-specific problems, more prevalent to the local setting. The overarching problems are in line with previous findings [6,22,49], and hence, the similar aspects will not be discussed any further here. In contrast, great variation emerged within practical problems, which can be accounted for by country-specific displacement-related factors. In terms of country-specific problems, camp-related concerns in Jordan such as physical safety concerns, unmet basic needs such as access to clean water, sanitation, medical services, adequate shelter, impairment of free movement, work exploitation and unmet psychosocial needs have also been highlighted in previous studies [11, 13, 30, 54]. Our study reflects the subjective burden of strong restrictions of freedom and limited access to work [41]. However, participants did not express concerns about physical safety, access to clean water, sanitation, work exploitation and shelter . A possible assumption that caravans in Al-Azraq camp were relatively adequate shelters is supported by a study, which found significantly greater dissatisfaction and need for psychological support in refugees staying in tents than in their counterparts staying in caravans [55]. However, a comparative study between Syrians in camp and non-campsettings in Iraq found that refugees in camps are better off, particularly in terms of access to food, education, registration and employment [56]. Financial issues were the primary problem in Turkey, which may be associated with widespread informal work and low payment due to the temporary protection status [57]. Even though Turkey adopted the Regulation on Work Permits for Foreigners under Temporary Protection in 2016, access to the labour market remained challenging and exploitation and discrimination, also described in our study, as well as harassment occur frequently [19]. Our study supports the difficulty of meeting financial needs despite official working permits as half of those who cited financial problems owned an official working permit and half of the participants who reported an employment problem related it to financial problems. A further displacement-related stressor, especially in Jordan and Switzerland, was employment, which is consistent with previous research [6,58]. However, certain contributing factors and consequences may vary between the countries. In Switzerland, it seems possible that the high percentage of employment issues is associated with the high rate of unemployment and labour market restrictions for asylum seekers. Our study partly reflects labour market barriers found among refugees elsewhere, including visa restrictions, poor language skills, qualifications from their home countries not being recognised, discrimination, lack of vocational skills and psychological or physical barriers [59]. The complexity and far reaching consequences of employment difficulties were shown in a previous study illustrating the relationship between temporary visa status or discrimination affecting employment opportunities and thus, financial issues subsequently affecting the refugee's social standing. Restricted employment opportunities may also affect affordable housing, which leads to increased instability, and in turn, to greater isolation [10]. In contrast, employment barriers in Jordan arguably can be attributed to sampling within a restricted camp that has less opportunity for employment. In Switzerland, our findings show the strong impact of the immigration policy of temporary admission and long asylum seeking process on subjective wellbeing; this finding is in line with a previous study [60] and supports the potential of its change for mental health improvement [61]. Research outside of Switzerland has shown that temporary protection independently increased the risk of ongoing PTSD, mental-health related disability, mood and anxiety disorders and hampered socioeconomic integration [7,29,62]. It is assumed that the instability due to the temporary status also impacted the high percentage of participants with feelings of uncertainty/insecurity. This association and its implication for health and wellbeing has been established in a previous study [63]. Our results also shed light on the negative impact of living in an asylum centre in Switzerland, which supports the evidence of previous research inand outside Switzerland, showing its detrimental effect on mental health and subsequent successful socioeconomic integration [18,29,64]. One further finding of the present study, to be mentioned is, that the host society has a distinct impact in community-vs. camp-setting on experienced problems: In Turkey and Switzerland participants reported undignified behaviour such as discrimination, racism by the host-society, which is in line with previous research [14,18] and may strongly affect mental health, social adaptation, fosters internalising behaviour and hampers successful socioeconomic integration [10,28,65]. It can be assumed that the more interaction with the host-society the more undignified behaviour arises. However, in Jordan, feelings of marginalisation from national and international agencies were not reported as it was demonstrated by previous research [12]. On the other hand, personal development/unmet needs were only reported in the community-settings, e.g. Turkey, but not in the camp-setting Jordan. Whether restricted opportunities within the camp are accountable may be doubtful but the findings highlight that participants in Jordan are only worried about daily life circumstances, longing for family and life in Syria/elsewhere, or general future uncertainty. This may emphasise the hopelessness camp residents feel about the future and the "life after the camp" [55,66]. --- Limitations This study has a number of limitations. The major weakness in this study is the transcription of the responses. PSYCHLOPS is designed for short responses. In Jordan, and partly in Switzerland as well, research assistants summarized the participants' responses and hence, it is possible that participants' own words were lost despite proper training in transcription. In Turkey, however, participants were instructed to share a synopsis, which would then be transcribed word-by-word. In both cases, the depth of the content of the actual experienced problems is reduced. More extensive responses would allow drawing a clearer picture of the participants' perception and additional in-depth interviews could enable to investigate detailed causalities and consequences of certain problems. Considering the variability of transcription mode, it is suggested that stricter guidance of the interviewers on how to write down PSYCHLOPS responses is recommended. Additionally, the richness of the data might be reduced due to the Arabic-German translations in Switzerland and Arabic-English translations in Jordan, Turkey and Switzerland. Since the study is limited to three unique sites, and the sample populations were selected based upon a certain distress level, generalization to the entire populations in these and other countries is not possible. However, through the inclusion of distressed individuals the problems of a vulnerable group are highlighted and hence, can help tailor appropriate psychological and other interventions for this target group. --- Public health implications Since only distressed SRAs as a particularly vulnerable population were included in this study, our findings could be of critical interest to immigration and public health policy makers as well as involved health and migrant organizations. Decision makers should be aware that practical stressors may have major consequences for psychological functioning and that all types of daily stressors may negatively impact successful integration [10,61]. The alleviation of post-migration stressors is therefore critical not only for the individual wellbeing or ethical reasons, but also with regard to long-term socioeconomic aspects of hosting societies [10]. Therefore, authorities should carefully balance their interventions and consider the return on investment of appropriate health care und psychosocial support. In doing so, our findings suggest that target solutions should specifically address the site-specific needs of SRAs. --- Conclusion This study was a first attempt to explore and compare the self-reported problems in SRAs resettled in three different countries in the Middle East and Europe. The results clearly indicate that distressed SRAs mostly suffer from a variety of post-migration stressors. Whereas psychological, social, physical and psychosomatic stressors are similarly distributed across study sites, practical problems show substantial variation between host countries and should therefore be specifically addressed by policy makers in order to foster psychological wellbeing and psychosocial integration. Future research should explore the presented countryspecific problems, underlying processes, causes and consequences in greater depth. Furthermore, since this study unilaterally examined problems, it is to highlight that a greater focus on resilience factors and empowerment could produce interesting findings that account for a more comprehensive needs analysis from refugees' own perspectives. --- --- Abbreviations SRAs: Syrian refugees and asylum seekers; PM+: Problem Management Plus; RASASA: Refugee and Asylum Seekers Assistance and Solidarity Association; PSYCHLOPS : Psychological Outcomes Profile; PTSD: Posttraumatic stress disorder --- --- --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Syrian refugees and asylum seekers (SRAs) face multiple stressors after flight, which may vary due to different geographic, economic, cultural and socio-political contexts in the host countries. Past research has recognised the importance of participants' own perspectives. The aims of this multi-country study were to identify and compare self-reported problems of SRAs between various settings. Methods: A semi-structured client-generated outcome measurement was used to collect data among adult SRAs in Jordan (N = 61), Turkey (N = 46) and Switzerland (N = 57) between September 2018 and November 2019. Answers were analysed following thematic analysis. Results: Over half of the participants reported practical problems with an emphasis on camp-related problems (Jordan), finances (Turkey), employment (Jordan and Switzerland) and government regulations (Switzerland), followed by psychological, and social issues.This study highlights the impact of local contextual factors on wellbeing. The findings emphasise that planning preventative procedures and mental health care services for SRAs need to consider local challenges affecting the population in specific countries.

introduction the syrian civil war has resulted in syrians being the largest forcibly displaced population over recent years more than 13 million people have left their homes with 61 million internally displaced people 66 million refugees and 118445 asylumseekers by the end of 2019 they are hosted in 127 countries with 83 having fled to neighbouring countries turkey hosts most syrian refugees with 36 million lebanon hosts 910600 and jordan hosts 654700 1 a vast number of syrian refugees and asylum seekers also arrived in europe including germany having registered 572800 1 sras and switzerland almost 20000 by the end of 2019 2 forcibly displaced people are frequently exposed to potentially traumatic events and other stressful experiences in their countries of origin as well as during and after flight which may impact their mental health and overall functioning 34 past research has emphasised the importance of a combination of preand postmigration stressors whereby the postmigration environment can play a significant role in modulating recovery from warrelated trauma and grief 56 displacementrelated stressors include but are not limited to poverty uncertainty of asylum seeking process unemploymentdependency on aid family conflict and loss of social network 6 7 8 these stressors impact mental health directly or through their adverse impact on the social ecology which refers to ones relation with the social and family environment 69 it is argued that each host country presents a unique set of postmigration factors which partly results from local policies therefore the type and severity of postmigration stressors can differ widely between countries 10 previous studies in jordans camps have reported displacementrelated problems such as poor living conditions insufficient access to services such as medical sanitation 11 marginalisation from international and regional agencies socioeconomic pressures 12 and work exploitation 13 concerning the legal status in turkey syrians are under temporary protection meaning they can stay as guests until they reside in a third country 8 there are also thousands of syrians without temporary protection status and an unknown number of syrian irregular migrants 14 similarly in switzerland from over 20′000 syrian refugees and asylum seekers by the end of 2019 almost half of them hold only the n or f permit meaning a tolerated stay not the recognition as refugees in switzerland 215 these permits need to be renewed every 6 or 12 months 16 n permit holders have serious restrictions in accessing the labour market governmental subsidies leaving the country and no right to family reunion 17 it applies to both country that the temporary protection status leads to feelings of uncertainty and fears of being sent home 818 concerning employment in turkey since the regulation on work permit on refugees under temporary protection in january 2016 access to formal employment has been established 19 however the issue of work permits is limited by specific criteria and illegal work as well as unfavourable working conditions are widespread unsurprisingly employment problems and poverty are reported as most salient problems among syrians in istanbul turkey 8 work permit challenges based on the legal status were also significant problems for syrians in switzerland 18 in turkey syrians have established their own neighbourhoods and communities in istanbul and cities along the border due to the vast influx despite commonalities between syria and turkey such as cultural and geographical proximity increased discrimination towards syrians due to their nationality culture and language has been reported in turkey 14 discrimination feelings of marginalisation and language difficulties related to entitlements based on legal status such as language courses have been reported by previous research in switzerland 18 stressors and mental health of sras have been predominantly assessed through nomothetic measurements often developed and validated in western contexts 20 studies have shown that standard instruments often fail to encompass all aspects of distress in crosscultural settings and that it is a fallacy to assume that symptoms in different cultural contexts carry the same significance across cultures 21 22 23 clientgenerated outcome measurements are personcentred by definition and unlike standardized measures they seek to encompass the individuals phenomenological experiences as well as their priorities local values perspectives and expectations 222425 individuals social circumstances and culture are at the core of the who global strategy on personcentred care which suggests that care should address physical socioeconomic mental and emotional wellbeing 26 a personcentred approach is appropriate for understanding the stressors and needs of sras because they emigrate to diverse cultural social political and religious contexts furthermore despite general cultural commonalities among sras there is also great diversity among syrians and their individual experiences 2127 this approach also accords with the unhcr mental health and psychosocial support programs these have highlighted the need for a culturally safe environment and respect of diversity when exploring syrians perspectives and hence favour a personcentred approach to psychosocial support and clinical interaction 22 moreover understanding stressors and needs including nonpsychological or social needs is a crucial first step before the provision of psychosocial support and effective mental health services or referral to other relevant services 27 28 29 inadequate assessment of postmigration stressors could risk overlooking key sources of ongoing stress in the social ecology that could be targeted for change 6 regarding sras mental health stressors and needs many assessments have been conducted in syrias neighbouring countries such as jordan lebanon and turkey 3031 and generalizability to western european countries is questionable comparative studies between lowand middle and highincome countries may shed light on key environmental factors affecting adjustment needs of sras in these different settings however such comparative studies are scant 832 and little is known about the sras salient problems from their own perspective the overall aim of this study was to use a personcentred approach to investigate selfreported problems of sras and to identify key stressors within jordan turkey and switzerland a mixedmethod study approach was used to gain a detailed understanding of the sras emic perspectives on their problems aside from understanding their emic perspectives we focus on the similarities and differences between the countries and describe local environmental factors which might account for the variability methods setting data were collected as part of three studies conducted in jordan turkey and switzerland which aimed to assess the feasibility of conducting large controlled trials designed to evaluate the effectiveness and implementation of problem management plus with sras 33 34 35 pm is a scalable lowintensity intervention developed by the who for people affected by adversity aiming to reduce symptoms of common mental disorders 3637 these trials are part of the larger strengths project scaling up psychological intervention for syrian refugees 38 recruitment in jordan participants were recruited through doortodoorscreening from the village 2 and the highly restricted fenced off village 5 in alazraq refugee camp unlike refugees in other parts of the camp such as village 2 those in village 5 were not allowed to leave the area visit relatives in other parts of the camp obtain temporary leave permits or access work outside the camp 41 in turkey participants were recruited from sultanbeyli an economically disadvantaged neighbourhood in istanbul via phone calls using the contact list from the collaborating refugee and asylum seekers assistance and solidarity association as well as through direct referral from rasasa social workers in switzerland participants were recruited through social media brochures wordofmouth propaganda and local stakeholders from german speaking cantons psychlops measure data were collected through the brief and idiographic questionnaire psychological outcomes profile based on ashworths original version 42 at the core of the questionnaire are three domains the participant was asked to give short freetext responses for the following problem items and functioning domain 1 choose the problem that troubles you most 2 choose another problem that troubles you and 3 choose one thing that is hard to do because of your problem psychlops has been used within large trials designed to test the effectiveness of pm in communities affected by adversity in kenya 43 and pakistan 44 data collection psychlops data were collected between the end of january and beginning of february 2019 in jordan in september 2018 in turkey and between january and november 2019 in switzerland research assistants were native arabic speakers and received a oneday or threeday training in data collection methods and research ethics after explaining the study by a research assistant to the participant who had previously screened positively written informed consent was obtained gendermatching with participants was achieved in most cases in order to access illiterate participants in jordan and turkey psyc hlops was conducted as a guided interview measure whereas in switzerland this was done only if necessary assessments were conducted in confidential rooms to ensure privacy using paperpencil method in jordan in separate rooms in the building of rasasa outside official hours using paperpencil method in turkey and in separate rooms of specialized centres on computer using the multi adaptive psychological software 45 in switzerland psychlops responses were recorded by the participants and research assistants in one or two short sentences to encapsulate the participants problems as closely and concise as possible data analysis analysis of sras selfreported problems focused on the first two questions of the psychlops tool translations of jordans and a number of switzerlands responses were conducted by a mental health professional interpreter responses in turkey were translated by a bilingual research member for analysis we used a datadriven approach in order to respect the geographical and cultural diversity and employed thematic analysis according to braun clarke 46 focusing on the semantic meaning all problem items were given a code codes were each compared and similar themes were condensed per question and country these themes were integrated into broader categories again compared and refined to minimize overlap and maximize coherency and consistency the research team then reviewed and mutually agreed on the coding framework finally a psychology student and ad coded the data set separately according to the final coding framework the interrater reliability was k 098 for all three countries once the coding was completed similarities and differences across the three countries were investigated the coding process and the reliability calculations were performed using nvivo 12 software 47 the sociodemographic variables were statistically analysed using spss statistics 25 48 the variable age was normally distributed years since flight from hometown from syria and arrival in host country were not normally distributed therefore for these variables median and interquartile range will be reported results demographic characteristics overall 164 participants participated across the three trials table 1 shows the sociodemographic characteristics across the three study sites the main differences were that the participants in switzerland left their hometown 2 years earlier were considerably more educated more frequently divorcedseparated or unmarried and more students than participants in jordan and turkey despite the high number of working permits in switzerland the unemployment rate was the highest in switzerland and more participants in jordan and turkey pursued gainful employment overview reported problems across all countries over half of participants stated two or three problems participants who stated more than one problem per question either described causes and consequences or listed multiple single problems between the countries problem types were similar with identical categories but varied in frequency as shown in table 2 the main two categories were a practical and b psychological further frequent categories encompassed social issues such as interpersonal problems separation from family members and problems related to family duties and physical and psychosomatic problems practical problems for a majority the troubling problems were of a practical nature a prominent concern among all participants was employment whereas camprelated issues emerged only in jordan financial concerns were most prevalent in turkey and governmentrelated issues and housing were of greater concern in switzerland a further breakdown of the coding is reported in table 3 jordan camp issues were identified by a significant proportion of participants in the jordan sample many participants expressed impairment of freedom oppression and enforcement of being in the camp whereby eight directly linked those problems to village 5 and challenging living conditions such as long waiting time for supplies electricity shortage distances to services or general terms for living conditions examples of the salient practical problems are shown in table 4 there were common concerns about employment participants expressed causes such as governmental regulations on working permits stay in the restricted village 5 of the camp lack of job opportunities or financial stress associated with unemployment financial concerns were the third most frequent practical problem seven used general terms such as financial problems or lack of money whilst others related to house and childcare expenses rising prices or were challenged by the role change to primary provider a slightly less prominent problem was not receiving appropriate medical treatment or worrying about it residence permit issues assigned to government regulations housing education and climate issues were of minor importance turkey many participants stated financial problems in turkey most participants expressed financial issues in a general way they stated causes for the financial problems such as the lack of financial support by an institutionorganization no work or the associated consequences such as not receiving appropriate medical treatment or financial instability regarding employment problems four participants related these problems to financial stress when considering work status four people pursued paid work three were homemakers and only one was unemployed respondents expressed problems such as not finding a job followed by work disability due to health reasons and the lack of social security after leaving a job one participant expressed problems at work including discrimination challenge of learning a new language was described as a problem including impact on education and inability to learn turkish due to family duties other less frequently stated problems were medical treatment unsuitable housing childrens problems at school and government regulations such as current residence permits preventing receipt of appropriate medical treatment or educational opportunity switzerland eighteen participants expressed employment problems whereby sixteen stated concerns about finding a jobinability to work some being unable to find a suitable job according to their original profession or expectation furthermore participants expressed difficulties in finding an apprenticeship or pursuing their studies or linked language competence with successful job seeking one person referred to exploitation at work eight out of twelve participants who stated problems with government regulations commented on the negative impact of residency status on freedom of movement family reunion and temporary residency retired 1 2 1 2 0 0 2 1 student 1 2 1 2 7 12 9 6 others 1 2 1 2 0 0 2 1 no legal work permission 44 72 33 71 16 28 57 note n j number of participants in jordan n t number of participants in turkey n s number of participants in switzerland another common problem was housing such as finding an appropriate apartment dissatisfaction with living conditions in asylum centres or cost of rent educational financial and language problems were each mentioned by six participants beside general terms specific descriptions ranged from finding an education place or apprenticeship discrimination at school cost of housing financial uncertainty and inconvenience in daily activities due lacking knowledge of the german language medical treatment and other problems were very minor taken together this section shows how strongly practical issues are linked to displacementrelated factors such as employment government regulations and language difficulties psychological problems various emotional cognitive and behavioural symptoms of mental disorders such as depression anxiety posttraumatic stress disorder and psychotic symptoms were expressed in all three countries illustrated in table 5 many issues were mentioned only once in general participants did not use diagnostic labels with one exception of psychosis they used various terms of emotional or psychological symptoms described their feelings by using simple language or used general terms in jordan frequent problems included worries about another person fear and anxiety and anger as was in switzerland the feeling of uncertaintyinsecurity the emotional impact of war such as missing family members memories of lost family members and past events in syria and fear for family members back in syria were of similar importance across all countries in turkey the great number and variability of psychological problems endorsed by participants didnt allow to build more particular problem categories psychological problems were frequently related to other nonpsychological problems either as causes or as consequences ones social network seemed to play a crucial role since over half of the psychological problems were of psychosocial nature meaning the interrelation of social environment and psychological wellbeing and hence showed frequent overlap with social problems others health problems and the wellbeing of family members of 65 participants who mentioned psychological problems 35 indicated also practical problems with some making a causal link with psychological issues overall the results show the prevalence of psychological problems and the importance of social network and local displacementrelated factors on psychological wellbeing and illustrate psychological problems as the common consequence of a range of stressors psychological 27 44 15 33 23 40 65 40 interpersonal 15 25 14 30 15 26 44 27 physicalpsychosomatic health 13 21 13 28 10 18 36 22 separation from family members 11 18 8 17 13 23 32 20 related to warhome country 7 11 6 14 7 12 20 12 related to family duties 10 16 5 13 2 4 17 10 personal developmentunmet personal needs 0 0 3 7 7 12 10 6 note n j number of participants in jordan n t number of participants in turkey n s number of participants in switzerland na not applicable table 3 subcodes of practical problem category of the three study populations subcodes practical problems jordan turkey switzerland total n n j n n t n n s n n employment 16 26 8 17 18 32 42 26 finances 11 18 17 37 6 11 34 21 camp related issues 26 43 na na 26 16 government regulations 3 5 4 9 12 21 19 12 housing 2 3 5 11 11 19 18 11 medical treatment 6 10 6 13 3 5 15 9 education 2 3 5 11 6 11 13 8 language na 7 15 6 11 13 8 others 1 2 0 0 2 4 3 2 note na not applicable social problems three categories could be assigned to social problems which encompass issues usually resulting from a personal or societal relationship first interpersonal aspects consisted of interpersonal problems within the family such as conflicts or concerns with relationships with family members another recurring interpersonal problem across all settings was undignified behaviour such as physical verbal or nonverbal violence towards individuals however conflicts linked to the host community and displacementrelated factors such as discrimination labour exploitation oppression were present only in turkey and switzerland second separation from family members was commonly described as emotional and geographical separation whereas the category of family reunion meaning the inability of reunification of family members in the host country emerged only in switzerland leavingdivorce from spouse assigned to interpersonal problems as well as consequences of separation from family members were expressed by participants in turkey and switzerland third family duties mostly described as household chores and parental responsibilities such as upbringing of marrying off children and consequences of family dynamics were more frequent among participants in jordan and turkey compared to switzerland exemplar quotes of social problems are shown in table 6 this category highlights the role of stress within the familial social network but also through the host society such as conflict healthrelated and displacementrelated concerns within the familycommunity furthermore the results also show a frequent overlap of interpersonal problems separation from family members and family duties with psychological problems physical and psychosomatic problems across the three study sites a broad range of health issues was described and rarely mentioned more than once additionally participants often used general terms or cultural idioms for participants in jordan and turkey worries due to another persons health problem as well as connection between health and practical problems such as lack of appropriate treatment and in turkey inability to work were more common in switzerland possible psychosomatic symptoms such as pain were of relevant concern compared to jordan and turkey some of the above described results are exemplified in table 7 these results indicate that not only personal physical integrity but also health issues in the social milieu critically influence psychological wellbeing furthermore health issues are associated with displacementrelated factors personal developmentunmet personal needs there was a sense of impairment in personal development and meeting personal needs including future job possibilities having a family or other aspirations which are illustrated by examples in table 8 these problems occurred only in turkey and switzerland discussion this study presents the idiographic perspectives of distressed sras on their problems after their flight to jordan turkey or switzerland to our knowledge this is the first attempt to compare selfreported problems of a vulnerable group of sras between three host countries based on a standardized clientgenerated outcome measurement we found similarities and differences between the settings in summary the results show that sras across the three countries suffer from postmigration problems frequently related to their social ecology primarily practical followed by psychological social physical and psychosomatic problems the findings differed somewhat between the settings with camprelated and employmentrelated issues more common in jordan financial problems in turkey and employment government regulations and housing problems in switzerland the finding of postmigration problems as major concerns of refugees and asylum seekers concurs with previous studies demonstrating the importance of postmigration stressors 6274950 demographic characteristics and contextual factors in jordan turkey and switzerland differed in a number of important ways it is possible that education affected the migration destination as the swiss sample showed more highly educated sras than jordan and turkey similar to our results carlson williams 51 found a positive selection for advanced education in syrian refugees migrating to europe compared to syrian refugees resettling in neighbouring countries such as lebanon or jordan a study by brücker and colleagues 52 found a similar pattern in a sample of syrian refugees in germany previous research suggested that advantaged social positions relate to an earlier flight which could explain the tendency of an earlier flight in the swiss sample 53 in turkey and switzerland the study design for recruitment implied a helpseeking behaviour whereas in jordan assessors conducted doortodoor screening therefore it can be assumed that in turkey and switzerland participants may be more affected and hence showed more interest in receiving help this study revealed that sras face overarching problems occurring in a similar way in all host settings as well as countryspecific problems more prevalent to the local setting the overarching problems are in line with previous findings 62249 and hence the similar aspects will not be discussed any further here in contrast great variation emerged within practical problems which can be accounted for by countryspecific displacementrelated factors in terms of countryspecific problems camprelated concerns in jordan such as physical safety concerns unmet basic needs such as access to clean water sanitation medical services adequate shelter impairment of free movement work exploitation and unmet psychosocial needs have also been highlighted in previous studies 11 13 30 54 our study reflects the subjective burden of strong restrictions of freedom and limited access to work 41 however participants did not express concerns about physical safety access to clean water sanitation work exploitation and shelter a possible assumption that caravans in alazraq camp were relatively adequate shelters is supported by a study which found significantly greater dissatisfaction and need for psychological support in refugees staying in tents than in their counterparts staying in caravans 55 however a comparative study between syrians in camp and noncampsettings in iraq found that refugees in camps are better off particularly in terms of access to food education registration and employment 56 financial issues were the primary problem in turkey which may be associated with widespread informal work and low payment due to the temporary protection status 57 even though turkey adopted the regulation on work permits for foreigners under temporary protection in 2016 access to the labour market remained challenging and exploitation and discrimination also described in our study as well as harassment occur frequently 19 our study supports the difficulty of meeting financial needs despite official working permits as half of those who cited financial problems owned an official working permit and half of the participants who reported an employment problem related it to financial problems a further displacementrelated stressor especially in jordan and switzerland was employment which is consistent with previous research 658 however certain contributing factors and consequences may vary between the countries in switzerland it seems possible that the high percentage of employment issues is associated with the high rate of unemployment and labour market restrictions for asylum seekers our study partly reflects labour market barriers found among refugees elsewhere including visa restrictions poor language skills qualifications from their home countries not being recognised discrimination lack of vocational skills and psychological or physical barriers 59 the complexity and far reaching consequences of employment difficulties were shown in a previous study illustrating the relationship between temporary visa status or discrimination affecting employment opportunities and thus financial issues subsequently affecting the refugees social standing restricted employment opportunities may also affect affordable housing which leads to increased instability and in turn to greater isolation 10 in contrast employment barriers in jordan arguably can be attributed to sampling within a restricted camp that has less opportunity for employment in switzerland our findings show the strong impact of the immigration policy of temporary admission and long asylum seeking process on subjective wellbeing this finding is in line with a previous study 60 and supports the potential of its change for mental health improvement 61 research outside of switzerland has shown that temporary protection independently increased the risk of ongoing ptsd mentalhealth related disability mood and anxiety disorders and hampered socioeconomic integration 72962 it is assumed that the instability due to the temporary status also impacted the high percentage of participants with feelings of uncertaintyinsecurity this association and its implication for health and wellbeing has been established in a previous study 63 our results also shed light on the negative impact of living in an asylum centre in switzerland which supports the evidence of previous research inand outside switzerland showing its detrimental effect on mental health and subsequent successful socioeconomic integration 182964 one further finding of the present study to be mentioned is that the host society has a distinct impact in communityvs campsetting on experienced problems in turkey and switzerland participants reported undignified behaviour such as discrimination racism by the hostsociety which is in line with previous research 1418 and may strongly affect mental health social adaptation fosters internalising behaviour and hampers successful socioeconomic integration 102865 it can be assumed that the more interaction with the hostsociety the more undignified behaviour arises however in jordan feelings of marginalisation from national and international agencies were not reported as it was demonstrated by previous research 12 on the other hand personal developmentunmet needs were only reported in the communitysettings eg turkey but not in the campsetting jordan whether restricted opportunities within the camp are accountable may be doubtful but the findings highlight that participants in jordan are only worried about daily life circumstances longing for family and life in syriaelsewhere or general future uncertainty this may emphasise the hopelessness camp residents feel about the future and the life after the camp 5566 limitations this study has a number of limitations the major weakness in this study is the transcription of the responses psychlops is designed for short responses in jordan and partly in switzerland as well research assistants summarized the participants responses and hence it is possible that participants own words were lost despite proper training in transcription in turkey however participants were instructed to share a synopsis which would then be transcribed wordbyword in both cases the depth of the content of the actual experienced problems is reduced more extensive responses would allow drawing a clearer picture of the participants perception and additional indepth interviews could enable to investigate detailed causalities and consequences of certain problems considering the variability of transcription mode it is suggested that stricter guidance of the interviewers on how to write down psychlops responses is recommended additionally the richness of the data might be reduced due to the arabicgerman translations in switzerland and arabicenglish translations in jordan turkey and switzerland since the study is limited to three unique sites and the sample populations were selected based upon a certain distress level generalization to the entire populations in these and other countries is not possible however through the inclusion of distressed individuals the problems of a vulnerable group are highlighted and hence can help tailor appropriate psychological and other interventions for this target group public health implications since only distressed sras as a particularly vulnerable population were included in this study our findings could be of critical interest to immigration and public health policy makers as well as involved health and migrant organizations decision makers should be aware that practical stressors may have major consequences for psychological functioning and that all types of daily stressors may negatively impact successful integration 1061 the alleviation of postmigration stressors is therefore critical not only for the individual wellbeing or ethical reasons but also with regard to longterm socioeconomic aspects of hosting societies 10 therefore authorities should carefully balance their interventions and consider the return on investment of appropriate health care und psychosocial support in doing so our findings suggest that target solutions should specifically address the sitespecific needs of sras conclusion this study was a first attempt to explore and compare the selfreported problems in sras resettled in three different countries in the middle east and europe the results clearly indicate that distressed sras mostly suffer from a variety of postmigration stressors whereas psychological social physical and psychosomatic stressors are similarly distributed across study sites practical problems show substantial variation between host countries and should therefore be specifically addressed by policy makers in order to foster psychological wellbeing and psychosocial integration future research should explore the presented countryspecific problems underlying processes causes and consequences in greater depth furthermore since this study unilaterally examined problems it is to highlight that a greater focus on resilience factors and empowerment could produce interesting findings that account for a more comprehensive needs analysis from refugees own perspectives abbreviations sras syrian refugees and asylum seekers pm problem management plus rasasa refugee and asylum seekers assistance and solidarity association psychlops psychological outcomes profile ptsd posttraumatic stress disorder competing interests the authors declare that they have no competing interests

background syrian refugees and asylum seekers sras face multiple stressors after flight which may vary due to different geographic economic cultural and sociopolitical contexts in the host countries past research has recognised the importance of participants own perspectives the aims of this multicountry study were to identify and compare selfreported problems of sras between various settings methods a semistructured clientgenerated outcome measurement was used to collect data among adult sras in jordan n 61 turkey n 46 and switzerland n 57 between september 2018 and november 2019 answers were analysed following thematic analysis results over half of the participants reported practical problems with an emphasis on camprelated problems jordan finances turkey employment jordan and switzerland and government regulations switzerland followed by psychological and social issuesthis study highlights the impact of local contextual factors on wellbeing the findings emphasise that planning preventative procedures and mental health care services for sras need to consider local challenges affecting the population in specific countries

Introduction Composite indices receive a lot of attention in debates on international development and sustainability. The Human Development Index is a case in point, aggregating individual measures of education, health, and income into a single number, which is then used for annual rankings of countries that meet with considerable public interest. The advantages of such aggregate indices are avoiding over-reliance on individual indicators like GDP per capita, and usefulness for simple comparison, analysis and advocacy . In complex cases, composite indices can also aid decision making by simplifying the considerable information that may be available to decision makers who may not have the time or capacity to use it, allowing scarce resources to be allocated better. Importantly, in the face of adverse climate change impacts and other environmental changes, a number of indices have been developed to assess exposure, vulnerability, resilience and adaptive capacity of impacted communities . These advantages notwithstanding, composite indices have been the source of considerable debate in the academic literature. Much of the discussion has revolved around the mechanics of the composite indices: the lack of a clear theoretical framework, the blurring of conceptual clarity that comes from mixing individual dimensions together, the inclusion or exclusion of relevant individual indicators, the aggregation method-including the weights for the individual indicators and the tradeoffs this leads to-robustness of rankings and more . A different-though not unrelated-question related to the usefulness of composite indices is whether they are actually trusted and used by decision makers. In other words, if a decision maker has access to both an aggregate index and underlying information on individual indicators, do they rely on the index or on their own aggregation when making decisions? This is the question we focus on in this article. We present results from a randomized experiment where we study the effect of having access to a migrant resettlement index on decisions to allocate migrants between host locations within a country. The resettlement index whose effect we test was developed by Walelign and Lujala . The index aggregates information on five asset and six condition dimensions central to livelihood reconstruction of migrants in host locations. The experiment was conducted in Bangladesh using graduate students from disciplines relevant to making these types of decisions as respondents. 1 The respondents were randomly assigned to three groups which all faced a discrete choice experiment where the task was to allocate internal migrants between two unnamed host locations in Bangladesh, but where the information available on the two locations varies by treatment arm. In the main control group, the two locations are described in terms of five individual indicators ; availability of cropland, distance to hospital, distance to school, poverty incidence, and frequency of floods, droughts and cyclones. The treatment group received information on the same five individual attributes, but also on the composite resettlement index. Since any difference in behaviour between the main control group and the treatment group could be driven by the number of attributes rather than the nature of the sixth attribute, we also included a second control group which received information on the five individual attributes plus an irrelevant attribute . From the responses, we then elicit the effect of each of the attributes on migrant allocations, which allows us to test whether the resettlement index is trusted and used, and its relative importance compared to the five individual attributes. The results show that the respondents in the treatment group relied on the resettlement index to allocate migrants, with estimates showing as great or greater emphasis being placed on the index than the five individual attributes. Additional analyses into mechanisms suggest that this is due to the perceived improvement in resettlement decisions the index contributes to, rather than order or experimenter demand effects. The use of the index does not vary with most background characteristics of the respondents, though we see somewhat lower reliance on the index from male respondents and more emphasis on the index by respondents who have a more favourable view of migration. Comparing the weight placed on the five individual attributes in the main control and treatment group, we see a slight drop in some of their coefficients in the treatment group, but results from the second control group make this finding hard to interpret. The irrelevant attribute included in the second control group proved irrelevant, as expected. However, we observe a similar drop in the weight of the other attribute coefficients as for the treatment group, which means that we cannot rule out that any movement in the importance of these individual attributes when the index is included could be due to the addition of a sixth attribute rather than the specific addition of the resettlement index. Our analysis speaks to the issue of how the next generation of decision makers assess information on community capacity to adapt to the effects of climate change in a context of extremely high exposure to environmental degradation. More specifically, the article makes three main contributions. First, we add to the understanding of the behavioural side of composite index use, essentially documenting a revealed preference among our respondents for having and using aggregate indices. In our case, it is likely that this is the result of a careful explanation of the index preceding the discrete choice tasks, which has instilled the necessary confidence in the index among our participants. Consistent with this, we show that the weight respondents place on the index proves to be increasing in the extent to which they believe the index was compiled by a competent research team, the ease with which it was conveyed in a clear and understandable manner, and the efficiency with which it can improve allocation decisions. The aforementioned finding that the index is emphasized more by those with a favourable view of migration also indicates that respondents more invested in the issue at hand may be more willing to use the index over other information. These findings can be used to understand settings in which developing and making composite indices available are more likely to be fruitful from an implementation point of view. These insights may also have relevance beyond the specific topic studied here, for example, in understanding information management in organizations more generally . With the increasing digitalization of decision-making processes in business and elsewhere, including the use of artificial intelligence to distil high-dimensional information, knowing the conditions under which aggregation leads to impacts on decision-making behaviour is important. Second, the discrete choice approach we adopt is particularly informative in allowing us to assess future decision makers' perceptions of the relative importance of host community characteristics important for resettlement capacity, as opposed to asking survey questions for one characteristic at a time. While surveys of experts are common in developing composite indices whose use we test here), a discrete choice approach is not typically used to map expert views. The advantage to doing so, as we show in this paper, is to get better information on the relative weights for the individual indicators included in decision making. In our control group, respondents put a particularly strong emphasis on past adverse environmental events when allocating migrants between locations, the impact being significantly stronger than for most of the other attributes . Our control group results also show that respondent background influences the weight a respondent places on the different attributes, and not always in the way one would intuitively expect. Respondents who grew up in locations with scarcity of cropland or frequent adverse environmental events, judged these attributes to be less important for resettlement decisions. While surprising, these findings nevertheless mirror recent insights from studies of potential migrants, suggesting that they may become less inclined to move after having experienced adverse environmental events . More generally, while independent experts may be more objective than students, our results highlight the importance of critically assessing patterns in expert evaluations and implications for the aggregation of their views. Third, our analysis speaks to the more technical literature on discrete choice experiments. A number of studies have shown that responses to such experiments are dependent on how they are structured, including on the number of attributes included . Our second control group results clearly suggest that this can be important, as the inclusion of an irrelevant attribute significantly changes results for the other attributes compared to the main control group with only five attributes. Since respondents are randomized into treatments, this does not reflect differences in background characteristics in the two control groups. For discrete choice experiments in general, this suggests that more effort should go into checking robustness of findings to alternative designs. And for randomized experiments like the one conducted here, it clearly suggests that if a treatment also leads to a change in design, as it does in our case, a second control group which can be used to assess the effects of such a change is absolutely essential. The article is structured as follows. Section 2 presents the resettlement index used for the experiment, the experimental design, and the empirical strategy employed. Summary statistics for our sample are presented in Sect. 3. Section 4 contains our main results, with mechanisms discussed in Sect. 5 and heterogeneous effects in Sect. 6. Section 7 concludes. --- Experimental design and empirical strategy The experiment is designed to test the use of the resettlement index developed by Walelign et al. for Bangladesh. The index is based on their climate change resettlement capacity framework , which focuses on livelihood reconstruction as a key to successful resettlement of climate change impacted people and communities. The CCRC framework identifies five asset and six condition subdimensions that capture the availability of different resources to the resettled and factors that constrain or facilitate the use of these resources . The framework is designed for the purpose of assisting international organizations, governments, planners, and policymakers in identifying both more and less suitable places to resettle communities displaced due to climate change. Besides the index for Bangladesh, the CCRC approach has been used to construct a resettlement capacity index for Ethiopia . Here, we test the impact of the resettlement index on decision making using data at the union level from Bangladesh. The index has been computed based on 100 underlying individual indicators, including the five indicators that we use as attributes in our discrete choice experiment. The experiment testing the effect of the resettlement index on migrant resettlement decisions was piloted on May 19, 2022, using a separate sample of 15 masters students recruited from disaster management studies at Dhaka University not included in our main experiment. For the main experiment, 410 masters students were recruited from Dhaka University and the Dhaka School of Economics. The students spanned five academic disciplines/programmes; development economics, environmental and resource economics, economics-other subdisciplines , planning and disaster management studies, and social sciences-other subdisciplines . The data collection for the main experiment was conducted from May 24 to June 29, 2022. The experiment was implemented in group sessions featuring 10-15 respondents at a time, overseen by a team of enumerators. The respondents were randomized individually into three treatment arms using randomly assigned login codes to the tablets on which the respondents recorded their responses to our questionnaire. After entering basic background information , respondents were shown a five-minute video explaining the discrete choice experiment, the attributes contained in the experiment, including the resettlement index and its construction from underlying data. The respondents then moved to the discrete choice experiment, explained in further detail below, before answering a set of questions designed to study mechanisms and heterogeneous effects in their responses. In the discrete choice experiment, respondents were asked to allocate 1000 internal climate migrants between two unions A and B. 2 The choice sets used in the experiment took the form captured by Tables 1,2, and 3. While the introductory video was identical for all respondents, the attributes used to describe the two unions varied between the treatment arms. In the control group, respondents were shown information on five individual dimensions for the two unions; the availability of cropland, distance to hospital, distance to school, poverty incidence, and number of past adverse environmental events . The attributes were chosen to reflect both the assets and conditions dimensions of the resettlement capacity framework of Walelign and Lujala , and we included attributes which are very basic and intuitive in these dimensions. To keep the design from being too demanding for the respondents, only two levels were used for each attribute, whether the union scored better or worse on each attribute compared to the average union in Bangladesh. Respondents were told that the two unions were located in rural areas and told to consider the two unions as identical in all other aspects than the ones included in the choice sets, including the cost of allocating migrants to the two unions. The eight choice sets that the control group responded to in succession were chosen through an orthogonal design procedure. For the treatment group, we added the resettlement index as an attribute, also with two levels of being better or worse than average . Apart from this addition, the eight choice sets faced by the treatment group were identical to those of the control group. The values of the index for each choice set were chosen as follows: From all combinations where the index favoured union A in four choice sets, and union B in four choice sets, we selected a combination which was orthogonal to the other five attributes. While the unions in the experiment were in principle hypothetical, their attributes make them all correspond to actual unions in Bangladesh. A key aim of including the added index attribute is to see whether its presence influences the use of the other five attributes. In order to test whether any change was due to the addition of the aggregate resettlement index, and not simply an increase in the number of attributes from five to six, we also included a second control group in our experiment. Instead of the resettlement index, this second control group included an attribute likely to be irrelevant to respondent decisions of resettling migrants . The attribute chosen was the number of neighbouring unions of each union. While in principle this attribute could be associated with some other union characteristic that the respondents might consider important for resettlement decisions, our pilot data indicated that this attribute did not influence decisions. The eight choice sets faced by the second control group were identical to the treatment group, with better/worse in the index attribute being replaced by more/ fewer neighbouring unions on the irrelevant attribute, since its likely irrelevance makes the direction of its levels unimportant. With two alternatives over eight choice sets and 410 respondents, our design generates a total of 410*8*2 = 6560 observations. Since our outcome variable is continuous rather than dichotomous, we analyse the data using ordinary least squares with fixed effects at the respondent-choice set level : where Allocation ijt is our dependent variable capturing the allocation of migrants of respondent i in choice set j to alternative t, and x ijt is the vector of attribute levels for respondent I's choice set j and alternative t, and the corresponding vector of coefficients for the attributes. The attribute level variables have all been specified as dummy variable which take the value of 1 if assets and conditions are favourable , and 0 otherwise. Since there are no observations for the resettlement capacity index attribute or the number of neighbouring unions attribute in the other treatment arms, the full set of attributes and observations cannot be included in the same estimation. We first estimate Eq. separately for each treatment group using the full set of attributes in order to see the influence of the resettlement capacity index on choices, and then, estimate equation for the full set of observations using only the five shared attributes, and including interaction effects between the attributes and dummies for the treatment and second control group, in order to study whether the availability of additional dimensions significantly affects the use of the five shared attributes. For robustness, we also conduct an additional conditional logit analysis using a dummy that equals one for the union with the largest allocation as the dependent variable, with observations with equal allocations dropped from the sample. Our main analysis focuses on testing the following four hypotheses for coefficient h g , where h denotes attribute, and g treatment group: Hypothesis 1: The resettlement index affects decisions of treatment group: Hypothesis 2: Including the resettlement index reduces the impact of the other five attributes: Hypothesis 3: Adding an irrelevant attribute does not affect decisions: Hypothesis 4: Adding an irrelevant attribute does not affect the impact of the other five attributes: In other words, our prior expectation is that the resettlement index should have a significant effect on allocation of migrants between unions , and that having access to it means that less weight is placed on other five dimensions school, poverty incidence, and floods, droughts and cyclone events). Including an irrelevant attribute should neither affect decisions nor the weight placed on the other attributes . If hypothesis 2 holds, hypothesis 4 is included to test that the lower influence of the other attributes in the treatment group is due to the inclusion of the resettlement index rather than merely an increase in the number of attributes. Allocation ijt = ij + x ijt + ijt 𝛽 resettlement index treatment > 0 --- Descriptive statistics The variables used in our analysis are defined in Table 5 in the Appendix. The dependent variables and attributes are as explained above, and together with the treatment variables form the main focus of the paper. However, we also include a number of survey questions which we use for analysing mechanisms and heterogeneous effects. Data from 410 respondents who each made eight comparisons of two alternative unions give us a total of 6560 observations. The main control group facing five attributes in the discrete choice experiment counts 136 respondents, and the other two treatment arms consist of 137 respondents. In Table 6 in the Appendix, we present descriptive statistics for our background variables at the individual level. 3 We return to the seven variables in the middle rows of the table in Sect. 5 on Mechanisms. For the demographic and attitude variables at the bottom of the table, we note that the backgrounds of our respondents are quite diverse. 61 per cent are male, a little over half are from an urban background, two-thirds study economics-the rest planning studies or other social sciences-almost half have a history of migrating in the first two decades of their lives, and over 60 per cent views migration to their home region as high in recent years. We also measure perceived conditions in the unions from which the respondents originate on each of the five attributes included in the discrete choice experiment. More than 60 per cent originate from unions where cropland per capita was scarce compared to the rest of Bangladesh, 45 and 25 per cent grew up in unions where hospitals and schools were more distant compared to the rest of the country, respectively, 42 per cent grew up in unions with a high level of poverty compared to the rest of Bangladesh, and 37 per cent grew up in locations where floods, droughts, and cyclones were more frequent than in the rest of the country. Means for the last two variables in Table 6 reflect the share that have a positive view of migrants , and of the importance of climate change as a phenomenon . We use the variables to analyse heterogeneous effects in Sect. 6 on heterogeneities. Table 7 shows that there is balance across treatment groups in demographic background and attitudes. While the control group facing five attributes has a lower proportion of respondents that study economics compared to the other two groups, a larger share of respondents in the control group with an irrelevant sixth attribute included grew up in an area where cropland was scarce than in the other two groups, and a higher proportion of respondents in the control group facing six attributes grew up in an area where poverty was common compared to the control groups facing five attributes, these differences are no more numerous than expected by chance. The final column of Table 7 presents the p-value of an F-test of the null hypothesis that the treatment arms do not predict the means on each balancing variable. There is balance on all variables except in studying economics and growing up where cropland is scarce, which again is no more than one can expect by chance. Randomization appears to have worked well in taking out differences in background characteristics between treatment groups. --- Main results The main results of the experiment are presented in Table 4. The first three columns present results for each treatment arm separately, with results for the main control group featuring five attributes in the discrete choice design in column one, results for the treatment group who additionally saw the resettlement index in column two, and results for the second control group including an additional irrelevant attribute in column three. Column four presents results using the full sample of observations, and including interaction effects between all the attributes and dummies for being in the treatment group or in the second control group with six attributes. Please note that in all regressions that include interaction terms, the main term of the variable the attributes are interacted with is subsumed in the fixed effects. The results in column two show that respondents in the treatment group use the resettlement index when choosing to allocate migrants between the two unions; the union that scores better on the index is on average allocated an additional 71 migrants according to the point estimate. The point estimate is also higher than those of the other five attributes, though significantly greater than only cropland per capita , distance to school , and poverty incidence . Comparing results from the main control group and the treatment group , there are notable drops in the coefficients of three of the attributes when the resettlement index is added; cropland per capita, poverty incidence, and floods, droughts and cyclones all see drops of about 20 units. However, as shown by the interaction effects in column four, none of these drops are statistically significant. Moreover, the results for the second control group in columns three and four shed some additional light on the effects of these attributes. As expected, the attribute presumed to be irrelevant is in fact irrelevant to the resettlement decisions . But its inclusion reduces the coefficients of the same three variables as in the treatment group; cropland per capita, poverty incidence, and floods, droughts and cyclones, and the interaction effects in column four show that these changes are significant. This does not affect our main result that the resettlement index is used by the respondents having access to it; however, it means that any movement we see in the other five attributes may be the result of adding a sixth attribute generally rather than an effect of specifically including the resettlement index. The results from the main control group in column one are also informative in how our respondents would perceive the relative importance of the five attributes for migrant allocation decisions when not having access to an aggregate index. Floods, droughts and cyclone events emerge as the relatively most influential one; the more favourable location is on average allocated 82 more migrants than the less favourable one. The coefficient of this attribute is also statistically greater than those of three of the other attributes; cropland per capita , distance to school , and poverty incidence , though not statistically greater than distance to hospital, nor are the other coefficients statistically different from each other. The pattern that emerges from this is nevertheless that for future decision makers in heavily climate change exposed Bangladesh, past environmental damage matters for the assessment of which areas are favourable for future settlement decisions, and more so than agricultural and economic conditions, and certain forms of infrastructure . 1 3 In Table 8 in the Appendix, we run conditional logit analyses corresponding to that of Table 7, using a dummy variable for the union allocated the largest number of migrants as the dependent variable . We do this to demonstrate that our results are robust to more traditional methods of analysing discrete choice experiment data; in addition, this also constitutes a test of whether our results are driven by respondents making extreme allocation decisions . As shown in Table 8, where results are presented as odds ratios, meaning values higher than one signify more refugees allocated to unions that do better on the attributes in question, and values lower than one signify fewer refugees allocated to the more favourable union, the results from the conditional logit analysis are qualitatively similar to our main results using linear fixed effects regressions. --- Mechanisms Judging from its impact on migrant allocation decisions in the discrete choice experiment, our respondents appear to view the resettlement index as useful. In this section, we perform additional analyses to shed some light on whether and why this is the case. One set of reasons for using the index could be that our respondents see the index as facilitating better allocation decisions, and/or allowing such decisions to be made more efficiently compared to considering a larger set of individual attributes. Another, less benign reason for using the index is that it is simply convenient for the decision maker that it saves time without making decisions better, or that using the index is a way of avoiding accountability for allocation decisions, since the index has been constructed by someone else than the respondent. Moreover, while the lack of significance of the irrelevant sixth attribute in the second control group suggests that the fact that being the last attribute in itself does not mean it is given attention, the possibility that the salience of being at the bottom of each choice card can be a reason for the significant effect of the resettlement index should be checked further. In addition, since the index was introduced in the video preceding the experiment, its importance in decision making could also be due to experimenter demand effects. In what follows, we explore these mechanisms further using information from survey questions on perceptions of the index asked after respondents had completed the choice tasks. Evidence from our survey questions indicates that our introductory video convinced respondents both of the expertise of the team constructing the resettlement index and provided respondents with a good understanding of its construction. When asked whether they agreed with the statement "The expertise of the team behind the index presented in the video seems convincing" , 86 per cent of respondents agreed or agreed very strongly with the statement. Similarly, 78 per cent agreed or agreed very strongly with the statement "It was easy to understand how the index that was presented in the video was constructed." The benefits of using the index in making migrant allocations thus seem to be clear to the respondents. In Table 9 in the Appendix, we present results for the treatment group where we interact the resettlement index with responses to these two questions in columns one and two, respectively. The results are summarized in the marginsplots in Figs. 1 and2. The plots essentially convey two things. Firstly, few respondents displayed a low belief in the expertise of the index team, or found the index difficult to understand, as reflected in the width of the confidence intervals at lower values of these variables. Secondly, the average marginal impact of the resettlement index on resettlement decision increases with agreement with both the expertise and ease of understanding of the index and is significant for the large majorities of respondents who agreed with these aspects, suggesting that trust in the expertise behind and the content of the index are important reasons why they have been used. 4 In column three of Table 9, we explore a further nuance in the potential benefits respondents see from using the index. One possibility is that they perceive the weights given to the five other attributes in constructing the index as convincing, another is that they believe the index incorporates more information than contained in the five attributes. While a majority of respondents agree or agree very strongly with the statement "The index presented in the video is based on more extensive information on the unions than the individual characteristics on access to land, health, education, poverty and exposure to hazards", interacting the resettlement index with this variable does not indicate that those in greater agreement tended to rely more on the index. On the contrary, index importance decreases with agreement with this statement, making it unlikely that incorporation of additional dimensions is driving views of the benefits of the index. The fourth column of Table 9 assesses the possibility that respondents believe the index does not only lead to better decisions, but also to greater efficiency in decision making. Two-thirds of respondents agreed with the statement "Having access to an index like the one presented in the video means that decisions can be made more quickly, while still being good decisions." Moreover, the marginsplot in Fig. 3 illustrates results when this variable is interacted with the resettlement index as in column four of Table 9. Again, the width of the confidence intervals at low levels of agreement that the index improves decision-making efficiency is due to a smaller number of observations here, and the effect of the index on decision making is significant for those who agree that it increases decisionmaking efficiency. In combination with the above results, this suggests that respondents see the index as both leading to better decisions, and also more efficient decision making. Two further survey questions allow us to address the more problematic possibility that the index is simply seen as a convenient way to simplify decision making without improving decisions, or as a way of avoiding accountability by being able to blame decision on someone else. While 76 per cent of respondents agreed or agreed very strongly with the statement "I believe other study participants will rely on the index to make decisions simply because it saves time, without necessarily improving their decisions", results from column five of Table 9, where this variable is interacted with the resettlement index indicate that agreement or disagreement with the statement does not preclude use of the index . Only about half of respondents agreed with the statement "I believe other study participants will rely on the index to make decisions because they can then blame poor decisions on flaws in the index". And the interaction of this variable with the resettlement index in column six of Table 9 shows that use of the index does not vary much with the extent of agreement with this statement. In other words, simple convenience or avoiding accountability does not seem to be influential on index use. The final column of Table 9 interacts the resettlement index with a dummy variable capturing whether respondents were able to correctly identify which position the resettlement index had in the choice cards used in the discrete choice experiment. Surprisingly, only 55 per cent of respondents in the treatment group correctly stated that the resettlement index came last among the attributes. In general, this lack of recollection of the order of attributes 4 On a related note, the control group facing a sixth, irrelevant attribute did not express a lower mean opinion of the expertise of the index team in the video than the main control group or the treatment group . This indicates that their lower emphasis on some of the five first attributes is not due to a loss of confidence in the meaningfulness of the discrete choice exercise when an irrelevant dimension is included. is also reflected in responses to other questions we asked about the attribute order. Only 52 per cent of respondents in the treatment group were able to correctly answer what the second attribute on the choice cards was , and only 41 per cent correctly answered that the fifth attribute was floods, droughts, and cyclone events. In general, the attention that respondents had to the order of attributes in the discrete choice experiment does not seem that high. Nevertheless, as seen in the final column of Table 9, results for the resettlement index are driven by those who correctly noted that the resettlement index was the last attribute on the choice card. We therefore cannot entirely rule out some order effect here. Nevertheless, and as stated earlier, it seems unlikely that order alone is driving the effect of the resettlement index, as in that case we should also see an effect of the irrelevant attribute included as the final attribute for the second control group. The attributes used in the discrete choice experiments were all presented in the introductory video, but there could still be a possibility that respondents perceived the resettlement index to be more important to the team of researchers, and the effects of the resettlement index in the treatment group due to experimenter demand effects. To gain some evidence on this, at the end of our survey we asked respondents a set of questions on what they perceived to be the purpose of the experiment. While many respondents were confident that they knew what the purpose of the experiment was, we also asked an open question asking them what they believed the purpose was. The answers were typically very general and did not indicate that respondents believed testing the effect of the resettlement index on migrant allocation decisions was the main purpose of the experiment. 5 It therefore seems unlikely that the effects uncovered are driven by perceived expectations from the team of researchers. --- Heterogeneous effects Using data from Bangladesh, Lujala et al. show that attitudes towards migrants and migration vary with a number of character traits, importantly spatial, attitudinal and social proximity to migrants and their situation. Views on the proper allocation of migrants across resettlement locations are likely to similarly depend on the background of the respondent, on life experiences and formed beliefs and attitudes. General traits like gender and whether you grew up in a rural or urban community comes with different experiences which may influence views on resettlement. Moreover, specific experiences related to migration, such as having migrated yourself or being from an area with substantial in-migration, may give you a different view of what an area needs to be a good destination for migrants. Whether you think a particular attribute is important to settle migrants in a location may also depend on whether that attribute was scarce in the region you come from. In addition, attitudes towards migrants and towards climate change may influence responses, with the possibility that those more critical to either phenomenon take the allocation task in our experiment less seriously. Using survey data on demographic, experiential, and attitudinal variables for our respondents, we explore such heterogeneities in this section. In Table 10 in the Appendix, we consider whether decisions in the discrete choice experiment vary with gender, urban vs rural background, and discipline studied. In column one and two, we interact all the attributes with a dummy variable for being male, for the main control group and the treatment group, respectively. The results in column two show that male respondents place less emphasis on the resettlement index; however, the effect remains significant for both genders. 6 Column one reveals some gender differences in the weight placed on the five attributes for the control group; males place less emphasis on available cropland and more emphasis on hospitals in their resettlement decisions. Columns three and four present corresponding results where the attributes are interacted with a dummy for whether the respondent grew up in an urban area. This does not significantly affect use of the resettlement index, as shown in column four. Urban respondents in the control group place less emphasis on closeness to hospitals and more on poverty in their allocation decisions, as seen in column three. The final two columns of Table 10 interact the attributes with a dummy variable capturing whether the respondent studies economics as opposed to planning studies or other social sciences. The results reveal little variation in responses across this disciplinary divide. Turning to the question of how specific experiences with migration and migrants may shape resettlement decisions, Table 11 offers evidence on this. In the first two columns, the attributes are interacted with a dummy variable capturing whether the household the respondent grew up in migrated from one union to another in the first two decades of the respondent's life. The last two columns interact the attributes with a dummy variable for whether the extent of recent migration to the area where respondent grew up is high. The use of the resettlement index does not vary with either of these two interaction variables . For the control group results, respondents with a history of migration place less emphasis on poverty incidence in their relocation decisions , and respondents from areas with a lot of in-migration put less weight on cropland, poverty and past adverse environmental events. --- 3 In Table 12, we test whether respondents place more emphasis on attributes which were scarce in the location the respondent grew up. To this end, we use data from the main control group, and in columns one through five interact each attribute with dummy variables capturing whether that attribute was scarce where the respondent grew up. The results reveal some patterns contrary to what could be expected; respondents who grew up in regions where cropland was scarce place significantly less weight on this attribute , and those that grew up in locations where past environmental events were frequent place less weight on this attribute in allocating migrants . One interpretation is that experience from such adversities may have tempered views that these attributes are essential for resettling migrants. And as noted, this is consistent with results from the study of potential migrants from climate affected coastal areas of Bangladesh conducted by Wiig et al. , which finds that previous experience of adverse environmental events makes people less inclined to migrate. For the other three attributes, there are no significant differences for respondents who have experienced scarceness in each of them. Finally, in Table 13 in the Appendix, we test whether responses depend on respondent views of migrants, and on climate change. In the first two columns, we interact the attributes with a dummy variable for whether respondents have a favourable view of migrants. This dummy reflects whether the respondent disagrees or disagrees very strongly with the statement "We should help people where they are rather than help them migrate to other locations". The results in column two show that respondents with a more favourable view of migrants place more emphasis on the resettlement index in their decisions, but the impact is also significant in the group with less favourable views. Results for the control group in column one indicate that those with favourable views of migrants place more emphasis on poverty incidence and past adverse environmental events; however, all attributes also have a significant impact on choices in the group with less favourable views. In the final two columns of Table 13, we similarly interact the attributes with a dummy variable reflecting respondent views on climate change. The dummy variable in this case captures disagreement or very strong disagreement with the statement "The problem of climate change is exaggerated in the media". Responses to this underlying question have a two-peaked distribution, suggesting two opposing camps on this question. Results in column four indicate, however, that differences in views on climate change do not lead to different emphasis on the resettlement index. And results in column three suggest that while those who disagree with the statement place more emphasis on cropland and poverty incidence in resettling migrants, the three other attributes influence decisions in the group who agree with the statement in question. The concern, that the experiment will be experienced as less meaningful for respondents who are more critical to migrants and to climate change, is hence not borne out. If this was the case, responses in this group should be mere noise, and the coefficients insignificant. We do not see this in the data, which means that there is little reason to conclude that the more migrant and climate change critical see the task or allocating migrants across two locations as less meaningful. In sum, the results discussed in this section show that the use of the resettlement index does not vary that much with respondent characteristics, the exceptions being that males put somewhat less emphasis on the index, and that those with more favourable views of migration use it more. The views of respondents on how the five individual attributes should be weighted varies with background, however. The most surprising findings in this respect are that respondents who grew up in areas where cropland was scarce and floods, droughts and cyclones frequent, tend to emphasize these attributes less in their migrant allocation decisions. In addition, we see some variation according to gender, urban background, migration experience personally and at the community level, and attitudes towards migration and climate change, but little variation over educational background. --- Conclusion In coming decades, the IPCC projects that climate change will affect the lives and livelihoods of hundreds of millions of people in developing countries. Considerable effort is going into understanding which areas of the world are the most vulnerable to these changes, and where adaptive capacity needs to be strengthened. Mapping vulnerabilities and potential through the creation of aggregate indices is one important way in which this is being done. While much of the analysis of these matters has focused on conceptual and mechanical aspects, attention to the behavioural side is also important. If aggregate information on vulnerabilities and adaptive capacities is not trusted or used by decision makers, their value added is limited. This article has tested the effect of a migrant resettlement index on migrant allocation decisions and found it to hold promise in influencing decisions. Under the conditions studied here, where perceptions of strong underlying expertise and ease of understanding the index have inspired confidence in its efficiency, the development and dissemination of these forms of composite information tools seem productive. This does not mean that technical challenges in compiling composite indices should be downplayed, and the technical and behavioural aspects are in fact tightly linked as it is hard to convince informed decision makers of the usefulness of indices that lack a strong basis. Some limitations to our analyses should be noted. The design of discrete choice experiments has to take into account the cognitive limitations of respondents in processing information, and there are consequently limitations on the number of attributes that can be included. Resettlement decisions can be affected by other attributes than those included here, and it is also possible that effects of some of our attributes reflect a perceived correlation with other underlying factors that our respondents would emphasize. In the way respondents were asked to make a choice between unions, we have nevertheless tried to make other aspects of the decision as equal as possible. Decisions made in discrete choice experiments are also hypothetical and could therefore potentially deviate from real decisions. We have used a sample of graduate students for our experiment, which means we are focusing on the next generation of decision makers. The extent to which current decision makers in the area of social planning would make similar decisions is more of an open question. Their years of experience may lead them to trust their own aggregation of individual indicators over composite indices; on the other hand, the index in question has been developed in communication with experts like them, which could produce greater confidence in the composite index. Of course, actual decisions within a full bureaucratic and political context are going to be different from the hypothetical and relatively constraint-free decisions we have asked our respondents to make. External validity of our results to other countries should also be considered, and the higher education sector in Bangladesh is substantially stronger than in many other developing countries, which could, on the one hand, lead students to get a better grasp of how the index in question is constructed, but, on the one hand, give them more of a background to make decisions based on their own assessment of the individual indicators. Finally, we stress that our analysis has focused on expert views of migrant resettlement, these may differ from the population of a country, whose preferences are also crucial knowledge in resettlement decisions. These challenges should be addressed in further research. --- Appendix Tables 5, 6, 7, 8, 9, 10, 11, 12, and 13; Fig. 4. --- Dependent variables Allocation of migrants Number of migrants allocated to each union in the discrete choice experiment Allocation dummy Dummy variable for union to which the greater number of migrants is allocated Attributes Cropland per capita Dummy for whether union in choice set has more cropland per capita than the average union in Bangladesh Distance to hospital Dummy for whether union in choice set has shorter distance to a hospital than the average union in Bangladesh Distance to school Dummy for whether union in choice set has shorter distance to a school than the average union in Bangladesh Poverty incidence Dummy for whether union in choice set has less poverty than the average union in Bangladesh Flood, drought, and cyclone events Dummy for whether union in choice set has fewer floods, droughts, and cyclone events than the average union in Bangladesh Resettlement index Dummy for whether union in choice set scores better than on the resettlement index than the average union in Bangladesh Number of neighbouring unions Dummy for whether union in choice set borders on more neighbouring unions than the average union in Bangladesh --- Treatment variables --- Control five Dummy variable of whether respondent is assigned to the discrete choice experiment control group with five attributes Treatment Dummy variable of whether respondent is assigned to the discrete choice experiment treatment group where resettlement index is included as an attribute Control six Dummy variable of whether respondent is assigned to the discrete choice experiment control group with a sixth attribute included --- Mechanism variables Belief in index team Respondent agreement with the statement "The expertise of the team behind the index presented in the video seems convincing." Index understanding Respondent agreement with the statement "It was easy to understand how the index that was presented in the video was constructed." Belief additional information Respondent agreement with the statement "The index presented in the video is based on more extensive information on the unions than the individual characteristics on access to land, health, education, poverty and exposure to hazards." Decision-making efficiency Respondent agreement with the statement "Having access to an index like the one presented in the video means that decisions can be made more quickly, while still being good decisions." Decision time saved Respondent agreement with the statement "I believe other study participants will rely on the index to make decisions simply because it saves time, without necessarily improving their decisions." Reduced accountability Respondent agreement with the statement "I believe other study participants will rely on the index to make decisions because they can then blame poor decisions on flaws in the index." Correct index position Dummy variable for whether respondent correctly identified the resettlement index as having been included as the final attribute in the discrete choice experiment Heterogeneous effects variables Male Dummy variable for gender of respondent Urban Dummy variable for whether respondent grew up in an urban area Economics Dummy variable for whether respondent studies economics Migration history Dummy variable for whether the household the respondent grew up in migrated from one union to another in the first two decades of the respondent's life Migration to home region Dummy variable for stated extent of recent migration to area where respondent grew up Results from linear regressions with choice set fixed effects. Robust standard errors in parentheses. For all independent variables, the higher value reflects more favourable socio-economic or environmental conditions. Main term for the interacted variables captured by the fixed effects ***Significance at the 1% level, ** at 5%, * at 10% Results from linear regressions with choice set fixed effects. Robust standard errors in parentheses. For all independent variables, the higher value reflects more favourable socio-economic or environmental conditions. Interaction term in each column as noted at top of table. Main term for the interacted variables captured by the fixed effects ***Significance at the 1% level, ** at 5%, * at 10% Results from linear regressions with choice set fixed effects. Robust standard errors in parentheses. For all independent variables, the higher value reflects more favourable socio-economic or environmental conditions. Main term for the interacted variables captured by the fixed effects. *** indicates significance at the 1% level, ** at 5%, * at 10% Results from linear regressions with choice set fixed effects. Robust standard errors in parentheses. For all independent variables, the higher value reflects more favourable socio-economic or environmental conditions. Interaction term in each column as noted at top of table. Main term for the interacted variables captured by the fixed effects ***Significance at the 1% level, ** at 5%, * at 10% ---

In settings where complex social decisions are made, information is often aggregated into indices to facilitate decision making. The value added of such composite indices depends, inter alia, on the extent to which decision makers trust and make use of them. This paper presents a randomized experiment on the use of an index designed to inform migrant resettlement decisions, using 410 graduate students in Bangladesh as respondents. Respondents were randomly assigned to control and treatment conditions. In the control group, respondents faced a discrete choice experiment where they were asked to allocate 1000 migrants between two locations described by five attributes (availability of cropland, distance to hospital, distance to school, poverty incidence, frequency of floods, droughts and cyclones). In the treatment group, respondents also had access to the migrant resettlement index for the two locations. Results show that the resettlement index is used by the respondents, and mechanism analyses suggest this is due to perceptions of improved benefits to costs from using the index to make decisions. Results from the control group also suggest that past adverse environmental events are particularly important for resettlement decisions, but less so for respondents who grew up in areas where such events were frequent.Migration • Climate change • Resettlement index • Decision making • Bangladesh • Discrete choice experiment * Ivar Kolstad

introduction composite indices receive a lot of attention in debates on international development and sustainability the human development index is a case in point aggregating individual measures of education health and income into a single number which is then used for annual rankings of countries that meet with considerable public interest the advantages of such aggregate indices are avoiding overreliance on individual indicators like gdp per capita and usefulness for simple comparison analysis and advocacy in complex cases composite indices can also aid decision making by simplifying the considerable information that may be available to decision makers who may not have the time or capacity to use it allowing scarce resources to be allocated better importantly in the face of adverse climate change impacts and other environmental changes a number of indices have been developed to assess exposure vulnerability resilience and adaptive capacity of impacted communities these advantages notwithstanding composite indices have been the source of considerable debate in the academic literature much of the discussion has revolved around the mechanics of the composite indices the lack of a clear theoretical framework the blurring of conceptual clarity that comes from mixing individual dimensions together the inclusion or exclusion of relevant individual indicators the aggregation methodincluding the weights for the individual indicators and the tradeoffs this leads torobustness of rankings and more a differentthough not unrelatedquestion related to the usefulness of composite indices is whether they are actually trusted and used by decision makers in other words if a decision maker has access to both an aggregate index and underlying information on individual indicators do they rely on the index or on their own aggregation when making decisions this is the question we focus on in this article we present results from a randomized experiment where we study the effect of having access to a migrant resettlement index on decisions to allocate migrants between host locations within a country the resettlement index whose effect we test was developed by walelign and lujala the index aggregates information on five asset and six condition dimensions central to livelihood reconstruction of migrants in host locations the experiment was conducted in bangladesh using graduate students from disciplines relevant to making these types of decisions as respondents 1 the respondents were randomly assigned to three groups which all faced a discrete choice experiment where the task was to allocate internal migrants between two unnamed host locations in bangladesh but where the information available on the two locations varies by treatment arm in the main control group the two locations are described in terms of five individual indicators availability of cropland distance to hospital distance to school poverty incidence and frequency of floods droughts and cyclones the treatment group received information on the same five individual attributes but also on the composite resettlement index since any difference in behaviour between the main control group and the treatment group could be driven by the number of attributes rather than the nature of the sixth attribute we also included a second control group which received information on the five individual attributes plus an irrelevant attribute from the responses we then elicit the effect of each of the attributes on migrant allocations which allows us to test whether the resettlement index is trusted and used and its relative importance compared to the five individual attributes the results show that the respondents in the treatment group relied on the resettlement index to allocate migrants with estimates showing as great or greater emphasis being placed on the index than the five individual attributes additional analyses into mechanisms suggest that this is due to the perceived improvement in resettlement decisions the index contributes to rather than order or experimenter demand effects the use of the index does not vary with most background characteristics of the respondents though we see somewhat lower reliance on the index from male respondents and more emphasis on the index by respondents who have a more favourable view of migration comparing the weight placed on the five individual attributes in the main control and treatment group we see a slight drop in some of their coefficients in the treatment group but results from the second control group make this finding hard to interpret the irrelevant attribute included in the second control group proved irrelevant as expected however we observe a similar drop in the weight of the other attribute coefficients as for the treatment group which means that we cannot rule out that any movement in the importance of these individual attributes when the index is included could be due to the addition of a sixth attribute rather than the specific addition of the resettlement index our analysis speaks to the issue of how the next generation of decision makers assess information on community capacity to adapt to the effects of climate change in a context of extremely high exposure to environmental degradation more specifically the article makes three main contributions first we add to the understanding of the behavioural side of composite index use essentially documenting a revealed preference among our respondents for having and using aggregate indices in our case it is likely that this is the result of a careful explanation of the index preceding the discrete choice tasks which has instilled the necessary confidence in the index among our participants consistent with this we show that the weight respondents place on the index proves to be increasing in the extent to which they believe the index was compiled by a competent research team the ease with which it was conveyed in a clear and understandable manner and the efficiency with which it can improve allocation decisions the aforementioned finding that the index is emphasized more by those with a favourable view of migration also indicates that respondents more invested in the issue at hand may be more willing to use the index over other information these findings can be used to understand settings in which developing and making composite indices available are more likely to be fruitful from an implementation point of view these insights may also have relevance beyond the specific topic studied here for example in understanding information management in organizations more generally with the increasing digitalization of decisionmaking processes in business and elsewhere including the use of artificial intelligence to distil highdimensional information knowing the conditions under which aggregation leads to impacts on decisionmaking behaviour is important second the discrete choice approach we adopt is particularly informative in allowing us to assess future decision makers perceptions of the relative importance of host community characteristics important for resettlement capacity as opposed to asking survey questions for one characteristic at a time while surveys of experts are common in developing composite indices whose use we test here a discrete choice approach is not typically used to map expert views the advantage to doing so as we show in this paper is to get better information on the relative weights for the individual indicators included in decision making in our control group respondents put a particularly strong emphasis on past adverse environmental events when allocating migrants between locations the impact being significantly stronger than for most of the other attributes our control group results also show that respondent background influences the weight a respondent places on the different attributes and not always in the way one would intuitively expect respondents who grew up in locations with scarcity of cropland or frequent adverse environmental events judged these attributes to be less important for resettlement decisions while surprising these findings nevertheless mirror recent insights from studies of potential migrants suggesting that they may become less inclined to move after having experienced adverse environmental events more generally while independent experts may be more objective than students our results highlight the importance of critically assessing patterns in expert evaluations and implications for the aggregation of their views third our analysis speaks to the more technical literature on discrete choice experiments a number of studies have shown that responses to such experiments are dependent on how they are structured including on the number of attributes included our second control group results clearly suggest that this can be important as the inclusion of an irrelevant attribute significantly changes results for the other attributes compared to the main control group with only five attributes since respondents are randomized into treatments this does not reflect differences in background characteristics in the two control groups for discrete choice experiments in general this suggests that more effort should go into checking robustness of findings to alternative designs and for randomized experiments like the one conducted here it clearly suggests that if a treatment also leads to a change in design as it does in our case a second control group which can be used to assess the effects of such a change is absolutely essential the article is structured as follows section 2 presents the resettlement index used for the experiment the experimental design and the empirical strategy employed summary statistics for our sample are presented in sect 3 section 4 contains our main results with mechanisms discussed in sect 5 and heterogeneous effects in sect 6 section 7 concludes experimental design and empirical strategy the experiment is designed to test the use of the resettlement index developed by walelign et al for bangladesh the index is based on their climate change resettlement capacity framework which focuses on livelihood reconstruction as a key to successful resettlement of climate change impacted people and communities the ccrc framework identifies five asset and six condition subdimensions that capture the availability of different resources to the resettled and factors that constrain or facilitate the use of these resources the framework is designed for the purpose of assisting international organizations governments planners and policymakers in identifying both more and less suitable places to resettle communities displaced due to climate change besides the index for bangladesh the ccrc approach has been used to construct a resettlement capacity index for ethiopia here we test the impact of the resettlement index on decision making using data at the union level from bangladesh the index has been computed based on 100 underlying individual indicators including the five indicators that we use as attributes in our discrete choice experiment the experiment testing the effect of the resettlement index on migrant resettlement decisions was piloted on may 19 2022 using a separate sample of 15 masters students recruited from disaster management studies at dhaka university not included in our main experiment for the main experiment 410 masters students were recruited from dhaka university and the dhaka school of economics the students spanned five academic disciplinesprogrammes development economics environmental and resource economics economicsother subdisciplines planning and disaster management studies and social sciencesother subdisciplines the data collection for the main experiment was conducted from may 24 to june 29 2022 the experiment was implemented in group sessions featuring 1015 respondents at a time overseen by a team of enumerators the respondents were randomized individually into three treatment arms using randomly assigned login codes to the tablets on which the respondents recorded their responses to our questionnaire after entering basic background information respondents were shown a fiveminute video explaining the discrete choice experiment the attributes contained in the experiment including the resettlement index and its construction from underlying data the respondents then moved to the discrete choice experiment explained in further detail below before answering a set of questions designed to study mechanisms and heterogeneous effects in their responses in the discrete choice experiment respondents were asked to allocate 1000 internal climate migrants between two unions a and b 2 the choice sets used in the experiment took the form captured by tables 12 and 3 while the introductory video was identical for all respondents the attributes used to describe the two unions varied between the treatment arms in the control group respondents were shown information on five individual dimensions for the two unions the availability of cropland distance to hospital distance to school poverty incidence and number of past adverse environmental events the attributes were chosen to reflect both the assets and conditions dimensions of the resettlement capacity framework of walelign and lujala and we included attributes which are very basic and intuitive in these dimensions to keep the design from being too demanding for the respondents only two levels were used for each attribute whether the union scored better or worse on each attribute compared to the average union in bangladesh respondents were told that the two unions were located in rural areas and told to consider the two unions as identical in all other aspects than the ones included in the choice sets including the cost of allocating migrants to the two unions the eight choice sets that the control group responded to in succession were chosen through an orthogonal design procedure for the treatment group we added the resettlement index as an attribute also with two levels of being better or worse than average apart from this addition the eight choice sets faced by the treatment group were identical to those of the control group the values of the index for each choice set were chosen as follows from all combinations where the index favoured union a in four choice sets and union b in four choice sets we selected a combination which was orthogonal to the other five attributes while the unions in the experiment were in principle hypothetical their attributes make them all correspond to actual unions in bangladesh a key aim of including the added index attribute is to see whether its presence influences the use of the other five attributes in order to test whether any change was due to the addition of the aggregate resettlement index and not simply an increase in the number of attributes from five to six we also included a second control group in our experiment instead of the resettlement index this second control group included an attribute likely to be irrelevant to respondent decisions of resettling migrants the attribute chosen was the number of neighbouring unions of each union while in principle this attribute could be associated with some other union characteristic that the respondents might consider important for resettlement decisions our pilot data indicated that this attribute did not influence decisions the eight choice sets faced by the second control group were identical to the treatment group with betterworse in the index attribute being replaced by more fewer neighbouring unions on the irrelevant attribute since its likely irrelevance makes the direction of its levels unimportant with two alternatives over eight choice sets and 410 respondents our design generates a total of 410 8 2 6560 observations since our outcome variable is continuous rather than dichotomous we analyse the data using ordinary least squares with fixed effects at the respondentchoice set level where allocation ijt is our dependent variable capturing the allocation of migrants of respondent i in choice set j to alternative t and x ijt is the vector of attribute levels for respondent is choice set j and alternative t and the corresponding vector of coefficients for the attributes the attribute level variables have all been specified as dummy variable which take the value of 1 if assets and conditions are favourable and 0 otherwise since there are no observations for the resettlement capacity index attribute or the number of neighbouring unions attribute in the other treatment arms the full set of attributes and observations cannot be included in the same estimation we first estimate eq separately for each treatment group using the full set of attributes in order to see the influence of the resettlement capacity index on choices and then estimate equation for the full set of observations using only the five shared attributes and including interaction effects between the attributes and dummies for the treatment and second control group in order to study whether the availability of additional dimensions significantly affects the use of the five shared attributes for robustness we also conduct an additional conditional logit analysis using a dummy that equals one for the union with the largest allocation as the dependent variable with observations with equal allocations dropped from the sample our main analysis focuses on testing the following four hypotheses for coefficient h g where h denotes attribute and g treatment group hypothesis 1 the resettlement index affects decisions of treatment group hypothesis 2 including the resettlement index reduces the impact of the other five attributes hypothesis 3 adding an irrelevant attribute does not affect decisions hypothesis 4 adding an irrelevant attribute does not affect the impact of the other five attributes in other words our prior expectation is that the resettlement index should have a significant effect on allocation of migrants between unions and that having access to it means that less weight is placed on other five dimensions school poverty incidence and floods droughts and cyclone events including an irrelevant attribute should neither affect decisions nor the weight placed on the other attributes if hypothesis 2 holds hypothesis 4 is included to test that the lower influence of the other attributes in the treatment group is due to the inclusion of the resettlement index rather than merely an increase in the number of attributes allocation ijt ij x ijt ijt 𝛽 resettlement index treatment 0 descriptive statistics the variables used in our analysis are defined in table 5 in the appendix the dependent variables and attributes are as explained above and together with the treatment variables form the main focus of the paper however we also include a number of survey questions which we use for analysing mechanisms and heterogeneous effects data from 410 respondents who each made eight comparisons of two alternative unions give us a total of 6560 observations the main control group facing five attributes in the discrete choice experiment counts 136 respondents and the other two treatment arms consist of 137 respondents in table 6 in the appendix we present descriptive statistics for our background variables at the individual level 3 we return to the seven variables in the middle rows of the table in sect 5 on mechanisms for the demographic and attitude variables at the bottom of the table we note that the backgrounds of our respondents are quite diverse 61 per cent are male a little over half are from an urban background twothirds study economicsthe rest planning studies or other social sciencesalmost half have a history of migrating in the first two decades of their lives and over 60 per cent views migration to their home region as high in recent years we also measure perceived conditions in the unions from which the respondents originate on each of the five attributes included in the discrete choice experiment more than 60 per cent originate from unions where cropland per capita was scarce compared to the rest of bangladesh 45 and 25 per cent grew up in unions where hospitals and schools were more distant compared to the rest of the country respectively 42 per cent grew up in unions with a high level of poverty compared to the rest of bangladesh and 37 per cent grew up in locations where floods droughts and cyclones were more frequent than in the rest of the country means for the last two variables in table 6 reflect the share that have a positive view of migrants and of the importance of climate change as a phenomenon we use the variables to analyse heterogeneous effects in sect 6 on heterogeneities table 7 shows that there is balance across treatment groups in demographic background and attitudes while the control group facing five attributes has a lower proportion of respondents that study economics compared to the other two groups a larger share of respondents in the control group with an irrelevant sixth attribute included grew up in an area where cropland was scarce than in the other two groups and a higher proportion of respondents in the control group facing six attributes grew up in an area where poverty was common compared to the control groups facing five attributes these differences are no more numerous than expected by chance the final column of table 7 presents the pvalue of an ftest of the null hypothesis that the treatment arms do not predict the means on each balancing variable there is balance on all variables except in studying economics and growing up where cropland is scarce which again is no more than one can expect by chance randomization appears to have worked well in taking out differences in background characteristics between treatment groups main results the main results of the experiment are presented in table 4 the first three columns present results for each treatment arm separately with results for the main control group featuring five attributes in the discrete choice design in column one results for the treatment group who additionally saw the resettlement index in column two and results for the second control group including an additional irrelevant attribute in column three column four presents results using the full sample of observations and including interaction effects between all the attributes and dummies for being in the treatment group or in the second control group with six attributes please note that in all regressions that include interaction terms the main term of the variable the attributes are interacted with is subsumed in the fixed effects the results in column two show that respondents in the treatment group use the resettlement index when choosing to allocate migrants between the two unions the union that scores better on the index is on average allocated an additional 71 migrants according to the point estimate the point estimate is also higher than those of the other five attributes though significantly greater than only cropland per capita distance to school and poverty incidence comparing results from the main control group and the treatment group there are notable drops in the coefficients of three of the attributes when the resettlement index is added cropland per capita poverty incidence and floods droughts and cyclones all see drops of about 20 units however as shown by the interaction effects in column four none of these drops are statistically significant moreover the results for the second control group in columns three and four shed some additional light on the effects of these attributes as expected the attribute presumed to be irrelevant is in fact irrelevant to the resettlement decisions but its inclusion reduces the coefficients of the same three variables as in the treatment group cropland per capita poverty incidence and floods droughts and cyclones and the interaction effects in column four show that these changes are significant this does not affect our main result that the resettlement index is used by the respondents having access to it however it means that any movement we see in the other five attributes may be the result of adding a sixth attribute generally rather than an effect of specifically including the resettlement index the results from the main control group in column one are also informative in how our respondents would perceive the relative importance of the five attributes for migrant allocation decisions when not having access to an aggregate index floods droughts and cyclone events emerge as the relatively most influential one the more favourable location is on average allocated 82 more migrants than the less favourable one the coefficient of this attribute is also statistically greater than those of three of the other attributes cropland per capita distance to school and poverty incidence though not statistically greater than distance to hospital nor are the other coefficients statistically different from each other the pattern that emerges from this is nevertheless that for future decision makers in heavily climate change exposed bangladesh past environmental damage matters for the assessment of which areas are favourable for future settlement decisions and more so than agricultural and economic conditions and certain forms of infrastructure 1 3 in table 8 in the appendix we run conditional logit analyses corresponding to that of table 7 using a dummy variable for the union allocated the largest number of migrants as the dependent variable we do this to demonstrate that our results are robust to more traditional methods of analysing discrete choice experiment data in addition this also constitutes a test of whether our results are driven by respondents making extreme allocation decisions as shown in table 8 where results are presented as odds ratios meaning values higher than one signify more refugees allocated to unions that do better on the attributes in question and values lower than one signify fewer refugees allocated to the more favourable union the results from the conditional logit analysis are qualitatively similar to our main results using linear fixed effects regressions mechanisms judging from its impact on migrant allocation decisions in the discrete choice experiment our respondents appear to view the resettlement index as useful in this section we perform additional analyses to shed some light on whether and why this is the case one set of reasons for using the index could be that our respondents see the index as facilitating better allocation decisions andor allowing such decisions to be made more efficiently compared to considering a larger set of individual attributes another less benign reason for using the index is that it is simply convenient for the decision maker that it saves time without making decisions better or that using the index is a way of avoiding accountability for allocation decisions since the index has been constructed by someone else than the respondent moreover while the lack of significance of the irrelevant sixth attribute in the second control group suggests that the fact that being the last attribute in itself does not mean it is given attention the possibility that the salience of being at the bottom of each choice card can be a reason for the significant effect of the resettlement index should be checked further in addition since the index was introduced in the video preceding the experiment its importance in decision making could also be due to experimenter demand effects in what follows we explore these mechanisms further using information from survey questions on perceptions of the index asked after respondents had completed the choice tasks evidence from our survey questions indicates that our introductory video convinced respondents both of the expertise of the team constructing the resettlement index and provided respondents with a good understanding of its construction when asked whether they agreed with the statement the expertise of the team behind the index presented in the video seems convincing 86 per cent of respondents agreed or agreed very strongly with the statement similarly 78 per cent agreed or agreed very strongly with the statement it was easy to understand how the index that was presented in the video was constructed the benefits of using the index in making migrant allocations thus seem to be clear to the respondents in table 9 in the appendix we present results for the treatment group where we interact the resettlement index with responses to these two questions in columns one and two respectively the results are summarized in the marginsplots in figs 1 and2 the plots essentially convey two things firstly few respondents displayed a low belief in the expertise of the index team or found the index difficult to understand as reflected in the width of the confidence intervals at lower values of these variables secondly the average marginal impact of the resettlement index on resettlement decision increases with agreement with both the expertise and ease of understanding of the index and is significant for the large majorities of respondents who agreed with these aspects suggesting that trust in the expertise behind and the content of the index are important reasons why they have been used 4 in column three of table 9 we explore a further nuance in the potential benefits respondents see from using the index one possibility is that they perceive the weights given to the five other attributes in constructing the index as convincing another is that they believe the index incorporates more information than contained in the five attributes while a majority of respondents agree or agree very strongly with the statement the index presented in the video is based on more extensive information on the unions than the individual characteristics on access to land health education poverty and exposure to hazards interacting the resettlement index with this variable does not indicate that those in greater agreement tended to rely more on the index on the contrary index importance decreases with agreement with this statement making it unlikely that incorporation of additional dimensions is driving views of the benefits of the index the fourth column of table 9 assesses the possibility that respondents believe the index does not only lead to better decisions but also to greater efficiency in decision making twothirds of respondents agreed with the statement having access to an index like the one presented in the video means that decisions can be made more quickly while still being good decisions moreover the marginsplot in fig 3 illustrates results when this variable is interacted with the resettlement index as in column four of table 9 again the width of the confidence intervals at low levels of agreement that the index improves decisionmaking efficiency is due to a smaller number of observations here and the effect of the index on decision making is significant for those who agree that it increases decisionmaking efficiency in combination with the above results this suggests that respondents see the index as both leading to better decisions and also more efficient decision making two further survey questions allow us to address the more problematic possibility that the index is simply seen as a convenient way to simplify decision making without improving decisions or as a way of avoiding accountability by being able to blame decision on someone else while 76 per cent of respondents agreed or agreed very strongly with the statement i believe other study participants will rely on the index to make decisions simply because it saves time without necessarily improving their decisions results from column five of table 9 where this variable is interacted with the resettlement index indicate that agreement or disagreement with the statement does not preclude use of the index only about half of respondents agreed with the statement i believe other study participants will rely on the index to make decisions because they can then blame poor decisions on flaws in the index and the interaction of this variable with the resettlement index in column six of table 9 shows that use of the index does not vary much with the extent of agreement with this statement in other words simple convenience or avoiding accountability does not seem to be influential on index use the final column of table 9 interacts the resettlement index with a dummy variable capturing whether respondents were able to correctly identify which position the resettlement index had in the choice cards used in the discrete choice experiment surprisingly only 55 per cent of respondents in the treatment group correctly stated that the resettlement index came last among the attributes in general this lack of recollection of the order of attributes 4 on a related note the control group facing a sixth irrelevant attribute did not express a lower mean opinion of the expertise of the index team in the video than the main control group or the treatment group this indicates that their lower emphasis on some of the five first attributes is not due to a loss of confidence in the meaningfulness of the discrete choice exercise when an irrelevant dimension is included is also reflected in responses to other questions we asked about the attribute order only 52 per cent of respondents in the treatment group were able to correctly answer what the second attribute on the choice cards was and only 41 per cent correctly answered that the fifth attribute was floods droughts and cyclone events in general the attention that respondents had to the order of attributes in the discrete choice experiment does not seem that high nevertheless as seen in the final column of table 9 results for the resettlement index are driven by those who correctly noted that the resettlement index was the last attribute on the choice card we therefore cannot entirely rule out some order effect here nevertheless and as stated earlier it seems unlikely that order alone is driving the effect of the resettlement index as in that case we should also see an effect of the irrelevant attribute included as the final attribute for the second control group the attributes used in the discrete choice experiments were all presented in the introductory video but there could still be a possibility that respondents perceived the resettlement index to be more important to the team of researchers and the effects of the resettlement index in the treatment group due to experimenter demand effects to gain some evidence on this at the end of our survey we asked respondents a set of questions on what they perceived to be the purpose of the experiment while many respondents were confident that they knew what the purpose of the experiment was we also asked an open question asking them what they believed the purpose was the answers were typically very general and did not indicate that respondents believed testing the effect of the resettlement index on migrant allocation decisions was the main purpose of the experiment 5 it therefore seems unlikely that the effects uncovered are driven by perceived expectations from the team of researchers heterogeneous effects using data from bangladesh lujala et al show that attitudes towards migrants and migration vary with a number of character traits importantly spatial attitudinal and social proximity to migrants and their situation views on the proper allocation of migrants across resettlement locations are likely to similarly depend on the background of the respondent on life experiences and formed beliefs and attitudes general traits like gender and whether you grew up in a rural or urban community comes with different experiences which may influence views on resettlement moreover specific experiences related to migration such as having migrated yourself or being from an area with substantial inmigration may give you a different view of what an area needs to be a good destination for migrants whether you think a particular attribute is important to settle migrants in a location may also depend on whether that attribute was scarce in the region you come from in addition attitudes towards migrants and towards climate change may influence responses with the possibility that those more critical to either phenomenon take the allocation task in our experiment less seriously using survey data on demographic experiential and attitudinal variables for our respondents we explore such heterogeneities in this section in table 10 in the appendix we consider whether decisions in the discrete choice experiment vary with gender urban vs rural background and discipline studied in column one and two we interact all the attributes with a dummy variable for being male for the main control group and the treatment group respectively the results in column two show that male respondents place less emphasis on the resettlement index however the effect remains significant for both genders 6 column one reveals some gender differences in the weight placed on the five attributes for the control group males place less emphasis on available cropland and more emphasis on hospitals in their resettlement decisions columns three and four present corresponding results where the attributes are interacted with a dummy for whether the respondent grew up in an urban area this does not significantly affect use of the resettlement index as shown in column four urban respondents in the control group place less emphasis on closeness to hospitals and more on poverty in their allocation decisions as seen in column three the final two columns of table 10 interact the attributes with a dummy variable capturing whether the respondent studies economics as opposed to planning studies or other social sciences the results reveal little variation in responses across this disciplinary divide turning to the question of how specific experiences with migration and migrants may shape resettlement decisions table 11 offers evidence on this in the first two columns the attributes are interacted with a dummy variable capturing whether the household the respondent grew up in migrated from one union to another in the first two decades of the respondents life the last two columns interact the attributes with a dummy variable for whether the extent of recent migration to the area where respondent grew up is high the use of the resettlement index does not vary with either of these two interaction variables for the control group results respondents with a history of migration place less emphasis on poverty incidence in their relocation decisions and respondents from areas with a lot of inmigration put less weight on cropland poverty and past adverse environmental events 3 in table 12 we test whether respondents place more emphasis on attributes which were scarce in the location the respondent grew up to this end we use data from the main control group and in columns one through five interact each attribute with dummy variables capturing whether that attribute was scarce where the respondent grew up the results reveal some patterns contrary to what could be expected respondents who grew up in regions where cropland was scarce place significantly less weight on this attribute and those that grew up in locations where past environmental events were frequent place less weight on this attribute in allocating migrants one interpretation is that experience from such adversities may have tempered views that these attributes are essential for resettling migrants and as noted this is consistent with results from the study of potential migrants from climate affected coastal areas of bangladesh conducted by wiig et al which finds that previous experience of adverse environmental events makes people less inclined to migrate for the other three attributes there are no significant differences for respondents who have experienced scarceness in each of them finally in table 13 in the appendix we test whether responses depend on respondent views of migrants and on climate change in the first two columns we interact the attributes with a dummy variable for whether respondents have a favourable view of migrants this dummy reflects whether the respondent disagrees or disagrees very strongly with the statement we should help people where they are rather than help them migrate to other locations the results in column two show that respondents with a more favourable view of migrants place more emphasis on the resettlement index in their decisions but the impact is also significant in the group with less favourable views results for the control group in column one indicate that those with favourable views of migrants place more emphasis on poverty incidence and past adverse environmental events however all attributes also have a significant impact on choices in the group with less favourable views in the final two columns of table 13 we similarly interact the attributes with a dummy variable reflecting respondent views on climate change the dummy variable in this case captures disagreement or very strong disagreement with the statement the problem of climate change is exaggerated in the media responses to this underlying question have a twopeaked distribution suggesting two opposing camps on this question results in column four indicate however that differences in views on climate change do not lead to different emphasis on the resettlement index and results in column three suggest that while those who disagree with the statement place more emphasis on cropland and poverty incidence in resettling migrants the three other attributes influence decisions in the group who agree with the statement in question the concern that the experiment will be experienced as less meaningful for respondents who are more critical to migrants and to climate change is hence not borne out if this was the case responses in this group should be mere noise and the coefficients insignificant we do not see this in the data which means that there is little reason to conclude that the more migrant and climate change critical see the task or allocating migrants across two locations as less meaningful in sum the results discussed in this section show that the use of the resettlement index does not vary that much with respondent characteristics the exceptions being that males put somewhat less emphasis on the index and that those with more favourable views of migration use it more the views of respondents on how the five individual attributes should be weighted varies with background however the most surprising findings in this respect are that respondents who grew up in areas where cropland was scarce and floods droughts and cyclones frequent tend to emphasize these attributes less in their migrant allocation decisions in addition we see some variation according to gender urban background migration experience personally and at the community level and attitudes towards migration and climate change but little variation over educational background conclusion in coming decades the ipcc projects that climate change will affect the lives and livelihoods of hundreds of millions of people in developing countries considerable effort is going into understanding which areas of the world are the most vulnerable to these changes and where adaptive capacity needs to be strengthened mapping vulnerabilities and potential through the creation of aggregate indices is one important way in which this is being done while much of the analysis of these matters has focused on conceptual and mechanical aspects attention to the behavioural side is also important if aggregate information on vulnerabilities and adaptive capacities is not trusted or used by decision makers their value added is limited this article has tested the effect of a migrant resettlement index on migrant allocation decisions and found it to hold promise in influencing decisions under the conditions studied here where perceptions of strong underlying expertise and ease of understanding the index have inspired confidence in its efficiency the development and dissemination of these forms of composite information tools seem productive this does not mean that technical challenges in compiling composite indices should be downplayed and the technical and behavioural aspects are in fact tightly linked as it is hard to convince informed decision makers of the usefulness of indices that lack a strong basis some limitations to our analyses should be noted the design of discrete choice experiments has to take into account the cognitive limitations of respondents in processing information and there are consequently limitations on the number of attributes that can be included resettlement decisions can be affected by other attributes than those included here and it is also possible that effects of some of our attributes reflect a perceived correlation with other underlying factors that our respondents would emphasize in the way respondents were asked to make a choice between unions we have nevertheless tried to make other aspects of the decision as equal as possible decisions made in discrete choice experiments are also hypothetical and could therefore potentially deviate from real decisions we have used a sample of graduate students for our experiment which means we are focusing on the next generation of decision makers the extent to which current decision makers in the area of social planning would make similar decisions is more of an open question their years of experience may lead them to trust their own aggregation of individual indicators over composite indices on the other hand the index in question has been developed in communication with experts like them which could produce greater confidence in the composite index of course actual decisions within a full bureaucratic and political context are going to be different from the hypothetical and relatively constraintfree decisions we have asked our respondents to make external validity of our results to other countries should also be considered and the higher education sector in bangladesh is substantially stronger than in many other developing countries which could on the one hand lead students to get a better grasp of how the index in question is constructed but on the one hand give them more of a background to make decisions based on their own assessment of the individual indicators finally we stress that our analysis has focused on expert views of migrant resettlement these may differ from the population of a country whose preferences are also crucial knowledge in resettlement decisions these challenges should be addressed in further research appendix tables 5 6 7 8 9 10 11 12 and 13 fig 4 dependent variables allocation of migrants number of migrants allocated to each union in the discrete choice experiment allocation dummy dummy variable for union to which the greater number of migrants is allocated attributes cropland per capita dummy for whether union in choice set has more cropland per capita than the average union in bangladesh distance to hospital dummy for whether union in choice set has shorter distance to a hospital than the average union in bangladesh distance to school dummy for whether union in choice set has shorter distance to a school than the average union in bangladesh poverty incidence dummy for whether union in choice set has less poverty than the average union in bangladesh flood drought and cyclone events dummy for whether union in choice set has fewer floods droughts and cyclone events than the average union in bangladesh resettlement index dummy for whether union in choice set scores better than on the resettlement index than the average union in bangladesh number of neighbouring unions dummy for whether union in choice set borders on more neighbouring unions than the average union in bangladesh treatment variables control five dummy variable of whether respondent is assigned to the discrete choice experiment control group with five attributes treatment dummy variable of whether respondent is assigned to the discrete choice experiment treatment group where resettlement index is included as an attribute control six dummy variable of whether respondent is assigned to the discrete choice experiment control group with a sixth attribute included mechanism variables belief in index team respondent agreement with the statement the expertise of the team behind the index presented in the video seems convincing index understanding respondent agreement with the statement it was easy to understand how the index that was presented in the video was constructed belief additional information respondent agreement with the statement the index presented in the video is based on more extensive information on the unions than the individual characteristics on access to land health education poverty and exposure to hazards decisionmaking efficiency respondent agreement with the statement having access to an index like the one presented in the video means that decisions can be made more quickly while still being good decisions decision time saved respondent agreement with the statement i believe other study participants will rely on the index to make decisions simply because it saves time without necessarily improving their decisions reduced accountability respondent agreement with the statement i believe other study participants will rely on the index to make decisions because they can then blame poor decisions on flaws in the index correct index position dummy variable for whether respondent correctly identified the resettlement index as having been included as the final attribute in the discrete choice experiment heterogeneous effects variables male dummy variable for gender of respondent urban dummy variable for whether respondent grew up in an urban area economics dummy variable for whether respondent studies economics migration history dummy variable for whether the household the respondent grew up in migrated from one union to another in the first two decades of the respondents life migration to home region dummy variable for stated extent of recent migration to area where respondent grew up results from linear regressions with choice set fixed effects robust standard errors in parentheses for all independent variables the higher value reflects more favourable socioeconomic or environmental conditions main term for the interacted variables captured by the fixed effects significance at the 1 level at 5 at 10 results from linear regressions with choice set fixed effects robust standard errors in parentheses for all independent variables the higher value reflects more favourable socioeconomic or environmental conditions interaction term in each column as noted at top of table main term for the interacted variables captured by the fixed effects significance at the 1 level at 5 at 10 results from linear regressions with choice set fixed effects robust standard errors in parentheses for all independent variables the higher value reflects more favourable socioeconomic or environmental conditions main term for the interacted variables captured by the fixed effects indicates significance at the 1 level at 5 at 10 results from linear regressions with choice set fixed effects robust standard errors in parentheses for all independent variables the higher value reflects more favourable socioeconomic or environmental conditions interaction term in each column as noted at top of table main term for the interacted variables captured by the fixed effects significance at the 1 level at 5 at 10

in settings where complex social decisions are made information is often aggregated into indices to facilitate decision making the value added of such composite indices depends inter alia on the extent to which decision makers trust and make use of them this paper presents a randomized experiment on the use of an index designed to inform migrant resettlement decisions using 410 graduate students in bangladesh as respondents respondents were randomly assigned to control and treatment conditions in the control group respondents faced a discrete choice experiment where they were asked to allocate 1000 migrants between two locations described by five attributes availability of cropland distance to hospital distance to school poverty incidence frequency of floods droughts and cyclones in the treatment group respondents also had access to the migrant resettlement index for the two locations results show that the resettlement index is used by the respondents and mechanism analyses suggest this is due to perceptions of improved benefits to costs from using the index to make decisions results from the control group also suggest that past adverse environmental events are particularly important for resettlement decisions but less so for respondents who grew up in areas where such events were frequentmigration • climate change • resettlement index • decision making • bangladesh • discrete choice experiment ivar kolstad

INTRODUCTION It is estimated that for every 100 women giving birth in the UK, there will be one woman experiencing a near miss: an obstetric complication requiring urgent live-saving medical care. 1 Potentially 8000 women and their families each year have to cope with a life-threatening emergency and its aftermath. The causes of these near misses are varied but include pre-eclampsia, haemorrhage, thrombosis, and sepsis, and may in some cases require an emergency hysterectomy or preterm delivery. Mother and newborn are often separated because women may have to spend time in intensive care or a high-dependency unit. Their babies may be born prematurely and require neonatal intensive care. Recent studies draw attention to the potential for long-term psychological and emotional impact on women of maternal morbidities. [2][3][4][5][6] In addition to their physical recovery, women can experience anxiety, isolation, and flashbacks in the aftermath. Birth trauma can have lasting consequences that impact negatively on maternal, infant, and family wellbeing. 7 Medically-complicated pregnancies can impact negatively on breastfeeding rates. 3,8 Women may be discharged from hospital having had major surgery and emergency treatment or time in intensive care. Some may have lost their baby as a result of their illness. Babies delivered preterm may need to spend long periods in neonatal intensive care. These experiences are a long way away from normal birth and physical and psychological follow-up from hospitals varies around the country. The aim of this study was to explore the long-term impact of a near-miss obstetric emergency. The study examines specifically the primary care support and services women may need after discharge. It was not possible to find any previous work that has directly addressed this issue. The study draws on qualitative interviews with women and their partners who experienced a near-miss event in childbirth in the UK as part of the National Maternal Near-miss Surveillance Programme. --- METHOD Women who experienced a life-threatening complication in pregnancy 9 were invited to take part in an interview study. The women's partners were also invited. --- Sample It was aimed to include a maximum variation sample of women living in the UK, 10,11 covering a wide range of conditions, based on the principal causes of direct maternal deaths identified in recent maternal death enquiry reports . 12 The overall sample included 36 females, and 10 male and one female partner . Recruitment packs were distributed through a number of routes to ensure a wide, varied sample; routes included support groups, the National Childbirth Trust, social network forums , a metropolitan newspaper advertisement, intensive care clinicians contacted through the Intensive Care National Audit and Research Centre, advertisement in the UK Obstetric Surveillance System newsletter, and word of mouth. To try and reach a wider ethnic minority population, recruitment packs were translated into Bengali and distributed through a consultant in an east London hospital. A British Somali interviewee was recruited through a local women's support group. Not all those who volunteered were interviewed, but the authors sought to ensure that a representative range of conditions and times since the event were included, to understand the longer-term effects of a near-miss event. Although the sample included more interviewees from professional classes than others, it does represent a broad socioeconomic diversity. --- Interviews Interviews took place between 2010 and 2014. After obtaining informed consent, one of the authors interviewed participants in the setting of their choice . Participants were asked about their or their partner's experiences of pregnancy and lifethreatening illness. The interview started with an open-ended narrative section where responders described what had happened, followed by a semi-structured section with prompts to explore any relevant issues that had not already emerged, including their recovery and family life since their near miss. The interviews were all audio or videotaped , and transcribed verbatim. --- Analysis The transcripts were read and re-read, a coding frame was constructed and the data coded. Anticipated and emergent themes were then examined across the whole data set as well as in the context of each person's interview. A qualitative interpretive approach was taken, combining thematic analysis with constant comparison. 13,14 NVivo was used to facilitate the analysis. The analysis presented here focuses on how responders described their experiences after discharge from hospital and particularly their needs for primary care support. --- RESULTS The women in the study had spent varying amounts of time in hospital as a consequence of their life-threatening illnesses. In addition to their physical recovery, they described the emotional impact of their emergency and the challenges of settling back to normal life. There was often no follow-up, either physical or psychological, from hospital so GPs were in the front line, caring for and supporting women and their families. --- Isolation Women described the difficulties they faced settling back into their social British Journal of General Practice, September 2015 e564 --- How this fits in? One in 100 women who give birth in the UK develop life-threatening illnesses during childbirth. Without urgent medical attention these illnesses could lead to the mother's death. Research into the long-term impact of these experiences indicates that they have long-lasting effects on women's mental as well as physical health, and impact their families. Support in primary care can play a valuable role in helping these families come to terms with their emergency experience. Other, for example appendicitis or failed intubation 4 --- Table 1. Conditions experienced by participants a Some women had multiple morbidities and appear in more than one category. HELLP = H EL LP . relationships with family, friends, and their local community. They often felt isolated; physically isolated because they were not well enough to get out to see people and unable to link with normal post-delivery support networks that other mothers could access. Emotionally, women often found it hard to relate to others who had no idea of the trauma they had experienced and how long recovery might take. One woman felt that her family and friends quickly forgot what she had been through at time of illness, not at interview): 'As soon as I came out they didn't care. That's when I really needed my friends. That's when I needed people to be there for me.' In particular, women felt isolated from other new mothers because their birth experience had been such a traumatic event, which they did not feel they could share. For first-time mothers this was particularly challenging. They felt excluded from normal support routes such as postnatal groups, or local playgroups: 'I think one of the hardest things was I felt very alienated from my peers at the time ... And it didn't take long before I distanced myself quite quickly. I felt very bitter, very uncomfortable being round people who seemingly had it so easy.' 'Well, I would have silenced the group if I had even mentioned any of it. So the kind of things that they were mentioning that were bothering them, I was just thinking, try dying in childbirth, you know, I felt like I was so out of, out of kilter with their experiences. So the things that were bothering me were so extreme that there wasn't a forum for me to discuss it.' 'It's a really hard thing to describe, but you almost feel excluded by the fact that you've had such a major event that you don't want to always be coming in and saying, "Well, hey, I had the worst scenario".' --- Physical recovery Women's experiences were very varied, due to the wide range and severity of their illnesses and how long they had been hospitalised. Several had undergone major surgery , and 18 had spent some time in high dependency or critical care. Women were often very physically weak, and felt bed or wheelchair-bound, when discharged. Those who had had abdominal surgery were still in pain, which took several weeks to subside: 'Very, very tired. Really, really tired. Tired and sore.' Responder :'I couldn't move. I couldn't straighten myself up. It was an effort to go upstairs to the toilet. I couldn't cook. I couldn't hold the babies. My son was only four and then obviously the middle one now, he was only 11 month old. He wasn't walking. I couldn't pick him up and it was like that for at least a week. I was basically just stuck on the couch.' Interviewer:'Okay and did you recover physically quite quickly?' e565 British Journal of General Practice, September 2015 A common frustration for women was not being able to look after their children: 'I was on a zimmer frame to start off with, to keep my balance and ... and then I had crutches to go home with. [um] And that was a whole new challenge, because it was, it was relief to be around my children, but being around them and not being Mum, not really being Mum. That was hard, you know.' Although most women made a good recovery, it often took weeks or months. Scarring can be a problem for some women who have had life-threatening complications. Both frightening and emotionally upsetting, it could also result in ongoing physical problems. Several women were dismayed as they realised they were going to be less fit for the rest of their lives. One woman developed long-term digestive problems caused by her internal scar tissue: 'It is a very odd thing, you catch yourself thinking, oh now I've become someone who is going to be less well for the rest of my life, and that is a weird feeling.' --- Emotional recovery Finding out what had happened, and coming to terms with the seriousness of their illness, was often emotionally difficult for women. There was great variation in how these traumatic events affected people. Some felt it did not affect their mental health, but others did, and described anxiety, panic attacks, flashbacks, and post-traumatic stress disorder in the aftermath of their experiences. Partners could experience these, as well as the women. Debbie had a uterine rupture and was advised that she needed to seek psychological help: '"Because you've gone through trauma". And she actually said, "If you're in a car crash nobody expects you just to get up on your feet again and carry on as normal, as soon as you're physically healed, you know, there's issues you need to talk about and fears." And she said, "There's no difference here with you. You've gone something very traumatic, and you should speak to somebody about it, if you're not quite ready to move on".' There was variation in when women and men first experienced anxiety, depression, or PTSD, how severe it was, and how long it took to recover. Lisa, 35, was interviewed a year after her daughter was born. She described a very difficult year as she experienced anxiety and panic attacks. But felt she was getting over it and starting to feel a lot better: 'I want to move on now'. Cara, 29, said she was 'very depressed and manic about my research into what had happened', in the first year, but each year got easier. But for some, their child's first birthday, marking the anniversary of their trauma, stirred emotions: 'It was actually a year after that I felt that I needed more help. [um] But I think that it just brought feelings out that I'd, I'd just bottled them up. I'd kind of packaged them away and said, that dealt with, and I hadn't worked through my feelings, I'd just pushed them to one side and said, I don't, that's fine, that's okay. [um] Put a smiley face on and got on with it. [laughs] [um] And it worked short term, but then it came back to bite me when I was least expecting it as well actually and so I struggled quite a lot around his birthday.' Some were offered counselling through the hospital, GP, or health visitor. Some sought counselling themselves. While some did not find it very helpful, many did. Others wanted counselling but were not offered any. There was great variation in when the women felt ready to talk: some quite soon, others not for a few months or even over a year. --- Long-lasting effects While some women seemed resilient and their emergency experience did not appear to have long-lasting effects on them or their families, others were more affected. Future pregnancy or fertility. Lifethreatening emergencies could have a profound impact on a woman's fertility and future pregnancies. Some women had hysterectomies to save their lives. While some did not feel this was a big issue if their families were complete, for others this was devastating. Several women need help weighing up the risks of another pregnancy, either with their GP or a consultant. Some women were still potentially able to get pregnant, but were advised against it by doctors because the risks were too high. Helen had HELLP syndrome with her first baby : 'But the thing that worries me now, is that if we want to have another child, [um] they've said that the risk of it happening again is 20-30% which is much higher than what I'd like. And that's the thing that concerns me more now, that I know what it was and what we went through.' Other family members. In terms of their relationships, many felt their experiences had made them stronger and brought them closer. For others, staying together after such a traumatic event was challenging, and some relationships did not survive the experience. In terms of the wider family, there was a range of views. Some felt their emergency had had a profound effect on their children, while others felt it had little impact or even improved their relationships with them. --- Support Women's experience of support varied. Some felt that the support from their local GP and health visitors was excellent, while others would have liked more support after such a traumatic time in hospital. Examples of good care. Several women felt they had very good care and support after discharge. Women appreciated GPs who were in touch and reassuring, and midwives and health visitors who were aware of what they had been through and visited regularly. Knowing that support was available from their GP made a real difference to women: 'She's been in constant contact with us. If I do need to have a chat and things I can go and speak to her … I trust her 101%. She's just there, they're just available.' Kerry had panic attacks and anxiety after her haemorrhage. Her GP was very patient, offering support and referral to counselling: 'He was really patient, because I did keep going back. I thought I had illness after illness. The words that he used did calm me down a lot ... Because I was so frightened that I was going to die after that. I always thought I had something life threatening.' Hanna had been in hospital for several weeks with pre-eclampsia and a haematoma. When discharged, she was frightened and told to contact her GP who was reassuring and helpful, checking her bloods: ' [S/He] called me at home to say, "Everything is fine. Don't worry ... it'll be fine." So for 2 weeks I was in contact with my GP and they really, really took care of me.' Lack of support. However, several women were surprised there was no communication between the hospital and GP, who seemed to have no idea what had happened. Some women felt there was very little support for them after discharge from hospital. Rob's wife had placenta praevia and a hysterectomy. He went on to develop PTSD himself. Rob felt their GP was 'worse than useless' and as a family they were left with little support. Lack of support may affect how women and their families recover. Sophie and Tom struggled after she had a pulmonary embolism and haemorrhage. They were told there was no help available for her after she was discharged and at home looking after her newborn and toddler: 'And I couldn't understand that, because I was still at risk. I still had a pulmonary embolism. And I said, "Well what happens if I'm on my own with the girls and I have a heart attack? Is there anything that we can do to reduce the impact on them if that were to happen?" And they just came up with nothing really.' Some women described putting on a brave face and this may have contributed to them not getting the support that they needed. Joanna said her GP was very supportive but she often put on a front when seeing him, so perhaps he was not aware how much the death of her baby had affected her. Ciara and Michelle were asked to complete the Edinburgh Postnatal Depression Scale with their health visitor, but said it was easy to know what the right answers were so as to appear as if they were fine. --- DISCUSSION --- Summary This study demonstrates the profound long-term impact a near miss in childbirth can have on new mothers. Their physical recovery could take a long time, and women were often not able to look after their babies as they wished in the early days. Emotional recovery was often difficult, with some women reporting anxiety, panic attacks, flashbacks, and PTSD. Long-lasting effects after discharge from hospital included fears about future fertility and pregnancies, social isolation, and lack of support. Other family members were also potentially affected. Several women received very good care and support after discharge, demonstrated by GPs being in touch and reassuring, and midwives and health visitors being aware of what had happened and visiting regularly. There is already some follow-up in place in the NHS; currently after discharge most women are visited by a midwife and then a health visitor who usually carry out a postnatal depression screen. However, this study highlights the importance of communication between primary and secondary care, and demonstrates that knowing proactive support was available from their GP team made a real difference to women. --- Strengths and limitations There are limitations to this study. The data presented are based on interviews with 36 women and 11 partners, and as with qualitative studies aiming for a maximum variation sample, the findings are not intended to be numerically representative. However, the sample was large enough to reach data saturation and included good variation in socioeconomic mix. Participants were mostly of white British origin and despite inclusion of women from Pakistani and Somali backgrounds, the ethnic diversity in the sample is not as wide as it might be. While no account is static -people's views and interpretation of their experiences are likely to change over time -an effort was made to interview individuals who were both close to events as well as those who were talking about experiences that had happened several years previously. --- Comparison with existing literature There are relatively few studies worldwide that have reported on the impact of lifethreatening conditions in childbirth. The current study's findings resonate with others reporting emotional trauma and long-lasting effects. 2,[4][5][6]15 While there is agreement that traumatic events can have significant impact on individuals', families', and communities' abilities to cope, the most effective ways of providing psychological help are not clear. 16 The literature surrounding PTSD after childbirth is sparse and the authors are not aware of any research on how to support women and their families after a near miss. While studies have highlighted the potential long-term impact of a traumatic birth, 7 there is little conclusive evidence on the best way to support women and their families. While several studies have suggested the importance of social support and community resources in supporting women after a birth trauma, 17 the women who have experienced a near miss often appear to be unable to access standard support due to feeling their experiences are so extreme or different to the norm. In addition, systematic reviews have shown that evidence for midwiferybased counselling or formal postnatal debriefing interventions to effectively address mental health problems is inconclusive. [18][19][20] However, Rowan et al 19 suggested offering women the opportunity to talk and the importance of health professionals being alert to the signs and symptoms of mental health problems after childbirth. --- Implications for research and practice There has been little research on the longterm impact of traumatic birth and how best to help women. There is inconclusive evidence on the impact of debriefing programmes. However, we know that those most likely to be well after childbirth are women who had no complications, no worries about their labour and birth, and are given information about their choices for care. 21 Women who experience a near miss have had none of these. For them, there is often no follow-up from hospital obstetric or midwifery staff. Primary care teams should be made routinely aware if a woman has had a near miss so that they can offer the support these women may need, and be aware that these new mothers may be isolated from their peers and therefore potential support networks. GPs and health visitors should be alert for mental health problems developing, mindful of the impact that the near-miss experience can have on the whole family , and be prepared to offer advice about future pregnancies. --- maternal death: improving the quality of maternity care through national studies of near miss maternal morbidity' programme . The views expressed in this publication are those of the author and not necessarily those of the NHS, the NIHR, or the Department of Health. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. --- Ethical approval Ethics committee approval was given for this study by the Berkshire Ethics Committee, 09/H0505/66. All participants gave informed consent before taking part and have given written consent to their interview data being included in publications. --- Provenance Freely submitted; externally peer reviewed. --- Competing interests The authors have declared no competing interests. --- Open access This article is Open Access: CC BY 3.0 license .

One in 100 women who give birth in the UK develop life-threatening illnesses during childbirth. Without urgent medical attention these illnesses could lead to the mother's death. Little is known about how the experience of severe illness in childbirth affects the mother, baby, and family.As part of the UK National Maternal Near-miss Surveillance Programme, this study explored the experiences of women and their partners of lifethreatening illnesses in childbirth, to identify the long-term impact on women and their families.Qualitative study based on semi-structured narrative interviews. Interviews were conducted in patients' homes in England and Scotland from 2010 to 2014.An in-depth interview study was conducted with 36 women and 11 partners. A maximum variation sample was sought and interviews transcribed for thematic analysis with constant comparison.Women's birth-related illnesses often had longlasting effects on their mental as well as physical health, including anxiety, panic attacks, and post-traumatic stress disorder. In some cases the partner's mental health was also affected. Women often described feeling isolated. Their experiences can have a profound impact on their relationships, family life, career, and future fertility. While some women described receiving good support from their GP, others felt there was little support available for them or their families after discharge from hospital.A near-miss event can have long-lasting and major effects on women and their families. Support in primary care, including watchful waiting for mental health impacts, can play a valuable role in helping these families come to terms with their emergency experience. The findings highlight the importance of communication between primary and secondary care.

introduction it is estimated that for every 100 women giving birth in the uk there will be one woman experiencing a near miss an obstetric complication requiring urgent livesaving medical care 1 potentially 8000 women and their families each year have to cope with a lifethreatening emergency and its aftermath the causes of these near misses are varied but include preeclampsia haemorrhage thrombosis and sepsis and may in some cases require an emergency hysterectomy or preterm delivery mother and newborn are often separated because women may have to spend time in intensive care or a highdependency unit their babies may be born prematurely and require neonatal intensive care recent studies draw attention to the potential for longterm psychological and emotional impact on women of maternal morbidities 2 3 4 5 6 in addition to their physical recovery women can experience anxiety isolation and flashbacks in the aftermath birth trauma can have lasting consequences that impact negatively on maternal infant and family wellbeing 7 medicallycomplicated pregnancies can impact negatively on breastfeeding rates 38 women may be discharged from hospital having had major surgery and emergency treatment or time in intensive care some may have lost their baby as a result of their illness babies delivered preterm may need to spend long periods in neonatal intensive care these experiences are a long way away from normal birth and physical and psychological followup from hospitals varies around the country the aim of this study was to explore the longterm impact of a nearmiss obstetric emergency the study examines specifically the primary care support and services women may need after discharge it was not possible to find any previous work that has directly addressed this issue the study draws on qualitative interviews with women and their partners who experienced a nearmiss event in childbirth in the uk as part of the national maternal nearmiss surveillance programme method women who experienced a lifethreatening complication in pregnancy 9 were invited to take part in an interview study the womens partners were also invited sample it was aimed to include a maximum variation sample of women living in the uk 1011 covering a wide range of conditions based on the principal causes of direct maternal deaths identified in recent maternal death enquiry reports 12 the overall sample included 36 females and 10 male and one female partner recruitment packs were distributed through a number of routes to ensure a wide varied sample routes included support groups the national childbirth trust social network forums a metropolitan newspaper advertisement intensive care clinicians contacted through the intensive care national audit and research centre advertisement in the uk obstetric surveillance system newsletter and word of mouth to try and reach a wider ethnic minority population recruitment packs were translated into bengali and distributed through a consultant in an east london hospital a british somali interviewee was recruited through a local womens support group not all those who volunteered were interviewed but the authors sought to ensure that a representative range of conditions and times since the event were included to understand the longerterm effects of a nearmiss event although the sample included more interviewees from professional classes than others it does represent a broad socioeconomic diversity interviews interviews took place between 2010 and 2014 after obtaining informed consent one of the authors interviewed participants in the setting of their choice participants were asked about their or their partners experiences of pregnancy and lifethreatening illness the interview started with an openended narrative section where responders described what had happened followed by a semistructured section with prompts to explore any relevant issues that had not already emerged including their recovery and family life since their near miss the interviews were all audio or videotaped and transcribed verbatim analysis the transcripts were read and reread a coding frame was constructed and the data coded anticipated and emergent themes were then examined across the whole data set as well as in the context of each persons interview a qualitative interpretive approach was taken combining thematic analysis with constant comparison 1314 nvivo was used to facilitate the analysis the analysis presented here focuses on how responders described their experiences after discharge from hospital and particularly their needs for primary care support results the women in the study had spent varying amounts of time in hospital as a consequence of their lifethreatening illnesses in addition to their physical recovery they described the emotional impact of their emergency and the challenges of settling back to normal life there was often no followup either physical or psychological from hospital so gps were in the front line caring for and supporting women and their families isolation women described the difficulties they faced settling back into their social british journal of general practice september 2015 e564 how this fits in one in 100 women who give birth in the uk develop lifethreatening illnesses during childbirth without urgent medical attention these illnesses could lead to the mothers death research into the longterm impact of these experiences indicates that they have longlasting effects on womens mental as well as physical health and impact their families support in primary care can play a valuable role in helping these families come to terms with their emergency experience other for example appendicitis or failed intubation 4 table 1 conditions experienced by participants a some women had multiple morbidities and appear in more than one category hellp h el lp relationships with family friends and their local community they often felt isolated physically isolated because they were not well enough to get out to see people and unable to link with normal postdelivery support networks that other mothers could access emotionally women often found it hard to relate to others who had no idea of the trauma they had experienced and how long recovery might take one woman felt that her family and friends quickly forgot what she had been through at time of illness not at interview as soon as i came out they didnt care thats when i really needed my friends thats when i needed people to be there for me in particular women felt isolated from other new mothers because their birth experience had been such a traumatic event which they did not feel they could share for firsttime mothers this was particularly challenging they felt excluded from normal support routes such as postnatal groups or local playgroups i think one of the hardest things was i felt very alienated from my peers at the time and it didnt take long before i distanced myself quite quickly i felt very bitter very uncomfortable being round people who seemingly had it so easy well i would have silenced the group if i had even mentioned any of it so the kind of things that they were mentioning that were bothering them i was just thinking try dying in childbirth you know i felt like i was so out of out of kilter with their experiences so the things that were bothering me were so extreme that there wasnt a forum for me to discuss it its a really hard thing to describe but you almost feel excluded by the fact that youve had such a major event that you dont want to always be coming in and saying well hey i had the worst scenario physical recovery womens experiences were very varied due to the wide range and severity of their illnesses and how long they had been hospitalised several had undergone major surgery and 18 had spent some time in high dependency or critical care women were often very physically weak and felt bed or wheelchairbound when discharged those who had had abdominal surgery were still in pain which took several weeks to subside very very tired really really tired tired and sore responder i couldnt move i couldnt straighten myself up it was an effort to go upstairs to the toilet i couldnt cook i couldnt hold the babies my son was only four and then obviously the middle one now he was only 11 month old he wasnt walking i couldnt pick him up and it was like that for at least a week i was basically just stuck on the couch interviewerokay and did you recover physically quite quickly e565 british journal of general practice september 2015 a common frustration for women was not being able to look after their children i was on a zimmer frame to start off with to keep my balance and and then i had crutches to go home with um and that was a whole new challenge because it was it was relief to be around my children but being around them and not being mum not really being mum that was hard you know although most women made a good recovery it often took weeks or months scarring can be a problem for some women who have had lifethreatening complications both frightening and emotionally upsetting it could also result in ongoing physical problems several women were dismayed as they realised they were going to be less fit for the rest of their lives one woman developed longterm digestive problems caused by her internal scar tissue it is a very odd thing you catch yourself thinking oh now ive become someone who is going to be less well for the rest of my life and that is a weird feeling emotional recovery finding out what had happened and coming to terms with the seriousness of their illness was often emotionally difficult for women there was great variation in how these traumatic events affected people some felt it did not affect their mental health but others did and described anxiety panic attacks flashbacks and posttraumatic stress disorder in the aftermath of their experiences partners could experience these as well as the women debbie had a uterine rupture and was advised that she needed to seek psychological help because youve gone through trauma and she actually said if youre in a car crash nobody expects you just to get up on your feet again and carry on as normal as soon as youre physically healed you know theres issues you need to talk about and fears and she said theres no difference here with you youve gone something very traumatic and you should speak to somebody about it if youre not quite ready to move on there was variation in when women and men first experienced anxiety depression or ptsd how severe it was and how long it took to recover lisa 35 was interviewed a year after her daughter was born she described a very difficult year as she experienced anxiety and panic attacks but felt she was getting over it and starting to feel a lot better i want to move on now cara 29 said she was very depressed and manic about my research into what had happened in the first year but each year got easier but for some their childs first birthday marking the anniversary of their trauma stirred emotions it was actually a year after that i felt that i needed more help um but i think that it just brought feelings out that id id just bottled them up id kind of packaged them away and said that dealt with and i hadnt worked through my feelings id just pushed them to one side and said i dont thats fine thats okay um put a smiley face on and got on with it laughs um and it worked short term but then it came back to bite me when i was least expecting it as well actually and so i struggled quite a lot around his birthday some were offered counselling through the hospital gp or health visitor some sought counselling themselves while some did not find it very helpful many did others wanted counselling but were not offered any there was great variation in when the women felt ready to talk some quite soon others not for a few months or even over a year longlasting effects while some women seemed resilient and their emergency experience did not appear to have longlasting effects on them or their families others were more affected future pregnancy or fertility lifethreatening emergencies could have a profound impact on a womans fertility and future pregnancies some women had hysterectomies to save their lives while some did not feel this was a big issue if their families were complete for others this was devastating several women need help weighing up the risks of another pregnancy either with their gp or a consultant some women were still potentially able to get pregnant but were advised against it by doctors because the risks were too high helen had hellp syndrome with her first baby but the thing that worries me now is that if we want to have another child um theyve said that the risk of it happening again is 2030 which is much higher than what id like and thats the thing that concerns me more now that i know what it was and what we went through other family members in terms of their relationships many felt their experiences had made them stronger and brought them closer for others staying together after such a traumatic event was challenging and some relationships did not survive the experience in terms of the wider family there was a range of views some felt their emergency had had a profound effect on their children while others felt it had little impact or even improved their relationships with them support womens experience of support varied some felt that the support from their local gp and health visitors was excellent while others would have liked more support after such a traumatic time in hospital examples of good care several women felt they had very good care and support after discharge women appreciated gps who were in touch and reassuring and midwives and health visitors who were aware of what they had been through and visited regularly knowing that support was available from their gp made a real difference to women shes been in constant contact with us if i do need to have a chat and things i can go and speak to her … i trust her 101 shes just there theyre just available kerry had panic attacks and anxiety after her haemorrhage her gp was very patient offering support and referral to counselling he was really patient because i did keep going back i thought i had illness after illness the words that he used did calm me down a lot because i was so frightened that i was going to die after that i always thought i had something life threatening hanna had been in hospital for several weeks with preeclampsia and a haematoma when discharged she was frightened and told to contact her gp who was reassuring and helpful checking her bloods she called me at home to say everything is fine dont worry itll be fine so for 2 weeks i was in contact with my gp and they really really took care of me lack of support however several women were surprised there was no communication between the hospital and gp who seemed to have no idea what had happened some women felt there was very little support for them after discharge from hospital robs wife had placenta praevia and a hysterectomy he went on to develop ptsd himself rob felt their gp was worse than useless and as a family they were left with little support lack of support may affect how women and their families recover sophie and tom struggled after she had a pulmonary embolism and haemorrhage they were told there was no help available for her after she was discharged and at home looking after her newborn and toddler and i couldnt understand that because i was still at risk i still had a pulmonary embolism and i said well what happens if im on my own with the girls and i have a heart attack is there anything that we can do to reduce the impact on them if that were to happen and they just came up with nothing really some women described putting on a brave face and this may have contributed to them not getting the support that they needed joanna said her gp was very supportive but she often put on a front when seeing him so perhaps he was not aware how much the death of her baby had affected her ciara and michelle were asked to complete the edinburgh postnatal depression scale with their health visitor but said it was easy to know what the right answers were so as to appear as if they were fine discussion summary this study demonstrates the profound longterm impact a near miss in childbirth can have on new mothers their physical recovery could take a long time and women were often not able to look after their babies as they wished in the early days emotional recovery was often difficult with some women reporting anxiety panic attacks flashbacks and ptsd longlasting effects after discharge from hospital included fears about future fertility and pregnancies social isolation and lack of support other family members were also potentially affected several women received very good care and support after discharge demonstrated by gps being in touch and reassuring and midwives and health visitors being aware of what had happened and visiting regularly there is already some followup in place in the nhs currently after discharge most women are visited by a midwife and then a health visitor who usually carry out a postnatal depression screen however this study highlights the importance of communication between primary and secondary care and demonstrates that knowing proactive support was available from their gp team made a real difference to women strengths and limitations there are limitations to this study the data presented are based on interviews with 36 women and 11 partners and as with qualitative studies aiming for a maximum variation sample the findings are not intended to be numerically representative however the sample was large enough to reach data saturation and included good variation in socioeconomic mix participants were mostly of white british origin and despite inclusion of women from pakistani and somali backgrounds the ethnic diversity in the sample is not as wide as it might be while no account is static peoples views and interpretation of their experiences are likely to change over time an effort was made to interview individuals who were both close to events as well as those who were talking about experiences that had happened several years previously comparison with existing literature there are relatively few studies worldwide that have reported on the impact of lifethreatening conditions in childbirth the current studys findings resonate with others reporting emotional trauma and longlasting effects 2 4 5 6 15 while there is agreement that traumatic events can have significant impact on individuals families and communities abilities to cope the most effective ways of providing psychological help are not clear 16 the literature surrounding ptsd after childbirth is sparse and the authors are not aware of any research on how to support women and their families after a near miss while studies have highlighted the potential longterm impact of a traumatic birth 7 there is little conclusive evidence on the best way to support women and their families while several studies have suggested the importance of social support and community resources in supporting women after a birth trauma 17 the women who have experienced a near miss often appear to be unable to access standard support due to feeling their experiences are so extreme or different to the norm in addition systematic reviews have shown that evidence for midwiferybased counselling or formal postnatal debriefing interventions to effectively address mental health problems is inconclusive 18 19 20 however rowan et al 19 suggested offering women the opportunity to talk and the importance of health professionals being alert to the signs and symptoms of mental health problems after childbirth implications for research and practice there has been little research on the longterm impact of traumatic birth and how best to help women there is inconclusive evidence on the impact of debriefing programmes however we know that those most likely to be well after childbirth are women who had no complications no worries about their labour and birth and are given information about their choices for care 21 women who experience a near miss have had none of these for them there is often no followup from hospital obstetric or midwifery staff primary care teams should be made routinely aware if a woman has had a near miss so that they can offer the support these women may need and be aware that these new mothers may be isolated from their peers and therefore potential support networks gps and health visitors should be alert for mental health problems developing mindful of the impact that the nearmiss experience can have on the whole family and be prepared to offer advice about future pregnancies maternal death improving the quality of maternity care through national studies of near miss maternal morbidity programme the views expressed in this publication are those of the author and not necessarily those of the nhs the nihr or the department of health the funders had no role in the study design data collection and analysis decision to publish or preparation of the manuscript ethical approval ethics committee approval was given for this study by the berkshire ethics committee 09h050566 all participants gave informed consent before taking part and have given written consent to their interview data being included in publications provenance freely submitted externally peer reviewed competing interests the authors have declared no competing interests open access this article is open access cc by 30 license

one in 100 women who give birth in the uk develop lifethreatening illnesses during childbirth without urgent medical attention these illnesses could lead to the mothers death little is known about how the experience of severe illness in childbirth affects the mother baby and familyas part of the uk national maternal nearmiss surveillance programme this study explored the experiences of women and their partners of lifethreatening illnesses in childbirth to identify the longterm impact on women and their familiesqualitative study based on semistructured narrative interviews interviews were conducted in patients homes in england and scotland from 2010 to 2014an indepth interview study was conducted with 36 women and 11 partners a maximum variation sample was sought and interviews transcribed for thematic analysis with constant comparisonwomens birthrelated illnesses often had longlasting effects on their mental as well as physical health including anxiety panic attacks and posttraumatic stress disorder in some cases the partners mental health was also affected women often described feeling isolated their experiences can have a profound impact on their relationships family life career and future fertility while some women described receiving good support from their gp others felt there was little support available for them or their families after discharge from hospitala nearmiss event can have longlasting and major effects on women and their families support in primary care including watchful waiting for mental health impacts can play a valuable role in helping these families come to terms with their emergency experience the findings highlight the importance of communication between primary and secondary care

Introduction Over the past ten years, the impact of technology on adolescents has been a growing concern among parents, educators, and researchers . Yet as COVID-19 shutdowns moved schools from in-person instruction to online learning platforms, thousands of elementary and secondary students were suddenly required to use technology for activities that had previously been conducted face-to-face. Schoolwork, extracurricular activities, and even connections with friends all moved online and, for many students, time spent on technology increased dramatically. At the same time, stay-at-home mandates brought both physical isolation from peers and concerns about an uncertain future, setting the stage for increased fear, anxiety, depression, and other mental health concerns. The move to online schooling during the COVID-19 pandemic has emphasized the critical need to understand student needs, perspectives, and well-being when designing online education . This study investigates adolescent well-being, perspectives of online education, and social needs during the COVID-19 pandemic. --- Literature review --- Impacts of COVID-19 upon adolescents Although the physical health impacts of COVID-19 upon adolescents have generally been mild , this age group is still subject to social distancing, "stay at home" orders, closure of face-to-face schools, and other measures taken to protect the health of individuals. Government mandates are important for maintaining physical health, but they have also disrupted a sense of normalcy, and have led to feelings of isolation, fear, and anxiety for individuals of all ages. Adolescents, who are developing a sense of autonomy and often depend on their social connections to build an understanding of themselves , may experience more intense reactions to this stress. Technology overload, particularly in children and adolescents, has been a concern as both isolation from peers and the move to online schooling have increased reliance on technology during the pandemic . Online education may provide few opportunities for social and emotional development, creating gaps that can lead adolescents to withdraw and increase their time online . While the ability to interact socially has been viewed as a critical component of online learning, achieving social presence is often a challenge in virtual environments . Educators may need to support the development of both social and academic skills by leveraging media and other technological resources that are not typically incorporated into face-toface school settings . An understanding of adolescent needs in online learning experiences is essential for addressing socioemotional gaps, aiding recovery from pandemic-related stress, and encouraging positive well-being . Positive well-being has been linked with motivation and learning , and an educational environment that supports positive well-being has been shown to boost adolescent learning and development . --- Adolescent development and technology use Adolescence, the transition from childhood into adulthood, is often a time of inner turbulence. The brain's organizational schema is restructuring, and the frontal cortex gradually takes a stronger role in self-control . As the brain develops, physical, emotional, and social changes may create an instability in adolescent behavior . Inner conflict builds as a continued sense of attachment and a developing need for autonomy cause adolescents to simultaneously pull away from and cling to their caregivers . As adolescents move increasingly towards autonomy, the desire to establish an understanding of personal beliefs and an awareness of personal identity becomes a priority . The need for social acceptance intensifies as adolescents try to identify with and build status among peers . Peers become a primary source of social and emotional support, and the feedback others provide must be balanced with self-perceptions . Adolescents may view technology as a path for meeting these needs. In smartphones, they often find autonomy, self-identity, social connections, and prestige . However, smartphone usage has been shown to interfere with social interactions in face-to-face classrooms , and may be even more concerning in online classrooms because of limited teacher oversight. High levels of technology usage have also been associated with mental health issues, withdrawal, and weaker social skills . For adolescents, social relationships appear to be central to positive affect and well-being . --- Well-being Subjective well-being is considered to have both a cognitive and an affective component . The cognitive aspect focuses primarily on life satisfaction, self-esteem, and, in some studies, optimism , whereas the affective component focuses on transitory experiences that work together to build an individual's interpretation of emotion . Life satisfaction considers the degree to which personal desires and goals are met, often within specific life domains . Life satisfaction is viewed as an internal characteristic that remains relatively consistent for an individual throughout situational changes and across the lifespan . Life satisfaction may reflect a collective view of a person's affect , because attitude and internal approach to life appear to influence one's life satisfaction more than external circumstances such as wealth or friends . Self-esteem is also known as self-confidence . Self-esteem is not related to specific life situations, but takes a more global approach, considering questions such as "At times, I think I am no good at all" and "I am able to do things as well as most other people." . Self-esteem may be a composite of everyday assessments of self-worth . This creates a fairly consistent selfesteem rating that is not influenced by changing emotions or life circumstances . Diener and Diener suggest that most individuals maintain a positive life perspective, which both supports the ability to recover from difficult situations and strengthens social and emotional health. Optimism, or positive thinking, is associated with motivation, goal achievement, and emotions . Some researchers consider optimism to be a confounding factor in subjective well-being, since common items on optimism scales are similar to those found on measures of self-esteem: "I hardly ever expect things to go my way" and "I'm optimistic about my future." The affective component of subjective well-being examines positive affect and negative affect . Positive affect and negative affect are considered independent attributes; an increase in one does not necessarily mean a decrease in the other , Instead, positive affect is often expressed in enthusiasm and energy; negative affect may be shown through sadness, loneliness, or guilt . Positive affect at school has been linked with motivation, academic success, and positive well-being . In contrast, uncertainty and inconsistency may create or intensify negative affect . Affect is considered a major indicator of well-being . The impact of COVID-19 shutdowns upon adolescent well-being has been a global concern . In a study of 1,143 parents in Italy and Spain, pandemic-related quarantines and isolation from peers were seen to exert a negative influence on children and adolescents . In addition to distractibility, boredom, loneliness, and worry, parents reported that their children increased their time on technology, slept more, and spent less time in physical activity. The study concluded that mental and social well-being must be priorities in both physical and online schools. However, identification of strategies that can effectively address adolescent well-being in online learning and social experiences will require insights into adolescent perspectives, attitudes, and feelings . This study investigates effects of the COVID-19 pandemic upon adolescent well-being, learning, and social needs. Questions include: • To what extent does adolescent well-being during the pandemic differ from prepandemic well-being? • What factors do adolescents view as influences upon their learning during the imposed shift to online schooling? • What social changes and concerns do adolescents report during the pandemic? --- Methods --- --- Data collection For initial data collection before COVID-19 shutdowns, data was collected onsite at the museum. Participants completed paper surveys related to well-being. For the final data collection during COVID-19 shutdowns, each participant completed the same surveys online and also participated in a thirty-minute one-to-one interview. The surveys addressed both cognitive and affective aspects of subjective well-being, with focus on three primary domains: life satisfaction, affect, and selfesteem. Optimism was not assessed because it has been considered a confounding factor and aligns closely with self-esteem. Semi-structured interviews, in which prepared questions served as a springboard for a more in-depth discussion, covered school technology usage, attitudes towards online education, social needs, and motivation for learning. Assessment measures for each domain are described below. --- Materials: Well-being --- Affect assessed through PANAS-C The Positive and Negative Affect Schedule for Children assesses an individual's outward expression of emotion. On this self-reported survey, the participant indicates the extent to which s/he has experienced each of twenty-seven emotions during the preceding week. A five-point Likert scale provides options of Very Slightly; A little; Moderately; Quite a bit;or Extremely. For each participant, an overall score in positive affect was determined from totaling the fourteen positive affect items, and an overall score in negative affect was determined from totaling the thirteen negative affect items. --- Life satisfaction assessed through BMSLSS The Brief Multidimensional Students' Life Satisfaction Scale is a self-reported survey designed to measure the life satisfaction of children and adolescents in each of six areas: family, friends, school, self, living environment, and life as a whole. For each area, participants are asked to complete the sentence: "I would describe my satisfaction with ____________ as …" A total of seven response options are provided: Delighted, Pleased, Mostly Satisfied, Mixed, Mostly Dissatisfied, Unhappy, and Terrible. The scores are averaged together to provide a global measure of life satisfaction. --- Self-esteem assessed through RSES The Rosenberg Self-Esteem Scale is designed for adolescents to self-report on personal confidence in their own abilities. The ten RSES items are ranked on a 4-point Likert scale that includes Strongly Disagree, Disagree, Agree, or Strongly Agree. Half of the items were reverse scored so that Strongly Agree received 1 point and Strongly Disagree received 4 points. Items were then totaled to provide an overall score in self-esteem. --- Semi-structured interviews on adolescent viewpoints of online education and social life during COVID-19 Semi-structured one-to-one interviews were conducted on Zoom with twenty participants. The format of this interview structure, in which prepared questions are adapted based on the participant's response, allowed for deeper conversations. Interviews lasted approximately thirty minutes and were videorecorded. The researcher typed detailed notes during the interviews and referred to the videorecordings for accuracy in final transcriptions. To analyze data from interview responses and openended questions, participant responses were divided into themes based on common phrases and ideas. Qualitative analysis of this information consisted of first cycle coding, in which two researchers independently read and explored the data for initial highlights and themes. Patterns and important features were noted through analytic memos and in vivo analyses . During secondcycle coding, pattern coding was conducted independently by the researchers to ascertain meaning from previous analyses. Words and phrases that best illustrate the themes were included in the study findings. The interviews provided insights into participants' online learning experiences and social life. Participants discussed the ability to focus on online schooling, best and worst things about the shutdowns, new insights about technology, and social connections with friends. A list of prepared interview questions is included in the Appendix. --- Results --- Descriptive statistics for continuous variables Data for the first research question was analyzed using IBM Statistical Package for the Social Sciences . The means and standard deviations for all of the continuous study variables are presented in Table 1. Age ranged from 12 to 17 with a mean of 14.24 . Pretest variables for all other instruments are detailed below. --- Research question 1: To what extent does adolescent well-being during the pandemic differ from pre-pandemic well-being? Three components comprised the concept of adolescent sense of well-being: positive affect and negative affect , general life satisfaction , and self-esteem . A paired-samples t-test was conducted to compare negative affect experienced by adolescents over time. There was a significant increase in the negative affect scores during COVID-19 shutdowns as compared with negative affect scores before COVID-19 shutdowns ; t = -3.47, p = 0.002. These results suggest that negative affect increased during the COVID-19 shutdowns. See Fig. 1. Participants reported the online learning content delivery system that was used by their schools. Google Classroom and Zoom were most common, with 51% of participants using at least one of these platforms. In addition, a variety of other online learning platforms and approaches were noted, and 48% of students indicated that their schools used multiple approaches. See Table 2 for a list of platforms and percentages of participants who used each. --- Life Frequent educational approaches included online meetings , videotaped content, and an assignment repository where students access and submit assignments. 43% of the students' schools had switched to a Pass/No Pass grading system, 43% continued using pre-pandemic grading procedures, and 14% were using "No Harm" grading in which only grades that were equal to or higher than a student's previous grades would count towards a student's grade point average. While some participants suggested that the Pass/No Pass system generally "leads students to give less effort towards assignments", others preferred this grading approach because "…my grades aren't as great…it is harder online". One student noted that the ability to retake tests was a benefit of online education. When asked to describe their lives during the pandemic, participants responded with a total of forty descriptors. Of these responses, 62.5% presented a negative valence , 27.5% presented a positive valence , and 10% were neutral . Common themes ranged from "boring" and "secluded/isolated" to "calm/peaceful/relaxed" . Attitudes towards online school were similar, with teens noting factors such as inconsistencies in school expectations and confusion about complicated work procedures. Participants mentioned that they "don't really enjoy school anymore" and noted that "the teacher is not there to help". Others felt less motivated, since "the pressure to do well is gone". The online environment worked well for a few participants, who remarked that they work best when allowed to take more initiative in their own learning: "I don't need a lot of guidance. I just do it" and "I tell myself if I get the schoolwork done, I'll have free time to do something else that I enjoy". See Fig. 2 and Table 3. The majority of participants noted personal increases in distractibility during online learning, e.g.: "I'm trying to get my [school] work done, and then I think I could check Instagram real quick…" The most common distractor listed by students was the smartphone. The lack of oversight during instruction was described as a hindrance because "we don't have teachers watching us and keeping us on task" and "If the teacher is lecturing, I can be playing a game on my phone". The percentage of students who described their phones as "distracting" increased from 15.9% before COVID-19 shutdowns to 21.5% during the shutdowns. However, students also described their phones as "connecting" and "necessary" , noting that "…technology can be beneficial in a time like this because it helps people connect" and "I do everything on my laptop. It's become an essential part of my life." Other descriptors included "calming", "entertaining" , and "a miracle". As one participant explained, "…people are discovering new and creative ways to go about their daily lives…" See Table 4 for themes and examples related to adolescent perceptions of technology in learning. --- Research question #3: What social changes and concerns do adolescents report during the pandemic? For most students , the greatest need during the pandemic was social interaction, but students expressed concern that their online learning environments provided few to no opportunities for social connections. Student-expressed school needs included variety in instructional approach and increased teacher contact/feedback . Participants viewed technology as both a social support and a hindrance . Structure, consistency, and clear work procedures were other online learning needs. Some students had developed strategies for completing online schoolwork, including using a checklist, segmenting assignments or workload , and working offline . See Table 5 for primary themes and examples related to adolescent perceptions of factors that influence online learning. Before the pandemic, almost half of participants noted that their preferred communication style was talking with others face-to-face through "a relaxed straightforward conversation" or "hanging out with my friends". Far fewer teens preferred to communicate through texting or social media . One student noted that, "I like to talk in person but enjoy using Snapchat and texting my friends when I can't hang out." When face-to-face communication was limited by the pandemic-related shutdowns, students switched primarily to texting, social media, or phone calls. Zoom meetings and Google Hangouts became new methods of connecting with friends, but "…it's not the same." One participant commented, "I need to get out and see people!", and others mentioned that they were "missing friends". In discussing the "best thing" about the shutdowns, 57% of participants mentioned increased time for specific activities: "more family time", "extra free time", "more video games", "more me time". In contrast, 76% of adolescents viewed the worst thing about the pandemic as limited social opportunities, with comments such as "not having social interactions", "missing friends", and "…it's hard to not be able to see your friends". "I haven't had any interactions with my teachers." "…More difficult because the teacher is not there to help…" "Your teachers aren't there to motivate you…" Distractibility "I don't really get anything done…" "We're at home and don't have teachers watching us and keeping us on task…" "I forget to do my schoolwork because I'm always playing games online." "At home, it's like you don't have to work…" Flexibility "I've felt more relaxed…" "You can just do your own thing at your own pace." "…Most definitely more aware of technology…" --- Discussion The purpose of this study was to investigate adolescent well-being and how well the adolescents' learning and social needs were being met as school closures during the COVID-19 pandemic required students to stay at home. Primary results include: • A significant decrease in positive affect during the pandemic, as compared with pre-pandemic measures. • A significant increase in negative affect during the pandemic, as compared with pre-pandemic measures. • No significant difference from pre-pandemic to during pandemic conditions in life satisfaction or self-esteem, as measured by the BMSLSS and the RSES. • When asked to describe their lives during the pandemic, the majority of participant responses reflected a negative valence. Participant attitudes towards school paralleled descriptors of life. • The majority of participants noted increases in personal distractibility during the pandemic. • The greatest need for most participants was social interaction, but opportunities for social connectedness in online learning were limited. • While participants often noted that technology was distracting, they also considered it to be connecting and necessary. • Before the pandemic, the preferred communication style for most teens was talking face-to-face. During the pandemic, teens had adapted to communicating through a variety of online means such as texting and social media, which were different from those used for their formal online learning. Major findings are addressed according to the research question each addresses. --- Research question #1: To what extent does adolescent well-being during the pandemic differ from well-being before the pandemic? The study showed a significant difference in the adolescents' positive and negative affect, but no significant difference in their self-esteem or life satisfaction before and during the pandemic. Positive affect showed a significant decrease during the pandemic, indicating a decline in positive emotions such as happiness, joy, and pride. This may be connected with physical isolation from peers and limitations in social opportunities resulting from COVID-19 shutdowns. Before the school closures, participants engaged in social interactions at school on most weekdays. During the pandemic, participants were involved in online schooling with limited opportunities for social interactions. Positive affect has been linked with social relationships , and comments such as "I miss my friends. Like sure I can see them via screen, but I miss them…School is like the place where you see people most…" signaled that the decrease in face-to-face interactions with teachers and peers may have contributed to lower positive affect. In addition, participants frequently reported that they were distracted by their phones, with one student recognizing what he viewed as a "myriad of distractions": friends, games, and social media. Negative affect, in contrast, increased significantly during the pandemic, signifying that participants were experiencing a rise in negative emotions such as sadness, fear, and loneliness. Multiple students indicated that their school expectations were confusing and inconsistent. All participants were facing an uncertain future. Uncertainty and inconsistency may have influenced the increase in negative affect, in line with the work of Di Santo et al. . In addition, loneliness resulting from the impacts of pandemic-related shutdowns may have intensified the overall negative affect. As one participant expressed: "I never realized how easy it was to just pick up the phone and call somebody whenever you felt lonely. But it still isn't the same. You still sometimes feel just as lonely." No participants specifically mentioned concerns about COVID-19 itself, but it is possible that an underlying fear related to the pandemic may have intensified negative affect in other areas. Positive and negative affect do not necessarily change in tandem; they represent two independent measures. The simultaneous changes in these areas suggest a lower sense of well-being among participants. Affect is considered a major factor in well-being , and the decline in well-being is reinforced by the high percentage of responses with negative valence when participants described their lives during the pandemic. It is also reflected in the hopelessness expressed by some participants in their last year of high school, e.g.: "I am very sad now…I am missing my senior banquet…and I just learned this week that I will probably never see most members of my senior class again." In contrast to affect, measures of both life satisfaction and self-esteem remained relatively consistent during the COVID-19 shutdowns. These findings align with previous research results indicating that life satisfaction measures frequently parallel those of self-esteem . Both life satisfaction and self-esteem may reflect an aggregate of a person's affect , and both suggest a life mindset that impacts one's perspective more strongly than momentary factors . For most participants, scores were high, indicating a generally positive perspective of life. A positive approach to life can build social connections, bolster resilience during negative circumstances, and promote more robust mental health . --- Research question #2: What factors do adolescents view as influences upon their learning during the imposed shift to online schooling? Regardless of the learning platform used, the outlook and needs for online schooling were similar between participants. Adolescent attitudes towards school often reflected their descriptors of life. Participants noted lack of engagement and decreased interest . One participant noted, "Honestly, I would prefer [face-to-face] school learning over doing online learning just because I like the interaction with friends. I was a little bit surprised…but after awhile you get bored [online]." Some wished for more contact with teachers, indicating the importance of the teacher-student relationship. This reinforces findings that indicate the importance of relationships in adolescent development . Other participants appreciated the opportunity to work independently online, supporting the adolescent need for autonomy . The majority of participants noted increased distractions during the pandemic. While lack of face-to-face time with friends, increased time on computers, and accessibility to smartphones were often mentioned as the primary reasons for distraction, underlying factors are likely to include abrupt changes in daily environments, fears about personal and family health, and uncertainty about the future. Di Santo et al. indicated a link between uncertainty/inconsistency and increased negative affect, which suggests that these pandemic-related factors may be decreasing adolescent well-being and impacting adolescent focus and productivity in online schooling. It is interesting to note that, while participants frequently were concerned about the distractions created by smartphones, they also described smartphones as "connecting" and "necessary". The tension between these opposing viewpoints may reflect the inner conflict frequently experienced in adolescence as brain regions develop at differing rates . --- Research question #3: What social changes and concerns do adolescents report during the pandemic? The greatest need expressed by most participants was social interaction, but participant comments suggested that opportunities designed to support social connectedness, especially in online learning, did not always address the need. One participant noted that "Social interaction isn't the same [online]. It's different in person, you know" and another commented, "[Face-to-face] school is like the place where you see people most". Before the pandemic, almost half of the participants selected faceto-face conversations as their preferred method of communication. During the pandemic, shutdowns limited face-to-face interactions. However, adolescents worked quickly to adopt new communication practices in order to stay in contact with friends. Although connecting with others in new ways can be uncomfortable and may pose challenges such as learning to navigate new technology platforms, peers are often a primary source of social and emotional support for adolescents . All students found ways to stay connected, using their available tools to communicate even amidst the challenges of the pandemic. One student's comment that technology "is only a tool" is a reminder that human input and creativity are needed to develop strategies for building social bonds online. --- Conclusion The qualitative methods used in this mixed-method study provided opportunities for rich conversations with the adolescents. Listening to the students provided deeper insights into their online learning experiences, social connections, needs, perspectives, and well-being. Students are the experts on their own experiences, and listening to experts should be a priority in educational settings. While curriculum developers and district leaders often base educational decisions and lesson plans upon recommended instructional practices and results from standardized tests, involving the students in conversations and seeking student input into the learning design can build stronger and more engaging learning experiences. Student voices will provide essential feedback for designing effective learning environments after the pandemic. The strong adolescent need for social interaction and the importance of adolescent communications with friends suggest that innovative opportunities for social opportunities in online schooling are critical. Using both familiar apps and new media, from texting and social media to creative new platforms, can allow students to implement discourse strategies that are relevant in their lives. Opportunities to create videos, interact with content, take virtual field trips, and embrace learning through game-like approaches could enhance not only social interactions, but also engagement and motivation in online learning . Teaching approaches that provide interest-based educational activities, support social interaction, and allow adolescents to take the lead in their own learning can motivate students and further accelerate learning. Online learning presents new challenges for educators, but students are important resources for insights that can lead to effective practices. Finding time to listen and respond to student voices is essential as educators work to design optimum approaches for educating the leaders of our future. --- Limitations and future directions The study was limited in the following ways. First, all the adolescents in this study were volunteer participants who visited the same local museum in a southern U.S. city. They may not represent adolescents or populations in other areas. Second, all data were collected online due to the pandemic, which may have limited the richness of the qualitative data. Third, the data were collected from a small sample size of 21 participants. However, the study, with findings based on quantitative data from validated instruments as well as qualitative in-depth interviews and voices from the 21 participants, serves as a catalyst for more in-depth discussions. The negative valence identified in the current study illuminates the need for future researchers to examine the learning outcomes of adolescents during the pandemic. Future research focusing on specific stress symptoms, learner satisfaction and burnout symptoms could contribute to our understanding of the factors that led to increased negative valence among the adolescents. Moreover, future scholars could also include longitudinal studies and explorations into the perspectives of the adolescents' teachers and parents, which could provide a more robust understanding of effective online learning approaches. Lastly, more research is needed to investigate the effectiveness of new approaches and strategies that were utilized in enhancing online learning during the pandemic. --- Appendix Questions for semi-structured interviews. 1. How does your school conduct classes? 2. Has your school switched to a Pass/No Pass system? If so, how has this impacted your role and responsibility as a student? 3. --- --- Conflicts of interest We have no conflicts of interest to disclose. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Health and safety concerns during the COVID-19 pandemic required many face-toface United States schools to suddenly shut their doors, moving classes to virtual learning environments. Amidst concerns of technology overuse, adolescents across the country saw dramatic increases in both personal screen time use and social isolation as they learned to navigate online schooling. Understanding the impact of the pandemic-related shutdowns upon adolescent well-being, learning, and social life is critical for designing effective online learning experiences, but research provides few insights from the adolescent perspective. This mixed methods study works to fill this gap by investigating adolescent needs and perceptions during the pandemic. The main questions asked are: • To what extent does adolescent well-being during the pandemic differ from prepandemic well-being? • What factors do adolescents view as influences upon their learning during the imposed shift to online schooling? • What social changes and concerns do adolescents report during the pandemic? Twenty-one adolescents completed Likert scale surveys and participated in semistructured one-to-one interviews. Results showed a significant decrease in positive affect and a significant increase in negative affect during the pandemic, suggesting a decline in well-being. The majority of participants reported high distractibility and noted the lure of entertaining technology, but also described their smartphones as "connecting" and "necessary". Social interactions were a priority for all participants, but participants agreed that opportunities for social connectedness in online education were limited. The challenges of online learning, the importance of identifying and responding to student needs, and suggested strategies for online education are discussed.

introduction over the past ten years the impact of technology on adolescents has been a growing concern among parents educators and researchers yet as covid19 shutdowns moved schools from inperson instruction to online learning platforms thousands of elementary and secondary students were suddenly required to use technology for activities that had previously been conducted facetoface schoolwork extracurricular activities and even connections with friends all moved online and for many students time spent on technology increased dramatically at the same time stayathome mandates brought both physical isolation from peers and concerns about an uncertain future setting the stage for increased fear anxiety depression and other mental health concerns the move to online schooling during the covid19 pandemic has emphasized the critical need to understand student needs perspectives and wellbeing when designing online education this study investigates adolescent wellbeing perspectives of online education and social needs during the covid19 pandemic literature review impacts of covid19 upon adolescents although the physical health impacts of covid19 upon adolescents have generally been mild this age group is still subject to social distancing stay at home orders closure of facetoface schools and other measures taken to protect the health of individuals government mandates are important for maintaining physical health but they have also disrupted a sense of normalcy and have led to feelings of isolation fear and anxiety for individuals of all ages adolescents who are developing a sense of autonomy and often depend on their social connections to build an understanding of themselves may experience more intense reactions to this stress technology overload particularly in children and adolescents has been a concern as both isolation from peers and the move to online schooling have increased reliance on technology during the pandemic online education may provide few opportunities for social and emotional development creating gaps that can lead adolescents to withdraw and increase their time online while the ability to interact socially has been viewed as a critical component of online learning achieving social presence is often a challenge in virtual environments educators may need to support the development of both social and academic skills by leveraging media and other technological resources that are not typically incorporated into facetoface school settings an understanding of adolescent needs in online learning experiences is essential for addressing socioemotional gaps aiding recovery from pandemicrelated stress and encouraging positive wellbeing positive wellbeing has been linked with motivation and learning and an educational environment that supports positive wellbeing has been shown to boost adolescent learning and development adolescent development and technology use adolescence the transition from childhood into adulthood is often a time of inner turbulence the brains organizational schema is restructuring and the frontal cortex gradually takes a stronger role in selfcontrol as the brain develops physical emotional and social changes may create an instability in adolescent behavior inner conflict builds as a continued sense of attachment and a developing need for autonomy cause adolescents to simultaneously pull away from and cling to their caregivers as adolescents move increasingly towards autonomy the desire to establish an understanding of personal beliefs and an awareness of personal identity becomes a priority the need for social acceptance intensifies as adolescents try to identify with and build status among peers peers become a primary source of social and emotional support and the feedback others provide must be balanced with selfperceptions adolescents may view technology as a path for meeting these needs in smartphones they often find autonomy selfidentity social connections and prestige however smartphone usage has been shown to interfere with social interactions in facetoface classrooms and may be even more concerning in online classrooms because of limited teacher oversight high levels of technology usage have also been associated with mental health issues withdrawal and weaker social skills for adolescents social relationships appear to be central to positive affect and wellbeing wellbeing subjective wellbeing is considered to have both a cognitive and an affective component the cognitive aspect focuses primarily on life satisfaction selfesteem and in some studies optimism whereas the affective component focuses on transitory experiences that work together to build an individuals interpretation of emotion life satisfaction considers the degree to which personal desires and goals are met often within specific life domains life satisfaction is viewed as an internal characteristic that remains relatively consistent for an individual throughout situational changes and across the lifespan life satisfaction may reflect a collective view of a persons affect because attitude and internal approach to life appear to influence ones life satisfaction more than external circumstances such as wealth or friends selfesteem is also known as selfconfidence selfesteem is not related to specific life situations but takes a more global approach considering questions such as at times i think i am no good at all and i am able to do things as well as most other people selfesteem may be a composite of everyday assessments of selfworth this creates a fairly consistent selfesteem rating that is not influenced by changing emotions or life circumstances diener and diener suggest that most individuals maintain a positive life perspective which both supports the ability to recover from difficult situations and strengthens social and emotional health optimism or positive thinking is associated with motivation goal achievement and emotions some researchers consider optimism to be a confounding factor in subjective wellbeing since common items on optimism scales are similar to those found on measures of selfesteem i hardly ever expect things to go my way and im optimistic about my future the affective component of subjective wellbeing examines positive affect and negative affect positive affect and negative affect are considered independent attributes an increase in one does not necessarily mean a decrease in the other instead positive affect is often expressed in enthusiasm and energy negative affect may be shown through sadness loneliness or guilt positive affect at school has been linked with motivation academic success and positive wellbeing in contrast uncertainty and inconsistency may create or intensify negative affect affect is considered a major indicator of wellbeing the impact of covid19 shutdowns upon adolescent wellbeing has been a global concern in a study of 1143 parents in italy and spain pandemicrelated quarantines and isolation from peers were seen to exert a negative influence on children and adolescents in addition to distractibility boredom loneliness and worry parents reported that their children increased their time on technology slept more and spent less time in physical activity the study concluded that mental and social wellbeing must be priorities in both physical and online schools however identification of strategies that can effectively address adolescent wellbeing in online learning and social experiences will require insights into adolescent perspectives attitudes and feelings this study investigates effects of the covid19 pandemic upon adolescent wellbeing learning and social needs questions include • to what extent does adolescent wellbeing during the pandemic differ from prepandemic wellbeing • what factors do adolescents view as influences upon their learning during the imposed shift to online schooling • what social changes and concerns do adolescents report during the pandemic methods data collection for initial data collection before covid19 shutdowns data was collected onsite at the museum participants completed paper surveys related to wellbeing for the final data collection during covid19 shutdowns each participant completed the same surveys online and also participated in a thirtyminute onetoone interview the surveys addressed both cognitive and affective aspects of subjective wellbeing with focus on three primary domains life satisfaction affect and selfesteem optimism was not assessed because it has been considered a confounding factor and aligns closely with selfesteem semistructured interviews in which prepared questions served as a springboard for a more indepth discussion covered school technology usage attitudes towards online education social needs and motivation for learning assessment measures for each domain are described below materials wellbeing affect assessed through panasc the positive and negative affect schedule for children assesses an individuals outward expression of emotion on this selfreported survey the participant indicates the extent to which she has experienced each of twentyseven emotions during the preceding week a fivepoint likert scale provides options of very slightly a little moderately quite a bitor extremely for each participant an overall score in positive affect was determined from totaling the fourteen positive affect items and an overall score in negative affect was determined from totaling the thirteen negative affect items life satisfaction assessed through bmslss the brief multidimensional students life satisfaction scale is a selfreported survey designed to measure the life satisfaction of children and adolescents in each of six areas family friends school self living environment and life as a whole for each area participants are asked to complete the sentence i would describe my satisfaction with as … a total of seven response options are provided delighted pleased mostly satisfied mixed mostly dissatisfied unhappy and terrible the scores are averaged together to provide a global measure of life satisfaction selfesteem assessed through rses the rosenberg selfesteem scale is designed for adolescents to selfreport on personal confidence in their own abilities the ten rses items are ranked on a 4point likert scale that includes strongly disagree disagree agree or strongly agree half of the items were reverse scored so that strongly agree received 1 point and strongly disagree received 4 points items were then totaled to provide an overall score in selfesteem semistructured interviews on adolescent viewpoints of online education and social life during covid19 semistructured onetoone interviews were conducted on zoom with twenty participants the format of this interview structure in which prepared questions are adapted based on the participants response allowed for deeper conversations interviews lasted approximately thirty minutes and were videorecorded the researcher typed detailed notes during the interviews and referred to the videorecordings for accuracy in final transcriptions to analyze data from interview responses and openended questions participant responses were divided into themes based on common phrases and ideas qualitative analysis of this information consisted of first cycle coding in which two researchers independently read and explored the data for initial highlights and themes patterns and important features were noted through analytic memos and in vivo analyses during secondcycle coding pattern coding was conducted independently by the researchers to ascertain meaning from previous analyses words and phrases that best illustrate the themes were included in the study findings the interviews provided insights into participants online learning experiences and social life participants discussed the ability to focus on online schooling best and worst things about the shutdowns new insights about technology and social connections with friends a list of prepared interview questions is included in the appendix results descriptive statistics for continuous variables data for the first research question was analyzed using ibm statistical package for the social sciences the means and standard deviations for all of the continuous study variables are presented in table 1 age ranged from 12 to 17 with a mean of 1424 pretest variables for all other instruments are detailed below research question 1 to what extent does adolescent wellbeing during the pandemic differ from prepandemic wellbeing three components comprised the concept of adolescent sense of wellbeing positive affect and negative affect general life satisfaction and selfesteem a pairedsamples ttest was conducted to compare negative affect experienced by adolescents over time there was a significant increase in the negative affect scores during covid19 shutdowns as compared with negative affect scores before covid19 shutdowns t 347 p 0002 these results suggest that negative affect increased during the covid19 shutdowns see fig 1 participants reported the online learning content delivery system that was used by their schools google classroom and zoom were most common with 51 of participants using at least one of these platforms in addition a variety of other online learning platforms and approaches were noted and 48 of students indicated that their schools used multiple approaches see table 2 for a list of platforms and percentages of participants who used each life frequent educational approaches included online meetings videotaped content and an assignment repository where students access and submit assignments 43 of the students schools had switched to a passno pass grading system 43 continued using prepandemic grading procedures and 14 were using no harm grading in which only grades that were equal to or higher than a students previous grades would count towards a students grade point average while some participants suggested that the passno pass system generally leads students to give less effort towards assignments others preferred this grading approach because …my grades arent as great…it is harder online one student noted that the ability to retake tests was a benefit of online education when asked to describe their lives during the pandemic participants responded with a total of forty descriptors of these responses 625 presented a negative valence 275 presented a positive valence and 10 were neutral common themes ranged from boring and secludedisolated to calmpeacefulrelaxed attitudes towards online school were similar with teens noting factors such as inconsistencies in school expectations and confusion about complicated work procedures participants mentioned that they dont really enjoy school anymore and noted that the teacher is not there to help others felt less motivated since the pressure to do well is gone the online environment worked well for a few participants who remarked that they work best when allowed to take more initiative in their own learning i dont need a lot of guidance i just do it and i tell myself if i get the schoolwork done ill have free time to do something else that i enjoy see fig 2 and table 3 the majority of participants noted personal increases in distractibility during online learning eg im trying to get my school work done and then i think i could check instagram real quick… the most common distractor listed by students was the smartphone the lack of oversight during instruction was described as a hindrance because we dont have teachers watching us and keeping us on task and if the teacher is lecturing i can be playing a game on my phone the percentage of students who described their phones as distracting increased from 159 before covid19 shutdowns to 215 during the shutdowns however students also described their phones as connecting and necessary noting that …technology can be beneficial in a time like this because it helps people connect and i do everything on my laptop its become an essential part of my life other descriptors included calming entertaining and a miracle as one participant explained …people are discovering new and creative ways to go about their daily lives… see table 4 for themes and examples related to adolescent perceptions of technology in learning research question 3 what social changes and concerns do adolescents report during the pandemic for most students the greatest need during the pandemic was social interaction but students expressed concern that their online learning environments provided few to no opportunities for social connections studentexpressed school needs included variety in instructional approach and increased teacher contactfeedback participants viewed technology as both a social support and a hindrance structure consistency and clear work procedures were other online learning needs some students had developed strategies for completing online schoolwork including using a checklist segmenting assignments or workload and working offline see table 5 for primary themes and examples related to adolescent perceptions of factors that influence online learning before the pandemic almost half of participants noted that their preferred communication style was talking with others facetoface through a relaxed straightforward conversation or hanging out with my friends far fewer teens preferred to communicate through texting or social media one student noted that i like to talk in person but enjoy using snapchat and texting my friends when i cant hang out when facetoface communication was limited by the pandemicrelated shutdowns students switched primarily to texting social media or phone calls zoom meetings and google hangouts became new methods of connecting with friends but …its not the same one participant commented i need to get out and see people and others mentioned that they were missing friends in discussing the best thing about the shutdowns 57 of participants mentioned increased time for specific activities more family time extra free time more video games more me time in contrast 76 of adolescents viewed the worst thing about the pandemic as limited social opportunities with comments such as not having social interactions missing friends and …its hard to not be able to see your friends i havent had any interactions with my teachers …more difficult because the teacher is not there to help… your teachers arent there to motivate you… distractibility i dont really get anything done… were at home and dont have teachers watching us and keeping us on task… i forget to do my schoolwork because im always playing games online at home its like you dont have to work… flexibility ive felt more relaxed… you can just do your own thing at your own pace …most definitely more aware of technology… discussion the purpose of this study was to investigate adolescent wellbeing and how well the adolescents learning and social needs were being met as school closures during the covid19 pandemic required students to stay at home primary results include • a significant decrease in positive affect during the pandemic as compared with prepandemic measures • a significant increase in negative affect during the pandemic as compared with prepandemic measures • no significant difference from prepandemic to during pandemic conditions in life satisfaction or selfesteem as measured by the bmslss and the rses • when asked to describe their lives during the pandemic the majority of participant responses reflected a negative valence participant attitudes towards school paralleled descriptors of life • the majority of participants noted increases in personal distractibility during the pandemic • the greatest need for most participants was social interaction but opportunities for social connectedness in online learning were limited • while participants often noted that technology was distracting they also considered it to be connecting and necessary • before the pandemic the preferred communication style for most teens was talking facetoface during the pandemic teens had adapted to communicating through a variety of online means such as texting and social media which were different from those used for their formal online learning major findings are addressed according to the research question each addresses research question 1 to what extent does adolescent wellbeing during the pandemic differ from wellbeing before the pandemic the study showed a significant difference in the adolescents positive and negative affect but no significant difference in their selfesteem or life satisfaction before and during the pandemic positive affect showed a significant decrease during the pandemic indicating a decline in positive emotions such as happiness joy and pride this may be connected with physical isolation from peers and limitations in social opportunities resulting from covid19 shutdowns before the school closures participants engaged in social interactions at school on most weekdays during the pandemic participants were involved in online schooling with limited opportunities for social interactions positive affect has been linked with social relationships and comments such as i miss my friends like sure i can see them via screen but i miss them…school is like the place where you see people most… signaled that the decrease in facetoface interactions with teachers and peers may have contributed to lower positive affect in addition participants frequently reported that they were distracted by their phones with one student recognizing what he viewed as a myriad of distractions friends games and social media negative affect in contrast increased significantly during the pandemic signifying that participants were experiencing a rise in negative emotions such as sadness fear and loneliness multiple students indicated that their school expectations were confusing and inconsistent all participants were facing an uncertain future uncertainty and inconsistency may have influenced the increase in negative affect in line with the work of di santo et al in addition loneliness resulting from the impacts of pandemicrelated shutdowns may have intensified the overall negative affect as one participant expressed i never realized how easy it was to just pick up the phone and call somebody whenever you felt lonely but it still isnt the same you still sometimes feel just as lonely no participants specifically mentioned concerns about covid19 itself but it is possible that an underlying fear related to the pandemic may have intensified negative affect in other areas positive and negative affect do not necessarily change in tandem they represent two independent measures the simultaneous changes in these areas suggest a lower sense of wellbeing among participants affect is considered a major factor in wellbeing and the decline in wellbeing is reinforced by the high percentage of responses with negative valence when participants described their lives during the pandemic it is also reflected in the hopelessness expressed by some participants in their last year of high school eg i am very sad now…i am missing my senior banquet…and i just learned this week that i will probably never see most members of my senior class again in contrast to affect measures of both life satisfaction and selfesteem remained relatively consistent during the covid19 shutdowns these findings align with previous research results indicating that life satisfaction measures frequently parallel those of selfesteem both life satisfaction and selfesteem may reflect an aggregate of a persons affect and both suggest a life mindset that impacts ones perspective more strongly than momentary factors for most participants scores were high indicating a generally positive perspective of life a positive approach to life can build social connections bolster resilience during negative circumstances and promote more robust mental health research question 2 what factors do adolescents view as influences upon their learning during the imposed shift to online schooling regardless of the learning platform used the outlook and needs for online schooling were similar between participants adolescent attitudes towards school often reflected their descriptors of life participants noted lack of engagement and decreased interest one participant noted honestly i would prefer facetoface school learning over doing online learning just because i like the interaction with friends i was a little bit surprised…but after awhile you get bored online some wished for more contact with teachers indicating the importance of the teacherstudent relationship this reinforces findings that indicate the importance of relationships in adolescent development other participants appreciated the opportunity to work independently online supporting the adolescent need for autonomy the majority of participants noted increased distractions during the pandemic while lack of facetoface time with friends increased time on computers and accessibility to smartphones were often mentioned as the primary reasons for distraction underlying factors are likely to include abrupt changes in daily environments fears about personal and family health and uncertainty about the future di santo et al indicated a link between uncertaintyinconsistency and increased negative affect which suggests that these pandemicrelated factors may be decreasing adolescent wellbeing and impacting adolescent focus and productivity in online schooling it is interesting to note that while participants frequently were concerned about the distractions created by smartphones they also described smartphones as connecting and necessary the tension between these opposing viewpoints may reflect the inner conflict frequently experienced in adolescence as brain regions develop at differing rates research question 3 what social changes and concerns do adolescents report during the pandemic the greatest need expressed by most participants was social interaction but participant comments suggested that opportunities designed to support social connectedness especially in online learning did not always address the need one participant noted that social interaction isnt the same online its different in person you know and another commented facetoface school is like the place where you see people most before the pandemic almost half of the participants selected facetoface conversations as their preferred method of communication during the pandemic shutdowns limited facetoface interactions however adolescents worked quickly to adopt new communication practices in order to stay in contact with friends although connecting with others in new ways can be uncomfortable and may pose challenges such as learning to navigate new technology platforms peers are often a primary source of social and emotional support for adolescents all students found ways to stay connected using their available tools to communicate even amidst the challenges of the pandemic one students comment that technology is only a tool is a reminder that human input and creativity are needed to develop strategies for building social bonds online conclusion the qualitative methods used in this mixedmethod study provided opportunities for rich conversations with the adolescents listening to the students provided deeper insights into their online learning experiences social connections needs perspectives and wellbeing students are the experts on their own experiences and listening to experts should be a priority in educational settings while curriculum developers and district leaders often base educational decisions and lesson plans upon recommended instructional practices and results from standardized tests involving the students in conversations and seeking student input into the learning design can build stronger and more engaging learning experiences student voices will provide essential feedback for designing effective learning environments after the pandemic the strong adolescent need for social interaction and the importance of adolescent communications with friends suggest that innovative opportunities for social opportunities in online schooling are critical using both familiar apps and new media from texting and social media to creative new platforms can allow students to implement discourse strategies that are relevant in their lives opportunities to create videos interact with content take virtual field trips and embrace learning through gamelike approaches could enhance not only social interactions but also engagement and motivation in online learning teaching approaches that provide interestbased educational activities support social interaction and allow adolescents to take the lead in their own learning can motivate students and further accelerate learning online learning presents new challenges for educators but students are important resources for insights that can lead to effective practices finding time to listen and respond to student voices is essential as educators work to design optimum approaches for educating the leaders of our future limitations and future directions the study was limited in the following ways first all the adolescents in this study were volunteer participants who visited the same local museum in a southern us city they may not represent adolescents or populations in other areas second all data were collected online due to the pandemic which may have limited the richness of the qualitative data third the data were collected from a small sample size of 21 participants however the study with findings based on quantitative data from validated instruments as well as qualitative indepth interviews and voices from the 21 participants serves as a catalyst for more indepth discussions the negative valence identified in the current study illuminates the need for future researchers to examine the learning outcomes of adolescents during the pandemic future research focusing on specific stress symptoms learner satisfaction and burnout symptoms could contribute to our understanding of the factors that led to increased negative valence among the adolescents moreover future scholars could also include longitudinal studies and explorations into the perspectives of the adolescents teachers and parents which could provide a more robust understanding of effective online learning approaches lastly more research is needed to investigate the effectiveness of new approaches and strategies that were utilized in enhancing online learning during the pandemic appendix questions for semistructured interviews 1 how does your school conduct classes 2 has your school switched to a passno pass system if so how has this impacted your role and responsibility as a student 3 conflicts of interest we have no conflicts of interest to disclose publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

health and safety concerns during the covid19 pandemic required many facetoface united states schools to suddenly shut their doors moving classes to virtual learning environments amidst concerns of technology overuse adolescents across the country saw dramatic increases in both personal screen time use and social isolation as they learned to navigate online schooling understanding the impact of the pandemicrelated shutdowns upon adolescent wellbeing learning and social life is critical for designing effective online learning experiences but research provides few insights from the adolescent perspective this mixed methods study works to fill this gap by investigating adolescent needs and perceptions during the pandemic the main questions asked are • to what extent does adolescent wellbeing during the pandemic differ from prepandemic wellbeing • what factors do adolescents view as influences upon their learning during the imposed shift to online schooling • what social changes and concerns do adolescents report during the pandemic twentyone adolescents completed likert scale surveys and participated in semistructured onetoone interviews results showed a significant decrease in positive affect and a significant increase in negative affect during the pandemic suggesting a decline in wellbeing the majority of participants reported high distractibility and noted the lure of entertaining technology but also described their smartphones as connecting and necessary social interactions were a priority for all participants but participants agreed that opportunities for social connectedness in online education were limited the challenges of online learning the importance of identifying and responding to student needs and suggested strategies for online education are discussed

The past three decades of neoliberal policy inputs and outputs have, to differing but considerable extents, transformed many Western countries' major media, educational, cultural, and recreational institutions into market and ideological apparatuses . As a result of this ongoing structural reconfiguration, successive millennial generations , and particularly those in the USA and the UK, have been increasingly expose to neoliberal discursive formations of self-interest, competiveness, and materialism . Correspondingly, nascent sociological research is consistently showing that although millennials do actively construct and negotiate their selfhoods around the competing discursive systems of culture and value available to them, very often these are, as Harvey et al. argue, 'related to the circulation of global tropes of consumption and idealised neoliberal subjectivities' . But what exactly constitutes neoliberal subjectivity? To date, the sociological literature has offered rich explanatory accounts that describe various interlocked systemic imperatives and structural, discursive, policy, and civil society components that help engender the microlevel processes of neoliberal subjectification . However, propositions about: the cognitive-affective mechanisms that explain how youth acquire and reproduce neoliberal ideology, or the dispositions and behaviours that typify a neoliberal subject, remain vague . Accordingly, a more in-depth conceptualization of these two psychosocial facets could help enhance and specify current understandings of how a neoliberal subject develops, thinks, feels, and acts. This could in turn advance empirical examinations of the emerging modes and societal consequences of neoliberal subjectification. Therefore, this article will provide an initial template for said conceptualization. To do so, we first review and draw links between the shared, synergistic, and complementary theoretical tenets from the literature on neurocognitive development and social cognition in order to lay a computational-representational paradigm-based account of the processes of subjectification and social reproduction.1 We then review the literature on neoliberalism and neoliberal hegemony as these apply to the USA and the UK: the world harbingers and enforcers of neoliberal doctrine . Finally, we synthesize the theoretical tenets and empirical findings discussed throughout the article within a modified version of the habitus formulation to sketch a testable cognitive-sociological model. This model provides a novel approach to help explain and empirically explore some of the distinct dispositional values, attitudes, and practices that youth raised in societies with institutionally and culturally prevalent neoliberal discursive formations may potentially develop and enact. This article can, therefore, be viewed as a response to ongoing calls for sociologists to engage with the cognitive sciences and clarify the psychological assumptions that are implicit in all sociological theories of culture and subjectivity . Indeed, as Turner argues, 'Minimizing the cognitive is a genuine alternative strategy to engaging with cognitive neuroscience, but only if we choose to push social theory to the far periphery of knowledge, into a ghetto of its own making.' --- Computational-Representational Theories Of Mind One of the leading paradigmatic positions in cognitive science is that the mind is a computational information-processing centre largely composed of evolutionarily endowed, hierarchically organized, and interconnected neural structures known as modules . Modules are associated with and anchored across particular regions of the brain, and are hypothesized to be autonomous and informationally encapsulated devices with domain-specific functions . To wit, each module is theorised to possess a genetically determined syntactic algorithm with fixed parameters that is designed to only and mandatorily process certain sensory inputs to perform distinct cognitive tasks e.g., facial pattern recognition. Because of these computational properties, modules enable us to rapidly process, parse, remember, and react to the constant stream of sensory information that we encounter every day . For the purposes of this article, a particularly important meta-module is termed the 'medial temporal lobe memory system' . This module encompasses the hippocamupus and the parahippocampal, perirhinal, and entorhinal cortexes; houses multiple memory systems ; and generates, stores, and interconnects smaller cognitive mechanisms known as schemas . Schemas , are generative and subjective knowledge structures, that are acquired and can be modified throughout life during exposure to and active interactions with the outside world or via thought processes. These structures can contain and process mental representations about the self, culture, abstract concepts, political ideologies, social norms, material entities, meanings of words, or experienced and imagined events etc. . Despite the wide range of possible representations that schemas can pertain to, an individual schema's content consists of subject specific, context-sensitive, and hierarchically slotted information that is varyingly fragmented, shallow, and abridged. However, singular units can link to associative networks of interrelated schemas to form more cohesive, coherent, and sophisticated mental representations . Extensive neuroimaging and experimental psychology research indicates that schemas are encoded and cultivated in neural networks through anchoring and reconstructive processes , that are enabled and reinforced by neuronal dopaminergic substrates and reactions . Schema encoding and subsequent augmentation often occurs when incoming information is contextually, semantically, affectively, and/or conceptually congruent or otherwise associated with pre-existing superordinate schemas, which serve as informational attractor and scaffolding mechanisms . For example, one's schema for doctors will likely be formed and syntactically defined upon first interacting with or learning about doctors. This coarse schema's base syntax can over time modify and expand itself in accordance with new information that corresponds to one's continued learning about and/or experiences with doctors or doctor-associated stimuli. These generative and combinatorial structural properties allow schemas to also connect and become co-activated with related schemas , which following the previous example, could include a nurse and/or health schema. Schema encoding, modification, and networking are also essentially the processes underpinning attitudinal development. According to Bohner and Dickel an attitude is a feeling or "evaluation of an object of thought [and attitude objects range] from the mundane to the abstract, including things, people, groups, and ideas". Attitudes can therefore be construed as affect-based schemas that contain and process affective meanings, and are tightly connected to or subsumed within related information-based schemas . One's attitudes on welfare for example, will be necessarily tied to one's knowledge about welfare programmes and recipients. Additionally, depending on the context of their formation, valence strength, and activation frequency, attitudes can be ad hoc and relatively disposable, or durable and potentially life-long, as is often the case with e.g., political attitudes and stereotypes . Moreover, weakly-held attitudes are highly amenable and negligibly affect judgement and behaviour. Conversely, strong attitudes are deep-seeded, resistant to change, and can powerfully affect motivation, judgment, behaviour, and the processing and development of information-based schemas . Furthermore, schemas are consolidated and lie dormant in long-term memory waiting to be activated and retrieved in working memory. Evan's updated version of the dualprocessing system paradigm, states that this process occurs through the activation of system 1 -associated with implicit/tacit cognition-which delivers cued information to system 2-associated with explicit/agentic cognition. Hence, when cued, schemas can, depending on the context of their activation, manifest as conscious thoughts and guide deliberative actions. However, situational frequency and contiguity augment a schema's activation potential and behavioural automaticity. This means that chronically elicited schemas become more salient, excitable, and reactive over time such that when triggered by proximate situational cues, they can actuate nonconscious judgements, decisions, and behaviours . These instances can be idiosyncratic and benign as can be the case for schemas that represent and guide one's morning routine practices or driving habits. Where this phenomenon becomes sociologically relevant, is in the case of schemas that contain intersubjectively shared sociocultural representations, because as will be discussed in the next section, their level of automaticity plays a critical role in subjectification and social reproduction . Yet, despite their power to propel individuals to nonconscious cognitive, affective and/or behavioural reactions, a schema's automatic function may in certain contexts and to varying degrees be superseded through concerted conscious effort . In particular, this can occur when individuals experience situations that run counter to their expectations, as these can induce an aversive arousal state . This is because people have an innate inclination to maintain cognitive consonance . Therefore, instances that activate internal inconsistency can force individuals to consciously engage with and then potentially alter their deep-seeded preconceptions and dispositional behaviours . However, this innate inclination can also lead individuals to reify their pre-existing schemas, and to unconsciously avoid information that may induce cognitive dissonance e.g., alternative political ideologies . To be certain, schema encoding, development, and processing are highly complex and dynamic phenomena that are dependent on various neurobiological chemical reactions, sensory motor systems, other cognitive mechanisms, innate psychological drives, and social propensities. These are far too numerous and complicated to go over in this parsimonious review, as are the theories and debates on how these all work and interact. However, the following summary statement and key points are quite empirically substantiated, and arguably accepted, shared, and/or implied by much of the neuroscience, cognitive psychology, and social cognition literatures. In sum, a schema's content, complexity, consolidation, saliency, behavioural automaticity, and connection to and co-activation with other schemas are largely determined by the frequency and socio-environmental and affective context in which it is accessed and utilised . But, once encoded, schemas can:  Store and organize memories, affects, knowledge and ideas; including their respective attributes and relationships to related schemas . This also includes information such as, motives, intentions, situations, and goals that "enable or inhibit certain behaviours, and causal sequence of events, as well as the specific behaviours themselves" .  Enable the processing of affective, contextual, discursive, and semantic meanings and associations .  Facilitate learning by enabling the rapid integration of new associations linked to incoming information .  Function as heuristic mechanisms that enable quick judgments and decisions .  Constitute an individual's mental representations of their self, and the intersubjectively shared cultural values, norms, attitudes and practices of their social groups . --- Social Cognition, Subjectification, and Social Reproduction Possibly the majority of social cognition theories stem from the computational representational paradigm described above, and thus share the same informationprocessing understanding of cognition, and emply a schema-based or analagous conception of mental representations. However, these SCTs tend to focus more on explaining the ways that innate and acquired cognitive structures enable and are influenced by social interaction, learning, self-awareness, group dynamics, and culture . There is naturally some disagreement between these various cousin theories , but they for the most part have shared, complementary, and non-conflicting tenets that, when considered together, paint an account of subjectification and social reproduction, which goes as follows. Generally, SCTs begin with the premise that humans start developing their schema architectures during infancy by observing and mimicking the interpersonal practices and linguistic uses of their immediate family, and concurrently through ongoing interaction with people and social institutions . Social institutions are understood by SCTs as patterned distributions of behaviours and material resources that explicitly and implicitly superimpose upon individuals, specific and organized forms of social order and information . These forms consist of cultural or political ideas, values, attitudes, histories, rules for acceptable behaviours, and practices, which usually function to perpetuate the status quo. Individuals, therefore, generate and form their subjectivities from active engagement with the social groups, institutional-discursive data, and cultural repositories available to them, in conjunction with repeated social interactions, rewards, sanctions, and negotiation of values with others. Thus, individuals can to a substantial degree constitute their subjectivities consciously because they are to a meaningful extent able to deliberatively take in, modify, and even dismiss the social information with which they are presented . This agrees with Bandura's argument that: 'Personal agency operates within a broad network of socio-structural influences. In these agentic transactions, people are producers as well as products of social systems.' SCTs further suggest, however, that subjectification is also a considerably nonconscious process that functions through innate cognitive and psychological propensities and mechanisms. Of note, these include theory of mind; conformist social learning, attribution, and prestige biases; and mnemonic storage and elaboration devices, which enable individuals to mentalize the beliefs, desires, and perspectives of others, predict behaviours, intuit symbolic meanings, and anticipate and adapt to social situational expectations . These also subliminally motivate individuals to want to identify with their respective social groups and culture, and to automatically attend to and construct mental representations of valuable, common, and widely shared social information . Put simply, this all means that people are significantly predisposed and probabilistically more likely to detect, schematically internalize, and over time implicitly conform according to, social information that is: repeatedly encountered and observed; cognitively, affectively, and behaviourally congruent and contiguous; and institutionally and culturally ubiquitous, valorized, and enforced . This will vary by individual, but the more this predominant social information becomes internalized, reinforced, and suffused in people's formative schema networks, the more they can do the following:  Form a major component of a person's self-identities .  Manifest as non-conscious cognitive, affective, and behavioural responses to lived relations and everyday institutional and cultural experiences and imperatives .  Lead individuals to naturalize, justify, legitimize, and conform to existing power relations and social inequalities .  Place durable neurocognitive parameters that can automatically block, bias, or distort the development of schemas for, or intake of, information corresponding to, opposing cultural and political ideas and practices .  Organize and constrain a wide range of behaviours in a fashion 'consistent with the structural conditions framing the situation, even when that behaviour is not directly and materially constrained by those conditions' .  Cause individuals to behaviourally and implicitly reproduce larger social structures and corresponding patterns of stratification and inequalities, even in situations 'in which the material constraints of the structure are insufficient to fully control individual behavior' . As this relates to social reproduction, SCTs posit that, in aggregate, these micro-level conditions can lead to macro-level sociocultural inertia . However, the generative and ultimately physically, biologically and socially constrained nature of human cognition means that an agent's encoding of even the most ideologically charged and institutionally disseminated social information is never an exact replication of the source data . Our unique cognitive faculties, experiences, cultural geo-historic specificities, social positioning, and agency lead us to remember, process, recombine, and reproduce even dominant social information in fuzzy, incomplete, novel, or permutated ways that can mildly to significantly differ from individual to individual and from generation to generation. Furthermore, agents are often surrounded by both stable and more dynamic sources of social information, such as the mass media. This results in exposure to '[a] continuous and overwhelming flow of information, which either endorses or challenges the status quo' . When looked at in tandem, all these inherent socio-cognitive dynamics can go some way towards explaining why we, for instance, are not institutional drones or carbon copies of our parents, and why societies are, to varying degrees, divergent and always changing. In other words, society does not indelibly stamp us, it instead provides us with foundational sociostructural algorithms that we are to some meaningful extent free to consciously modify and act on. Therefore, while relatively homeostatic, any given set of hegemonic institutional arrangements is never permanently fixed, as societies are inherently chaotic systems that are sensitive and continuously subject to spontaneous micro-and mesolevel agent-based modifications. While the fused SCT account outlined above is somewhat similar to Talcott Parson's structural functionalism and Pierre Bourdieu's field theory, it differs from these classic sociological theories in the proceeding ways. First, unlike Parson's 'oversocialised man' or Bourdieu's 'habitus', this account is based on empirically tested conceptualizations of how people's neurocognitive architectures are developed and augmented through social interactions and both automatic and deliberative agency. Second, these architectures are composed of schemas that contain specific yet modifiable and context-sensitive content. This very much differs from Bourdieu's habitus construct, which effectively entails a content-free, general learning, relatively fixed, and reactive mechanism . Third, this account does not reduce subjectification or social reproduction to either socio-structural or cognitive-structural determinants, nor to conscious or nonconscious agency. Rather, it suggests that subjectification and social reproduction are the interrelated products of mutually reinforcing and dynamic interactions between biological-genetic, cognitive-affective, and institutional-discursive mechanisms and processes. These in turn enable and are enabled by volitional, dispositional, habitual, and spontaneous cognition and action. That said, later sections will demonstrate how this account can be further incorporated into a habitus reformulation to explain neoliberal subjectification and reproduction, but before doing so, we must first briefly discuss the literatures on neoliberalism. --- What is Neoliberalism? Neoliberalism refers to a political-economic paradigm based on an ideology that calls for the state implementation, facilitation, and enforcement of free-market economic systems and logic across national and global settings, and essentially across all forms of human organization and decision-making . Initially rising to prominence in the 1980s in the UK and the US, neoliberalism has significantly shaped the 21 st century world order . This paradigm has been influenced by several Western epistemic communities . Thus, various provincial strands of neoliberalism have sprouted e.g., Brazilian New Capitalism, German Ordoliberalism . This section, however, will only focus on outlining the key theoretical premises and policy prescriptions associated with the dominant UK and US strand. The core of neoliberal theory and ideology as can be extracted from the works of seminal neoliberal theorists, starts with the assumption that human beings are predominantly possessive and instrumentally rational individuals. This indicates that while humans are capable of altruism, they will primarily and in the first instance behave in ways that are in accordance with their perceived self-interests . From this essentialist conception of human nature follows the key normative position that despite their selfinterested predispositions, people's motivations and actions can and should be channelled for progressive socioeconomic development. However, this must only be done through politicaleconomic systems that engender relatively unfettered market forces, negative freedom, and the legal protection and appropriation of private capital . Conversely, any attempts to harness the powers of the state to redistribute wealth and regulate markets for the public good, however benevolent and well intentioned, will have disastrous socio-economic outcomes. This is primarily because these objectives as traditionally advanced by state socialism and to a lesser extent by Keynesian forms of regulated capitalism, require excessive government economic intervention that distorts the natural pricing equilibrium mechanisms of supply and demand. Invariably, this results in the inefficient and wasteful allocation of finite resources and services . Furthermore, these political-economic systems necessarily infringe on individuals' freedom to utilize their capital as they choose, which has the consequent effect of stifling the psychological incentives necessary for entrepreneurial innovation and economic growth. Coupled, these cumulative macro and micro effects inevitably generate high inflation, stagnant economies, and unproductive state dependent citizenries that in extreme cases can lead to despotism . As such, neoliberals advocate for monetary policies aimed at controlling inflation . They postulate that in favouring monetary over fiscal policies, governments and central banks can help to increase and stabilize the real value of financial assets. This puts more money into the hands of investors and entrepreneurs, and incentivizes them to make investments, which will lead to the creation of jobs and more efficient economic growth than can be achieved by means of government fiscal stimulus policies. Neoliberals further argue that in order to maintain international competitiveness and induce and accelerate economic growth, countries should 1) eliminate or drastically reduce trade barriers, corporate and income taxes, government public expenditures, and financial, labour and environmental regulations; 2) partially or fully privatize their natural resources, state enterprises, and services; and 3) focus on generating exports. In so doing, countries can gain from their comparative advantages in factor endowments, maintain market credibility, achieve fiscal solvency, and attract foreign direct investment. However far from laisse-faire, neoliberals argue that a sound and prosperous economy necessitates state intervention to enforce contracts, protect property rights, and shore up markets in times of economic crisis . Thus, a minimal degree of funding for public services and private enterprises through fiscal revenues is consistent with neoliberal theory , provided that these are not "inimical to the initiative and functioning of the market" . Nonetheless, neoliberals emphatically argue for the reduction of the welfare state by for example, making welfare benefits means-tested and temporary. They further propose that the primary function of welfare and education institutions should be to condition and train individuals to be selfreliant, entrepreneurial, and responsible decision makers. Moreover, public institutions should be made to compete for public funds against other public institutions and private profit and non-profit organisations. To facilitate this public institutional restructuring, neoliberals advocate for neo-managerial policies and corporate style accountability metrics and targets to help eliminate wastefulness, incentivize positive performances, measure outcomes, and maximise customer satisfaction . Neoliberals hypothesize that the sufficient enactment of their policy prescriptions will in the long-term create prosperous and dynamic, but stable and efficient national and international markets, in addition to the skilled, self-reliant, and flexible workers needed to maintain and compete in them . Geo-political specificities notwithstanding, since the governments of UK Prime Minister Thatcher and US President Reagan, the ideas and policies described above have been steadily implemented and advanced by interlocking groups of elite politicians, businesspeople, and intellectuals . However, rather than ushering in more stable, beneficent, and equitable market societies than the post-WW2 Keynesian system, the neoliberal epoch has been marked by frequently recurring global financial crises, deep recessions, skyrocketing levels of socioeconomic inequality and environmental devastation . Despite these consistent detrimental outcomes, neoliberal hegemony has not been supplanted, nor faced any serious unsettling as, to all extents and purposes, outbursts of public unrest and popular social movements have been relatively short-lived, subdued, or co-opted . --- Neoliberal Hegemony It is not the intent here to imply that neoliberalism has become totalised, fixed, and uncontested. UK and US societies are like all others, marked by ideological ruptures and points of contestation generated by the constant dynamism of competing forces. Indeed, the neoliberal era has seen multitudes of resistance from the 1990s anti-globalization movements, to the 2010s Occupy encampments, to the recent rise of far-right nativist groups. Nevertheless, the fact does remain that major US and UK cultural and public institutions, such as mass media and education, have been considerably restructured by the types of policies described above, and turned into neoliberal market and ideological apparatuses that are significantly shaping millennials' selfhoods, social relations, and practices. 2 For example, neoliberal policies such as the US's 1996 Telecommunications Act and the UK's Communication Act 2003 lifted restrictions on media ownership. Resultantly, print media and public broadcasts continue to be co-opted and stripped of substance by corporate conglomerates, or worse still, turned into manufacturers of ridiculous infotainment that celebrates the opulence of the rich and famous , or vilifies the poor . In the UK for instance, there has been a recent influx of what is described as 'poverty porn' television shows . These are documentary style programmes that depict welfare recipients as underserving and lazy scroungers. As Jensen , argues, these shows "perform an ideological function [by generating] a new 'commonsense' around an unquestionable need for welfare reform". Neoliberal ideology can also be traced in the mainstream press' carefully spun and widely circulated sound-bites and opinion pieces that call for the reduction or elimination of welfare services, taxes, and union rights; the privatisation of public institutions and services; and the removal of economic, labour and environmental regulations . Notably, these messages are often developed by neoliberal think-tanks e.g., Adam Smith Institute, Heritage Foundation, Centre for Policy Studies, Institute of Economic Affairs . Moreover, this ideological saturation also includes an erosion of criticisms of corporate practices and neoliberal policies, along with a near constant vilification and misrepresentation of egalitarian ideals, unions, teachers, public schools, welfare recipients, redistributive policies, and market-critical political figures and organisations . The few independent media that report non-elite interests, critical voices, and substantive policy debates are marginalized, constantly under-funded, and have very limited communicative reach . Although we can only speculate at this point and notwithstanding the contribution made by other possible causal factors, these media conditions and distributed discourses may to some extent be contributing to at least two related phenomena. The first is the UK public's decreasing support for paying more taxes to raise benefits for low-income and unemployed people, which has been declining for 30 years, and is noticeably lowest amongst millennials . The second is the declining union membership in the UK and USA, which is also lowest amongst millennials . Relatedly, popular culture now disseminates neoliberalism congruent discourses of materialism, competitiveness and self-interestedness that are more emphatic and prevalent than during pre-neoliberal times . 3 For example, a psycholinguistic study of the lyrics from the US's Hot 100 Billboard songs from 1980-2007, found that since 1980, the words 'I' and 'Me' have appeared more frequently in popular music lyrics, while prosocial words like 'We' and 'Us' have significantly dwindled . The researchers also note that the rise in selfcentred and antisocial lyrics found in popular music correlates with several large-scale psychometric survey results indicating that American millennials are more narcissistic and self-interested than previous generations. Indeed, as Twenge and Campbell argue, the large majority of birth cohort studies have reported significant increases in individualistic and materialistic traits and decreases in civic interest in the American millennial generation. Related developmental psychology studies also show that the ubiquity and resulting exposure to materialistic media messages over the past 30 years, are correlated with rising levels of concerns over attaining wealth, fame, status, and material possessions amongst UK and US millennials . Whereas other studies have speculated that this exposure may be contributing to post-1980 generational decreases in empathy, altruism, and communality . Correspondingly, over the last two decades, UK and US commercial broadcasts have been dominated by reality television shows such as X-Factor, American Idol, and The Apprentice, which feature and promote cut-throat competition, narcissistic characters, rugged individualism, and materialism. In direct reference to these types of shows, Konrath et al., note that, "overall, the agentic and narcissistic qualities found in modern media seem consistent with decreasing empathy". --- With regards to education institutions, policies such as the US's 2009 Race To The Top Initiative and the UK's Education Act 2011, further instituted and extended the use of market-inspired accountability metrics to measure schools' competence and rank, and to in some instances determine their funding . As these metrics are primarily based on how well students perform on high-stakes standardised tests, teachers have been increasingly trained in and pressured to focus on, 'teaching to the test' classroom practices . These practices are normally modelled on rote learning and behaviourist approaches, in that they are specifically designed to train students to attain an automated and uncritical acceptance of predetermined answers. Additionally, students are generally told that their test scores will determine whether and which university they can attend, which will in turn determine what types of jobs they can expect to attain . Current public education thus largely functions as another pivotal institutional environment where millennials are tacitly socialized to adopt consumerist, competitive, and instrumentalist mindsets and behaviours, which are concomitant with neoliberal ideology. Again, while we can only speculate at this point, these educational changes may help to partly explain why UK university enrolment in public service-orientated courses, such as education, which usually attracts students hoping to become teachers, has fallen from 198,120 in 2004/5 to 173,015 in 2013/14. Inversely, enrolment for business courses, which generally lure students hoping to get high-paying corporate jobs, has risen from 290,455 in 2003/4 to 336,600 in 2013/14 . These figures closely match longitudinal trends in the USA , and business is now by far the most popular university course in the UK and the USA. All these institutional and discursive-formational changes have also coincided with a substantial weakening of labour unions and increase in the commodification of public spaces and leisure . This further diminishes millennials' probability of encountering counter-hegemonic ideas and practices, which then potentially negatively moderates their understanding of, interest in, or ability to imagine alternative cultural, institutional, and political-economic arrangements. The socio-structural and ideological convergence and synchronisation described in this section has thus resulted in a conjuncture where most US and UK millennials have no choice but to be repeatedly exposed to institutionally and culturally omnipresent neoliberal discursive formations. Hence, as suggested in recent ethnographic accounts, millennials are developing subjectivities that strongly reflect a neoliberal syntax or habitus as it were, which leads them to practices that contribute to the wider processes of neoliberal hegemony and reproduction . For example, with regards to his field study on young UK call-centre workers, Lloyd --- Constituting A Neoliberal Habitus: A Working Model The habitus construct has been routinely and widely criticised for being loosely defined, unfalsifiable, and psychologically inadequate . 4 Van dijk , for example, argues that the habitus offers a less explicit notion of a system of mental social representations, and its conception of 'disposition' is premised on circular reasoning because it "defines cognitive structures in terms of their output which precisely need to be explained in terms of other cognitive representations." . Despite these limitations, the habitus is a useful and rather pliant conceptual device that can be retrofitted with the empirically substantiated theoretical insights from the literatures discussed throughout this article to create a provisional ideal-type neoliberal habitus characterization. Before doing so, three reiterations must be made. First, the conception of habitus offered here is defined as an agent's acquired sum of related, content-specific, and contextually activated schemas that form a particular major component of the self, such as a role, identity, or sociocultural framework. These schemas can prompt nonconscious cognitive, affective, and behavioural reactions, but also fuel and can be modified and acted on via agential deliberation. Moreover, a subject can develop multiple habituses that can differ in magnitude, weight, consolidation, and automaticity, as well as overlap, be separate from, or conflict with one another. Hence, this habitus conception accounts for the capacity of subjects to develop multiple roles, identities, and cultural and political scripts, and to hold and act on these even when they contain inconsistent elements. Second, schema encoding and development are the products of dynamic experiential, social interactional, and accretionary cognitive processes. To wit, schemas are first encoded from exposure to and interaction with novel environmental stimuli e.g., words, images, social practices etc., as these instances can spontaneously generate within a subject an initial affective, lexical, and semantic mental impression i.e., a contextually and conceptually specific referent . This base syntax can be enhanced through subsequent exposure to contextual cues and information revealed during interaction . Furthermore, increasing a schema's activation potentiates its power to guide perception and recall, generate expectations and inferences, filter out competing or dissonant information, cue related schemas, and orient actions . When a given schema exceeds an activation threshold, it can then become automatically expressed, reinforced, and/or coactivated with related schemas during exposure to relevant stimuli . Thus an encoded schema's dispositional strength, salience, weight, and network size are primarily determined by activation frequency-which is, in turn, dependent on: Proximate, situationally specific cues and triggers, not directly on large-scale structural or cultural contexts, though structural and cultural changes can affect the distribution of such proximate cues and thereby the probabilities of activation of schemas . Third and correspondingly, high levels of cultural-political discursive, material, and functional convergence and synchronicity between major social institutions increase the distribution, commonality, observability, and enforcement of dominant forms of social information. Individuals growing up and interacting in these auto-correlated environments are more likely to have the representations and affective meanings of said information encoded in their formative sociocultural schemas . In these conditions, subjects are also more likely to have these schemas be chronically activated, which can over time, lead them to as Schroder and Thagard, argue: "implicitly reproduce the social order of their culture" . Brubaker et al., note that in this respect, sociocultural schemas complement and can be used to re-specify the original habitus concept, as they effectively refer to 1) widely shared mental representations of distinct sociocultural dispositions and practices which orient corresponding outputs; and 2) some of the key cognitive-affective mechanisms through which subjects acquire and reproduce a culture and political-economic ideology . An individual's sociocultural habitus can, therefore, be thought of as a network of associated and contiguous sociocultural schemas that correspond to the specific discourses and practices of whatever dominant institutions and culture they are subjected to during their ontogenetic development. Moreover, when instantiated, i.e., activated by relevant stimuli, this habitus orients contextually corresponding practices that maintain and reproduce existing societal arrangements. Additionally, individuals raised in institutional and cultural settings that regularly promote a hegemonic ideology, and where exposure to counter-hegemonic discursive formations is limited, should on average develop and display more ideologically consistent-harmonious sociocultural habituses. Consistent with this reasoning, the content and development of a neoliberal habitus are thus largely a function of recurring engagement with institutionally and culturally omnipresent and enforced neoliberal discursive formations . We will now elaborate on how this particular sociocultural habitus can theoretically manifest in UK and US millennials, but we must first emphasize that this probabilistic formulation does not preclude or negate the possibility that millennials can and may be developing alternative or inharmonious habituses. Developmental research has consistently found that youth are highly susceptible to peer and media influences, receptive to popularly held beliefs and attitudes, and more likely to implicitly and explicitly conform to and enforce commonly observed norms . Correspondingly, contemporary UK and US youth are frequently presented with social information that reflects or is congruent with neoliberal ideology. This includes beliefs and values such as capitalism rewards hard work, education leads to high paying jobs, wealth and material possessions increase happiness, welfare is too generous, unions are bad, etc. These are of course simplistic metonyms for complicated social information that is presented, framed, and enacted in myriad fashions through various mediums and complex forms of social interaction. But they more or less capture the gist of what, as i briefly outlined in the previous section, UK and US millennials are frequently presented by media, schools, and society at large . Furthermore, media and schools are the institutions where most youth possibly spend the majority of their waking hours interacting with others and learning about culture and politics. This indicates that said youths' formative sociocultural schemas are regularly instantiated. During instantiation, incoming information is normally assimilated or accommodated into relevant pre-existing schemas. Instantiation thus facilitates encoding, and every instantiation can gradually augment a schema's structure. Several factors play a role in this, but information/stimuli that are thematically, conceptually, or otherwise related or repeatedly presented together , are easier to process and more likely to become encoded . Moreover, there is a high degree of conceptual, affective, and behavioural congruity between materialism, individualism, anti-unionism, and anti-welfare discursive formations, for example, they all promote self-interested thoughts, attitudes, and practices. These discursive formations are also regularly proximately presented in mass media. For example, UK popular tabloids like the Sun and Daily Mail often feature stories about welfare 'cheats' or 'greedy' unions surrounded by adverts for consumer products. It stands to reason then that chronic engagement with these neoliberal congruent discursive formations will to some degree make an impression on young people's neurocognitive architectures. If sufficiently strong, this impression can in relevant social contexts, organize and orient their behaviours. However, while it can be assumed that this impression will vary by individual, neuroschematic content cannot be directly observed. Therefore, to test these assertions, semantic and lexical conceptualizations of sociocultural schemas and practices that reflect typical neoliberal discursive formations must instead be developed to serve as plausible observable indicators. Based on everything discussed thus far, such proxy sociocultural schemas and practices that can reasonably be said to correspond to a neoliberal habitus, may in part entail those listed in Table 1. These are admittedly crude and arbitrarily worded conceptualizations, and some of the listed schemas and practices may need to be discarded or modified and others added, following empirical scrutiny. Nonetheless, while this typological composite sacrifices the subtleties and complexities of social reality and of plausible neuroschematic representations, it can a` la Weberian tradition, be used to explore and compare how, why, and the degree to and context in which real cases diverge from or converge with it. --- Neoliberal Habitus --- Sociocultural Schemas Corresponding Social Practices  Financial wealth is a mark of success.  Owning more and expensive material possessions increases happiness.  Individuals should be self-reliant, selfconcerned, and entrepreneurial.  Public institutions should be run like businesses.  Capitalism is the only viable economic system.  Welfare recipients and impoverished peoples are mostly lazy and unambitious.  Government social programs are overly generous and economically burdensome.  Increasing taxes to fund social services is unfair to individuals that work hard.  Unions increase prices, create job losses, and prevent the firing of incompetent workers.  Rejecting socialist/communitarian ideas and policies.  Supporting welfare reforms that limit the timeframe and amount of benefits that can be claimed.  Supporting politicians that prioritise market/economic growth over social, labour, and environmental protections.  Supporting politicians that promise cuts to taxes and funding for social programmes.  Refusal to join a union, participate in strikes, or honour picket lines.  Minimal contributions to charities and environmental conservation. It must be stressed that the model described above, consisting of both the neoliberal habitus conceptualisation and typological composite is like most initial theoretical abstractions, a messy first approximation in need of conceptual refinement. This includes an account of how other subjectivity-habitus types fit or differ from it, which cannot be sufficiently discussed here. That said, the listed sociocultural schemas and practices are conceptually consistent with the literature on neoliberal subjectivity and hegemony . They are also largely based on the hitherto unconnected empirical evidence showing some of the ways that UK and US millennials' educational, political, and social-psychological values, attitudes, and practices resonate with neoliberal ideology, as described in the previous section. Hence, in pulling these otherwise disparate bits of evidence together and adding a situationally corresponding behavioural component, this model can be used to explore and test the extent to which UK and US millennials are developing and enacting a neoliberal habitus. --- Falsification: Some Suggestions Although this is not the space to outline a detailed research programme, the model offers a reference point for observable value, attitudinal and behavioural outputs, and proposes that the strength and development of these outputs are, in large part, determined by frequent engagement with culturally and institutionally ubiquitous, promoted and enforced neoliberal congruent discursive formations. Thus, the neoliberal habitus composite for instance, can be utilised to form qualitative interview schedules and guide ethnographic observations in schools, youth centres, and social media sites. In brief, this qualitative methodology would entail observing and documenting the extent and real-life instances in which youth consciously or implicitly articulate, reify, contest, or reject, as well as are presented and socially pressured to conform to, values, attitudes, and practices akin to those listed in the composite. However, an easier and more concrete way to test the model, is to use the typological composite to develop psychometric survey scales, and/or a variation of the Implicit Association Test -which is used to measure individuals' non-conscious attitudinal associations, valence, and biases . These can be coupled with other survey or experimental instruments that gauge contextual behavioural responses, such as vignettes that describe neoliberal welfare and economic policies, and measure participants' support for their enactment. Additionally, gauging exposure and pressure to conform to neoliberal congruent discursive formations can for starters be done by measuring the frequency with which the following occur: 1. Participants consume materialistic and politically mainstream media content. 2. Participants are complimented by their peers for purchasing branded consumer products, and ridiculed for having outdated products. 3. Participants are encouraged by their parents, peers, teachers, or media to select careers primarily on salary concerns, and discouraged from aspiring to typically lesser-paid socially minded careers . 4. Participants are encouraged by their parents, peers, teachers, or media to vote for mainstream pro-market party candidates, and discouraged to vote for or engage with market-critical politicians, parties, and ideas. This quantitative methodology can then be used to test two preliminary hypotheses: H1: The schemas in the model are hypothesized to be contagious, such that the activation of one should theoretically prime the activation of the others. These schemas are therefore predicted to be significantly and positively correlated with each other and with the featured social practices. H2: Increase in the frequencies of cases 1, 2, 3, or 4, will positively moderate the holding and enactment of the values, attitudes, and practices listed in the model. The statistical significance of H1 and H2 will likely be affected by relevant demographic factors and psychographic factors . The mediating and moderating effects of these factors should thus be examined. Lastly, whichever methods are used to test this model, its testing can help: to identify some of the necessary and sufficient conditions and factors that generate, potentiate, or hinder the processes of neoliberal subjectivity-habitus formation; and to inform understandings of the societal consequences of these processes; the sociological research for both of which is currently limited. --- Conclusion When considered together, growing evidence from parallel bodies of sociological and psychological research suggests that the ongoing neoliberal subjectification of UK and US millennials is associated with various adverse social and psychological effects . This process may also be generating indifference towards or directly feeding the growing levels of socioeconomic disparity and environmental degradation induced by the past 30 years of neoliberalism. It is this article's contention that to better understand and investigate all these interrelated phenomena, current sociological accounts can benefit from a more in-depth conceptualization and formalization of the specific subjectivity habitus that can develop from extended interaction with institutionally and culturally prevalent neoliberal discursive formations. To this end, a cognitive-sociological model is proposed to explain and examine the ways in which sociocultural cognitive-affective mechanisms enable, constrain, and mediate individual thought and action, and the ways these then help to sustain the current neoliberal order. While this model in no way captures the complexity of these dynamics, it incorporates rich theoretical insights from the cognitive sciences, and offers a novel framework for how to more robustly conceptualize and empirically explore them. Finally, although this model is situated within a US and UK context, it offers a set of falsifiable propositions and methodological recommendations that can be applied and tested in countries with advanced or burgeoning neoliberalization. --- Notes: 1. Subjectification is defined here as the process of becoming a subject i.e., of forming a selfidentity or multiple identities. Social reproduction refers to "all the mechanisms, processes, and practices by which multiple social hierarchies, divisions and relations of wealth, power, and influence are sustained and re-created over time" . 2. Some of the examples that I provide to empirically support this claim have been plucked from nationally representative datasets and extensive developmental psychology research, but are conceptually consistent with the literature on neoliberal hegemony and subjectification. Thus, the account and examples that I provide in this article are not based on the research or meant to bolster popular accounts that depict millennials as being self-entitled and unwilling to commit to employment . Such dispositions may indeed be in some way a product of neoliberal policy and structural changes, but there is currently little, and even then conflicting, empirical evidence to support the notion that millennials exhibit these dispositions more so than previous birth cohorts . Moreover, because of this very limited empirical grounding, the analyses and model described in this article does not account for this infant research. 3. Self-interestedness, competitiveness, materialism, and rationalism are also core to liberal precursors and thus not unique to neoliberalism. The argument here is simply that these traits are considerably more amplified and promoted in neoliberal societies. 4. The original habitus construct is defined by Bourdieu as a: "system of lasting, transposable dispositions which, integrating past experiences, functions at every moment as a matrix of perceptions, appreciations, and actions and makes possible the achievement of infinitely diversified tasks, thanks to analogical transfers of schemes permitting the solution of similarly shaped problems". --- Van Kesteren M T, Beul S F, Takashima A, Henson R N, Ruiter D J and Fernández G Differential roles for medial prefrontal and medial temporal cortices in schema

Disconcerting findings from sociological research suggest that Western youth are developing subjectivities that reflect neoliberal discursive formations of self-interestedness, competitiveness, and materialism. However, propositions about 1) the cognitive-affective mechanisms that explain how youth acquire and reproduce neoliberal ideology, or 2) the dispositions and behaviours that typify a neoliberal subject, remain vague. Therefore, in this article I provide a novel conceptualisation of these two psychosocial facets that can help advance understandings and investigations of the emerging modes and societal consequences of neoliberal subjectification. Specifically, I review major theoretical tenets from the respective literatures on neurocognitive development, social cognition, neoliberalism, and neoliberal hegemony. I then synthesise these tenets within a modified habitus formulation to sketch a testable cognitive-sociological model for explaining and exploring some of the distinct dispositional values, attitudes, and practices that youth raised in societies with institutionally and culturally prevalent neoliberal norms and discourses may potentially develop and enact.

the past three decades of neoliberal policy inputs and outputs have to differing but considerable extents transformed many western countries major media educational cultural and recreational institutions into market and ideological apparatuses as a result of this ongoing structural reconfiguration successive millennial generations and particularly those in the usa and the uk have been increasingly expose to neoliberal discursive formations of selfinterest competiveness and materialism correspondingly nascent sociological research is consistently showing that although millennials do actively construct and negotiate their selfhoods around the competing discursive systems of culture and value available to them very often these are as harvey et al argue related to the circulation of global tropes of consumption and idealised neoliberal subjectivities but what exactly constitutes neoliberal subjectivity to date the sociological literature has offered rich explanatory accounts that describe various interlocked systemic imperatives and structural discursive policy and civil society components that help engender the microlevel processes of neoliberal subjectification however propositions about the cognitiveaffective mechanisms that explain how youth acquire and reproduce neoliberal ideology or the dispositions and behaviours that typify a neoliberal subject remain vague accordingly a more indepth conceptualization of these two psychosocial facets could help enhance and specify current understandings of how a neoliberal subject develops thinks feels and acts this could in turn advance empirical examinations of the emerging modes and societal consequences of neoliberal subjectification therefore this article will provide an initial template for said conceptualization to do so we first review and draw links between the shared synergistic and complementary theoretical tenets from the literature on neurocognitive development and social cognition in order to lay a computationalrepresentational paradigmbased account of the processes of subjectification and social reproduction1 we then review the literature on neoliberalism and neoliberal hegemony as these apply to the usa and the uk the world harbingers and enforcers of neoliberal doctrine finally we synthesize the theoretical tenets and empirical findings discussed throughout the article within a modified version of the habitus formulation to sketch a testable cognitivesociological model this model provides a novel approach to help explain and empirically explore some of the distinct dispositional values attitudes and practices that youth raised in societies with institutionally and culturally prevalent neoliberal discursive formations may potentially develop and enact this article can therefore be viewed as a response to ongoing calls for sociologists to engage with the cognitive sciences and clarify the psychological assumptions that are implicit in all sociological theories of culture and subjectivity indeed as turner argues minimizing the cognitive is a genuine alternative strategy to engaging with cognitive neuroscience but only if we choose to push social theory to the far periphery of knowledge into a ghetto of its own making computationalrepresentational theories of mind one of the leading paradigmatic positions in cognitive science is that the mind is a computational informationprocessing centre largely composed of evolutionarily endowed hierarchically organized and interconnected neural structures known as modules modules are associated with and anchored across particular regions of the brain and are hypothesized to be autonomous and informationally encapsulated devices with domainspecific functions to wit each module is theorised to possess a genetically determined syntactic algorithm with fixed parameters that is designed to only and mandatorily process certain sensory inputs to perform distinct cognitive tasks eg facial pattern recognition because of these computational properties modules enable us to rapidly process parse remember and react to the constant stream of sensory information that we encounter every day for the purposes of this article a particularly important metamodule is termed the medial temporal lobe memory system this module encompasses the hippocamupus and the parahippocampal perirhinal and entorhinal cortexes houses multiple memory systems and generates stores and interconnects smaller cognitive mechanisms known as schemas schemas are generative and subjective knowledge structures that are acquired and can be modified throughout life during exposure to and active interactions with the outside world or via thought processes these structures can contain and process mental representations about the self culture abstract concepts political ideologies social norms material entities meanings of words or experienced and imagined events etc despite the wide range of possible representations that schemas can pertain to an individual schemas content consists of subject specific contextsensitive and hierarchically slotted information that is varyingly fragmented shallow and abridged however singular units can link to associative networks of interrelated schemas to form more cohesive coherent and sophisticated mental representations extensive neuroimaging and experimental psychology research indicates that schemas are encoded and cultivated in neural networks through anchoring and reconstructive processes that are enabled and reinforced by neuronal dopaminergic substrates and reactions schema encoding and subsequent augmentation often occurs when incoming information is contextually semantically affectively andor conceptually congruent or otherwise associated with preexisting superordinate schemas which serve as informational attractor and scaffolding mechanisms for example ones schema for doctors will likely be formed and syntactically defined upon first interacting with or learning about doctors this coarse schemas base syntax can over time modify and expand itself in accordance with new information that corresponds to ones continued learning about andor experiences with doctors or doctorassociated stimuli these generative and combinatorial structural properties allow schemas to also connect and become coactivated with related schemas which following the previous example could include a nurse andor health schema schema encoding modification and networking are also essentially the processes underpinning attitudinal development according to bohner and dickel an attitude is a feeling or evaluation of an object of thought and attitude objects range from the mundane to the abstract including things people groups and ideas attitudes can therefore be construed as affectbased schemas that contain and process affective meanings and are tightly connected to or subsumed within related informationbased schemas ones attitudes on welfare for example will be necessarily tied to ones knowledge about welfare programmes and recipients additionally depending on the context of their formation valence strength and activation frequency attitudes can be ad hoc and relatively disposable or durable and potentially lifelong as is often the case with eg political attitudes and stereotypes moreover weaklyheld attitudes are highly amenable and negligibly affect judgement and behaviour conversely strong attitudes are deepseeded resistant to change and can powerfully affect motivation judgment behaviour and the processing and development of informationbased schemas furthermore schemas are consolidated and lie dormant in longterm memory waiting to be activated and retrieved in working memory evans updated version of the dualprocessing system paradigm states that this process occurs through the activation of system 1 associated with implicittacit cognitionwhich delivers cued information to system 2associated with explicitagentic cognition hence when cued schemas can depending on the context of their activation manifest as conscious thoughts and guide deliberative actions however situational frequency and contiguity augment a schemas activation potential and behavioural automaticity this means that chronically elicited schemas become more salient excitable and reactive over time such that when triggered by proximate situational cues they can actuate nonconscious judgements decisions and behaviours these instances can be idiosyncratic and benign as can be the case for schemas that represent and guide ones morning routine practices or driving habits where this phenomenon becomes sociologically relevant is in the case of schemas that contain intersubjectively shared sociocultural representations because as will be discussed in the next section their level of automaticity plays a critical role in subjectification and social reproduction yet despite their power to propel individuals to nonconscious cognitive affective andor behavioural reactions a schemas automatic function may in certain contexts and to varying degrees be superseded through concerted conscious effort in particular this can occur when individuals experience situations that run counter to their expectations as these can induce an aversive arousal state this is because people have an innate inclination to maintain cognitive consonance therefore instances that activate internal inconsistency can force individuals to consciously engage with and then potentially alter their deepseeded preconceptions and dispositional behaviours however this innate inclination can also lead individuals to reify their preexisting schemas and to unconsciously avoid information that may induce cognitive dissonance eg alternative political ideologies to be certain schema encoding development and processing are highly complex and dynamic phenomena that are dependent on various neurobiological chemical reactions sensory motor systems other cognitive mechanisms innate psychological drives and social propensities these are far too numerous and complicated to go over in this parsimonious review as are the theories and debates on how these all work and interact however the following summary statement and key points are quite empirically substantiated and arguably accepted shared andor implied by much of the neuroscience cognitive psychology and social cognition literatures in sum a schemas content complexity consolidation saliency behavioural automaticity and connection to and coactivation with other schemas are largely determined by the frequency and socioenvironmental and affective context in which it is accessed and utilised but once encoded schemas can  store and organize memories affects knowledge and ideas including their respective attributes and relationships to related schemas this also includes information such as motives intentions situations and goals that enable or inhibit certain behaviours and causal sequence of events as well as the specific behaviours themselves  enable the processing of affective contextual discursive and semantic meanings and associations  facilitate learning by enabling the rapid integration of new associations linked to incoming information  function as heuristic mechanisms that enable quick judgments and decisions  constitute an individuals mental representations of their self and the intersubjectively shared cultural values norms attitudes and practices of their social groups social cognition subjectification and social reproduction possibly the majority of social cognition theories stem from the computational representational paradigm described above and thus share the same informationprocessing understanding of cognition and emply a schemabased or analagous conception of mental representations however these scts tend to focus more on explaining the ways that innate and acquired cognitive structures enable and are influenced by social interaction learning selfawareness group dynamics and culture there is naturally some disagreement between these various cousin theories but they for the most part have shared complementary and nonconflicting tenets that when considered together paint an account of subjectification and social reproduction which goes as follows generally scts begin with the premise that humans start developing their schema architectures during infancy by observing and mimicking the interpersonal practices and linguistic uses of their immediate family and concurrently through ongoing interaction with people and social institutions social institutions are understood by scts as patterned distributions of behaviours and material resources that explicitly and implicitly superimpose upon individuals specific and organized forms of social order and information these forms consist of cultural or political ideas values attitudes histories rules for acceptable behaviours and practices which usually function to perpetuate the status quo individuals therefore generate and form their subjectivities from active engagement with the social groups institutionaldiscursive data and cultural repositories available to them in conjunction with repeated social interactions rewards sanctions and negotiation of values with others thus individuals can to a substantial degree constitute their subjectivities consciously because they are to a meaningful extent able to deliberatively take in modify and even dismiss the social information with which they are presented this agrees with banduras argument that personal agency operates within a broad network of sociostructural influences in these agentic transactions people are producers as well as products of social systems scts further suggest however that subjectification is also a considerably nonconscious process that functions through innate cognitive and psychological propensities and mechanisms of note these include theory of mind conformist social learning attribution and prestige biases and mnemonic storage and elaboration devices which enable individuals to mentalize the beliefs desires and perspectives of others predict behaviours intuit symbolic meanings and anticipate and adapt to social situational expectations these also subliminally motivate individuals to want to identify with their respective social groups and culture and to automatically attend to and construct mental representations of valuable common and widely shared social information put simply this all means that people are significantly predisposed and probabilistically more likely to detect schematically internalize and over time implicitly conform according to social information that is repeatedly encountered and observed cognitively affectively and behaviourally congruent and contiguous and institutionally and culturally ubiquitous valorized and enforced this will vary by individual but the more this predominant social information becomes internalized reinforced and suffused in peoples formative schema networks the more they can do the following  form a major component of a persons selfidentities  manifest as nonconscious cognitive affective and behavioural responses to lived relations and everyday institutional and cultural experiences and imperatives  lead individuals to naturalize justify legitimize and conform to existing power relations and social inequalities  place durable neurocognitive parameters that can automatically block bias or distort the development of schemas for or intake of information corresponding to opposing cultural and political ideas and practices  organize and constrain a wide range of behaviours in a fashion consistent with the structural conditions framing the situation even when that behaviour is not directly and materially constrained by those conditions  cause individuals to behaviourally and implicitly reproduce larger social structures and corresponding patterns of stratification and inequalities even in situations in which the material constraints of the structure are insufficient to fully control individual behavior as this relates to social reproduction scts posit that in aggregate these microlevel conditions can lead to macrolevel sociocultural inertia however the generative and ultimately physically biologically and socially constrained nature of human cognition means that an agents encoding of even the most ideologically charged and institutionally disseminated social information is never an exact replication of the source data our unique cognitive faculties experiences cultural geohistoric specificities social positioning and agency lead us to remember process recombine and reproduce even dominant social information in fuzzy incomplete novel or permutated ways that can mildly to significantly differ from individual to individual and from generation to generation furthermore agents are often surrounded by both stable and more dynamic sources of social information such as the mass media this results in exposure to a continuous and overwhelming flow of information which either endorses or challenges the status quo when looked at in tandem all these inherent sociocognitive dynamics can go some way towards explaining why we for instance are not institutional drones or carbon copies of our parents and why societies are to varying degrees divergent and always changing in other words society does not indelibly stamp us it instead provides us with foundational sociostructural algorithms that we are to some meaningful extent free to consciously modify and act on therefore while relatively homeostatic any given set of hegemonic institutional arrangements is never permanently fixed as societies are inherently chaotic systems that are sensitive and continuously subject to spontaneous microand mesolevel agentbased modifications while the fused sct account outlined above is somewhat similar to talcott parsons structural functionalism and pierre bourdieus field theory it differs from these classic sociological theories in the proceeding ways first unlike parsons oversocialised man or bourdieus habitus this account is based on empirically tested conceptualizations of how peoples neurocognitive architectures are developed and augmented through social interactions and both automatic and deliberative agency second these architectures are composed of schemas that contain specific yet modifiable and contextsensitive content this very much differs from bourdieus habitus construct which effectively entails a contentfree general learning relatively fixed and reactive mechanism third this account does not reduce subjectification or social reproduction to either sociostructural or cognitivestructural determinants nor to conscious or nonconscious agency rather it suggests that subjectification and social reproduction are the interrelated products of mutually reinforcing and dynamic interactions between biologicalgenetic cognitiveaffective and institutionaldiscursive mechanisms and processes these in turn enable and are enabled by volitional dispositional habitual and spontaneous cognition and action that said later sections will demonstrate how this account can be further incorporated into a habitus reformulation to explain neoliberal subjectification and reproduction but before doing so we must first briefly discuss the literatures on neoliberalism what is neoliberalism neoliberalism refers to a politicaleconomic paradigm based on an ideology that calls for the state implementation facilitation and enforcement of freemarket economic systems and logic across national and global settings and essentially across all forms of human organization and decisionmaking initially rising to prominence in the 1980s in the uk and the us neoliberalism has significantly shaped the 21 st century world order this paradigm has been influenced by several western epistemic communities thus various provincial strands of neoliberalism have sprouted eg brazilian new capitalism german ordoliberalism this section however will only focus on outlining the key theoretical premises and policy prescriptions associated with the dominant uk and us strand the core of neoliberal theory and ideology as can be extracted from the works of seminal neoliberal theorists starts with the assumption that human beings are predominantly possessive and instrumentally rational individuals this indicates that while humans are capable of altruism they will primarily and in the first instance behave in ways that are in accordance with their perceived selfinterests from this essentialist conception of human nature follows the key normative position that despite their selfinterested predispositions peoples motivations and actions can and should be channelled for progressive socioeconomic development however this must only be done through politicaleconomic systems that engender relatively unfettered market forces negative freedom and the legal protection and appropriation of private capital conversely any attempts to harness the powers of the state to redistribute wealth and regulate markets for the public good however benevolent and well intentioned will have disastrous socioeconomic outcomes this is primarily because these objectives as traditionally advanced by state socialism and to a lesser extent by keynesian forms of regulated capitalism require excessive government economic intervention that distorts the natural pricing equilibrium mechanisms of supply and demand invariably this results in the inefficient and wasteful allocation of finite resources and services furthermore these politicaleconomic systems necessarily infringe on individuals freedom to utilize their capital as they choose which has the consequent effect of stifling the psychological incentives necessary for entrepreneurial innovation and economic growth coupled these cumulative macro and micro effects inevitably generate high inflation stagnant economies and unproductive state dependent citizenries that in extreme cases can lead to despotism as such neoliberals advocate for monetary policies aimed at controlling inflation they postulate that in favouring monetary over fiscal policies governments and central banks can help to increase and stabilize the real value of financial assets this puts more money into the hands of investors and entrepreneurs and incentivizes them to make investments which will lead to the creation of jobs and more efficient economic growth than can be achieved by means of government fiscal stimulus policies neoliberals further argue that in order to maintain international competitiveness and induce and accelerate economic growth countries should 1 eliminate or drastically reduce trade barriers corporate and income taxes government public expenditures and financial labour and environmental regulations 2 partially or fully privatize their natural resources state enterprises and services and 3 focus on generating exports in so doing countries can gain from their comparative advantages in factor endowments maintain market credibility achieve fiscal solvency and attract foreign direct investment however far from laissefaire neoliberals argue that a sound and prosperous economy necessitates state intervention to enforce contracts protect property rights and shore up markets in times of economic crisis thus a minimal degree of funding for public services and private enterprises through fiscal revenues is consistent with neoliberal theory provided that these are not inimical to the initiative and functioning of the market nonetheless neoliberals emphatically argue for the reduction of the welfare state by for example making welfare benefits meanstested and temporary they further propose that the primary function of welfare and education institutions should be to condition and train individuals to be selfreliant entrepreneurial and responsible decision makers moreover public institutions should be made to compete for public funds against other public institutions and private profit and nonprofit organisations to facilitate this public institutional restructuring neoliberals advocate for neomanagerial policies and corporate style accountability metrics and targets to help eliminate wastefulness incentivize positive performances measure outcomes and maximise customer satisfaction neoliberals hypothesize that the sufficient enactment of their policy prescriptions will in the longterm create prosperous and dynamic but stable and efficient national and international markets in addition to the skilled selfreliant and flexible workers needed to maintain and compete in them geopolitical specificities notwithstanding since the governments of uk prime minister thatcher and us president reagan the ideas and policies described above have been steadily implemented and advanced by interlocking groups of elite politicians businesspeople and intellectuals however rather than ushering in more stable beneficent and equitable market societies than the postww2 keynesian system the neoliberal epoch has been marked by frequently recurring global financial crises deep recessions skyrocketing levels of socioeconomic inequality and environmental devastation despite these consistent detrimental outcomes neoliberal hegemony has not been supplanted nor faced any serious unsettling as to all extents and purposes outbursts of public unrest and popular social movements have been relatively shortlived subdued or coopted neoliberal hegemony it is not the intent here to imply that neoliberalism has become totalised fixed and uncontested uk and us societies are like all others marked by ideological ruptures and points of contestation generated by the constant dynamism of competing forces indeed the neoliberal era has seen multitudes of resistance from the 1990s antiglobalization movements to the 2010s occupy encampments to the recent rise of farright nativist groups nevertheless the fact does remain that major us and uk cultural and public institutions such as mass media and education have been considerably restructured by the types of policies described above and turned into neoliberal market and ideological apparatuses that are significantly shaping millennials selfhoods social relations and practices 2 for example neoliberal policies such as the uss 1996 telecommunications act and the uks communication act 2003 lifted restrictions on media ownership resultantly print media and public broadcasts continue to be coopted and stripped of substance by corporate conglomerates or worse still turned into manufacturers of ridiculous infotainment that celebrates the opulence of the rich and famous or vilifies the poor in the uk for instance there has been a recent influx of what is described as poverty porn television shows these are documentary style programmes that depict welfare recipients as underserving and lazy scroungers as jensen argues these shows perform an ideological function by generating a new commonsense around an unquestionable need for welfare reform neoliberal ideology can also be traced in the mainstream press carefully spun and widely circulated soundbites and opinion pieces that call for the reduction or elimination of welfare services taxes and union rights the privatisation of public institutions and services and the removal of economic labour and environmental regulations notably these messages are often developed by neoliberal thinktanks eg adam smith institute heritage foundation centre for policy studies institute of economic affairs moreover this ideological saturation also includes an erosion of criticisms of corporate practices and neoliberal policies along with a near constant vilification and misrepresentation of egalitarian ideals unions teachers public schools welfare recipients redistributive policies and marketcritical political figures and organisations the few independent media that report nonelite interests critical voices and substantive policy debates are marginalized constantly underfunded and have very limited communicative reach although we can only speculate at this point and notwithstanding the contribution made by other possible causal factors these media conditions and distributed discourses may to some extent be contributing to at least two related phenomena the first is the uk publics decreasing support for paying more taxes to raise benefits for lowincome and unemployed people which has been declining for 30 years and is noticeably lowest amongst millennials the second is the declining union membership in the uk and usa which is also lowest amongst millennials relatedly popular culture now disseminates neoliberalism congruent discourses of materialism competitiveness and selfinterestedness that are more emphatic and prevalent than during preneoliberal times 3 for example a psycholinguistic study of the lyrics from the uss hot 100 billboard songs from 19802007 found that since 1980 the words i and me have appeared more frequently in popular music lyrics while prosocial words like we and us have significantly dwindled the researchers also note that the rise in selfcentred and antisocial lyrics found in popular music correlates with several largescale psychometric survey results indicating that american millennials are more narcissistic and selfinterested than previous generations indeed as twenge and campbell argue the large majority of birth cohort studies have reported significant increases in individualistic and materialistic traits and decreases in civic interest in the american millennial generation related developmental psychology studies also show that the ubiquity and resulting exposure to materialistic media messages over the past 30 years are correlated with rising levels of concerns over attaining wealth fame status and material possessions amongst uk and us millennials whereas other studies have speculated that this exposure may be contributing to post1980 generational decreases in empathy altruism and communality correspondingly over the last two decades uk and us commercial broadcasts have been dominated by reality television shows such as xfactor american idol and the apprentice which feature and promote cutthroat competition narcissistic characters rugged individualism and materialism in direct reference to these types of shows konrath et al note that overall the agentic and narcissistic qualities found in modern media seem consistent with decreasing empathy with regards to education institutions policies such as the uss 2009 race to the top initiative and the uks education act 2011 further instituted and extended the use of marketinspired accountability metrics to measure schools competence and rank and to in some instances determine their funding as these metrics are primarily based on how well students perform on highstakes standardised tests teachers have been increasingly trained in and pressured to focus on teaching to the test classroom practices these practices are normally modelled on rote learning and behaviourist approaches in that they are specifically designed to train students to attain an automated and uncritical acceptance of predetermined answers additionally students are generally told that their test scores will determine whether and which university they can attend which will in turn determine what types of jobs they can expect to attain current public education thus largely functions as another pivotal institutional environment where millennials are tacitly socialized to adopt consumerist competitive and instrumentalist mindsets and behaviours which are concomitant with neoliberal ideology again while we can only speculate at this point these educational changes may help to partly explain why uk university enrolment in public serviceorientated courses such as education which usually attracts students hoping to become teachers has fallen from 198120 in 20045 to 173015 in 201314 inversely enrolment for business courses which generally lure students hoping to get highpaying corporate jobs has risen from 290455 in 20034 to 336600 in 201314 these figures closely match longitudinal trends in the usa and business is now by far the most popular university course in the uk and the usa all these institutional and discursiveformational changes have also coincided with a substantial weakening of labour unions and increase in the commodification of public spaces and leisure this further diminishes millennials probability of encountering counterhegemonic ideas and practices which then potentially negatively moderates their understanding of interest in or ability to imagine alternative cultural institutional and politicaleconomic arrangements the sociostructural and ideological convergence and synchronisation described in this section has thus resulted in a conjuncture where most us and uk millennials have no choice but to be repeatedly exposed to institutionally and culturally omnipresent neoliberal discursive formations hence as suggested in recent ethnographic accounts millennials are developing subjectivities that strongly reflect a neoliberal syntax or habitus as it were which leads them to practices that contribute to the wider processes of neoliberal hegemony and reproduction for example with regards to his field study on young uk callcentre workers lloyd constituting a neoliberal habitus a working model the habitus construct has been routinely and widely criticised for being loosely defined unfalsifiable and psychologically inadequate 4 van dijk for example argues that the habitus offers a less explicit notion of a system of mental social representations and its conception of disposition is premised on circular reasoning because it defines cognitive structures in terms of their output which precisely need to be explained in terms of other cognitive representations despite these limitations the habitus is a useful and rather pliant conceptual device that can be retrofitted with the empirically substantiated theoretical insights from the literatures discussed throughout this article to create a provisional idealtype neoliberal habitus characterization before doing so three reiterations must be made first the conception of habitus offered here is defined as an agents acquired sum of related contentspecific and contextually activated schemas that form a particular major component of the self such as a role identity or sociocultural framework these schemas can prompt nonconscious cognitive affective and behavioural reactions but also fuel and can be modified and acted on via agential deliberation moreover a subject can develop multiple habituses that can differ in magnitude weight consolidation and automaticity as well as overlap be separate from or conflict with one another hence this habitus conception accounts for the capacity of subjects to develop multiple roles identities and cultural and political scripts and to hold and act on these even when they contain inconsistent elements second schema encoding and development are the products of dynamic experiential social interactional and accretionary cognitive processes to wit schemas are first encoded from exposure to and interaction with novel environmental stimuli eg words images social practices etc as these instances can spontaneously generate within a subject an initial affective lexical and semantic mental impression ie a contextually and conceptually specific referent this base syntax can be enhanced through subsequent exposure to contextual cues and information revealed during interaction furthermore increasing a schemas activation potentiates its power to guide perception and recall generate expectations and inferences filter out competing or dissonant information cue related schemas and orient actions when a given schema exceeds an activation threshold it can then become automatically expressed reinforced andor coactivated with related schemas during exposure to relevant stimuli thus an encoded schemas dispositional strength salience weight and network size are primarily determined by activation frequencywhich is in turn dependent on proximate situationally specific cues and triggers not directly on largescale structural or cultural contexts though structural and cultural changes can affect the distribution of such proximate cues and thereby the probabilities of activation of schemas third and correspondingly high levels of culturalpolitical discursive material and functional convergence and synchronicity between major social institutions increase the distribution commonality observability and enforcement of dominant forms of social information individuals growing up and interacting in these autocorrelated environments are more likely to have the representations and affective meanings of said information encoded in their formative sociocultural schemas in these conditions subjects are also more likely to have these schemas be chronically activated which can over time lead them to as schroder and thagard argue implicitly reproduce the social order of their culture brubaker et al note that in this respect sociocultural schemas complement and can be used to respecify the original habitus concept as they effectively refer to 1 widely shared mental representations of distinct sociocultural dispositions and practices which orient corresponding outputs and 2 some of the key cognitiveaffective mechanisms through which subjects acquire and reproduce a culture and politicaleconomic ideology an individuals sociocultural habitus can therefore be thought of as a network of associated and contiguous sociocultural schemas that correspond to the specific discourses and practices of whatever dominant institutions and culture they are subjected to during their ontogenetic development moreover when instantiated ie activated by relevant stimuli this habitus orients contextually corresponding practices that maintain and reproduce existing societal arrangements additionally individuals raised in institutional and cultural settings that regularly promote a hegemonic ideology and where exposure to counterhegemonic discursive formations is limited should on average develop and display more ideologically consistentharmonious sociocultural habituses consistent with this reasoning the content and development of a neoliberal habitus are thus largely a function of recurring engagement with institutionally and culturally omnipresent and enforced neoliberal discursive formations we will now elaborate on how this particular sociocultural habitus can theoretically manifest in uk and us millennials but we must first emphasize that this probabilistic formulation does not preclude or negate the possibility that millennials can and may be developing alternative or inharmonious habituses developmental research has consistently found that youth are highly susceptible to peer and media influences receptive to popularly held beliefs and attitudes and more likely to implicitly and explicitly conform to and enforce commonly observed norms correspondingly contemporary uk and us youth are frequently presented with social information that reflects or is congruent with neoliberal ideology this includes beliefs and values such as capitalism rewards hard work education leads to high paying jobs wealth and material possessions increase happiness welfare is too generous unions are bad etc these are of course simplistic metonyms for complicated social information that is presented framed and enacted in myriad fashions through various mediums and complex forms of social interaction but they more or less capture the gist of what as i briefly outlined in the previous section uk and us millennials are frequently presented by media schools and society at large furthermore media and schools are the institutions where most youth possibly spend the majority of their waking hours interacting with others and learning about culture and politics this indicates that said youths formative sociocultural schemas are regularly instantiated during instantiation incoming information is normally assimilated or accommodated into relevant preexisting schemas instantiation thus facilitates encoding and every instantiation can gradually augment a schemas structure several factors play a role in this but informationstimuli that are thematically conceptually or otherwise related or repeatedly presented together are easier to process and more likely to become encoded moreover there is a high degree of conceptual affective and behavioural congruity between materialism individualism antiunionism and antiwelfare discursive formations for example they all promote selfinterested thoughts attitudes and practices these discursive formations are also regularly proximately presented in mass media for example uk popular tabloids like the sun and daily mail often feature stories about welfare cheats or greedy unions surrounded by adverts for consumer products it stands to reason then that chronic engagement with these neoliberal congruent discursive formations will to some degree make an impression on young peoples neurocognitive architectures if sufficiently strong this impression can in relevant social contexts organize and orient their behaviours however while it can be assumed that this impression will vary by individual neuroschematic content cannot be directly observed therefore to test these assertions semantic and lexical conceptualizations of sociocultural schemas and practices that reflect typical neoliberal discursive formations must instead be developed to serve as plausible observable indicators based on everything discussed thus far such proxy sociocultural schemas and practices that can reasonably be said to correspond to a neoliberal habitus may in part entail those listed in table 1 these are admittedly crude and arbitrarily worded conceptualizations and some of the listed schemas and practices may need to be discarded or modified and others added following empirical scrutiny nonetheless while this typological composite sacrifices the subtleties and complexities of social reality and of plausible neuroschematic representations it can a la weberian tradition be used to explore and compare how why and the degree to and context in which real cases diverge from or converge with it neoliberal habitus sociocultural schemas corresponding social practices  financial wealth is a mark of success  owning more and expensive material possessions increases happiness  individuals should be selfreliant selfconcerned and entrepreneurial  public institutions should be run like businesses  capitalism is the only viable economic system  welfare recipients and impoverished peoples are mostly lazy and unambitious  government social programs are overly generous and economically burdensome  increasing taxes to fund social services is unfair to individuals that work hard  unions increase prices create job losses and prevent the firing of incompetent workers  rejecting socialistcommunitarian ideas and policies  supporting welfare reforms that limit the timeframe and amount of benefits that can be claimed  supporting politicians that prioritise marketeconomic growth over social labour and environmental protections  supporting politicians that promise cuts to taxes and funding for social programmes  refusal to join a union participate in strikes or honour picket lines  minimal contributions to charities and environmental conservation it must be stressed that the model described above consisting of both the neoliberal habitus conceptualisation and typological composite is like most initial theoretical abstractions a messy first approximation in need of conceptual refinement this includes an account of how other subjectivityhabitus types fit or differ from it which cannot be sufficiently discussed here that said the listed sociocultural schemas and practices are conceptually consistent with the literature on neoliberal subjectivity and hegemony they are also largely based on the hitherto unconnected empirical evidence showing some of the ways that uk and us millennials educational political and socialpsychological values attitudes and practices resonate with neoliberal ideology as described in the previous section hence in pulling these otherwise disparate bits of evidence together and adding a situationally corresponding behavioural component this model can be used to explore and test the extent to which uk and us millennials are developing and enacting a neoliberal habitus falsification some suggestions although this is not the space to outline a detailed research programme the model offers a reference point for observable value attitudinal and behavioural outputs and proposes that the strength and development of these outputs are in large part determined by frequent engagement with culturally and institutionally ubiquitous promoted and enforced neoliberal congruent discursive formations thus the neoliberal habitus composite for instance can be utilised to form qualitative interview schedules and guide ethnographic observations in schools youth centres and social media sites in brief this qualitative methodology would entail observing and documenting the extent and reallife instances in which youth consciously or implicitly articulate reify contest or reject as well as are presented and socially pressured to conform to values attitudes and practices akin to those listed in the composite however an easier and more concrete way to test the model is to use the typological composite to develop psychometric survey scales andor a variation of the implicit association test which is used to measure individuals nonconscious attitudinal associations valence and biases these can be coupled with other survey or experimental instruments that gauge contextual behavioural responses such as vignettes that describe neoliberal welfare and economic policies and measure participants support for their enactment additionally gauging exposure and pressure to conform to neoliberal congruent discursive formations can for starters be done by measuring the frequency with which the following occur 1 participants consume materialistic and politically mainstream media content 2 participants are complimented by their peers for purchasing branded consumer products and ridiculed for having outdated products 3 participants are encouraged by their parents peers teachers or media to select careers primarily on salary concerns and discouraged from aspiring to typically lesserpaid socially minded careers 4 participants are encouraged by their parents peers teachers or media to vote for mainstream promarket party candidates and discouraged to vote for or engage with marketcritical politicians parties and ideas this quantitative methodology can then be used to test two preliminary hypotheses h1 the schemas in the model are hypothesized to be contagious such that the activation of one should theoretically prime the activation of the others these schemas are therefore predicted to be significantly and positively correlated with each other and with the featured social practices h2 increase in the frequencies of cases 1 2 3 or 4 will positively moderate the holding and enactment of the values attitudes and practices listed in the model the statistical significance of h1 and h2 will likely be affected by relevant demographic factors and psychographic factors the mediating and moderating effects of these factors should thus be examined lastly whichever methods are used to test this model its testing can help to identify some of the necessary and sufficient conditions and factors that generate potentiate or hinder the processes of neoliberal subjectivityhabitus formation and to inform understandings of the societal consequences of these processes the sociological research for both of which is currently limited conclusion when considered together growing evidence from parallel bodies of sociological and psychological research suggests that the ongoing neoliberal subjectification of uk and us millennials is associated with various adverse social and psychological effects this process may also be generating indifference towards or directly feeding the growing levels of socioeconomic disparity and environmental degradation induced by the past 30 years of neoliberalism it is this articles contention that to better understand and investigate all these interrelated phenomena current sociological accounts can benefit from a more indepth conceptualization and formalization of the specific subjectivity habitus that can develop from extended interaction with institutionally and culturally prevalent neoliberal discursive formations to this end a cognitivesociological model is proposed to explain and examine the ways in which sociocultural cognitiveaffective mechanisms enable constrain and mediate individual thought and action and the ways these then help to sustain the current neoliberal order while this model in no way captures the complexity of these dynamics it incorporates rich theoretical insights from the cognitive sciences and offers a novel framework for how to more robustly conceptualize and empirically explore them finally although this model is situated within a us and uk context it offers a set of falsifiable propositions and methodological recommendations that can be applied and tested in countries with advanced or burgeoning neoliberalization notes 1 subjectification is defined here as the process of becoming a subject ie of forming a selfidentity or multiple identities social reproduction refers to all the mechanisms processes and practices by which multiple social hierarchies divisions and relations of wealth power and influence are sustained and recreated over time 2 some of the examples that i provide to empirically support this claim have been plucked from nationally representative datasets and extensive developmental psychology research but are conceptually consistent with the literature on neoliberal hegemony and subjectification thus the account and examples that i provide in this article are not based on the research or meant to bolster popular accounts that depict millennials as being selfentitled and unwilling to commit to employment such dispositions may indeed be in some way a product of neoliberal policy and structural changes but there is currently little and even then conflicting empirical evidence to support the notion that millennials exhibit these dispositions more so than previous birth cohorts moreover because of this very limited empirical grounding the analyses and model described in this article does not account for this infant research 3 selfinterestedness competitiveness materialism and rationalism are also core to liberal precursors and thus not unique to neoliberalism the argument here is simply that these traits are considerably more amplified and promoted in neoliberal societies 4 the original habitus construct is defined by bourdieu as a system of lasting transposable dispositions which integrating past experiences functions at every moment as a matrix of perceptions appreciations and actions and makes possible the achievement of infinitely diversified tasks thanks to analogical transfers of schemes permitting the solution of similarly shaped problems van kesteren m t beul s f takashima a henson r n ruiter d j and fernández g differential roles for medial prefrontal and medial temporal cortices in schema

disconcerting findings from sociological research suggest that western youth are developing subjectivities that reflect neoliberal discursive formations of selfinterestedness competitiveness and materialism however propositions about 1 the cognitiveaffective mechanisms that explain how youth acquire and reproduce neoliberal ideology or 2 the dispositions and behaviours that typify a neoliberal subject remain vague therefore in this article i provide a novel conceptualisation of these two psychosocial facets that can help advance understandings and investigations of the emerging modes and societal consequences of neoliberal subjectification specifically i review major theoretical tenets from the respective literatures on neurocognitive development social cognition neoliberalism and neoliberal hegemony i then synthesise these tenets within a modified habitus formulation to sketch a testable cognitivesociological model for explaining and exploring some of the distinct dispositional values attitudes and practices that youth raised in societies with institutionally and culturally prevalent neoliberal norms and discourses may potentially develop and enact